Mainland China is passing through a critical phase in the health emergency, more severe than in early 2020, as the country of origin of SARS-CoV2. In the absence of reliable data on the toll on human health and lives, rough estimates 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 the uncertainty regarding continuation of the benefits of relaxation in COVID-19 norms and measures to prevent further waves. It is a time to reflect, review the situation and respond to possible waves, which will differ from country to country and within regions.
A strategic experiment, China’s policy
At the beginning of the evolving COVID-19 pandemic, countries followed their strategies as little was known 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 major approaches; The first was promoting herd immunity by allowing the virus to infect everyone, which also advocated focused protection of those at risk. The biggest problem with this approach was that it resulted in many deaths of the elderly and vulnerable.
The second was to follow the other extreme, known as the zero-covid strategy, which involves not allowing a single case of COVID-19 by imposing strict lockdowns, closing borders, and travel restrictions. As vaccination rates (with effective vaccines) increased significantly, countries following the strategy abandoned it midway because it was unsustainable. These countries ramped up vaccine production, leveraged vaccination distribution and urged the public to follow COVID-appropriate behaviour.
China pursued an 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 different infectivity and virulence, China stuck to the same policy. The zero-covid strategy made the Chinese population relatively more vulnerable to the virus without better vaccines and stronger health systems. At a time when China is facing a spate of cases, it has stopped testing all infected persons and revised the criteria to identify COVID-19 deaths. Besides underestimating cases and deaths, the real concern is missing the development of new variants. The more new variants circulate and find new hosts to lodge in, the greater the likelihood of mutation and evolution into new forms. Rapid circulation in large-scale susceptible populations may result in new variants, which may spread to other areas. It is important to track genetic variations in China and study the infectivity and virulence of people in the rest of the world.
ride the rolling tide
The next concern is how the ongoing wave in China can scare other countries.
Given the understanding that only Omicron and its sub-lineage are circulating in China, it is highly unlikely that this could lead to large waves of infection or death in India. This claim stems from hybrid immunity, offered by both a higher burden of Omicron and greater vaccine coverage with the primary dose. In the past, complacency has cost countries more in human lives in addition to economic and social losses. Therefore, proactive measures taken by the government are appropriate, including a high level of commitment and review of the programme. In particular, consequential actions should focus on expanding booster coverage, strengthening surveillance, and re-orienting health systems for pandemic preparedness.
Despite high coverage, about 8% of adults missed a second dose of the vaccine, creating a large pool for infections and complications. In addition, India must ensure that the 2-3 million young adults who are added to the adult population each month are vaccinated. Those who have missed the second dose should be given priority and vaccinated through outreach activities. Furthermore, 73% of adults have not yet received a booster dose; 60% of the elderly are yet to be covered. Evidence suggests that heterologous booster doses increase the level of neutralizing antibodies. Among the available options for boosters, Corbevax and Covishield are the frontrunners for boosting antibody levels, according to data from Tamil Nadu’s Christian Medical College Vellore. The recent inclusion of an intranasal COVID-19 vaccine is exciting; We need data on how well they can increase antibody titers compared to other vaccines.
The potential for a new variant to emerge from the high-circulation ecosystem in China is a real concern. The primary need to understand this will be based on data provided by China in terms of epidemiological data, clinical features, mortality and genomic sequencing. In the absence of the reliable data needed for modelling, it is almost impossible to realistically plan for potential waves. China recently revised its guidelines to classify deaths due to pneumonia and respiratory failure among infected persons as COVID deaths. Also, the country has decided not to publish daily Covid data from 25 December.
It is unfortunate that the World Health Organization or other global powers are influential enough to ensure that China shares critical data. In the absence of data, countries are instinctively taking recourse that no possible wave could be more destructive than the largest waves due to earlier variants. While hoping for the best, it may be best to assess whether preparedness can match the hospitalization burden during earlier waves. Continued advanced efforts in genomic sequencing may provide timely information on new variants.
Shared Database, Community Participation
Management of 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 to each wave, it is time to strengthen bottom-up surveillance systems in an integrated manner to detect thresholds for various pathogens affecting human and animal health. Instead of the devastation associated with outbreaks, our options for resilient structures and human resources can be strengthened to deliver better results. India has multiple disease surveillance systems, and with considerable duplication of efforts. It is time to create shared databases and monitoring across sectors and identify new solutions that address root causes and links between risks and impacts.
Integrating and integrating efforts to balance and optimize the health of people, animals and the environment is called “one-health”. It can prevent, predict, detect and respond to global health threats. Because this approach spans many sectors and disciplines, governments must mobilize it to partner with communities to create long-term, sustainable solutions. Community engagement is also important to promote risk-reducing habits and attitudes and to support early detection and prevention of disease threats.
Giridhar R Babu is professor of epidemiology at the Public Health Foundation of India, Bengaluru