The world is slowly opening up, but India’s is a grim reminder
CLINICAL MATTERS
Dr. Edsel Maurice T. Salvana
The United States Centers for Disease Control (CDC) recently released an infographic outlining what activities could be done by vaccinated persons compared with non-vaccinated persons. One of the most exciting facts from this document is that vaccinated persons can now remove their masks outdoors, even when gathering together with other people. A mask is still recommended in crowded outdoor events as well as indoors.
After more than a year of wearing masks, an official US government advisory saying that it is okay to remove your mask in certain circumstances is an incredibly positive sign. Considering that the US has yet to fully control its pandemic, this move shows the increasing confidence that physicians and public health experts have in the ability of vaccines to protect us all.
The current CDC advice recognizes that our current vaccines are still not completely transmission blocking (you can still get disease and transmit it, but it won’t be deadly), but are indeed very good at preventing severe disease. When public health officials craft advice for safety measures, they look at two sides—the risk to the person himself, and the risk to the public.
In the case of our current vaccines, the risk of severe COVID-19 becomes very small once one is fully vaccinated. Therefore, the main consideration becomes the risk of transmitting disease to others since a vaccinated person may still occasionally carry asymptomatic or mild infection.
With the recent increased attention given to potential aerosol transmission of COVID-19, removing one’s mask indoors remains risky. The CDC infographic advices that even vaccinated persons wear masks indoors. The role of airborne transmission continues to be debated and most scientific bodies still believe that the majority of COVID-19 transmission is droplet and at close range. All bets are off indoors, however, where improper ventilation and distancing can result in concentration of infectious particles, particularly at restaurants where people remove their masks to eat.
Once outdoors, virus particles are quickly diluted and waft away as long as the setting is not crowded and there is ample air circulation. When together with others outside, the risk is less. Even more so if everyone is vaccinated. Note that the CDC still advices vaccinated persons to always bring a mask. It is still recommended to have a mask handy in case someone draws near, or if you have to go indoors. Moreover, the impact of the new and more infectious variants on this advice remains largely unknown. Caution should be taken especially in areas with a predominance of variants of concern, as well as in areas with ongoing surges where the number of people who are infected is high.
In the Philippine setting, the applicability of this advice is still being studied. While the US has already vaccinated a substantial proportion of its population, we are still in the early stages of getting everyone immunized. The current surge in Metro Manila, which seems to be tapering off, still involves a large number of infected individuals. There is also a lack of large open spaces in the city, and public transport remains unreliable in its ability to maintain proper ventilation and physical distancing. The CDC recommendation may not be something we can adopt at this time. It is something to look forward to, however, as more people get vaccinated and the number of cases drop.
In a few webinars I have participated in with international colleagues, including some from Australia and Singapore, I looked with envy as they carried on conversations without masks indoors. This is doable in their countries since their community rates of transmission are very low and most of them have been vaccinated. It is a reminder that some places in the world are slowly going back to normal. Israel, which has been the poster child for rapid vaccination, has pretty much reopened. Across the world, many countries are starting to think about easing travel restriction and their policies on quarantine for vaccinated individuals.
While some countries may only consider admitting travelers who got vaccines that are approved by the destination country, the US has explicitly stated that it will recognize vaccines that have a WHO Emergency Use Listing, even if they do not have specific emergency approval in the US. This means that a vaccine that passes muster with the WHO is good to go for America.
While all these signs of returning to normalcy are coming up, the grim situation in India reminds us that COVID-19 is far from done. Like any infectious disease, growth is exponential when people get careless. With the premature relaxation of control measures in India, the country is now seeing the folly of letting its guard down. These include reports of large religious festivals and political rallies without proper distancing and the use of masks, both of which turned into super spreader events and are now causing an imminent collapse of the healthcare system.
As it takes 14 to 21 days to discharge a severe COVID-19 case from a hospital, it may take weeks to months before the situation normalizes. Projected deaths in India are expected to approach nearly one million people before their current surge is over
In the Philippines, this is the nightmare scenario we were so scared of when we advised the government to close early last March 2020. The Indian surge and our own recent surge is showing us that shutting down early was not an overreaction. With our current surge plateauing, a cautious and gradual approach is advised, as this can still get away from us as we open further.
While the economic implications are indeed dire, the cost to the economy of having to lock down all over again and the number of deaths that could have been prevented should temper any undue exuberance to prematurely declaring victory. India, Brazil, and the US remain cautionary tales for underestimating the virus and using the economy as an excuse to open up too fast.
We are in the end game, and the virus is making its last stand. How many the virus kills in these waning days of the war depends on the individual and collective choices we make.