THE TIMES KUWAIT REPORT
Last week, media reports indicated that in the wake of an increase in number of infection cases and rise in patients being admitted to intensive-care units in hospitals, the authorities were considering reintroducing curfews and imposing stricter restrictions on movement of people.
A surge in infections in recent weeks, in particular from the new Delta variant of SARS-CoV-2 virus that causes COVID-19, has been worrying health authorities. Latest figures from the Ministry of Health (MoH) on 9 July confirm that coronavirus cases have jumped recently to reach 372,549, and deaths have risen by 18 to touch 2,089. Meanwhile, the number of people currently hospitalised with the virus stood at 18,252, with 321 of them in intensive care units (ICU).
Despite this spate of infections, apparently wiser counsel prevailed among members at a recent meeting of the Cabinet’s Corona Emergency Committee. Following the meeting, the Minister of Defense Sheikh Hamad Al-Ali Al-Sabah, who chairs the Committee, said that reimposing curfew was excluded from the list of measures being contemplated by the committee. He pointed out that a curfew could be avoided, as alternative methods such as vaccinations are now available to thwart the spread of the virus and limit its repercussions.
Introducing complete lockdowns, or the less restrictive night-time curfews, places policy-makers in a double bind. They are aware that the cost of imposing an extended restriction on interaction and movement of people will be devastating to businesses and to the country’s economy. However, they also acknowledge that during a time of rapid escalation in infections and fatalities from the virus, if people remain reluctant to self-limit their mobility, the cost in terms of lost lives from not introducing a lockdown or curfew could be enormous to families, society and to the country.
Faced with this dilemma, policy-makers in Kuwait have over the past year and a half opted to introduce lockdowns and a series of stringent curfews. While these restrictions have drawn flak from many people, it has also found favor and support from a wide section of the public, and in particular from the healthcare fraternity. Confusion over introducing an effective strategy, especially in the early stages of the pandemic, was not limited to Kuwait. Emblematic of this widespread uncertainty is the contradictory stand on the issue of lockdowns by the World Health Organization (WHO) and the International Monetary Fund (IMF).
The WHO, which is the umbrella organization for ensuring global healthcare, was initially reluctant to recommend travel bans and lockdowns, saying that it would impact the economies of poor countries and livelihood of vulnerable people. On the other hand, the International Monetary Fund, which is an entity concerned more with the health of global economy, came out in support of restrictions. The IMF stated that lockdowns help bring infections under control quickly, and this paves the way to a faster economic recovery, as people would feel more comfortable about resuming normal activities.
In Kuwait, opponents of curfews have argued that restrictions on mobility and interaction of people have made no appreciable impact in curtailing the spread of the infection or in its lethality. However, curfew proponents point out there has been a significant impact on the spread of infections from lockdowns, but that it becomes evident only in retrospect.
They also rationalize restrictions as being necessary to give authorities time and resources to respond effectively, and also to prevent overwhelming the country’s health system. Whatever the arguments for and against lockdowns, and notwithstanding snide remarks by opponents that curfews are meaningless as the virus does not adhere to any set timetable in infecting people, most epidemiological experts concur that lockdowns did help in reducing transmissions.
In many places, lockdowns have been proven to decrease transmissions measurably, especially during the phase where the SARS-CoV-2 virus tends to spread rapidly in a community. But scientists also admit in hindsight that a more targeted or proportional approach, rather than a nationwide lockdown, could have helped mitigate the spread of infections and limit its impact, while balancing other economic, social and health concerns.
The authorities in Kuwait need to be lauded for not backtracking on their decision to continue with curfews and other restrictions despite demands by sections of the public to rescind these rules. The government has chosen to follow a science-based response that is in line with accepted international health policies and practices. But continuing the same prohibitory policies in the face of a rapidly evolving health environment is not pragmatic and expedient anymore. The Cabinet’s Coronavirus Emergency Committee has to be commended for realizing this and not reacting to the ongoing increase in infection cases by imposing yet another curfew.
It is evident that extended suspension of economic and social activities is an expensive option that is not a viable approach over the long-term, and is also no longer relevant given the alternatives now available. Not only do we now have more knowledge about the virus and its functioning, we also have better treatment options and preventive protocols, in particular through gaining immunization from one of the several effective vaccinations developed recently against the virus.
Kuwait’s vaccination drive got off to a start in late December 2020, with the first doses being given to frontline medical workers. According to the Ministry of Health (MoH), as of 4 July more than 2,375,455 doses of anti-COVID-19 vaccine had been administered in the country. The vaccination statistics also reveals that although the total vaccination figures represent over half of the population of 4.7 million people, only less than 20 percent (923,307) of the population have received both the doses needed to ensure maximum possible protection from the virus. Undoubtedly, we need to speed-up the vaccination drive.
On average, the MoH has been administering 12,500 vaccinations each day, from the 30-odd designated vaccination centers in the country. The recent decision to ramp up the number of vaccination centers to 40, to coincide with the expected arrival of more batches of vaccines from abroad, as well a new decree to allow private hospitals to purchase and administer anti-COVID-19 vaccines approved by MoH directly from vaccine vendors, are expected to result in a marked increase in the pace of vaccinations in the coming weeks and months.
Besides responsibility on the part of the public to adhere to health guidelines such as social distancing and wearing of face masks, what is needed now is a strong and sustained public health response that includes escalating the pace of the vaccination drive so as to immunize everyone at the earliest date. The health ministry has already confirmed that it plans to vaccinate around three million people by September, and thus come closer to its objective of vaccinating 70 percent of the population so as to achieve community immunity before the end of the year.
When it comes to infectious diseases that turn into viral epidemics and pandemics the holy-grail of authorities and the medical fraternity has been to achieve community immunity (CI), or ‘herd-immunity’ as it is more crudely known. The reasoning behind CI is that when enough people in a community are immunized against a contagious disease, other vulnerable members of the community who have not been immunized due to health-related or other issues, are protected from infection because there is little opportunity for the virus to take hold and spread in the community.
Epidemiologists can now estimate the proportion of a population that needs to be immunized before CI begins to take hold. This threshold depends on the basic reproduction number, R0, which is the average number of people to whom one infected individual transmits the infection, in a theoretically fully susceptible, well-mixed population. If R0 is larger than 1, the number of infected people will likely increase exponentially in the community, and an epidemic could ensue. If R0 is less than 1, the outbreak is likely to peter out on its own over time.
According to medical literature, the formula for calculating the herd-immunity threshold is 1–1/R0. For instance, measles, an extremely infectious disease, has an R0 typically between 12 and 18, which works out to a CI threshold of 92–94 percent of the population. For a virus that has a lower R0, the threshold would be lower. In other words, the more people who become infected by each individual who has the virus, the higher the proportion of the population that needs to be immune to reach CI.
However, the R0 is problematic as it depends on a number of variables, including susceptibility in the population, transmission to asymptomatic people who are not counted in the R0 figure, and how frequently people interact, all of which are dynamic and evolve as the epidemic progresses in the community. For this and other reasons, a variation of R0 called the R effective (abbreviated Rt or Re) is sometimes used in these calculations, as it factors-in changes in population susceptibility. At any time, Re = R0 × (1 – Pi), where Pi is the proportion of the population who are immune at that time.
Although these formulas help calculate the CI threshold, in reality, community immunity is not achieved at an exact point in an immunization program that would allow us to claim everyone is now safe. Because variables used in R0 calculation can and do change, CI is also not considered a stable state. Most estimates had placed the CI threshold for the SARS-CoV-2 virus at 60–70 percent of the population gaining immunity, either through vaccinations or from past exposure to the virus. But as the pandemic prolongs and progresses without any marked abatement in its spread and virality, the thinking has begun to shift.
Many epidemiologists now admit that arriving at a CI threshold through vaccinations is increasingly unlikely due to several reasons. For one, it is not yet clear whether vaccinations being administered currently are effective in preventing transmission. Without a vaccine to block transmission, there can be no effective CI. The alternative way to realize CI in the population would be to give everyone the vaccine and ensure that no new infections enter the country, which is again an almost impossible task to implement.
Another reason for uncertainty surrounding CI is that we do not have an equitable distribution of vaccines worldwide, and no one community can be considered truly safe until everyone is safe. Given existing huge variations in the efficiency of vaccine roll-outs in many places and disparity in distribution between and within nations, it is highly unlikely that we will be able to achieve CI on a global scale any time soon.
Moreover, even as vaccine roll-out plans face delays and hitches in its distribution, new variants of SARS-CoV-2 are also emerging, any one of which could end up becoming more infectious and resistant to available vaccines. Theoretically, vaccinating everyone quickly and thoroughly can prevent a new variant from gaining a foothold. But given the unevenness of vaccine roll-outs and delays involved, this prospect too becomes quite challenging to achieve.
There is also the question of whether the effectiveness of vaccines wane over time. With the limited trials that preceded roll-out of vaccines, manufacturers have no reliable data on durability of their vaccine’s effectiveness. It is very likely that currently available anti-COVID vaccines will reduce in its preventive potency over time, just as many other vaccines do. Pfizer-BioNTech have already announced that a third booster dose would be needed to prolong the effectiveness of their vaccine and to make it protective against current variants of the virus.
In addition to all of the above reservations on vaccines and CI, the all important factor involved in CI is individual behavior. Empirical evidence from countries that have achieved high vaccination rates is that as more people get vaccinated, the rate of interactions are also seen to increase. This in turn alters the CI equation, which is dependent in part on how many people are exposed to the virus.
For instance, if a vaccine offers you 90 percent protection and that before the vaccine you met at most one person, but now following vaccination you meet with ten people, you are then back to square one. The aim is to break the transmission path, but limiting social contact over extended periods remains an unenviable option that authorities would prefer not to implement or enforce.
Epidemiologists are now increasingly admitting that CI threshold should not be considered as a ‘we are now safe’ threshold, but rather as a ‘we are now safer’ threshold. Relying on CI as an indicator to return to ‘normal’ pre-pandemic lives is also not an option that most epidemiological experts now recommend. A better approach they say would be to consider the virus as just another impediment to our daily lives and learn to live with it.
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