Interview: Dr P. Chitson – Physician
‘A daily count of more than 2 deaths per million puts us in the highest category!’
* ‘We don’t know yet whether a fourth dose would be needed and it seems that mixing vaccines gives better results’
* ‘Already schools have been closed, but we need more targeted restrictions’
Dr P. Chitson, Specialist in Internal Medicine, is a physician with wide experience in the public and private healthcare spheres in Mauritius for nearly 40 years. He was instrumental in setting up the NCD Unit (1987) in the Ministry of Health and was responsible with the overseas teams of experts for the organisation and conduct of the several surveys that have been carried out since. He has been following very closely the Covid-19 pandemic from its very beginnings and keeping up to date with the latest all aspects of the disease. He shares with our readers his views on the evolving situation.
Mauritius Times: Despite all the global efforts that have been underway ever since Covid-19 burst on the world scene, it would appear that the virus remains undaunted in its march. Are we winning or is Covid winning?
Dr P Chitson: In the past, humanity had faced many pandemics which decimated many human societies, especially isolated indigenous populations like in the Americas where more people died from viruses than armed conflicts. With natural selection and ‘some form of herd immunity’ most pandemics became endemic over time, after many years.
Humanity had managed to eliminate only a few viruses, notably the smallpox. In a way we have been lucky that with molecular technology we have been able to identify quickly the gene sequence of the virus and that vaccines have been produced in record time. In a war there are always casualties but if the world had a more unified approach in the fight against the virus especially more equity in vaccine distribution, the Covid-19 pandemic would have been more rapidly controlled.
Rich countries will eventually control the virus but what will happen in poorer countries is the great unknown as we still don’t know if the virus will become more lethal or peter out.
* Right from the beginning of the pandemic there have been controversies about its origins, treatments and then about vaccines. The only constant has been the sanitary measures. As things are at present, have we gained more clarity about the various modalities proposed to contain the pandemic? What will help us gain such clarity?
The way the virus is evolving and adapting to many hosts suggests that the virus has been around for some time now in the past in the animal or human kingdom, probably since some years! Initially it was thought that the main mode of transmission was through droplets and direct contact but with the Delta variant aerosol (through tiny droplets in the air) transmission might be the more important factor, thus the need for proper ventilation of closed spaces, like public transport, offices, restaurants, crucially our own home and crowds where people talk and sing!
To the chagrin of many countries, especially in Europe (Denmark, UK), which only stopped sanitary measures a few months ago, another wave is in the making and WHO is giving dire warnings that with winter approaching, by next year half a million people may die in Europe.
Too much hope was put on vaccines; even the supposedly best ones (mRNA) started to lose their real-life effectiveness after 3-4 months, their effectiveness against catching infection for the Delta variant is only 50% and effectiveness against mortality is less than 70%. So, a booster dose will be needed for ALL vaccines.
Mauritius started immunization in February this year and now we are seeing another wave due to the Delta variant and waning immunity of the vaccines. In Mauritius, because the absolute number of deaths from people who have had Sinopharm (inactivated vaccine like Covaxin, both approved by WHO) is higher, the tendency is to think that this particular vaccine is less effective against death than the Western ones.
However, this might not be the case – there are more absolute number of deaths from people who took Sinopharm simply because the population inoculated with Sinopharm is much larger than the population inoculated with other vaccines. On a relative basis, it is possible that the mortality rates for both vaccines are not too far apart.
Real life data from Chile and other countries in South America which used mainly Sinopharm suggest that a third dose of the vaccine is having good success. Similarly, Israel which started vaccination late last year had another wave after 5-6 months despite two doses of mRNA vaccine and resorted to boosting their population with a third dose of Pfizer vaccine, again with marked decline in infection and mortality. Singapore is facing a similar situation with around 4000 cases per day.
We don’t know yet whether a fourth dose would be needed and it seems that mixing vaccines gives better results. Fortunately, more types of vaccines, nasal spray or oral vaccines might be available in the future. Theoretically nasal spray vaccine would be better as it stops entry of the virus through the nose and other mucous membranes and thus prevents the virus from reaching the lungs where the most damage is done.
Monoclonal antibodies and drugs have now been shown to be effective in controlling the virus but again poor countries might not benefit from these expensive drugs anytime soon and the virus might also develop drug resistance.
* Why is there so much variation in the outcomes to response in various countries? Does this point to the need for a more uniform approach globally, or is this a utopian goal?
Vaccine diplomacy, lack of consensus even within countries (antivax fake news), unwillingness of Big Pharma in sharing technology and political factors are the main stumbling block. Cultural cohesion and good governance help. Finally, some people especially the elderly and people with co-morbidities don’t respond well to vaccines, and it has also been found that genetic factors also play a role in mortality from Covid-19. However scientific publications will guide medical interventions, are more reliable and peer reviewed.
* Can we expect an end to the pandemic as was the case for influenza H1N1? How long do you expect that this can take?
The H1N1 virus type was already here many years ago – this means that the elderly had some immunity and that was why young people were most affected. After a few years, with vaccination and ‘herd immunity’ the virus had become less lethal and is now endemic in the world but all the known viruses should be under surveillance.
I suspect the same will happen to Covid-19, but more importantly I think trade in wild animals should stop and that countries should work together in preventing new pandemics that could be just around the corner.
* Is it going to be vaccines only, treatments only, sanitary measures only – or a balanced mix of these? Who or what will help to achieve this balance, if this is the way forward?
A bit of humility will help scientists, politicians and academics in the ‘science’ of Public Health. We need all the above measures mentioned in your question, but we should not forget that health is feeling well physically, emotionally and spiritually! A happy, fit and properly nourished person has been shown to have excellent immunity to diseases. Harmful habits like smoking, excessive alcohol intake, lack of exercise and obesity are risks factors for severe Covid complications.
* There is no denying that the local situation, with the surge we are currently being assailed by, is almost dire. Are we today in a crisis situation?
We are now facing the third wave with the Delta variant and a daily count of more than 2 deaths per million puts us in the highest category!
* Is it likely to be worse than what we endured during the first and second waves of the pandemic in the country?
It is already worse with the high mortality and with the health system under stress.
* How have we reached here?
The surge in the UK came with the opening of schools and I suspect that’s what happened in Mauritius, plus the declining immunity due to passage of time, the Delta variant and the slow acceptance of the population for booster shots. Some form of public restrictions must be put back.
* What are some of the factors or forces that are impacting our perceptible loss of control over the spread and virulence of the virus?
Internationally there have been two extremes, one like China with zero Covid policy, and others with variable opening up policies. Viruses mutate and the world is still under siege from the Delta variant. Future mutations are difficult to predict and will be facilitated in countries with low immunization and surge in cases, and even in rich countries a substantial proportion of their population is not yet fully vaccinated with 2 doses, let alone 3 doses.
* What needs to be done urgently to reduce infections and deaths?
We are on the rising curve. In a way Mauritius has been lucky in receiving enough vaccines and the public should be encouraged to have booster doses. I think some choice must be given to the public regarding mixing the booster vaccine if there is no shortage.
However, Covid fatigue has set in especially among the healthcare personnel. Perception of risks has changed for the worst with Mauritians not following proper sanitary measures and poor communication from the authorities. There is inadequate health information and education targeting the public at large. Already schools have been closed, but we need more targeted restrictions.
* Do we have to devise new strategies and protocols, especially with regard to self-isolation in the home?
I think we need to have a telemedicine desk with trained personnel to advise people who are self-isolating at home. Most people can use WhatsApp. These patients need to self-monitor their oxygen level, just like those suffering from diabetes and hypertension. Adequate access to those medical devices must be urgently provided as they are not that expensive and are user friendly.
Proper guidelines must be circulated to the public for those who should need hospital care. We should not forget that Covid-19 increases the risk for other conditions like heart attack, strokes, renal complications and clotting problems, apart from lung complications and these should be checked for.
* As regards local resources, what more is required and how best can they be deployed and utilized?
Mauritius is one of the few countries where rapid antigen tests are sold to the public on a wide scale and are being used more and more at home, being more convenient and with less risk of contamination at Health Centres.
These tests have good specificity – meaning that if a test is positive there is more than 99% chance that the person is infected with Covid. A negative test may not rule out infection yet and a repeat test may turn out positive the next day. Already many patients have been self-isolating on their own when the test is positive.
PCR (molecular test) tests are expensive and time consuming and need to be used in specific contexts, but rapid antigen test can be used at schools, work places, health institutions and even at home as preventive measures.
* Some government institutions and private companies, both locally and outside Mauritius, are seriously considering going back to the hybrid model with home and office working. In light of the recent Covid-19 upsurge, what would you recommend?
With modern communications, work place might even become obsolete, but humans are social beings, and the office will still be important as human behaviour is quite complex. Face to face contact, body language and other aspects of human communication can only occur when we meet each other — hopefully on a positive note! But with the worse to come, work from home and ‘zoom’ meetings would be necessary to avoid a worsening health crisis.
* Published in print edition on 12 November 2021
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