COVID-19: THE PANDEMIC OF OUR TIME
By Mohan Manthiry
As the figures say it.
Analytics and data crunching on COVID-19 cases and its spread got all governments, institutions and news media on full throttle. For once we had continuous free flow of information that provided the fodder to work towards predictive models and use of artificial intelligence to decipher information on the spread of the coronavirus and to overcome the rate of infection and mortality. Governments were relying on some of these data models that depended on control measures enforced and its compliance by the population. Most of these predictive models could not reveal an accurate outcome as the infection progressed. The critical factor to flattening the curve is dependent on the measures taken by different countries. Most important being the awareness and compliance by all in the community. STAYING AT HOME seems to work in breaking the transmission chain, which is the biggest challenge, especially for countries with a high number of positive cases.
The novel coronavirus unveiled the vulnerability and helplessness of many governments in managing the pandemic and the weakness in the health system. More pronounced in some of the OECD countries considered to have technologically advanced infrastructure and health system. Gapping weakness was evident in the governance structure, management, resource allocation and preparedness in facing a pandemic.
However, Taiwan, with a population of over 23 million, did a commendable work to stop the spread of the virus and recorded only 429 cases and six deaths. Taiwan did not lockdown the country to keep its citizens to stay home but took early steps to shut its borders, enlisted its experts and implemented swiftly screening, testing, contact tracing and enforced quarantine. The novel way to stop this novel virus. The steps taken were very appropriate, quick and coordinated to prevent the spread into the community. Data capture and analytics, including the use of artificial intelligence for real-time updates on the spread and risk stratification, aided in containing the virus.
Graph 1: Global GOVID-19 deaths per million population, top 14 countries as at 1 May 2020 (InfoMed)
Table 1: Comparing the top highest number of cases globally and the regional countries including Malaysia as of 1 May 2020.
What do the figures show?
- The caveat to the statistics above is the fear on the lack of testing and inadequate reporting procedures which means the number of cases and the death toll could be much higher, especially in the developing and under-developed countries. Total cases directly correlate to the contact tracing and testing done for both symptomatic and asymptomatic cases, the testing method and kit used. The variation by countries could be high.
- For total cases per million population – Spain is the highest with 4,565 cases per million, and Malaysia is at 185 cases, while the global average is 412 cases per million.
- As for the total deaths per million population, Belgium has the highest rate, with 655 deaths per million people, and Malaysia’s ratio is at 3.2 per million. In contrast, the global average is 30 deaths per million. In comparison, Taiwan has only 0.3 deaths per million, whereas China reported 3.2 per million. The developed countries like the US, Spain, Italy, UK and France had remarkably high death rates. One possible explanation could be the high percentage of the ageing population and the spiked rates of deaths in the nursing homes. But Japan considered having one of the highest elderly population registered only 3.2 deaths per million!!
- Malaysia imposed early lockdown and closed its borders. The statistical results confirm its effectiveness in keeping the spread under control.
Table 2: Malaysia’s COVID-19 mortality as at 3 May 2020 (based on MOH data)
There was a variation in containment measures adopted, and some of the methods applied to flatten the infection curve and bring it down were:
- China implemented total lockdown by province and city.
- Malaysia, Singapore and Taiwan's approach was ramping up testing, contact tracing and quarantine.
- Some countries left it to the people to build herd immunity. Considered a dangerous strategy as it is gambling with people's lives but kept the economy going.
Table 3: How did the different countries perform?
From the analysis and reporting, countries that reacted quickly to do lots of testing and isolation manage to avoid large scale infection. China is the first respondent, took stringent action to isolate and conduct extensive testing to stop the spread to outside Hubei province, the epicentre. Otherwise, for a country with more than 1.3 billion population, it would have been catastrophic.
When comparing the number of positive cases versus the death rate, there seems a significant variation as in Table 1. This can be attributed to different factors which include the demography of the population, the extensiveness of the testing done, the sensitivity of the testing, the contact tracing and follow-up, the capacity and capability of the treatment (hospitals) and reporting.
Some experts expect the majority of the population to get infected in the years to come even after the development of a vaccine.
Examining the different scenarios and actions taken coupled with the experts’ advice, the key strategies to manage and contain this virus in priority is as follows:
1. Handwashing
2. Social distancing compliance
3. Early pro-action to lockdown
4. Extensive testing
5. Efficient contact tracing
6. Leadership which is apolitical and gets advice from the experts
7. Hospital preparedness and equipment
Increase in Cases – dependent on: · Compliance of the population to voluntary quarantine and social distancing · Testing, how aggressive it is, that you can trace the positive cases · The symptomatic and asymptomatic cases prevalence · The handwashing compliance to break the spread
· The contact tracing to identify the potential positive cases
TESTING, DRUG, VACCINE AND SCIENCE
Testing has been the mainstay for COVID-19 tracing and prevention efforts. Its importance cannot be understated. There has been a multitude of testing methods emerging from the laboratories, pharmaceuticals and research institutes. Governments were scrambling to do these testing in a timely manner to fathom the spread of the coronavirus and gain evidence on the extent of the spread of the virus in the community and its transmission. Testing for the positive COVID-19 cases allows the officials to understand and identify the effective, evidence-based strategies to allocate resources appropriately.
PCR TEST – These are polymerase chain reaction-based nucleic acid tests that can identify the viral genetic material obtained from nasopharyngeal swabs of individuals being tested. PCR-based tests are considered more accurate. However, they are more technically involved and challenging to perform. They can only inform whether an individual harbor the virus during the time of testing (even before you have symptoms) and can be used in conjunction with a patient medical history and physical examination to aid in COVID-19 diagnosis. The test results are not available for several days after testing (ecri.org).
SEROLOGY TEST - Potential treatment involves identifying the antibodies produced by the human immune system that would be most effective against COVID-19. Once these antibodies are identified, and if it works, it can be manufactured and used as a treatment or to prevent the disease. This immunoassay is a biochemical test is less accurate and more difficult to develop than PCR-based tests, but it can be performed at the point of care and produce faster results, typically within one hour. However, these tests only show positive results late in your disease, so it does not help you to make the decision on whether to quarantine or not. Another issue with the antibody testing is that the tests available as for now have problems with false positive. The presence of antibodies against the SARS CoV-2 virus suggests the individual has protection from the virus, and it is still unknown how long this immunity can last and if can be reinfected.
RTD – Rapid diagnostic test is the simplest test which can be performed on the spot and at home like the pregnancy test. You take a swap from your nose just as in the PCR test, but you do the processing on the spot and get the results immediately. Although it will not be as sensitive as a PCR test, it can be quite accurate for someone who has the symptom. As at today, many such tests are being promoted in the market with accreditation of its sensitivity and accuracy.
CONVALESCENT PLASMA THERAPY - Much testing is ongoing to use the plasma from a recovered COVID-19 patient, ensuring its free of the coronavirus and giving the plasma to those who are positive. It is a type of passive antibody therapy, in which blood plasma is isolated from people who have recovered from COVID-19 and is administered to those with the disease to suppress viraemia and improve clinical symptoms. Although so far, there is no definitive clinical evidence of its efficacy, it is being used under compassionate use rules. The plasma from one donor can only be used to treat a few patients, and the success depends on the presence of a high concentration of anti-SARS-CoV-2 antibodies.
DRUG THERAPY - There is also from the therapeutic angle, work on the use of antivirals drugs is being tested. This drug therapy functions to keep the virus from reproducing, which worked for the Ebola virus. End of April 2020, the US announced that patients hospitalized with advanced COVID-19 with lung involvement and who received the antiviral agent Remdesivir recovered faster by 31% than those who received placebo. The mortality rate was 8.0% for the group receiving Remdesivir versus 11.6% for patients who received placebo. On that basis, Remdesivir was made the “standard of care” for patients with COVID-19. Although this is the preliminary stage, similar trials of drugs for COVID-19 are being conducted globally to build on Remdesivir’s findings.
VACCINE - Vaccine is the gold standard used before to eradicate and prevent diseases such as measles and smallpox. Typically, it takes more than five years to bring it to the population globally. In the case of COVID-19, unprecedented before, researchers are compressing the processes in the creation of the RNA vaccine. Conventional vaccine approaches have not been as effective against rapidly evolving pathogens like influenza or emerging disease threats such as the COVID-19, Ebola or Zika viruses. RNA based vaccines could have an impact in these areas due to their shorter manufacturing times, cheaper and greater effectiveness. RNA vaccines are produced in the laboratory and are safer for the patient, as they are not produced using fragments of the virus but is by giving the body the genetic code needed to produce lots of copies of these fragments or the engineered virus-derived RNA strand. When the body’s immune system sees the viral fragments, it learns how to attack them, making the body as the vaccine manufacturing unit.
Vaccine should address the following issues: That the vaccine goes through three phases of trails (phase 1 safety trial, phase 2 control trial and phase 3 trial the longest and introduced to a large group under ‘natural disease conditions’ Vaccine’s efficacy and safety for use in humans Safety tests to determine that a vaccine does not make the disease worse Must produce sufficient protection in the older population, considering the age-related deterioration of the immune system (immune senescence) Its production capacity and uncertainty in demand Vaccine storage and refrigeration facilities to maintain its efficacy and how to get to the people who need it Innovation in delivery – needle-free, skin patch (self-administered)?
On 24 April 2020, World Health Organization led a list of countries (including Malaysia), industry groups, and non-governmental organizations committed to joining a project for developing and producing new drugs, vaccines, and tests for Covid-19 — and ensure worldwide access to the products called the “Access to COVID-19 Tools Accelerator.” WHO is encouraging countries and organization to pledge contributions to the tune of US8 billion as the initial funding for the project and the key goal is to level the global playing field to ensure the products will be available to the rich and poor populations alike.
Many cities and countries around the world are considering giving "immunity passports," a certification to those who have already had Covid-19 infection, and which would allow them to potentially resume going to work and participate in other activities. Scientists believe that previously infected individuals will be protected due to antibodies, but the WHO issued guidance on 24 April 2020 expressing concern about relying on such "passports" because how much protection the antibodies confer — and for how long — is still unknown. The WHO is also warning that many testing kits to check for SARS-CoV-2 antibodies still need to be properly validated.
How the coronavirus vaccine will work (Source BBC)
The Oxford Vaccine trial work began on a vaccine in January 2020. The vaccine was developed in under three months by a team at Oxford University. Sarah Gilbert, professor of vaccinology at the Jenner Institute, led the pre-clinical research. The vaccine is made from a weakened version of a common cold virus (known as an adenovirus) from chimpanzees that have been modified so it cannot grow in humans.
Elisa Granato, one of the two who received the jab, told the BBC: "I'm a scientist, so I wanted to try to support the scientific process wherever I can." The vaccine has to be demonstrated that it actually works and stops people getting infected with coronavirus before using the vaccine in the wider population.
Table 4: A glimpse on the potential vaccine in progress (courtesy stat.news.com)
LESSONS LEARNED
There is raised awareness on health with the global population, especially on infection, what they are, how to get tested, the activities that cause the most risk of infection and who is most susceptible to the disease.
THE POSITIVE SIDE TO COVID-19
The positivity from COVID-19, and what it has taught the world:
- The value and importance of healthcare and the need for awareness.
- The economic impact when healthcare goes awry.
- Impressed on the global population, the government and policymakers the economic power of health care and the need to prioritize the importance of health for all irrespective of race, religion, age and status.
- The issues in the global supply chain and its interdependence.
- The differentiating power of countries in addressing the situation in terms of ramping up the services and facilities.
- International cooperation, transparency and the World Health Organization as the guardian to world health. Need for a relook at the global health collaboration.