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Monday, August 03, 2020

The Sandip Roy Show

What makes people tick? What are the stories they carry with them? In a world of shouting heads, veteran journalist, radio commentator and novelist Sandip Roy sits down to have real conversations about the fascinating world around us and the people who shape it. Catch these engaging interviews every other Sunday

Episode 45 March 8, 2020

Getting a coronavirus reality check, with Dr Gagandeep Kang

Coronavirus has a lot of people worried. Till now it has infected at least one lakh people in 90 countries and claimed the lives of over 3,400 so far. But to put things in perspective, 770,000 people still die every year from AIDS and related illnesses, and around 15,00,000 of tuberculosis. So why is this new coronavirus causing so much panic? In this episode, Sandip talks to Dr. Gagandeep Kang, one of India’s leading clinical scientists, about the myths around the virus, why she is hopeful for a vaccine, how climate change affects the spread of such viruses and more.
Transcript:
Sandip Roy
Hello and welcome to the Sandip Roy Show on Express Audio.

[Music]

The Paris Book fair, cancelled. The London Book Fair, cancelled. Primary schools shut in Delhi. The Prime Minister’s Holi milan, cancelled. Facebook’s annual conference will be replaced with local events and live-streamed. The Mobile World Congress (MWC), the biggest smartphone conference of the year has been cancelled, even Tokyo’s famous Cherry Blossom festival has been cancelled. Though I guess the Cherry Trees will still blossom. Welcome to the world in a time of Corona.

But its also worth remembering the total number of cases around the world are still less than 100,000. Fatalities are little over 3,000. Just to put it in perspective, 770,000 people still die every year from AIDS and related illnesses. 1.5 million from Tuberculosis. So what is it about Corona that is causing so much panic? People are hoarding everything from masks to toilet paper, even though we are told constantly to just remember to wash our hands regularly.

This week, we decided to get a corona reality check from one of India’s leading clinical scientists, who knows a thing or two about viruses and vaccines. Dr Gagandeep Kang, helped develop the Rotavac, India’s first indigenous vaccine against the Rotavirus, which causes severe diarrhoea and would lead to the death of some 80,000-100,000 children in the country every year. She is the fellow of London’s Royal Society. The first Indian woman scientist to receive that honour and is the executive director of the Translational Health Service and Technology Institute in Faridabad.

[Music]

Dr Gagandeep Kang, welcome to the show.

Dr Gagandeep Kang
Thank you for having me here.

Sandip Roy
As we speak, I was just reading what Donald Trump has said about the virus, ‘It’s like a miracle. It will just disappear.’ Are you as optimistic?

Dr Gagandeep Kang
Um..Not quite. But then I don’t believe a lot of what Donald Trump says.

Sandip Roy
But I also read that you feel that 8 out of 10 people will recover on their own. How do you assess that?

Dr Gagandeep Kang
If we look at the data that we’ve seen coming out of China, and now other countries, those figures seem to be holding. Out of ten People who will get infected, and maybe even more than ten, eight people will have very mild symptoms and will recover. They will have fever and a dry cough and they will recover from that. You really need to worry about severity only if you have predisposing factors, other diseases or if you’re an older individual.

Sandip Roy
So when you mean other diseases, are you talking about if you already have something like pneumonia?

Dr Gagandeep Kang
Well if you had pneumonia, you would be in hospital and you would then be acquiring a hospital acquired infection. But I was thinking more along the lines of cardiovascular disease, hypertension, diabetes, if you have compromised lung capacity, for example, if you have asthma or chronic obstructive pulmonary disease. That’s when you need to worry because lung compromise can be a very serious issue.

Sandip Roy
What about in India? Given our fight against tuberculosis and the rates of tuberculosis here, does that place India in any greater danger relative to susceptibility to the Coronavirus?

Dr Gagandeep Kang
Well, I think in terms of tuberculosis, you’re actually thinking about a different situation where there is a lot of exposure to TB. But most people that you will encounter with TB, will already be on treatment. So they will not have immediate lung compromise at that time. People who have had chronic lung damage because of tuberculosis or those who are acutely infected, yes, there is a possibility that this might be more severe in them. But for them, any respiratory infection would be a serious issue. It is, we must remember, a tiny fraction of the population.

Sandip Roy
So the government has announced that it will screen all international passengers coming to India. Is there anything more you wish we were doing currently?

Dr Gagandeep Kang
I think the policy that the government has taken is an entirely appropriate one. If you see what is happening around the world, travel is a risk. So you’re screening people with thermal screening and taking records of where they’ve been and where they are planning to go and asking them to check in with health authorities. When they have symptoms, they are being tested. So this is an appropriate response.

We hope that it will pick up the bulk of disease that’s coming into the country. It is possible that there will be a small proportion of people who are incubating, who will not be picked up on the thermal screening and then you want them to come back to you when they actually manifest with symptoms so that they can be tested. This is what has happened with the travellers and we’ve been able to identify people who subsequently develop disease having entered the country when they did not have symptoms. We’ve been able to track their contacts and then assess the contacts to see who is infected or not. So the approaches that have been taken have been entirely correct. Will we miss some cases? Will some people fall off the grid? That is possible. But so far we haven’t seen that happen.

Sandip Roy
And what about the virus that was already in the country before this ‘All international passengers rule’ came into being?

Dr Gagandeep Kang
So, we hope again that people will have symptoms and will come in for screening when that happens. I think if you’re thinking about what else we could be doing, there are from an epidemiology perspective, looking at infectious diseases, there are other approaches to screening. This approach is called risk based screening where travel is a risk factor, but you could also use a symptomatic screening approach which is anybody who has severe lower respiratory tract infection, you might want to screen them to see whether you have or have not missed any cases. They may not necessarily have a travel history, they may have acquired it if there was community transmission. But that would be one approach.

The other would be to look at the presence of antibodies in the blood of people in the community to see whether the virus entered and caused asymptomatic infections. When you measure antibodies, it’s a measure of prior exposure and you can develop antibodies with any infection whether that is symptomatic or without any symptoms.

Sandip Roy
So how hard is it going to be to come up with a vaccine for it? I mean, what is the journey from sequencing the genome to a vaccine?

Dr Gagandeep Kang
So this is the first disease that I’ve seen that actually gives me hope that we can make a vaccine in a very short time frame. If you look at where we are, we got the sequence at the beginning of January, and two weeks ago a company called Moderna in the US announced that they have the first vaccine candidate. They’re going to work with US governmental agencies and others to make sure that this goes into human testing in April. We also have another product which is an early stage vaccine candidate which has come from the University of Queensland and what they are doing there is [that] they are evaluating production technologies.

So it’s not just enough to have a candidate. You also need to think about how it will be made. So what they’re planning to do in Australia is to make lots and lots of candidates see which one works, but they’ll have the process issues ironed out with the first one that they’ve made. So from January to early March, we’ve already come this far. We know that there are 30 programmes, more than 30 programmes, around the world that are focusing on developing vaccines and thinking about how vaccines need to be manufactured. The extent of information, the extent to which we are using technology and the ways in which we are collaborating are very different than we’ve had In any other outbreak.

Sandip Roy
That’s interesting. In some ways…why does COVID-19 create so much more panic than say SARS or Swine Flu or Ebola? Which had higher mortality rates, actually.

Dr Gagandeep Kang
Actually, Swine Flu did not have higher mortality rates. As a percentage of those infected, certainly SARS did. But I don’t think COVID-19 is creating more panic than we have seen in the past. I think what we are seeing is a much more interconnected world where everybody is sharing information all the time. Much of that information is inaccurate. And unfortunately, we know very well that what is untrue spreads much faster than what is true.

Sandip Roy
So in a way, this is our big viral epidemic in a time of real social media explosion, which probably was not true in the cases of those other ones.

Dr Gagandeep Kang
Yeah, going viral in more ways than one.

Sandip Roy
But is it also true that things like MERS, SARS, Ebola, Yellow Fever, all of these, caused thousands of deaths across Asia, America and Africa, but didn’t have such a severe impact on India?

Dr Gagandeep Kang
I don’t think that that is the case. Many viral outbreaks tend to be localised and a lot depends on the way in which these viruses are transmitted. So if you look at something that is vector borne, for example, with Zika, you need to have the vector and you need for the virus to circulate in your population. And you saw that we had Zika cases here. Were there more than what we actually saw.? That’s entirely feasible because a lot of Zika infections are asymptomatic.

If we look at Ebola, Ebola is person to person transmission. So you need to spend a significant amount of time, physically in contact with a person, in order to acquire an Ebola infection. That’s why Ebola epidemics are never huge. The largest one was 2014-2015 in West Africa and that was less than 30,000 people being infected. When you look at respiratory viruses, those are very different and even there it matters what kind of respiratory spread we have. So if it is respiratory spread like measles, if we didn’t have vaccinated populations, it would spread all over the world. And India, in fact has the largest number of measles cases in the world. We ignore it because it’s something we see every day.

If you look at swine flu, that actually came into India and over 50% of people in India had exposure to swine flu very very quickly. We didn’t know it because the bulk of infections were asymptomatic. What we saw was only the numbers that came to hospitals and were tested in hospitals. Subsequently, we’ve done antibody surveys that showed us that levels of exposure were really high. So if you look at COVID-19, it is being spread as a respiratory agent but it’s being spread through what we call droplet infections. And these droplets, fortunately for us are ones that don’t travel very far. So it is usually within a metre. So if you stay about 2-3 metres away from a person who is coughing or sneezing, and you’re not there for a very long time, your chances of acquiring infection actually pretty low.

Sandip Roy
So is it also true that Indians because they are exposed to a lot of other things have created antibodies, that they might be more immune to something like the Coronavirus?

Dr Gagandeep Kang
I think that’s a little bit unlikely. You do build up immunity over time. You build up immunity to viruses that circulate in our populations. So if you look at Indians, we have antibodies to hundreds of thousands of things that we have been exposed to. The SARS-CoV-2 is a new virus. So there is no reason, unless it was circulating undetected among us, that we should have antibodies and therefore protection against that. I think it’s very unlikely but then having an antibody test, as I mentioned earlier, would be very helpful for us to evaluate whether that’s true or not.

Sandip Roy
And might a vaccine in India need to be different? Because when you were doing your work on the Rotavirus, which causes, you know, some 200,000 deaths annually among children, spelled with symptoms like diarrhoea, wasn’t one of the things you noticed that the vaccines that were being used were not always as effective in India?

Dr Gagandeep Kang
So the reason that the Rotavirus vaccines were not as effective in India is because we have damaged guts and the Rotavirus vaccine is an oral vaccine. When we are thinking about respiratory viruses, you can give respiratory vaccines as a nasal spray or as an injection. It’s feasible that a nasal spray vaccine might work differently because mucosal immunity will be different in different populations. But it’s very unlikely that an injectable vaccine will work differently in different populations. Injectable vaccines access the immune system almost directly. So therefore, the variation and response is not very high. And it’s important to remember that vaccines are actually made to do somewhat better than nature. We want to induce an immune response without getting people sick. So what we give people is something that will induce a really good protective immune response.

Sandip Roy
Have you found in your work with Vaccines here, that there’s any growth, rise and cultural resistance to vaccines? And are people superstitious about it? Things like that…

Dr Gagandeep Kang
So, the issue of superstition with vaccines was one that was very common when I was a medical student, 40 years ago. At that time, diseases like measles that resulted in rashes were called ‘Amma visitations’. There was a goddess for smallpox. Those you don’t see any more. And in fact, some of my teachers told me that the treatment for ‘Amma visitations’ used to be branding. And when they had to introduce new vaccines into the population, they said, look at this new improved technology for branding and gave people the BCG vaccine which leaves a scar, or Smallpox vaccine.

So that led to a change in behaviour and people and if I study how vaccines are given to people today, even in the most remote populations, their reason for not vaccinating children is a lack of awareness, not because of superstition. Where we are seeing a lack of confidence in vaccines is actually now in educated populations that have an incomplete understanding of how immune responses work. So there you will frequently have people saying, ‘Oh, my child is so young, why should I expose them to so many things? There might be side effects, or it will be…I shouldn’t be giving so many injections together. I should wait till my child’s immune system is more mature’… all of these reflect an incomplete understanding of immunisation and how vaccines work.

Sandip Roy
And with this Coronavirus recently there had been reports that say, the AYUSH ministry had recommended some Unani herbs as preventative measures, a homeopathic medicine was doing the rounds being given out by some departments in Telangana…Does this actually make jobs of people like you much more difficult?

Dr Gagandeep Kang
I think there’s a lot to be learned from traditional medicine. There are approaches that we have had to health and to wellness that have been part of our traditions for centuries. So I think there may be something there. But I think what western medicine has evolved over time is a rigorous evaluation of treatments. Does it really work? Or is this a belief system? So what I really would like to see is for AYUSH, for Unani, homeopathic, any other medicines you care to name, put them through a blinded evaluation, where the investigator and the patient don’t know what they are getting. And then have somebody else assess whether it worked or not. The problem that we have is that if we believe in something, we frequently believe that it is making us better whether it really does that or not. So unbiased, rigorous evaluations of all systems of medicine, including traditional medicine, should be done.

Sandip Roy
It’s been about 100 years since the Great Flu. Since then, how are viruses changing?

Dr Gagandeep Kang
Viruses aren’t really changing. Viruses evolve very quickly. It’s been estimated for my favourite bug, the Rotavirus, it’s estimated that if it replicates once it induces at least 1 mutation in that replication. And since it takes about 20 minutes for that to happen, you can understand how quickly viruses can evolve. We have a clear understanding from HIV and from other viruses that it becomes almost impossible to identify founder populations of the virus once a person has been infected for a while because it’s been taken over by viruses that have mutated within the human body. So viruses have not changed since 1918. What really has changed is our interaction with a range of viruses.

Viruses tend to be very host-species restricted. So a virus evolved to live in humans stays with humans. A virus for monkeys will be with monkeys. Now, if you have a situation where humans and monkeys, or humans and bats, or humans and cats and dogs interact much more than they ever did in the past, you create situations where viruses might mutate enough to spread across species. So overcoming that host-species barrier restriction is what is leading to us seeing many many more viruses coming into humans then we knew off in the past. As climate change happens, as we change the environment that we live in, I think we are just going to see more and more viruses coming into human populations. Many will be asymptomatic. Many will die out. But a few will take hold and even fewer of those will cause disease.

Sandip Roy
So how does climate change contribute to the spread of such viruses?

Dr Gagandeep Kang
So there are different ways that climate change affects viral circulation in human populations. One of those relates to temperature and humidity. Viruses require a host. They cannot survive in the environment for a very long time. But if you provide them with temperature and moisture requirements that allow them to survive better in the environment, then they will persist and infect people.

It’s also possible that some viruses don’t survive very well in the cold, so you may not see viruses during winters and you will see them in summers. As temperatures go up, you might see them more frequently. The other way is, climate change changes our environment. How many trees do you have? What kinds of animals, birds can live in various places? How do humans interact with that vegetation and that wildlife? All of these can result in changing ecosystems and in changing interactions between species that can lead to the emergence of new viruses and the spread of those viruses once they have emerged.

Sandip Roy
So in a way, when viruses have to jump species…even though people laughed at some of the people in India, who from the one of the Hindu groups who said that ‘Oh, this is God’s revenge on the Chinese for eating non-vegetarian foods and everyone just should just go vegetarian’, even though people laughed at that, is there actually a larger, more serious point in there?

Dr Gagandeep Kang
I think people interact with food in many different ways. It’s not like you can’t acquire a viral infection from shellfish or from plants because a lot of food-borne disease can actually occur in vegetarians as well. The commonest cause of food-borne gastroenteritis is a virus called Norovirus. It’s actually human to human transmission but it can come through eating salads. So, I don’t think blaming people for their food habits is necessarily the right way to go. What we should be thinking about is food safety and we don’t do that enough for vegetarians or for non-vegetarians.

One of the commonest things that you get from eating chickens is Campylobacter. In India, we are probably protected because we cook all our food to death anyway. But if you were to go into eating more raw food, we would need to worry about food safety much more than we do at the moment. As far as China is concerned, the emphasis has to be on food safety. How do you set up screening mechanisms that allow you to say whether this food might be dangerous for something that is common, or something that is rare?

Sandip Roy
So when it comes to public health, what are the challenges you face in making people aware of the problem without spreading panic? I mean, is that a challenge for us in containing an epidemic…I mean, what is the challenge for us in containing an epidemic compared to both a vast country like China, or a small state like Singapore?

Dr Gagandeep Kang
I think learning as much as you possibly can about an infectious agent is critically important to informing what we do for public health. Knowing how dangerous a pathogen is, in what proportion of people it will cause disease? Who can transmit the infection? At what stage? How do you diagnose it? How does it spread? What kinds of treatments are needed for this? All of this helps us to design strategies for public health.

When you think about respiratory viruses in this particular case, respiratory viruses are a bit harder to handle than viruses that spread only by person to person contact. But nonetheless, we can develop strategies for controlling respiratory viruses. China has shown that a lock down can help. But it’s also important to remember that in China, while you might have had a lockdown in one particular province, they did graduate their response to what needed to be done depending on the number of cases and the severity of those cases in other provinces. Similarly, in Singapore, or if you look at Vietnam, they’ve done a really rather good job of controlling the virus and making sure that it didn’t spread.

The approach that you will take to viruses and to public health measures really depend on the number of cases that there are. If you have 10 cases, it’s possible for you to identify the case and every single last one of their contacts and quarantine them. If you have a million cases, then there is no way that you’re going to be able to identify all of their contacts and be able to quarantine them. So the approach needs to be taken understanding the virus but also understanding for your particular situation. Where are we at in this epidemic? Will this virus continue to spread? Will this virus die out? There are some features that tell us that it will spread. It seems to spread more easily than SARS. But there are also these reassuring features that tell us that it can be controlled. Numbers in China are not exploding, they are coming down. Vietnam has been able to control the virus. So I think as we learn more, we will be able to do more. Currently in India, we are doing the right thing. We have limited number cases, we are doing contact tracing, we are doing isolation. Is this sufficient? The days to come will tell us whether it is or not.

Sandip Roy
What are the greatest myths that you would wish to dispel? Since you said there’s so much information, many of it untrue floating around.

Dr Gagandeep Kang
So, there are so many myths, it’s hard to pick a few. But I would say telling people that medicines that are unproven will work, neem boiled in water or homeopathic medicines will work, is not good because it gives people a false sense of reassurance. There have been enough examples of stigma for people of Chinese origin. I don’t think that that is appropriate at all. It is nobody’s fault if they get infected. There has been stigma around people who came off the Diamond Princess and I don’t think that that is appropriate at all either. You cannot treat people badly because they were infected over something that they had no control over. The one that I liked best was drinking Corona beer gives you coronavirus. I would advise that actually anytime you get more stressed go for that.

Sandip Roy
And one of the things that doctors keep saying is that the big thing is to try and wash your hands regularly and try and stop touching your face. That is really, really hard to do to stop touching our face. And I kept wondering that instead of people running around to buy marks everywhere, why not popularise disposable gloves because at least wearing the gloves gives you…it’s like a clue to, visual clue, that might prevent you from touching your face.

Dr Gagandeep Kang
I would emphasise the hand washing completely. And that is not just for this coronavirus, it’s for practically 60% of diseases you get because you pick them up on your hand. And then you transfer it to your nose, eyes, mouth, sits around on your skin for a while. So, promoting hand washing is absolutely the best thing we can do to protect ourselves from a range of respiratory illnesses and a lot of illnesses that come through the faecal-oral as well. The idea of visual clues that tell you that you shouldn’t be touching your face or that you should be careful about what you are encountering, absolutely, I think that is a really good idea. Don’t touch your face with the gloved hands because that’s just on the outside.

Sandip Roy
Because the virus is on the glove.

Dr Gagandeep Kang
Yeah, absolutely.

Sandip Roy
So right now, even as temperature changes, as it becomes warmer here, some people are saying that maybe the virus will die out in places but it means also that next year, it can come back, you know, just like a flu virus?

Dr Gagandeep Kang
I don’t think we know enough to be able to say that summer will come and we will be in good shape because the virus won’t be able to survive. But this is a virus that is limited to humans. So whatever we do to control it is a good idea because it needs additional susceptible humans in order to be able to spread. Where influenza is concerned in India, we have enough evidence to show that influenza, which is very much a winter disease in other parts of the world is also sometimes depending on the strain, a summer or monsoon disease for us. So, I’m not sure that our temperatures will necessarily protect us. I’ll wait and see.

Sandip Roy
So since you say that, with climate change and all of this, more such viruses might show up, how can we use what we learn from tackling Corona to face viruses of the future? I mean, is this sort of dry run for the future?

Dr Gagandeep Kang
I think looking at patterns of infection is very important and then thinking through what preparedness looks like. So if there is a respiratory disease outbreak as opposed to a food and water borne outbreak, how should public health authorities respond? And respond at a range of scales, whether that is within a community or across the country. What we haven’t invested in so far is rational preparedness for infectious diseases. And that is something that we should be thinking about. In this case, the government has started out doing the right thing. But it has taken a certain amount of effort to get there. It wasn’t something that was in place before. But this is a good signal, just as I said, with vaccines, we are doing things today that we did not do in the last set of outbreaks. So I’m hoping that we will learn from this. The importance of doing dry runs, of simulations, is something that we should also be thinking about for the future, particularly for public health response.

Sandip Roy
Dr Kang, thank you so much for joining us today.

Dr Gagandeep Kang
Thank you.

Sandip Roy
Dr Gagandeep Kang is the executive director of the Translational Health Service and Technology Institute in Faridabad and a professor at the Christian Medical College in Vellore.

Leave us a review wherever you get your podcasts from. Find us on Facebook and Twitter and Instagram @Expresspodcasts. Have a happy holi, be safe and wash your hands. Thanks for listening. This is Sandip Roy on Express Audio.

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Getting a coronavirus reality check, with Dr Gagandeep KangCoronavirus has a lot of people worried. Till now it has infected at least one lakh people in 90 countries and claimed the lives of over 3,400 so far. But to put things in perspective, 770,000 people still die every year from AIDS and related illnesses, and around 15,00,000 of tuberculosis. So why is this new coronavirus causing so much panic? In this episode, Sandip talks to Dr. Gagandeep Kang, one of India's leading clinical scientists, about the myths around the virus, why she is hopeful for a vaccine, how climate change affects the spread of such viruses and more. Transcript: Sandip Roy Hello and welcome to the Sandip Roy Show on Express Audio. [Music] The Paris Book fair, cancelled. The London Book Fair, cancelled. Primary schools shut in Delhi. The Prime Minister's Holi milan, cancelled. Facebook's annual conference will be replaced with local events and live-streamed. The Mobile World Congress (MWC), the biggest smartphone conference of the year has been cancelled, even Tokyo's famous Cherry Blossom festival has been cancelled. Though I guess the Cherry Trees will still blossom. Welcome to the world in a time of Corona. But its also worth remembering the total number of cases around the world are still less than 100,000. Fatalities are little over 3,000. Just to put it in perspective, 770,000 people still die every year from AIDS and related illnesses. 1.5 million from Tuberculosis. So what is it about Corona that is causing so much panic? People are hoarding everything from masks to toilet paper, even though we are told constantly to just remember to wash our hands regularly. This week, we decided to get a corona reality check from one of India's leading clinical scientists, who knows a thing or two about viruses and vaccines. Dr Gagandeep Kang, helped develop the Rotavac, India's first indigenous vaccine against the Rotavirus, which causes severe diarrhoea and would lead to the death of some 80,000-100,000 children in the country every year. She is the fellow of London's Royal Society. The first Indian woman scientist to receive that honour and is the executive director of the Translational Health Service and Technology Institute in Faridabad. [Music] Dr Gagandeep Kang, welcome to the show. Dr Gagandeep Kang Thank you for having me here. Sandip Roy As we speak, I was just reading what Donald Trump has said about the virus, 'It's like a miracle. It will just disappear.' Are you as optimistic? Dr Gagandeep Kang Um..Not quite. But then I don't believe a lot of what Donald Trump says. Sandip Roy But I also read that you feel that 8 out of 10 people will recover on their own. How do you assess that? Dr Gagandeep Kang If we look at the data that we've seen coming out of China, and now other countries, those figures seem to be holding. Out of ten People who will get infected, and maybe even more than ten, eight people will have very mild symptoms and will recover. They will have fever and a dry cough and they will recover from that. You really need to worry about severity only if you have predisposing factors, other diseases or if you're an older individual. Sandip Roy So when you mean other diseases, are you talking about if you already have something like pneumonia? Dr Gagandeep Kang Well if you had pneumonia, you would be in hospital and you would then be acquiring a hospital acquired infection. But I was thinking more along the lines of cardiovascular disease, hypertension, diabetes, if you have compromised lung capacity, for example, if you have asthma or chronic obstructive pulmonary disease. That's when you need to worry because lung compromise can be a very serious issue. Sandip Roy What about in India? Given our fight against tuberculosis and the rates of tuberculosis here, does that place India in any greater danger relative to susceptibility to the Coronavirus? Dr Gagandeep Kang Well, I think in terms of tuberculosis, you're actually thinking about a different situation where there is a lot of exposure to TB. But most people that you will encounter with TB, will already be on treatment. So they will not have immediate lung compromise at that time. People who have had chronic lung damage because of tuberculosis or those who are acutely infected, yes, there is a possibility that this might be more severe in them. But for them, any respiratory infection would be a serious issue. It is, we must remember, a tiny fraction of the population. Sandip Roy So the government has announced that it will screen all international passengers coming to India. Is there anything more you wish we were doing currently? Dr Gagandeep Kang I think the policy that the government has taken is an entirely appropriate one. If you see what is happening around the world, travel is a risk. So you're screening people with thermal screening and taking records of where they've been and where they are planning to go and asking them to check in with health authorities. When they have symptoms, they are being tested. So this is an appropriate response. We hope that it will pick up the bulk of disease that's coming into the country. It is possible that there will be a small proportion of people who are incubating, who will not be picked up on the thermal screening and then you want them to come back to you when they actually manifest with symptoms so that they can be tested. This is what has happened with the travellers and we've been able to identify people who subsequently develop disease having entered the country when they did not have symptoms. We've been able to track their contacts and then assess the contacts to see who is infected or not. So the approaches that have been taken have been entirely correct. Will we miss some cases? Will some people fall off the grid? That is possible. But so far we haven't seen that happen. Sandip Roy And what about the virus that was already in the country before this 'All international passengers rule' came into being? Dr Gagandeep Kang So, we hope again that people will have symptoms and will come in for screening when that happens. I think if you're thinking about what else we could be doing, there are from an epidemiology perspective, looking at infectious diseases, there are other approaches to screening. This approach is called risk based screening where travel is a risk factor, but you could also use a symptomatic screening approach which is anybody who has severe lower respiratory tract infection, you might want to screen them to see whether you have or have not missed any cases. They may not necessarily have a travel history, they may have acquired it if there was community transmission. But that would be one approach. The other would be to look at the presence of antibodies in the blood of people in the community to see whether the virus entered and caused asymptomatic infections. When you measure antibodies, it's a measure of prior exposure and you can develop antibodies with any infection whether that is symptomatic or without any symptoms. Sandip Roy So how hard is it going to be to come up with a vaccine for it? I mean, what is the journey from sequencing the genome to a vaccine? Dr Gagandeep Kang So this is the first disease that I've seen that actually gives me hope that we can make a vaccine in a very short time frame. If you look at where we are, we got the sequence at the beginning of January, and two weeks ago a company called Moderna in the US announced that they have the first vaccine candidate. They're going to work with US governmental agencies and others to make sure that this goes into human testing in April. We also have another product which is an early stage vaccine candidate which has come from the University of Queensland and what they are doing there is [that] they are evaluating production technologies. So it's not just enough to have a candidate. You also need to think about how it will be made. So what they're planning to do in Australia is to make lots and lots of candidates see which one works, but they'll have the process issues ironed out with the first one that they've made. So from January to early March, we've already come this far. We know that there are 30 programmes, more than 30 programmes, around the world that are focusing on developing vaccines and thinking about how vaccines need to be manufactured. The extent of information, the extent to which we are using technology and the ways in which we are collaborating are very different than we've had In any other outbreak. Sandip Roy That's interesting. In some ways...why does COVID-19 create so much more panic than say SARS or Swine Flu or Ebola? Which had higher mortality rates, actually. Dr Gagandeep Kang Actually, Swine Flu did not have higher mortality rates. As a percentage of those infected, certainly SARS did. But I don't think COVID-19 is creating more panic than we have seen in the past. I think what we are seeing is a much more interconnected world where everybody is sharing information all the time. Much of that information is inaccurate. And unfortunately, we know very well that what is untrue spreads much faster than what is true. Sandip Roy So in a way, this is our big viral epidemic in a time of real social media explosion, which probably was not true in the cases of those other ones. Dr Gagandeep Kang Yeah, going viral in more ways than one. Sandip Roy But is it also true that things like MERS, SARS, Ebola, Yellow Fever, all of these, caused thousands of deaths across Asia, America and Africa, but didn't have such a severe impact on India? Dr Gagandeep Kang I don't think that that is the case. Many viral outbreaks tend to be localised and a lot depends on the way in which these viruses are transmitted. So if you look at something that is vector borne, for example, with Zika, you need to have the vector and you need for the virus to circulate in your population. And you saw that we had Zika cases here. Were there more than what we actually saw.? That's entirely feasible because a lot of Zika infections are asymptomatic. If we look at Ebola, Ebola is person to person transmission. So you need to spend a significant amount of time, physically in contact with a person, in order to acquire an Ebola infection. That's why Ebola epidemics are never huge. The largest one was 2014-2015 in West Africa and that was less than 30,000 people being infected. When you look at respiratory viruses, those are very different and even there it matters what kind of respiratory spread we have. So if it is respiratory spread like measles, if we didn't have vaccinated populations, it would spread all over the world. And India, in fact has the largest number of measles cases in the world. We ignore it because it's something we see every day. If you look at swine flu, that actually came into India and over 50% of people in India had exposure to swine flu very very quickly. We didn't know it because the bulk of infections were asymptomatic. What we saw was only the numbers that came to hospitals and were tested in hospitals. Subsequently, we've done antibody surveys that showed us that levels of exposure were really high. So if you look at COVID-19, it is being spread as a respiratory agent but it's being spread through what we call droplet infections. And these droplets, fortunately for us are ones that don't travel very far. So it is usually within a metre. So if you stay about 2-3 metres away from a person who is coughing or sneezing, and you're not there for a very long time, your chances of acquiring infection actually pretty low. Sandip Roy So is it also true that Indians because they are exposed to a lot of other things have created antibodies, that they might be more immune to something like the Coronavirus? Dr Gagandeep Kang I think that's a little bit unlikely. You do build up immunity over time. You build up immunity to viruses that circulate in our populations. So if you look at Indians, we have antibodies to hundreds of thousands of things that we have been exposed to. The SARS-CoV-2 is a new virus. So there is no reason, unless it was circulating undetected among us, that we should have antibodies and therefore protection against that. I think it's very unlikely but then having an antibody test, as I mentioned earlier, would be very helpful for us to evaluate whether that's true or not. Sandip Roy And might a vaccine in India need to be different? Because when you were doing your work on the Rotavirus, which causes, you know, some 200,000 deaths annually among children, spelled with symptoms like diarrhoea, wasn't one of the things you noticed that the vaccines that were being used were not always as effective in India? Dr Gagandeep Kang So the reason that the Rotavirus vaccines were not as effective in India is because we have damaged guts and the Rotavirus vaccine is an oral vaccine. When we are thinking about respiratory viruses, you can give respiratory vaccines as a nasal spray or as an injection. It's feasible that a nasal spray vaccine might work differently because mucosal immunity will be different in different populations. But it's very unlikely that an injectable vaccine will work differently in different populations. Injectable vaccines access the immune system almost directly. So therefore, the variation and response is not very high. And it's important to remember that vaccines are actually made to do somewhat better than nature. We want to induce an immune response without getting people sick. So what we give people is something that will induce a really good protective immune response. Sandip Roy Have you found in your work with Vaccines here, that there's any growth, rise and cultural resistance to vaccines? And are people superstitious about it? Things like that... Dr Gagandeep Kang So, the issue of superstition with vaccines was one that was very common when I was a medical student, 40 years ago. At that time, diseases like measles that resulted in rashes were called 'Amma visitations'. There was a goddess for smallpox. Those you don't see any more. And in fact, some of my teachers told me that the treatment for 'Amma visitations' used to be branding. And when they had to introduce new vaccines into the population, they said, look at this new improved technology for branding and gave people the BCG vaccine which leaves a scar, or Smallpox vaccine. So that led to a change in behaviour and people and if I study how vaccines are given to people today, even in the most remote populations, their reason for not vaccinating children is a lack of awareness, not because of superstition. Where we are seeing a lack of confidence in vaccines is actually now in educated populations that have an incomplete understanding of how immune responses work. So there you will frequently have people saying, 'Oh, my child is so young, why should I expose them to so many things? There might be side effects, or it will be...I shouldn't be giving so many injections together. I should wait till my child's immune system is more mature'... all of these reflect an incomplete understanding of immunisation and how vaccines work. Sandip Roy And with this Coronavirus recently there had been reports that say, the AYUSH ministry had recommended some Unani herbs as preventative measures, a homeopathic medicine was doing the rounds being given out by some departments in Telangana...Does this actually make jobs of people like you much more difficult? Dr Gagandeep Kang I think there's a lot to be learned from traditional medicine. There are approaches that we have had to health and to wellness that have been part of our traditions for centuries. So I think there may be something there. But I think what western medicine has evolved over time is a rigorous evaluation of treatments. Does it really work? Or is this a belief system? So what I really would like to see is for AYUSH, for Unani, homeopathic, any other medicines you care to name, put them through a blinded evaluation, where the investigator and the patient don't know what they are getting. And then have somebody else assess whether it worked or not. The problem that we have is that if we believe in something, we frequently believe that it is making us better whether it really does that or not. So unbiased, rigorous evaluations of all systems of medicine, including traditional medicine, should be done. Sandip Roy It's been about 100 years since the Great Flu. Since then, how are viruses changing? Dr Gagandeep Kang Viruses aren't really changing. Viruses evolve very quickly. It's been estimated for my favourite bug, the Rotavirus, it's estimated that if it replicates once it induces at least 1 mutation in that replication. And since it takes about 20 minutes for that to happen, you can understand how quickly viruses can evolve. We have a clear understanding from HIV and from other viruses that it becomes almost impossible to identify founder populations of the virus once a person has been infected for a while because it's been taken over by viruses that have mutated within the human body. So viruses have not changed since 1918. What really has changed is our interaction with a range of viruses. Viruses tend to be very host-species restricted. So a virus evolved to live in humans stays with humans. A virus for monkeys will be with monkeys. Now, if you have a situation where humans and monkeys, or humans and bats, or humans and cats and dogs interact much more than they ever did in the past, you create situations where viruses might mutate enough to spread across species. So overcoming that host-species barrier restriction is what is leading to us seeing many many more viruses coming into humans then we knew off in the past. As climate change happens, as we change the environment that we live in, I think we are just going to see more and more viruses coming into human populations. Many will be asymptomatic. Many will die out. But a few will take hold and even fewer of those will cause disease. Sandip Roy So how does climate change contribute to the spread of such viruses? Dr Gagandeep Kang So there are different ways that climate change affects viral circulation in human populations. One of those relates to temperature and humidity. Viruses require a host. They cannot survive in the environment for a very long time. But if you provide them with temperature and moisture requirements that allow them to survive better in the environment, then they will persist and infect people. It's also possible that some viruses don't survive very well in the cold, so you may not see viruses during winters and you will see them in summers. As temperatures go up, you might see them more frequently. The other way is, climate change changes our environment. How many trees do you have? What kinds of animals, birds can live in various places? How do humans interact with that vegetation and that wildlife? All of these can result in changing ecosystems and in changing interactions between species that can lead to the emergence of new viruses and the spread of those viruses once they have emerged. Sandip Roy So in a way, when viruses have to jump species...even though people laughed at some of the people in India, who from the one of the Hindu groups who said that 'Oh, this is God's revenge on the Chinese for eating non-vegetarian foods and everyone just should just go vegetarian', even though people laughed at that, is there actually a larger, more serious point in there? Dr Gagandeep Kang I think people interact with food in many different ways. It's not like you can't acquire a viral infection from shellfish or from plants because a lot of food-borne disease can actually occur in vegetarians as well. The commonest cause of food-borne gastroenteritis is a virus called Norovirus. It's actually human to human transmission but it can come through eating salads. So, I don't think blaming people for their food habits is necessarily the right way to go. What we should be thinking about is food safety and we don't do that enough for vegetarians or for non-vegetarians. One of the commonest things that you get from eating chickens is Campylobacter. In India, we are probably protected because we cook all our food to death anyway. But if you were to go into eating more raw food, we would need to worry about food safety much more than we do at the moment. As far as China is concerned, the emphasis has to be on food safety. How do you set up screening mechanisms that allow you to say whether this food might be dangerous for something that is common, or something that is rare? Sandip Roy So when it comes to public health, what are the challenges you face in making people aware of the problem without spreading panic? I mean, is that a challenge for us in containing an epidemic...I mean, what is the challenge for us in containing an epidemic compared to both a vast country like China, or a small state like Singapore? Dr Gagandeep Kang I think learning as much as you possibly can about an infectious agent is critically important to informing what we do for public health. Knowing how dangerous a pathogen is, in what proportion of people it will cause disease? Who can transmit the infection? At what stage? How do you diagnose it? How does it spread? What kinds of treatments are needed for this? All of this helps us to design strategies for public health. When you think about respiratory viruses in this particular case, respiratory viruses are a bit harder to handle than viruses that spread only by person to person contact. But nonetheless, we can develop strategies for controlling respiratory viruses. China has shown that a lock down can help. But it's also important to remember that in China, while you might have had a lockdown in one particular province, they did graduate their response to what needed to be done depending on the number of cases and the severity of those cases in other provinces. Similarly, in Singapore, or if you look at Vietnam, they've done a really rather good job of controlling the virus and making sure that it didn't spread. The approach that you will take to viruses and to public health measures really depend on the number of cases that there are. If you have 10 cases, it's possible for you to identify the case and every single last one of their contacts and quarantine them. If you have a million cases, then there is no way that you're going to be able to identify all of their contacts and be able to quarantine them. So the approach needs to be taken understanding the virus but also understanding for your particular situation. Where are we at in this epidemic? Will this virus continue to spread? Will this virus die out? There are some features that tell us that it will spread. It seems to spread more easily than SARS. But there are also these reassuring features that tell us that it can be controlled. Numbers in China are not exploding, they are coming down. Vietnam has been able to control the virus. So I think as we learn more, we will be able to do more. Currently in India, we are doing the right thing. We have limited number cases, we are doing contact tracing, we are doing isolation. Is this sufficient? The days to come will tell us whether it is or not. Sandip Roy What are the greatest myths that you would wish to dispel? Since you said there's so much information, many of it untrue floating around. Dr Gagandeep Kang So, there are so many myths, it's hard to pick a few. But I would say telling people that medicines that are unproven will work, neem boiled in water or homeopathic medicines will work, is not good because it gives people a false sense of reassurance. There have been enough examples of stigma for people of Chinese origin. I don't think that that is appropriate at all. It is nobody's fault if they get infected. There has been stigma around people who came off the Diamond Princess and I don't think that that is appropriate at all either. You cannot treat people badly because they were infected over something that they had no control over. The one that I liked best was drinking Corona beer gives you coronavirus. I would advise that actually anytime you get more stressed go for that. Sandip Roy And one of the things that doctors keep saying is that the big thing is to try and wash your hands regularly and try and stop touching your face. That is really, really hard to do to stop touching our face. And I kept wondering that instead of people running around to buy marks everywhere, why not popularise disposable gloves because at least wearing the gloves gives you...it's like a clue to, visual clue, that might prevent you from touching your face. Dr Gagandeep Kang I would emphasise the hand washing completely. And that is not just for this coronavirus, it's for practically 60% of diseases you get because you pick them up on your hand. And then you transfer it to your nose, eyes, mouth, sits around on your skin for a while. So, promoting hand washing is absolutely the best thing we can do to protect ourselves from a range of respiratory illnesses and a lot of illnesses that come through the faecal-oral as well. The idea of visual clues that tell you that you shouldn't be touching your face or that you should be careful about what you are encountering, absolutely, I think that is a really good idea. Don't touch your face with the gloved hands because that's just on the outside. Sandip Roy Because the virus is on the glove. Dr Gagandeep Kang Yeah, absolutely. Sandip Roy So right now, even as temperature changes, as it becomes warmer here, some people are saying that maybe the virus will die out in places but it means also that next year, it can come back, you know, just like a flu virus? Dr Gagandeep Kang I don't think we know enough to be able to say that summer will come and we will be in good shape because the virus won't be able to survive. But this is a virus that is limited to humans. So whatever we do to control it is a good idea because it needs additional susceptible humans in order to be able to spread. Where influenza is concerned in India, we have enough evidence to show that influenza, which is very much a winter disease in other parts of the world is also sometimes depending on the strain, a summer or monsoon disease for us. So, I'm not sure that our temperatures will necessarily protect us. I'll wait and see. Sandip Roy So since you say that, with climate change and all of this, more such viruses might show up, how can we use what we learn from tackling Corona to face viruses of the future? I mean, is this sort of dry run for the future? Dr Gagandeep Kang I think looking at patterns of infection is very important and then thinking through what preparedness looks like. So if there is a respiratory disease outbreak as opposed to a food and water borne outbreak, how should public health authorities respond? And respond at a range of scales, whether that is within a community or across the country. What we haven't invested in so far is rational preparedness for infectious diseases. And that is something that we should be thinking about. In this case, the government has started out doing the right thing. But it has taken a certain amount of effort to get there. It wasn't something that was in place before. But this is a good signal, just as I said, with vaccines, we are doing things today that we did not do in the last set of outbreaks. So I'm hoping that we will learn from this. The importance of doing dry runs, of simulations, is something that we should also be thinking about for the future, particularly for public health response. Sandip Roy Dr Kang, thank you so much for joining us today. Dr Gagandeep Kang Thank you. Sandip Roy Dr Gagandeep Kang is the executive director of the Translational Health Service and Technology Institute in Faridabad and a professor at the Christian Medical College in Vellore. Leave us a review wherever you get your podcasts from. Find us on Facebook and Twitter and Instagram @Expresspodcasts. Have a happy holi, be safe and wash your hands. Thanks for listening. This is Sandip Roy on Express Audio.
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