CME INDIA Presentation by Dr. Chandrakant Lahariya, Senior consultant physician and diabetologist, New Delhi. (He has worked with WHO and UNICEF in the past.)

Zero-covid’ is not a strategy for COVID-19 response.

• China adopted ‘Zero COVID strategy’ with stringent measures and harsh restrictions for nearly three years.
• This was continued- despite epidemiological evidence of its ineffectiveness and abandoning of Zero covid strategy.
• This lesson was evident after similar measures by other countries such as Australia, New Zealand and Singapore.
• Then, with the highly transmissible Omicron, it became unequivocally clear that ‘Zero-covid’ is not a strategy for COVID-19 response.
• China definitely continued the enforcement of Zero-COVID approach till a few weeks ago.
• After that it was abandoned in haste following citizen protest and civil unrest – something otherwise unusual for China.

Why this sudden surge after nearly 35 months of zero-COVID strategy?

• It essentially indicates that with a reported low infection rate, of around 1.4 billion people in China, some hard facts were ignored largely. These four facts are worth to ponder:
  • Only a small proportion of population developed immunity through the natural infection.
  • Though China has vaccinated a vast majority of the population; the efficacy of the COVID-19 vaccines used in China is the lowest amongst all approved COVID-19 vaccines at around 52%.
  • China had started COVID-19 vaccination nearly two years ago, and completed it at a fast pace. We know that the vaccine induced immunity declines with time. Thus, even with high vaccine coverage, the protected population in the best-case scenario- remained just half of total eligible population and in the worst-case scenario (considering decline in protective immunity over time), to even a smaller proportion.
  • he protection and the immunity developed after natural infection lasts longer than the vaccine induced immunity. However, the population in China has only vaccine induced immunity which wanes off with time.  

• In early December 2022, when China made a tectonic policy shift from zero-covid strategy, the country—arguably—had an estimated 850 million to 1,120 million of susceptible people, most of whom had not been exposed to any variant of SARS CoV2.

The current surge in China is not something we should be surprised about

• We know that Omicron is the current dominant variant of concern.
• It spreads fastest amongst all COVID-19 variants.
• The current surge in China is not something we should be surprised about. Rather, what is more surprising is that China did not prepare ‘zero-COVID’ exit strategy in a nuanced and meticulous way.
• In Dec 2022, the world has a far better understanding of how to respond and how to take care of those who get infections.
• There are vaccines which protect from moderate to severe diseases.
• There are COVID-19 drugs which work best in population groups such as in China- with no past infection and no vaccination.
• With sudden relaxation in the COVID-19 curbs specially when vulnerable population groups such as elderly remain unvaccinated, the surge in China is what an epidemiologist would say unavoidable.
• In fact, in the time ahead as immunity wanes, the similar though localised surges might be reported from other countries and sub-national settings.
•  All countries should be prepared and should have mechanisms in place for responding to such eventualities.

Read it not with just a pinch, but with ‘handful of salt’

• The lack of official information from China and unverified videos of overburdened hospitals in social media gives space for the estimates and mathematical projections and fuelled the misinformation. 
• Those who have worked in disease modelling know that COVID-19 situation has become far more complex and factoring in all of those determinants and variables, makes any mathematical models unstable and thus unreliable.
• A simplified models with multiple assumptions generate estimates with very wide confidence intervals, which may not be any better than the guesstimates.
• Clearly, the estimates on COVID hospitalization and deaths in China should be read with, not with just a pinch, but with ‘handful of salt’.

Attention needed not panic or worry for other countries

• Considering the world is in mid of a pandemic, the COVID-19 surge in any part of the world is a reason for attention by every other country.
• It is not a reason to panic or worry.
• Three years into the pandemic, no two countries are comparable, because of the differences in the rate of natural infection, in the efficacy and coverage with vaccines, also due to whether vaccines were administered before or after natural infection in those settings and the time elapsed since the completed vaccination.

India: What’s Prediction?

• India has high natural infection (after three waves), high adult vaccine coverage with high efficacy vaccines, and a hybrid immunity (which is far superior than vaccine induced immunity) unlike China.
• The surge in China cannot give rise to a fresh wave in India or any other country.
• The only unknown is whether it is the Omicron variant which is circulating in China or if it is a new variant.
• China does not have an impressive record on reporting about SARS CoV2 infection and spread, in the past.
• Considering these facts, the countries need to be extra cautious and urgently need to step up genomic surveillance.

Should we bring back the mask mandate?

• The surge in China is a reminder.
• It reminds that the world cannot drop its guard against the virus.
• However, the response should not be knee jerk.
• There are no role of flight bans or other travel restrictions.
• Essentially, just because cases are rising in China, it is not a reason to bring back the mask mandate either.
• One real ongoing challenge is tackling misinformation. It is possible that soon -in India and other settings- there would be talks and suggestions to implement preventive measures such as bring mask mandates back, consider moving to hybrid mode of schools and other unscientific measures which gives governments a semblance of doing something.
• Any of these measures have no role as of now, in any setting outside China.

Need to urgently step-up Genomic surveillance, sewage surveillance and monitor any early trend in India

• The surge in China has not changed anything in India and there is no need to change people-related approaches in COVID-19 response in India.
• At an individual level, there is nothing to worry about for people in India. 
• All countries other than China, Including India, need to urgently step-up Genomic surveillance, sewage surveillance and monitor any early trend in clinical symptoms and outcome of infections. Government authorities need to keep a close watch on trends in China and other countries.

‘He who rides a tiger is afraid to dismount’

• The epidemic and pandemic response need nuanced, evidence guided strategies derived from the ongoing learning and not dogmatic response.
• ‘He who rides a tiger is afraid to dismount’ is a famous saying.
• China’s zero -COVID strategy was like riding a tiger.
• As China has dismounted, the policy maker there urgently needs to bring granularity in response, adopt calibrated steps, remove restrictions and implement steps to protect the vulnerable.
• More importantly, it is a moral responsibility of the government in China to report COVID-19 specific data (cases, deaths and data for genomic surveillance) with the world and international bodies.

CME INDIA Learning Edge

1. Many observations and predictions in this article do not necessarily point to a data driven analysis.
2. Physicians and public need to follow Ministry of Health (Govt of India) guidelines.
3. As looks most appropriate, Variants now driving the surge in China are not new.
4. It has been circulating in India and many parts of the world for few months.
5. Our electronic media is fueling the situation in frantic way and creating mass panic. Media should rather discuss science not lockdown and grim scenarios.
6. Majority of eminent epidemiologists agree that in India, no new threat will emerge due to solid scientific predictions.
7. CME INDIA agrees with Dr. Gagandeep Kang (Virologist) saying, “If you have any respiratory infection, stay home. If you need to go out, go masked. If you are vulnerable, stay masked in unfamiliar company or if someone around you is obviously ill. If there is a lot of infections/cases in the community, staying masked in crowds is good.”



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