Insight – Endemicity and the economy, dance in the fight against diseases

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It has been 611 days since Covid-19 was first reported in Wuhan, China. As disasters unfolded, Covid-19 was truly unprecedented.

The initial response which used aggressive public health and social (PHSM) measures was presented as a compromise between lives and livelihoods.

Lombardy, Italy idealized this comparison in the early days, where a late response led to many deaths.

However, it quickly became clear that this juxtaposition was much more complex than previously imagined. The cost of transmission control was the fall of economies beyond the levels of the Great Depression and the collapse of societies under the invisible walls of the lockdown.

Nevertheless, time and science have shown the way forward. Effective governance led by the science-backed PHSM has been essential to protect both lives and livelihoods. Supporting these measures with high levels of immunization has also been shown to accelerate progress towards recovery.

While experts generally believe that the possibility of herd immunity to disease transmission remains unlikely with the first generation of vaccines, many countries have successfully started the road to recovery using this approach.

Nevertheless, the increase in mutant strains of SARS-nCoV-2 has unfortunately derailed much of this progress. Despite very little evidence to suggest immune evasion of the current circulating variants against severe disease, it has become clear that the increasing suitability of these strains is likely to allow active circulation of these strains in the immediate future.

Since Malaysia’s prevalence of the disease is between 10% and 20% of the population, full vaccination of the population is unlikely to end transmission of Covid-19 in the near future.

Assuming evidence-based disease control mechanisms are in place and vaccination rates increase, Covid-19 will likely be transformed from a rabid killer to a much less fatal flu-like illness with periodic breakouts of infection in the immediate future.

It will be the path of disease persistence, the path of endemicity. Essentially, this means that infections will continue to persist in communities, just like the flu. Therefore, it will be necessary for the public health apparatus to continue to monitor the disease with clear action thresholds and clear actions if the thresholds are exceeded.

Dance in disease control

Tomas Pueyo has suggested that the PHSM against Covid-19 is like a dance, and the first blockages, a hammer. Based on current evidence, the hammer has been our weapon of choice against the pandemic, unnecessarily putting the economy and society at risk.

If we want to succeed in crossing endemicity, we must progress to control the disease for the sake of economic and social sustainability, hence the illustration of a dance.

Finding that balance, and doing it quickly, will likely dictate how quickly Malaysia will recover from this crisis and learn to live with the pandemic.

The coordination of this dance will require a multi-agency collaboration involving the whole company.

At the center of this push must be a shift in testing strategy where testing must become a way of life. Population-level testing with the adoption of rapid tests should be continued.

Access to tests, the procedure for performing the tests and contact tracing based on the reporting of results must become second nature to the general population.

The ecosystem supporting each of these processes must be carefully constructed.

The test ecosystem must be more than just an application, it must bring the test into every living room of the population.

Testing should be supported by robust contact tracing and disease control systems. The current public health apparatus was not designed for long-lasting pandemics in large populations.

Innovation will be essential in upgrading these systems, but so will investments. Contact tracing itself should be supported by proximity-based protocols and not just location-based protocols that can quickly detect potentially high-risk contacts and quickly notify disease control teams. These applications must be integrated into an integrated and intelligent national disease control architecture.

Too many man-hours have been wasted on redundant tasks that waste valuable human resources unnecessarily.

The action thresholds, action and emergency plans prescribed can be integrated into the above architecture. These should include clear indicators that guide action.

This may include:

> Disease transmission indicators such as the number of cases and deaths and its percentage variation, the number of breeding animals, the epidemic threshold based on seasonal patterns and surveillance of excess mortality,

> Care capacity indicators such as the number of beds available in general or intensive care units, the number of health personnel infected with Covid-19 and the limit of back-up capacity, and

> Public health capacity indicators such as the number of cases with a source identified within a predefined time frame, a predefined proportion of contacts must be identified within a time frame and some must be isolated and quarantined.

These are examples of clear indicators that can be used to monitor endemic disease. These must be linked to a robust health information architecture capable of supporting and integrating all workflows in an efficient and transparent manner.

Vaccinations should also be continued aggressively, knowing that this is not a quick fix. Covid-19 is here to stay with variants and waning immunity, additional investment will be needed to protect the population from death and disease via booster doses or next-generation vaccines.

Resuscitate the economy

The whole system must be linked by a truly multidisciplinary team that would include people from all walks of life. Most importantly, the process must be transparent and with constant engagement with all levels of the company.

To improve trust, data must also be democratized and made available to the population. Communication needs to be improved, and it can only improve if trust is earned.

The economy and the links with health can no longer be ignored. This disease control framework proposed here must include an economy that works.

Contingencies must be explored and investments must be made to ensure the preservation of livelihoods.

Although there are 611 pandemic days, it is clear that the end remains elusive. With each passing day, it becomes more and more evident that damaging blockages cannot be the long term solution.

As vaccination rates rise, so do the other efforts mentioned above as we prepare to enter the era of the Covid-19 endemic. Failure to do so will result in an additional 611 days of infections, deaths, failures and tragedies.

Dr Dhesi Raja is the director of medical innovation for Ainqa and a specialist in public health medicine. The opinions expressed here are those of the author.


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