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Be prepared for Covid to be around for foreseeable future: Dr Nabarro

WHO’s special envoy for Covid-19 Dr David Nabarro says that we have to learn to live with the virus. ‘It hasn’t gone anywhere and it’s now multiplying,’ he tells The Daily Guardian in an interview, adding that no one knows how long it will take for a vaccine to be developed.

Shalini Bhardwaj

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response has to be modified when it comes to encouraging Covid readiness. There is a need for clear and well-communicated strategic principles, modified in light of new evidence. This should be accompanied by guidance on how the principles can be adapted so they enable all stakeholders to work out for themselves and how they can best contribute to the response in their own localities. Second, those responsible for managing responses should take advantage of opportunities. They have to “convene, coordinate, curate and communicate”. When these elements are prioritised, power and authority at the local level are used to their best effect. We offer four suggestions on how this can be done: l There must be a narrative. It should describe a clear vision and identifiable pathways for societies to move into the Covid-ready state. How to encourage this to emergence from the present situation with widespread movement restrictions? l Information must be locally specific. If people are to be enabled to act at a local level, they depend on high quality and specific information about what is happening in their locations. Where is the virus? How many people are infected? Which groups are most at risk? l Responses must make sense to people. This is about people being able to make sense of the narrative and updates in the news. What are the implications of the latest scientific findings? What does that say about safety in schools, on public transport, the wearing of face coverings? Every effort must be taken to avoid stigmatisation. l Values of decision-makers must be explicit. People are bound together in solidarity, getting ahead of the virus, by a sense of what they hold in common. This includes caring for older people and those who are vulnerable. Our values are known because we state them, but they are believed when we live them. We may not be believed if we say we value care workers if it becomes clear that they are unable to be tested for the virus or to access equipment they need for protection. What we do and how we do it is much more powerful than anything we say. The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) looks like a super mysterious virus throwing googlies even after six months of the pandemic. We as pulmonologists imagine lung fibrosis to happen in chronic phase (after weeks) of any pneumonia or Acute Respiratory Distress Syndrome (ARDS). Some of the observations based on autopsies done in SARS-CoV-2: 1. A total of 159 patients with ARDS, fibrosis was noted in three (4%) of 82 patients with a disease duration of less than a week, 13 (24%) of 54 patients with a disease duration of between one to three weeks, and 14 (61%) of 23 patients with a disease duration of greater than three weeks. 2. The post-mortem also reveals vascular endothelial inflammation with intracellular SARS-CoV-2 virus and disrupted endothelial cell membranes. Electron microscopy showed that there is enhanced intussusceptive angiogenesis (the process whereby a new blood vessel is created) which intrudes the lumen (the cavity or channel within a blood vessel) and further leads to thrombosis (clot inside a blood vessel). This finding is not seen in other ARDS like influenza during acute stages. 3. There is evidence that vascular dysfunction (a disorder of the vascular system characterised by poor function of the blood vessels) is a key component of the switch from ARDS to fibrosis, with VEGF (Vascular Endothelial Growth Factor), Interleukin 6 (IL-6), Interleukin-1 (IL-1), Tumor necrosis factor (TNF) Alfa as main mediators. 4. It remains unclear why certain individuals can recover from it whereas in others there is a shift to unchecked cellular proliferation with the accumulation of fibroblasts and myofibroblasts and the excessive deposition of collagen alongside other components of the extracellular matrix to result in progressive pulmonary fibrosis. Three tips to prevent fibrosis: a) any potential antifibrotic intervention should be considered within the first week of ARDS onset; b) drugs which inhibit IL-1 “Nintedanib” can play a beneficial role. The role of IL-6 inhibitors is still not clear and confusing. An experimental study showed that IL-6 in the early phase of lung injury promotes fibrosis and that inhibition in the later stages of injury at the onset of the fibrotic phase might ameliorate fibrosis; c) older the age and severe the disease (requiring ICU) leads to more chances of pulmonary fibrosis. The writer is a pediatrician at Sir Ganga Ram Hospital in New Delhi. The World Health Organization (WHO) and UNICEF have warned that around 2-3 million children across the world may miss life-saving vaccines and immunisation programmes around the world due to disruptions caused by Covid-19. These vaccines are used to protect children against life-threatening diseases such as measles, smallpox, DTP3, among others. According to new data by WHO and UNICEF, these disruptions are now a threat which can reverse the hard-won progress against deadly diseases through immunisation programmes. “Vaccines are one of the most powerful tools in the history of public health, and more children are now being immunized than ever before. But the pandemic has put those gains at risk. The avoidable suffering and death caused by children missing out on routine immunisations could be far greater than Covid-19 itself,” said Dr Tedros Adhanom Ghebreyesus, Director General, WHO. Several countries are facing disruptions in the delivery and uptake of immunisation services due to the coronavirus outbreak and lockdown. Due to an increase in the number of cases not only in India but in various countries, at least 30 measles vaccination campaigns are at risk of being cancelled, which could result in a further outbreak in 2020 and beyond. In many cases where services for vaccination are offered, people are unable to reach for their kids’ vaccination due to interruptions, economic hardships, restrictions on movement, or fear of coronavirus infection. Most of the cases are from Africa where one of the reasons is lack of access to health services during the pandemic. Two-third of them are concentrated in 10 middle and low-income countries like Angola, Brazil, Democratic Republic of the Congo, Ethiopia, India, Indonesia, Mexico, Nigeria, Pakistan, and Philippines. Covid-19 has directly affected immunisation which is one of the most cost-effective public health interventions till date. Covid-19 is not an airborne disease, says Dr David Nabarro EXCLUSIVE PRESCRIPTION Medical news DOC TALK World Health Organization’s special envoy for Covid-19, Dr David Nabarro, says that air is not the primary mode of coronavirus transmission and there is not enough evidence to suggest the same. medically speaking the daily guardian 18 july 2020 8 new delhi Covi d and after: Is India prepared for mental health pandemic? SARS-CoV-2: Super mysterious virus causing big damage 3mn kids won’t be vaccinated due to Covid, warns WHO Shalini Bhardwaj New Delhi Dr Srinivas Rajkumar New Delhi

In an exclusive Interview with The Daily Guardian, Dr David Nabarro, who is a special envoy to the World Health Organization (WHO) for Covid-19, said that the infection should be considered a constant threat to humanity. “It hasn’t gone anywhere and it’s now multiplying. We have to live with it. I do not know how long it will take for a vaccine to be developed and when it will be accessible to everyone, everywhere,” said Dr Nabarro.

 Covid-19 has infected more than 32,510,655 people and killed over 989,287 people worldwide. “Today, it is really a struggle to make sense of this virus causing Covid-19 and the extent to which it has spread. Our starting point is that the world is going to beat the virus, but the world is also going to learn that the virus is a constant threat,” said Dr Nabarro.

 According to Dr Nabarro, the virus multiplying and spreading from one person to another can only be stopped or controlled by keeping in mind a few important points. “This virus multiplies by jumping from person to person. But if people are not close to each other, we can stop the virus from actually moving from one person to the other. And then, when the virus is moving between people, it’s possible to stop it from doing so, to interrupt transmission. But that is isolating people from each other, and that’s the secret to getting ahead of this virus — it is the only defence. And we have to do that because this virus can kill, it can kill the people it infects,” he warned. “So, we need to keep ahead of it by stopping it from moving from person to person, with physical distancing, face protection by using masks, maintaining the hygiene of our hands when we cough — and through the practice of staying away from others,” he added.

 Some scientists and doctors are saying that the world is already going through the second stage of the Covid pandemic. On that matter, Dr Nabarro said, “This virus hasn’t gone anywhere at all. It is spreading through small outbreaks, which are then getting bigger. It’s happening continuously. In some places, the movements are slow because they have very good defences and those defences are being implemented quickly. But in some places, where, perhaps, it’s been hard to defend, the virus is quite widespread. So, I am not talking about ‘waves’, I am talking about resurgences of the disease, in the form of spikes or surges, and then those turning into outbreaks.” 

“The precautions we need to take to stay Covid-19-free relate to what we do in terms of physical distancing, face protection, maintaining hygiene, isolating when we are sick and protecting others who are at risk,” said Dr Nabarro, adding that the people at a higher risk are healthcare workers. The contagious coronavirus has affected healthcare workers the most, with thousands of them having died across the world till date. “The people who work in healthcare, nurses and doctors, attendants and people who provide health services: we have to give them special attention. They have high death rates, with many thousands of health workers dying in the last few months,” Dr Nabarro stated.

 Talking about other major challenges which people are facing, Dr. David commented, “Covid is also causing lots of problems. We need to recognise that it causes health challenges, makes people sick, and some of them very sick, but it is also leading to all sorts of other challenges. There are unemployment systems in place, a system protecting people who are poor. You have to recognize that poor people get hit the worst, and if their movement is restricted, the poor suffer the most. So, Covid is also revealing some of the inequities in our society, and we must support poor people first.”

 Besides social concerns, the vaccine is the biggest question on everyone’s minds right now. About that, said Dr David, “We don’t know whether the vaccine we have works well or whether we will have a vaccine which is safe. But we know we need to wait for sometime before the vaccine is widely available.” So, what can we do until a safe and effective vaccine is out? “All you can do is learn to live with the threat of Covid, and at the same time, try to find new ways of diagnosing it, so we can test more easily. We will try to find out the vaccine, but don’t wait for one particular thing to appear, especially since we have no certainty that it will come. Try not to put dates on when we will have vaccines. If you do that, you create false expectations,” advised Dr Nabarro.

 Lastly, addressing the concern about how long this virus will remain with us, Dr David said, “This virus is a coronavirus, and generally, a coronavirus is quite stable. There is a lot of evidence that this virus stays pretty consistent. But it hurts people and kills people, and I think we need to be prepared for this virus to be around for the foreseeable future and become another issue in our ecosystem which we have to manage.”

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Medically Speaking

OXFORD-ASTRAZENECA VACCINE IS SAFE, SAYS SERUM INSTITUTE

Shalini Bhardwaj

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OXFORD

In a statement released by AstraZeneca, the company has admitted to its dosing error and said that the Oxford-AstraZeneca vaccine is safe and effective. Partnered company Serum Institute of India (SII), which is holding trials for the vaccine in India, also said that the vaccine candidates are safe and trials are running smoothly with strict adherence to all the necessary protocols in India and that there is no need to panic.

“The AstraZeneca-Oxford vaccine is safe and effective. Even the lowest efficacy results are at 60-70%, making it a viable vaccine against the virus. That said, varied age groups with different dosage forms will result in slight variations and efficacy. We must be patient and not panic. The Indian trials are running smoothly with strict adherence to all the necessary processes and protocols. So far, there are no concerns. However, we are going through the data that is available and will make a further statement, if needed,” the Pune-based SII said in a statement.

DCI FACES IRREGULARITIES AND CORRUPTION CHARGES

DCI FACES IRREGULARITIES AND CORRUPTION CHARGES

After the removal of Dr Majumdar as president of the Dental Council of India (DCI), the appointment of the council’s secretary has come under the spotlight. Due to procedural lapses and non-transparency in the appointment of DCI’s secretary, Dr Sabyasachi Saha may be disallowed to exercise his powers as the post-holder.

“The appointment of Dr Saha was made with the approval of the central body of DCI. Till the time the governing body reconsiders its earlier decision to appoint Dr Sabyasachi Saha as secretary, Dr Saha may be disallowed to exercise his powers as secretary, DCI, and M L Meena, Joint Secretary (Legal & Admin) may be asked to officiate as secretary, DCI in the interregnum,” said a letter issued to the Acting President by Nipun Vinayak, Joint Secretary, Department of Health & Family Welfare.

MEDICAL COLLEGES TO OPEN DOORS FOR STUDENTS

MEDICAL COLLEGES TO OPEN DOORS FOR STUDENTS

Maulana Azad Medical College (MAMC) has issued a notice to reopen the institute by December 1. The notice has been issued after receiving recommendations from apex medical regulator, the National Medical Commission (NMC), which recently issued directions to reopen medical colleges on or before December 1, 2020.

All institutions will have to adhere to Covid-related SOPs. The circular said, “All medical colleges/institutions shall ensure strict compliance of guidelines issued by the Ministry of Health Ministry Welfare State/UT Government about Covid-19 preventive measures including social distancing, use of mask and sanitisation measure of hostels, class, laboratories, lecture theatres, etc.”

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ANTIBIOTIC RESISTANCE: SILENT KILLER IN THE SHADOWS OF COVID-19

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ANTIBIOTIC RESISTANCE: SILENT KILLER IN THE SHADOWS OF COVID-19

Covid-19 has led to loss of many lives and crippling of economies of several countries. However, beyond the most obvious fallouts of this deadly disease caused by an insidious virus, the shadow of upsurge of antibiotic resistance is looming over the entire mankind which will be realised in the time to come. A medical revolution of colossal proportions happened on 28 September 1928, when the first antibiotic was discovered by Sir Alexander Fleming, a Scottish bacteriologist. This discovery was heralded as a path-breaking moment in the history of medicine as it seemed that the human race had finally found a new direction to combat deadly bacterial infections. What followed that event was the discovery, mass production, and prescriptions of several antibiotics over the next few years.

A mass optimism swept the world towards the dawn of a new period termed as the antibiotic era. A race to produce new antibiotics led to hundreds of antibiotics being churned out and consumed by the masses for bacterial infections. Even in his acceptance speech of Nobel Prize conferred to him, Sir Fleming had warned mankind against indiscriminate use of antibiotics, since that would lead to the bacteria developing resistance against the antibiotics which had been designed to kill them. Unmindful of this warning, overuse of antibiotics all over the world finally led to a global phenomenon, known as Antibiotic Resistance. This was a blanket term to describe the emergence of novel bacterial strains which are resistant to several antibiotics, known as multi-drug resistant bacteria (MDR) and all antibiotics, 2 known as all drug resistant bacteria (ADR).

The battle between the humans and these bacteria, also known as ‘Super bugs’ has set the ball rolling once again, for the sharp descent into the ‘Pre-antibiotic’ era in the future.

The new drug pipeline for drug-resistant bacteria is drying out, causing alarm and concern about the impending doom of mankind. While sometimes resistance occurs naturally, in most cases, it happens due to clinical misuse and self-medication. The other causes for antibiotic resistance are irresponsible disposal of untreated chemicals from manufacturing units and healthcare systems in the environment, indiscriminate feeding of antibiotics to livestock, and overuse of pesticides on crops, which are consumed unknowingly by humans. The multipronged solution to the worldwide predicament of antibiotic resistance includes creating awareness among the common man about the phenomenon of antibiotic resistance in order to prevent self-medication, careful monitoring of specific bacterial responses to various antibiotics, limiting the prescriptions of antibiotics by clinicians, and prevention of environmental pollution.

There is also a need to discover and design new drug molecules which could be used in lieu of the commonly prescribed antibiotics. In recent times, the outbreak of the pandemic of Covid-19 has only led to escalate the imminent threat of antibiotic resistance. Though Covid-19 is caused by a coronavirus, its health complications are often compounded by serious secondary bacterial infections. In the ensuing chaos of this pandemic, two diverse phenomena are occurring which are causing overuse of antibiotics. One, several patients are not being able to access the healthcare workers due to lockdowns and are indulging in self-medication. Second, since Covid-19 has caught the world at the wrong foot unexpectedly, many antibiotics are being widely used to combat bacterial infections in the Covid-19 patients in hospitals all over the world.

The sudden emergence of this deadly virus has not given enough time to the healthcare workers to prudently balance the treatment of the patients against the future danger of the antibiotic resistance, which will be felt for centuries to come. The bright side of the problem is that the emergence of this pandemic has brought the spotlight on the infectious diseases caused by superbugs, which is making the governments and policymakers of all the countries in the world take these phenomena seriously. This event has indicated that despite the cutting-edge technologies and sophisticated medical care, pandemics of gigantic magnitudes caused by superbugs may happen in future as well. Despite the doomsday prophecies, it is hoped that this global crisis will help the world to educate itself better about the constant and impending threat of superbugs and antibiotic resistance, and recognise the critical tip of the iceberg that we are collectively sitting on.

The mankind has valiantly fought and emerged victorious after the onslaught of past pandemics. Hence, careful monitoring of antibiotic use and aggressive repurposing of drugs to enhance the drug pipeline for new antibiotics while limiting environmental pollution will give a new direction for mankind to overcome the global threat of antibiotic resistance.

Prof Sujata Sharma is associated with the Department of Biophysics, AIIMS, New Delhi.

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SOCIAL VACCINATION IS STILL THE WAY FORWARD

Dr Neeraj Nischal

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SOCIAL VACCINATION IS STILL THE WAY FORWARD

The festive season is here, and so is winter. With all of us stranded at home for most of the year, the desire for celebration and social gathering is climbing. We are all eagerly waiting for the distribution of Covid-19 vaccines, so we may gain immunity and go about our lives as it was the case in the pre-coronavirus era. Vaccine development and immunisation are, however, time-consuming. Thus, while the scientific community works on a biologic solution, we must continue to take part in the practice of the ‘social vaccine’.

The Covid-19 social vaccine includes social distancing, hand hygiene, face masks, and isolation. Since the discovery of the mode of spread of the SARS-CoV-2 virus, these measures have been widely popularised. Over the last nine months, Covid fatigue has set in all of us, and there has been laxity in the practice of the laid down Covid appropriate behaviour. Without reinforcement, this will only worsen.

We are currently in the unlock process after a long lockdown phase. At this time, the number of cases in certain parts of India is again on the rise. The disease is just as, if not more rampant in its spread, and has not heeded to our efforts of lockdown. Social vaccination is still the only way to safeguard ourselves. The virus will enter our homes if we falter and permit it. It is up to us to keep ourselves and those around us safe and healthy.

To elaborate the measures yet again, social distancing includes physical distancing of individuals by at least six feet. We do not have to be socially or emotionally distant in these times, just physically distant. We have been blessed with technology to bring the world closer. The utilisation of these online platforms will help us socialise when we have to practice social distancing. Washing your hands with soap and water (or alcohol hand rubs) for at least 20 seconds, frequently, will keep you from spreading the virus by touch. Let us strengthen the Indian tradition of ‘Namaste’, and say no to handshakes. Face masks will not only protect you from Covid-19 but other winter viruses like the common cold, and influenza. Most importantly, remember to be socially vigilant, and isolate yourself if you are symptomatic.

A vaccine is not a magic bullet to end the pandemic. The introduction, logistics, and effects of vaccination is a drawn-out process. Even with a sound biological vaccine, social vaccination is still the most crucial aspect of disease prevention. The two should go hand-in-hand to control the disease and are not mutually exclusive. Both of these would need staggering community participation, with the social vaccine requiring the full and conscious effort of the entire population without which it is bound to fail. The fate of the pandemic rests in the hands of each and every one of us. Here’s to celebrating the festive season the way it was meant to be, with lights and goodwill.

Dr Neeraj Nischal is Associate Professor, Medicine Department, All India Institute of Medical Sciences, New Delhi. He wrote this article with the help of Dr Sujay Halkur Shankar, Resident Doctor at AIIMS.

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We have to watch out for mutations of the virus: Dr Shahid Jameel

Virologist Dr Shahid Jameel discusses the parameters for an effective vaccine against the coronavirus pandemic and how to prepare for a large-scale vaccination drive.

Shalini Bhardwaj

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Dr Shahid Jameel

In an exclusive Interview with The Daily Guardian, Dr Shahid Jameel, Virologist and Director of Trivedi School of Biosciences at Ashoka University, talks about how to judge the efficacy of a Covid-19 vaccine, how India needs to plan for the vaccination drive and whether the novel coronavirus is likely to mutate in the near future. Excerpts:

Q. What would you say about the companies claiming the efficacy of their vaccines only through press releases?

A. Press releases are quick ways for companies to make their achievements public, but they are geared more towards shareholders and financial markets. A factual position can only be judged when the scientific details of a trial are published in a peer-reviewed publication. We should wait for those. At this time, the percentage of efficacy is not important and should not be used to compare different vaccines. All this means is that vaccines based on the viral spike protein will work to protect against disease, and sometimes against infection as well.

Q. What kind of a vaccine should be given to the people?

A. A vaccine that has been proven to be safe and has good efficacy. This is the reason why human clinical trials are done in stages – Phase 1 for safety in small numbers of volunteers; Phase 2 for safety and immunogenicity in larger numbers of volunteers; and Phase 3 for safety and efficacy in very large numbers of volunteers with gender, racial and age diversity.

Q. How much efficacy should that vaccine have before being approved for people?

A. It depends upon how infectious a virus is. In this case, the WHO and US FDA have set a benchmark of 70% efficacy before a vaccine candidate will be considered for approval.

Q. Why have there been errors with the AstraZeneca vaccine?

A. I cannot answer that. All I know is what the company has said. Errors happen, but what is important is how transparently they are addressed. I am sure the regulators in all countries that want to license this vaccine will look at the data very carefully.

Q. How does India need to plan ahead for successful vaccination?

A. India’s plan should include the following. Firstly, who should get the vaccine first? The primary aim should be to use the vaccine to protect frontline workers (healthcare, sanitation, essential services), reduce mortality (elderly and those with comorbidities) and control the pandemic.

Secondly, to work out the storage-transfer-delivery logistics down to the last detail. India has a lot of experience with the polio vaccine but that was an oral vaccine not an injectable one. India also has a lot of experience with childhood and maternal vaccines, but we have never delivered such large amounts of a vaccine during a pandemic.

Thirdly, the current capacity is to deliver 1.5 million doses per month, or 18 million doses per year. The Health Minister stated that 250 million Indians would be vaccinated in 2021. That means 500 million doses. At current staff strength, it would take more than two years. Therefore, we must increase trained staff.

Fourthly, should we vaccinate those in high priority groups (e.g. healthcare workers) who have already been infected? This would make little sense and waste precious doses. If we decide not to, then there should be an inexpensive test to find out those who already have antibodies. Today the test costs as much as one vaccine dose. That cost has to be factored in.

Lastly, make the plan available for public scrutiny and comment. This will increase trust in the vaccination programme.

Q. What are the parameters which need to be considered for emergency approval of vaccines?

A. Emergency Use Approval looks primarily at safety in large and diverse populations and also a reasonable level of efficacy.

Q. For how long will these vaccines work?

A. We don’t know the answer to this simply because vaccine trial follow-ups have not been done for long enough. Extrapolating from natural infection, neutralising antibodies wane off in about six months, but that does not mean loss of protection since there are T cells and memory recall responses. Even natural infection has not been followed long enough after recovery to fully answer this question. But, going by other endemic coronaviruses, protection may last up to a year or more.

Q. Do you think this virus can mutate? If it does, what is likely to happen?

A. Every virus mutates and so does this one. RNA viruses mutate faster than DNA viruses. However, compared to other RNA viruses, coronaviruses have the lowest rate of mutation. With over 224,000 SARS-CoV2 genomes sequenced by now, mutations in the spike protein neutralizing domain have not been seen. So, that’s good from the vaccine perspective. But this region has no selection pressure on it to change. Once vaccines are deployed in a big way, such mutations will arise. We would have to watch out for that.

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Pfizer seeks emergency use of Covid-19 vaccine

Shalini Bhardwaj

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Pfizer has announced that its vaccine is 95% effective on the basis of its Phase-3 trials. On Friday, Pfizer said that it is asking US regulators to allow the emergency use of its Covid-19 vaccine.

The company announced that they will submit a request to the US Food and Drug Administration (FDA) for Emergency Use Authorisation, which will potentially enable the use of the vaccine in high-risk populations in the US by mid to end of December 2020.

“Our work to deliver a safe and effective vaccine has never been more urgent, as we continue to see an alarming rise in the number of cases of Covid-19 globally. Filing in the US represents a critical milestone in our journey to deliver a Covid-19 vaccine to the world and we now have a more complete picture of both the efficacy and safety profile of our vaccine, giving us confidence in its potential,” said Dr Albert Borla, Pfizer CEO and chairman.

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India to get 400-500 mn vaccine doses by July: Harsh Vardhan

Shalini Bhardwaj

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Harsh Vardhan

Union Health Minister Dr Harsh Vardhan has said that India is set to get 400-500 million vaccines by July 2021. He gave this statement during a virtual programme organised by FICCI FLO.

During the programme, National Treasurer Lalita Nijhawan, in an FAQ session, asked the Health Minister about the method of distribution of the vaccines across the country.

“First of all, priority has been given on the basis of medical grounds because we are a country of 135 crore people. For such large numbers of people, nobody can arrange large quantities of doses of vaccines in a single go. By July to August 2021, we will have 400-500 million dosages available. Now it is under clinical trials in many companies,” said Dr Harsh Vardhan.

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