Professor Nyunt Thein: Emeritus Professor in Medicine,Former Head of Department of Medicine, University of Medicine (1) Yangon
The world has faced an unexpected and unpredictable disease, COVID-19 since the end of 2019.In late 2019, a cluster of cases of pneumonia with unknown etiology appeared in Wuhan City, Hubei Province of China. Several of the initial patients visited a wet seafood market where other wildlife species were also sold. Subsequent virus isolation from human patients and molecular analysis showed that the pathogen was a new coronavirus. In 31st December 2019, Republic of China informed WHO about the occurrence of new Corona virus infection causing severe respiratory illness inWuhan, Hubei province. On 9th January 2020, WHO announced that this virus infection had human to human transmission. The disease started at Wuhan, spread to other provinces in China and to many countries worldwide. On 30th January 2020,WHO declared this illness as “Public Health Emergency of International Concern”. Since it is caused by a new variant of Corona virus previously related with SARS, it was previously called SARSnCoV. On 11 February 2020, it wasofficially labeled as COVID-19 and considered as a “Pandemic disease” on 11th March 2020, afterhaving spread to more than (60) countries. While the majority (80 to 85% of cases) result in mild symptoms, most common symptoms being fever, dry cough,dyspnea, and tiredness.Other less common symptoms are:aches and pains, sore throat , diarrhoea , nausea and vomiting conjunctivitis, headache, new loss of taste or smell, rashes on skin, or discolouration of fingers or toes. Some progress to acute respiratory distress syndrome (ARDS) likely precipitated by a cytokine storm, multi-organ failure, septic shock, and thrombosis. The time from exposure to onset of symptoms is typically around five days, but may range from two to fourteen days.
Up till 14th June 2020 morning, the reported cases globally(213 countries and territories around the world and 2 international conveyances), in newspapers and reports was confirmed cases(7,872,656) with (432,475) deaths with (4,042,466) cases recovered Just like our country, some Asian countries have low incidence of confirmed cases (tens or hundreds) and zero mortality was observed in Bhutan, Timor- Leste, Cambodia, Lao, Vietnam and Mongolia. This point is extensively studied by many scientists but no concrete findings havebeenestablished yet.
Since it is a new virus and disease, no one in the world knows everything about it and scientists around the world are trying their best to learn more with new findings reported every day. Since it is regarded as a “Pandemic”, WHO has laid down basic guidelines for prevention, control, containment and management of this superspreading disease and each country has had to adapt and modify these guidelines appropriately according to own perspectives, resources, facilities and context. From the very beginning, WHO has encouraged “test, test, test” for detection of the cases which could not be performed by low and middle-income countries. The sequence of actions included test, quarantine, contact tracing, quarantine, lock down(complete/ semi or partial),supported by Stay Home, Social / Physical Distancing, Hand Hygiene and Frequent Hand Washing, Proper and Effective use of Various Face Masks for allpeople. These measures are mainly for prevention, control and containment.
The currently available data suggests that many laboratory parameters are deranged in patients with COVID-19, and some of these may also be considered significant predictors of adverse clinical outcomes. The most frequent abnormalities were lymphopenia(35–75% of cases), increased values of CRP (75–93%), LDH (27–92%),ESR (up to 85%) and D-dimer (36–43% ), as well as low concentrations of serum albumin (50–98%) and hemoglobin (41–50%). Many laboratory abnormalities were instead predictive of adverse outcome, including increased white blood cell count, increased neutrophil count, decreased lymphocyte count, decreased albumin, increased LDH, ALT, AST, bilirubin, ferritin, creatinine, cardiac troponins, D-dimer, prothrombin time, procalcitonin and CRP value.
Regarding imaging, Chest Radiograph in early phase of disease are normal in half of the cases. Chest X-ray abnormalities include mainly interstitial changes, Ground glass opacities (GGOs), Effusions withLymphadenopathy being uncommon.The most common location is the lower lobe and nearly 20% have bilateral and multifocal lesions are seen in 24%.Up to 50% of patients with COVID-19 infection may have a normal CT chest scan 0 – 2 days after onset of flu-like symptoms from COVID-19. Usual CT features are Ground-glass opacities and consolidation, with or without vascular enlargement, interlobular septal thickening, and air Broncho gramsign.Crazy paving and consolidation become the dominant CT findings, peaking around 9 – 13 days, followed by slow clearing.
Concerning management of cases of COVID-19, WHO has published“Clinical management of COVID-19: Interimguidance” on 27 May 2020. Most of the countries have modified this according to their owncontext, resourcesand perspectives. Management depends on the severity of the disease:mild asymptomatic, mild symptomatic, moderate with pneumonia, severe with severe pneumonia, critical COVID-19 with septic shock.
Regarding the drugtreatment, in the early phase, no specific medication was prescribed (except ordinary pain killer and anti-pyretic) in view of viral aetiology. Among the people infected, 80 to 85% have only mild symptoms and some may be totally asymptomatic. The remaining 10 to 15% may have severe symptoms and 3 to 5% may have life endangering respiratory distress and even need oxygen therapy via CPAP or ventilatory support in ICU setting. Therefore,some medicationswereprescribed. After the outbreak in Wuhan, China, the Scientists there have been successful in detecting the nature of the virus including genome. Since the genome is somewhat similar to HIV, the use of the Anti-retroviral drugs (Lopinavir/ Ritonavir combination) was started. In some countries, the antibiotic Azithromycin was used. Since most of the severe complications are not due to the virus itself but because of Cytokine Storm, immunosuppressive agents like Chloroquine/Hydroxychloroquine, Steroid like Dexamethazone and Interleukin blocker like Tocilizumab were used in various centers.InJapan, drugs previously used for influenza (Favipiravir)(Avigan) was given. Drugs used for some worm infestations like Ivermectin was tried in some setting. All of these regimes are not evidence based, scientifically proved and the results were also quite equivocal. They have been using on compassionate ground since there was no approved regimes.
Among the not yet proven treatments, one drug was outstanding:Remdesivir, a product of Gilead Science, USA which was initially approved to use for Ebola virus infection since 2017. Since COVID-19, like Ebola virus is caused by a strain of Corona Virus group, this drug was used as a trial in Wuhan outbreak. It has to be given intravenously for (10) days; 200mg on first day and 100 mg for nine more days. The trial was done in (237) patients who had severe COVID infection: (79) patients were given their routine treatment and Remdesivir was added to (158) patients. The finding of that trial was described in “The Lancet” Journal and the result did not show much difference in the two groups but suggested that more research was needed with a larger group.
On 21st February 2020, Gilead Science started a historic trial called ACTT(Adaptive COVID-19 Treatment Trial) with Remdesivirin in 68centers (47 in USA and 21 in EU and Asia) recruiting(1063) patients. The first historic patient was an American on the “Diamond Princess Cruise” which boarded atYokohama, Japan and study was done at University of Nebraska Medical Center. The trial was done only in severe cases of COVID and compared two groups: one receiving (10) days regime of Remdesivir in addition to conventional supportive management. The results showed that the “treatment group “had faster recovery than “control group”(11 days Vs 15 days). For survival benefit, the mortality rate in treatment group was 8% and control group was 11.6% but it was not statistically significant.Generally, for a new drug to be used widely, the scientific studiesneed to be done, firstwithanimal studies and then with human trials, with (4) phases involving thousands of participants. Only after that when the efficacy and safety is absolutely sure, the drug will be approved and issued License by FDA. But the “pandemic” nature of the disease and promising result of this trial,US FDA has allowed this Remdesivir for EUA: Emergency Use Authorization forsevere COVID cases in their county.
Gilead Science continued to conduct alarger two step trial namely SIMPLE Trial. In First SIMPLE trial, among the severe COVID in patients, one group was given (10) days regimes whereas second group was given (5) daysregime andthe response observed. It was conducted on (397) patients and the result was promising. The study now extended to (5600) patients in more than (180) trial sites in USA, France, Italy, Spain, Germany, Sweden, Switzerland, Netherland, UK, China, Taiwan, Hong Kong, Japan and Korea. Second SIMPLE trial will be conducted as the first phase in (600) patients with moderately severe cases.
In fact, this drug,Remdesivir is a product of Gilead Science, approved and licensed to use for Ebola disease in 2017. Gilead Science has a twenty year patency of this drug till 2037. At the moment, Gilead Science has supplied the drug to conduct various trials and research in various centers and regions.
WHO has also started a trial namely “Solidarity Trial“in (4) groups of patients, each group receiving different drugs (1) Remdesivir, (2) Chloroquine/ hydroxychloroquine, (3)Lopinavir+ Ritonavir and (4)Lopinavir+ Ritonavir plus Interferon beta 1a .This trial is being done in (100) countries including India. On June 01, 2020, India allowed the usage of the popular drug, Remdesivir for emergency treatment in critical cases.
Another large trial: “ Recovery Trial ” is also in progress and conducted at Oxford University , UK with (5000) participants and divided into (6) groups : one group was treated with supportive treatment only and the patients in remaining groups receiving different regimes; (1) Lopinavir+ Ritonavir combination, (2) Chloroquine/ hydroxychloroquine,(3) Azithromycin , (4) Dexamethasone low dose and(5)Tocilizumab. Sun Pharmaceuticals is also testing a repurposed drug, AQCH as a part of COVID-19 treatment plan.
Further treatment options for COVID -19 are also on the way, including giving “Convalescent Plasma” from fully recovered patient. The first published report of convalescent plasma against COVID-19 regarding five seriously ill patients in China was reported in a preliminary communication in JAMA about5 seriously ill patients in Chin( posted online March 27). Two more reports from Wuhan, one published April 6 and the other published April 15, described infusing convalescent plasma into a total of 16 patients seriously ill with COVID-19. All three articles said the therapy appeared to save lives; the authors called for randomized controlled trials to confirm their findings
Since this treatment is not established, accepted and practiced before, it is important to determine through clinical trials, before routinely administering convalescent plasma to patients with COVID-19,to make sure that it is safe and effective to do so.Another is expanded access, also called “compassionate use,” which enables patients with a serious or life-threatening disease to obtain an investigational medical product outside of a clinical trial when there is no alternative treatment available. If such patients can not obtain convalescent plasma through clinical trials or an expanded-use protocol, their physician can request a single-patient emergency Investigational New Drug Application (eIND).Houston Methodist Hospital reported that on March 28, it became the first US hospital to provide convalescent plasma to a patient with COVID-19, under an eIND.
The FDA’s National Expanded Access Treatment Protocol entry criteria are fairly broad: Adults aged 18 years or older with COVID-19 whose disease is severe to life-threatening or deemed by their physician likely to become so are eligible. By April 27, 2115 sites had registered to participate and enrolled 5968 patients, 2576 of whom had received convalescent plasma.
This is also studied at London’s Guy’s and St Thomas’ hospital in UK, Inova Advanced Lung Disease and Transplant Program at Inova Fairfax Hospital in Virginia, USA, Germany and some other countries. This treatment is given only to severe COVID cases at the moment.
Some Scientists are trying out the use of Monoclonal Antibody treatment. Separate studies in Israel and the Netherlands claim to have created antibodies that can block the coronavirus infection, a potential future treatment touted as a game-changer until a vaccine becomes available. Many scientists in many countries (USA, Netherland, Israel, India ) are looking into the use of such an antibody in Covid 19 treatment.
In any infectious disease, vaccines play a major role in prevention, control andmanagement. In normal times, vaccine development takes many years but today we are seeing accelerated timelines coupled with pressure from governments, the media and the public.Optimistic experts hope that a viable vaccine may be ready by the end of 2020. Other experts caution that the timeline may be unrealistic. Only a small number of those vaccine candidates are being tested on people, and chances are many of the other projects won’t survive beyond the laboratory stage. Even so, vaccine experts point out that funding has been plentiful, many different approaches are under study, and collaborations between small firms developing the vaccines and large drug companies with the capacity to mass produce them all give reason for hope.
In March, 2020, Moderna company (Boston based biopharma, USA) began testing its messenger RNA (mRNA) vaccine in a phase I clinical trial in Seattle, Washington. The study included 45 healthy volunteers (ages 18 to 55), who got two shots 28 days apart. The company has developed other mRNA vaccines before. Those earlier studies showed that their platform is safe, which allowed the company to skip certain animal testing for this specific vaccine. Moderna announced that this vaccine, mRNA-1273, had been cleared by the FDA to move into a Phase II trial. The study, which has enrolled 600 participants in early May was designed to assess whether or not the potential vaccine can induce a person’s immune system to produce antibodies that recognize SARS-CoV-2. Recent news revealed that Moderna will start Phase III of COVID-19 Testing in July, with 30,000 volunteers receiving 100 microgram doses of the vaccine,
When COVID-19 appeared in December, the Inoviocompany had already been working on a DNA vaccine for MERS, another coronavirus. This allowed the company to quickly develop a potential vaccine for SARS-Cov-2. Company officials said they expect to have all 40 volunteers signed up for their initial clinical trial by the end of April.
University of Oxford in England, led by Professor Sarah Gilbert, became Europe’s first to enter human trials. The vaccine is based on a technology using a modified virus to trigger the immune system, made from a weakened version of a common cold virus (adenovirus), and taken from chimpanzees. The adenovirus is genetically altered so it can not reproduce itself. The vaccine is combined with genes of the spike protein to trigger production of vaccines to create a SARS-CoV-2 look-alike that doesn’t cause disease but does trigger an immune response to destroy the SARS-CoV-2 virus. A clinical trial with this vaccine ChAdOx1 nCoV-19 began in late April with more than 500 participants. British regulators pushed forward with a large Phase II study involving 6,000 people. Oxford officials said the potential vaccine has an 80 percent chance for success and could be available as early as September. After reaching a license agreement with Oxford University and others, AstraZeneca agreed to supply more than 2 billion doses globally, anticipating delivery of 400 million doses before the end of 2020. In early June, Brazil, hard hit with COVID-19 cases, joined the clinical trials, planning to test 2,000 volunteers there.’
Universities of Queensland in Australia, and the Imperial College in England are also involved in undertaking vaccine development research. China is also involved extensively in development of Vaccine for COVID-19. Currently, a vaccine was produced from chemically inactivated version of thevirusin China.Development of effective vaccine for COVID-19 is also being tried in Korea, Germany, Taiwan, Japan, Iran,Turkey and India.In addition to new vaccines, various scientists, researchers and vaccine experts are studying the role of existing vaccines like OPV (oral polio vaccine) and BCG for preventing COVID-19.
In the absence of standard treatment regimen and effective vaccines,the countries are handling this pandemic disease with their utmost effort byfocusing mainly on prevention, control and containment.
More than one-third of the world population was locked down, as part of the ‘suppression’ strategy first proposed by Imperial College London, United Kingdom. Such a strategy is aimed at reducing the spread of infection, protect health services and save lives. However, it has major economic impact globally and has had a deep social and psychological impact on many people. Therefore, it is not feasible to maintain the current lockdowns indefinitely.
At any stage of the pandemic, political decisions must be built upon a mixture of scientific evidence of the outbreak control and political imperative to ensure economic continuity. The fear of a second wave must always be uppermost in the mind of decision-makers and the country should have a clear plan and preparation for such an eventuality. The director of the Centers for Disease Control and Prevention, United States, warned that a second wave of COVID-19 is inevitable, and it is ‘likely to be more devastating’. Any decision on unlocking towns and cities should consider a range of existing and emerging evidence so far.
Novel evidence is emerging day-by-day as we learn how to tackle the virus effectively. Still, many gaps in our knowledge do exist. These include, as described above, the absence of a vaccine, despite major efforts both publicly and commercially, and no definitive treatment despite the use of many existing and emerging drugs, blood transfusions and plasma treatment. Furthermore, little evidence of full immunity is available and reinfection is reported. Some countries are assessing the level of immunity through antibodies’ tests, yet emerging studies demonstrate that there is more than one genotype of COVID-19 virus (SARS-CoV-2) with different infectivity level, spread and immunity. In the absence of a vaccine or treatment, computer modeling suggests that it can take nine waves of infection to achieve herd immunity.
The current coronavirus is not like the seasonal influenza and the next wave, if any, will be during any season. Even though this has yet to be proven, we must remember that seasonality does not constrain new viruses in the same way that long-existing viruses are affected.Although80 to85 % of the COVID-19 cases are either subclinical or mild, the lack of credible treatment to deal with moderate and severe cases and the absence of a vaccine to achieve full herd immunity, may lead some countries to endure repeated waves of infection. Overall, we are aware that our social life and economy are suffering, jobs are lost, families are separated, and mental health is at risk. Any analysis or risk assessment for unlocking should be framed within public health principles outlined as follows, and consider the above scientific evidence, or lack of it.
Public health principles for unlocking towns and cities
Governments cannot continue locking down towns and cities forever. A clear and explicit “exit strategy” to unlock and restore “normality” is needed for each country with emphasis on key public health principles and indicators unique to the population. Each government, based on these principles, must decide how long the lockdown and social distancing should continue, what should be eased, the stages of easing such a lockdown and measures taken to monitor the abatement of the virus. Most countries need to develop a collaborative stepwise approach and prepare for the transition to ease the shutdown, especially those with shared borders or land mass. Four important principles should be carefully analysed and calibrated. Relaxed measures should be a holistic approach incorporating all the four public health principles rather than the decline of infection. These principles are; infection status; community acceptance; public health capacity; and health system spare capacity.
The Infection Status
First, the infection status depends on the rate of infection, expressed as an incidence rate. This is the number of new cases within a time period, as a proportion of the number of people at risk. A declining incidence rate is evidence that the virus transmission has slowed down. i.e., the infection curve is flattening and the basic reproduction number (Ro) is below 1. Secondly, the doubling rate of infection, referring to the number of days needed to double the number of infected people. Increase in doubling time indicates a slowdown in transmission (if underlying reporting remains unchanged). A doubling rate between two weeks and one month, or longer, could allow for easing restriction. Third point is, case contacts, ideally expecting the number of contacts generated per case to be one or less. Finally testing positivity rate as the proportion of all samples testing positive; this should be no more than 5%.
Community acceptance
Unlocking, partially or completely, is a political decision based on clear and specific public health advice at the highest level in government. The measures that need to be taken may continue to affect communities’ economy and lifestyle in the short and long term. Therefore, to ensure full public engagement, it is vital that governments are transparent and include community acceptance in the equation. This is a complex issue and the “new normal” means adjusting work, social, and economic activities, which may not be fully resumed until an effective treatment and / or a vaccine are available.
Some elements of social distancing should continue. These range from prohibiting gatherings (social, religious, conferences, large sport events, cinemas, gyms, theatres etc.); limiting movement of people between towns and cities depending on the subnational analysis of the rates of infection; to continuation of shielding people over the age of 70 years old, vulnerable children and those at high risk (e.g. immune-compromised) until further notice. Avoidance of customary greetings such as handshakes and kissing as well as concurrent vigorous hand washing advice will be the norm for some time to come. Travel on public transport and commercial aircraft will be redesigned to maintain social distancing through seat spacing and passengers number restrictions. Shopping and other social activities should follow strict rules on social distances and protect workers in the service industry. Student learning and examinations, including those of medical schools, should seek to continue to comply with social distancing measures. Economically, the population must accept new or increases in taxation for a period to forfeit the dire economic situation created by COVID-19’s lockdown. Furthermore, certain employees, public and private, may need to accept “reasonable” reductions in incomes and reduced benefits. These indicators must be assessed fully regarding public engagement and acceptance. At the same time, immediate measures must be introduced to prevent worsening poverty and to alleviate any suffering caused by COVID-19.
Public health capacity and measures
Public health capacity draws not only on resources but also on organizational structures, partnerships, leadership and governance in the country specific context. It is vital that public health capacity is given the full support required in terms of workforce, laboratories, transport, medical equipment, personal protective equipment, settings and other logistics. Data collection, analysis, modelling, projections and reporting should be given full priority in collaboration with academia and international organisations such as WHO and the United Nations Children’s Fund (UNICEF).Surveillance is a vital part of public health functions. There shouldbe a highly effective surveillance systems in a variety of settings to assess current infections and predict any possible new wave(s) of infections, thereby triggering the correct measures for suppressing it (being ahead of the curve). Such surveillance should include a well-defined system of active case finding, testing, isolation of positive cases, tracking all immediate contacts, and ensuring quarantine accommodation is decent and under continuous surveillance. All ports of entry should also be subjected to such a system. Health authority should provide adequate, transparent and timely public information, which should be in all languages used by the communities. Last but not least, the emergency preparedness plan must be updated on a regular basis taking into account the speed of development in this pandemic. Such updated plans must be shared with all sections of government, which should ensure that indicators of public health capacity are at the appropriate level before considering relaxing lockdown measures.
Health system spare capacity
Protecting the health system to ensure that it will not be overwhelmed is one of the major public health challenges during this pandemic. Except for a very few countries, most health systems around the world were not prepared for this pandemic. This was reflected in rather weak public health infrastructure, shortages in intensive care beds, shortage of equipment (oxygen supply, ventilators, personal protective equipment, transport, morgues, etc.), and shortages of staff. In reality, most health systems were operating at near 99% capacity before the pandemic. Therefore, in preparation for the partial or complete “unlock”, the entire health system must be ready. Singapore, Taiwan and South Korea have learnt the lesson of SARS-1 and MERS in the last two decades and prepared their health systems for such eventualities. These countries invested in their health systems for the future to save lives and reduce the economic cost in the event of a pandemic repeat. Other countries should do the same.
Intensive care training should be mandatory for all medical and nursing students. Ambulance services should be enhanced, both in number and training. Finally, volunteer services and community groups should be structured and organised to have maximal cooperation and support.
All these measures should be part and parcel of the country or local emergency preparedness plans, which must be robust, evidence-based and ensure community engagement. We must be vigilant through surveillance, monitoring and risk assessment and it must be clear to the public that, if the trend shows an increase in the number of new cases, a quick emergency brake and re-introduction of physical distancing measures to contain the virus will be required.
For most of the developing countries including us, preventive measures are vital in control and containment of current episode as well as prevention of second and further waves. The next 6 months will surely bring us still more knowledge about the coronavirus, but until the vaccine and effective medical treatment is ready; life likely won’t go back to normal.
Therefore, we must adapt to a new reality. We need to find a way to live with this virus and minimize its harms. We all should prepare ourselves for “New Normal” life. Stay home, social distancing, wearing face masks according to the need and hand hygiene will be “norm” for everyday life for all.
We should still practice “Stay Home” policy for venerable groups. Phase wise (Stepwise) release of all activities should be like any other countries. Any lifting of restrictions will rely on high levels of support and compliance from the whole population with any continued physical distancing. Around the world, nations are considering different options for easing or re-imposing restrictions These are likely to include the easing of restrictions in a phased manner, opening up different parts of the economy sector by sector, considering different restrictions in different areas dependent on how the pandemic is progressing, and considering options for different groups of the population – as is currently the case with those shielded for clinical reasons.
Social Distancing must be emphasized in all places, preferably 6 feet apart especially outside home including work places in offices, factories, industries, schools, bus stops etc. and also in parks, beaches, shopping centers / super markets and so on. Previously held meetings, seminars conferences and congress will be modified to be “web streaming events”. Electronic based activities should be practiced as much as possible in every sector.
Some degree of travel ban and restriction should continue according to own country’s situation. All persons entering into the country by air or by sea or by any routes should be asked to fill health declaration form including contact and travel history in detail properly and all should be checked body temperature by infrared thermometer. In current situation, all the passengers must be quarantined in designated areas (hotel quarantine / community facility quarantine) for at least 2-3 weeks (depend on own guideline of the country) and test should be done at least two times during quarantine period. If test is positive, in our country, the person should be admitted to designated hospital even he or she is totally asymptomatic. Intensive contact tracing of test positive person should be carried out and they also should be treated as above. Even the individual has two negative tests during quarantine period and allowed to go back home, he or she should be advised to do home quarantine for further 1 -2 weeks with strict social distancing which should be continued like any other persons.
Wearing the face masks should be second nature of our people (just like who goes outsidefrom home always wearing footwear, slippers or shoes. automatically).Non-medical persons should use homemade cotton/ fabric face maskfor daily use and surgical masks and special masks like N-95/ KN-95. FFP-2/FFP-3 should be reserved for front line health care workers. Because of scientific research,technology anddevelopment, unlike previous days, some of the homemade masks now a day have been improved a lot and can have some protective properties of virus and bacteria ranging between 45 to 91% filteringcapacity. WHO continues to recommend that a person with symptoms suggestive of COVID-19, even if symptoms are mild, should wear a medical mask (and seek medical attention).In areas whereCOVID-19 is widespread, WHO advises governments to encourage the use of medical masks among vulnerable populations: people aged 60 years and older, and those with underlying comorbidities.
Hand hygiene is another equally important preventive measure and proper and standard had washing with soap at least 20 seconds should be done, not only before and after taking meals and after toilet, but also whenever the individual touches any object and coming back home from outside. If the soap is not available, hand sanitizers / gel containing 70% alcohol can be used and smalltubes should always be carried for necessary use. Public hand washing facilities like water basin, soap and tissues should also be provided in all working and public places mentioned above. It is also important not to touch any part of face especially “T zone”with hands.
Physical distancing, hand hygiene, and other critical behaviors will be essential in each sector. We will engage with experts in each sector to understand the practical consequences. In addition to the effect of different options for easing restrictions on the transmission of the virus, we will consider the practicality of measures, their sustainability, their proportionality, the ease of reintroducing measures in the event that exponential transmission was to reoccur, and the clarity of the message for the public. Options for varying the restrictions include full and partial lifting of existing measures. In terms of partial adjustments to measures, there are a number of approaches that can be taken and we will consider them in accordance with the principles set out by the responsible bodies. These include variations by geography, by sector, or by specific groups of the population. Looking forward, they also include the potential introduction of new restrictions and (partial) re-imposition of measures to keep the virus suppressed, guided by the evidence and broader considerations which have set out.
Another important point in this “COVID Era” is about Non-COVID health problems. Being a rainy season, we will now be facing Seasonal Influenza, Dengue Hemorrhagic Fever,Chikungunyainfection and water-borne infections like Cholera, Gastroenteritis, Dysenteries, and Viral Hepatitis A&E. Just like any other developing countries, while we are struggling with communicable diseases, we are also have facing more and more cases of non-communicable diseases (NCDs) like hypertension, diabetes, heart diseases, strokes, cancers and COPD and efficient, timely and effective management of these NCDs are equally important.
In conclusion, we all have to live with COVID-19 by full understanding and strict practice of many precautionary measures and although physical distancing is strongly advised and practiced, we all should be united in our hearts and minds to have enjoyable, fruitful and meaningful New Normal lives.
Disclosures: I have no conflict of interest although some pharmaceutical firms are mentioned in this article. I have used facts, figures and points from many reliable websites including Myanmar MOHS, WHO, CDC, UNICEF, John Hopkins, Royal College of Physicians of UK, Gavi, the vaccine alliance,Medscape CME, Web Med and also, publications from journals. Information mentioned in this article is true and valid till 14th June 2020.
