Vaccines and Therapeutics
Covid-19 vaccines have reduced significantly severe disease, hospitalisations, and deaths. Preliminary findings show that boosters are more effective against the Omicron variant compared to the primary series of mRNA, viral-vectored, protein and inactivated vaccines, although there are unanswered questions about the sustainability of the immunity.
There is also data that immunity from prior infection is insufficient against Omicron but may protect against severe disease and death. It is important to remember that individuals’ immunological responses vary.
There are still unanswered questions about Covid-19 vaccines. What is the optimal dosing interval? What is the optimal combination and schedule? Is there an effective prime/ boost regimen when combining vaccines? Would these answers be available, as soon as possible, from local scientists, through focused research? Or would Malaysia have to extrapolate from studies in other countries?
There are several effective therapeutics e.g., remdesivir, dexamethasone, monoclonal antibodies available against earlier variants including Delta. However, all but one of the monoclonal antibodies are ineffective against Omicron, requiring redesign.
Reports of the availability of oral antivirals like Molnupiravir and Paxlovid have raised hope and expectations. However, there are issues with these medicines that have yet to be resolved like severely limited supply, even in developed countries; inadequate coordination between testing and treatment; monitoring for emergence of virus strains resistant to treatment; and pre- and post-exposure prophylaxis.
Malaysia implemented its Covid-19 vaccination months after other countries in the Asia Pacific did. Hopefully, the lessons from the delay would not have been lost on policymakers.
The need for continuous attention, monitoring and action on next-generation Covid-19 vaccines and therapeutics has to be reiterated. In addition, improvements in the regulatory processes are needed.
The concerns of the vaccine-hesitant have to be addressed with more needed to be done to persuade them to get vaccinated.
Vaccine mandates continue to be a contentious issue globally. Decisions will have to be made about whether to have vaccine mandates and, if so, the circumstances in which they are applicable e.g., health care settings, school attendance.
Public and health care professionals need communication from the authorities, who should let their experts talk about updates, goals, and plans.
Similarly, communication from the ground is needed. Public and health care professionals need their questions answered. But, more importantly, policymakers need to hear the perspectives from the ground.
Whilst there will not be agreement always, the authorities need to listen to the frontliners. Listening is different from hearing as it requires effort that is active, intentional, and focused. The issue of risk communication was addressed in an article written at the beginning of the pandemic.
The risk communication by the authorities, since the pandemic began, left much to be desired until the current health minister took office in late August 2021. Since then, there have been marked improvements in the quality of ministerial statements.
However, those involved in making public announcements should take heed, internalise, and emulate the principles and vignettes in the World Health Organization’s January 2018 document “Communicating risk in public health emergencies”.
Covid-19 exposed the chasms in Malaysian public health. There were, among others, limited personnel, imprecise data on disease spread, very limited genomic surveillance, imprecise projections, and use of data from other countries that may not be generalisable. All these factors contributed to threats to lives and societal functioning.
The delay in the recognition that Covid-19 was a public health problem was reflected in the clinical response in the first year of the pandemic. This contributed to the disastrous numbers in the second year of the pandemic.
The whole-of-society collaborative concept was spewed ad nauseam in the first year of the pandemic. However, the implementation and non-compliance to non-pharmaceutical intervention (NPI) measures and the behaviours of some politicians undermined public trust.
Going forward and in order to respond to future outbreaks, there is need for real-time information systems, a rejuvenated public health workforce, flexibility, and public trust with the implementation of measures that are founded on the belief in the value of collective action for the public good.
An integrated, digital information system would include real-time electronic collection of information on respiratory viral infections, including Covid-19, hospitalisations, deaths, disease-specific outcomes, and vaccinations that incorporate socio-demographic and other relevant data. The system should include data from all health care facilities.
Data from environmental and genomic surveillance should also be included. This will facilitate the tracking of outbreaks and target containment.
The public health workforce needs to be strengthened considerably with inclusion of personnel from non-traditional sources like teachers and volunteers from non-governmental organisations.
The latter could be trained in the administration of testing; vaccination; adherence to ongoing treatment for common infectious and non-communicable diseases; and delivery of other public health services to the vulnerable and homebound.
School health services need to be strengthened to meet the unmet public health needs of children and adolescents. This would necessitate adequate funding and staffing.
Measures that improve ethnic diversity and cultural competence of the health care workforce will help to alleviate disparities; improve outcomes and rebuild public trust more widely.
Standard Operating Procedures
The government announced on October 18, 2021, that the 181 standard operating procedures (“SOP”), which have been condensed into one SOP with nine guidelines, was awaiting approval. However, it appears that approval is taking time.
Has the urgency waned because of the abatement of the Delta wave in Malaysia? Everyone should know that the Omicron wave is sweeping through Europe, North America, and more recently, the Asia-Pacific. It will be naïve to think that Malaysia’s Omicron wave will be mild.
Whilst considerations are being given to the removal of restrictions, it should be staggered with particular attention given to what is an acceptable national/ state risk level.
Acceptable Risk Levels
The goal has to be “living with Covid”. The eradication or elimination (“zero Covid”) strategy adopted by China is not a practical possibility in Malaysia now. There was a window of opportunity for such a goal at the beginning of the pandemic, but that is gone.
Infectious diseases cannot be eliminated when there is limited life-long immunity following infection or vaccination or non-human infection reservoirs.
The majority of Covid-19 infections are asymptomatic or mildly symptomatic. Its short incubation period precludes targeted strategies. It does not appear that there is life-long immunity to Covid-19 following vaccination or infection.
The current vaccines prevent severe disease and hospitalization. Breakthrough infections can occur in those who completed their current vaccination schedule.
“Endemicity”, like “herd immunity”, are the two most misused terms in the pandemic.
Endemicity is the “new normal”. This means that Covid-19 has to be accepted as an infection that is always present in the population just like all other respiratory viral infections e.g., rhinovirus causing the common cold, influenza, respiratory syncytial virus (“RSV”) etc.
Endemicity does not equate with no cases or that Covid-19 is harmless. Covid-19 will be just like dengue and malaria, which are endemic in Malaysia, with cases occurring all the time with spikes at times, the numbers of which do not usually overwhelm the health care system. The public have lived with the threats of these infections, although more could have been done to reduce their individual and collective risks.
This was well summarized by Aris Katzourakis, an evolutionary virologist at Oxford University: “Stating that an infection will become endemic says nothing about how long it might take to reach stasis, what the case rates, morbidity levels or death rates will be or, crucially, how much of a population — and which sectors — will be susceptible. Nor does it suggest guaranteed stability: there can still be disruptive waves from endemic infections, as seen with the US measles outbreak in 2019.
“Health policies and individual behaviour will determine what form — out of many possibilities — endemic Covid-19 takes…Thinking that endemicity is both mild and inevitable is more than wrong, it is dangerous: it sets humanity up for many more years of disease, including unpredictable waves of outbreaks. It is more productive to consider how bad things could get if we keep giving the virus opportunities to outwit us. Then we might do more to ensure that this does not happen.”
An informed decision has to be made on what is an acceptable national/ state risk level of viral respiratory diseases, including SARS-CoV-2. This level should reflect the community prevalence, hospitalisations, deaths, hospital bed capacity, and health care workforce.
Such national/state levels would enable decisions on planning and the timing of emergency mitigation measures.
It cannot be stated that Malaysia is now in an endemic state with SARS-CoV-2. Viral spread has not stabilised. There are still swings nationally and in certain states. Societal disruptions have not disappeared.
When the country reaches an endemic state, the virus will not make an announcement although some politicians may try. Endemicity will happen gradually, and no one will know until it has passed.
Despite Covid-19, there has been no concerted attempt to institute the necessary reforms to address severe defects in the health care system. Without a strategic plan for the “new normal” with endemic Covid-19, there will be unnecessary morbidity and mortality, widening health inequities and substantial economic loss.
The resources needed to build and sustain an effective health infrastructure will be substantial. Policymakers should not only consider the costs but also the benefits, including lower morbidity, fewer deaths and lost productivity from Covid-19, all infections, and non-communicable diseases.
Is there a political will to act? Or will the status quo remain?
Dr Milton Lum is a Past President of the Federation of Private Medical Associations, Malaysia and the Malaysian Medical Association. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.
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