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December 28, 2022 12:16 am | Updated 12:16 am IST
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A health worker in Jing’an district in Shanghai, China | Photo Credit: AFP
Mainland China is going through a critical phase in the health emergency, more dire than in the early days of 2020, as the country of origin for SARS-CoV2. In the absence of reliable data on the toll on human health and life, rough approximations indicate millions of people with symptomatic diseases and adverse outcomes in China. Instead of gearing up for the holiday season, the rest of the world is now grappling with uncertainty about continuing the benefits of relaxations in COVID-19 norms and measures for the prevention of further waves. It is time to reflect, review the situation, and respond to the potential waves, which will differ from country to country and regions within.
At the beginning of the evolving COVID-19 pandemic, countries followed their own strategies as many were clueless about how to deal with the sudden emergence of the SARS-CoV-2 virus. Instead of a cohesive, uniform global strategy, countries experimented on their own. There were two principal approaches; the first was promoting herd immunity by allowing the virus to infect everyone, which also advocated focused protection of the people at risk. The biggest problem with this approach was that it resulted in many deaths among the elderly and the others who were vulnerable.
The second was to follow the other extreme, known as the Zero-COVID strategy of not allowing even a single case of COVID-19 by imposing strict lockdowns, closing borders, and imposing travel bans. As the vaccination rates (with effective vaccines) increased significantly, countries that followed the strategy abandoned it mid-course as it was untenable. These countries scaled up vaccine production, leveraged vaccination delivery, and urged the public to adhere to COVID-appropriate behaviour.
China followed the unrealistic and prolonged Zero-COVID strategy as a lofty goal, as if the virus was destined to disappear on its own. While the virus was emerging in different forms with varying infectiousness and virulence, China stuck to the same policy. The Zero-COVID strategy rendered the Chinese population relatively more vulnerable to the virus without better vaccines and strengthened health systems. At a time when China is confronted with witnessing many cases, it has stopped testing all infected persons and modified the criteria for identifying COVID-19 deaths. Apart from underestimating cases and deaths, the real worry is missing the development of newer variants. The more the new variants circulate and find newer hosts to lodge upon, the higher the chances for mutation and evolution to newer forms. Rapid circulation in a largely susceptible population may result in newer variants, which could spread to other areas. It is important to track the genetic variations in China and study the infectiousness and virulence of people in the rest of the world.
The next concern is how the ongoing wave in China could threaten other countries.
Given the understanding that only Omicron and its sub-lineages are circulating in China, it is very unlikely that these can result in large waves of infection or fatality in India. This assertion arises from hybrid immunity, offered by both the high burden of Omicron, and greater vaccine coverage with primary doses. In the past, complacency has cost countries a greater toll on human lives apart from economic and social loss. Therefore, proactive measures taken by the Government are justified, including a higher level of commitment and review of the programme. In particular, the resulting actions should focus on expanding booster coverage, strengthening surveillance, and reorienting the health systems for cohesive pandemic preparedness.
Despite high coverage, nearly 8% of adults have missed the second dose of the vaccine, constituting a large pool for infection and complications. Also, India must ensure that 2-3 million young adults added each month to the cohort of adults are vaccinated. Those who missed the second dose should be prioritised and vaccinated through outreach activities. Further, 73% of adults are yet to receive booster doses; with 60% of the elderly remaining to be covered. Evidence suggests that heterologous booster doses increase the levels of neutralising antibodies. Among the available options for boosters, Corbevax and Covishield are the frontrunners for increasing the antibody levels, as in data from Christian Medical College Vellore, Tamil Nadu. The recent inclusion of the intranasal COVID-19 vaccine is exciting; we need data on how this can increase the antibody titers compared to other vaccines.
The possibility of a newer variant emerging out of the high-circulation ecosystem in China is a real concern. The primary requirement for understanding this will be based on the data made available by China in terms of epidemiological data, clinical features, mortality, and genomic sequencing. In the absence of reliable data required for modelling, it is nearly impossible for realistic planning for potential waves. China also revised its guidelines recently to classify only fatalities in infected persons caused by pneumonia and respiratory failure as COVID deaths. Also, the country has decided not to publish daily COVID data from December 25.
It is unfortunate that the World Health Organization or other global powers are influential enough to ensure China shares the critical data. In the absence of data, countries are resorting to intuitively contend that any likely wave cannot be more devastating than the largest waves due to the earlier variants. While hoping for the best, assessing whether the preparedness can match the burden of hospitalisation during the earlier waves might be best. Continuing enhanced efforts in genomic sequencing can provide timely information on newer variants.
Managing multiple waves of COVID-19 is an index of the future burden of zoonotic diseases and serves as a reminder to assess and strengthen underlying disease surveillance and health system components. Instead of limiting these assessments and corrections for each wave, this is the time to strengthen the bottoms-up surveillance systems in an integrated manner to detect thresholds for different pathogens affecting human and animal health. Instead of devastations associated with outbreaks, our choices for resilient structures and human resources can fortify in offering better outcomes. There are multiple disease surveillance systems in India, and with considerable duplication of efforts. This is the time to build shared databases and surveillance across different sectors and identify new solutions that address the root causes and links between risks and impacts.
Integrating and unifying the efforts to balance and optimise the health of people, animals, and the environment is called “One-health”. This can prevent, predict, detect, and respond to global health threats. Since this approach involves multiple sectors and disciplines, governments should aim to mobilise these by building partnerships with communities to create long-term, sustainable solutions. Community engagement is also critical to promote risk-reducing habits and attitudes and supporting the early detection and containment of disease threats.
Giridhara R. Babu is a Professor of Epidemiology at the Public Health Foundation of India, Bengaluru
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