Interview: Prof Kian Fan Chung
‘Partial control is not the objective: total control is. One just cannot allow a single virus to lurk around’
‘Legalising cannabis beyond medicinal use is not the way forward to help curb the traffic and use of more dangerous drugs’
Our interviewee in today’s issue is Kian Fan Chung, MD, DSc., a Mauritian who is Professor of Respiratory Medicine and Head of Experimental Studies at Imperial College London, and Physician at the Royal Brompton & Harefield NHS Trust, London, UK. He heads the Asthma Consortium of the NIHR-funded Biomedical Research Unit of the Royal Brompton NHS Trust. He has also advised the Ministry of Health and Quality of Life in preparing an Action Plan for respiratory Diseases. He makes an overview of the Covid situation, commending the Public Health Services of the country for their successful handling of the pandemic to date. He shares his views on the vaccine developments taking place and the rolling out of vaccination eventually, on the need for continuing with the preventive measures, on air pollution locally, and on the medicinal use of cannabis.
Mauritius Times: Europe remains one of the regions worst affected by Covid-19, with ten of the 20 countries with the highest death count per million people being on the continent. The other ten are in the Americas. Isn’t it much safer for Mauritius to keep its borders closed in these circumstances, though that they have been partially re-opened, for a longer time?
Prof Kian Fan Chung: It was 10 months since we came to hear of Covid-19 for the first time and it is now the right time to take stock of how different parts of the world have dealt with this pandemic. At the moment, we have two extreme situations, one in countries in the Far East such as China, Taiwan and Singapore where the pandemic has been well-controlled with only cases coming in from abroad and a few local outbreaks that have been dealt with rapidly and efficiently, and the other extreme characterised by European countries such as UK, France, Spain, Italy and Germany and the US where cases are rising very fast to extremely high levels of infection.
It is pleasing to note that Mauritius remains in the first category where the infection has been effectively controlled, and one of the measures taken was to effectively close the borders, which for a (relatively) small island can be done effectively. In the UK, the borders have never been closed and neither had there been an effective quarantine system set up for those who were entering the country. Mauritius also has been effective in the setting up of centres to isolate, quarantine and treat those who had symptoms of Covid-19, with the severe cases transferred to intensive care units, a system that was initiated in Wuhan on a grander scale that has been shown to work, but this has not been done in UK or other European countries. This might be another reason why we in Europe have yet to tame this pandemic.
* Genome researchers at the University of Huddersfield and Portugal’s University of Minho have recently published their findings in the peer-reviewed journal Microorganisms, which suggest that travel restrictions across Britain and Europe seem to have been too little and too late. Does this explain why many countries are having to go for a second lockdown?
This is part of the reason but an important one. Indeed, travel restrictions in and out of the UK has really not been imposed in any way and travellers coming into the UK (residents or foreigners) were not strictly asked to confine for 14 days, and only lately they were asked to do this at home. There has been no particular surveillance set out for this. Hence, when UK residents were allowed to spend holidays in Spain and other European countries, many came back potentially carrying the virus and have likely been spreading it in their communities.
There are also other reasons why we are in our second lockdown in England at present. The first lockdown we had in the UK back in March to June (taken at least one month too late) was successful in suppressing hospital admissions and deaths, but the number of new cases of infection at the lifting of the lockdown was still high with nearly 800 daily new cases being still registered. This, in combination with people less strict in observing the rules of social distancing, mask wearing and hygiene measures, and with the government failing to provide enough Covid tests and an effective contact and trace system, meant the number of cases started to accelerate towards the end of September, three months after the lifting of the earlier lockdown. Hence the second lockdown, which was (again) delayed and should have been taken earlier.
* It would also appear that most of Africa and Asia, on the contrary, have reported less Covid-related deaths; the ten with the lowest death count per million are in these parts of the world. Would this have to do with a favourable biology or with these (developing) countries’ capacities to deal with pandemics more effectively?
The number of new cases and death rates from Covid-19 in Africa have been lower than the rest of the world. There are potentially a number of reasons for this. First, most African countries took quick and drastic actions such as the introduction of public health measures and lockdown. Second, there was a high level of acceptance by the public of these measures in a continent that has the youngest population where the median age is only 19! Finally, the usual high temperature and reduced humidity of many African countries do not favour the spread of Covid-19.So there has been both effectiveness in dealing with the pandemic, and favourable conditions for the virus to be less effective in infecting and in causing severe illness.
In Asia, the results have been mixed. There are countries such as India where the spread of the virus is ongoing but with a relatively high death rate although this is disputed. The recent surge in India particularly in New Delhi has been linked to the high level of pollution.
In China, where the virus originated, extreme swift measures were taken to control the infection. The experience of the previous SARS epidemic in 2004 was also a help in galvanising action in China. There was also the setting up of hospitals to isolate, quarantine and treat all those who had symptoms of Covid-19 helping to restrict spread of this very contagious human-to-human transmitted and dangerous virus that killed particularly the elderly vulnerable people.
* The questions that are on everybody’s mind are how much longer will it take to develop a safe and effective vaccine, and secondly whether we’ll be out of the woods once this is done. What do you think?
The important emphasis is on the safety and effectiveness of any future vaccine. There are intense activities going on in developing vaccines in US, Europe, Russia, India and China, and the most advanced ones in Phase III trials now are in China (Sinovac, Sinophan, CanSino), in US (Moderna, Pfizer) and in UK (Oxford University with Astra Zeneca). Initial results are going to be available in early 2021. One British minister in the UK suggested having the vaccine in the UK by Easter (April) next year. The big issue is the effectiveness of the vaccine.
The AstraZeneca, Pfizer and Moderna protocols revealed that their trials are designed to test whether their vaccines reduce cases of symptomatic Covid-19, not cases of severe disease, such as those that require hospitalization and can end in death. The hope is that there will be at least 60% of prevention of being infected. Is this sufficient? One does not know and we will have to see.
Will it be the 100% solution? Will have to wait and see. Hopefully. In addition, it will take time to provide any effective vaccine to the whole population. So, I foresee that we will still be emphasising the precautions that we should all take to reduce the risk of infection and who knows whether this will allow us to go back to some modicum of ‘normal’ life again. Individually, we would still have to abide by the rules of social distancing and mask wearing.
* One would assume that some particular groups of persons – frontline health-care workers, the elderly and those who are more vulnerable to serious illness – will get priority access to that safe and effective Covid vaccine once developed, produced and distributed, and initial supplies are going to be limited. It’s going to be a long wait for the rest of us, right?
Priority lists are already being discussed and finalised at various levels such as at WHO and at governmental levels.
The US National Academies of Sciences, Engineering and Medicine has proposed first to vaccinate health care workers at the frontline, then people with certain conditions that put them at high risk of having severe Covid-19 disease and older adults, then essential service workers at high risk of exposure, people in homeless shelters and prisons and older adults and with underlying health conditions.
In the UK, the Prime Minister has announced that the vaccine will be broadly reserved for those adults above 50 years of age, particularly health workers at the frontline and care home workers and the vulnerable particularly with medical conditions, with the oldest getting priority.
* In the meantime, what precautions should one take if one needs to travel?
To stay safe when you travel particularly on an aeroplane, one needs to obey the usual rules of maintaining social distancing as far as possible, wearing a cloth face mask, avoiding contact with anyone who is sick, limiting contact with frequently touched surfaces, such as handrails, elevator buttons, and using hand sanitizer or washing hands.
In the airplane, the quality of the cabin air is good, with the air that enters the plane consists of 50% air from outside and 50% air that is recycled through very efficient filters.
* Despite being tenth most densely populated nation in the world, Mauritius has done rather well in fighting the Covid virus. What does this say about our public health system and its level of preparedness to face the Covid pandemic and indeed future ones?
There is no doubt that Mauritius has done well and, like China, has not recorded any new cases of Covid infection for several months with all new cases occurring in those arriving into the country. However, it is not time to lower the guard yet. Controlling the borders is key for Mauritius. Also surveillance needs to continue so that any potential outbreaks can be dealt with rapidly and efficiently.
The population also must be reminded to follow the rules of social distancing. Overall there has been an excellent level of preparedness, and Mauritius followed closely the successful experience of China in controlling totally the infection. Partial control is not the objective: total control is. One just cannot allow a single virus to lurk around. Within the total control situation, it becomes easier and safer to allow economic activities to resume.
* On the other hand, you have been quite outspoken about the closure of the Promenade Roland Armand along Vandeermech Street, Rose Hill, saying that this was the right thing to do in view of the traffic-related pollution in that region. Is it true that exposure to air pollution has more serious health effects than previously thought?
The reason I was pleased that the Promenade Roland Armand was closed was that it does not make sense to exercise in a polluted environment.
In 2018, we published work in The Lancet which showed that the respiratory and cardiovascular benefits derived from exercise such as walking were annulled by doing it in a polluted environment such as walking along the busy Oxford Street in London (Lancet. 2018 Jan 27;391:339-349), results that were picked up in many newspapers round the world.
The destruction of the trees on the Promenade would have increased the exposure of any walkers/joggers to the pollutants. So, advising the public to use alternative greener facilities for their exercise was reasonable, but as far as I know, there has been no measurement of the pollutant levels in those recommended areas. This is something that has to be done.
Yes, there is increasing evidence that air pollution not only affects our respiratory and cardiovascular systems. Reports are now coming through with potential effect on cerebrovascular disease and neuropsychiatric diseases, with interference with children’s academic performance at school. This is on the basis that the fine particles found in pollution can cross into the brain directly.
Fine particles of pollution can also transfer across the placenta to the baby in the womb and can therefore damage the baby. There is also the possibility that pollution contributes to the obesity problem in China. More recently, there has been the observation in the US that those who live in highly polluted environments have a worse outcome if they catch Covid-19 infection. These are worrying but these reports need confirmation.
* We would like to think that the air we breathe in Mauritius is far less polluted than what obtains elsewhere despite the increasing number of vehicles on our roads. Is that indeed the case?
I have very little information regarding the levels of pollution that exists in Mauritius. There are currently no air quality monitors set up in Mauritius, although I understand that the government has agreed at the last parliament sitting to set up a number of stations for this purpose. What I am alluding to is the website run by the World Air Quality Index project at https://waqi.info/ where one can see the level of pollution in all parts of the world. As of today, for example, many sensors in London are indicating an unhealthy level of pollution, while the sensors in Reunion island are all indicating a ‘good’ level of pollution that would not be harmful to healthy as well as those with chronic health conditions such as lung or heart conditions.
The other issue that my research is in fact showing is that one needs to measure the pollution exposure at an individual level. The amount of pollution that we get exposed to is dependent on our personal lifestyle, on the mode of transport we use, on the work we do, etc. It is also clear that there is not just traffic-related pollution, but there is also pollution in buildings and at home. Levels of personal pollution exposure can now be measured by wearing personal pollution monitors, which my team is doing in a research project called INHALE we are doing in London (https://www.imperial.ac.uk/earth-science/research/inhale/).
Therefore, because of these two issues, the answer to your question is we do not know. I would hazard a guess that pollution in Mauritius is likely to be a problem for many Mauritians, and we cannot be certain how much this affects Mauritians without having measurements of pollution done and also without knowing how much personal exposure to pollution is present.
* We understand that you have also supported the idea of legalising cannabis for medical use in Mauritius. What does the evidence say about the benefits to patients?
There is a place for the legal use of medicinal cannabis.
In the UK, medicinal cannabis can be prescribed by specialist doctors on a case-by-case basis for only certain health conditions notably for certain forms of epilepsy in both children and adults, in those who have received chemotherapy for treatment of cancer that is causing nausea and vomiting, and those with multiple sclerosis condition who have muscle stiffness and spasm.
Medicinal cannabis is used as a last resort in these conditions when other conventional treatments have not helped. Products containing cannabidiol (CBD) are not considered illegal in UK so long as they contain only traces of tetrahydrocannabidiol (THC) which is the main psychoactive component of cannabis.
* The challenge that Mauritius is presently facing in that area is the prevalence of drug use and trafficking in the country. Do you think we should go farther than the legalisation of cannabis for medical use to help curb the traffic and use of more dangerous drugs?
My personal opinion is that I don’t think so. I feel that the answer lies in tackling the source of drug trafficking, but I recognise that this major problem of drug use is a complex issue with many deep-seated societal aspects. However, I do not believe that legalising cannabis beyond medicinal use is the way forward.
* Published in print edition on 10 November 2020