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COVID-19 response over next 6-18 months critical, says Soumya Swaminathan

WHO’s Dr. Soumya Swaminathan. File   | Photo Credit: PTI

Predicting that the COVID-19 pandemic is likely to have subsequent waves as well, Dr. Soumya Swaminathan, chief scientist at the World Health Organization, who has been maintaining a keen eye on the developments in India, says the efforts put in in the next 6-18 months will be most critical in battling the pandemic.

“A lot depends also on the evolution of the virus itself, the ability of vaccines to keep up with variants, and it also depends on the duration of protective immunity of vaccines. A lot of this is changing,” she says.

Watch | In conversation with WHO Chief Scientist Soumya Swaminathan

“We know that there will be definitely an end to the acute phase of the pandemic — when we have vaccinated about 30% of the world’s population, which is what we would like to see by the end of 2021. Then we can start seeing a significant reduction in the deaths.” Then 2022 can be about ramping up vaccination.

Making clarifications on treatment protocols, Dr. Soumya said it was important for the people to understand that the wrong drug given at the wrong time could actually have more bad effects than good.

Many of the drugs commonly being used now have not been shown to have any effect. Nations can customise the WHO protocols for their local contexts, she advises.

Among the key voices of the WHO, Dr. Swaminathan’s clarity of thought, articulation and deep awareness of the Indian context have set her in the centre of the pandemic maelstrom as a reliable voice.

In an online interview to The Hindu, she provides detailed responses to a range of topics that are simmering, resolves some doubts, and advocates strategies to adopt gainfully. Investments in health care are crucial, she says, because it is now clear that there is nothing without health, and without sufficient physical and mental well being, it would be impossible to take the path to recovery as well.

Excerpts from the interview

‘What we know so far is variant B1.617 is definitely more transmissible’

A current topic of concern to a lot of people is the question of virus mutation - ‘variants of concern’ and ‘variants of interest’. Can you tell us what it is that we need to know about this in as much as it impacts our lives? How are these variants categorised?

Variants are basically the virus mutating or evolving, and so there are changes in the viral genome. And this is normal, it is expected. For RNA viruses, as they multiply  and every time the virus replicates, it has brings about a small change, it's an error basically, most of them are of no importance, they don't affect the virus in any way. Some of them could have some impact on how the virus is able to spread, some may make it easier, and some may make it more difficult for the virus.

In particular, changes in areas such as the spike protein, which is the protein of the virus that helps it to come and attach itself to the human cells. Sometimes those changes, or mutations make it more easy for the virus to attach itself to the respiratory tract cells. And so it's easier then for it to infect. It also helps it to multiply faster, and create a higher viral load in the respiratory tract. So the variants of interest are categorised when there are some observations that the variant may be behaving a little bit differently. 

So that's usually the initial observation by the epidemiologists of that place, which suggests that a certain variant with some specific mutations is behaving differently. And then as more research is done, and more data is accumulated, we decide whether that's a variant of concern or not.

And to classify it as a variant of concern, it needs to have certain properties, it has to be either shown to be more transmissible than the original strain, which originated in Wuhan. It has to show more clinical severity in patients who get infected, or it has to show resistance to antibodies, either from people who've had previous infection, or from people who have received the vaccine. So a strain that fulfils one or more of those criteria is called a variant of concern. 

So far, WHO has four variants of concern, the latest being the B 1.617, first described in India, but now found in about 50 countries worldwide.

I think for the public, what is important is that it doesn't really matter. The variant of the virus is still the same virus, and it's still behaving in the same way and having the same effects on people. A particular variant may be more transmissible, which is what we're seeing in India today, that it spreads much more easily, but you have to give it the opportunity to spread. So I think if people can remember that they have to do the same things, they have to wear a mask, avoid crowds, preferably avoid meeting people in indoor settings with poor ventilation, maintain physical distance as far as possible, and basic hygiene. So the principles of public health and of personal protection have not changed at all. They are the same. So it really doesn't matter whether it's one variant or another, we need to do the same things especially when the community transmission is happening at such a high rate

There seems to be signs that B 1.617 is highly transmissible, but is there data on resistance and virulence? 

Yes, I think what we know so far B1.617 is definitely more transmissible, one and a half to two times more than the original strain.  In fact, it's even more transmissible than the B 117, which  was identified in the UK, and which had at one point become the predominant strain in India. But it's now being replaced by the B 1.617. 

Now, there are sub lineages that have been described, the B 1.617 itself has been divided into different strains - each of them has a slightly different set of mutations, with slightly different properties. We are looking for more results coming through at the moment. I haven't seen any data that says it causes more severe disease, there is some preliminary data that it has a reduction in vaccine neutralising antibody activity, Now, that's a lab study. 

What we don't have is data from the real world as to whether there is a higher chance of getting infected, or of getting seriously ill with the new variant after vaccination with either Covishield or Covaxin, or any of the other vaccines. There's really an urgent need for us to do more comprehensive research studies, which go hand in hand with the sequencing. The sequencing alone is not going to give us the information we want; you need the data on the clinical profile of patients, epidemiology and transmission. And we need data on people who received the vaccine and have been followed up for a period of time to look at the breakthrough infections, what is the rate and pattern of breakthrough infections? We expect breakthrough infections. So it's not a surprise, but we need to see what rate at which it is occurring. And, are people really getting ill, or are people getting mild infections after vaccination. So that is really going to give us the information we need about this variant and will be important for us to plan ahead.

So the message is to go ahead and get vaccinated with the vaccines available now?

Absolutely. So as per our current knowledge, the vaccines that are available in India are still highly effective against the new strain. Of course, everybody knows somebody who has had two doses of the vaccine and was infected, maybe even hospitalised. There is no doubt that such cases will occur because none of the vaccines offer 100% protection. But the vast majority of people who receive two doses will be protected against severe disease, which leads to admission in the ICU. That is why we need the data at the population level, and anecdotal evidence is not good enough for us to say that vaccines are not working at this point. We firmly believe that vaccines still are providing a good amount of protection to people.

Do you have concerns about the pace of vaccination across the world and in India?

What we see is big differences between countries. We see some countries where 40 or 50% of the population has now been protected with two doses of the vaccine. We start seeing the the very beneficial impact that it is having on their population, in terms of the reduction in infection rates in terms of dramatic reduction in hospitalisations, and deaths. And the fact that they're now able to open up and allow people back to some degree of normalcy.

Also read | How significant is the new 'double mutant' variant?

But this is only in a couple of countries. In the vast majority of the world, vaccination coverage is still very, very low. And in fact, in many countries, they have not yet vaccinated even the healthcare workers and the older people who are the most vulnerable. So in such countries, there is a huge risk that future waves will continue to occur will continue to devastate the population, both in terms of health and lives, but also in terms of the economy. Economic recovery is linked with the speed at which people are able to get vaccinated. 

At the moment though, we're in a living in a situation of constraints, supplies, limited supplies, where we have to prioritise who gets the vaccines first. When we get to a point where there's enough vaccine available, then of course, we should ramp up to vaccinate everyone as quickly as possible. 

At this stage, I think it's really important to think about targeting those who should be prioritised, both in terms of saving lives. And in terms of protecting the health system.

You spoke of future waves, is it even possible to have a prediction about how long COVID-19 is going to last, and how many waves are to follow?

We’re at the stage of the pandemic, where it's still a very acute and  difficult phase. We have to focus on how we get through the next six to 12 months, which could be the most difficult. And then really talk about the longer term plan on whether it's going to be elimination or control.

A lot depends also on the evolution of the virus itself, you know, the ability of vaccines to keep up with variants, and it also depends on the duration of protective immunity of vaccines. A lot of this is changing. For example, we know now that vaccine-induced immunity, and immunity from natural infection lasts for at least eight months, because that's the longest follow up that we have. So time as time goes on, we get more and more data, but it seems to be quite encouraging that vaccine-induced immunity lasts and we know from other coronaviruses from the MERS Coronavirus, for example, that cell-mediated immunity was present even after six years of somebody getting the infection. Of course, the SARS-COV-2 virus is different, so we need to understand it better. 

At this point, I think it's it's hard to predict the long term, we know that there will be definitely an end to the acute phase of the pandemic- when we have vaccinated let's say about 30% of the world's population, which is what we would like to see by the end of 2021 . Then we can really start seeing quite a significant reduction in the deaths due to this infection, and then 2022 can be really ramping up vaccination to cover 60 -70 -80%. We still don't know what the herd immunity level that is needed. Hopefully, we should then see the virus return to, to maybe just  another viral infection, like influenza, which you take certain precautions against, but it's there, comes seasonally and you deal with it. But I think we're looking at basically the next 6 -18 months as being extremely critical.

So in a country with a federal structure like India, there are multiple variations of the ‘treatment protocols’, including use of ivermectin, monoclonal antibodies, steroids, and plasma. What is a prescribed protocol that governments can adopt?

So what we've tried to do at the WHO is to have ‘living guidelines’, which are evidence-based, and they are updated regularly whenever there is a change in the available evidence. So based on that, we have made recommendations on a number of drugs. As you know, last year, there was a lot of interest in repurposed drugs like hydroxychloroquine and lopinavir, ritonavir. We looked at interferon beta, remdesivir. Drugs were tested in the Solidarity Trial, and the Recovery Trial, based on these trials, we update our guidance. 

It's done by a group called the Guidelines Development Group, which is an independent group of experts that gets the evidence reviewed, and then bases their recommendations on whether the drug is efficacious in terms of reducing mortality, or reducing the duration of hospitalisation or reducing the severity of illness, is it safe. They also look at things like patient preferences, and equity aspects. 

Based on that, so far, we have only one drug that has a big impact on mortality, and that is steroids or dexamethasone. But again, it is important to note that it only has an impact when it is given to people who are in hospital receiving oxygen. So it is given at the stage of the disease where there is inflammation, which is preventing the oxygen from flowing to the lung, and it's given to reduce that inflammation. 

It's important to understand that this viral infection COVID-19 has phases. The first phase is when the virus is replicating. Most people may have mild symptoms. This is the first week of the disease. At this stage, the only thing that could have an effect are some of the monoclonal antibodies and anti-viral that are now under development, and look promising. They are showing some promise in early treatment in the first week, because that's when you want something to act against the virus. 

In the second phase of the disease, which usually starts after seven days or after 10 days is when, in some people, the inflammatory response starts attacking the body cells, and you start getting also the coagulation problems, clots in the lungs and in other organs. This is when steroids are helpful, as are some immunomodulatory drugs, and drugs that prevent clotting.

Then you have the later phase, which is the long COVID, or the post COVID syndrome, which occurs in a certain proportion of people, you know, about 10% or so, bear symptoms last for many weeks or months. And at that time, there is still research going on as to what treatments are effective.

It's important for people to understand that the wrong drug given at the wrong time, can actually have more bad effects than good. Many of the drugs commonly being used now, like doxycycline, azithromycin and ivermectin have not been shown to have any effect. In fact, WHO has provided a recommendation against the use of ivermectin except in clinical trials, and also against the use of remdesivir, hydroxychloroquine, lopinavir, etc.

So what is needed, I think, is for countries to develop guidelines, national treatment guidelines, that are evidence based, frequently updated, and context-specific for each country. Ideally, this should be done at the national level, so that every state does not have to get their own treatment guidelines.

There has been a bit of excitement about showing a plateauing of active cases in India. Your thoughts?

Well, it's encouraging to see that the numbers are not going up further, and that they are plateauing. It is because of certain states, large states like Maharashtra showing an impact in reducing cases, thanks to the actions that they've taken. 

Now, I would be very cautious because India is a huge country, and there are still many parts of the country which have not yet experienced the peak, they are still going up. And therefore, one could end up with a very long plateau at a very high level of cases. This happened in the United States, it happened in Brazil. So it is very feasible in large countries, that you could achieve a plateau because of some states actually going down while other states are still going up. The other thing is that the testing is still inadequate in a large number of states. And when you see high test positivity rates clearly, we are not testing enough. And so the absolute numbers actually don't mean anything when they are taken just by themselves; they have to be taken in the context of how much testing is done, and test positivity rate. The national positivity rate, around 20%, is very high. 

There are states that rely largely or, entirely on RT PCR to test. But scaling this up and delivering results quickly might not be possible. Is the Rapid Antigen Test the way to go?

The rapid antigen tests now that are available do have good sensitivity and specificity, maybe a little less than the RT-PCR, but  offer a huge advantage in terms of the ease of use, and the rapidity with which you can get results. I think there is a definitely scope and potential to use more rapid antigen tests, especially in situations where access to PCR is not that easy. In remote rural areas, for example, if you want to investigate clusters of fever, then this would be a very good approach. So I think making sure the right antigen test is being used, and using it widely, I think will definitely help in increasing the testing rates across the country. 

Is it even possible to calculate the exact number of people who are dying of COVID in a country? If we are undercounting, will the real number be a guesstimate at best?

There is no doubt that there is undercounting and that is true in all countries. There are a couple of ways of going about trying to establish the true number of infections and deaths and deaths from long COVID. The methodology for each will be different. For infections, I think what ICMR has been doing in terms of the serosurveillance, is a good surrogate to tell you what percentage of the population has been exposed. And from the data that we have so far, we know that the percentage of the population that was exposed by January 2021 was about 20-21% of the adult population, and a similar proportion of children. So that tells you the amount of underreporting in case in terms of the infections, you can calculate. 

For excess mortality, one needs to go and look at death records, which take time to get updated. But this can be done - countries like South Africa and Mexico, have actually come up with the figure of excess mortality. So let's say you know, we have two and a half lakh deaths reported due to COVID, so far, over the last year and a half, one could go back and look over the last several years at the annual incidence of deaths. Usually year to year, that figure doesn't change very much; then you can look at 2020, or up to March 2021, to see the pattern. And if you see an increase in deaths in 2020, above that reported in 2019-2018 -2017-2016, then you can attribute those excess deaths due to COVID.

Not all those people may have died of COVID, by the way, because many people would have died of other diseases for which they could not access care during that time, but it does give you an idea of the excess mortality and a large proportion of that, could be COVID. And they could be other ways - doing verbal autopsies where you can actually find out the cause of death. In terms of long COVID I think one needs long term cohort studies. Globally now there is, you know, much more importance being paid to long COVID it's clear that people who have mild symptoms or are asymptomatic can also have long COVID, even children can suffer from long COVID.

Do you think there are enough staff on the field, or is augmentation of human resources necessary? 

The health workforce is a very big issue; the COVID pandemic has really brought out the gaps in our health systems. We definitely need to focus on expanding our health workforce, particularly at the level of the primary care centers. Not just doctors, but also the the other kinds of staff that you need - nurses, physiotherapists, rehab rehabilitation specialists, mental health specialists. I'm talking about healthcare workers who can be trained to deliver some of these services. Then you need public health people at the district level, and surveillance staff. Now, how does one do this, we have to not only recruit but also train. 

I think a good example is the fact that we're investing in all these ventilators now. But we know that ventilator management is complex, only people trained in critical care can operate ventilators. So in addition to the hardware, you also need the trained workforce. Now we have the digital platforms to do this - using telehealth and tele mentoring, we can train the workforce. 

A good example is what's been started in Chhattisgarh now by the State government, using something called the echo platform, and with a tie up with the Mayo Clinic, U.S. It is more of a dialogue, which happens between the doctors on the ground who are actually treating patients and who are asking real questions about real patients, and the experts who have treated COVID. We need to use it way beyond COVID.

Will this help bolster the resilience of health systems?

When we talk about resilience of a health system, what we saw was the entire workforce got diverted to COVID. So TB case finding went down, malaria interventions went down. People with non communicable diseases are not getting their care, people with cancer died because they didn't get care, essential surgeries could not be performed. So we need to be able to deal with the pandemic, or future pandemics or epidemics at the same time as delivering essential health services. The WHO has done two sets of surveys looking at the coverage of essential health services across many countries, and what we've seen is that compared to last year, definitely, this year, it's better in many countries, but this was January February. So it was before this wave in India.

Still, over 30% of essential health services is impacted, including immunisation, antenatal and child care services, nutrition services, and so on. So all of these are going to have long term impacts. We're going to see the impact on other diseases, and I'm particularly worried about childhood malnutrition, and coupled with the fact that they are missing out on education. I think we need really serious thinking about how are we going to handle impact on our children. Now, we've seen many children are getting orphaned. Many children are going to go further into poverty, trafficking of girls may increase - all of these are by products of the pandemic that will need to be handled particularly in a large country like India, where a large proportion are under 15 years.

Should India launch vaccinations for pregnant women and children?

The WHO makes policy recommendations on vaccines through the strategic advisory group of experts. So currently, we have guidelines for the Pfizer, Moderna and AstraZeneca vaccines - even for pregnant women.

It's a trade off between benefits and risks, and it's increasingly clear that pregnant women, if they get infected, do tend to get more severe disease and end up in ICU. So it is important, I think, to include pregnant women in the vaccination program, particularly when in living in high transmission areas. There is enough data now with the AstraZeneca vaccine that there is any contraindication in pregnant women, but for Covaxin, we still need some more data.

There is a great deal of mental health distress in populations. The inability to step out or socialise and then the loss of near and dear to COVID. Is there anything States can do to “lift the spirits of the people” as it were?

It's true that the mental health impact of this pandemic is huge, and a lot of it is because of the reasons you stated. I particularly worry about young people who are at the end of their school or beginning college or are coming out of college, where the future looks very uncertain. They're not able to plan their future; there are people who have lost jobs, livelihoods, close family members, - all reasons why there should be an increase in anxiety, depression, etc. I think we are not well equipped to face that as such, mental health services are practically non existent in most parts of the country. Now, there's a huge increased demand for that. So I would go back to training a workforce that can do this - using counsellors, providing skills, upgrading their skills, setting up helplines where people can reach out and talk in the local language. When some warning signs get picked up on such calls, then those people must see a specialist so that you avoid extreme things like suicide. In Tamil Nadu, of course, there are strong mental health NGOs, like Banyan and the Schizhoprenia Research Foundation, that have done a lot of work in the community. There are also others in other parts of the country. Those community-based models need to be scaled up. 

And again, this is an opportunity, I think, for us to use our young people who are out there, many of them do not have jobs right now and don't have the prospect of jobs, so why not train them in these ancillary services where they can be brought into the health system, and given employment and at the same time, they're doing our service that we need. So it would be a win-win, it needs a huge investment into the health system. 

That's the first thing we need is the resources. But we've seen now without health, there is nothing else. There cannot be economic growth. And you need both physical and mental health of the population right to be to be productive. So it's investing in capital. 

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Printable version | Jun 25, 2021 11:21:25 AM |

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