COVID-19 Update: Pandemic fatigue, winter surge, reinfections, vaccine and drug hiccups

Random Musing: The column reviews the status of Covid-19 infections globally, the possible surge of cases in winter, the reported cases of Covid-19 re-infections, the possible delays in vaccine development and the Covid fatigue worldwide especially India (including Manipur).

The Covid-19 pandemic is not showing any signs of slowing down yet. As of this writing, there are about 39.6 million (396 lakh) cases of infections globally, with over 1.1 million (11 lakh) deaths (Worldometers data, worldometers.info/coronavirus, last accessed, Oct.17, 2020). India is the second worst affected country, with more than 74 lakh (7.4 million) cases of infections, and over 1.1 lakh (110,000) deaths. The daily rise in positive cases has been in the range of 60,000 or above for the past several days. Manipur's situation is quite serious and, unless all of us take strict control measures, it may reach alarming levels. Despite the government containment measures and strategies, if the public doesn't strictly abide by the recommended control and preventive measures such as wearing of masks, maintaining social distancing, and hand hygiene, and religious maintenance of quarantine/isolation SOPs, the outbreak may go out of control. Till date, the number of confirmed cases in Manipur has shot up to 15,141 cases with 11.443 recoveries, and 3587 active cases and the number of deaths stand at 111 (as of Oct. 17, 2020).

There is currently no approved drug or vaccine for Covid-19. Several vaccine candidates are in late-stage trials. A safe, effective, and affordable vaccine in wide usage may only be available by the middle of 2021 only. Meanwhile, we have to strictly adhere to standard prevention and control procedures such as wearing of masks, hand hygiene and physical distancing. In today's column, I would like to review the status of Covid-19 infections globally, the possible surge of cases in winter, the reported cases of Covid-19 re-infections, the possible delays in vaccine development and the Covid fatigue worldwide especially India (including Manipur).

The possible winter surge

Experts have warned about possible surge in Covid infections during the peak winter months (October-January). What are the reasons for the rise of coronavirus transmissions in winter season? Firstly, viruses tend to survive longer in cold and dry climate. Secondly, low humidity promotes evaporation in virus particles leading to aerosol formations that can enhance the airborne spread of disease. Thirdly, lack of sunshine depletes vitamin D levels which lowers immunity making us more susceptible to viral infections, including Covid-19 infections (Dr Richa Sareen, The Economic Times, Sep. 30, 2020). Fourthly, people tend to congregate in poorly ventilated indoor environments that increases the likelihood of transmissions among close contacts. Lastly, the winter season is full of festivities such as durga puja, diwali, ningol chakkouba, Christmas and new year celebrations during which people tend to assemble in large crowds.

Second wave: US and Europe

The second wave of Covid-19, it is reported, has already affected the US and Europe. Western Europe has been particularly hit hard. Almost all the countries of Western Europe including UK, Italy, Spain, France, and Germany have reported sudden surge in cases in the past few weeks. All these countries have imposed new control measures recently.

Israel is the first country to impose a second nationwide lockdown. UK has recently declared 3-tier lockdown. Spain has imposed strict restrictions in Madrid and surrounding areas, and France has declared strict night curfew for a month. Netherlands has imposed partial lockdowns for 4 weeks; Italy has enforced new restrictions on public gatherings; whereas Germany has announced tight new restrictions on public life to stem the spread of Covid-19.

Covid-19 re-infections

It's not very clearly known to the scientific community how long the immunity against SARS-CoV-2 lasts. Whereas immunity to measles and mumps are known to last a lifetime, that against Covid-19 seems to wear off in just a few weeks or months at the most. This leads to the scary scenario of at least a subset of people who recovered becoming re-infected, besides the burden of taking care of new infection cases. The good news is that reinfections are still rare. But cases of reinfections have been reported in the scientific literature.

The leading medical journal, Lancet Infectious Diseases has recently reported the curious case of a 25-year old man from Nevada, US (Tillett, R.L. et al. October 12, 2020; http://doi.org/10.1016/S1473-3099(20)30764-7). The patient had two positive tests, first on April 18, 2020 and second time on June 5, 2020 with two negative results in May 2020.  It was reported that the second infection was more severe than the first. Genomic analysis indicated that the two instances of infection were caused by two different variants (strains) of SARS-CoV-2, the coronavirus that causes Covid-19.

Reinfection cases have also been reported from Hong Kong, Netherlands, Ecuador, Belgium, and India. The WHO has documented about two dozen cases of Covid-19 reinfection. If reinfections become the norm, it would have serious implications for vaccine development. It's not yet clear as and when a successful comes on the scene, whether that will remain effective for long periods or if the vaccine needs to be modified at regular intervals.

The Virus and drug hiccups

There has also been setbacks in the drug and vaccine development process. Earlier, I have written about the halting of the Oxford/AstraZeneca vaccine due to  a serious ailment observed in one of the trial volunteers. Since then, the trial resumed at many sites but it still is stalled in the US. In the past week, Johnson & Johnson (J&J) has halted the phase-3 trial of its single shot vaccine of which this author has written about in an earlier column. The trial was halted due to "an unexplained illness" in one of the volunteers (Bloomberg News, Oct. 13, 2020). J&J is one of the frontrunners along with Moderna, Pfizer, and AstraZeneca in the vaccine race, besides the Chinese and Russian vaccines. Shortly after, Eli Lilly had to halt trial of its ACTIV-3 monoclonal antibody drug (of which too I have written about earlier) against Covid-19 due to safety concerns (CNBC News, Oct. 13, 2020).

Meanwhile, Russia has registered its second vaccine called EpiVacCorona (a peptide-based, 2-shot vaccine) after it registered its first vaccine, Sputnik V, on August 11, 2020 (Times Now Digital, Oct. 15, 2020). However, the acceptability of the Russian and the Chinese vaccines seem quite low as trial results are not shared in a transparent manner with the global scientific  community and they also cut the corners and rushed the development process, approving use of their vaccines even before the completion of late-stage trials. We are now left with the American (Moderna or Pfizer vaccine) or British vaccine (Oxford vaccine). But President Trump's claim to approve a vaccine before Nov. 3 US Presidential election against the wisdom of US FDA and other scientific agencies and experts have led to vaccine skepticism and vaccine opposition among a significant section of the American population.

The Catch-22 situation

Globally, the Covid pandemic is still raging. The situation in Europe and US is quite alarming. New cases may erupt in other parts of the world too. India's scenario seem relatively rosier but there are caveats too. India's Covid curve hasn't flattened yet, only there seems to be a downward trend in the Covid graph of its first wave. What would happen if, god forbid, there's a sudden surge in peak winter as the temperature drops, and the climate becomes more virus-friendly compounded by pandemic fatigue-mask-use, social distancing, crowd-avoidance and testing fatigue-, reinfections, vaccine and drug delays and SARS-CoV-2 mutations. Moreover, many experts believe that there is a possibility that the number of infections as well as mortalities may be underreported in India, especially from small towns and interior villages (one theory says that low mortality in India might be due to widespread BCG vaccinations in the Indian population (Lancet editorial, The Lancet, Sep. 26, 2020).

What should we do at this juncture is a deep conundrum. If you don't impose restrictions; the number of infections and deaths will rise, if you do, there will be economic hardships and pandemic fatigue. But we cannot leave the situation to blind chance and magical thinking. We must chalk out new strategies and plans to contain the disease and reduce the number of deaths!

Reducing morbidities and mortalities

Even if we don't have an approved drug or vaccine for Covid-19, we know a lot better about the virus and have better treatment regimens. So, how do we wriggle out of this impasse? For once at least, science and politics must walk hand in hand. We must devise new preventive, control, isolation and treatment strategies based on the latest scientific knowledge and the political, public health, and civil society leaders must see to it that these strategies and protocols are strictly enforced across all strata of society including the elites and the privileged.

Recommended four key strategies

The WHO on October 7, 2020r ecommended four key strategies to tackle the pandemic fatigue:

1. Understand people (for developing effective policies)

2. Engage people (as part of the solution)

3. Help people (to reduce risk)

4. Acknowledge and address people's hardships (for example, economic hardships during lockdowns and lack of money for testing and treatment).

Different countries and societies have dealt with the deadly virus in various ways. Sweden seemingly relied on herd immunity; South Korea on universal mask wearing, avoidance of crowds, aggressive testing & rapid contact tracing, and quick isolation/quarantining of potentially infected people/seriously sick patients; and Vietnam on clear & accurate public-health communication. Let's crunch some interesting numbers. The countries with fewer than 50 deaths per million include: Indonesia (40), Australia (35), Japan (13), South Korea (8), Vietnam & Taiwan (both under 0.5). Compare this with the case of India, 81.2 deaths per million and that of Manipur, 36.33 deaths per million (assuming Manipur's population to be 3 million)! Cogitate over a worrying statistic: Vietnam with a population of 95 million has reported just 35 deaths so far, whereas Manipur with just a miniscule 3 million population has current death toll of 111, which is likely to surge in the coming weeks and months.

The million-dollar question. What's to be done now?

To be or not to be. To do or not to do, that's the perplexing question. Till a vaccine or drug arrives, we must strictly follow the non-pharmaceutical interventions. We may easily remember and religiously observe 3 Ws and avoid 3 Cs. Wear a mask, watch your distance, and wash your hands (regularly). Avoid crowded places, avoid close spaces (with poor ventilation), and avoid close contact situations. Even though many of us considers wearing a mask as a kind of cruel joke, scientific evidence clearly points out its effectiveness in slowing the transmission. A research preprint has reported that when an infected person and a non-infected person both wear masks, the probability of transmission is reduced by up to 80% compared to a scenario in which neither is masked (Goyal, A. et al., medRxiv, Oct. 5, 2020; http://doi.org/10.1101.2020.09.13.20193508).

The silver bullet for Covid-19 is an efficacious, safe, and affordable vaccine and/or drug. But we don't have it yet. But as Derek Thompson writes in The Atlantic magazine (Oct. 12, 2020), there are "bronze bullets abound." The 3 Ws and 3 Cs are some of these bronze bullets. At this critical point of the pandemic, it's we-hoi polloi, common people-who with our (in)appropriate behaviour will determine the trajectory of Covid-19 in Manipur. Once again I humbly appeal to fellow citizens to abide by the 3 Ws and 3 Cs guidelines strictly!

In addition, the public health authorities may consider a few things, if feasible:

1. Localized, focused lockdowns in specific areas

2. Mass testing at containment zones and hotspots of infections

3. Rapid contact tracing and isolation/quarantining of potentially infected cases/sick patients

4. Weekly publications of Covid graphs with categories of infected people and mortalities

5. Strengthening of healthcare facilities

6. Timely supportive care and treatment of serious Covid (and non-Covid) cases

7. Clear and accurate messaging from a designated public health official (just one designated person) on a regular basis (say weekly, if not daily). 

Long live Manipur, and long live Manipuris!

(The views expressed are the writer's own)

First Published:Oct. 18, 2020, 10:48 a.m.

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