Interview with Prof. Si Huyen Nguyen, PNTU HCMC
Interviewed by: That Thong Ton, DĐKP Magazine
In the current corona situation, especially in the western countries, the Vietnam phenomenon is submerged. The low number of people with Sars-CoV-2 who are tested positive in Vietnam and no deaths from COVID-19 do taken scientists around the world aback, they can hardly believe these numbers. In the fight against COVID-19, Vietnam mainly pursues a policy with strict personal control, individual isolation and quarantine measures with selective implementation of the Sars-CoV-2 tests. Bearing in mind the high number of unreported and symptom-free people, these measures can certainly not be the only explanation that the spread of COVID-19 could and can be effectively controlled. Indeed, it has to be emphasized that a high mortality rate did not occur in Vietnam compared to Europe and USA. In this regard, we have had a conversation with Prof. Nguyen from the Pham Ngoc Thach University HCMC and did find highly interesting new aspects in the field that we would like to share with you. The interview is reproduced below.
About Prof. Dr. Si Huyen Nguyen:
Vice Dean of Vietnamese German Faculty of Medicine (VGFM), Pham Ngoc Thach University Ho Chi Minh City (PNTU HCMC), Dương Quang Trung 2, P12, Q.10, Ho Chi Minh City, Vietnam. Website: www.pnt.edu.vn, http://kyvd.pnt.edu.vn/
HELIOS St. Marienberg Hospital, Department of Cardiology, Intensive Care Medicine and Sleep Medicine, 38350 Helmstedt, Germany
Honorary professor at the University of Hue / Vietnam
President of German Vietnamese Association of Cardiology. Email: firstname.lastname@example.org, www.dvfk.org
German office: Langer Kamp 6, 38350 Helmstedt, Tel. 05351-141471
DĐKP: Good morning, Professor Nguyen. First of all, we would like to thank you very much for taking time to conduct this interview with us. Would you firstly give us a brief overview of the current situation and the development of the corona pandemics in industrialized countries such as USA and Europe?
NGUYEN: With regular monitoring of the development of COVID-19 in Germany, Italy, Spain, the United Kingdom and the United States, it is certainly not difficult to see that the COVID-19 pandemics has spread very rapidly in these countries. The current high death rate from the COVID-19 pandemics in Europe and the United States is updated daily on the John Hopkins University website. However, it does not reflect the medical expertise of these countries, but rather the difficulty of an overburdened health care system in responding appropriately to such situations, even if they have a very high scientific background. Unfortunately, it must be noted that in most countries the danger of this pandemics was underestimated in the early stages. Germany seems to be different. The development of the COVID-19 in Germany has been so far well controlled. In my opinion, the death rate in Germany is realistic. Nevertheless, the death rate (in Germany and elsewhere) only shows that these patients were infected by Sars-CoV-2, but whether they actually died from the corona virus or not is not clear. Usually these patients have a high degree of comorbidity such as high blood pressure, diabetes mellitus, chronic heart or lung diseases or diseases associated with an immune deficiency. So far there are no investigations about it. In any case, the strict preventive measures which have been implemented recently [in particular the avoidance of social contacts as well as the maintenance of a contact distance of 1.5 to 2 meters and hygienic measures such as regular hand washing] have effectively contributed to slowdown the spread of COVID -19.
DĐKP: How is the Covid-19 developed in the near future? When can we expect the end of the pandemics?
NGUYEN: The progression of COVID-19 in various countries differs from the peak of the epidemics, depending on the measures which were taken sooner or later in the respective country to constrain the spread of COVID-19. The resulting health and economic consequences for the involved countries are currently not predictable. Regarding the development of COVID-19, it can already be pointed out that the progression of COVID-19, as long as a specific vaccine is not yet available, can only be stopped by an immunity of around 60-70% of the population, according to well-known epidemiologists and virologists.
DĐKP: Would you tell us when an effective mass vaccine could be available?
NGUYEN: Vaccine research is currently advancing at unprecedented speed. Nevertheless, the vaccines ultimately have to be manufactured using appropriate technology, and all of this takes time. According to Professor Drosten, director of the Institute of Virology at the Charité University Clinic in Berlin, we could possibly expect an effective vaccine for the broad population by summer 2021.
DĐKP: In fact, we don’t have any vaccines at the moment. However, we still need to find a way for treating infected patients. Are there any medicines that can be used for this purpose?
NGUYEN: In fact, there already has been an experimental use of drugs to treat COVID-19, such as Remdesivir, chloroquine, hydrochloroquine, which effectively inhibit Sars-CoV-2 reproduction in vitro. However, their effectiveness has not yet been clinically demonstrated, based on evidence. As long as there are no evidence-based studies exist in this area, any treatment with these drugs is carried out either off-label use or for scientific reasons. Currently, there are no official recommendations in Germany for the use of these drugs.
Recent studies with BCG tuberculosis vaccines against Covid-19, based on previous research, show that BCG lowers virus levels in patients infected with a virus similar to SARS-CoV-2. But we are still waiting for detailed information.
DĐKP: Who belongs to the group of people at risk and what is the possible course of a COVID-19 infection?
NGUYEN: A mild course of the disease is seen in 80% of cases. No special treatment is required. It must be pointed out that we do not know the proportion of symptomatic to asymptomatic patients in this group (the so-called unreported cases) . According to Professor Kim Woo-Ju, a South Korean infectious disease expert, this figure is about 20% in South Korea, and according to German experts, these unreported cases could be higher. Furthermore, about 15% of the patients are in a condition requiring clinical observation, 5% of the patients nead intensive medical treatment. The number of deaths currently varies between 3.2% and 12.9% (ratio of deaths to infected patients with a positive test). But this is inaccurate, since the number of really infected patients is in fact unknown. Patients who are seriously ill and cannot be rescued with intensive medical care die at mean about 3 weeks after the beginning of symptoms.
According to the epidemiologist Professor Stefan Willich from the University of Charité Berlin, the statistics on deaths from COVID-19 (status in Germany on 1.4.2020) show that about two thirds occurred in older people over 80 years old, 30% in the age group between 60 and 80 years and 5% in the age group under 60 years. Therefore, the age groups of people over 60 and especially over 80 years should be given special protection against COVID-19 infection. Of course, people with chronic diseases including cardiovascular or lung diseases or patients with an immunodeficiency syndrome in general are belonging.
DĐKP: How do you assess the danger of COVID-19?
NGUYEN: When talking about the danger of an illness, two factors have to be considered: the mortality and the consequences of the illness. The current death toll from the COVID-19 pandemics is indeed a matter of concern and remains worrying, although the current high mortality rate in the affected countries mainly occurs in cases where the health system is overburdened. Regarding the consequences of the disease, there are suspicions of a number of different inflammatory organ diseases, including gastrointestinal, neurological, cardiac and nephrogenic, as well as the possible development of pulmonary fibrosis after pneumonia with Sars-CoV-2.At present, however, the time for post case investigations is not long enough to be able for assessments of these cases. What is the real number of fatalities without overloading medical care systems? No one can answer at the moment, since the “fight against the virus” is not yet accomplished. An interesting example is the course of the COVID-19 in Vietnam, which, unlike in the western countries, surprisingly does not seem so dramatic. We should definitely take a closer look at this phenomenon from a different perspective.
DĐKP: While countries with highly developed health care system, such as USA, most European countries and many countries in Asia, have a very high number of infected people, Vietnam with limited medical care system has for today, on April 25, 2020, only 270 people who are tested positive or infected. How do you explain that?
NGUYEN: For me, some measures were difficult to understand: despite the direct proximity to China, the border was not really closed, during the time of the outbreak in Vu Han, normal regular air traffic from Wuhan, South Korea and Japan to Vietnam did continue. Although Vietnam has carried out strict personal control measures, due to the high number of unreported cases (untested infected people with no symptoms) the situation could not be fully controlled.
In Europe the COVID-19 infection has spread very quickly. Theoretically, there is no reason why the COVID-19 in Vietnam should behave differently. With geographical proximity to China, extensive trade, social contacts and mass tourism from China, Vietnam even exposes ideal conditions for the rapid spread of COVID-19 infection.
Based on this consideration, it can be assumed that COVID-19 came to Vietnam very early, predominantly infected the young population and thus spread unreportedly through these population without significant symptoms compared to the rate of infection in Europe, especially in Italy, and in the United States. It seems to be possible that since December 2019 millions of Vietnamese, mainly young people, have been infected with Sars-CoV-2 and have already healed, which may have led to a certain broad immunity of the population and therefore (to some extent) to a natural barrier for the spread of COVID-19.
DĐKP: Please allow me to interrupt you. According to epidemiological estimates, the spread of COVID-19 would only decrease if the general immunity in the population had reached the 60-70% mark. That would be approximately 50-60 million persons in Vietnam. Could we have reached this level in the past 5 months?
NGUYEN: Theoretically, the rapid spread of COVID-19 in Europe and the United States shows that we cannot exclude this possibility, especially because of the high population density and high mobility of young people in the public life. In reality, I estimate that an immunity of 30-40% of the population in Vietnam – and this could probably be the number that comes close to reality – would be enough to significantly reduce the infection rate for older people. The percentage of older people in Vietnam is relatively small. Moreover, most elderly people also tend to live in seclusion, mostly in the family, and tend to be less involved in public life.
From the Dutch study of the Netherlands [Reuters, Word New April 16, 2020] it was estimated that possibly 3% of the population in the Netherlands had already produced antibodies against Sars-CoV-2. This means that the number of unreported cases is around 500,000, 17 times higher than the official number of people who are tested positive, which at the time was around 30,000. I think with these numbers, which are probably still underestimated, it can be imagined how fast the COVID-19, with a replication factor of 2-3, (i.e one infected person infect 2-3 more people), could have spread in Vietnam, if the infection chains would have not started at the end of January 2020 – as in Europe – but rather earlier, i.e around December 2019.
DĐKP: Not only there are few infections, also the number of deaths in Vietnam is zero, which is hard to understand. How do you explain that?
NGUYEN: The answer is quite interesting if you look what it’s happen from different perspectives. I would like to take Germany as an example for comparison. Germany has a land area and population density that are very similar to Vietnam. I would like firstly to provide some important data from Germany and Vietnam to clarify the situation. According to the Robert Koch Institute, the central institue of the federal government in the field of disease monitoring and prevention, 152,438 people were infected in Germany at the time of April 25, 2020 and 5.500 died. The Sars-CoV-2 test has been carried out in Germany until April 19, 2020 on 2.072.669 people [see RKI]. To date in Vietnam, a total of around 213.000 tests (as of April 29. 2020, see Wiki) have been carried out. This limited test performance means that people who die from their underlying diseases or age-related illnesses in Vietnam do not know whether the death is related to COVID-19 or not.
I am simply assuming that some deaths from COVID-19 are suspected. In Germany, on the one hand, the test is positive for many people, but it is also a question of whether they died because of their underlying illnesses or COVID-19.
On the other hand, here in Vietnam, in my opinion, two factors play an important role that could have had a decisive impact on the difference between the death rate in Germany or Europe and in Vietnam, respectively. On the one hand, there is the enormous difference in the proportions of population above the age of 60 and, on the other hand, the socio-cultural difference between Europe and Vietnam in everyday dealings with each other. The socio-cultural behavior in everyday life can be seen to a certain extent as a European or Western form of less protected behavior and a Vietnamese form as more “contra corona”.
DĐKP: These are interesting theses! Could you please explain it in more details?
NGUYEN: If we know that people over 60 years of age, as mentioned above, have increased mortality from COVID-19 infection and social contact increases the risk of infection, we may assume that people in Vietnam simply have “natural protective benefits” from their everyday life against COVID-19.
The first benefit is that, in Vietnam the percentage of people above 60 is about 10% (in other reports the portion of people above 65 is 5.5%, respectively). This figure is very low compared to Germany at 23.4%. The average age of the Vietnamese is 30.9 years, in Germany 44.4 years, life expectancy in Vietnam is 73.6 years, in Germany 80.9 years. The population in Vietnam rose from 54 million in 1980 to 97 million in 2020. It should be noted that up to 90% of the Vietnamese population is currently in an age range in which death rate due to COVID-19 is rare.
Such “phenomenon” as in Vietnam can also be seen in some other countries with few COVID-19 fatalities. They have similar demographic structures, e.g. even in a populous country like India.
The second benefit is decisive for limiting the spread of COVID-19 in society, particularly for the elderly. There is a difference in everyday behavior between Europeans and Vietnamese, influenced by socio-cultural traditions and customs. In Europe there is a common behavior: you often shake hands when greeting, close friends or family members hug and kiss on the cheek, open conversations between young and old people are as a matter of course. In Vietnam there is rather a “contra corona behavior“: through family education, which is largely influenced by Confucianism, there is a high respect for older people, especially for parents, grandparents, aunts and uncles in the family itself, which spontaneously leads to a certain social, physical distance to older people. This kind of gap has always been an old tradition, in both family and social life. There is also a certain language barrier, which also tends to promote additional social distancing. The form of greetings in the Vietnamese language constrains himself as little siblings, children or grandchildren in the communication with older people, and vice versa, as a big uncle, uncle or aunt, parents in the communication with young people. This barrier forces the young people to accept their “lower” position in the hierarchical structures prevailing in the society. In Vietnam, open conversations between old and young people are less common. In addition, people in Vietnam usually retire after the age of 60. They tend to live in seclusion with their family, and participate less in activities in public life.
DĐKP: What do you think Vietnam should do now with the increasingly complicated situation of COVID-19?
NGUYEN: Vietnam is in a state of “total social isolation” since April 01st, 2020, as Prime Minister Nguyen Xuan Phuc announced. This drastic measure and the previously targeted screening, testing, surveillance and quarantine measures have proven effective, not only in Vietnam but also in many other countries to prevent the spread of COVID-19. This time could be used to identify the sources of infection and to keep down them effectively by consistently tracking the infection chains, in particular isolation, surveillance and quarantine measures.
The difficulty for many countries is currently how to get out of this situation in order to return to normal social activities and to recover the economic damageas soon as possible, simultaneously to be prepared for another severe COVID-19 outbreak.
So far we do not know how many people really have been infected. Calculations based on predictions without this knowledge are inaccurate. Therefore, in order to better understand this situation, it is important to carry out a wide-ranging investigation using antibody tests – this may at random in the beginning – in order to better understand the current immunological status against Sars-CoV-2 and thus the extent of the infection.
DĐKP: We know that Germany intends to carry out antibody tests in the general population. Would you please explain us the importance of such testing?
NGUYEN: Under normal conditions with SARS-CoV-2 infection it can be assumed that a humanbeing, according to the RKI, should be considered immune to this disease in at mean 7 to 14 days after have been infected with the Sars-CoV-2 virus. Sufficient antibodies against the virus have been formed during this period. A positive antibody test means that you have already gone through the disease and have now developed sufficient immunity to this disease. The results of the antibody tests would lead us to two situations:
- If the immune status in the population is low, this is a warning that the infection will recur when the measures to limit social contacts are no longer strict. Also during this time government and health care professionals need to perform mutual policies for balancing the protection of people’s health and the prevention of an economic recession.
- If the immune status of the population is high: This would be a reasonable explanation for the hypotheses we mentioned above: COVID-19 should have arrived in Vietnam very early, would have spread very quickly among young people, making them immune on average after 7-14 days. The natural immunity that is spreading among many young people represents in turn a natural obstacle for further spread of COVID-19. Under these conditions, normal social activities could be permitted under certain precaution. However, this does not mean that COVID-19 has been eliminated, it only shows that the level of infection is gradually decreasing and under control. Therefore, policies to limit social exposure must continue to be strictly observed, e.g.
. Contact at a distance of 1.5-2 m (especially towards older people).
. Hygienic measure with frequent hand washing
. Wearing (non-medical) masks is particularly effective when as many people as possible wear these masks, especially in closed rooms. Everyday non-medical masks cannot protect high-risk groups and older people if the mask carrier is noteless infected, with little or no symptoms. Therefore, besides everyday masks, the most important issue is the compliance to the above mentioned contact distancing!
According to Prof. Drosten, virologist at the Charité University Berlin, it can be assumed that antibody tests may be available for general examination in Germany in the next 6-8 weeks. A problem that needs to be considered is a possible cross-reaction with other coronaviruses from previous diseases.
There is also the possibility of obtaining antibody serum for passive immunisation from people who have become immune after COVID-19.
DĐKP: Before we end this very interesting conversation with you, we should be very grateful for a short summary. Which messages would you like to give for Vietnam?
NGUYEN: First of all, I am very grateful to DĐKP for giving me the opportunity to talk to you and your readers about COVID-19. In my mind, the course of COVID-19 in Vietnam lets one’s imagination run in a different light , which seems to allow an optimism in this sometimes hopeless fight against COVID-19.
The successes achieved so far in the fight against Covid-19 in Vietnam are on the one hand undoubtedly the result of the efforts of the Vietnamese health authority, which operates comparatively with limited resources, and on the other hand they can also be attributed to unexpected factors in this connection: the demographic structure created by wars in the past and the social, in particular physical distance in everyday dealings, which is caused by traditional behavior in any case.
One last point I want to talk about and which is very close to my heart: In the state of “complete social isolation” in the context of Vietnamese society with large family life including three generations in the same house, the risk of the infection spreading in the family, especially for the elderly, is enormous. The number of infected asymptomatic young people in a densely populated country like Vietnam is certainly still not small. Under these circumstances, the risk of infection for family members may be dangerously high, although the incidence of COVID-19 transmission in a family is surprisingly low, only 15% according to a trial in Germany. But it is extremely important to maintain hygienic standards, mostly washing the hands frequently and keeping in mind the contact distance (1.5 to 2 m), especially towards older people, in daily life as well as within the family. Families should be aware of this on a regular basis.
ĐĐKP: On behalf of the readers thank you very much for your effort.
Prof. Dr. Nguyen Si Huyen is currently the coordinator for the training of the students of the Vietnamese German Faculty of Medicine (VGFM) in the practical year at the Braunschweig Clinic, Wolfsburg Clinic, Wolfenbüttel Clinic and the Duchess Elisabeth Hospital Braunschweig. The VGFM is the result of a cooperation between the University Medical Center of Johannes Gutenberg University Mainz (JGUM) and Pham Ngoc Thach University (PNTU) Ho Chi Minh City (HCMC) and was founded on March 30, 2013 in HCMC. It is operated as a “joint venture” in HCMC in Vietnam. The VGFM students study medicine according to the curriculum of the JGUM and take the same exams of the IMPP (Institute for Medical and Pharmaceutical Examination Questions) as for their German students. It is the first medical degree in Vietnam to have an equivalent German medical degree.
Academic ceremony 26 graduates of the VGFM PNTU in the Hall of the Altstadtrathaus Braunschweig (BS) on February 21, 2020. From right: Prof. NM Xuan, Rector of the PNTU, Dr. T. Bartkiewicz, Medical Director of the Braunschweig Clinic, Dr. A. Chandra, former medical director of the Wolfsburg Clinic, Dr. H. Köhler, HEH Braunschweig, Prof. GD Kneissl, VGFM, Prof. SH Nguyen, VGFM, Prof. W. Bautsch, Klinikum BS. An event by the Braunschweig Clinic and Pham Ngoc Thach University HCMC. Photographer: Peter Sierigk, Municipal Clinic Braunschweig.
Professor Wilfried Bautsch:
I read with great interest the interview that Prof. Nguyen gave on the topic “Covid-19 in Vietnam”. Vietnam has incredibly low infection rates and to date no deaths from Covid-19. This cannot be explained by the fact that the test numbers are still relatively low in international comparison. As an explanation, Prof. Nguyen suspects that, on the contrary, Vietnam experienced the spread of SARS-CoV-2 very early on, which went largely unnoticed, since Vietnam has a comparatively young population (in which the disease is largely mild) and that older population has largely been spared from contact with younger people due to socio-cultural differences compared to the European tradition. The reported figures are therefore not from the beginning of this pandemics in Vietnam, but rather the late findings in a population that has already been largely immunized.
The declaration is very original, coherent and certainly – if it is confirmed – of great importance for the international assessment of the pandemics. The further development of infection numbers in Vietnam is therefore of great importance. In my opinion, seroprevalence tests should also be carried out in Vietnam, because the hypothesis could be supported or refuted relatively easily.
Institute for Microbiology, Immunology and Hospital Hygiene
Municipal Clinic Braunschweig gGmbH
Academic teaching hospital of the Hannover Medical School
Chief Physician: Prof. Dr. Dr. Wilfried Bautsch
Celler Strasse 38,
38114 Braunschweig / Germany