Noting that lockdown has great repercussions for economy, society and psychology, Union Health Minister Harsh Vardhan in the exclusive interview to The Hindu said that lockdown has its socio-economic implications, in addition to the health-related issues. "Given the diversity of a country like India, it becomes essential to use this extreme strategy very judiciously,’’ he said.
He cautioned that any relaxation to the lockdown should not damage the gains in disease containment. "It would suffice to say that we need an optimal mix of relaxations and restrictions so that disease control continues along with nil or minimal impacts on economy,’’ said the Minister.
Speaking about the world-wide rush to find a treatment of vaccine for the virus he said that so far four treatment options have been identified - Remdesivir; Lopinavir/Ritonavir; Lopinavir/Ritonavir with Interferon beta-1a; and Chloroquine/ Hydroxychloroquine, which are under consideration.
"International clinical trials have been started to assess their relative effectiveness against COVID-19. By enrolling patients in multiple countries, World Health Organisation’s Solidarity Trial aims to rapidly discover whether any of the drugs slows disease progression or improves survival. Further, 7 candidate vaccines are at clinical evaluation stage while another 82 are at preclinical evaluation stage which include those developed by half a dozen Indian firms also,’’ he said.
Speaking about the large number of asymptomatic cases in India the Minister added that identification of all these asymptomatic cases will require repeated testing of 130 crore population which is a resource expensive and time consuming exercise for any country and is neither possible nor recommended because of its feasibility.
The full text of the interview:
How long can we continue with lockdown, social distancing and delayed transmission in the absence of any treatment? Also, are there any frontrunners in the WHO solidarity trials?
It is true that in the absence of treatment, social distancing measures cannot continue forever to restrict the transmission. Lockdown is an extreme social distancing intervention available to break the chain of transmission and prevents spread of the disease. This does not destroy or kill the virus but is an important measure that flattens the peak of the epidemic, slows the growth of the epi-curve and provides time to the health and social systems to mount a response. Lockdown and social distancing, when supported with public health measures like case detection, contact tracing, isolation and management of cases, help in containing the disease effectively. At the same time, a countrywide lockdown has socio-economic implications, in addition to the health-related issues. Given the diversity of a country like India, it becomes essential to use this extreme strategy very judiciously.
As regards the frontrunner in solidarity trials, based on evidence from laboratory, animal and clinical studies, four treatment options were identified — Remdesivir; Lopinavir/Ritonavir; Lopinavir/Ritonavir with Interferon beta-1a; and Chloroquine/ Hydroxychloroquine, which are under consideration. International clinical trials have been started to assess their relative effectiveness against COVID-19. By enrolling patients in multiple countries, the solidarity trial aims to rapidly discover whether any of the drugs slows disease progression or improves survival. Further, seven candidate vaccines are at clinical evaluation stage, while 82 others are at preclinical evaluation stage, which include those developed by half a dozen Indian firms also.
Is the government recommending opening of certain areas because of the economic considerations, knowing that the virus hasn’t peaked yet in India and the PM has said that it will happen in June-July?
As I have indicated earlier, even though lockdown is of immense importance in breaking the chain of transmission and control of the disease, it has great repercussions for economy, society and psychology. Therefore, any decision on relaxation of lockdown after its continuous imposition has to take into consideration the wide diversity in the country and such relaxation should be done in a way that it does not damage the gains in disease containment during the lockdown. At this stage, it would suffice to say that we need an optimal mix of relaxations and restrictions so that disease control continues along with nil or minimal impacts on economy.
Keeping this in mind, while devising the strategy of dividing the country into three zones – green, red and orange, identifying the containment regions in red zones, as well as identifying possible relaxations in various zones, we are making sure that the disease situation is monitored regularly at various levels across the country and the situation does not deteriorate.
India seems to have a peculiarly large number of asymptomatic patients. How will we manage this group now in the absence of aggressive testing that was being proposed for this period?
An asymptomatic case is a person infected with COVID-19 virus, as confirmed by laboratory test, but does not develop symptoms. Asymptomatic transmission refers to the transmission of the virus from a person having disease without any symptoms. There are few reports of laboratory-confirmed cases that are truly asymptomatic, and as on date, there has been no documented case of asymptomatic transmission. However, this does not exclude the possibility that it may occur. Asymptomatic cases have been reported as part of contact tracing efforts in some countries.
A patient develops symptoms when the viral load is high in the throat and nose and the diagnosis of infection can best be made using RT-PCR test when a patient reports symptoms. Almost 80% patients of COVID-19 tend to report no or very mild symptoms and such patients may not even report such mild symptoms when they occur in isolation. Recently, the Centre for Disease Control and Prevention (CDC), Atlanta, U.S., has also included symptoms of headache, muscle pain, pink eye, loss of smell, loss of taste, intense chills and sore throat in the list of COVID-19 symptoms. Though additional studies have been recommended before these symptoms can finally be included in the list, it is realised that these symptoms might be present but not reported by patients in India.
Any carrier of infection can pose challenges in containing the transmission of COVID-19 to others. However, all those who are contacts of any lab-confirmed case are advised home isolation and to maintain safe physical distance. Identification of all these asymptomatic cases will require repeated testing of our 130 crore population, which is a resource-expensive and time-consuming exercise for any country and is neither possible nor recommended because of its feasibility.
Where does India stand in terms of infrastructure to manage a surge in cases (beds/ventilators/ blood capacity and dialysis machines)?
India stands at a reasonably good position in terms of infrastructure to manage a surge in cases. Before we move forward, I would like to inform that 80% of the infections of COVID-19 are mild or asymptomatic, 15% are severe infections requiring oxygen and 5% are critical infections that may require artificial ventilation. The more important thing is oxygen supply, which is needed in 20% of the cases, 15% through masks or cannula and 5% through a ventilator.
As of now (May 6), the status in dedicated facilities identified by Central Ministries, States and UTs is: Total number of 2,41,505 isolation beds (excluding ICU beds), total ICU beds are 27,663, total oxygen-supported beds are 88,753 and ventilator-supported beds are 19,257. In addition, several domestic manufacturers for ventilators have been identified and orders for 60,848 ventilators have been placed, which will be received in a phased manner in May and June. Many hospitals and medical colleges are increasing the number of ventilator beds. Several hospital owners in the private sector have come forward to dedicate their facilities for the cause of the nation.
Dialysis facilities are available across the country through the Pradhan Mantri National Dialysis Programme in 862 dialysis centres through 5,305 dialysis machines across the country. Moreover, data suggests that the prevalence of acute kidney problems among patients with COVID-19 is low. We have issued revised guidelines for dialysis in view of COVID-19. For management of blood requirement in the country, an online portal — e-RaktKosh — is available, which manages receipt, issuance as well as current availability of blood. The lockdown has resulted in a decrease in blood donation due to restricted movement of donors and mobile vans. However, I have written to State & UT Health Ministers to issue special permission to voluntary blood donors as well as mobile vans to facilitate their movement and promote blood collection during the lockdown period. As on date, we have around 3,311 licensed blood banks in the country collecting almost 12.4 million units of blood per year.
I have myself organised a video conference with volunteers and office-bearers of the Indian Red Cross Society all over the country to facilitate blood collection. I also inaugurated a blood donation camp on the Red Cross premises on May 4 to give a boost to voluntary blood donation. Apart from this, I have also been holding regular meetings (through video conferences) with various social support organisations such as Rotary International, Lions Clubs International, my own political party workers etc. and exhorting them to come forward and wholeheartedly participate in voluntary blood donation. We are committed to maintaining an adequate supply of safe blood and ensuring its appropriate use for the needy.
With hospitals becoming hotspots and India being traditionally short of medical manpower, how will we manage when the lockdown ends and people come out and transmission hits again?
It is a fact that the COVID-19 outbreak has placed unprecedented demands on our already overburdened health system. However, given the current scenario and crisis posed by COVID-19, our health facilities and workforce are currently busy with lots of activities related to it. Resources available with other government departments like Railways, ESIC, defence and other public sector units have also been actively pressed into action. Various professional bodies like Indian Medical Association (IMA) as well as nurses’ associations are also involved in this mammoth task of controlling COVID-19. Medical practitioners belonging to various streams of traditional medicine under AYUSH are also assisting in control measures.
Further, the government has also taken proactive measures to engage with the large private sector healthcare resource pool available in the country. The Central government as well as the States are engaged in a continuous dialogue with private healthcare providers’ associations as well as hospital chains. As I said earlier, several hospital owners in the private sector have come forward to dedicate their facilities for the cause of the nation.
Without autopsy etc., are we eliminating possible COVID-19 deaths? What is termed as a COVID-19 death ?
COVID-19 death is defined as a death resulting from a clinically compatible illness in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be attributed to COVID-19. There should be no period of complete recovery between the illness resulting from COVID-19 and death. See, the primary aim of an autopsy is to ascertain the exact cause of death, if it could not be ascertained by the doctors or if it is under challenge. Thus, most of the autopsies performed globally are either medico-legal or clinical. Medico-legal autopsies are conducted in cases of unnatural, unwitnessed or suspicious deaths in accordance with the laws of the land. This is also the principle followed in India. In case of COVID-19 deaths, the cause of death for a patient under treatment can be ascertained by the attending doctor, so autopsies are not necessary.