Police block motorists from passing at a checkpoint set up at the border between Phnom Penh

Police block motorists from passing at a checkpoint set up at the border between Phnom Penh and neighbouring Kandal province in 2020. On 1 November this year, Prime Minister Hun Sen declared Cambodia ‘fully reopened’. (Photo: TANG CHHIN Sothy / AFP)

Is Cambodia’s Endemic Covid-19 Approach Sensible?

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With high vaccination rates, Cambodia has decided to reopen. Learning to live with the virus may be the right decision but ending random testing could pose risks.

Cambodia recorded its sharpest daily decline of Covid-19 cases when they fell from 978 on 30 September to 232 on 1 October 2021. This dramatic drop of 76 per cent in a day was due to a change in the approach taken towards testing. By eliminating random testing of asymptomatic individuals, the reported numbers reflect only cases that have been presented for testing following the onset of symptoms. 

This change has had real impacts because it has affected policy relating to lockdowns and border measures. After the Pchum Ben festival ended on 7 October, Prime Minister Hun Sen announced that should case numbers remain low for 10 to 15 days, the country should reopen.

Perhaps unsurprisingly, case numbers have remained low, leading to the easing of lockdowns and the opening of borders. On 1 November, Prime Minister Hun Sen declared Cambodia ‘fully reopened’ and to ’expect crowded shops and roads’. So, is this approach to ending the pandemic illusionary, delusionary or visionary? The answer depends partly on whether it is time to redefine the pandemic by changing the way in which it is measured. In other words, do circumstances warrant a shift in focus from infection rates to hospitalisation rates? This, in turn, depends on the vaccination rate and the capacity and quality of the healthcare system.

Cambodia’s record on vaccinations has been remarkable. Its vaccination rate at above 85 per cent of its total population is one of the world’s highest because it has vaccinated most of its children aged between 6 and 12 years and has started a vaccination program for the remainder. Cambodia has one of the youngest populations in Asia, and extending vaccinations to these age groups is essential for reaching herd immunity.

Although the healthcare system in Cambodia is continuously improving, its capacity is still limited. For instance, there are currently only 0.7 hospital beds per 1,000 people compared to 2.6 in Vietnam and an average of 4.7 amongst the OECD countries. This suggests that a surge in cases requiring hospitalisation could quickly overwhelm the healthcare system. The question then arises as to how the decision to stop random testing affects this risk?

Reopening while reducing domestic surveillance like testing could backfire if emerging signs of an outbreak that could overwhelm the healthcare system are missed as a result. That is a risk that Cambodia now appears willing to take.

It would certainly diminish the usefulness of the positive rate, which measures the share of tests returning a positive result. Apart from being an indicator of the adequacy of testing itself, it can also be used to monitor the outbreak and introduce pre-emptive measures. The rate fell from 12.8 per cent on 28 May to 7.0 per cent on 19 June, presumably due to the lockdown (the WHO has suggested that rates under 10 per cent indicate adequate testing). But the rate can no longer be useful without random testing. Reopening while reducing domestic surveillance like testing could backfire if emerging signs of an outbreak that could overwhelm the healthcare system are missed as a result. That is a risk that Cambodia now appears willing to take.

Testing for daily changes in asymptomatic infections is justified only if the government plans to use the information for policy, however. Since Cambodia is shifting to using vaccination rather than infection rates as its main policy guide, the main impact of stopping random testing as it moves from a pandemic to an endemic state would be savings in diagnostic costs. Furthermore, since testing and tracing were far from comprehensive to begin with, officially ending random testing may not amount to as much of a change as it might seem. In fact, differences in infection rates across Southeast Asian countries may have as much to do with different types and amounts of testing and reporting as anything else.

With limited healthcare capacity, Cambodia will have to rely on the efficacy of its extensive vaccination program, consisting mainly of Sinovac, to protect its community against the worst effects of the pandemic. The biggest threat to this approach is the emergence of a new variant that significantly erodes the efficacy of current vaccines to prevent severe disease. This concern underlies much of the delay in opening borders in Asia.

The evidence suggests that border closures have failed to keep the new variants out for two reasons. First, borders are never completely closed, by design, because it would be both impractical and unsustainable. Second, because borders are not completely shut, domestic safeguards need to be perfect but they are not. Selective travel bans could work if only we could reduce the time taken to determine the risks carried by new variants, say from the genetic sequencing alone, instead of waiting until they present in large case numbers. Until this becomes possible, border measures will not protect against future variants, but improved domestic protocols might. Testing and quarantining of all international arrivals probably reduces the risk of importing a new variant to that of one emerging indigenously.

The current state of healthcare in Cambodia is a reminder that the lives-versus-livelihoods trade-off is different in poor countries. When fiscal resources are limited and safety nets are wanting, lives or livelihoods are often one and the same amongst the poor. Poor countries must consider the lives lost or shortened through livelihoods destroyed by lockdowns with lives lost directly to the virus. In Cambodia today, there is more that can be done to mitigate the former than the latter. In this context, the switch now from pandemic to endemic may prove to be visionary even if the sudden drop in infections is largely illusionary, and changing policy based on it seemingly delusionary.

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