With the world and India entering the middle phase in a two-pronged fight against the COVID-19 pandemic, including public health measures to curb the spread of the novel coronavirus and the race to develop a viable vaccine solution , global and regional cooperation between nations has never before been as important as it is today. Poonam Khetrapal Singh , Regional Director World Health Organisation South-East Asia Region, discussed the big questions on institutional learnings, transnational collaborationand challenges for India with Narayan Lakshman . Edited transcript:
When do you think India could realistically expect a COVID-19 vaccine to be available at scale, and what steps in vaccine development remain until we reach that point?
Different vaccines are being developed using different technologies and platforms and are likely to have different efficacies, product profiles and characteristics. This robust vaccine pipeline gives us hope, even if there are many unpredictable factors which will determine their success.
There are promising results from the clinical trials for some vaccine candidates, which is very encouraging. However, we need to wait for completion of the vaccine trials and their outcomes to be in a better position to understand by when the vaccines will be ready for use. It is important that the potential vaccines meet the recommended mandatory standards of efficacy and safety before they are used for mass vaccination of human populations.
WHO is working with partners all over the world to accelerate research and development of a safe and effective vaccine and ensure equitable access for the billions of people who will need it. But even with an accelerated process, development and production of a vaccine for COVID-19 will take time. We must continue to accelerate vaccine research while doing more with the tools we have at hand.
India is among the largest vaccine manufacturers and is rightly called the pharmacy of the world. Undoubtedly, they would play an important role in making the vaccines available globally.
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Is WHO doing anything about ensuring equity in access, once a vaccine is available? Please tell us about the COVAX Facility.
In April 2020, a global collaboration of governments, global health organisations, civil society groups, businesses and philanthropies came together to form the Access to COVID-19 Tools Accelerator, or the ACT-Accelerator. The idea is to form a plan for an equitable response to the pandemic. There are 4 pillars under the ACT Accelerator, of which vaccines is one.
A COVAX Facility has been established recently under the vaccine pillar of the ACT accelerator to manage the large, diverse portfolio of vaccines that are under development, to ensure a global sharing of risks associated with the development of COVID-19 vaccines and an equitable access based on fair allocation of the available vaccines.
The COVAX Facility is a mechanism designed to guarantee rapid, fair and equitable access to vaccines worldwide. By connecting a pool of demand to a pool of supply, it will allow countries access to a broad portfolio of COVID-19 vaccines and provide manufacturers access to a demand-secure market.
All countries are being invited to participate in the Facility. The participating countries are expected to receive access to vaccines procured by the Facility at the negotiated price. The Facility aims to deliver 2 billion doses by end of 2021 to prioritised population groups in all participating countries.
WHO is committed to and will continue to advocate to countries to ensure that as medicines and vaccines are developed, they are shared equitably with all countries and people.
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In your view how should the vaccine delivery system be designed to deliver at the massive scale that’s required?
The vaccine delivery systems will have to be country-specific and will have to adjust to meet the requirements of the potential vaccine.
Innovative delivery strategies, leveraging existing vaccination platforms targeting high-risk groups such as health care workers will have to be utilised.
The principles of a COVID-19 vaccine delivery system should ensure key components such as availability of key personnel and the cold chain storage and transportation capacity as well as any potential gaps/needs in either of these. Strengthening information systems to allow timely monitoring and reporting of doses administrated and vaccination coverage at national and subnational level will be essential as also a functional vaccine safety system that allows reporting of adverse events following immunisation (AEFI) committee. Communication and demand promotion should be an integral part of the system.
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How efficacious will the vaccine be in terms of protecting people from the virus? Who will be prioritised and will booster shots be necessary?
There are currently 23 vaccines in clinical trial. We expect more to follow as there are at least 160 candidate vaccines. We are engaging with vaccine developers and others to ensure that we have standard end points and data collection mechanisms to regularly monitor both efficacy and safety of the vaccine candidates. These trials, once completed, will help to understand better the extent and duration of protection.
Different platforms are being used for development of different vaccines. The characteristics of different vaccines, therefore, vary. Only once we have the results of different trials, we will be in a position to inform whether boosters will be required or not.
An equitable distribution of a safe and efficacious vaccine is one of WHO’s priorities and we will continue to advocate with member countries and work with them providing guidelines and updated information on the population at risk and those who should be vaccinated on a priority.
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How has the departure of the U.S. from the WHO impact the organisation’s functioning and what measures can it take to shore up its finances?
WHO’s relationship with the U.S. is much broader and goes well beyond funding. It is about working together. The U.S. has been a vital partner to WHO since its creation in 1948. Over the years, the U.S. funds have supported programmes like polio eradication, health emergencies, TB, maternal health, immunisation etc. Together, we have worked to save the lives and improve the health of hundreds of millions of people around the world. WHO is reviewing the impact of the withdrawal and will collaborate with partners for work to continue.
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What are the big learnings for the WHO from this crisis?
This pandemic will have many lessons for everyone. The new coronavirus has affected millions of people across the world. Not just lives, livelihoods are lost and economies severely impacted. The pandemic has demonstrated that indeed health is central to the overall well-being of a country. We clearly need to invest more in strengthening our health systems and making them resilient to emergencies of pandemic proportion. A multi-sectoral approach is needed in pandemic preparedness and response.
Like in the past following the H1N1 pandemic and the Ebola outbreak, WHO would conduct detailed evaluation post-COVID-19 pandemic which would help it take measures to effectively respond to such events in future.
This has also been a practice at the regional level. Since the Indian Ocean tsunami in 2005, the WHO South-East Asia Region has been investing in strengthening emergency preparedness and response, periodically assessing risks and readiness, and putting processes and systems in place for an effective response like a regional health emergencies funds.
As a flagship priority, member countries of the region and WHO have worked closely for strengthening emergency risk management. Health emergencies in recent years such as the Nepal earthquake in 2015 and the ongoing Rohingya crisis in Bangladesh, witnessed fewer fatalities and health impacts than anticipated, because of the enhanced preparedness measures which enabled rapid agile response.
In September last year, WHO and member countries of the region adopted Delhi Declaration to strengthen emergency preparedness capacities at national as well as sub-national levels by scaling up risk assessment, increasing investments and enhancing implementation of multi-sectoral plans, which was timely and helped countries in the region respond to the COVID-19 outbreak at the outset with whole-of-government and whole-of-society approach.
What role is there for regional public health cooperation in the recovery from this pandemic, for instance relating to (a) vaccine development (b) case tracing, monitoring and surveillance?
From sharing lessons learnt, best practices, joint reviews to technical, financial and material support to responding to health emergencies, there is a strong culture of cooperation in the region, facilitated by WHO.
The Regional Strategic Preparedness and Response Plan for WHO South-East Asia, developed in February, in line with the global plan, has been guiding WHO’s outbreak response in the region. Based on this framework, WHO has been supporting the COVID-19 response in the region.
A meeting with vaccine manufacturers and national regulatory authorities of vaccine manufacturing countries like India, Indonesia and Thailand was organised by WHO South-East Asia Regional Office on 29 April to facilitate information sharing on COVID-19 development.
Since the start of the outbreak, WHO has been facilitating capacity building sessions and interactions for and between member countries on key response measures such as surveillance, contact tracing, infections prevention and control, laboratory strengthening, community engagement etc.
There is concern, given the past and present record, that more such viral pandemics could originate in China. What can the WHO do about it? What steps would it advise the world community to take?
The International Health Regulations (2005), which 196 countries across the globe have agreed to implement, lists out core capacities that countries must have and the measures that they need to take in response to emergence and re-emergence of international disease threats and other health risks.
The post-pandemic evaluation would determine further advise to the world, including WHO, to be better prepared for future.
Turning to the case of India and the lockdown strategy: how can India balance the need to slow the virus’ spread with the imperative of resuming economic activity?
As countries ease lockdowns and work towards finding the right balance to save lives as well as livelihood, the focus should be on local epidemiology to adjust and implement public health and social measures. A national risk assessment should be supported and implemented through subnational or even community level risk assessment, as the transmission of COVID-19 is not typically homogenous within any country.
The risk assessment should be based on epidemiological factors, healthcare capacities and public health capacities. Protection of vulnerable populations should be central in the decision to maintain or lift a measure.
Areas that are now witnessing plateauing of cases or a downward trend, have achieved this with aggressive implementation of core public health measures — detect, isolate, trace contacts and treat cases — complemented by protective measures like physical distancing, covering coughs and sneezes, and frequent handwashing.
This “new normal” does not mean “business as usual”. We must continue with the core public health and physical distancing measures and stay vigilant. India is already doing so. It is heartening to see India demonstrating unwavering commitment in its fight against the pandemic.
How much impact can social distancing, handwashing and mask use have if economic activity resumes?
People who are in close contact (within 1 meter) with an infected person can catch COVID-19 from infectious droplets from mouth and nose or aerosols. Hence, it is important to maintain social distancing, clean hands frequently, and cover mouth with a tissue or bent elbow when sneezing or coughing. Cleaning hands frequently is also critical. Wearing a fabric mask is an important measure to protect yourself as well as others. Fabric masks, if made and worn properly, can serve as a barrier to droplets expelled from the wearer into the air and environment. However, masks must be used as part of a comprehensive package of preventive measures, which includes frequent hand hygiene, physical distancing, respiratory etiquette, environmental cleaning and disinfection.
It is clear from available evidence and experience, that limiting close contact between infected people and others is central to breaking chains of transmission of the virus causing COVID-19.
What would you describe as India’s biggest challenge in tackling the pandemic?
India took early and decisive measures since the start of the outbreak and has since been scaling up capacities — ramping up testing, building and readying hospitals, training health workers, procuring medical needs etc, However, we are aware of the varying capacities at the national and State levels. Also, it’s not unusual in a country as big as India and its population size, that the measures taken may often not be uniformly sufficient across all areas. Scaling up capacities and response is dynamic in a country like India and remains a constant need and challenge.
When do you think India is poised to hit the peak of new cases and what numbers are we looking at?
It is hard to predict as the pandemic is still accelerating globally. The response in every country, everywhere must be to test, isolate, trace and care. That is every country’s best defence against COVID-19.
