This set of notes and ideas is styled as a FAQ and is focused on how to understand Covid-19 better, vaccination (boosters, children), ventilation optimisation, improving home and office safety.
The information regarding Covid-19 changes rapidly and is very fluid. The pandemic is always evolving. Hence, what is said today may need to be revised tomorrow. We need to follow all of the data, science and evidence; we cannot follow only part of the evidence.
Is The Delta Variant More Severe?
There is increasing data and clinical experience to suggest that the Delta variant is not just more contagious, but more severe than the original Covid-19 virus.
There is data from the United Kingdom to show that hospital admissions are twice as likely with the Delta variant than with the Alpha variant. A recent study in Canada showed that the Delta variant (compared to non-variants of concern) had a 120 per cent higher risk for hospitalization, 287 per cent for ICU admission and 137 per cent for death.
Unpublished data from Florida, Untied States showed 3.1 to 3.8 times higher mortality rates in children and young adults with the Delta variant. Local data on deaths in Malaysia showed the huge escalation of deaths in the Delta wave — 76 per cent of all deaths so far have occurred from July to September 2021, with one in five brought in dead, one in three occurring in healthy persons (no comorbidities), and 45 per cent under 60 years of age.
Remember that this is without vaccination — full vaccination reduces your risk of severe disease or death by 10 times.
Will I Get A Breakthrough Infection After Vaccination?
There is still some debate as to whether there is real vaccine waning immunity or if Delta is evading vaccination. There has been increasing data to show that at least one in three persons who is fully vaccinated with mRNA or Adenovirus vaccines may get a breakthrough infection, and that this rate is higher the longer the time from the vaccination date.
However, the majority of the data supports the belief that mRNA or Adenovirus vaccines are still protective against severe disease and hospitalisation in the range of 85 to 95 per cent. The data for long-term effectiveness of the Sinovac vaccine is still unclear.
There is some suggestion from our local data that the effectiveness of Sinovac at preventing hospitalisation and ICU admissions is not as strong as the Pfizer or AstraZeneca vaccines.
As a higher proportion of the population is infected, we should expect that the majority of cases will begin to appear in the vaccinated (breakthrough) but will generally be mild. Vaccinated individuals clear the infection quicker, vaccinated individuals have milder disease, and vaccinated people are less contagious.
This outlines the need for universal masking and maintaining critical SOPs even after vaccination. In addition, to monitor the outbreak in Malaysia, we should also move away from looking at new cases to looking at new hospital admissions (see CovidNow website), and especially look at hospitalisation and severe disease in the vaccinated by type of vaccine.
In View Of Breakthrough Infections, Do I Need A Booster Vaccination?
We need to follow the data (see above), which suggests that vaccines are still protective against severe disease and hospitalisation. There is no evidence yet for routine booster jabs for the general population.
We cannot just rely on antibody waning studies, but must also consider cellular immunity. Using antibody tests to identify those who need a booster is of limited value.
Hence we continue to require ongoing real world data on serious illness with breakthrough infections (hospitalisation, death, long Covid). There is good data that immunocompromised individuals should receive a third dose (this is not a booster), as they do not respond well to two doses.
There may be compelling reasons to boost frontliners as any breakthrough would impair their ability to work for 10 days, which would mean losing staff at critical workplaces. We need more data on the need for boosters for the public. But those aged over 60 years with underlying health conditions who received Sinovac may benefit from a mRNA or Adenovirus vaccine booster.
We must remember vaccine inequity as we plan boosters — if we do not support other nations who have limited vaccine supply, new vaccine-evading variants may emerge and overwhelm the whole world.
Is Endemic Covid-19 Coming?
The future outcome of the Covid-19 pandemic is extremely difficult to predict, and dependent on many factors such as:
- Degree of immunity from natural infection.
- Duration and extent of vaccine protection (waning if any).
- Breakthrough infections and transmissibility.
- Social contact and behaviour, including vaccine hesitancy.
- New Variants of Concern (especially vaccine-resistant ones).
- New therapeutic options and the development of a pan-coronavirus vaccine.
- What burden of disease is acceptable, and the capacity to cope.
We hope to transition from a pandemic to endemic situation, whereby the virus is still circulating, but sufficient individuals have immunity from vaccination and natural infection to lessen transmission, hospitalisations and deaths.
The reality is probably a cyclic epidemic situation (hopefully diminishing over time) on top of an endemic rate.
However, in the meantime, those who are not vaccinated face a significant risk from the Delta variant. Of concern is a Delta pandemic among children, as seen in some countries.
How Can We Protect Our Children?
It is good that we are vaccinating our teenagers, but we need to work to protect children below 12. As the economy opens up progressively, we have seen a higher proportion of children infected with more severe illness, admitted into ICUs, and even dying.
A key initiative we need to take is to ensure the safety of all our kindergartens and schools (primary and secondary), especially with regard to improved ventilation. “Suggestions for Getting Children Back to School Safely” and “Ventilation and Air Filtration” can be found here.
The key steps to take at kindergartens and schools are:
- Improve the quality and fit of masks (remember to support children from poorer families).
- Focus on airborne transmission and optimise ventilation in classrooms with a view to have fresh air exchange occurring at five to six times air exchanges every hour per room (recommended by Harvard) or 10 l/s per person (recommended by the Department of Occupational Safety and Health (DOSH). Keep doors and windows open and use outward-facing fans or exhaust fans at the windows. Consider using portable air cleaners with good particle filters. Use carbon dioxide (CO2) monitors as proxy indicators of poor ventilation.
- Keep students in “class safety bubbles” to avoid them mixing with students from other classes, and limiting the spread if anyone gets infected.
- Consider weekly RTK-Ag testing for all teachers and students (especially for unvaccinated children in kindergarten and primary schools).
- Involve parents in decision-making in schools, by getting them to work closely with teachers to prepare schools and maintain ongoing safety measures.
Parents also need to be aware of the risk to children from adult breakthrough infections, and must continue to be vigilant at limiting unnecessary social interaction and travel for themselves and their children.
How Can I Reduce My Risk Of Breakthrough Infections? How Do We Make Workplaces Safer? What Is Safe To Do Socially?
It is very likely that all of us will be exposed or be infected by Covid-19 at some time, despite being vaccinated. We should aim to reduce the viral load we receive, as this will potentially reduce severity.
We would like to reduce our risk to other family members, especially for those older with chronic illnesses, and also our children. Some suggestions include:
- Encourage everyone to be vaccinated.
- Optimise the quality and fit of the mask you use. Add a face shield if possible.
- Work from home as much as possible.
- Consider weekly RTK-Ag tests for all staff if going to the workplace.
- Maintain online interactions for conferences and meetings to limit travel and physical interaction with others.
- Encourage unwell teachers not to go to school and give staff paid sick leave when needed.
- Improve ventilation considerably with a target of five to six air fresh air exchange occurring every hour per room (recommended by Harvard) or 10 l/s per person (recommended by DOSH). Keep doors and windows open and use outward-facing fans at the window. Consider using portable air cleaners with good particle filters. Use carbon dioxide monitors as proxy indicators of poor ventilation. Click here for more information.
- Don’t eat meals together with people outside of your immediate family, because that’s when you will unmask.
- Avoid in-dining unless the location has evidence of significant ventilation improvement.
- Don’t unmask in public and workplace toilets, which are often locations with poor ventilation, which can be improved by using exhaust fans).
- Maintain your personal fitness, keep weight optimal, and optimise the control of any chronic disease.
What Should I Do If I Have A Breakthrough Infection (For The Vaccinated)?
All of us need to be on guard against any breakthrough infection. Recognise that this may happen in one in three vaccinated persons (or higher). The key seven symptoms that are predictive of Covid-19 include loss or change of sense of smell, loss or change of sense of taste, a fever, a persistent cough, getting chills, loss of appetite, muscle aches and having a sore throat.
If you have any of these symptoms, or have been in contact with a Covid-positive person, or suspect you have Covid-19, you should immediately do a RTK-Ag test, stop working, return home, self-isolate with a mask. and keep away from other family members.
Once confirmed to be Covid-positive, you should:
- Isolate yourself in a room with an attached bathroom for 10 days with good ventilation, and opt for contactless food delivery. If this is not available or possible, then consider going to a quarantine centre.
- Those who are positive and over 60 years old and have significant illnesses (comorbidities) should consult a doctor about their quarantine location.
- Notify the authorities using the MySejahtera application.
- Inform all your workplace and family contacts (for the past five days) that you are Covid-positive. and encourage them to mark themselves as close contacts using MySejahtera and get a RTK-Ag test.
- Your workplace may need to close until testing results are back for all the staff members and surface disinfection done (unnecessary if more than 72 hours unused).
- Anyone living in the same house as you who are at high risk or vulnerable (the elderly, chronically unwell or pregnant) should consider living away from for the duration of the quarantine.
- Monitor your oxygen saturation with a pulse oximeter three times a day.
- Have a medical staff monitor your progress daily using a video chat.
- Vaccinated individuals can return to work after a 10-day isolation, without testing, as they are usually no longer infectious.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.