British politician Winston Churchill once said, “However beautiful your strategy, you should occasionally pause and look at the results”. This applies very aptly to the juncture that we are at today in the COVID-19 pandemic. India has done well so far in its fight, but now is the time to reassess, realign and take stock of the situation if we want to win the battle. Our strategy must continuously evolve in the fields of vaccination, diagnostics, contact tracing, tracking, sero-surveillance, data analysis, modelling-forecasting and communication advocacy to overcome the challenges in a dynamic COVID environment.
Vaccines against COVID-19 have brought a glimmer of hope globally and in India. As of March 1 2021, 1.48 million doses have been administered in India. The government has done well to open up vaccinations to private healthcare sector at a reasonable cost price, but the process needs to be hastened as only 1 per cent of the country’s population has been vaccinated in the past month and a half. Assuming that the efficacy of the vaccines is 60 per cent, we need to vaccinate 100 per cent of our population to achieve a herd immunity of 60 per cent which at the present rate could take many years and would lose relevance. Other vaccine candidates are at least a year away and optimisation of the vaccination drive with two available vaccines must be achieved by addressing vaccine hesitancy, ramping up the manufacture, balancing export with domestic requirement and a glitch-free working of the Co Win portal. The availability of vaccines for the seniors (above 60) and above 45 with co-morbidities is a good strategy for trust building, but some other high risk mobile spreaders could be targeted. The prime minister getting the indigenous vaccine has sent a positive signal for vaccine acceptance. The future should see a bouquet of vaccines to choose from and an assembly line project to administer the vaccines in about three to six months to have an impact.
With about 200 million tests done thus far in India, the country is second to the USA in the total number of tests conducted, but low when compared to other developing countries at 139 tests/1,000 population. RTPCR (reverse transcription polymerase chain reaction, CBNAAT (Cartridge based nucleic acid amplification test) True NAAT and multiple Rapid antigen testing have formed the backbone of clinical COVID-19 diagnostic testing. Almost half of the testing has been through rapid antigen testing which could give 50 per cent false negatives. The RTPCR, though the gold standard requires expertise, infrastructure and personnel constraints could make it outside the reach of the underprivileged — despite price revisions. The search for a simple, sensitive, cost effective, accessible point of care test is still on, aided by effective public private partnerships. Emerging technologies like Crisper-FELUDA, saliva-based tests etc. should be explored, encouraged, assessed and validated with a clear and simple approval system in place. Testing for immunity against COVID-19 is tricky, incompletely understood and as of now utilises a surrogate IgG antibody. More research to develop kits to assess quantitative IgG should be conducted. Genomic surveillance is now a necessity to keep track of the variants not only from overseas patients but also for home grown variants. Of the 11 million confirmed infections of COVID-19 at the time of writing this article in India, only 5,000 sequences had been deposited in GISAID (Global initiative on sharing all Influenza data) — only 0.05 per cent, which is lower than the WHO recommended rate of 0.3 per cent. In December 2020, the government committed to sequence 5 per cent of the positive cases and formed INSACOG, which is a national network of labs performing genetic sequencing.
The full potential of this information should be correlated with the clinical and epidemiological data to institute targeted public health interventions for outbreak management, in designing upgraded primers for diagnostic tests to avoid mutants escaping detection and inform vaccine manufacturers. It is the right time for smart testing.
As the kits for testing (PCR, Rapid antigen testing and antibody tests) are not completely indigenous, in the spirit of Atmanirbhar Bharat we need to build our own research and lab capacities with infrastructural development, targeted training, a centralised procurement to drive down costs and incentivisation. The kit manufacturers should have access to an accurate forecasting of the demands ahead so that they can be in a state of readiness with a four-six week lag time to cater to the domestic market alone or also compete in the global market, should the demand for tests go down. In the interim, however, import regulations for some key ingredients of the kits should be relaxed. Prices could be made more competitive by pooled PCR testing in low prevalence settings and accessibility increased by a hub and spoke model to cover all areas of the country.
As per the last ICMR survey conducted in January 2021, three fourths of the population was susceptible to the infection. So, tracing, tracking and well planned sero-surveys should be continued in the post vaccination phase focusing on super spreader events and cluster analysis without stigmatising the sources. Surveys could be conducted at the state level and supported by the Centre to understand the immune status of the community. Tracking could be enhanced and helped by the digital technologies using Aarogya Setu and ITIHAS (IT enabled integrated hot spot analysis) and be privacy protected and socially accepted.
To overcome vaccine hesitancy and encourage the public to continue to observe precautions, we need to build trust by effective communication and transparent sharing of data. Access to data, its analysis, and subsequent formulation of public health response with centralised coordination and operational monitoring with a team of experts is the key to the control of all such future pandemics. The fight is far from over and one has to be cautious and vigilant. One must guard against a lot of misinformation reaching the public and build trust with simplification of scientific messages and increasing awareness by effective communication and counselling. In accordance with the National Digital Health Mission, digital architecture for COVID could help the public make informed decisions by sharing real time data.
Many questions remain unanswered — whether Covid-19 will become endemic like the influenza, if there is a need to test individuals for antibodies before vaccination, the duration and strength of immunity post a natural infection versus that developed after vaccination, what was the real reason of decline of India’s cases and so on. As we evolve, many of them would be answered.
Ganguly is former Director General, Indian Council of Medical Research. Jaggi is Chairperson, Labs and Infection control, Chief, Education and Research, Artemis Hospital, Gurgaon