When is the pandemic ending? This is the crucial question that has been racking the brains of healthcare authorities, scientists and medical experts around the world for the past several weeks. We still don't have a clear-cut answer. However, there are now several considered viewpoints about this issue.
Besides the rate of vaccination and the emergence/non-emergence of new risky variants, there is one dicey factor: human behaviour. The pandemic has entered its 20th month now and in the US-the worst-hit country-cases have begun to decline after a wave of delta infections peaked at over 172,000 daily cases in mid-September. The US has fully vaccinated about 55% of its population (India, less than 30% fully vaccinated). Dr Rochelle Walensky, CDC Director, says that ending the pandemic will largely depend on human behaviour (CNBC, Oct. 8, 2021). And we all know that human behaviour is a tricky thing!
As the delta variant is very contagious and as immunity wanes over time, herd immunity against delta and other highly transmissible variants increasingly seem like an inconceivable target. Even if that was possible, the threshold for achieving it might be very high now, 90-95 per cent of the population administered full vaccination (as against 60-70 per cent envisaged earlier). In every country, there are pockets where the vaccination rate and protection is very low. The virus isn't stupid, it's going to go to low vaccinated areas and spread there fast. Unless we extend the vaccine coverage equitably around the glove, and uniformly around each country, the pandemic isn't going to end suddenly.
As Walensky aptly says, "we are battling with one another and not battling with the common foe, which is the virus itself."
According to Dr Scott Gottlieb, an epidemic expert, there are two factors that will influence the pandemic's end: approval of Covid vaccines for kids and Merck's antiviral pill (Deseret News, Oct. 8, 2021).
Anti-Covid Pills
Several Covid prevention pills (drugs/medicines) are now on the way from the laboratory to the clinic. These medicines mitigate the risk of developing serious COVID infections. Many of them have been shown to significantly reduce the risk of hospitalizations and deaths.
One such pill is the one developed by the pharmaceutical giant, Pfizer Inc (TOI, Sep. 30, 2021). it's a protease inhibitor and has been code-named as PF-07321332. It works by blocking the activity of a key enzyme needed for the virus (SARS-CoV-2) to replicate. The antiviral is to be administered orally to a person suspected to have been infected with the Covid virus in the early stage and prevent serious illness, hospitalization, and death.
The clinical trials of the drug is in its preliminary phase and it's being tested in over 2,600 volunteers in combination with another antiviral called Ritonavir. The findings of the trial are expected to be available for review by the first quarter of 2022. If it's found to be effective and safe, the pill may be made available before the end of 2022.
The caveat is that this Pfizer drug will only be useful for only the nascent stages of infection and the medicine may not be suitable for people who are hospitalized or have severe infections.
Another drug in the pipeline is molnupiravir (The Economic Times (ET), Oct. 2, 2021). The pill's maker, Merck, claims that it could reduce hospitalizations and deaths by about 50 per cent in people recently infected with the coronavirus. The company aims to request health authorities in the US and around the world to authorize the use of the drug soon. If approved, molnupiravir will be the world's first specific anti-COVID oral pill in the world. In contrast, remdesivir was originally developed as an antiviral drug for the Ebola virus and is administered by IV injection.
Molnupiravir can ease coronavirus symptoms in mild to moderate patients, just like Tamiflu does with flu. If kids' vaccines and anti-Covid pills start getting deployed, we may soon enter the endemic phase of Covid-19 even if the virus is still going to lurk around us. If approved, Merck's pill will be the first oral antiviral treatment for COVID-19. The currently authorized drugs e.g. remdesivir must be given intravenously or injected. The pill could keep hospitals from overflowing, especially in regions where vaccination rates are low. But Merck's findings are yet to peer-reviwed and whether the drug's clinical trial success will translate into a real-world breakthrough remains to be seen. And, many low-income countries may not have the diagnostic capacity to treat patients early in the course of COVID-19 infection (Nature, Oct. 9, 2021).
Other antivirals are also in the pipeline. Gilead Sciences is developing a pill version of remdesivir. Atea Pharmaceuticals is also testing an antiviral compound. Pfizer is also conducting phase 2/3 trial of an antiviral pill, to treat people who are newly infected.
Molnupiravir needs to be given in the first five days after onset of symptoms, and the need to rapidly diagnose people with mild infections before it turns serious will be a big challenge for many low-to-middle-income countries. Merck plans to produce 10 million doses of the pill by the end of 2021, with a projected cost of about $700 per course of treatment (The Hindu, Oct. 2, 2021).
COVID Vaccines for Kids
Pfizer has recently sought approval for its vaccine for children aged 5-11 (The Economic Times, Oct. 9, 2021). Many countries have begun vaccinating adolescents of age 12 and above but very few have extended the coverage to children younger than that. Some countries such as Cuba, Cambodia, UAE, and Venezuela have started vaccinating young children of various age groups.
Israel have begun vaccinating children aged 5-11 with co-morbidities from July end.
Many experts opine that the risk of Covid to young children must be carefully weighed against the potential side effects of Covid jabs. The WHO insists that adults in poor countries must be vaccinated first before extending jabs to children in rich countries.
ZyCoV-D vaccine for children of age 12 and above is a needleless 3-dose vaccine that has got DCGI approval recently and the government is planning its roll out the vaccine sometime in October-November 2021. The size of children's (below the age of 18) population in India is quite big: about 41% of the approximately 1.3 billion total population.
Several other children's vaccines are also in the pipeline in India. SII has got approval for phase 2 and 3 clinical trials of its vaccine, Covovax, for children of age 7 to 11. The trials began in August. Bharat Biotech has completed clinical trials for its Covaxin vaccine for kids aged 2-18. It has already submitted its trial data to DCGI for possible approval (DW Channel, Oct. 9, 2021).
Possible Measures for Manipur
We need to assume that there may be a third wave in Manipur too. Even if that may turn out to be a wrong anticipation, it's better to err on the side of caution. Accordingly, we must initiate measures to squarely face a possible third wave in our state. These may include:
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Preparations for administering vaccines to kids in Manipur & booster shots to high-risk people (elderly, healthcare workers and people with weak immune systems).
Conducting immediate seroprevalence studies to understand what percent of population in Manipur and in its different districts are still susceptible to the coronavirus.
Speeding up vaccinations in a big way; aggressive vaccinations with monthly targets to cover all eligible population with first doses in the next few weeks (4-6 weeks); and targeted vaccinations of all adult population with second doses in the next 2-3 months.
Regular & repeated COVID testing in hotspots.
Enhancing the ratio of RT-PCT to Rapid Antigen Testing (RAT).
Weekly "awareness messaging" about the pandemic to the public by a designated healthcare official.
Genomic sequencing of a subset of positive cases and surveillance of the variants including the delta variant: which COVID strains are there in Manipur, where are they, and where are they moving towards; and whether any new variants are emerging.
Contact tracing and government-monitored isolation of positive cases, wherever feasible.
Boosting up healthcare provisions such as medical oxygen plants, tankers and cylinders; steroids, antifungal drugs, oxygen concentrators, ventilators, oximeters, masks, PPEs, sanitizers etc.
Strengthening of healthcare infrastructure such as construction of new COVID hospitals.
Provision of more COVID care centres (CCCs), more Covid beds and ICUs in existing hospitals
Constitution of a special taskforce for the third wave; a separate taskforce for pediatric COVID is also highly recommended.
Special provisions for kids such as pediatric hospitals, wards, and ICUs, pediatric oximeters, concentrators, and ventilators and strengthening of staff such as pediatricians and pediatric nurses and paramedical workers etc.
