Updated: March 15, 2021 8:19:41 am
Dr Pradip Awate is the state surveillance officer for Maharashtra, in charge of monitoring epidemic-prone diseases in the state as part of the Integrated Disease Surveillance Programme of the Union Health Ministry. He is also one of the most crucial players in designing intervention and response strategies against the Covid-19 disease in Maharashtra.
Anuradha: During this pandemic, Maharashtra has consistently been the worst-affected state. However, the cases did start declining after a point. Does the current trend of rising cases qualify as a second wave?
Yes. What we are currently looking at does appear to be a second wave. The magnitude and speed of new cases are comparable to the first wave.
Anuradha: Why are the cases rising so rapidly again, that too, mostly in Maharashtra? What has gone wrong in the state?
Nothing, actually. There are different epidemic curves for different states depending on the geography, weather pattern, and even international connectivity. If you remember, the first case in India was detected in Kerala, about one-and-a-half months prior to Maharashtra. But after that, cases increased very quickly in Maharashtra, while Kerala had very few of them. After a few months, Kerala’s curve began to grow while Maharashtra’s slowed down. Now, Maharashtra has picked up again, while Kerala has started to see a decline. In other states, the curves have been different. It just goes to show that local conditions play a big role in the spread of the disease.
Manoj: Nagpur is going into a week-long lockdown from Monday. Are lockdowns a solution?
As an epidemiologist, and a person who has been observing such trends, I would say that a lockdown is not the answer to control the surge that we are seeing. In fact, even the central team that visited Maharashtra a few days ago said lockdowns are not the answer.
Lockdown is basically a pause button. Its importance is mostly in the initial phases when there is a need to build up capacities in terms of hospitals, surveillance, laboratory network. One has to expand the existing infrastructure keeping in mind the expected rise in cases. At that time, a lockdown certainly has a very important role to play.
However, in the current situation, I think surveillance should be of primary importance. Maybe partial lockdowns are useful as they force people to adopt Covid-appropriate behaviours. But a total lockdown is not very desirable at this stage. This Friday, we had a review meeting in Pune, and some restrictions were placed on the timings of restaurants, hotels, markets and malls, and schools and colleges were asked to close down. But everyone agreed that there was no need to implement a total lockdown in Pune.
Manoj: Then, why do you think Nagpur opted for a lockdown? Is it a decision taken by the district authorities? Is the state government not consulted on this?
Currently, the Disaster Management Act and Epidemic Act are in place. The district magistrate and municipal commissioners have been empowered to take decisions regarding local situation. The state government definitely is informed, but, the district administrations are empowered to take their own decisions following their assessments.
Manoj: Would you say imposing a lockdown in Nagpur was not a correct decision?
The only thing I would say is that a lockdown is not the answer to the present problem. You know there are important side effects of a lockdown. It has major social and economic impacts, some of which are worse than the impact of Covid-19. Hence, we do need to factor in the social and economic impacts of a lockdown before imposing it.
Tabassum: Is the virus in Maharashtra different from the one found in other parts of India? Have we found any specific mutation here?
Looking at the surge in Maharashtra, particularly in Amravati, Nagpur, Akola, and in the Buldhana and Washim regions, many are of the opinion that there must be a different variant of the virus circulating in Maharashtra. We have sent many samples, almost 100 samples each from Amravati, Akola and Yavatmal, and about 50-60 samples from other districts, for gene analysis. So far, over 900 samples have been sent to National Institute of Immunology and National Centre for Cell Sciences for genome sequencing. Till now, there have been no reports of any new or special variant of the virus from Maharashtra, except for the 15 people with a travel history to UK who had been found infected with the UK strain.
However, it is a fact that many of these samples are still being analysed and their results are not available yet. So, it is possible that in the coming days, we might discover that some new variant is indeed present in the state.
Tabassum: What are the lessons learnt from this pandemic so that we are better prepared in the future?
There are quite a few important lessons. First of all, public health was never a top priority in India — neither for politicians, nor for the general public, doctors and the media. Never was public health issue regularly flagged on the front page of a newspaper. Covid-19 has changed that. This pandemic has told everyone that the public health system cannot be treated like a backbencher. It should be on the forefront of public policy.
The second lesson is in terms of infrastructure. I work for the Integrated Disease Surveillance Programme, or IDSP, which was started in the wake of the Surat plague in 1994. Compared to the present crisis, it can only be considered a small outbreak. There were about 700 cases, but almost half the population of Surat had to leave the city. The economic loss was huge. The IDSP was created to detect early warning signals of any such pandemic in future, and control local outbreaks.
Despite having a great objective, there are several infrastructural issues. Look at Maharashtra for example. It is one of the most developed states in the country, with almost 50 per cent of the population residing in urban areas. But apart from cities like Mumbai or Pune, many parts of the state do not even have basic health facilities. Newer municipal corporations like Parbhani, Latur, Chandrapur, or Jalgaon do not even have basic equipments to deal with a crisis. The state will need to build its public health infrastructure. There are weaknesses in the rural health programme as well, but at least there is a structure. There is a sub-centre for every 5,000 people. Then, there are primary health care centres above that. A similar structure needs to be built in the urban centres as well, especially in the newly-developed areas.
There are a few other lessons that might seem to be outside the domain of public health, but are equally important. Affordable housing is one of them. What we have observed is that most of the people who have died of Covid-19 reside in slum areas where the population density is high. Not just Covid-19, the prevalence of tuberculosis cases is much higher in these areas. The quality of housing is an important determinant of your health. That is why, providing affordable houses can be a very good intervention from the point of improving public health.
Also, in Maharashtra, whenever such a crisis emerges, like at the time of swine flu, or the emergence of Zika virus, all the focus is centred around two hospitals – the Kasturba Gandhi hospital in Mumbai and Naidu hospital in Pune. These infectious diseases’ hospitals were built in the British era. In the last few decades, we have not built enough infectious diseases’ hospitals with state-of-the-art facilities. We need to do that. Kasturba and Naidu alone would not be sufficient for future requirements. There should be at least one good such hospital in every district of the state.
Partha: When the cases were declining, there were suggestions that India was developing herd immunity. But, the cases have strarted rising again. Clearly, we are far away from herd immunity. What is the percentage of population that needs to get infected for herd immunity to kick in?
Herd immunity is a very important process, and its attainment depends on the basic reproduction number, or how fast the disease is spreading in the population. For Covid-19, it was considered that if 60-70 per cent of the population gets infected, it would be sufficient for herd immunity to set in.
There are two ways to achieve herd immunity, through natural infection or through vaccination. Natural infection is a painful process, because it also involves mortality. There would be many deaths on the way to achieving herd immunity.
The proportion of population that needs to be infected for herd immunity to kick in is different for different diseases. For measles, it may be more than 85 to 90 per cent because the disease spreads at a very fast rate. The results of the sero-surveys conducted by ICMR show that there is at best only a 25 per cent sero-positivity in the population. So, it is very clear that herd immunity has not been reached, even though in some pockets of dense populations, more than 50 per cent people have been found to be infected.
Herd immunity does play a role when the disease prevalence reaches 50-60 per cent. The transmission slows down considerably in that area. Even now, in Pune, for example, we are noticing that areas that had high prevalence rates earlier are not showing a surge. The new cases are coming up in areas where not many cases were recorded previously. This time, most of the cases are coming from the middle-class localities and high-rise buildings.
Partha: Should we not start vaccinating everyone?
We definitely need to vaccinate everyone. But remember, the vaccines are currently being used only under emergency authorization.
Though the trial results of these vaccines have been very positive, we only have data for a short time. With vaccines for other diseases, we do not allow it to be used unless we have data over several years, and we are absolutely sure that it is entirely safe and efficacious. These vaccines have been developed within a year. Naturally, scientists, and even topmost experts, are very cautious. Everyone is being very very careful.
That is why, we are doing, what is called, AEFI surveillance, or adverse events following immunization. Every recipient is being monitored, every side effect is being investigated. The data is being collected and analysed. But that does not mean that vaccines are being restricted. We have already seen that the private sector has also been roped in. And in a month or two, I guess, vaccinations would become open for all.
Partha: Currently, a lot of paperwork is required for Covid-19 vaccination. We do not have this for other vaccines. When do you think will Covid-19 vaccines be as easily available as a polio shot?
There are important differences. Firstly, polio drops are oral vaccines. Any person can administer these. It is easy. Secondly, polio vaccines have been tested over time. It was developed in the 1950s, and since then, millions of doses have been administered. Its safety and efficacy is beyond doubt.
Covid-19 vaccines are new and have been developed in a rush. Therefore, they require closer monitoring and scrutiny. That is why records have to be maintained. Documentation is necessary to keep track of any adverse events. This is called pharmaco-vigilance. It is standard procedure whenever a new drug or vaccine is introduced.
Alifiya: It seems that pandemic fatigue has set in because of which people are not following Covid-appropriate behaviours. What is the government doing to deal with this?
Our initial response to the epidemic was hospital-centric. We tried to upgrade the infrastructure, provide more hospital beds, oxygen cylinders, ventilators and critical care facilities. This was all essential. But, to break the chain of transmission and bring down the numbers, we need to focus on surveillance as well. Right now, our approach should be focused on ground realities.
We need to have robust field teams to do influenza-like surveillance, aggressive contact tracing and monitoring patients who are isolated at their homes. Even today, on an average, 35 to 40 per cent of the infected cases are under home isolation. It is necessary to ensure that they are following all the prescribed norms at home and not violating the protocols. In many areas of Maharashtra, like in Amravati, it has been noticed that an entire family has tested positive. Whether that is because of increased transmissibility of the virus, or due to the fact that people did not take proper care during home isolation, is being investigated.
At the same time, we need to increase our testing numbers. However, these tests have to be targeted ones and not on random people. We need to identify people with higher chances of getting infected, and for that, we need to have a network of fever clinics. We do have these fever clinics in all the districts, but this fatigue that you talked about, has set in not just in the general public, but also in the public health system. The fever clinics have stopped functioning in many cities. We need to have at least four to five fever clinics per lakh population. These clinics can screen people for symptoms like fever, common cold and sore throat, and those patients can then be tested. If such cases are identified at an early stage, and then tested and segregated from the rest of the population, including their families, this will help in breaking the chain of transmission.
Alifiya: One of the big casualties of the pandemic has been education. There have been lots of concerns about online exams. Is it possible to conduct exams offline? How real is the danger of the disease spreading if such exams are conducted?
I think it is possible to conduct exams offline but meticulous planning is required. Looking at the number of the students who appear for these exams and the effort that would be required to prepare the test centres, I don’t think it is an impossible task. In fact, for our own public health department, we conducted a recruitment drive recently and had an offline exam for the theory paper for which nearly 50,000 applicants had come. It can be done, with proper preparations and precautions.
Dipanita: Initially, there was a lot of hesitancy among people regarding the Covid-19 vaccine. However, that is slowly going away. What role do you think has social media played in convincing people?
When the vaccine was new, people did have apprehensions and that is not unexpected. But now, you see people are posting their selfies after taking the vaccine. It is helping to convince the fence-sitters. Plus, some time has passed since vaccination has started. Almost everyone knows someone who has already taken the vaccine and is doing fine. So, word of mouth also plays a big role.
Ajay: What proportion of population would we need to get vaccinated?
As you know, vaccination would build immunity at the individual as well as community level. It will help us in attaining herd immunity. So we need to vaccinate at least as many people as is needed for herd immunity to kick in.
However, we do not really know how long the immunity will last. There is an uncertainty regarding that.
Nirupama: What would be your advise to people who have received both the doses of the vaccine? Can they resume their normal activities?
No vaccine is 100 per cent effective, and Covid-19 ones are certainly not. It is not that everyone who gets the vaccine will be immune to the virus. Also, even after the vaccination is done, it takes time to build the immunity. It would develop after a gap of few months. Besides these, as I had mentioned earlier, we do not know how long the immunity will last. So, considering all these factors, I strongly advise people to continue maintaining Covid-appropriate behaviours even after taking the vaccine.
Nirupama: In the current wave, we are seeing that most of the cases are not as severe as they used to be. What conclusions can we draw from that?
That is true. Even as cases continue to rise, we are observing that these newer ones are much less virulent. While the cases are rising, the CFR, or the case-fatality ratio, is declining. The monthly CFR rate for Maharashtra in December was 2.19 (219 deaths per 10,000 infections). This has come down to 1.66 in January, 0.83 in February and 0.46 in March till now.
The virus circulating right now does seem to be less virulent than earlier. However, we are keeping our fingers crossed, because the behaviour of the virus in many other locations outside India is very different. Brazil, for example, is reporting more than 1,500 deaths every day.
But, if the cases continue to rise and hospitals get overburdened once again, it is possible that the death rate may increase again due to lack of medical care. We are trying our best to avoid that kind of a situation and working towards breaking the chain of transmission.
Atikh: At the Friday meeting in Pune, it was suggested that at least for the city, vaccination should be opened up for everyone and more stocks should be allocated. What is the rationale for this?
I was present in that meeting. The reasoning is that if Pune is indeed the worst-affected district in the country, then why not provide more vaccines to the city and ensure that everyone gets it faster and the outbreak is contained. The demand is coming in from the elected representatives as well.
Amitabh: You said at the start of the interaction that the speed and magnitude of infections in the current wave was similar to the first. Are we then headed towards a similar peak, wherein Maharashtra would be reporting about 25,000 cases a day?
Maharashtra has already started reporting around 16,000 cases a day. It does seem, right now, that we would touch the 20,000-a-day mark very soon. Our aim is to prevent that from happening, but looking at the current trends, the 20,000-figure is a possibility.
Amitabh: How is this current wave different from the first one?
The most important difference, as I mentioned, is the fact that the virus seems to be weaker, and most people only have mild or no symptoms at all. The death rate in Maharashtra, except for three or four districts, is less than 1 per cent. That is quite a hopeful sign for me. While the increasing cases are worrisome, it is reassuring to see that people are not dying. We are now monitoring the CFR on a weekly basis, district wise.
Amitabh: Do we have any possible reasons for why the Covid-19 trajectories are so different in different states. Because, the reasons being offered for the rise in cases in Maharashtra are not unique to this state alone.
This is a difficult question to answer and to be frank, we do not fully know it. The trajectories of other countries are also very different. And you would notice, the countries with better infrastructure have experienced more deaths. The analogy might not be entirely accurate, but I think, Maharashtra is exemplifying this same kind of trend within India. It is one of the more developed states, more urbanized, with better facilities. And it also has the highest number of cases and deaths.
Anuradha: Is there any change in the age profile of people getting infected?
We have been looking at the time, place and person analysis of the current surge. And, there is no stark difference in the age profile right now. People in the 30-60 age group comprise 60-65 per cent of the infections. This number is similar in the second wave as well.
Tabassum: How long would we have to continue wearing masks, and practice physical distancing?
This again is a very difficult question to answer. There are lots of variables that are unknown or uncertain. Emergence of new variants, the effectiveness of vaccines against them, the duration of immunity gained through vaccinations are all factors that would decide how long do we need to wear masks, practice physical distancing and follow Covid-appropriate behaviour.
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