On 30 January 2020, the WHO’s Director General declared that the COVID-19 outbreak constituted a Public Health Emergency of International Concern. Earlier last week, nearly three and a half years later, he, on the advise of the expert committee decided to downgrade the status, and declared that it would no longer be a PHEIC, naturally there was great curiosity about what this meant for the world - particularly if people and nations could let down their guard, painfully held up for the last three years. Here, Soumya Swaminathan, former Chief Scientist, WHO and current chairperson, MSSRF, weighs in with her expertise, explaining the issue in plain vanilla terms. Ramya Kannan listens in.
Is the recent declaration by the World Health Organisation that COVID is no longer a public health emergency of international concern, a sign of hope? Or, are there layers to this?
We have not reached the end of the pandemic; what is over is the acute phase of the pandemic, which had been characterised as a public health emergency of international concern, which has now been lifted by the WHO. So it’s no longer considered a public health emergency, but the WHO Director General did warn that it is still a global threat. There are a couple of reasons for that. The first one is that the evolution of COVID is still unpredictable, we could have at any time, a variant that’s not only more transmissible but could also cause an increase in clinical severity of disease. So the only way ahead is to be prepared - continue the monitoring, the surveillance, especially the genomic surveillance, and correlate that with the clinical and epidemiological findings, to give early warning of any changes in the virus behaviour.
If at any time any country reports that they have seen a variant, or a recombinant, that has properties of increased clinical severity, then the WHO might go back again to this public health emergency situation. For the next couple of years, I would say, till this virus actually settles into a pattern, which it has not yet done, we cannot be sure of what’s next - its next form, and what it will do.
And this is why I think it’s really important to explain to people that we are not out of COVID-19, that, of course, COVID-19 is here to stay, we all know that. But we could still face some surprises, so we need to monitor and adapt our responses as the situation demands.
There are also other factors, one of which is the waning of immunity. So whatever immunity we now have today because of vaccines, and natural infection, is expected to wane over a period of time. For something like influenza, we are now used to an annual vaccine, particularly for high risk groups, and every year the vaccine’s composition changes. We don’t yet know if COVID is going to require something similar.
Are we going to need a variant adapted vaccine every year, every couple of years, particularly for the high risk groups to protect us from severe disease, or is the immunity we have today going to last us for many decades or lifelong -that question can only be answered in over a period of time.
The third variable, of course, is human behavior. During the first two years of the pandemic, people were very guarded. People wore masks, they avoided unnecessary gatherings, they minimised travel etc. Clearly all that is no longer happening. People are gathering in large numbers for social and work related reasons, there’s international travel, therefore chances that new variants will spread quickly, are also very high. So these are the reasons why we need to continue to be quite cautious and vigilant.
Will the government have to put down a policy for COVID vaccination for adults and children?
So as of now, the policy is for people to get their primary dose of vaccination, which is two doses, plus a third dose or a booster dose. This itself, in many countries, has been at a very low rate of uptake, including in India, where I think it’s under 20% for the third dose, and that even in the high risk groups, about 30 %.
We have had a number of variants in the past 1.5 years, but all within the Omicron family, and studies have shown that the original vaccines still have a high degree of protection against severe disease. But what we can clearly see now is that they don’t protect us against infection, and that many people are getting infected, reinfected, etc, with every new strain, which is a little more transmissible than the previous one.
What this is telling us is that we still don’t have the perfect vaccine that prevents infection and disease. So we still need to search for that; whether we’re going to need to adapt it every year is still an open question.
The WHO’s technical advisory group on COVID vaccine composition that is constantly monitoring not only the evolution of the virus, but also the studies which are looking at the effectiveness of different vaccines across different populations, different age groups, different demographics, will inform us whether we will need new and adaptive vaccines.
Again, there is a need for research, long term cohort studies and follow up studies in our own population, which will inform the government policy on whether we need additional boosters, which groups need them and how often.
Is there hope from the nasal vaccine - will it actually prevent infections?
That is the hope, but to prove it, we need the data. It’s a good time to collect that kind of data and in India, we saw a surge the last few weeks. If we had a number of people who’ve been vaccinated versus those who are not, we could have seen if there had been any difference between infection rates. That’s the kind of study we’ll have to do now, because almost everybody has antibodies. So you can’t do a classical vaccine efficacy study anymore. But it’s relatively easier to look at protection from infection, because that is still happening, even in vaccinated populations.
Has the issue of vaccine equity, the call to provide vaccines to all, lost steam?
Yes, I think a couple of things happened. One is that after two years of the pandemic, as people got into 2022, and particularly after Omicron, they thought that they could now live with COVID, it is just not going to be as bad and as severe; and there was fatigue. Basically, people wanted to get back to normal life and particularly to economic activity. Through the course of 2022, the availability and access to vaccines also went up dramatically. It was the first half of 2021 during which there was this acute shortage because they were limited supplies. People were desperate. And it was very hard to watch that inequity. Later on as vaccines became more available that itself produced different challenges - in some of the lowest income countries, even though the vaccine was made available, they were not able to roll it out at the scale and speed that was necessary.
Still, there is a very big gap in the percentage who have been vaccinated; the inequity persists. The reason in the beginning - poor supply , unfair distribution of vaccines - is no longer the case. Supplies are no longer limiting. There other factors which are limiting the poorest countries that have also suffered the most in terms of economic damage. They already have fragile health systems, many of them are conflict countries. And so all of these reasons is why there’s still that gap. Also, when we talk about inequity, it’s not just vaccines, but a host of other products, including antiviral drugs.
You had tweeted about not dismantling systems that have been set up for COVID. Is it okay for physical infrastructure to be repurposed into other health uses?
Countries have to move into a modality of dealing with COVID along with the other health challenges, including other infectious diseases. I think it’s a very good opportunity to not dismantle what was built, but to see how it can be integrated and streamlined, including being prepared for any emerging or emerging infections.
So one good example is the genomic surveillance network (INSACOG) that India set up, as also did other countries. We have a network of scientists who have been working together analysing the data and providing reports in real time. If this can now be integrated into a respiratory disease surveillance, or integrated viral disease surveillance network, then the capacity we have built along with the expansion of public health labs that the government is investing in can be put to good use, efficiently and cost effectively.
We should also strengthen community-based surveillance or participatory surveillance, wastewater or sewage, surveillance, and other kinds of surveillance which will pick up unusual events. Ports of entry also need to have a plan.
If these laboratories can put out regular reports to the public, on which virus is circulating, who is it likely to infect, what are the clinical features and what’s the treatment, we can also avoid the use of unnecessary antibiotics and, inform people of the right kinds of preventive methods to use.
The other aspect is risk communication. Health departments have to be constantly monitoring topics that the public is discussing (including on social media), and not be just responsive, but proactive in terms of communicating health risks. This is not just for outbreaks and viruses, but in general for health. Nutrition is a good example of where we need much more public information and massive nutrition literacy campaigns that can inform and educate people about what a healthy diet looks like.
The third is the clinical care pathway, starting from the primary health care level, and the health and wellness centres. What does a community health officer do if they see somebody with warning signs? Where do they refer the patient to, who will admit the patient? Is oxygen available?
In fact, now, I’m very happy to see that the health ministry actually has a good document on how to manage people with post COVID symptoms. That’s the kind of thing we need, we need guidance for both private and public sector, private doctors particularly need to follow protocols, avoid use of unnecessary antibiotics and steroids and drugs that are not effective.
I would like to stress the importance of diagnosing, managing and preventing non communicable diseases. People who have underlying risk factors are at much higher risk for COVID and post COVID complications.
And then, of course, we need to think about research and development, including developing more antivirals. We talk a lot about access to diagnostics, India is in a relatively much better position, but it’s one of the priorities in the G 20. We have to be prepared, as I said, for not just a new variant of COVID, but something new, a new virus, tomorrow, avian flu, anything can come along, we need to check if our systems are ready, how long will it take us to produce a diagnostic test, 0r a vaccine?
The G7 has come up with this 100 day goal - that in the next pandemic, we should have a vaccine in 100 days. So the goal is to do better than we did this time.
What about Adverse Effects Following Immunisation (AEFI)? Is it still significant to monitor that?
We are past that, I think, in the sense that we’re no longer doing active vaccination. So, I believe there is a system to record AEFI but the public may not have access to the data. The public hears only about one case, or two cases, when something bad happens, and then it’s a dramatic event. Obviously, it is very bad for the person to whom that happens. But when you put it in the context of the number of vaccines (billions) that have been administered, the incidence of serious adverse events is in the range of five to six per million.
We need to look at the incidence of these severe and serious (not minor side effects) effects like clotting that occurred with the AstraZeneca vaccine, or myocarditis with mRNA vaccines. There may be some mortality related to that, though rare, many of them recover. Then the risk-benefit ratio actually, is clearly on the side of benefit. You’re saving so many lives through vaccination. But you have these very rare side effects which one expects from any health product, whether it’s a vaccine or a drug; even if it’s 99.99% safe, there is still that one in a million case.
In fact, one of the things the WHO was really concerned about when doing the accelerated timeline for vaccines, and giving emergency use authorisation, was to scrutinise carefully, the safety data, and post roll out, there was constant updating of the safety information. The issue, of course, is that safety data comes mostly from high income countries, AEFI recording is not good enough in many countries, including low and middle income countries. So that’s what we need to improve.
It should be easier to collect such information now using digital tools like the CoWin App, and that information needs to be analysed and then presented to the public in a manner where it is transparent, but also which people understand that there is a system to monitor, and that the government will take action if anything untoward happens.
A short message for the people, what precautions should they take?
Today we have the knowledge and the tools to deal with COVID, just as we deal with many other infections. People need to use that knowledge to the best of their ability to protect themselves and their families. So for an individual, I think it means doing your own risk assessment. Do you have factors that make you more susceptible? To get severe disease? Have you been vaccinated? Have you had your booster dose, the third dose. And if you are somebody who is more vulnerable, or you have a very elderly person at home, then you would continue to wear masks, especially in closed and crowded settings. People need to know that it’s still good to wear a mask, and you must wear a mask if you are sick, if you have a cough and cold, it does not matter if it is COVID or not. It makes public health sense to wear a mask if you have a cold and cough and if you’re going out of home, so that you’re protecting others. Hand Hygiene is extremely important. These are things which will protect us from other respiratory infections, apart from COVID. So it is good practice for us. I think vaccination, wearing masks, avoiding crowded places if you think that you’re a vulnerable person, maintaining respiratory hygiene and hand hygiene, and keeping your self informed using credible sources of information are important.
