A recent report by ANI quoted IMA President Prof. Dr. J.A. Jayalal as saying that the states of Kerala and Maharashtra are receiving more international tourists and there is a lot of interstate movement which might be a major reason for rise in Covid-19 cases. Notably, IMA has already called Kerala government’s decision to ease COVID-19 restrictions on the occasion of Eid al-Adha or Bakri Eid as ‘unwarranted’.
In an interview with Medically Speaking, the IMA President claimed that the Kerala government was adamant on opening the schools and relaxing covid restrictions which lead to 17,580 cases and 138 deaths in the state.

He further added that the massive shortage of vaccine is a result of the lack of planning on the part of the Indian government. “I do not agree with the prediction that the third wave will have a disastrous effect. I am confident that the third wave will come. The way in which we have taken up the vaccination drive, followed by the Covid appropriate behaviour and the natural immunity of the people- all these things will ensure that the third wave will not be as disastrous as the second wave,” he said.

Following are a few snippets from the interview:

The IMA has time and again warned the central and state governments. You told the Kerala government not to go ahead with the bakr eid celebrations. What will be your first reaction to those state governments and people who are going ahead with festivities thinking that the second wave is over and we have a short window to celebrate?

Prof Dr Jayalal: Democracy always leads by popularity. During the pandemic, the health of the people is of utmost importance. The IMA plays a major role to tell what is right and how the people should mend their ways to ensure safety and security in the country.

What do you say about the Kerala government? The IMA government asked them to not go ahead with the bakr eid celebration. Also, the number of tourists in states like Himachal Pradesh have peaked in the past few days. What do you think the state governments should do and where are they lacking?

Prof Dr Jayalal: It is the duty of the government to tell the people what to do. Unfortunately, the Kerala CM was very adamant on opening the schools and relaxing the Covid restrictions. This led to 17,580 cases and 138 deaths in Kerala. India is a federal structure. We cannot allow one state to go according to their whims and fancies. That is going to have an impact on the entire country. That is why we are asking the government to come forward to curtail these cases.  The cases are increasing day by day. That is why the IMA is asking the people and governments to mend their ways.

Do you think that schools should remain shut for the time being?

Prof Dr Jayalal: We need to exclusively plan about reopening the schools. People should not come in crowds. They should maintain social distancing, wear masks and follow the vaccination protocol. The schools should not be kept closed for a long time as it can have a psychological impact on the children. We will advise that schools should be opened in a graded and sustained way. The schools need not be open on all five days. The students can be called for just two days.

Children have been silent carriers of Covid in the last wave as well. How important is it to vaccinate them? Where are we when it comes to vaccinating the children in our country?

Prof Dr Jayalal: If the parents and the adults of the family are vaccinated and masking is practised then Covid will not have a disastrous effect on the children.

Where do you see we are months from when the drive started? Many experts feel that we would not be able to vaccinate the whole population of the country by the end of the year. What will be your reaction to that?

Prof Dr Jayalal: On June 21, India proved that 8.8 lakh people were vaccinated. That means that we have the capacity to vaccinate upto ten million people. Secondly, the country needs to have a sufficient supply of vaccines.

Where are we lacking? Why such a massive shortage of vaccines?

Prof Dr Jayalal: We are lacking because the government did not plan on how they would be going with the vaccine production. They were just depending on two companies which had a limited capacity. They can make 2.5 or three million vaccines. That does not meet the needs of the ten million people. We are taking a lot of time to import the Sputnik vaccine, although the permission has already been given. In Tamil Nadu, a big nine hundred crore vaccine unit is idle. If the government was really interested, they would have worked some ways by which the vaccine production would have augmented. But we are ready to support the government and before 2021 we plan to vaccinate the complete population.

When we speak of shortage of supply, we have seen a great tussle between the state  and the centre. Similar tussle played out when the Centre said that ‘no deaths have been reported because of lack of oxygen supply’. How would you react to the politics happening around it and to the statement that ‘no deaths happened due to the shortage of oxygen’ ?

Prof Dr Jayalal: What the mind does not know, the eyes will not see. That is what is happening with the Honourable Health Minister today. He has said that none of the states have given an official report about deaths due to shortage of oxygen, so he is not wrong on his part. This is the most painful thing during Covid. There have been so many doctor deaths but the government has no official data about their deaths.

Many doctors say that the third wave is impending. Some say that it is already here. Where will you say India stands when it comes to the third wave?

Prof Dr Jayalal: I do not agree with the prediction that the third wave will have a disastrous effect. I am confident that the third wave will come. The way in which we have taken up the vaccination drive, followed by the Covid appropriate behaviour and the natural immunity of the people- all these things will ensure that the third wave will not be as disastrous as the second wave. I expect that the number of cases will be lesser than projected. The mortality rate will also be less because we have augmented our infrastructure, manpower and resource material. When we are well prepared to face the situation, we have nothing to worry about.

Do you think we are well prepared? 

Prof Dr Jayalal: In comparison to the second wave, we are well prepared for the third wave. We know our faults and gaps now. Those gaps have been filled up. Unless the virus is arrogant with us, we will sail safely through the third wave.

A few weeks ago, B Medical Systems, a global player in the vaccine cold chain industry, announced a partnership with Dr. Reddy’s Laboratories for the pan India rollout of Sputnik V vaccines.

B Medical Systems will be offering their vaccine freezers, which can store vaccines at temperatures as low as -25°C. To address the immediate needs, these units were delivered by air freight from Luxembourg.

According to Jesal Doshi, Deputy CEO of B Medical Systems, it is tough to alter people’s minds about vaccine efficacy while kept in an ice box or a local refrigerator. Mr. Doshi claims that various vaccinations require different temperatures and that if they are not provided the appropriate temperatures, they would lose their efficacy.

Mr. Doshi claims that Pfizer is a very effective vaccine with a logistic cost of less than a rupee, and that the Indian government’s failure to get the vaccine into the nation is a source of significant concern.

Here are a few excerpts from the discussion with Mr. Doshi:

You have recently tied up with Dr Reddy’s lab for pan-India rollout of Sputnik V. Tell us more about that? Tell us about the work B Medical has done to help with the rollout of Covid 19 vaccines?

Jesal Doshi: For more than 40 years, B Medical Systems has been the world’s oldest and biggest firm dedicated only to the cold chain of vaccinations providing safe transportation for vaccines, pharmaceuticals and blood. We are a company based in Luxembourg, Europe, and we have been operating there until early this year, when we were invited to start manufacturing in India by Prime Minister Narendra Modi. We built up our own manufacturing plant in India after receiving that invitation in a record-span of four months. This is the first time we’ve manufactured outside of Luxembourg, and I’m quite proud of the fact that we chose India to do so.

Coming to the pact with Dr. Reddy’s, nearly every vaccination is temperature sensitive and may lose its potency if not kept at the proper temperature. Sputnik requires a temperature of -18 degrees Celsius for storage, whereas other vaccinations require a temperature of 2-8 degrees Celsius. Pfizer, on the other hand, requires storage at -60°C or lower, making it difficult to retain these vaccines at a proper temperature under such harsh circumstances, which is where we come in. We ensure that any vaccine, at any temperature under any condition is maintained correctly and hence assuring that the recipient receives the rightly stored and transported vaccine.

There are many areas where the terrain may be hostile, electric supply may be erratic – How do you manage in such areas?

Jesal Doshi: There are two different challenges, one being the terrain and the other one being very peculiar to the nation, i.e., “Thanda Hai To Chalta Hai” wherein people use iceboxes and cold-drink refrigerators for storing vaccines that require a temperature of 2-8 degree Celsius, rendering them totally useless.

Second, our firm employs equipment that operates on a wide range of power sources. For example, we have equipment that can run entirely on solar energy, a DC battery, kerosene, or regular power. Using any of these power sources, they can all sustain temperatures ranging from -18 to 25 degrees. We operate and maintain the whole cold chain supply in extremely remote locations such as Afghanistan and Congo.

We already have immunisation programmes in India but here we are talking about vaccinating the entire adult population is this country – do you think we have the cold chain support to do that?

Jesal Doshi: India has administered more or less about 40 crore people and believe it or not, it was the easy part of the journey because now we will face issues reaching people in the most difficult locations. If you look at the figures, you will notice that majority of the population in the rural areas haven’t received vaccines yet.

We are providing solutions to the central as well as the state government and working with Dr. Reddy’s for the Sputnik. We are ensuring that vaccines reach the remotest areas so that every individual is vaccinated.

For the benefit of your views help us understand the importance of a reliable cold chain system in these times?

Jesal Doshi: I think even if you have the best vaccine in the world, it will not work without an appropriate cold chain. Vaccines can decompose if not dealt with the right temperature. Most nations immunise all of their children, but after decades of mass immunisation, we have yet to reach a 100% vaccination rate, with the main issue being a lack of effective cold chain.

In India, there is an absence of an appropriate cold chain to take charge of the Sputnik vaccine. This is also the reason why Pfizer has not been introduced in the country. Till now, we have introduced Pfizer in more than 25 countries around the world including Africa.

Is India ready or will be prepared to bring Pfizer into the country considering the high efficacy of the vaccine?

Jesal Doshi: It is a misconception that storing and transporting Pfizer needs huge investment. When you look at the challenges around the vaccine shortages, it is very affordable to bring vaccines like Pfizer into the country, transportation of which costs not more than a rupee.

How can India improve its current cold chain system?

Jesal Doshi: In such cases, increasing vaccination availability might be a viable option. You must adhere to a regimen and ensure that there are no negative repercussions. Pfizer, for example, is widely disseminated around the world because to its effectiveness and lack of reported adverse effects. The vaccination is still not available in the country, which is a source of great disappointment for me.

Take us through the challenges you faced during this drive bad the lessons learnt from it.

Jesal Doshi: It is a matter of great pride for India to be regarded as the world’s vaccine capital, but the issue today is to maintain and supervise the safe storage and transportation of vaccines. Real-time monitoring is provided, allowing you to follow the availability of vaccinations throughout the world and ensure that each one is properly maintained. You can help save lives by maintaining a proper cold chain.

Mr. Doshi’s advise on the necessity for improvements in health infrastructure and vaccine availability during this epidemic, in which many people are dying, is extremely important.

Some proof-of-concept HIV vaccines in early human trials generate antibodies that actively hinder protection by degrading the vaccine’s payload, suggests a new study from Scripps Research.

Their study was published in the journal Science Advances. While scientists have had rapid success engineering vaccines against the pandemic coronavirus in less than a year’s time, HIV, the virus responsible for the AIDS epidemic, has proven significantly more challenging. Understanding how “off-target” antibodies may be undermining HIV vaccine prototypes allows for design improvements, says the study’s lead author, Andrew Ward, PhD, a structural biology professor at Scripps Research in La Jolla, CA.

“Our study provides critical insights for further improvement of HIV subunit trimer vaccines for future rounds of the iterative vaccine design process,” Ward and colleagues write. Despite more than 30 years of effort, the world still lacks an effective vaccine against acquired immunodeficiency syndrome (AIDS). Given the rapid success of the coronavirus vaccines, it may seem perplexing, but the reasons are many. The coronavirus infects cells in the airways and elsewhere. But HIV, short for “Human Immunodeficiency Virus,” infects the very immune cells needed to generate an immune response. That’s just the beginning of the challenge.

Compared to HIV, the coronavirus is slower to change and relatively stable. HIV has proven a master of disguise, able to cloak itself in a changing coating of protective sugar molecules stolen from its host, to make it appear friendly. Plus, it churns out mutated versions at an astonishingly rapid rate, staying one step ahead of people’s immune responses.

“The HIV surface spike is a sugar-coated, shape-shifting nightmare for antibodies to latch onto and provide protection,” says Dennis Burton, PhD, chair of the Department of Immunology and Microbiology at Scripps Research, and co-author on the paper.

“HIV exists in literally hundreds of thousands of different variants of concern compared to the handful for coronavirus,” Burton notes. To outfox HIV’s changeability, scientists have developed techniques to “rationally design,” or engineer, vaccine particles intended to prompt the formation of antibodies that broadly neutralize many subtypes of HIV.

Much like the current array of pandemic coronavirus vaccines, these HIV vaccine prototypes consist of a fragment of the actual virus, the surface spike known as the envelope glycoprotein (Env), which is found on the virus exterior.

A new study has highlighted the protective factors that can help people cope with the severe strain caused by the COVID-19 pandemic. The study conducted by the University of Bonn is based on a large joint online survey at the University Hospitals Bonn, Erlangen, Ulm, Dresden, and Cologne, which also involves many other hospitals in Germany. The results have been published in the journal PLOS ONE. Perceived coherence was found to be particularly important – in simple terms: the feeling that life has meaning and challenges can be classified in an understandable way.

The researchers invited employees in health care to take part in an online survey from April to July last year, i.e. during the first wave of the pandemic. “Alongside physicians and nursing staff, this also included two groups who have so far been overlooked in the discussion,” explained Professor Dr Franziska Geiser, Director of the Clinic for Psychosomatic Medicine and Psychotherapy at University Hospital Bonn.

Geiser added, “Firstly, the comparatively small number of pastoral workers in the hospitals. Secondly, the many medical and technical employees – the medical technical assistants within the examination, radiology, and the laboratories.”

More than 4,300 completed questionnaires were evaluated during the current study. A good 80 per cent of the participants worked in hospitals at the time of the survey, 11 per cent at University Hospital Bonn. They were asked to state, among other things, how stressed they felt by their work at present and before the survey and how often they suffered from symptoms of depression and anxiety.

Information was also collected on three possible “resilience factors”, which are assumed to protect against mental consequences of stress: social support, religiosity, and sense of coherence. More than 20 per cent of the respondents in each case stated that they had symptoms of depression or anxiety to an extent requiring treatment. “We do not know exactly what the situation was like for this sample before the pandemic,” explained Geiser.

He continued, “However, the values found are higher than in earlier studies among physicians and nursing staff, so we can assume there has been an increase during the pandemic. While, during normal times, physicians and nurses display higher mental strain than the rest of the population, they actually had lower anxiety values during the pandemic in our survey. This naturally makes us curious about possible protective factors.”

All the more so as Geiser is part of an interdisciplinary DFG research group at the University of Bonn, which is dedicated to researching resilience.

Sense of coherence particularly stands out among the potential resilience factors. The term comes from salutogenesis, a concept developed by medical expert Aaron Antonovsky in the 1980s, which focuses on searching for health-promoting factors and attitudes. “Sense of coherence refers to the extent to which we perceive our life as understandable, meaningful, and manageable,” explained Jonas Schmuck from Geiser’s working group, who is the lead author of the study together with Dr Nina Hiebel.

The more pronounced the sense of coherence among employees, the less often they suffered from mental symptoms. “However, a causal relationship cannot necessarily be derived from this,” said Geiser as a warning against drawing premature conclusions. “It may also be the case that anxiety or depression themselves minimize perceived coherence.” Nevertheless, she believes that this factor actually makes us more resilient to stress and particular challenges. In her view, the study thus brings to light important conclusions on how people should handle crises like the COVID-19 pandemic in the future. “The more complex the situation, the better we need to communicate,” she stressed.

People with larger waistlines, high blood pressure and other risk factors that make up metabolic syndrome may be at higher risk for having a second stroke and even dying than people who do not have metabolic syndrome, according to a meta-analysis.

The findings of the analysis were published in the online issue of Neurology, the medical journal of the American Academy of Neurology. Metabolic syndrome was defined as having excess belly fat plus two or more of the following risk factors: high blood pressure, higher than normal triglycerides (a type of fat found in the blood), high blood sugar and low high-density lipoprotein (HDL) cholesterol, or “good” cholesterol.

“Studies have shown conflicting results on whether metabolic syndrome, which has been tied to an increased risk of a first stroke, also increases the risk of a second stroke and death, so we wanted to analyze all of the research available,” said study author Tian Li, MD, of Fourth Military Medical University in Xi’an, China.

“These findings will help people with metabolic syndrome and their health care providers know that they should be screened for risk of recurrent stroke and given preventative treatments,” added Li. For the risk of stroke recurrence, the meta-analysis combined results from six studies with 11,000 participants who were followed for up to five years. During that time, 1,250 people had a second stroke.

The analysis found that people with metabolic syndrome were 46 per cent more likely to have a second stroke than people who did not have the syndrome. Looking at each component of metabolic syndrome, researchers found that having a low level of good cholesterol and having two or more components of the syndrome were associated independently with an increased risk of a second stroke.

Having excess belly fat, high blood sugar and high blood pressure were not associated with increased risk of the second stroke on their own.

For the risk of death from any cause, the meta-analysis combined eight studies with 51,613 people who were followed for up to five years. During that time, 4,210 people died.

People with metabolic syndrome were 27 per cent more likely to die during the study than people without the syndrome. None of the individual components of the syndrome was independently associated with an increased risk of death. “These results add to the evidence that people with metabolic syndrome should take steps to modify their risk of second stroke and even death where possible, through medication, diet, exercise and other recommended lifestyle changes such as stopping smoking,” Li said.

Li noted that the studies were observational, so they do not prove that metabolic syndrome is a cause of recurrent stroke or death. They only show an association.

According to the World Health Organization, “Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis B virus (HBV). It is a major global health problem. It can cause chronic infection and puts people at high risk of death from cirrhosis and liver cancer.”

WHO estimates that 296 million people were living with chronic hepatitis B infection in 2019, with 1.5 million new infections each year. World Hepatitis Day takes place every year on 28th July to bring the world together under a single theme to raise awareness on the global threat of hepatitis especially with more focus on viral hepatitis and to influence real change.

To discuss the same we had a panel of experts: Dr. Anil Arora, Head of Gastroenterology Dept, Sir Gangaram Hospital; Dr. Sanjeev Sehgal, Principal Director, Liver and Hepatology, from Max Chain of Hospitals; Dr. Sudeep Khanna, Senior Consultant, Gastroenterology Dept, Apollo Chain of Hospitals.

Q.Dr. Sehgal, why is hepatitis such a crucial problem? According to WHO reports a person dies of Hepatitis dies every 30 second.

A. Dr. Sanjeev Sehgal: Hepatitis is a huge burden in our country as it is worldwide. Hepatitis basically means inflammation of the liver and the prime reason for this are the hepatitis viruses which are of four types primarily: Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D. Hepatitis A & B are self-limiting and spread through blood, water or any fluid. But Hepatitis C & D are huge burden in our country and spread through parental fluid. In India, Hepatitis B has a prevalence of 2-7% and Hepatitis C is 0.5-1.5%. They constitute a huge number of patients in the county and are very important cause of liver related deaths in the country. They also cause liver failure, liver cancer and so on. Thus, it should be our topmost priority to treat and cure this disease.

Q.40 million people in India are HBV infected and constitute about 11% of the global rate. What would you say Dr. Arora?

A. Dr. Arora: This topic is very pertinent as Covid will come and go but the illnesses like Hepatitis have not gone ever since. Certain viruses spread through contaminated water and infected fluid, which are totally preventable. This is a prevalent issue in developing countries like India and South Asian nations whereas it has been totally eradicated in developed countries. Simple provision of safe drinking water and hygiene can prevent Hepatitis A & E. Virus spread through parental route are problematic. Hepatitis B & C are neglected, and like you said there are 40 million carriers of the infection unaware of the fact that they are infected, hence they are not only potentially disease developers but are also becoming a threat for their families. By increasing awareness, we can prevent this.

Q. Dr. Khanna would you agree with Dr. Arora that there is a problem of awareness that needs to be tackled right away?

A. Dr. Sudeep Khanna: I would like to add something to it, people know that something like this exists but they are not ready to accept it. A recent study conducted on 1 lakh children from India concluded that only 50% of the children were vaccinated against Hepatitis B.

Q. Isn’t it covered under Universal Health Immunization? Then why aren’t people getting vaccinated?

A. Dr. Sudeep Khanna: For the same reason as why they wouldn’t get anti-covid vaccine. This becomes a problem for us to help people. The vertical and horizontal transmission from mother to baby and during close contact is the most common cause of Hepatitis B. People need to be tested, treated and educated.

Q. Dr. Arora, we rightly spoke about how people are not even ready to accept it. So what can people do to prevent this stigma?

A. Dr. Anil Arora: A wonder drug called DAA has been discovered which can cure almost any type of Hepatitis C and hence it is as curable as any other disease but Hepatitis B is problematic. They are not aware of the fact that they may be carrying the virus in their blood for ages before they come down with advanced diseases like Cirrhosis and Carcinoma. My advise will be that anybody with a history of liver transplant, blood transmission, surgery, needle prick trauma or even dental manipulation should get a checkup for Hepatitis B. Now coming to vaccination, Hepatitis B vaccines has been available for over three decade at very low rate and very efficient.

Q. There are about 1.1 million who have died due to Hepatitis, and 3 million are still carrying the disease worldwide. How do we really address this in India especially with the urban rural divide?

A. Dr. Sudeep Khanna: Multimedia and TV are such a big medium and still unused to their full capacity. A lot of people don’t know about Hepatitis C and lack of initiative from the authorities and doctor bodies are causing this. The disease is significantly asymptomatic and by the time they are symptomatic it is too late. So it is all about awareness.

Q. Dr. Arora, what can one do if one is already infected with Hepatitis B? What about cure?

A. Dr. Anil Arora: There are two aspects of patient suffering from Hepatitis B, unlike other illnesses, if someone gets an infection today, there are 5% chances that as an adult they will carry the virus in the blood for the next 6 months that is called chronic carrier state and may develop the disease later in life. They remain asymptomatic and thus do not bother about it. This is where screening is needed and if a person is accidentally positive for Hepatitis B, he can be treated with antiviral therapy or else he may spread it to his family. In early diagnosis, regular follow up goes a long way in preventing the chronic illness.

Q. Dr. Sehgal, can a patient of Hepatitis B follow up with their checkup if infected with Covid?

A. Dr. Sanjeev Sehgal: Patients ask that if I am Covid positive then what happens with the other problems of mine and if you look at Hepatitis, the patients are consulting specialist doctors, and hence can manage with a tele consultation and it is not required to come to the hospital. If there is an emergency, then they should visit the hospital no doubt. If a Hepatitis patient is Covid positive and taking the concerned medications, I would recommend that they don’t stop taking medicines for Hepatitis as this may provide a flare to the disease.

Q. Dr. Khanna, are the patients with Hepatitis at a greater risk if they get Covid? Are they furthermore immune suppressed like we have seen in Cirrhosis?

A. Dr. Sudeep Khanna: If one has Cirrhosis, they are not at higher risk of getting infected. If in case the liver function goes down, the risk of Covid complication increases. Similarly, being infected with Hepatitis B or C does not mean that you are at higher risk of getting Covid. There should be no fear of vaccination.

Q. Dr. Arora, what would you say on the point “No fear of vaccination”?

A. Dr. Anil Arora: Liver is a vital organ in many functions including metabolism and immunity. Once you have severe Covid, liver gets involved in the immunity in many patients. Patients who have underlying liver disease should be given vaccine on a priority basis because liver handles all the drugs given to the covid patient.

Q. In what conditions in Covid patients does it lead to diseases like Cirrhosis other complications?

A. Dr. Sanjeev Sehgal: If you develop Jaundice due to contaminated food or water, it is a small chance that they may develop rapid deterioration and altered sensorium thus may have to be admitted to ICU. If someone has chronic disease like Hepatitis B or C and catch infection like Pneumonia, Covid, etc. then they may develop a liver failure. These are the two situation which may cause rapid deterioration and both the type of patients should be diagnosed early and quick treatment can save these patients.

Q. How can the person know that they are carrying the Hepatitis infection?

A. Dr. Sudeep Khanna: For most of the patients, the disease is asymptomatic. And hence is it not possible for them to diagnose through symptoms. Tiredness, although is a primary symptom so if you have fatigue throughout the day, you may have Hepatitis. One other way is to know if a family member is diagnosed with Hepatitis, one may be a carrier for the disease. Also, screening the high risk population is a way out.

Q. Dr. Arora, we spoke about who all should get tested, what will be your suggestion to all the policy makers?

A. Dr. Anil Arora: the only way to pick it up early and diagnose is by testing. So my suggestion is that whenever going for any sort of blood test or screening, get tested for Hepatitis B and C and executive check up is becoming a routine. It should be mandatory and if an asymptomatic patient is not checked up early, the cost of long-term disease treatment is enormous while it is very cost effective in early stages.