As India grapples with a second wave of Covid-19 cases, Dr Guleria has been central to the country’s disease response. As head of clinical research group of the national Covid-19 task force, he is instrumental in framing treatment policies.
The AIIMS chief says vaccination will open up but “gradually”, advises caution over theories regarding re-infection, addresses the “Bihar paradox” when polls did not see a surge, and says approvals for vaccination in children must be fast-tracked. The session was moderated by Principal Correspondent Kaunain Sheriff M.
KAUNAIN SHERIFF M: India is witnessing a second wave of Covid-19. How do you read the new numbers?
I think the numbers are worrying… Firstly, this wave is much steeper than what we have seen in the past. It has taken much less time to cross the 80,000 cases per day mark this time. Secondly, the degree of fear or panic that was there when we had crossed the 80,000-mark last time does not seem to exist today. There is no Covid-appropriate behaviour. Despite the numbers crossing the 80,000-mark, people are planning holidays, hotels are full at all hill stations. So that is worrying. We don’t have data which suggests that we have a good degree of immunity. A majority of our population is susceptible and we are also seeing new variants of the virus now, which we know can be more infectious. They can also develop ‘immune escape’, which may allow some degree of reinfections.
KAUNAIN SHERIFF M: Are we seeing a significant difference in the transmissibility and severity of the disease now?
We are definitely seeing more transmission. The curve is much steeper and it could be related to the fact that the virus is more infectious, it is spreading more and we are also allowing it to spread because of our lack of Covid-appropriate behaviour.
The second issue is regarding mortality. The data currently is not that strong. There is a feeling that this second wave may cause less mortality, but we need to be very careful when we interpret that. Currently, the rise in cases is in the younger age group where we know the mortality is less. We also know that people in the younger age group will take this infection home to their parents or grandparents or people with comorbidities… So I think it’s too early to say that the mortality is less.
AMITABH SINHA: I understand that we might not have the full details yet, but what is the best explanation for the five-month slowdown in cases starting mid-September?
One possibility is the link between people showing Covid-appropriate behaviour and an aggressive containment strategy. Secondly, in some areas, a lot of people got the infection and therefore developed immunity, breaking the chain of transmission. That may have contributed to a decrease in cases as well… Now, people said that there is good herd immunity in Mumbai, Pune, because a large number of people got infected in these cities (in the first wave). But these cities are still seeing a surge. We therefore need more epidemiological and genome sequencing data.
Another possibility that led to the decline earlier could be that people developed some degree of immunity but the virus itself evolved over a period of time and now it has developed some degree of ‘immune escape’. Plus, there were still a large number of people who were susceptible. The combination has led to the resurgence that we are seeing right now.
AMITABH SINHA: Do we have any understanding of what could be the proportion of reinfections now?
That is a difficult question and it is something for which we urgently need to get data on. The issue here is that we know that almost 30-40% of people may have asymptomatic infection. These people may have never got tested. They had the immunity at that point in time, and therefore, they were responsible for bringing the cases down. But now they may have got the infection again, which we think is the first infection. But actually, it may be a reinfection, right?
Our sero surveillance data suggested that at the national level, only around 20% people had antibodies. In some cities, that figure stood at more than 50% in some population dense areas. Yet, we are seeing a surge in these areas, where the immunity was believed to be high. That is why we need to really look at it very critically to know if the cause for the surge is only related to lack of Covid-appropriate behaviour, is it related to some variation in the virus, or is it related to some other factors.
UNNI RAJEN SHANKER: Are you happy with the pace of vaccination?
Vaccination is something for which we would always like to have as big a base as possible… We are a very large country. If we say that we would want to vaccinate the entire adult population, then that would be close to a billion people. And we will need two billion doses. Now there is no way that we could get two billion doses (at one go) if we were to open it up for everyone. The challenge therefore would be how do we balance the doses available per month or per fortnight, with the number of people that we can vaccinate based on the priority list.
Things may also get a little disrupted… Say there are 27 crore people over the age of 45. Now, one assumes that all of them will come for vaccination. But if only 50% of them turn up for vaccination… So one needs to see the trend. After a week or 10 days, if you find that the number of people coming for vaccination is falling, open it up to a lower age group, and do it gradually. At the same time, we need to render a strategy to see that we are not missing out people because we are not able to reach out to them. They may not be tech savvy, they may be in rural India, or they may not be clear how to come to a vaccination site. It may be a good idea to develop vaccination camps. But we also need to make sure that we have everything ready for any adverse reaction.
UNNI RAJEN SHANKER: From the drive so far, do you see any reluctance among people in taking the vaccine?
When we opened up vaccination for people over 45 years, we had a huge response… But these are early days. If this continues, then we are in a very good position. But let’s say 10 days from now we find only 50% of the people are showing up… it means that we are reaching a saturation point among those who want to get themselves vaccinated… So maybe we should then lower the age group, so that those who are waiting can get covered and we would also have enough doses for it. So one has to keep analysing data on a regular basis. There are still people over the age of 60 who have not got themselves vaccinated. So, if they don’t want to get vaccinated, they should not hold up the queue.
KAUNAIN SHERIFF M: In many of the surge districts (8 out of 10 of them are in Maharashtra) the vaccination coverage is quite poor. How important is vaccination as a strategy to contain this surge?
Vaccination is one of the strategies but it is not the only strategy. We should have three-four strategies working parallely. After we give the vaccine, the adequate antibody response will take a few weeks… Secondly, along with vaccination, we need to have an aggressive testing, tracking and isolation policy. Six months ago, it was being done very aggressively by states, but we have now become lax. If a person tests positive, no one really goes and checks who they have come in contact with and we fail to break the chain of transmission. So we need to identify areas where we are seeing the surge, develop them into containment zones, test everyone in that area, isolate those who are positive, quarantine those who have come in close contact with patients and test them after five to seven days, and not allow people from that area to go to another area. We still have a large number of people travelling from one state to the other, and they are carrying the infection with them. This surge is not going to be limited to only a small area, this will happen in other parts of the country also.
Also, we need to prevent crowding; these are super-spreading events. I have actually come to the conclusion that it is going to be very, very difficult. We have to develop strategies based on what we can do despite people not following Covid-appropriate behaviour. The easiest thing to do is to blame the others and say look, it’s your fault, you didn’t wear your mask etc. But as healthcare professionals, we have to accept behavioural changes and find a solution.
RAHUL SABHARWAL: In terms of the roadmap, have you decided on the next category that you might want to open up? Also, anecdotally, or by speaking to hospitals, do you have any idea of how severe reinfections are?
The roadmap has two parts to it. One is logistics, and the other is what one would like to do. Now, what one would like to do is to first cover those with comorbidities in the younger age group. But we also know that a majority of the people with comorbidities, 70-75%, will be in the older age group. So if we cover people in the age group of 45 and above, we will cover almost 75 to 80% of people with comorbidities. But there are younger people also who have comorbidities… but are not over the age of 45. One would like to cover them.
The challenge that we have there is that you have to have very robust criteria to identify these people and then get them vaccinated. The easiest way (to vaccinate) is through the age bracket, because you have I-cards, Aadhaar, which shows your age. So logistically, it would be easier if we just go by age. But I would also want that at some point in time we develop a strategy to cover those who have comorbidities.
Coming to reinfections. In the past people did feel that reinfection is usually milder and most reports suggested that if you have had Covid-19 earlier, you have some degree of immunity. However, there have been a few case reports, some from the US also, of people who had a more severe reinfection. That needs to be looked at more critically. But, by and large, the general feeling in the scientific community is that reinfection should be milder. Remember, the rider here is that we are assuming that reinfection is with the same strain that you had in the past… But now we are dealing with a lot of unknowns because the virus is also changing. So therefore, how does the virus behave in terms of its virulence and infectiveness is something that we need to keep studying regularly. This is like an ongoing game of chess that we have between mankind and the virus…
KAUNAIN SHERIFF M: Many frontline workers have received both doses of the vaccine. Is significant protection being offered by these vaccines to this group?
Frontline and healthcare workers have some degree of protection. But I won’t say that it’s 100% as not all of them have taken the vaccine. When we look at the generic data, not all healthcare workers have come forward for vaccination. I have asked a lot of them the reason. Some say that they want to wait for more data to come out. Others say, ‘Maybe I have already got Covid-19 because I am working in a hospital and therefore, I already have some immunity. So I should not take the vaccine.’ So I find that unlike the general public, and I may be wrong here, there is more vaccine hesitancy in the healthcare workers because of maybe reading up more and therefore getting more worried about things which really don’t matter.
KAUSHIK DAS GUPTA: Do you consider political events such as the Bihar elections or protests in different parts of the country super-spreader events?
I call it the Bihar paradox. I have not been able to understand what happened. We had a huge election with no Covid-appropriate behaviour… Yet, we did not see a surge in cases. I looked at the data and spoke to people there because I thought that we were testing less. But that was not the case. People argued with me at that point that already a large number of people in Bihar had got the infection because of the returning migrant labourers… and there was already a good amount of immunity. That is why the election did not cause such a big surge… But I agree that all crowded places where there is no social distancing and no one is wearing a mask are potential super-spreader events.
SANDEEP SINGH: Do you think there is a possibility of another lockdown?
I don’t see a nationwide lockdown happening. But I do think that we need to look at containment areas. In areas where we are seeing a surge, we need to develop a strategy for containment where we don’t allow the infection to spread outside. We are very stringent in the measures that we follow there in terms of testing, tracking, treating and isolation… But we need to do this aggressively.
KAUNAIN SHERIFF M: In India, do we need to fast-track the process of clinical trials of the vaccine for children?
We need to fast-track and get approvals for vaccination in children globally. It’s important to remember that children are not little adults. So it’s not that you just give half the dose. You have to look at the dose depending on the body weight, and also side effects, which may be different in children as compared to adults. Therefore, that data needs to be collected. But we need to have vaccines for children. It’s for the safety of children when they go to schools or when they are travelling.
AMITABH SINHA: Are we saturated in terms of our testing capacities? Also, are we going ahead with another round of countrywide sero-surveys?
Testing is a strategy which is very important and we need to maximise it as much as we can. Although we are doing 15 lakh (tests in a day), we need to build it up. We have the capacity to do that. We started off with the demand for a lot of viral transport media, nasal swabs and RT-PCR kits, which were coming from outside. Now they are all being manufactured in our country at a much lower rate. So the cost of testing has also come down dramatically. A number of labs have now come up and we also have Indian testing kits… So testing can actually be further ramped up.
It’s the same for sero-surveillance. It has to be a continuous process. So we have to go back and do sero-surveillance because we need to see how the data has evolved.
ASTHA SAXENA: Will there be a need to restrict services to non-Covid patients to ensure more space for Covid patients now, given the surge in cases?
This is the biggest challenge that we are facing in most hospitals. When the caseload decreased, we converted a lot of Covid areas into non-Covid areas. So a lot of our hospital infrastructure and human resources went to non-Covid areas. There were many patients waiting for routine surgeries. Now, because of the surge, our Covid areas have started seeing huge admissions. We are pulling back people from non-Covid areas back into Covid areas. The challenge now is to balance between Covid and non-Covid sections. For example, trauma cases cannot be restricted. During the lockdown, we had fewer trauma cases because of low traffic. Now the traffic has returned to pre-Covid times.
RAJ KAMAL JHA: Given our numbers and how the virus spreads, there may be a third, even a fourth wave… so how do we learn to live with Covid here? And, one year from now, where do you see the pandemic and our conversation around it?
We will continue to have waves… But possibly the peak and the number of cases will gradually come down as we vaccinate more and more people. Therefore, from a pandemic, it will become more like an endemic disease like the flu, which we see every year. Some sort of a seasonal pattern will develop as far as Covid is concerned. But I don’t see it disappearing totally and we will have to learn to live with it. Therefore, some degree of Covid-appropriate behaviour will become part of our life — whether it is wearing a mask or regularly washing hands.
Regarding how things will be one year from now, it’s a tough question because it’s difficult to predict the future. But I do agree that this year is what I call the year of vaccinology. We will see a lot of research on vaccines and we will see new generation vaccines coming up. Not only will we have newer vaccines, which are already under clinical trials for Covid-19 strains but we will have more data in terms of how effective is the immunity of each of these vaccines over a period of time.
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