Moving into summer months, India could get hit very hard, says virologist Peter Hotez

U.S. virologist expresses concern about India’s crowded urban areas in low-income neighbourhoods where people are forced to live in proximity

As the world continues to grapple with the debilitating human toll and economic consequences of the ongoing COVID-19 pandemic, experts such as Dr. Peter Hotez, Dean for the National School of Tropical Medicine and a Professor at the Departments of Paediatrics and Molecular Virology and Microbiology, at the Baylor College of Medicine in Houston, have been at the forefront of both research and treatment of the infection.

Along with other healthcare workers, medical professionals such as Dr. Hotez are recognised as frontline warriors in the battle against the coronavirus in the U.S., currently the global epicentre of the pandemic.

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Dr. Hotez’s perspective is also valuable for his multi-decade involvement in treating neglected tropical diseases, including in India, where he has worked extensively on better understanding the spread of and treatment options for elephantiasis, hookworm, leishmaniasis, and dengue. He spoke to  Narayan Lakshman  about the current state of play with the battle against the coronavirus and what hope there is for the future.

What is the current situation in the U.S., where President Donald Trump recently said fatalities could reach 1,00,000. Why did the numbers spin out of control this way and is there hope that the curve can be flattened?

There is quite a bit of concern here. This is now our third major coronavirus pandemic or epidemic. We have had SARS-1 in 2003 then MERS in 2012, and now COVID-19. This began, of course, in Central China, moved to Europe and the U.S., which has had a significant percentage of the world’s cases, around one third. New York City, sadly and tragically, has been one of the epicentres of that.

It really took off because the virus probably entered the U.S. earlier than we suspected. A national emergency was not declared until the middle of March. It is likely that the virus entered the U.S. in early February, back-tracing it. That means that transmission went on for about six weeks before any efforts for social distancing were implemented.

We know from the models, especially from Harvard University, that that produces tragedy. That means that if you allow transmission to go on for six weeks before you intervene, then that makes the difference between having thousands of patients in your intensive care units and local hospitals, versus having just a handful. Unfortunately, we are in the former situation for some parts of the U.S., especially the northeast, including New York and Boston, which have been hit very hard. Some of the West Coast cities and down here and Texas it has been a little better because the virus did not enter as quickly. Now, we are seeing this is a true pandemic.

Tell us a little bit more about the work that you do as relating to COVID-19, in terms of research and treatment.

We moved to Texas a decade ago, because Texas, it turns out, is a great place to do science. We have a huge contingent of Indian scientists in our university. We went to the Texas Medical Centre, where we have the Baylor College of Medicine and Texas Children’s Hospital and there, we established an institute for developing vaccines for some of the neglected diseases that we have talked about.

Also, about a decade ago, we had adopted a coronavirus vaccine programme because there was a group at the New York Blood Center that had made some exciting discoveries to develop and prove a vaccine that would be both effective and safe. They partnered with us, and we wound up getting support from the U.S. National Institutes of Health and developed recombinant protein coronavirus vaccines.

The problem was, for a decade nobody cared much about coronaviruses or their vaccines and then of course the world changed a few months ago and now there is quite a bit of interest to see how we could repurpose some of our vaccines that are already manufactured toward COVID-19 and develop some new vaccines as well.

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Vaccines offer the greatest promise for protecting large populations at risk, like in India. The problem with vaccines is also that they are the highest bar to achieve because with a vaccine you are generally injecting healthy individuals to prevent them from getting sick. So, you have to be absolutely pristine, in not only showing that the vaccines work, but also your safety profile. That is what takes time. In the meantime, there are some new, promising treatments on the horizon.

I am very excited, for instance, about convalescent plasma . It is a relatively low-tech solution which involves identifying individuals who have recovered from their COVID-19 and have antibodies. It is almost like a blood transfusion – you remove their blood, give them back their red blood cells, collect the plasma which contains high levels of antibodies, confirm that you can measure the antibodies, then you can give it to patients who are sick. Especially if you give it in the early stages of the illness, it can greatly reduce morbidity and mortality. It’s a great treatment and there are about 4,000 patients in the U.S. who have now received it. The problem is that it is hard to scale because it requires you having a base of patients with the illness.

Now there are version 2.0 efforts by companies and academic laboratories to make therapeutic monoclonal antibodies based on this principle. That, or hyperimmune globulin, will likely be the first treatments that should see rollout across the world.

In India, while the number of infections continue to rise, the government moved aggressively to impose a nationwide lockdown. Could the fact that we are not seeing the sort of fatality numbers that you did in the U.S. be down to India facing a different coronavirus strain?

 I do not think it is going to turn out to be a coronavirus strain issue. It is possible that this is a new virus pathogen. But I think it is most likely because India did implement some social distancing early on, like we did in Texas. So, India may have mitigated the worst aspects of this.

But I would say that we should not be complacent, because I am still worried for India because you are moving into the summer months and we know that sometimes in tropical countries, the global south, or in places like South Asia, Africa, Australia and South America, sometimes for influenza the seasonality is inverted.

In the U.S., influenza peaks through January and the spring, it then drops off during June to August. In the southern hemisphere and in places like India, it is the opposite: the worst may be yet to come. I do not want to give apocalyptic predictions, but you cannot afford to be complacent. You have to assume the potential for things to get much worse as you head into July and August. We are already seeing that happening in Brazil now, which is getting hit very hard, especially in some of their crowded urban areas in Fortaleza, Belem, and Manaus.

I am particularly worried about India’s crowded urban areas in low-income neighbourhoods, where people are forced to live in proximity, including in Mumbai. I am holding my breath because I still do think that there is a possibility that India could get hit very hard.

It is interesting that you say that, because so far as weather-related or seasonality questions are concerned, some people are saying that it is the opposite, that the heat of the summer months could slow viral transmission.

It is not so much that. I agree with you premise that the sunlight and hot weather may have an effect on reducing transmission. But we know that that is not the only factor. For instance, with influenza, it peaks in the northern hemisphere in the winter, it peaks in the summer months in the southern hemisphere, but in the tropics, it is there all year round. So, it is not purely the effect of sunlight and warm temperatures.

There seem to be other factors that are in play, for example density and crowding are still really important issues that may even override warm, tropical weather. That may explain some of the transmission. So, I do worry about the densely populated areas as we move into the June-July-August.

This is a new virus, we have not been through a full year of the virus, and any predictions or suggestions are speculative, including mine. If I were looking at this from the standpoint of the Indian Ministry of Health and Family Welfare, I would say that we cannot be complacent and we are concerned about what will happen over the next few months in the crowded urban areas.

My guess is that they are doing just that. There are some outstanding people, both in Indian universities and in the MoHFW. So, I am guessing those kinds of discussions are underway.

Should we be worried about reports from New York about COVID-19-positive children succumbing to symptoms that resemble Kawasaki disease?

It caught us a bit off-guard because in China we did not hear much about paediatric syndromes. Our understanding was that children were mostly handling the virus pretty well, not getting very sick, with the exception of about 10% of young infants. These symptoms first came out of the United Kingdom and then we saw them in New York, a syndrome that looks like vasculitis, an inflammation of the blood vessels, linked to this virus, maybe later on in the course of the illness. This Kawasaki-disease-like syndrome is still not common – there have been about 100 cases in New York, where the epidemic has been the worst. Every children’s hospital has cases right now.

This is related to the fact that the virus that causes COVID-19, the SARS2-Cov, binds like the previous SARS virus to a certain receptor in the tissue, called the ACE2 receptor, which stands for angiotensin-converting enzyme 2. It is found on the cells of the blood vessels of the heart and the lungs, which is the area that we are seeing gets affected.

We are also seeing, unfortunately, a lot of cases in the U.S. among adults, of clotting defects, which we are trying to understand. We are seeing lots of different types of thromboses, or clotting of the blood, leading to blockage, which in turn lead to strokes, pulmonary emboli, and maybe associated with coronary artery thrombosis, giving people heart attacks. That is the new, ominous twist that we had not understood was widely occurring in China earlier but now we are certainly seeing it occurring in the U.S.

We have to look closely to see what happens in India. The other thing I am concerned about is certain comorbid conditions, predisposing people to severe illness, and examples include diabetes and hypertension. Now that cardiovascular diseases and diabetes are taking off in India, I am concerned that this is going to be an important risk factor for COVID-19 as well. When you combine the crowded urban areas with the high rates of comorbid conditions, these are red flags to watch out for as India moves into the summer months.

If there is one broad lesson of the COVID-19 pandemic for developing countries such as India, is it to be better prepared for future events of this sort in terms of creating a sufficient pandemic preparedness? Do you think countries like India, which have been ravaged by TB, malaria, and a range of NTDs for decades, will learn this lesson and act accordingly?

This is not unique to India. Every nation on the planet has to learn some lessons from this. But things will change after this pandemic. India has an enormous amount to offer. I continue to be impressed by the quality of some of the universities in India.

I am impressed with its capacity for innovation, especially around vaccines. India is an example of what a country can do even despite its levels of poverty, in terms of over-achieving and having an impact in terms of pandemic preparedness.Do you think countries like India, which have been ravaged by TB, malaria, and a range of NTDs for decades, will learn this lesson and act accordingly?

PH: This is not unique to India. Every nation on the planet has to learn some lessons from this. I keep on predicting with each pandemic that things will get better, but they never do. I predicted that the world would change after SARS1 in 2003, H1N1 in 2009, MERS in 2012, Ebola in 2014, Zika in 2016 – the list goes on, and now this – but lessons are only slowly learned. But things will change after this pandemic.

India has an enormous amount to offer. I continue to be impressed by the quality of some of the universities in India. I am impressed with its capacity for innovation, especially around vaccines. The way I see this playing out, India is going to be an important player and not passively. India has capacity for greatness in the area of biotechnology, especially vaccines. I am a very enthusiastic supporter of India and we are always looking for partnering opportunities. India is an example of what a country can do even despite its levels of poverty, in terms of over-achieving and having an impact regarding pandemic preparedness.

I have a new book coming out at the end of the year called “Preventing the Next Pandemic: Vaccine Diplomacy in an Age of Anti-Science,” and I talk quite a bit about India there because of my experiences with all of their successes in the past.