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Wednesday, May 27, 2020

‘The dream is to have zero cases but we’ll have to live with COVID-19 for quite some time’

In an e-Adda hosted by The Indian Express, Dr Randeep Guleria, Director, All India Institute of Medical Sciences (AIIMS), who is part of the core team monitoring the pandemic in India, spoke on what the lockdown has achieved, how we cannot lower our guard and learning to live with the virus

Written by Ravish Tiwari , Kaunain Sheriff M | New Delhi | Updated: May 10, 2020 9:05:21 am
Dr Randeep Guleria at the e-Adda on Monday.

In an e-Adda hosted by The Indian Express, Dr Randeep Guleria, Director, All India Institute of Medical Sciences (AIIMS), who is part of the core team monitoring the pandemic in India, spoke to The Indian Express Political Editor Ravish Tiwari and Principal Correspondent Kaunain Sheriff M on what the lockdown has achieved, how we cannot lower our guard and learning to live with the virus

On what the lockdown data tells us

There is now a lot of data that has come not only from India but also globally as to how this pandemic and how this new novel virus behaves. I think it is something that we all need to look at critically because it will impact our life no matter what our occupation is, or what we are worried about; whether it is health or even non-health related issues. First thing is, what has emerged as obvious from data that has emerged from China, Europe or the US, is that something like a lockdown or social distancing is paramount if you want to flatten the curve. India did that early, and it was something that was a point of satisfaction. We were upfront when it came to international flights, lockdown, and if you look at the number of cases compared to other countries, we have a less steep rise, although the cases do continue to increase; so that is something that is satisfying because it has not really overwhelmed the healthcare facilities as it has done in many countries. We all know that our healthcare facilities are already stretched to some extent. We are a resource-limited country but we managed as of now to be able to not have ICUs or hospitals full of COVID patients, as it has happened in many western countries. That way, it is a satisfying thing, but the challenging part is the future. What are we going to do subsequently considering the population we have, the fact that we have a varied number depending on the socioeconomic status, from people living in urban slums to the rural population to crowded cities, people travelling in metros, in Mumbai rails, how are we going to handle that as we start lifting the lockdown. How are we going to make sure that this curve doesn’t rise steeply as things evolve over the next six to eight weeks, those are going to be crucial because what we managed to do, as of now, is to buy time to prepare ourselves but we still are seeing a rise in the number of cases, therefore we need to be very cautious as we go in May and June.


On what we know about the virus

So, we are learning more and more about the virus. There were two or three things that we initially thought — that the infection occurs only once you get symptomatic and the initial data tended to suggest that once you have symptoms of fever, cough, cold, sore throat, body aches, then only you are infected and that led to the whole strategy of isolating people and testing them once they had symptoms. Subsequent data suggested that this virus is actually more smart than what we thought.

You can have a large number of individuals who are asymptomatic and still have the infection and still transmit the virus in the community without the person realising that he has got symptoms, that’s why the strategy changed to everyone in the community wearing a mask. The other thing we realised was that even in those who are symptomatic, you have a pre-symptomatic stage in some individuals. That is even before you become symptomatic, for the preceding 24 to 78 hours, you may still be transmitting the disease and therefore you may still be causing the infection. These factors are a cause of concern because that means that the number of people who would be transmitting the disease in the community is much more than what you would pick up by just testing symptomatic individuals. That is one thing that is a cause of concern and therefore your strategy has to change to more and more containment, lockdown and making sure the hotspots are aggressively sort of kept locked and no movement occurs from there because it is not people who are symptomatic but also asymptomatic people who would transmit the disease.

“It is important to remember that the testing strategy in a country like India has to be based on what question do we want to answer, what is it that we want to find out by doing the testing,” Dr Randeep Guleria said.

The positive thing that we have been able to get in the last few weeks, one is being able to improve our infrastructure in terms of planning, in terms of knowing that majority of individuals will recover and many just need oxygen with proper supportive treatment and maybe just three to five per cent will require the critical care of ventilatory support that is required. We have also learnt that the younger age group by and large tends to be safe and gets a mild illness, and if we need to focus our resources, we need to focus them on the elderly and on the high- risk group who have associated comorbidities because they are more prone to serious infection.

We have also known that some of the drugs that are already available in the country may have some benefits and that has let us to try and start using them even though the evidence is still being generated. So we have tried to do that because we can’t wait for the evidence. It may take a year to do proper studies and by the time we would have lost a lot of lives, so that has also helped us in trying to develop treatment strategies. Finally, of course, the whole community has come together in developing new drugs and is also working together to get a vaccine out as early as possible.

There is now evidence that is coming out that this virus not only affects the lungs, it causes a hypercoagulable state that causes clotting in the blood. It causes swelling of the blood vessels, what you call endotheliitis, therefore it causes involvement of the heart, what we call myocarditis. We have had a few patients who had a stroke and subsequently developed COVID symptoms and tested positive. So this is now reported even in the West. You can have neurological manifestations in patients who are COVID positive and realising that even other organs like the kidney, or in other people diarrhoea can also happen. As we start seeing the entire spectrum of viral infection, we are realising that there can be many atypical presentations. In the majority it will be respiratory involvement but you can have some atypical presentation and therefore you should have a high index of suspicion.

On India’s lower mortality rate

Whatever data we have, based on surveillance and based on testing, does suggest that mortality in India is lower than what has been seen in the western world and there are a lot of people who have given various hypotheses for this. One being that our average age is younger, we are a younger population and this causes higher mortality in the older age group. The other theory is that we have all had BCG vaccines, which is basically shown in some studies to cause immunity that helps against viral infections and that may be protective. The other theory of course is that having recurrent infections, our immune system is already very active and therefore may be attuned to dealing with the virus in a better manner. Some people argue that maybe there is a mutation in the Indian strain, but we don’t have data to support that. I also feel that we need to see how it evolves over the next two months. The number of cases is still increasing to some extent. Therefore, it is important for us to see how things evolve. As of now we have a lower mortality and I think it may be further lower because remember the denominator that we are looking at in calculating the mortality are those who are positive. There are a large number of people who are asymptomatic, who also have the disease, who we are not counting, so if we count them, then the denominator will be much bigger and the actual mortality will be much lower. So I think overall the mortality is relatively low but it is still a cause of concern, especially in the older age group and people with comorbidities.

On community transmission and our testing strategy

It is important to remember that the testing strategy in a country like India has to be based on what question do we want to answer, what is it that we want to find out by doing the testing. When we started, the challenge was to see what are the cases that are coming from outside, what are the cases that are positive among international travellers. The second testing strategy then evolved (from the question) that are we missing out some patients who are coming with SARI, that is Severe Acute Respiratory Infection, and therefore the testing strategy was that all patients admitted with severe pneumonia need to be tested and that was what was done.

Along with that, we have another surveillance system known as IDSP, which is the government of India surveillance system that looks at across districts, people who have ILI– influenza-like illness–and people who get admitted because of severe acute respiratory illness like pneumonia. One kept looking at that data also to see for any red flags or see if there was anything that was different this year from last year, so we had surveillance data and lab data, which did not show a dramatic increase in either the number of cases of SARI or as far as the surveillance data was concerned. But as the pandemic progressed and as we had more and more cases, the testing strategy became more liberal and now we are testing a lot of individuals with influenza-like illness even in the hotspots. Our testing, which was around 10,000 tests a day, is now close to more than 70,000 tests a day. Hopefully, by this weekend or early next week, we will actually be able to do hundred thousand tests a day. So the number of tests we are doing is almost equivalent to what is being done in the rest of the world.

The only issue is if you look at it on the basis of our population, then it seems less, because the population of our country is much larger. I think it is important to remember that the testing strategy has to be able to look at what you want to answer rather than testing everyone who is presenting because it would be a waste of resources. Regarding the question of community transmission, I think it is basically an issue of semantics. If you really look at various parts of the country, many districts have very few cases and have no case for two weeks or a month, so to say that there is community transmission across India is not correct. But you have hotspots where there is an issue of people who are being diagnosed and their close family members are becoming positive and you are always worried that they may also be giving infection to other members in the community, so those are the areas where you need to be very vigilant because those are areas where a number of people would be getting the infection because of the proximity that they have, whether it is a colony, people who are living together in an urban slum and one needs to be very careful because my concern is these hotspots, which we need to really focus on in terms of bringing down the number of cases.

On the importance of syndromic surveillance to track this infection

I think syndromic surveillance is very important and I would say that in the cold spots, areas that are not hotspots, the green zones, one will have to continue to do syndromic surveillance because you would want to be sure that in those areas you are not missing out a cluster or outbreak that might happen because of someone coming to that area or a COVID-19 (positive person) coming to a green area, and that actually turning into orange and red zone. There has to be active surveillance that has to be done at district level, state level and at a national level and the data has to be analysed regularly. At the same time one can also look at strategies for testing in these areas. You could do pool testing, where a number of samples could be pooled for people who have ILI, you see if any of them are positive because if they are negative then you can say this is a non-COVID ILI and this is an area where you are having influenza like illness but this is not COVID related and therefore this area continues to be green. So you will have to build strategies, both in terms of surveillance and in terms of making sure that the green zones remain green.

On the trends emerging from the surveillance data

The trends that have come out from surveillance data from these areas actually are pretty satisfying because they don’t really tend to point towards any increasing clusters or any increasing numbers of ILI cases. They have even compared that to last year’s data to see the number of cases… there is a seasonal variation also for ILI, so comparing the seasonal number of cases in each area that happened last year compared to this year, there is really no signal that suggests that some areas are having a huge number of cases and that is something which is satisfying, but like I said, we have to be very vigilant, the next few weeks are very important.

On micro-planning and looking at Kerala’s strategy

One is looking at the national curve, but at times that can be misleading, so one will need to have a micro-planning and a micro look, which could be state-wise, district-wise. You will also need to have different strategies when it comes to metros. Most of the hotpots are occurring in cities and that is because of the general density of population and the fact that a large number of people who work there live in crowded facilities or houses where five members of a family live in one room or the migrants labourers are all living together. Different strategies will have to be evolved for metros and for areas that are showing an increased number of cases. So there has to be micro-planning also. You cannot just look at the curve for India as a whole. It is a very large country and there are some states which have done well. Kerala is one example, and it is also worthwhile to look at what did they do that made the difference and can that be replicated in other areas where we still have an increasing number of cases.

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On the importance of community participation

There has to be a lot of community participation because we have to prevent the number of cases from coming to the hospital. To do that you have to have a lot of participation of citizens in terms of people strictly following self-quarantine or home quarantine or coming forward to get themselves tested and if they are positive, going to a quarantine facility so that they don’t spread the disease in the community. It needs aggressive action by the administration to make sure that this is implemented because there are certain areas where the population density is very large and you will have to create infrastructure or facilities to do that. That is also a challenge that different states are facing and you have to be very aggressive in terms of surveillance, monitoring and developing such strategies.

On future strategy and the way forward

The dream would be to have zero cases but I don’t think that will happen in the very near future. We will have to literally live with COVID-19 for quite some time and. We would have less number of cases but one is very worried that we remain vigilant and not sort of start relaxing our guard. The number of cases are still increasing every day. Although we have flattened the curve, it is still rising, it is not showing a decline in the number of cases and that is why we need to focus a lot on these hotspots. At the same time the rise in the curve is not so sharp that we can’t handle it as of now. So we need to keep preparing, developing strategies as far as hotspots are concerned and also realise the fact that when it comes to coming back to our new normal, we will have to have strategies which will be able to work or we will have to develop with COVID-19 being around, whether it is travel, work, related to other things.

On the efficacy of plasma therapy

Convalescent plasma is one form of therapy, and it is not something that is new. It was tried even during the Spanish flu in 1918 and more recently for Ebola. What it basically is that you are taking the antibodies from the blood of a person who has recovered, he donates his blood, the plasma is taken and we check if there are enough good antibodies and these are given to a very sick patient. These antibodies boost his immune system and help him fight the infection. This is one part of the overall treatment strategy. It is not that this is the only treatment strategy, but there is limited data, and there are two studies on COVID-19–one on ten cases and the other on five cases, which tend to show that plasma therapy along with other treatment strategies, did have a benefit. But as I said, it is a complicated process, you need to have people who come forward to donate blood, the blood has to be analysed to check it’s safe and it has enough antibodies and then it is given to a sick person. It is something that may help, as a jump through the standard treatment policy, but I think you could say that this will be the only treatment that we will use, therefore it is not the so-called magic bullet to really cure COVID-19.

On the use of Hydroxychloroquine and Remdesivir

Hydroxychloroquine and chloroquine are drugs, which showed in vitro, that is in lab data and in animal studies, to be useful both for COVID-19 and for the other coronaviruses, that is SARS and MERS. Based on that there was one study in France that showed some benefit in decrease in the viral load and some improvement. A study from China also showed some degree of benefit. There are other studies that have not been able to show that much of a benefit as was shown in the Chinese or the French study. We are not really very clear as to how effective it is. However, a detailed analysis was done of the literature. Hydroxychloroquine is also a drug that many of us have used for a very long time, may be more than 20 years, for a large number of illnesses, including rheumatoid arthritis, joints-related problems, lung-related problems, and I have found it to be very safe.

People have taken it for many years without having significant side effects. So it is felt that the safety of the drug is good, you have to monitor for certain conditions that we need to put up and there has to be some degree of close monitoring by the health professionals. The evidence of its efficacy was questionable but at the same time it was felt that if we wait for evidence it will be too long and we may have a large number of people who may die. Therefore, a risk-benefit analysis suggested that Hydroxychloroquine could be used and that’s why it was recommended by the ICMR. It’s now a treatment for only two categories. One is health care workers, who are actually managing COVID-19 patients because they are the ones who are at a risk of getting the infection and if we are able to decrease the viral load in them, it will help. Secondly (those) in close contact of a COVID-19 positive patient. The other drug that has now come up is Remdesivir. It was basically a drug that was developed to treat Ebola, and it was tried but did not do that well as part of treatment for Ebola. It was also used for one patient in the US on a trial basis and that patient recovered. Subsequently there has been some data that doesn’t show it could work very well.

Hydroxychloroquine, FDCA, Gujarat FDCA, Ahmedabad FDCA, Gujarat coronavirus, COVID-19 cases Gujarat, India news, Indian Express In a humanitarian gesture, India on Wednesday gifted life-saving drugs, including Hydroxychloroquine tablets. (AP Photo)

A recent study published in The Lancet from China suggested that it tended to show that it did not have a mortality benefit, no benefit as far as survival was concerned, but it did show that the degree of the stay in the hospital or the time to recovery was shortened to some extent for those who took Remdesivir. It is a drug that needs more studies or details but because of the fact that we don’t have anything, the FDA gave emergency use authorisation to Remdesivir. It has also allowed Hydroxychloroquine to be used and we need to have more studies. WHO is conducting a large multinational trial known as solidarity trial, in which one arm is giving Remdesivir and the other arm is giving chloroquine, the one arm is also giving an anti-HIV drug, like Lopinavir and Ritonavir. We will need to see the data as it emerges as to the benefit. It is still early days. As we don’t have a definite therapy, it seems that trying something will be better than not having anything available, but it has to be done at a close monitoring and as a research tool.

On tele-consultation and the new normal in healthcare

Two things are going to happen and it may be looked as an opportunity if you want to put it that way. One is the issue of tele-consultation and because of the fact that you are talking of social distancing and not having patients who are coming to the hospital, there will be a lot of push to have consultations which could be done using phone or video conferencing. Some patients find this useful because they feel it saves them travel time and at the same time they don’t have to wait for many hours outside the clinic or the OPD to get their appointment. It is done from their house and therefore it is more comfortable to them. Especially for the elderly and those with chronic illness who just need advice, let’s say a diabetic on adjusting their insulin dose or a person who needs some advice on adjusting his blood pressure medicine, this type of consultation will be useful rather than him having to come to the hospital and wait there for a long period of time and also have the risk of getting infection. So tele-consultation will become something that will become the new normal. Secondly, there will be changes in the way we examine patients and how we interact with them in terms of more and more infection control measures. Social distancing while examining patients, wearing a mask while examining patients and regularly washing your hands and wearing gloves will become something that will become a norm. It will also change the way we do surgeries, being extra careful in terms of infection control. Also, in terms of how we do procedures, one would be able to protect healthcare workers in case someone has COVID- 19. Remember, like we said in the beginning, many patients are asymptomatic…therefore you will have to assume everyone is positive unless proved otherwise, if you want to be protected and be safe. There will be dramatic changes as far as the health management strategies are concerned.

On the role of the private sector to combat COVID-19

It has to be a combination of public-private partnership. The private sector has to come on board if you are going to really manage COVID-19. For various reasons, currently the private sector is not as active as the public sector. The brunt of management, whether it is the COVID centres, hospitals, is predominantly on the government sector. There are various private hospitals that have come forward and have COVID hospitals, and I think that is a very good step, but a lot more needs to be done. Also, you must understand that there is a huge strain on the private sector because of the lockdown and because of the fact that patients are scared to come to hospital. A lot of routine work, which was what the private sector was sort of running on, has come to a halt. Routine surgeries, like let’s say, joint replacement or angioplasty or bypass surgery or other routine surgeries for hernia, gallbladder or laparoscopic surgery, all have actually been postponed or come to a halt and that is causing is huge strain on the private sector, both in terms of hospital admissions and the earnings that they have. There will have to be a lot of brainstorming on how to get everything back on track.

A lot of changes need to be done both in turning a hospital into a COVID centre. One, of course, is the fact that the patients will be reluctant to come to the hospital for routine procedures if it gets labelled as a COVID hospital. Secondly, you will have to invest more. You will have to get PPEs that you were not getting, you will have to make different arrangements in terms of social distancing, air-conditioning and things like that, a lot of structural changes also need to be done by the hospital, and it increases the cost that it has. Also there has to be willingness of all the healthcare workers to be actively involved in managing COVID-19 positive patients. Remember that if you look at the global data, a large number of healthcare workers have got infected with COVID-19 and many have lost their lives, so there is also a concern and fear in healthcare workers.

On what to watch out for as the lockdown eases

It is important to look at how our hotspots and coldspots are behaving. Are the number of cases coming down or are more coldspots becoming orange spots. The second issue, of course, is to see what happens as the lockdown gets partially lifted in some areas. Is there an increase in the number of cases? So, is the result encouraging enough to say that even after lifting the lockdown in these areas we have been able to not have a spike in the number of cases? We need to be very vigilant that there is no mixing of travel or movement of people from hotspots to coldspots, because that will cause a huge concern and that needs to be monitored in a very minute manner.

On the movement of migrants from cities to their homes

There are two issues, the health issue and the economic and social issue. From the health point of view, if I was to really say something that would be ideal, it would be that no one should move, which is why the lockdown came in such a dramatic manner. If we had said that people can move and then we had the lockdown, the very purpose of the lockdown would be lost. At the same time, the lockdown has been there for quite some time, it is causing a lot of hardships to migrant workers, labourers and daily wage people. Therefore, a strategy needs to be developed so that that is also looked at. At the same time wherever they go, they will need to be quarantined, to be monitored, so that we make sure that they are not giving the infection to the community that there are going to. I think that is already being done both at the state and the district level.

On why we have not started antibody testing

I think it is important to understand the utility of antibody testing. Antibody testing is not a good diagnostic test. If you have COVID-19 infection, the first test or the test which is actually the gold-standard is your nasal or throat swab where it is tested for the virus by RT-PCR. Now, if you get the infection, after some time, the body’s immune system starts reacting and tries to fight the infection by forming antibodies. These antibodies vary and take days to develop. So, what we are finding is that these antibodies will take up to 10 days to two weeks to develop in an individual. So, it’s no point in having a test that gives you a diagnosis after 10 days to 14 days because by that time the person has already got the infection, he is maybe recovering or has given the infection to a large number of people. So, the utility of antibody testing as a diagnostic tool is very limited. The utility of the test is more towards surveillance. Suppose I want to find in a hotspot how many people got the infection and recovered from it while being asymptomatic and became alright. So, I can then do the antibody testing in a large population to see how many of them have antibodies and have thereby got the infection without knowing it and have recovered from it. So, it’s more of a surveillance tool, it’s not a diagnostic tool and that is why it will not work if you start using it for diagnosis. If you look at the previous data of antibody testing tools for viral infections, whether it is H1N1 or SARS or MERS coronavirus, they really haven’t performed well in terms of picking up the antibodies in clinical studies.

On what the post-COVID world is going to look like

This is going to have a huge effect on various industries, whether it is the hospitality industry, or the entertainment industry or airlines. How do we really travel with social distancing? Do we, therefore, leave some seats empty as compulsory and if we do that, how do airlines make a profit or how do they operationalise themselves? How do we sit on buses and trains with social distancing? Is just wearing a mask good enough as far as travelling is concerned or do you have to have empty seats in between? These are challenges which we will face over the next few months. Similarly, restaurants or shopping malls, how do we have people going there, or are shopping malls something that will stay shut for months to come? So, I think there is a lot of work that needs to be done in terms of developing a new normal and seeing how that new normal is practical so that we can live as far as our day-to-day activities are concerned and our economy can grow as it should. A balance has to be developed and one has to look at strategies that are doable, practical, and safe. So, there is a lot of brainstorming that needs to be done, and I think that’s being done not only here, but at a global level.

Q&A

Arvind Paranjpye

Director, Nehru Planetarium, Nehru Centre

If I was tested positive, go through a treatment, become negative, then is it possible for me to become positive again?

Currently, what we are able to see is that in a large number of people, if they become COVID19 positive and recover, they form antibodies in the blood and these antibodies give some protection as far as subsequent infection is concerned and that is why this whole concept of herd immunity is there. If a large number of people get these antibodies, then the number of people getting infected will gradually decline. What we really don’t know is how strong is the antibody reaction and is it sustainable for a long period of time. This is a new virus and this is something that is not very clear. What is also being seen is that in some people the virus tends to stay for a much longer period, so you may be positive, the viral load becomes less, it may not be picked up, but you may still have the virus in your secretions and later on subsequent tests may actually show that you are positive and it may not have been eliminated from the initial time that you got the infection. But whatever data is emerging is that there are people who develop antibodies, it does take time. It will take up to three weeks in some individuals to form antibodies, for how long they provide the so-called immunity passport is not very clear.

Neelkanth Mishra

Equity Strategist

I had a question regarding the granularity of control. Clearly, we have gone to the district level now but as we are finding in Delhi, where we have seen areas where there is an industrial township, but just two or three infections and the whole township is shut down. At some point if we have to live with the virus for this long, given that the 130 districts are in the red zone add up to half our GDP, can that really be managed centrally? What are the mechanisms we can put in place so that we have more discretion given to district administrations without creating perverse incentives where they report low cases deliberately to keep the district open and how much can central surveillance be raised so that those perverse incentives are controlled? Because otherwise it may be shutting down a lot more of the economy than we need to.

I think it is a very important issue that you have raised and it is something that we have to keep in mind. I do agree with you that in certain areas, and those includes the metros and cities, you have to have more granularity. You can’t look at it from a district point of view but you have to look at it from a local hotspot area and be able to see what is the locality or area where the cases are coming from and work on a strategy of only being able to close that area and keep the other areas under close supervision but allow them to function. Closing a large area out of panic will cause a huge economic impact and that granularity is already being looked at and developed for metros and cities, unlike the rural parts where you could work on a district model. Also, you have a very valid point regarding the economy and that is why we need to develop a strategy where we balance running the industries and other things but at the same time taking precautions that it doesn’t lead to a spike in the number of cases. So different strategies need to be developed and they have to be different for different areas in the country. We can’t have one strategy for the entire country. There has to be a granularity when it comes to larger places like cities or industrial towns. I also agree with you that there has to be some degree of monitoring to make sure that the testing is done properly because being in the green zone gives you a lot of advantage as far as economy is concerned but it also has a threat that if you call yourself a green zone when you are not a green zone, you can actually have a very serious health effect.

Mae Thomas

Founder, Maed in India

We know that COVID-19 is of the same family of viruses, like SARS and MERS. Does this mean that the coronavirus will continue to adapt and there will be more variations of it, and how do we prevent this from happening again?

Both SARS and MERS belong to the family of coronaviruses. These are the two major coronaviruses that have caused infection in humans, there have been other coronaviruses that have also had a mild illness as far as humans are concerned but have never had a large fatality as compared to these two viruses. Viruses are known to adapt or mutate to some extent and that is part of what they do, however COVID-19 is a novel virus, which is not linked in that manner to SARS or MERS coronavirus, although it belongs to the same family. It also has adapted itself. SARS was a virus which caused more of the lower respiratory tract infection, more of pneumonia and had a mortality of ten per cent, but it was not that effective in causing an infection of the upper airways and therefore causing a large human-to-human spread. The same is true for MERS. However, COVID-19 is a novel virus which is not linked in that manner to SARS or MERS coronavirus, although it belongs to the same family. It has also adapted itself. If you look at SARS for that matter, it was the virus that caused more of the lower respiratory tract infection and pneumonia and had a mortality of 10 per cent, but it was not that effective in causing infection in the upper airways, therefore not causing large human-to-human spread. The same is true for MERS. It has a case fatality of over 30 per cent, but it did not have the ability of causing a large spread because it was not that infectious. COVID-19 has developed that ability to be more infectious and spread to a number of people, it causes more of an upper respiratory involvement, and you have mild and asymptomatic people also. So, it behaves differently from what SARS or MERS behaved. But that is also a problem because that is why the number of cases are so many, unlike what we’ve seen in SARS and MERS. But I do agree, we have to be very vigilant. The virus does adapt, after all it is also trying to survive, despite what we do, and viruses have been there for a very long time, and they are known to adapt. But as we develop treatment strategies, they would be able to take care of the part of the virus that doesn’t really change that much and would be effective even if the virus adapts to some extent.

Swati Piramal

Vice-Chairperson, Piramal Enterprises

What is the policy for recovered COVID-19 patients, especially in the healthcare settings? Should they be going back to work in hospitals, dialysis units and others because we don’t exactly know when they stop transmitting the virus? What is the responsibility of the employer if the patient has recovered, it’s a negative twice tested? Are we sure they won’t affect other people? Do we have a policy on that?

So, there are two things to remember. One is that if a person tests negative twice 24 hours apart after 14 days, then we ask him to home quarantine for another 14 days and then go back to work. Some in the West have argued that these persons have some protective immunity, therefore it’s maybe better people go back to work, but we’re not sure about that. The other thing to remember is that there is a lot of data that is now emerging, even if you’ve a person who is asymptomatic or has mild symptoms, and recovers, he may have the RT-PCR which may show the virus but the cultures don’t show the virus after 14 days, and the chances of these patients being infectious is very low. So, if you have a swab which is negative twice, and the person is otherwise healthy, he could be able to go back to work and that is being done not only for healthcare professionals but even for people who are working in other areas.

Dr Sansar Chand Sharma

Medical and Health Sciences Dean, SGT University

We stood with the government for quarantining people coming from abroad and our hospital has been converted into a COVID-19 hospital. The government now wants us to treat non-COVID-19 patients. How do we begin with the treatment of non-COVID-19 patients? Also, soon MBBS students will be returning to colleges and there comes the question of social distancing. These are the challenges that we’re facing, can you suggest anything for this?

Yes, these are the challenges, and we have to work with the new normal. As far as COVID and non-COVID treatment is concerned, if you’re treating both, then it is better to have two separate blocks or areas with proper segregation. The challenge that we have — I’m sure you will also have — is that your strength as far as human resources is concerned will be split and divided. But you’ll have to develop strategies for that, we’re also doing that, and trying to see how we can do limited care for non-COVID patients. One way we’re doing that is by using tele-consultations, trying to reach out to our patients, both new and old, getting their appointments through our teleconsultation centres, and thereby calling them for consultations. If they need to be there physically, give them an appointment but make sure that the OPD area is not crowded.

About teaching, it is a big challenge. Therefore, the whole concept of virtual classrooms comes in where you’ll have to focus more on teaching students via webinars or mechanisms without crowding in the lecture theatres. Some colleges are splitting the batches into morning and evening shifts. There is also the issue of how much you can teach virtually and for how much they need to be present. But we have to develop strategies for the next few months or a year, considering that social distancing is going to be a norm.

Jyoti Parikh

Executive Director, IRADe

Can you tell us if you’re doing any modelling exercises and is there a long-term vision for the healthcare system for the country? Local healthcare centres, nursing homes and institutional architecture need to be seamlessly developed. Also, will this come back again in subsequent years?

Modelling is being done both in terms of how the cases are evolving, when we may have a peak and what would be the capacity that we need both for human resources for hospitals and ICU beds. There is a whole team that is doing that. There are various experts, including the Medical Council of India, are taking this as an opportunity, where the focus is on how do we develop a better infrastructure as far as health is concerned, both in rural areas and tertiary hospitals, the mechanisms for connectivity, whether it is through referrals or e-consultations, so that our system becomes robust. In many countries, it has taken some dramatic things to happen for the health system to improve. In the UK, the NHS, which is a very good health system, evolved after the Second World War and since then has become a standard system as far healthcare of the citizens is concerned. Thirdly, regarding the virus coming back again, we are not very clear. There is a concern that the virus may come back in winter, we may have another spike, a second wave as it is called, and people are looking at that and worrying about it. I’ll just give a small example of another pandemic which is supposed to be the biggest pandemic that mankind has ever faced — the Spanish flu of 1918. If you go back and see history, what we’re doing today was done at that point in time, colleges were closed, schools were closed, you can go back and see the papers, there was social distancing, stadiums were converted into halls and people were kept at one metre apart, everyone wore masks and there were huge number of deaths. In India itself, seven million people died in the 1918 pandemic. From there we have made a lot of progress. Also, more deaths occurred in the second wave. There was a lockdown and people followed it really well, but after it was lifted, they went back to normal, there was no social distancing, people kept celebrating the fact that they were out and that led to a second wave with higher mortality. So, we have to learn from history, and as it evolves over the next few months, social distancing and being careful is something we would have to do. Taking care of the elderly, making sure that they are protected are steps that we would have to follow for many months to come. We should not look at this as a short-term battle but as a long-term battle, which may last even a year or two. The pandemic in 1918 lasted for two years.

Yoginder Alagh

Vice-Chair and Professor Emeritus, Sardar Patel Institute of Economic and Social Research and former Union Minister

It has been said that the preventive aspect is as important as the curative aspect. Some of your comments suggest that it is being thought of, and if we’re concentrating on the community aspect, particularly in this case, where people tend to live together in slums and so on, then what is roughly the share of resources that you will give to the curative and the preventive aspect. If the preventive aspect is important, will you also worry about things like poverty, because we do know that slums are strongly related to urban poverty?

If we have to put our money somewhere, it has to be on preventive strategy as we don’t have a definite treatment. Those patients who have severe illness, in the ICU on ventilator, if you look at data from the West, the mortality is as high as 70 per cent. So the focus has to be on preventive strategy, which focuses on two broad pillars, one is a non-pharmacological approach, that is basically looking at social distancing, cough etiquette, hand washing and wearing a mask, and to all of it, you add the whole issue of socio-economic status. How do you get this implemented in an urban slum or in an area where there is already poverty and people are crowded together and can’t afford to really have social distancing that we’re trying to impose upon them? That is a challenge and that is why there is a need to have citizen participation — interaction with citizens, local community workers and community opinion leaders — to see how we can run strategies where these people can be provided some support, which will help in developing or propagating non-pharmacological strategies. Should we have halls or stadiums where people can stay. Second pillar which we need to focus on is the vaccine. Vaccine is also a preventive strategy, which is the pharmacological measure on which we need to put a lot of work aggressively, and I know a lot of Indian companies working, not only on their own but collaborating with international researchers, on a vaccine as early as possible. If we’re able to have an effective and safe vaccine, we can produce it in large numbers and we’ll be able to prevent the infection by vaccinating a large number of people. Third thing that I feel is important, and it is linked to non-pharmacological management, is protecting high-risk groups. So whether we are in an urban or rural area, we know that people with comorbidities and those who are elderly, are at a higher risk of a severe illness, and they are the ones who will cause the increase in mortality, so we need to work aggressively in protecting them till the time we have definite treatment and a vaccine. If there is infection in the younger population, the mortality is much lower, so I think the strategy has to be based on non-pharmacological means and we have to see how we can implement them and hopefully get a vaccine as early as possible.

Divyesh Mundra

Deputy Manager, Chairman’s Office, Narayana Health

As the chair of the clinical research group, the immediate priority was to establish the COVID India clinical research collaborative network. What is its status? One of the terms of reference for your clinical research group was to identify partners for implementation. Could you share how many partners and who are the partners identified for implementation?

The clinical work is already established. There are three or four research priorities that India has which are specific to the country. One, of course, is to look at is there a role of giving convalescent plasma and a network of various institutes has been formed. There are about 22 institutes that are a part of the network in terms of convalescent plasma treatment. There is also a strategy of developing a registry and many institutes are coming on board as far as that is concerned. We are giving Hydroxychloroquine and there is a need to see how useful that is. A group is also being developed to look at the utility of BCG vaccination because there is some data that suggests that it may be useful. So, the focus is to look at groups that have areas on which they can work on and also look at groups that are doing a lot of basic research and they can collaborate with the clinical partners. Remember, we have to do these projects of collaboration in areas where there are available cases or the material is available for us to do research in. So, based on that, the networking has been developed and a large number of research projects are being rolled out. The challenge for us is to try and get results early because many of these projects will take months to get a statistically significant number in terms of the sample size and we are trying to see how we can shorten that and do some interim analysis to be able to get results in quick, which can have bearing on our treatment as of now whether we need to give BCG vaccine, whether we need to continue with Hydroxychloroquine or whether convalescent plasma is a good form of treatment in our country. So, these are important questions that have clinical bearing and management both in terms of cure and in terms of decreasing mortality. The group is trying aggressively to develop these types of research groups and I am hopeful that we should be able to get some of these answers in the next few months.

Jagdish Walawalkar

CMD, Ideal Education Pvt Ltd

You said the virus is going to stay here for some more time, can you estimate at least how much time it will take? When will it come back – you said that it may come back around winter?

For how long the virus is going to stay is a question everyone wants to know. If you go by previous data, then SARS came and went quickly. This coronavirus, it seems, will take a longer period of time and I don’t see it going away very quickly over the next few months. Some people who are optimistic would say that it may go away by September or October. I feel that we have to be sort of ready for another wave, which may come in the winter months unless we are very careful. But, it’s very difficult to predict because it’s a novel virus. How it will behave and how the temperature and the humidity of our country will affect it is something that we need to see over the next few weeks or months.

Amy Kazmin

South Asia Bureau Chief, Financial Times

You said that the next six to eight weeks will be really critical because India has not been able to push the curve into a down turn even under the most stringent lockdown that it has had over the last six weeks. What steps do you think the government needs to take in order to make sure that the curve doesn’t shoot up steeply as the lockdown eases? Is there any way in which the strategy, either in terms of testing or containment or both and other things, also needs to change? Could you talk about the readiness of the healthcare system now compared to what it was in late March before the lockdown was imposed?

The lockdown has helped in flattening the curve but the curve has not shown a downward trend and that is a cause of concern and that’s why I said the next four to six weeks are going to be very important because the lockdown can’t be there forever. So, the solution there is to identify those areas where the maximum number of cases are coming, the so-called hotspots, work aggressively in these areas in terms of containment, in terms of identifying and doing more testing, thereby being able to try and bring down the number of cases in these hotspots, and gradually try and convert them to orange or green spots and that is the strategy which the government is following. At the same time, continue good surveillance in the green zones or the cold areas so that they don’t have a spurt of cases and you have to make sure that there is restricted movement or no movement from a red zone to the other zones itself. That needs to be done and that I think is something that is required. What the lockdown has done and has helped us in is exactly what you said — preparing as far as the health facilities are concerned. It gave us time because the number of cases did not rise sharply or there was no steep rise in the last few weeks and because of that, the health infrastructure could be made more robust, we could have COVID hospitals, care centres, ICUs, we could do a lot of training for health professionals to management or infection control. We were able to look at oxygen and ventilator support even up to a district level and we developed strategies of how to advise doctors by developing various means, like the facility at AIIMS which was mentioned as ‘Connect’, by which our critical care specialists can actually talk to doctors at the district level and guide them in ventilator management of these very sick patients if they do come to a district hospital. So, it has given us time to prepare and we are better prepared than what we were before the lockdown or in the early stages of the lockdown. The challenge, of course, is to see how we perform once the cases start increasing. But I do agree that the curve is still not showing a downward trend. It is still on a rising trend and that we need to monitor very closely over the next few weeks.

Abantika Ghosh

Deputy Associate Editor, The Indian Express

You mentioned that we need to learn to live with this virus, we need to learn to go to work with this virus. We seem to have managed to flatten the curve. Did we through the lockdown kind of delayed that learning curve because today we see all this jostling in the alcohol shops, even on the day of Janta Curfew, when at 5 pm when people were supposed to laud healthcare workers, they started coming out on the roads and crowding, so essentially the behaviour change communication that had to happen seems to have been taken over by the lockdown. Do you see that being a problem as we ease the lockdown?

So, I think that is the biggest challenge that we have right now. We have been able to keep the curve flat, but it’s not something that we can do for long and the other issue is that lockdown cannot be indefinite. We will have to accept that COVID-19 is there to stay and we can’t wait for it to really go away and then lift the lockdown. So, we will have to develop strategies to live with it. But, having said that, we have to really work aggressively on looking at how we can get community participation in trying to do whatever we are saying at a very micro level so that social distancing and the responsibility of each citizen is understood, whether it’s the fact that if he goes to a crowded area, he can give the infection to others, he can get the infection and bring it to his family members and give it to some of his parents or an elderly in the family and they can succumb to the illness and it can be fatal for them. That type of understanding still needs to be there, and at the same time, we need to balance it with the economic means of an individual too. So, it’s a big challenge for a country where we need to look at how do we implement this new normal of social distancing, of travel with this distancing in place and also look at the economic side of this entire story so that we are able to do that in a proper manner and not have an increase in the number of cases, yet decrease the hardships on the citizen as much as possible. The solution in my mind lies in communication and education and getting aggressive community participation. Everyone has to realise their responsibilities. This is a war that has to be fought at the community level. It cannot be fought at a hospital level.

Rohit Sabdhani

Student, SKIT Jaipur

Why is the use of HCQ only limited to two categories of patients? Why not everyone? Doesn’ it violate my right to have access to a life-saving drug, or is it linked to a scarcity of drugs in India?

I think the important issue to remember here is that when we advise any one individual to take a drug, we have to make sure that it is safe and we don’t land up with someone having a serious side-effect or it causing toxicity. We have to be sure that this drug is effective. Both of these things are the cause of concern because this is a drug that is still not proved in clinical trials to be effective as far as COVID-19 is concerned. We also put out what are the contraindications for using the drug. Remember that the elderly or other people who may be taking other drugs which are also cardiac toxic or can cause arrhythmias. Hydroxychloroquine added to that lead to a higher chance of an irregular heartbeat and that can actually sometimes be very serious. So, because of that, one has to be a little cautious and that’s why we are not giving it for everyone. The drug is made by a lot of Indian companies so there is not really much of a shortage as far as the drug is concerned. But it is a safety issue that is driving the current guidelines. If we are able to say comfortably that it may work, and it is safe to a larger group, one could change the strategy as we get more and more data and what we are doing what is known as pharmacovigilance collecting data among healthcare workers to see that in these normal individuals, is it causing any serious side-effects.

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