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"After 20 Million Dead, World Health Organisation declares pandemic over" - I Disagree [1]
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Date: 2023-05-05
The reporting of the latest World Health Organisation decision as ever leaves much to be desired, including the suggestion that the COVID is now endemic. Unfortunately that is not the case. More responsible reports are that the WHO has correctly removed the worldwide health emergency status however it can also suggest that the emergency is fully over for everyone every where. This is most certainly not the case and implies a binary switch from pandemicity to endemicity without recognising the Shrodinger’s cat could be “a bit poorly” when the box is opened.
Quite correctly, if some remarked a bit late, the WHO declared SARS-CoV-2 to be a “worldwide health emergency”. After first being identified in China, the infection has spread rapidly to other countries and other continents. Without knowlege and an established method of treatment, patients with serious disease were causing huge pressure on health systems wherever the virus hit. The WHO decision merely recognises that worldwide the different health systems are no long in danger of being overwhelme by large numbers of very ill people.
As with any organism, SARS-CoV-2’s purpose is to leave copies of its genes to survive after that individual dies. A virus does not have its own reproductive or digestive systems but relies on a host cell to provide the necessary. Once it infects a cell, it hijacks the cell’s own process of dividing into two to use the bits of amino acids to replicate the virus. Eventually the cell dies and all those daughter viruses go in search of a new host. Like a photocopier trying to copy a book page, the replication can go wrong as the cell is programmed to make copies of its own DNA prior to division, not thousands of copies of the virus’s RNA. Minor errors mean the virus can still reproduce but can change its characteristics to produce one virus that has a competitive advantage in certain hosts.
In terms of human health, a virus has one of two evolutionary paths to ensure its survival. We have two examples of viruses that have emerged from an animal reservoir that have created health emergencies in recent years. Outbreaks of Ebola have been found in different areas of Africa and indeed this has two variants associated with the sites of different animal reservoirs. Ebola causes severe illness and has a high mortality rate. So somebody with it effectively takes to their bed to die without enormous medical intervention. Without it the virus has limited opportunity to find a new host so spreads slowly. If outbreaks were not controlled by modern medical interventions like isolation, it would be a case of huge numbers of death over a short period because it is so infectious. Eventually it would burn through potential hosts and return to its animal reservoir. With modern procedures, outbreaks are just that and controllable before they become epidemics let alone pandemic.
Ebola outbreaks in Africa are associated with “bush meat” sold in local markets. COVID almost certainly has similar origins in bats either sold in Chinese “wet markets” or infecting other live animals sold there. It then followed the alternative evolutionary path of becoming more infective but causing milder disease. This was not a direct line of descent. The Omicron variant is believed to have evolved in Southern Africa directly from the “Wohan” strain rather than being derived from the Alpha etc earlier variants. One theory is that it passed to an animal resevoir and back again to humans. The variant meant a fundamental change in terms of human health as it changed the focus of the disease from the deep lung to the upper respiratory system. The pneumonia typical of the disease is now a series of “cold-like” symptoms. It is now only serious in those vulnerable because of co-morbidities and those with compromised immune system.
Here is where I disagree that that COVID has become an endemic rather than a pandemic disease. COVID has left its pandemic stage and is now becoming endemic. That does not mean that thosb e with compromised immune systems or with several co-morbidities should not take appropriate precautions.
Animals ensuring their genes survive into the next generation is a bit more complicated than for a virus. For a start, they have to survive to reach an age when they can breed. Humans have to compensate for our comparatively puny bodies by outcompeting using the lump of fatty tissue behind our eyes. Unfortunately it requires considerable time to be fed with all the information it needs so has to be cared for by its elders and in turn care for its young. To even get to the point of intense knowledge acquisition, a child has to survive the range of endemic disease it finds. It gets off to a start with maternal transmission of antibodies. Once born it gets a bit of help through breastmilk but mostly is on its own. So humans have evolved so their newborns and young have very strong immune systems to generate immune responses against those endemic diseases. Humans in Africa and around the Mediterranean adapted to malaria by evolving blood cells that could change shape. Now their descendants have trouble with sycle cell syndrome! Otherwise our young have “childhood diseases” to furnish them with protection long enough to raise the next generation. Some have high mortality or cause damage to the reproductive system — our vaccines have eliminated a lot of those problems. Some viruses change or immunity fades so there are regular outbreaks of diseases, often seasonal, that, in effect act as boosters for our immune system.
Here is where I question designating COVID as “endemic”. It downplays the importance of the vulerable who rely on vaccinations and masking for protection. One worry is that the vaccines used in North America and Europe did not use the traditional “dead virus”. Instead they used a harmless, deactivated virus or a lipid “capsule” to deliver a small part of the virus’ genome that produces the infamous “spike protein”. The problem is that this part is most liable to change and is one of 20 or so “antigens” that the body can produce an immune response to. (There is some cross-immunity induced by these viruses to other variants but that might not be a response to the vaccine.) The other “antigens” like the protein making up the shell of the virus are less liable to change and share similar structures with other coronaviruses. It’s a similar idea to using cowoox to protect against the very similar smallpox. It means that vaccination and prior exposure to the whole virus provide the best protection against serious disease going forward.
COVID outbreaks are likely to closely match the traditional flu seasons for the simple reason that the conditions favoring its transmission are similar. For the same reason booster COVID vaccinations are likely to follow a similar pattern as annual flu shots for the vulnerable. While in the long term SARS-CoV-2 is likely to join the four other coronaviruses known to produce the common cold, we still do not have a whole population who have been through the maternal transmission/childhood exposure sequence to have immunity to protect them from serious COVID until they need a vaccination. There are still many who are naive to the whole virus. As well as those isolating and masking, some will have had sufficient neutralising antibodies after vaccination to prevent infection during peak periods.
It’s this transitional period between pandemic and endemic that perhaps needs even more and better public information. While the severity of diseases will progressively lower with repeated exposure, there will still be several seasons when extreme pressure from combined flu and COVID outbreaks. While there are similarities, the extraordinarily higher transmission rate, and the possibility of shedding the virus while asyptomatic, means that periodic encouragements to mask during such periods should be given. The purpose is not to stop the inevitable transmission but to slow it sufficiently that the healthcare system is not overwhelmed by serious cases. Such precautions are common in some Asian countries and were even before COVID.
Woefully lacking has been consistent and considered advice about lifestyles to improve the individual’s immune system. The importance of diet has been fairly well rehearsed by different studies, notably the ZOE tracking project.
Lip service was played in the UK to the importance of Vitamin D supplementation for those with naturally darker skins in dark weather. For the most part we cannot get vitamins D and K from our diets. K is available from fermented foods but the UK and US tend not to go for saurkraut or kimchi as part of their regular diets. We don’t get D from food, it is produced in the skin from UV exposure. When we emerged in East Africa we had plenty of sunshine eall year and no sunscreen or clothes to stop the UV. Too much UV is not a good idea so we inherited dark skin from our ancestors. The melanin provides UV protection. Then we decided to explore foreign climes and those who ended up in cloudy rainy England gradually lost the melanin, but kept the blue eyes. Those in the North still do not produce as much as those in Africa and in winter months probably fall below the D level in the body to start to compromise the immune system. So for people from areas where the adaptation to low light has not happened, or their descendants are at particular risk. The UK did at least recognise this by offering free D supplements to affected ethnic minority groups but the amount was very low, enough to take them out of the “at risk of deficiency disease” range.
Definitely underplayed was that one of if not the co-morbidity presenting the greatest risk is obesity. Now all of these are actually sensible preparations for the next pandemic, whether that be a new flu variety or a newly emergent disease. This year is ideal to encourage the normalisation of masking and handwashing by recommendations during outbreaks. Diet and other measures are now profoundly difficult to implement. Michelle Obama’s example is a good one.
So governments need to guide their populations through the transition period by clear and logical advice. One group who certainly needs to be reassured are those who are perhaps taking too extreme measures and are suffering social deprivation as a result. We are in danger of an AIDS=death mindset when this will become increasingly less the case with improved therapies and as much fuller “herd immunity” develops.
If we learn the lessons of the pandemic, we should have a generally more healthy population. After WWI when the numbers in the UK who had to be refused because of bad health caused concern about national security, this has been a military priority for the nation. With all the new toys the armed forces have this is not so desperate but the same applies to a healthy civilian workforce. It should also result in lower healthcare costs.
There are also more positive benefits. One is the reason the UK provided so many virus gene sequences. These were necessary to track the evolution and spread of new variants. At the start of the pandemic the US had very uneven numbers of gene sequencing machine and the facilities in universities, hospitals etc were not coordinated at all. The pandemic meant a lot more machines were purchased for hospitals. This means there are a lot more available for medical use than there were before, which gets us to the reason for the UK to have so many.
Part of the NHS, Genomics England, has a huge database of whole human genome sequences which has grown out of the “100,000 genome project”. This is being used to diagnose rare genetic diseases and assess which treatment regimen would be best to treat a cancer. Finding the genes that have mutated to cause the cancer and cross referencing to clinical records of treatment and outcomes enables the most effective to be identified. This can also in future be used to speed up development of new drugs. It’s also been recently found that early detection and sequencing means there is less opportunity for other gene damage, needing different drugs to develop.
Genetic diseases are not only the result of inheritance. Random errors in the DNA can occur at conception or be caused by exposure to thing like chemicals when in the womb. Different gene differences may cause very similar symptoms but need very different treatment. There can be very few in each country born with a particular gene difference so whole genome sequencing is now available in the UK to diagnose these, again using the genomic and NHS databases. Genomics England provides this service for consultation by other countries and this has already helped a number of children abroad.
So we should look forward to some positive legacies of what has been a terrible time for every country. Leave the deaths for memories and get on with building a better life. That;s a lesson for war and pestilence.
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