“Will we pay a health price at the expense of economic gains? Only time will tell”

Covid situation in Mauritius

* ‘For real protection against Covid-19, we need to protect 100% of the population and that is no small feat for any government’

Dr DeorajCaussy currently practises as an Independent Epidemiologist (Integrated Epidemiology Solution at drdeorajcaussy.com), after a long career working in various laboratories, including with the US Centers for Disease Control. He joined WHO as an epidemiologist and retired as Regional Epidemiologist in Asia, based in India. In this interview he gives his views on the current spate of the pandemic globally and in Mauritius, and says that there are a lot of uncertainties about various aspects such as the end of the pandemic, whether it will become endemic, the likely origin, the responses to the infection amongst others. He emphasizes that strategies and protocols must be based on and re-aligned as required according to scientific evidence.

Mauritius Times: We are now over one and a half years into the Covid pandemic, and it continues to spread in successive waves. Can you sum up the current global situation?

Dr Caussy: The global situation is a mirror reflecting each country’s political will, technical expertise, the degree of preparedness and ability to respond to an emergency. Countries from Asia like Singapore, Thailand, Taiwan had lived the first pandemic of SARS in 2003 and were proactive in their degree of preparedness and prompt in their response. This was also observed in countries like New Zealand and Australia that live under constant threat of Asian epidemics.

Other countries like UK and US, which rank amongst the top in the world for the degree of pandemic preparedness by WHO International Health Regulations, flawed badly because of lack of political will and by trivializing the severity of the virus, and paid a heavy death toll. Other nations fall in between either because of lack of preparedness, political will or inadequate infrastructure and a fragile health system or a combination thereof.

* It has made a comeback, almost with a revenge, in countries such as Israel and Singapore which were among the first to successfully control it initially. How do you explain this?

We must differentiate between different types of infections, asymptomatic and symptomatic and their associated types of illness. Typically, in a population about 30-40% of the infections are asymptomatic and for the remaining that show symptoms the disease may range from mild, moderate to severe forms requiring hospitalization. It is incorrectto look at raw numbers without analyzing them by sub-groups of age or types of infection.

A person who is asymptomatic has a subclinical infection and a person with symptoms may have a mild form of the infection resembling influenza-like symptoms. We cannot lump them all in the same category, this is where an inch of real and not pseudo-epidemiology comes into play! In reality, we are looking at two different scenarios in each country.

* Do you think there will be an end to the pandemic?

Pandemic is by definition a global epidemic; as long as there are hotbeds of active infections in one part of the world, the risk is high for the other parts of the world. History bears witness that pandemics have made and unmade empires,and caused wars to be lost.

At this point we only have couple of years of observation and scientific data on the coronavirus, its mode of transmission, its health and socio-economic impacts and ways to control it. In all honesty, it would be premature to extrapolate with certainty. My own hunch is that the end of the pandemic is not looming in the near future, it would be an unprecedented miracle of science if this were to occur.

* Some say it can become endemic, others that it may become like the influenza which surfaces annually in the winter months. What is the difference between these two scenarios, and which one do you estimate is more likely in case of Covid-19?

Endemicity means the virus cannot be eradicated, it will always be present at a given level in the communities and will require constant control measures. Influenza shows a periodicity of infection, it comes back every year with a minor mutation but then it periodically undergoes drastic mutation resulting in the emergence of a novel virus with pandemic potential.

Again, it is too soon to say which form Covid-19 will take. Therefore, we must always be prepared for the unknown that can take us by surprise; some may have wishful thinking that it will behave like influenza, but no one has the answer with certainty today. It is a trillion-dollar question!

* What is the latest regarding the origins of the Covid-19 coronavirus? Will this matter be finally settled? What are the implications if there is no definitive conclusion?

This is a hotly contested debate. Basically, there are two competing theories: animal origin or laboratory escape. It is difficult to corroborate either of these theories. While the animal origin theory has credence, as many viruses are of zoonotic origin, it does not eliminate the fact that a virus of animal origin could have been further modified in a laboratory and escaped from the laboratory.

WHO bears full responsibility for messing up the investigation of the origin of the virus at the beginning stage. Instead of exercising its power vested by the International Health Regulations, WHO played politics and lip service to China by failing to declare the virus a public health emergency of International Concern or with pandemic potential. The first WHO mission to China hadnothing but praise for the way China had handled the epidemic. Investigatingthe origin one year later is like looking for a needle in a haystack. So, you take your pick.

* What’s your assessment of the Covid situation in the country presently? Have we tamed the beast or are the persisting uncertainties about the virus hampering progress?

In Mauritius, we are in a full-blown epidemic with no respite in sight and the situation calls for extreme vigilance and precaution. We are crossing the Rubicon, we hear of covid-associated mortality frequently, we cannot let our guard down. I urge everyone, including those who have been vaccinated, to fulfill their civic duties and observe the rules of social distancing by wearing masks and not to be mis-inspired by persons who have downplayed the importance of this virus and who have set wrong examples by not practising what they advocate.

We can derive lots of information by looking at the frequency and patterns of the disease over a time period, just like a picture can paint a thousand words, an art that is acquired by experience and not by pretending. When we examine such a graph, provided courtesy of John Hopkins University (See Figure 1: Epidemic curve of Covid-19 in Mauritius), we see some sad and eyebrow-raising flagrant, disconcerting facts:

1) the virus has been lingering 2020 and it never really disappeared, despite the fact that we boasted to have rid the virus and attained a covid-free or covid safe state; 2)there is no peak yet, which implies that the epidemic is propagating and our means to control it are ineffective; 3) there are significantly higher deaths in the current waves despite our claims that we have perfected the clinical management and our boasting of implementing the most up-to-date protocol, and 4) we made glaring mistakes in managing the epidemic by not intervening at the critical moments and by ignoring sound scientific advice.

Most likely explanations of the current outbreaks are that the vaccine coverage is inadequate and non-pharmaceutical measures like wearing masks, avoiding crowds, and keeping a social distance need to be revisited to fix the deficiencies. Sadly enough, many of these complications could have been averted had we been proactive from the beginning and listened to the voice of science rather that adopt a dogmatic, tunnel vision policy of excluding, slandering, and discrediting it.

* Government is proposing to reopen our borders to fully vaccinated international travellers, in particular tourists, with no restrictions as from 1st October. From a scientific perspective and on the basis of what’s happening elsewhere, how do you view this decision?

It is a delicate and tricky act to balance the health risk to economic benefit ratio since health and economic development are interrelated: a healthy nation is a productive nation and conversely a productive nation is a healthy nation.

Many governments around the world have taken this bold step of opening the borders but they have erred on the side of caution. Consider countries like France, UK, or Canada – they have ensured that their population, especially the vulnerable ones, are fully protected through vaccination, education, and provision of adequate medical care for those who get the disease. In these countries, the health systems have been revamped to ensure proper surveillance, monitoring and provision to cope with surge capacities. They have also taken steps to reduce mortality by providing prompt and appropriate medical care. Are we at this level in Mauritius? Will we pay a health price at the expense of economic gains? Only time will tell.

* There is also the issue of the efficacy of the different vaccines being administered in the country against the variants that would have reached the country. What’s your take on that?

There is a plethora of vaccines in the global market, and we have been tardy in choosing and procuring the right vaccine since we placed an over-reliance of the WHO Covax facility that ended up being a tragic disaster for Africa and Latin America. We have not been spared either as our vaccine supplies are varied – while some have undergone rigorous scientific testing, others are still awaiting international approval. It stands to reason that the efficacy of the vaccines will reflect the types of vaccine we use.

Variants are always a source of concernin vaccine efficacy; the sudden emergence of a variant can destroy a vaccine strategy. Luckily, to date the Pfizer, AstraZeneca and Moderna vaccines are showing protective effects against all hitherto identified variants of concerns, as supported by the British cohort study. This is a fast-emerging field, and we cannot etch our strategies in glass; we must be flexible to incorporate new knowledge in designing our control strategies.

* In view of the appearance of the variants of the coronavirus here, would it suffice to have 60%-70% of the population fully vaccinated for us to reach the herd immunity that is presently thought necessary to cope with the pandemic?

Herd immunity is an outdated, archaic theory that has no place in controlling Covid-19. Herd immunity theory holds for a disease with a single causative agent that does not undergo mutation, but this is far from true for Covid-19. For real protection against Covid-19, we need to protect 100% of the population and that is no small feat for any government.

If that is not possible, then one should strategically immunize the most vulnerable population first; unfortunately, this was not adopted in the initial vaccination phase locally. We missed a golden window of opportunity to protect the most vulnerable groups and we can all bear witness to the sad and tragic results now.

* In the UK, the Joint Committee on Vaccination and Immunisation met last Thursday to examine interim results from the Cov-Boost study, which looked at the “impact of one of seven different vaccines as a third dose, on top of either the Pfizer or AstraZeneca vaccines”. Do you think Covid vaccine booster shots necessary in the local context?

Again, we are skating on thin ice! We do not have all the information we need. In precautionary principle, we err to protect lives and livelihoods and not solely for economic gains. Many diseases like pulmonary pneumococcus infection or varicella zoster require a booster dose in the elderly and those with immunological deficiencies. So, administering a third booster dose, under recommendation of an independent panel of experts, would be a prudent strategy to undertake.

* Finally, there have been complaints and criticisms about the way the dead are being disposed of, particularly regarding the respective intimate families being denied the possibility of seeing their loved ones or attendance at the funerals, conduct of last rites, etc. Do you have any suggestions that would meet both public health safety criteria and the wishes of the grieving families?

Death is the final stage of parting and every culture and religion have their beliefs and rituals that permit them to cope with the grief.

I personally as a virologist and an epidemiologist, have serious reservations about the infectivity of dead bodies from SARS-CoV-2 virus that is predominantly, if not exclusively, transmitted by air or droplets. A dead person does not breathe and is not spewing loads of virus in the air. The Covid virus is not found in swarming number on the body. So, the risk of transmission is minimal if one observes the elementary principles of public health. Now for a virus like Ebola it is a very different situation because the virus is found on the body of the dead person and is transmissible during performance of rituals. Covid-19 is not Ebola!

Paradoxically, with proper training and education, we have been able to reduce the risk of transmitting Ebola during burial to the extent that the bereaved families can participate. Both the international and local authorities should take a serious look at this by conducting a meta-analysis of the existing evidence to formulate an evidence-based policy that strikes the balance between socio-cultural needs and public health protection.

* Published in print edition on 14 September 2021

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