NEW DELHI: The threat of the spread of mutant variants, its implications and the ‘second wave’ of Covid-19—which The Sunday Guardian’s ‘Medically Speaking’ section was among the first to report—is looming large in the country today. The Sunday Guardian discussed the matter with prominent medical experts Dr Harsh Mahajan, founder of Mahajan Imaging and chief radiologist, Dr Dhiren Gupta, Chairman-elect of the Indian Academy of Paediatrics (Intensive Care Chapter) and doctor at the Sir Ganga Ram Hospital, Dr Avinash Bhondve, former president of IMA Maharashtra, Dr Neeraj Nischal, Associate Professor of Medicine at the All India Institute of Medical Sciences and Dr J.A. Jayalal, National President, Indian Medical Association, to find out how the situation can be managed better.
Dr Neeraj Nischal
Dr Harsh Mahajan
Dr Dhiren Gupta
Dr Avinash Bhondve
Q: Are we seeing the second wave of Covid-19 or moving towards it?
Dr Nischal: This concept of a wave has been described by epidemiologists. Based on the experience of previous pandemics, it is certain that there will be multiple waves. The moment we lower down our guards, as long as we have vulnerable populations and do not vaccinate most of the population, these waves are going to come. That’s why we have to ensure that we follow the Covid-appropriate behaviours we have been talking about for the last one year. But it is easier said than done. Everyone is saturated and we all want to go out and enjoy the way we did in the past. But the pandemic has not gone away. We will be in big trouble if we lower our guards and that is why, second wave or not, things depend on us. If we allow it to propagate, we will definitely have the second wave, and if we control it right away, we might be safe from the situation which most European countries and the US faced recently.
Q: Maharashtra is going through a bad phase. There was a time when the number of cases was declining but if we see the latest data, the maximum cases have been reported from Maharashtra. What can be the reason behind it? Are people taking it for granted?
Dr Bhondve: Let us talk of some practical and theoretical things. First of all, as Dr Neeraj rightly said, the waves will keep on coming. In early February, new cases were around 2,000 a day, which have gone up to more than 23,000. Before that, in the month of December and January, the number of cases and daily cases and all other parameters came down, but never touched the zero line or went back to the base line. So, this is the rise in the number of cases. There are many reasons. We always blame the common people for not using masks or not observing social distancing, but these things were there even in December and January. The main reason behind the rise in new cases since early February is the government of Maharashtra giving instructions to district officers to increase testing and contact tracing. It was clearly advised that for every patient 280 contacts should be traced. When this number started increasing, it was quite obvious that 90% of the cases, which were asymptomatic or mildly symptomatic, were diagnosed.
Also, the rate at which patients are increasing is very fast. The patients are mostly in the age group of 20 to 45 years, and they are mostly asymptomatic or mildly symptomatic. There was a similar scenario in Britain, where they investigated this and did long sequencing on most of these patients. Like it was a variant in Britain, it could be a variant which has evolved in Maharashtra. These types of sequencing should be done on the patients from Maharashtra like it was done for the patients who came from Britain, South Africa and Brazil.
I think the sum total of all these things is the reason behind the rising cases in Maharashtra.
Q: So, how is Covid-19 striking back?
Dr Mahajan: We know this RNA virus tends to mutate very rapidly. If we see, there are over 100,000 mutations, and over 7,000 have happened in India itself. Out of that, the variants that concern the most have been the three—the UK, South Africa and Brazil variants—as Dr Bhondve also said. In India, about 7,000 patient samples have been genome sequenced, out of which about 200 are from Maharashtra. Out of these 200, in 20% of them they have found two mutations. This is at present. However, as time passes and we do more sequencing, we will know whether it is really the one causing this rapid surge because it is already known that it can be more contagious. The government has now said that 5% of all positive samples across the country will be sequenced. In December, the government also formed institutes for genomic surveillance. So, it’s only when we do more genomic sequencing, that we will know the kind of mutations happening, how they are spreading across the country, if they are similar to the strains found in other parts of the world, and if this is a new Maharashtra strain. But the important point is that if we protect ourselves and we follow Covid-appropriate behaviour, especially the use of masks and practising hygiene and social distancing, we can overcome any mutations and variants. However, we have seen of late, not only in Maharashtra or Punjab, where most of the new cases are happening, but also in Delhi and other parts of the country, that people have reached a level of fatigue. There is a release now, markets are full and weddings are happening, even indoors with hundreds of people. If we continue this, irrespective of what the variant may be, we will get more cases.
But Maharashtra does appear to be at the start of a second wave, as has been said. This may also be due to enhanced testing and very stringent contact tracing where we are picking up more of the asymptomatic variety. This is also the time when the vaccination drive in these pockets needs to be accelerated and the Central Government has to give permission to states to vaccinate those between 20 and 45 years as they are the ones who are getting maximally infected.
Q: What would you like to say about people forgetting to follow Covid-appropriate behaviour?
Dr Gupta: We know this is going to come, which means we cannot stop it. These viruses are going to be here with us. What we need to find out is how we can prevent infections and reduce the number of patients getting infected. Dr Harsh has beautifully defined it. I would like to define it on the levels of the individual, the government and the virus. On the virus level, we know it has marked each and every community. This virus knows much more than what the medical sciences know about this virus.
On the government and individual levels, what I have found is that people are scared of the side effects of the vaccine. So, as Dr Mahajan said, all the population should be vaccinated very quickly. This way we can prevent this virus from circulating quickly, prevent its mutations and suppress such waves, which are otherwise bound to happen. Secondly, there is the problem of ignoring Covid-related behaviours. The kisan andolan is still in full swing, cricket matches have begun, and even politicians are moving here and there without masks. With this type of attitude, whatever we do and whatever programs we start at whatever level, the public is going to behave like this. But what we can do is enhance our vaccination program. There is a lack not only on the government level; it is also the public that is responsible. They are so scared of the vaccine’s side-effects that they forget how bad this virus is. I have worked in the Covid ward and seen people who got infected. Young people think that they cannot get infected or if they do, it would be mild, but they forget that they are the people who are going to spread this virus to the elderly.
But these things are not very simple. I have seen many doctors getting fed up with masks and we have seen that continuously wearing them for 12 hours induces some hypoxia. So, it’s easier to preach. But at the individual level, Covid-appropriate behaviour is very important. We should get vaccinated and, as Dr Mahajan said, open up vaccinations for 20-40-year-olds too and also allow all sorts of vaccines available in the market. We have inoculated more than 2 crore people and no major side effects have happened. We have also got our indigenous vaccine, i.e. Covaxin. This should be promoted as well. We should ask other companies, which have been approved in the US, like Pfizer or Moderna, to export to India. It should be like a flea market: whosoever wants to get it and can pay should get whatever they think is medically suitable. Everyone has to pitch in, including the government, because this is going to rise. I look at the Covid wards, we get a daily warning from our medical director about them being full. So, this is the only way to stop it or slow it down.
Q: The IMA has already urged people and the government to not drop their guard against Covid-19.
Dr Jayalal: Yes, it is quite painful to know that even after very sustainable efforts by the government and healthcare professionals to control the virus, there has been a sudden spike in cases across the country. It is painful to note we have crossed even 36,000 cases in a day, which only denotes we are reaching the second wave. But it is nothing new and it is not in our hands because with any pandemic, multiple waves are inevitable. So, at this moment, we don’t need to panic. We need to sensitize our people. One of the most important things for hospitals and other places where people are accumulated is proper ventilation. Schools have opened and children are coming in, but in many school buildings, the infrastructure and ventilation systems are not adequate. The government should spend much more effort on this because this is not on the children, it is on administrators and management. When we were starting with the pandemic, one of the greatest tasks the Indian Medical Association undertook was to equip hospitals with Covid-appropriate infrastructure with one-way traffic to patients, restrictions on the number of people entering, masking and proper cleaning of the place, etc.
Also, with the elections now, we have seen videos where for every nomination, though there is a control measure, for example, only five to ten persons should go, thousands of people are crowding. The Election Commission has taken a very important step by making sure all officers at the election booths are vaccinated. Now we have also requested the government to make it mandatory for agents coming to the political booths to show vaccination certification. Moreover, as Dr Harsh Mahajan and others said, vaccination should be made more available. There is no point restricting vaccinations when India is able to export more than 5.8 crore vaccines. Vaccination should be provided at the doorstep level. We need to be on a war footing.
Common sense has to prevail among the public too. People believe that Covid is not going to do anything to them and that kind of mindset has settled in because political leaders are not leading by example. That should be punished. We would like to express on behalf of the IMA that in all the countries, the second wave has been more disastrous than the first. Though we have scientific knowledge and know the effects of disasters, we must aggressively fight it. Be assured that the Government of India and the medical fraternity will be on the front lines and we will control and treat people as much as possible. The only thing we want is that the government and our colleagues come together and follow Covid protocol.
Q: Do you think speeding up vaccinations can reduce Covid-19 cases in Maharashtra?
Dr Bhondve: Yes, definitely. As Dr Jayalal rightly said, vaccinations can be increased. I would like to inform all of you that when the two vaccines were allowed to be used on an emergency basis, it was only the IMA under Dr Jayalal that declared that the vaccines are safe. At the same time, neither the Government of India nor any state governments have come out with a statement saying the vaccines are safe and everybody has to take it. With previous vaccines like for polio and other things like the Swacchta Abhiyaan, there were a lot of advertisements. Celebrities were asked to talk about it on TV. But nothing has been done for the Covid vaccinations. This has had a very bad impact on the common people. Right now, even in the first phase, only 40%-50% of doctors and healthcare workers were vaccinated. In the stage where all people over 60 years are being vaccinated, if you observe the statistics, there are people who are not even aware that there is vaccination available and they should get vaccinated. As Dhiren sir rightly said, we have to educate such people. Then there are divyaang people or the handicapped. They are supposed to take the vaccination but none of them are getting it. Meanwhile, for people who are between 45 and 59 years of age, the numbers are not sufficient.
Secondly, the Government of India said that all vaccination centres should run 24×7. But this is not being seen. All hospitals should be allowed to do vaccinations and take care of any side effects. In Pune, we have around 600 hospitals. So, if we allow even 500 hospitals, at a rate of 100 people, we can vaccinate 50,000 people more. So, the timing and number of hospitals should be increased. And as Dr Dhiren rightly said, more than 3 crore people have been vaccinated and there are no serious side effects. So why not open up the market and vaccines be given by hospitals without all these registrations? During the Covid situation, when the beds in government hospitals were full or restricted, the government allowed beds in all private hospitals, even ones with 5 and 10 beds. So, for accelerating the vaccination drive, all private hospitals should be given a freer hand. Even the VCI head has said this. But it is not being implemented practically. We hope this gets implemented and the vaccine campaign is accelerated so we can control it in 6-8 weeks.
RNA virus tends to mutate very rapidly. If we see, there are over 100,000 mutations, and over 7,000 have happened in India itself. Out of that, the variants that concern the most have been the three—the UK, South Africa and Brazil variants.