Abstract
The scourge of COVID-19 pandemic continues world over against hopes of early end. The world took a sigh of relief when the pandemic showed a decline in the European countries, but that was short-lived. These countries are now experiencing a much more vehement second wave. More than 200 countries reported a cumulative total of 61.85 million confirmed cases and 1.44 million deaths COVID-19 cases till November 2020 (WHO). Strikingly, the developed regions of the world have been affected more, with Americas 26.22 million cases, Europe 18.28 cases and East Asia 10.74 million cases. Africa and Western Pacific regions have reported relatively lower number cases, 1.49 million and 0.87 million cases, respectively. Twelve countries, namely, United States of America, India, Brazil, Russian Federation, France, Spain, the United Kingdom, Italy, Argentina, Columbia, Mexico and German have contributed more than 66% of the total confirmed cases, globally with the first four worst affected. The case-fatality rate due to COVID-19 varied widely across countries, ranging between 1% and 5%. USA and European countries have much higher case fatality rates mainly due to the higher proportion of the elderly population and associated comorbidities, as compared to low-income countries.
What the world has seen is probably the tip of the iceberg. Household surveys to detect COVID-19 cases and subsequent RT-PCR testing revealed that almost 70%–80% positive cases were asymptomatic. This fact was further confirmed by sero-surveillance studies in several countries that many more people had acquired immunity against COVID-19 due to sub-clinical and mild infections than the reported number of confirmed COVID-19 cases. As per a recent sero-surveillance study done by ICMR, India has shown that more than 70 million people in India have developed acquired immunity against COVID-19. Asymptomatic and subclinical cases have serious implications for widespread transmission and explosive progression of the pandemic.
The initial response by most countries was built on the China experience of handling COVID-19 outbreak and the guidance issued by WHO. Most countries adopted the strategy of curbing on international travel, screening of all international travellers at point of entry, countrywide lockdown and containment of COVID-19 infection through isolation, quarantine, contact tracing, surveillance and treatment. The general public was advised to avoid non-essential travel, visiting crowded places, use face mask or face cover, follow social distancing, adopting hand hygiene and respiratory etiquettes. Several countries adopted extreme measures of national lockdown. These measures were very effective in breaking the chain of transmission and slow down the spread of disease. The spread of COVID-19 disease followed the varying pattern in different countries primarily influenced by the nature of control measures adopted and the implementation effectiveness of these measures. Developed counties and large countries like India and Brazil disproportionately reported more cases.
Paradoxically the countries with better health systems reported higher case fatality rates. The clinical course COVID-19 revealed that it was more severe among elderly and persons with co-morbidities such as diabetes, cardiovascular diseases, hypertension, chronic lung diseases and cancers. The population characteristics and proportion of elderly in population and a higher burden of non-communicable diseases could have been responsible for higher case fatality rate in developed countries.
The COVID-19 pandemic demonstrated a varying pattern in different countries. In some countries, the disease is showing a rising number of cases after a decline from the initial peak. Many countries in Europe and the United States of America have witnessed a second wave of the disease. Some states in India also see a similar pattern. Is the appearance of the second wave of infection is normal epidemiologic behaviour, or is it due to complacence on the part of the community, or fatigue of the health systems and health workforce in the implementation of public health interventions to halt transmission of the disease? Initial public health response against COVID-19 was coordinated and comprehensive, which had a high level of political and bureaucratic support. It included drastic measures like complete countrywide lockdown of all activities. The full lockdown disrupted all economic activities and had a severe unintended impact on the livelihood of people and the disruption of routine health services thus long lockdowns were untenable. The countries started unlocking to normalise economic and productive activities in a phased manner. These measures slowly and consistently brought normalcy of economic activities. However, well-meaning unlock efforts which opened up economic and social activities have adversely affected the non-pharmaceutical measures such as social distancing, use of face mask, hand hygiene. The public health response of early detection of cases or suspects, isolation of infected patients, contract tracing, quarantine of healthy contacts and surveillance of influenza-like illness also suffered. The prolonged pandemic for many months leads to fatigue in already stretched health systems and the public at large also became less careful in adherence to personal prevention behaviours. The result of the dilution of efforts in the implementation of public health interventions is exhibited in the present surge in a number of new cases in many countries. This second wave of new cases has outstripped the treatment facilities created during the initial phase of the pandemic during the complete lockdown period. The hype created around the availability of a vaccine was also responsible for the laxity in the minds of people. The second wave of COVID-19 pandemic is perhaps the disastrous consequence of the complacence of health systems, and irresponsible behaviour of the communities and people.
Many countries have adopted modified lockdown and restricted movement of people to curb the second wave of COVID-19 infections. European countries have successfully adopted these measures. Some states in India are also seriously contemplating the implementation of these measures to curb a recent surge in new infections that is putting massive pressure on already strained health systems.
The international experience suggests that there is no place for complacence in implementation of containment measures against any pandemic, including COVID-19. The desired public health measures of containment—early detection of suspected cases through effective active and passive surveillance, enough testing faculties to diagnose infection, adequate facilities for isolation of confirmed cases both at home where feasible and in dedicated COVID-19 facilities, adequate management of patients following standard treatment protocol, strict adherence to preventive measures such as social distancing, consistent and proper use of face mask, hand hygiene and respiratory etiquettes. The pandemics of SARS, MERS, ZICA were contained effectively in the past with efficient implementation of public health interventions. The COVID-19 pandemic would be controlled through effective public health interventions as has been done in countries such as New Zealand, South Korea, Thailand, Australia and China.
People have come to terms with COVID-19 pandemic and aligning their lifestyle to a new normal, believing that it is going to stay, and they must learn to live with it. People are very optimistic that an effective vaccine against COVID-19 will be available soon and defeat Coronavirus. Scientists around the world are developing many potential vaccines for COVID-19. More than 10 vaccine candidates are in phase three clinical trial of vaccine safety and effectiveness. Most of these vaccine candidates have reported high levels of effectiveness ranging between 90% and 95%. However, we have to wait for a couple of more months for final results and approval for the use of these vaccines. We still do not have adequate information on the number of doses required for the development of immunity, the route of administration, temperature stability, cost of vaccines and safety.
The impact of the vaccine on the pandemic will depend on several factors, such as the effectiveness of the vaccines, timely regulatory approval, production of large quantities and mass coverage in the population. We must appreciate that vaccine do not save lives or control any epidemic. It is the vaccination program that saves lives and reduces the burden of disease in the population. Only high levels of coverage in population with a vaccine would halt the pandemic. It would require augmentation of existing routine immunisation infrastructure and the health system for effective logistics and supply of vaccine for distribution, maintenance of cold chain, ensuring affordability and enhancing acceptance along with preparing public health workforce for delivering the vaccine.
Till an effective vaccine is available, public health interventions are the only measures to prevent and control the spread of the disease. There is no place for complacence.