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Medisina at Politika by Dr. Rey Pagtakhan  

Review of the COVID-19 pandemic experience

by Dr. Rey Pagtakhan

    trudeau jan 26 2021
Prime Minister Justin Trudeau reassures Canadians about the COVID-19 vaccine supply after the European Union raised the possibility of imposing export controls, January 26, 2021

“If the virus not only replicates but also manages to spread, human to human, among a few dozen other individuals, that’s an outbreak. If it sweeps through a community or a country, that’s an epidemic. If it encircles the world, it’s a pandemic.” – David Quammen, Spillover: Animal Infections and the Next Human Pandemic.

It has been a year of anguish and longing for optimism since COVID-19 began its global circulation. It has caused monumental damage to living and livelihoods and exacted an enormous human toll on health and life. Worldwide, the magnitude of the disease has surpassed the 100-million mark and the gravity of death has exceeded two million. Canada’s shares of the burden stand at 772,441 sickened and 19,739 deceased. These have been the grim hallmarks of this pandemic until the recent availability in Canada, USA, U.K. and the European Union of the Pfizer/BioNTech and Moderna and vaccines. Optimism has never been greater.

Let us look back on the year past to share what we have learned from our experience covering the pandemic.

A year ago, today, the Canadian Filipino Net (CanFilNet) published “Novel Coronavirus Infection: Information and Guidance” about the new respiratory disease, that emerged in Wuhan City, China on December 8, 2019 as a cluster of 11 patients with pneumonia of unknown origin. When the cluster became an outbreak of 59 patients, China notified the United Nations World Health Organization (WHO) about this new disease on December 31st.

A week later on January 8, 2020, Chinese scientists identified the viral pathogen and posted online its genetic sequence. This posting helped start the early development of mRNA vaccines against COVID-19 and, thereby, saved years that would have otherwise been needed. On January 12, the WHO confirmed that a novel coronavirus was the cause of the undiagnosed pneumonia. On January 13, the first case outside China was confirmed in Thailand on a resident who had just returned from Wuhan.

WHO declares highest public health alert

On January 30, the WHO announced it as a public health emergency of international concern.

Both CanFilNet and the Pilipino Express have covered the evolution of this globe-trotting agent of acute respiratory disease and death since our February 16, 2020 issue when we noted the initial grim statistics for China: 42,670 patients sickened, 1,018 deceased, and over 60 million residents quarantined in their homes and apartments.

Travel as the early mode of spread

The first cases seen in Canada during the first and last quarters of 2020 had come, like the first case in Thailand, via international travel: from Wuhan, Qatar, Egypt, Philippines, and the USA. One of the other two first cases came from another province and one from a cruise ship. Subsequent transmissions occurred between community members.

Early in the evolution of this pandemic, Canada’s National Microbiology Lab in Winnipeg performed the diagnostic testing for the COVID virus on samples from suspected cases sent by provinces and territories, either as the sole test or as a check of an in-province test result. The lab diagnosed the first confirmed case in Canada on January 27, 2020. Since then, provinces and territories have established their own testing capacity but have occasionally sent samples to the national lab for confirmation.

We have developed a much better understanding of the virus and the disease, which now have their official names, SARSCoV-2 and COVID-19, respectively. We have a better appreciation of its impact in all its aspects – social, financial and economic.

The severity of infection varies from mild, moderate, severe to critical based on their signs and symptoms and their need for oxygen and mechanical ventilators to help in breathing. Nearly 80 per cent of the infections are mild, including 40 per cent without signs or symptoms. The moderately severe to critical group – nearly 20 percent of the total infected – have posed a high disease burden, overwhelmed hospitals and intensive care units and health care workers, and exposed the insufficiency of protective personnel equipment supply.

It takes on average five days after exposure and almost always before the end of the 14th day to develop the signs and symptoms. This is the incubation period and it relates to the symptomatology caused by the virus, not to its transmissibility. In fact, infected people are already able to spread the virus before symptoms appear. Moreover, even those who never go on to develop the disease – the asymptomatic carriers – are contagious.

On March 12, the WHO officially declared the world’s sixth pandemic. It was the first time that a member-virus of the coronavirus family has caused a global epidemic. Within 100 days from its start, its geographic spread reached all regions of the UN health agency, six continents, and 114 countries, affecting over 100 thousand patients and causing over 4000 deaths. At this point, Canada experienced a 150-fold increase in new patients during a preceding two-week period. Canada’s whole-of-government response to the disease established the more than one billion dollar COVID-19 Response Fund to fight the effects of the virus in Canada.

All provinces declared either a public health or state of emergency, or both, for a 14-day duration at the onset of Spring. They put in place the public health tools of social distancing, enforceable bans on mass gatherings, closure of recreational facilities, withdrawal of non-essential public services, limits to travel, home quarantine, and stay-home directives. Breach of these measures incurred fine and/or jail term.

We have since learned that acquisition of SARSCoV-2 virus can result in different clinical outcomes among individuals in the same risk group: 1) respiratory failure and death; 2) severe pneumonia and recovery on oxygen therapy, with or without ventilator; 3) mild pneumonia and spontaneous recovery at home; and 4) asymptomatic carriers who may not even be aware and only detected when tested as a contact.

What we do not know is why the differences in response following exposure to the same virus.

For example, it is still impossible to predict who will end up as an asymptomatic carrier spreading the virus or who will succumb to the infection.

Knowing more about the virus

Before summer ended, we came to know even more about the virulence of this virus. It could inflict damage, directly or indirectly, almost anywhere in the human body from head to toes with very serious consequences. These include: persistent pain or pressure in the chest; bluish lips or face, and stabbing headache; repeated shaking with chills, muscle pain and a state of exhaustion; loss of taste or smell and seizures; anorexia, nausea, and vomiting; disorientation, inability to arouse or stay awake, delirium and falls; red or purple rash resembling frostbite (“COVID toes”); exceedingly low blood oxygen levels without the accompanying breathlessness (silent hypoxia); and signs and symptoms of severe stroke.

Understanding these unusual symptoms provides new insights to front line workers and carries implications for patient care. The difficulty in breathing that we normally attribute to lung damage might actually be defects in the control of breathing by the nervous system. The presence of neurological symptoms – the loss of taste or smell – could alert the attending doctor about who might go sooner into acute respiratory failure and, thereby, help in the triaging of patients.

New and repurposed prescription drugs

There are now two medications: remdesivir for adult and pediatric patients hospitalized with severe pneumonia and requiring oxygen therapy. The second drug is dexamethasone, an existing drug in use for other clinical conditions. While it has now been recommended for hospitalized COVID-19 patients on mechanical ventilators or supplemental oxygen, note has been made that the drug may be harmful if given for less severe COVID-19 infection. Evidently, the arrival of the two medications for a particular phase of hospitalized COVID-19 patients has prevented a number of deaths that would have otherwise occurred.

Wearing a mask

At the onset of summer, we featured a photo-image of former US President Jimmy Carter – a Nobel Peace Prize recipient – and first lady Rosalynn Carter while explaining the rational use of face masks to help prevent to any degree achievable the further spread of COVID-19.

While masks are primarily intended to reduce the emission of virus-laden droplets, which is especially relevant for asymptomatic or pre-symptomatic infected wearers who feel well but may be unaware of their infectiousness to others, they also help reduce inhalation of these droplets by the wearer.

US President Joe Biden has always spoken eloquently on the importance of wearing face masks. “I view wearing this mask not so much protecting me, but as a patriotic responsibility. All the tough guys say, ‘Oh, I’m not wearing a mask, I’m not afraid.’ Well, be afraid for your husband, your wife, your son, your daughter, your neighbour, your co-worker. That’s who you’re protecting having this mask on, and it should be viewed as a patriotic duty, to protect those around you.”

Children in the pandemic

We have also come to appreciate that children are very much in the eye of the pandemic storm.

When hospitalized, as many as 32 per cent of the patients required oxygen therapy, half of whom also need a ventilator. They can also develop serious sequelae, such as severe inflammatory syndrome, following an acute COVID-19 infection.

Schooling and college

As autumn appeared, we focused on the impact of the pandemic on schooling for children and back to college for young adults. While there was a nearly universal chorus to bring children safely back to school even in the midst of COVID-19, there were also some very strong voices against mandatory in-person instruction without flexibility. I have never observed such an intensity of deeply held opposing viewpoints about school re-opening from my reading of the mainstream media, professional pediatric associations, health agencies, and scientific reports on the burden of the pandemic on children.

Why some college students break pandemic rules

We were reminded that collegiate rites of passage to adulthood encourage youth to take risks to find new connections. Restrictions to behaviour could only lead to rebellion. That’s why fraternity and sorority bid days at the start of the semester are accompanied by mass gatherings and parties – notwithstanding, the rules against them.

However, developmental psychologists reminded us that risky behaviour may be a function of their normal physiological and emotional development, not a conscious breach of prescribed public health rules.

COVID-19 and influenza duo

As we prepared for the fall and winter seasons, we realized the arrival of the seasonal flu in the midst of the pandemic would make for a fearful duo. We offered the needed advice to get the flu vaccine at the first opportunity. It is our best protection against the fearful duo.

It was around this time that we experienced the surge of cases and wondered whether we were seeing the second wave of the pandemic. We remembered that the historic influenza pandemic of 1918-1919, also known as the Spanish flu, came in three waves. Its highly fatal second wave accounted for most of the American deaths attributed to it. This is the reference being made when we speak of COVID’s second wave and its dreaded severity. But the Spanish flu’s greater severity was due to a mutation of the virus into a more virulent strain. Presently, the occurrence of variant strains has very much been in the news.

The wide circle of tragedy

No death is ever “just a number.” Bereaved children get pushed into or near poverty and risk foster care placement after deaths of parents. Applying a “bereavement multiplier of nine for every death,” as developed by researchers at the Penn State University, we appreciate the gravity of the current toll of deaths in Canada and in the world. Long-term impacts and disabilities do exist: long-term damage to patients’ lungs, heart, immune system, and brain. As much as a third of the patients who recovered had difficulty breathing and unusual fatigue months after their diagnosis and close to 89 per cent of recovered patients have abnormal findings on cardiovascular imaging.

Unprecedented times in vaccine development

Near the end of summer, 14 vaccine candidates anticipated clinical testing. In particular, Moderna and Pfizer were working at an unprecedented speed. Their products would eventually receive emergency use approvals in Canada, USA and Europe last December. Both are mRNA-based vaccines.

“It’s actually important to test a lot of vaccines. If we could have five vaccines that are safe and work and are potent, that would be much better. It reduces the chances for manufacturing bottlenecks. With five vaccines, maybe we could manufacture enough for everybody on the planet,” said Gary Kobinger, director of the Infectious Disease Research Centre at the Université Laval in Quebec City.

Joyful winter with vaccines

That two safe and effective vaccines, Pfizer/BioNTech and Moderna – each with average efficacy of 95% ­– would become available for use come December was more welcome.

Drs. ER Rubin and DL Longo wrote in their editorial on the Pfizer vaccine in the December 12, 2020 issue of the New England Journal of Medicine: “What appears to be a dramatic success for vaccination holds the promise of saving uncounted lives and giving us a pathway out of what has been a global disaster. … The level of safety the vaccine has demonstrated thus far is remarkable. With this number of participants and this follow-up period, safety does not arouse specific concern.”

How exciting it was, indeed, to know that Canadians, together with other countries, has begun its mass immunization against COVID-19. This sets the stage for ending the acute pandemic realistic before the end of the 2021.

Vaccination update

As of January 27, 77.37 per cent of the 1,122,450 vaccine doses supplied to provinces and territories have been injected – from 30.5 per cent in the Yukon to 94.4 per cent in Quebec and even 104.1 per cent in Saskatchewan, which found extra doses in each vial. The total administered doses reflects a 2.29 per cent vaccination rate for the total Canadian population, ranging from 0.91 per cent in Nova Scotia to 21.01 per cent in the Northwest Territories. Data from all individual provinces and territories can be found on the Public Health Agency of Canada’s website.

Vaccine supply

As of January 27, 2021, vaccines are projected to come from six suppliers.

  1. Pfizer/BioNTech – up to 76 million doses of the vaccine were ordered. It began rollout in Canada on December 14, 2020.
  2. Moderna – 40 million doses ordered. It rolled out on December 31, 2020.
  3. Oxford/AstraZeneca – 20 million doses on order.
  4. Janssen – up to 38 million doses on order.
  5. Novavax – up to 76 million doses on order.
  6. Medicago – up to 76 million doses on order

Delays in delivery

No sooner have we asked ourselves to temper our optimism and news of delays in vaccine delivery has been announced. The next delivery from Pfizer will not come as originally scheduled due to the continuing manufacturing disruptions at its facility in Belgium.

Prime Minister Justin Trudeau reassured Canadians that “the overall goal, to have every Canadian vaccinated by September, would be on track.” However, the overall decrease over the next month could be as much as half as originally planned. Major Geneeral Dany Fortin, the commander in charge of the vaccine rollout, said, “There will be a considerable impact across all provinces.”

Why it is hard to make vaccines and boost supplies?

Lauran Neergaard (AP News, Jan 28 2021) summed up the answers to this question. Many detailed steps and ingredients of supplies go into the manufacture of vaccines. Add to that the millions of doses in demand and one sees the enormous challenge faced by manufacturers. All countries are asking for their fair share of supply. In response, pharmaceutical firms are retooling their factories and have to produce their supplies at the volumes needed. The process of producing a vial of vaccine requires meticulous care – any little refinement needed causes delay. Different vaccines require different technologies, raw materials, equipment and expertise. Creating an mRNA vaccine is an involved chemical process and not as easy to translate from small to super-large volumes. Working with biologic ingredients faces variability. And all the steps in the production must follow strict control procedures to ensure the quality of each batch.

Knowing these particulars require of us patience rather than unnecessary belligerence.

The current situation

Except in Nunavut where there is an increase, there has been a drop of new cases across Canada.

Per 100,000 population, B.C. saw a one per cent drop –that is, nearly a plateau – while Prince Edward Island dropped 100 per cent – that is, no new cases seen. The Canadian average drop is 18 per cent.

Total cases per 100,000 people remain high in five provinces: Quebec (2,985), Alberta (2,753), Manitoba (2,095), Saskatchewan, (1,922) Ontario (1,756), and British Columbia (1,267).

Globally, the total number of cases has reached 101,687,508 with the following 10 countries sharing the greater burden: USA (25,793,302); India and Brazil (9 to 10-million); Russia, United Kingdom and France ( three-million range); and Spain, Italy, Turkey and Germany (two-million range).

Canada’s share of the burden comes to 772,441 cases – 22nd place among countries. The Philippines at 521,413 places it in the 32nd position.

Globally, 2,195,871 people have lost their lives to the disease, with the USA nearing half a million (433,719). Canada and the Philippines stand at 19,739 and 10,600, respectively.

Rey D. Pagtakhan, P.C., O.M., LL.D., Sc.D., M.Sc., M.D. – former cabinet minister and Parliamentary Secretary to Canada’s Prime Minister and retired lung specialist and professor – graduated from the University of the Philippines. He did postgraduate studies/training at Washington University and University of Manitoba and spent a sabbatical year as Visiting Professor at the University of Arizona.

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