Global collaborative effort needed to mitigate the pandemic: Professor Balkhy WHO Assistant Director-General praises Kingdom's staged response to COVID based on risk assessment, healthcare capacity

JEDDAH — Professor Hanan H. Balkhy, MD. FAAP. MMed and assistant director-general, antimicrobial resistance, in World Health Organization (WHO), said that the ability to mitigate what is taking place today and to ensure it does not happen again will largely depend on a global collaborative effort by all countries and relevant organizations — most importantly the World Health Organization (WHO), as it is the leading global health agency today.
Professor Balkhy, while stressing that we are facing a pandemic that has not been experienced during this century, made this statement during an exclusive interview with Okaz/Saudi Gazette on Friday. She also praised the Kingdom's efforts in stemming the outbreak, with a staged response to the pandemic based on a risk assessment that took into account the healthcare capacity, specifically the intensive care support capacity, the community structure and most importantly being mindful of mitigating transmission to other countries with the early shut down of the religious sites, and visitors for the Umrah.
"Saudi Arabia under the leadership and the guidance of the Custodian of the Two Holy Mosques King Salman and Crown Prince Muhammad Bin Salman have rightfully focused the early stages of the response on the identification of suspected cases, isolation and contact tracing. As many countries suffered from the surge of cases into the healthcare system, specifically those with a fragile elderly population and overwhelming the intensive care units, the Kingdom quickly repurposed the healthcare system to address, as a priority, COVID cases," Professor Balkhy said.
She spoke of the WHO's efforts in isolating the source of the virus and the movement of the pathogen whether it is animal to human or human to human, while calling on the community to reassess the interaction between humans and animals. She also said the WHO, working with partners around the world, has prioritized the importance of developing a vaccine in order for the return to normal ways of living. Here are the excerpts:
Q: How do you see the response of Kingdom of Saudi Arabia to COVID-19?
Hanan: The Kingdom of Saudi Arabia has been one of the countries implementing a staged response to the pandemic based on a risk assessment that took into account the healthcare capacity, specifically the intensive care support capacity, the community structure and most importantly being mindful of mitigating transmission to other countries with the early shut down of the religious sites, and visitors for the Umrah.
During the early stages of the pandemic, there was global anxiety on the impact of this virus on the healthcare systems, the lack of a validated diagnostic test, and the lack of country capacity to respond to the disease. So the Kingdom of Saudi Arabia under the leadership and the guidance of the Custodian of the Two Holy Mosques King Salman and Crown Prince Muhammad Bin Salman have rightfully focused the early stages of the response on the identification of suspected cases, isolation and contact tracing.
As many countries suffered from the surge of cases into the healthcare system, specifically those with a fragile elderly population and overwhelming the intensive care units, Kingdom of Saudi Arabia quickly repurposed the healthcare system to address, as a priority, COVID cases. This strategy spared the healthcare system from collapsing, specifically when compared to other major around the world.
During these first two phases, the Kingdom of Saudi Arabia placed curfews and lockdowns in different cities of the country as deemed necessary by epidemiological data. Workplaces were guided to follow a strategy to mitigate contact and break the chain of transmission and many businesses were then working from home.
Q: In the current stage, what are the important measures that Saudi Arabia needs to apply?
Hanan: In the current phase, the country has a much better understanding of the clinical presentation and a more systematic way to identify bed capacity and can much better gauge their interventions based on data. As with other countries a sustained public health system needs to be in place to enable the services to open up gradually and recover from the economic damage that has taken place because of COVID-19. Hospitals and healthcare workers are more aware of the importance of complying with personal protective equipment (PPE), and more mindful of their role in preventing the spread of the disease.
During this phase, as with many countries around the world, a solution for the extensive lockdown and the impact on the countries economy, especially the small businesses becomes a priority. In addition the importance of providing healthcare services that have been placed on hold due to the repurposing for COVID, needs to be understood and resumed — for example the need to continue with treatment for cancer patients, dialysis patients, non communicable disease monitoring and treatment and childhood vaccine programs.
Q: How do you describe the responsibility in containing this virus?
Hanan: This is the most critical phase for any country as it will depend on the partnership between the people and the government, a joint responsibility to allow life to go back to a more normal form, while keeping in mind that the virus exists in the community and vigilance is needed to sustain low community transmission. The success of any given country to restore the lost business capacity, normalcy of life and livelihoods will highly depend on this partnership. And the Kingdom of Saudi Arabia is no different.
Q: What are your recommendations? When will the C19 vaccine be introduced?
Hanan: We are facing a pandemic that has not been experienced during this century. The ability to mitigate what is taking place today and to ensure it does not happen again will largely depend on a global collaborative effort by all countries and relevant organizations — most importantly the World Health Organization (WHO), as it is the leading global health agency today. But before I explain more it is prudent for the reader to understand what is the actual theory for such a virus to appear, and what were the previous experiences on this?
Q: Why have we experienced this pandemic now?
Hanan: Why now is not so clear, but 70 percent of human infections originate from animal sources. And this phenomenon is known as the species jump, where genetic mutations take place providing the pathogen with the ability to infect the human cell for the first time, hence also referred to as emerging pathogens. Sometimes these pathogens lose their ability to continue as a human pathogen and we only see limited human-to-human transmission.
A good example was what happened with SARS in 2003. It originated from the Civet cat, caused close to 8,000 infections and 700 deaths (need to verify the numbers). Another example of a new pathogen infecting humans is MERS Coronavirus. Originating from bats and infecting humans through an intermediary host, the camel. This virus however, did not regress and continues to cause human disease mainly in the Arabian Peninsula. Other examples include the avian influenza, arising from chicken, and swine influenza, arising from pigs. The confirmation of the source of thee viruses is through whole genome sequencing, relating to genetic information in known gene banks that are accessible to scientists.
Q: Is the only solution then to create a barrier between animals and humans? Is that even a reasonable conclusion?
Hanan: Of course that would not be feasible, but the interaction between humans and animals needs to be reassessed, especially that communities have certain traditions that may be difficult or even impossible to change. What is clear though, that human interactions with animals need to be based on proper hygiene practices, separating the living quarters between humans and animals, proper hand hygiene after being in contact with animals, providing animals with vaccines when available and ensuring proper care of the health of animals. A more crucial intervention is to avoid exposure to exotic animals in the wild as much as possible. These simple practices will limit the possibility of animal pathogens jumping into the human world where potential propagation may take place.
Q: It seems that you are focusing on the role of people in controlling what you have described as the species jump. What is the role of the WHO?
Hanan: The WHO is the leading global health agency and during this pandemic it has been criticized for slow, lack or inappropriate response to the COVID pandemic. The WHO has led the way in controlling many outbreaks around the world; the most recent prior to COVID was the worst EBOLA outbreak in history. However, the success to fully control the spread of a new virus relies on global partnership in the response and collaboration from the local and neighboring health agencies.
One of the main pillars for the WHO is early detection, and there the WHO relies on information stemming from countries' strong public health systems. Where identifying an emerging pathogen is made possible by having an index of suspicion of a cluster of patients presenting with a specific syndrome. So you may imagine the importance of countries investing in early detection through establishing nationwide surveillance systems and reporting processes.
The WHO has provided guidance on how to achieve such a goal and has established this guidance, though the agreement with member states, based on the international health regulations (IHR) and the establishment of an IHR focal point in every country. Once the suspicion is there a cascade of processes needs to quickly follow for proper interventions to mitigate the spread. One of those processes is informing the WHO for a collaborative effort to take place ensuring local and global protection.
This is a very complex process that many countries decide not to engage in as the ramifications of identifying an emerging pathogen on the countries economy through closing borders and limiting travel are much more concerning to the country than the potential spread of a disease. And the COVID scenario has now reached a tipping point of balancing between interventions that are necessary to mitigate transmission versus interventions that would damage the economy and negatively impact other health necessities for the community.
This pandemic has emphasized our ability to truly change our method of living, where social distancing and enhanced hygiene are doable in all aspects of life. The interesting observation that this imposed new way of life has led to further benefits to the environment that we once thought were impossible.
Q: So can you elaborate on the fact that this virus is not genetically mutated and released into the community for political gains?
Hanan: The COVID virus, isolated from humans studied so far, was found to be genetically closely related to coronaviruses isolated from the bat population. This is similar to what was identified for the cause of SARS; suggesting that both have ecologically originated from bats. Intermediate hosts are still to be identified and more collaborative work will take place on this issue soon. More importantly, the available data today dismisses the possibility of the virus being a result of human manipulation or engineering, and dismissing the conspiracy theory.
Q: Can asymptomatic spread take place or is taking place by COVID-carriers who do or do not fall sick, the post-lockdown race for herd immunity has sped in many countries in recent days.
Hanan: It is important that we differentiate between those who are infected but never go on to develop symptoms (asymptomatic) and those who are infected but have not yet developed symptoms (presymptomatic). It is clear that asymptomatic can transmit the disease but we need more research to estimate the extent of transmission from this population. On the other hand transmission form presymptomatic patients especially in the few days before onset of symptoms is significant. It is important we don't forget that COVID-19 has appeared only 6 months ago. There is much that needs to be studied about this virus, including seasonality, burden of pathogen needed for infectivity, duration of immunity, reinfection rates and many other aspects of the disease.
Q: Is the solution to overcome this pandemic in allowing for herd immunity?
Hanan: The concept of herd immunity is an interesting one, as you would expect that those infected will be protected if not for life then for a significant amount of time. This also is not fully understood. Regardless, since the disease is mainly mild it is hoped that communities that have not applied or complied with restrictions may have a higher community transmission allowing for more individuals to become infected and thus immune. It goes back to the balance between the social restriction, economic impact and the protection of the healthcare system from total collapse. The best scenario would be for a community to be able to function as normal as possible with the least amount of community transmission. And again that requires a community-government partnership.
Q: What have been other modes of transmission, can it pass through breast milk or blood donation?
Hanan: There is no evidence of the virus being transmitted though breast feeding, breast milk or blood donation and so there are no recommendation for preventing either breast feeding or blood donation. It is important to follow guidance on blood donation, however, as those with symptoms regardless of the COVID pandemic may be excluded from donation anyway, as per routine blood bank protocols.
Q: The WHO has created a lot of confusion with adding and removing hydroxychloroquine to the treatment regimen for COVID? Why is that?
Hanan: It is important to clarify that HQ was never part of the treatment guidelines published by WHO for COVID, and the treatment guidelines focused on supportive therapy including for example: modes of ventilation, fluid therapy and treatment of septic shock while no direct viral therapy was recommended for COVID patients outside of clinical trials.
So, there is a major misconception on COVID treatment guidelines published by the WHO. The confusion in public was because the WHO had convened in February an expert group to identify the relevant research tracks and help prioritize the research agenda for COVID. Among the 9 tracks identified was the therapeutic research agenda track. Within this track 4 main randomized control trials (RCT) were identified, one of those tracks in HQ. It is important to acknowledge that this is the first time where a global initiative at this scale has been launched. Similar to any sound RCT a Data Safety Monitoring Board (DSMB) was established.
This is an independent body of experts that ensures the development of a solid study protocol and regularly reviews data from the trial. The DSMB, based on the data, will advise on whether the trial can continue safely, or whether it needs to be temporarily suspended for data verification or whether it needs to be terminated. So the DSMB temporarily suspended the HQ RCT trial led by the WHO due to the need then to assess safety data. After reviewing the data and when there were no concerns on the safety of the drug the DSMB gave the green light for the trial to continue. It is important to emphasize that we don't have conclusive results from this trial yet on the effectiveness of HQ. This is a rapidly developing field and the information is being updated on a daily basis.
Q: Human trials for a vaccine have begun, and there are many attempting to create a vaccine worldwide. Which are the ones that WHO sees as most promising and why?
Hanan: The WHO, knowing that this is a rapidly spreading virus, has prioritized the importance of developing a vaccine in order for the return to normal ways of living. The WHO has been working with partners around the world to help facilitate funding of vaccine development and collaboration in conducting clinical trials for vaccine development. We need to also acknowledge that vaccine development is usually a lengthy road where 10-15 years are needed to develop and test a vaccine.
With COVID, and due to the rapid availability of the full genome sequencing of the virus, which is necessary to develop a vaccine, the first clinical trial started 2 months after the virus sequencing. We expect at least 2 vaccine candidates to complete the clinical trial phase by the end of the year. But the results are not available as of yet. Once a candidate vaccine has been reached there needs to be further collaboration on production, supply and delivery globally.
Q: What are the risks associated with limited human trials for a vaccine to be released in 2020 as widely reported?
Hanan: If a vaccine is developed, yet not widely distributed, the globe will continue to be at risk of widespread transmission.
Q: Are there encouraging signs of breakthroughs in COVID treatment methods to minimize fatalities in the foreseeable future?
Hanan: Unfortunately none of the treatment options have completed RCTs that can conclusively inform us on a viable treatment that reduces death or shortens the duration of illness and hence hospitalization.
Q: Regular intake of vitamins C, D and zinc supplements are being widely promoted for immunity buildup, including traditional foods, herbs, spices, methods and medicines as well. What is your take on this?
Hanan: There are no conclusive trials to confirm the benefits of any of these as treatment interventions.