Pandemic endgame
AS WE head into the endgame of this pandemic, there are lots of considerations. To begin with, let us look back at the beginning of it all. There was a market in Wuhan that was the epicentre of the novel coronavirus and recent significant analysis reinforces that view.
If you look at the structure of the virus, it is an incredible entity with waving spike proteins on its surface that allow the spike to catch on to human lung cells easily. The spike protein itself has a stalk with a “hip”, “knee” and “ankle” that allows it to wave. If you look at computer-generated graphics of the virus, one cannot help but realise that it is truly a thing of deadly natural beauty akin to a king cobra with hood extended about to strike.
To date the pandemic has officially claimed 6.2 million lives but we also have news that WHO has declared that the number of excess deaths due to overburdened health care systems globally is about 15 million. Indeed, in Singapore we see that our healthcare system is currently burdened with all the pent-up demand that has been brewing over the last two years.
We also wonder at the speed and accuracy of our response to the virus when it came to vaccine development. From the publication of the viral genome by Chinese scientists in January 2020, I received my Pfizer vaccine in January 2021 here at home. This unprecedented speed has never been achieved and to date we have administered 11.7 billion doses in a period of 16 months. We have built a wall of vaccinated individuals numbering in the billions and yet the variants like Delta, Omicron and her sisters have just pierced through the wall with impunity.
As we learn to live and cope with the virus in Singapore, we look with mixed feelings at what countries with zero tolerance policies are doing. It seems futile to lock down entire metropolises to do massive swabbing. After all, when you swab populations in the millions, you are merely stopping infected individuals from becoming symptomatic. You are certainly not stopping the transmission of the virus.
When the original strain infected one patient, that patient will transmit it to three others. Today the Omicron will infect one patient who will then transmit it to seven others. The doubling time of Omicron is now three days compared to seven days when the virus first appeared. The fatality is also lower at 0.1 per cent or 1 in 1,000. All this results in huge numbers that have overwhelmed healthcare systems, resulting in excess deaths.
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When the virus first exploded in Hong Kong early this year, we were astounded to see more than 9,000 deaths in the first five months of the year alone. Hong Kong and Singapore both share similar characteristics, but the vaccine uptake in the elderly above 80 years old in Hong Kong was found wanting. This resulted in case fatality of 9.45 per cent in those above 80 years of age. The factors in play included vaccine hesitancy especially amongst the children of the elderly and negative press coverage of the vaccine rollout. The tale of the two cities teaches us a bitter lesson that vaccines are still the cornerstone of protection against the virus.
On top of the vaccines, we also have new antivirals available such as Paxlovid and Lagevrio (Molnupiravir). Paxlovid has been shown to reduce death and hospitalisation by 88 per cent if taken early. These drugs should be a good measure for high-risk patients -- the elderly or the unvaccinated. These will plug the gap for us in the war against the virus and, again like the vaccines, have been invented or repurposed in record time.
The majority of my patients who have caught Covid have found that their disease is mild. One still needs to know that we may have modified the disease with vaccines but it is by no means mild. We have seen patients who continue to cough for a month after the disease and when we CT-scan their lungs, we found patches. This brings to mind the question of Long Covid. The criteria for Long Covid are symptoms for a period of four weeks or more after the infection.
We estimate that Long Covid probably affects 10 to 30 per cent of patients who catch the disease. We also found that there are some patients who are more likely to have Long Covid. These include diabetics, those with autoimmune disease, and those who had reactivation of a latent virus such as shingles, and those who had a high viral load.
The commonest symptoms are fatigue, headache, loss of smell and taste, breathlessness, weakness, pain and poor sleep, in the order of most common to least common. There are two current theories about Long Covid; the first is that the virus lingers on in certain sites in your body that offer sanctuary to the virus. These include the thyroid gland, esophagus, spleen and even the testicles. The second theory involves the formation of micro clots in the blood that contain autoantibodies. The body has a clotting mechanism and also a system that dissolves clots. For some reason these microclots cannot be dissolved and circulate, causing inflammation and even bigger clots.
Hence there is data from the US Veterans Administration where the number of patients who had heart attacks, strokes, abnormal rhythms of the heart, clots in the leg veins and in the lungs grew many-fold. For these reasons, I would suggest that we keep our boosters current, continue masking indoors, and if you feel unwell after your infection, do see your doctor.
As for the endgame, what will happen to the pandemic? We can look at history: SARs faded away in 2003, polio was halted by the Salk vaccine in 1955, smallpox disappeared in 1796 by way of a cowpox vaccine, and the Spanish flu of 1918 exists today in a mild form. We have vaccinated billions of peoples in a short time, the variants continue to come but are getting more infectious and milder to survive the wall of vaccines. Our society has come to accept Covid as a way of life with recovery of economic activities. It is my hope that these dark two years will eventually fade away as a bad memory only to be recollected as valuable experience should the need arise.
This article is produced monthly in collaboration with Royal Healthcare Specialists Centre
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