Not the end yet but start living with smart surveillance, spot variants and take steps early

In metro cities like Delhi and Mumbai, it’s getting over but in Tier 2 cities, it is still a problem. Some of them are yet to be affected. Of course, testing is not uniform across India, so the plateau may persist a bit before the decline.

This isn’t the end of COVID-19. But if by endgame we mean it’s time for schools to re-open, for us to get back to near-normal with relatively small and not very difficult precautions, that should have already started. Honestly, we shouldn’t keep schools closed, at least in the big cities. The endgame has nothing to do with the end of COVID-19 as a pandemic, it has to do with the end of COVID-19 as a threatening disease that overwhelms healthcare systems.

On the emergence of a dangerous mutant

We confuse the virulence of a virus with our own immunity and a combination thereof. When the Spanish invaded South America, they carried many diseases and viruses which did not affect Europe but caused deaths there. Chicken pox killed many native Americans. In the beginning, none of us was immune to the virus. Delta turned aggressive because a large population was still not immune or vaccinated and no herd immunity can develop when the virus evolves. So, we should be counting how many susceptible people are left. We’ve seen that once you are infected, have got two doses of vaccines, the likelihood of dying reduces significantly.

By the time Omicron peaked, we had immunity from the big Delta wave and the vaccination of about 80 to 90 per cent adults. That protected us from death and destruction of the healthcare system. Post-Omicron, the number of people at high risk of dying from COVID-19 will get so small that healthcare systems will not get overwhelmed despite infections. The destruction will lessen with time unless the virus changes very significantly, which isn’t an immediate possibility.

Dr Anurag Agrawal (right) in conversation with Amitabh Sinha

On whether the virus can ever be eliminated

If I have to pick between this virus ending up like small pox or polio, which have been eliminated, and flu, where there is a continuing struggle, I will pick flu. COVID-19 is not going away. It will get less and less frequent, affecting only the immuno-suppressed, the unhealthy, those at severe high-risk, the very old and the very young. But the destruction and difficulty it causes will become much less, unless the virus changes very significantly, which is always a possibility but not an immediate high possibility. SARS-CoV-2 doesn’t mutate a lot but it is an RNA virus, so it mutates more than many DNA viruses. And with a larger pool of hosts in human beings, the virus is getting a chance to optimise itself and mutate. Besides, to eradicate something, it is important that it does not have a host outside humans. SARS-CoV-2 has found animal reservoirs, where it can keep evolving further.

On why herd immunity is elusive

I would argue there have been multiple temporary herd immunity phases, just not a long lasting one. Why did Delta end in Delhi? Because in one of our studies we found that about 88 per cent of the cohort had been infected. At that level, you get herd immunity against that variant and its derivatives. That is why Delta-plus, which was very similar to Delta variant, did not make much headway. Now Omicron is a very heavily mutated derivative of the Beta variant from South Africa. It is just not like Delta at all. Therefore, any antibodies you have developed will not bind and neutralise it. On the other hand, the T-cells, those that have a memory of severe disease and kill infected cells, will still remain effective. So, severe diseases are prevented but not the infection itself. Herd immunity is an infection concept, not infection to severity. You need high quality studies with people you are sure have never been infected earlier to get a better answer.

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On Omicron as a natural vaccine

I don’t like that phrase at all. To call something a vaccine, the side effects must be very low, comparable to vaccines. With our current vaccines, we expect something to go wrong in one in a lakh or may be 50,000 cases. Now, look at the Infection Fatality Rate (IFR) of Delta and Omicron. Delta’s was somewhere around two in a 1,000. Omicron is 60 to 70 per cent lower than that, in certain age groups it might be only 25-50 per cent lower. And you realise that is not a very safe prospect. In Delhi, there are roughly 40 people dying these days, of which half would be incidental. If you had a vaccine, which was seeing 20 people dying everyday, you would stop that vaccine, never use it. That is why calling Omicron a natural vaccine is not right.

On the fear of a dangerous variant and surveillance

Fear is never a solution. Giving up school, work, businesses and staying indoors have their own complications. Given that the risk of death is low while most people are vaccinated and have some immunity, just get on with your lives. That has got nothing to do with the possibility of a worse variant as the virus will try to propagate itself and escape immunity. It will weaken with immuno pressure. Maintain high-quality surveillance, detect variants and take steps early.

India needs a smart, not brute surveillance. Look at South Africa. They don’t sequence a lot but they were very effective in spotting Omicron and Beta before that. Their general epidemiology is very strong. We must not be obsessed with the daily number of genetic sequences. You want sequencing labs to have a rapid turnaround and rush all the data to common platforms, so that you can make sense of whether the new sequences are matching with something happening clinically. We now have an Integrated Health Information Portal (IHIP) to do that.

Also, an outbreak is the worst time to sequence as the causative variant is dominant. It is that part in the middle, during a trough, that you need to continue sequencing. We need to maintain a good stable level of sequencing, coupled with intelligence from the ground. As for the rest of us, be alert, follow advisories and don’t panic. The Government must make sure the public messaging is right.

On learnings from the pandemic

Why did SARS-CoV-1 not spread? Because the mutant viruses were not that potent or fighting fit. If you look at the SARS-CoV-2 virus, one of the two initial strains could have died out. Had the D614G mutation not occurred, the pandemic would have taken a different track. That resulted in the virus sweeping across the globe. But then we weren’t doing enough sequencing. Otherwise, we could have focussed more on masks and ventilation early on. Vaccine equity would have helped too. No country is safe till everyone is safe. And common sense measures are important despite advances in science.

On whether the next generation of vaccines will be more effective

An ideal vaccine prevents infection and blocks severe disease. An acceptable vaccine protects the individual against severe disease but then the target is universal vaccination of all people at risk. I would love to see better vaccines that protect us against all coronaviruses, vaccines that are not against a single ancestral sequence but against a multiplicity of possibilities.

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Audience Questions

On the necessity of booster shots

From the WHO point of view, it’s a trade-off between global equity and further lowering the risk for a select few. The priority is always to get more people fully vaccinated. Some UK data has shown that the effectiveness of protection does go up to 70 to 80 per cent with a booster from 65 to 70 per cent but it doesn’t block infection. So, in terms of the severity of the disease, the gain is smaller. If there is minimal benefit, there is no point in giving boosters to everybody, especially given the fact that all vaccines are not exactly the same. Therefore, precautionary doses for healthcare workers, the elderly and those at high risk make for a sensible approach. Most Indians are infected and vaccinated, so our immunity may already be equivalent to three vaccine doses in terms of Western data. How frequently India needs boosters cannot be decided without Indian studies about immunity.

On whether night curfews, lockdowns and school closure control transmission

Schools are high priority and when classrooms have big windows or when classes can be done outdoors, the risk is actually small. It is not surfaces but air that is the main source of transmissions. India is in a better place for staying open compared to many countries where everything is closed and air-conditioned.