|Year : 2020 | Volume
| Issue : 3 | Page : 16-19
COVID-19: End game
Shruti Vashisht1, Sanjay Rai2, Sougat Ray3, Vivek Phutane4
1 PhD Scholar, Centre for Community Medicine, AIIMS, New Delhi, India
2 Prof & Nodal person for HIV sentinel Surveillance, AIIMS, New Delhi, India
3 Prof, Community Medicine & SSO (Health), HQWNC, Mumbai, India
4 Assosciate Prof, ACMS, New Delhi, India
|Date of Submission||11-Aug-2020|
|Date of Decision||16-Aug-2020|
|Date of Acceptance||22-Aug-2020|
|Date of Web Publication||09-Oct-2020|
Dr. Shruti Vashisht
Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
The COVID-19 pandemic has swept the entire world in a few months' time, much faster than any epidemic before. The scientist, doctors, and politicians worldwide are fervently working round the clock to bring an end to this pandemic which has otherwise stalled the lives of the populations. In the absence of any reliable treatment or vaccine, nonpharmaceutical interventions are presently are the mainstay to prevent and possibly end the COVID-19 pandemic. The development of herd immunity either through natural infection or induced through vaccine can bring down the epidemic. However, it may take a few more months before the normalcy returns.
Keywords: COVID-19, end game, herd immunity
|How to cite this article:|
Vashisht S, Rai S, Ray S, Phutane V. COVID-19: End game. J Mar Med Soc 2020;22, Suppl S1:16-9
| Introduction|| |
A single question ringing in the minds of the entire humanity today, “Is there an end of the present COVID-19 situation?” Moreover, for the first time worldwide, the astrologers and medical pundits are unable to come out with any specific answer. To the ongoing trials for various vaccines and therapeutic drugs, to the prominent Yog Guru's in India coming up with apparently 100% treatment drugs, the endeavor is on, how to end this pandemic. The first case of COVID-19 in India was reported on January 30, 2020 and the number of cases continues to rise. As on August 2, 2020, 08:00 IST there had been a total of 1,695,988 and 36,511 deaths in India. India has become the worst-hit nation by the COVID-19 pandemic and to predict when the conditions will be back to normal is very difficult.
SARS-CoV-2 the agent behind the dreaded COVID-19, emerged from China in December 2019 and was declared a global pandemic by the World Health Organization on March 11, 2020. Before this, (SARS-CoV) and middle east respiratory syndrome coronaviruses, Swine flu, Ebola virus and Zika virus have caused the various outbreaks of varying proportions. Most of these outbreaks, after the initial havoc, tend to die naturally or are generally controlled by the efforts of the global scientific and medical communities. The 1918 flu is a classic example of the ravages of a pandemic and the value of quarantines and social distancing. The flu killed 50 million to 100 million people worldwide. The victims were young, middle-aged adults, and elderly alike. After sweeping through the world, flu faded away, evolving into a variant of the more benign flu that comes around every year. However, it never ended.
| Public Health Measures|| |
Aggressive public health measures have been implemented by the countries across the world to check the growth of this pandemic. The strategy to combat the pandemic includes nonpharmaceutical and pharmaceutical interventions (NPIs). Unfortunately, the NPIs are presently nonexistent. Although various drugs are undergoing trials for the prevention or treatment of the novel coronavirus disease, yet there is no success expected in the next few months.
The NPIs are the only available options to prevent the spread of the disease. The NPIs approach has the two main measures of either suppression or mitigation. The suppression measures aim to reduce the effective R to below 1 (Ro < 1) and the mitigation measure aim to reduce the health impact of the epidemic. This arm of intervention include the components ranging from strict enforcement of lockdowns either piecemeal or in toto, personal protective measures such as compulsory donning of face masks, respiratory hygiene, hand hygiene, quarantine, isolation, and travel limitations. The overall aim of these public health interventions is to ensure social distancing, protection of risk groups like the elderly with comorbid conditions and also importantly to provide the essential buffer time to the health services which generally cannot cope with unexpected huge surges in demand.
The Government of India swiftly imposed strict measures to curb the spread of the disease. After the report of first case on January 30, 2020, lockdown was announced on March 24, 2020, and then extended for three times till May 31. Prior to this lockdown, numerous containment measures had already been imposed across the country which varied in intensity, including travel restrictions, closing educational establishments, gyms, museums, and theatres; bans on mass gatherings; and encouraging firms to promote remote work. The lockdown, on one hand, has done it's bit initially, but it has also led to most people losing their jobs, their way of life, mental peace, and emergence of the never thought before migrant crisis. The economic impact of COVID-19 has been substantial and broad-based. High-frequency indicators point to a sharp decline in the economic activity. During the lockdown, an estimated 140 million people lost employment while salaries were cut for many others. More than 45% of households across the nation have reported an income drop as compared to the previous year.
The nature of NPIs and its effect has been different in different regions of the world. The nature of NPIs required depends more on the individual national situation and cannot be a “One size fits all” solution. As per the WHO, the experience in Japan, the Republic of Korea, Hong Kong SAR (China), and other parts of China suggests that COVID-19 may be contained without substantial restrictions on the social and economic activities when the reproductive number at a given time, or R(t), remains around 1, the number of cases is low, and there is a strong mechanism for case detection and contract tracing. New Zealand on the other hand, started with an elimination strategy at a time when there were only just over 100 COVID-19 cases and no deaths. This included everything which is a part of NPIs but with increased intensity and rigor. The “go early go hard” strategy suited them perfectly fine and they achieved COVID-19 free status on June 3, 2020.
| End Game|| |
Endgame of the pandemic, involves the ideal medical ending of the pandemic. This includes either the development of an effective treatment or a vaccine. Many clinical trials are ongoing for the treatment of COVID-19. The “Solidarity Clinical Trial” is one such trial which aims to rapidly discover whether any of the drugs slow disease progression or improve survival. Over 400 hospitals in 35 countries are involved in this trial which is experimenting separately with Remdesivir, Lopinavir/Ritonavir combined, Lopinavir/Ritonavir combined with interferon-beta, and hydroxychloroquine. In the latest update of the interim trial, results show that hydroxychloroquine and lopinavir/ritonavir produce little or no reduction in the mortality of hospitalized COVID-19 patients when compared to standard of care. Thus, solidarity trial investigators will discontinue the trial's hydroxychloroquine and lopinavir/ritonavir arms, with immediate effect. U.K. mega trial called Recovery (Randomised Evaluation of COVID-19 therapy), which has been testing existing drugs as therapies for the new infection delivered widely, revealed that dexamethasone, reduced deaths by one-third in patients on a ventilator. Remdesivir, a prodrug of an adenosine triphosphate analog, with potential antiviral activity against a variety of RNA viruses has been approved by the USFDA but has shown no statistically significant clinical benefits.
Another ending of the pandemic may come around with the development of herd immunity either through vaccine or through a natural infection. The classical herd immunity level (hC) is defined as 1 − 1/R0, where R0 is the basic reproduction number. For covid-19 it is estimated to lie somewhere in the range 2.2–3.5 depending on country and region. Crude estimates suggests that herd immunity threshold (hC) to Covid-19 needs to be of the order approximately 60% for the infection incidence to be stable. Herd immunity is the mainstay of any policy when a vaccine is developed. Currently, there is no effective vaccine, but, group of experts with diverse backgrounds are working toward the development of vaccines against COVID-19. As on 31 July 2020, there were 139 Covid-19 vaccines in the preclinical stage, while 26 candidate vaccines in clinical evaluation. In India, seven vaccine candidates have been approved for the conduct of trials and are in various stages of testing. The forerunner is the whole-virion inactivated SARS-CoV-2 vaccine (BBV152) developed by Bharat Biotech International Ltd. The Phase-I trials in India have started July 2020 and it may take another substantial amount of time in months before the results are declared. However, the consequences to reaching herd immunity threshold naturally may be serious and far-reaching – a large fraction of the human population would need to become infected with the virus, and millions would succumb to it. Countries like Sweden where no distancing was enforced and only the risk categories were protected has no proof of reaching a complete “herd immunity”. The number of fatalities may have reduced but, in a pattern not dissimilar from other places where more severe distancing measures had been enforced. Therefore, establishing herd immunity through natural infection for ending the pandemic may not be an ultimate desired goal of the governments.
Medical historians and experts speak of an another kind of ending based on the experiences of the past pandemics – the “social” ending. This type of an ending takes place when the people or the populations are no longer afraid of the disease. The loss of job, dwindling savings of money and hunger, overpowers the fear of the disease. This along with gradual lifting of the lockdown and implementation of the “The New Normal” rules for various commercial organisations, the climax to the social ending begins much before the medical ending. Similar phenomenon was seen in the 1918 Spanish Flu pandemic, with people desperate to get back to normalcy after the combined trauma of World War 1 and the outbreak. However, little research, till date has been done on the long-term consequences of the 1918 catastrophe.
In India, lockdown was lifted amid a spike in the cases. Continuing with the lockdown would have come at a huge cost for the country. Furthermore, the death rate in the country has remained lower than the global death rate due to COVID-19. As on August 6, 2020, the global death rate due to COVID-19 was 3.8% and that of the country was 2.5%. Thus, India proceeding toward social end may not be a distant reality, as one can already see overcrowded roads in the metropolitans.
| Epidemiological Predictions|| |
Infectious disease modeling is an expansive field and epidemiologic models are critical planning tools for policy-makers, clinicians, and public health practitioners. These models are to infectious diseases as astrology predictions are to individual future. Thus, before reaching a conclusion on to whether they are inherently flawed or reliable solutions to public health problems, a cautious approach and understanding of the basic model assumptions are required. The models influence policy-making when there is a lack of knowledge about the natural history of the disease and also the medical resource are limited. In quest to provide an answer to the time when this pandemic ends, many epidemiologist and mathematicians have made predictions. One such time series analysis conducted by Bhalwar et al. predicts the “stabilisation” of the epidemic between July 16, 2020, and August 1, 2020, in India. They indicate this by using regression between the “ratio of cumulative total of cases detected: Cumulative cases who reached end point” and the ratio of “cases detected on that day: Cases who reached end point (cured/discharged/died) on that day.”
Prediction on the continuation of NPIs too has been done by various specialists. Specialists at Imperial College London recently projected that to avoid a rebound in transmission and reduce the number of deaths by hundreds or thousands, rolling periods of social distancing and school closures will have to be maintained through late 2021.
It is pertinent to mention here that the different scientists/experts use different models that may give different forecasts. Thus, there will be no one voice and many contrary scientific opinions may arise giving range of views for the best predicted direction of the pandemic and it's control. However, both science and modeling can provide a direction in the general area for a policy which the governments can judge best for their people.
| Stigma|| |
Snowden in his book points that humans keep repeating many of the mistakes that triggered or exacerbated epidemics in the past. The epidemics and pandemics give “rise to characteristic fears and anxieties.” They leave a legacy in their wake which gives rise to stigmatisation, scapegoating, mass hysteria, and outbursts of religiosity. The COVID-19 pandemic is said to have the largest social, scientific and cultural impact. The societies are full of examples, where the medical tenants were refused entry into house by the landlords, backs were turned on a cured COVID-19 patient standing in his own balcony, chemical spraying was done on migrants returning to their states and many more. In such a situation it is more likely that most asymptomatic and some symptomatic may avoid doctors, and their disease will go undetected. Aggressive health education may decrease the stigma. But like the epidemic itself, the natural death of the stigma may also occur when the disease happens in own or in the family.
| Conclusion|| |
Time to near normalcy, as measures to curb the pandemic take hold and scientists across toil to come up with the cure or the vaccine, is not near. The options solely remain with the people themselves, to go about with their daily routines simultaneous with the necessary precautions like social distancing measures, use of hand sanitisers and masks and saving the at risk groups. The option of going out and baring it all, letting Herd immunity and Darwin's hypothesis, “Survival of the fittest” play its part is a questionable option.
Ideally, the pandemic control measures, alongside steps to reduce impacts of the pandemic on the health system and healthcare workers, rapid and potentially large expansion of other workforce and support systems is the need of the hour.
No diseases, leading to pandemics, for example, flu or plague have ever ended. Only disease to have ended till date is “Small Pox”. Therefore, people shall have to learn to live with this disease, simultaneously removing the unnecessary social stigma etched in their minds. The governments should take lessons from more than 50 years of experiments – successes and failures – in that eradication is most likely to work when doctors, politicians, drugmakers, the media and citizens work together. As Snowden puts, Saluspopulisupremalex, public health should be the supreme law.
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Conflicts of interest
There are no conflicts of interest.
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