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It’s a good idea to have more vaccines: Dr Rakesh Mishra

In the coming months, we will understand more about the utility of different vaccines, says top scientist Dr Rakesh Mishra.

Shalini Bhardwaj

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Top scientist Dr Rakesh Mishra, who is a director of CSIR-CCMB labs, talked to The Sunday Guardian on mutant variants. Excerpts:

Q: What exactly is the double mutant variant and how is it going to affect us in future?

A: Double mutant variant as the name suggests has two changes in its genome one L is converted into R at 452 position and in one E is converted Q at 484 position. So when these two mutations are together, we call it double mutant and in cases that we have sequence genomes, these two mutation are going together, so that way, its giving its signature to a new variant. Particularly in Maharashtra, about 20% of the cases are due to this new variant as of now, although in other states it’s not very prominent. It’s 1 or 2% or even less.

Q: How it is going to affect and who is responsible for this mutant variant?

A. Responsible! Virus mutate in natural ways and if we allow the virus to spread, then it will have more chance to mutate and only people are allowing it spread so people are responsible in that way but while this is natural process we should keep that also in mind, as far as problems are considered since even in Maharashtra, where it is seen in highest proportion which is only 20 %, that means 80% of the cases of Maharashtra are not because of this variant and in other states we don’t see this variant so much. So this means this variant is not responsible for the recent rise in the cases; something else is responsible. Also, we have not seen increased symptoms or mortality; in fact more and more people are asymptomatic; not more than 85% and mortality has decreased, which means we understand the disease better and proper care has been given by doctors and that’s why mortality is less. This also means that this variant, like other circulating variants, is not more dangerous. So it not a fast spreader, it is not clinically more dangerous, but whether it will be a problem for the vaccine or not that is something we have to confirm because there are only reports that both of these mutations can have immune escape behavior.

If it was actually happening at least in our case, we would have seen by now some re-infection cases which we have not seen so far. May be, there is less data, so we can’t conclude very much but early indications are that immunity acquired by prior infection and therefore by vaccination is protecting against this virus as of now; so more data will be required. There are experimental ways of figuring that out which is to culture the virus in laboratory and see if the anti-bodies of vaccinated people or recovered people can neutralise this virus and that’s what we are doing and I am sure many laboratories are doing in the country. We have started culturing this virus and in the coming weeks, we’ll know if any protection of vaccine is compromised in this case, but that will take a little time. Early indications are that we need not to worry in that context here.

Q: Does the government require more vaccines to control such mutant variants?

A: It is always good to have. Vaccine is a weapon against infection. The more weapons you have, the better you are. These vaccines have come as a emergency approval and within a year the vaccine is available which most of us thought will not be possible. That it has happened is a remarkable achievement of the industry, the scientists and also of our regulatory bodies who have gone so carefully and given these approvals and they have proven to be right because the vaccine is safe. Now more than 5 crore people have taken vaccines and they are doing well. Vaccination in UK is reducing the infection significantly, that observation has already been made, so it is a very good tool. More is better so because these vaccines are emergency approval, we don’t understand fully, particularly the long-term effects of these vaccines or age group and other medical conditions; how long they will protect, which variant which one will protect; all those data will emerge only after vaccination follow up which is happening in many countries, including in our country.

In the coming months, we will understand more about the utility of different vaccines. Whether one vaccine is better for younger people, and another is better for older people, we don’t know today, but we might understand it in the coming months; so therefore, it is very good idea to have more vaccines. We should have 6, 10 vaccines, so that we can ensure that the pandemic is controlled and we don’t get into more problems in the future. In fact, we should try and vaccinate at a very high rate the largest number of people possible before the virus recovers and makes more variants. We can eliminate the virus by vaccinating large number of people. So that is a good strategy to follow and while we do all this, whether vaccination or no vaccination, Covid appropriate behaviour is the most important point today. So even if  we are vaccinated, it will take month, to month-and-a-half to get the full effect of the vaccine. The vaccine does not mean that you will not get infected, it means that we will not get very sick; that you make not require to go to the hospital and lives will be saved. But the virus may still hang around, so the most important thing is to wear masks and avoid crowing and do hand hygiene.

Q: How does mutation takes place?

A: Mutation is a natural process of these viruses like is common flu we see every year. We get cough and cold; so is the same with the virus. Once it comes, our system fights it and within a week or 10 days, we get rid of it, but after a few months, it changes its coat and comes back and infects again. So it is the same thing happening with the coronavirus. The Covid-19 virus keeps changing, it is very natural. In fact, all of us are different because our ancestors had some mutants which we have inherited; that’s why we look different; all of us have genomic chances. They originated with mutation at some point or the other and mutation, if it is good for the species, it persists and if they are bad, we perish. Similarly, in virus, if the mutation is bad, that particular virus will die and if the mutation in advantageous for the virus, it will adopt better and spread more. So, it is a natural process for all living beings; that’s why we see variety in life.

Q: Do you think in future it can be deadly if people do not take care of themselves, and not follow the guidelines?

A: Absolutely. If lakhs and lakhs of people are infected and the virus is having a good time spreading all over, it will generate more variants and there is no doubt about that. Maybe we are lucky that the double mutant is not very dangerous at this moment, but in future, some other variant may emerge that may be more infectious and that may not respect vaccination. That may cause more mortality. All those things are possible; therefore, wearing masks and maintaining social distancing and hygiene is a must to defeat this virus.

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Medically Speaking

AGE DISTRIBUTION SAME IN SECOND WAVE, OXYGEN DEMAND HIGH, SAYS ICMR DIRECTOR GENERAL

Shalini Bhardwaj

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In a virtual press conference, three senior members of the national Covid-19 task force, Niti Aayog member V.K. Paul, ICMR Director General Balram Bhargava and AIIMS Delhi director Randeep Guleria, presented data pertinent to the ongoing Covid wave.

Dr Bhargava said there is no difference between the first wave and the second wave and the data showed that over 70% of patients in hospitals in both waves of the infection are above 40 years of age, indicating that seniors are still at higher risk. “Older population continues to be more vulnerable to be admitted in the hospital in the current wave,” Bhargava said while sharing the data.

There is no difference in the percentage of deaths between the first wave and second wave from the data we have,” the ICMR DG added, as per ANI reports.

The statistics presented also outlined that there is a higher need for supplemental oxygen — over 54% in hospitalised patients during the second wave. However, it also showed a decrease in the demand for ventilators, which has come down during the second wave, with only 27.8% of those admitted in hospitals needing it, as compared to over 37% who required it during the first wave.

He also said that more cases of breathlessness are being reported during this wave, while in the last wave, symptoms like dry cough, joint pain, headaches were more prevalent.

The ICMR DG also listed three main reasons for the higher transmissibility of Covid-19: laxity, Covid-inappropriate behaviour and various unidentified mutations. “We have had a tremendous amount of laxity, Covid-19-inappropriate behaviour and various unidentified mutations. Of them, some are of concern — the UK, Brazilian and South African variants, which have been demonstrated to have higher transmissibility,” he said. He also added that a double mutant has been found in India but its higher transmissibility has not been established.

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A COCKTAIL OF DRUGS CAN BE MORE HARMFUL FOR COVID: AIIMS DIRECTOR

Shalini Bhardwaj

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In an interview on Monday, AIIMS Director Dr Randeep Guleria briefed the public on the importance of drug management during the ongoing pandemic, which has sparked concerns about shortages of medicines like Remdesivir.

“As far as drug management is concerned, there are two aspects – one is drugs and the other is the timing of drugs,” he said, warning that, “Giving a cocktail of drugs can also be more harmful.”

He also spoke about treating Covid-19 through drugs, steroids and CT scans. However, he advised against the use of Remdesivir for people recovering at home. “Studies have shown that Remdesivir is not a magic bullet and it is not reducing mortality. We may use it as we don’t have an antiviral drug. It’s of no use if given early to asymptomatic individuals/ones with mild symptoms. Also of no use, if given late,” he said.

“The majority of patients will improve with just symptomatic treatment. It’s only when you have moderate patients who are admitted that we need to look at steroids and other antiviral drugs (like Remedesivir) by following protocols and rationally give treatment,” he added.

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Variants, inappropriate behaviour, Covid fatigue have led to a surge: Top doctors

The ongoing coronavirus surge is not really a sudden, one-off incident. About 100 years ago, there was a similar pandemic, healthcare experts tell The Sunday Guardian in an exclusive interview.

Shalini Bhardwaj

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Top doctors and healthcare experts Dr Rakesh Mishra, director of CSIR-CCMB, Dr Padma Srivastava, senior neurologist from All Indian Institute of Medical Sciences, and Dr S.K. Sarin, director of ILBS, told this paper why they think India is witnessing a massive surge in Covid-19 cases now and how this surge can be controlled. Excerpts:

Q. What explains the sudden surge in Covid-19?

Dr Rakesh Mishra: The most logical reason for the surge in Covid cases is that 2-3 months ago, things were in control, but gradually we started to become careless and common people thought that coronavirus is now gone and normal life can be resumed. We are seeing the consequence of that carelessness. When the number of cases rise, it picks up like a chain reaction. Political activities, farmers’ protests, marriage parties, local trains, schools reopening, restaurant opening, bars opening, malls opening and all such things mean lots of exposure to people in public and these things led to the sudden increase in cases. Also, over a period of time, more variants have emerged and this has affected a large number of people.

Q: In Punjab, we are seeing a lot of people been infected by the UK variant?

Dr Rakesh Mishra: You can actually link that very nicely if you see the data of the UK variant. It means that these are the travellers who initially came from the UK and then participated in some activity where a large number of people came together and then they went to smaller cities and villages and started to spread the virus. But the reason for spreading is only one which is when people are not careful. When people are in close proximity without protection to an infected person, who is also not protected, this is bound to happen. It doesn’t matter which variant it is.

Q. What would you like to say about the sudden surge?

Dr Padma Srivastava: Again, as Dr Mishra said, it is not really sudden. About 100 years ago, there was a very similar pandemic. There was also a second wave which was steeper and worse and then a third wave and then probably, it just vanished. So, what we are seeing today is not an unexpected development. What has happened now, as professor Mishra said, is the presence of variants. To add to it is Covid-inappropriate behavior, which may be due to Covid fatigue as well as overconfidence following the arrival of Covid vaccines. So, people threw caution to the wind at a time when mutants were present and active. Historically, we are going to hit waves and waves again. And for safety, vaccination and Covid-appropriate behaviour are the best bet.

Q: The situation in India is worsening, what are the steps we should all take now?

Dr S.K. Sarin: First, we have to accept that we have a difficult situation and we are actually having more infections now than we anticipated. This is likely to probably overshoot last year’s numbers; so first, we have to accept that we are down in the dumps, we are in trouble and, therefore, if we accept that, then certainly, we have to manage at least this wave of severe and rapidly spreading infection and then, the second step would be to think about how we can prevent a subsequent wave and not let these waves keep on coming and disturbing our economy and lives.

As Dr Mishra and Dr Padma have already said, in my opinion, this was anticipated even in January when things opened up very rapidly. We had the first mutant coming and the UK variant had come or at least was detected at that time and from then on, everyone knew that like in UK, in three months, it would lead to a major proportion of people getting infected. We are not doing as many sequencing as we should for the virus types, but it is anticipated that in a few weeks, this may become a major problem of viral variants infecting Indians. Of course, other variants are there; the virus has a life cycle of about 12-16 weeks until the time it has a major mutation.

So while they are occurring, we should be aware of mutants coming and infecting the population in different cities where it was not there. What is worrying is that we had opened up almost all our transport systems and our offices back in January thinking that the virus has gone away; also, we thought that now that the vaccine has arrived, all of us will be vaccinated soon. These two things have probably help the spread of the virus now. The worry now is the number of deaths piling up in the next 2 to 4 weeks’ time when the infection becomes deeper and more and more people get infected. I think the situation is difficult, but all of us have a collective responsibility.

Q: How can we check such waves?

Dr Rakesh Mishra: Genome sequencing let you explore the aspects of the virus–what kind of changes it is acquiring and if there is any particular area where a particular variant is increasing in number. We have to keep in mind that we are only generating the mutants by allowing the virus groups to spread across a large number of people and mutations are a natural process of any life form. Genome sequencing provides valuable information which gives us some hints about what might be happening, but to control the spread of the virus, we all have to be extremely careful and behave in a Covid-appropriate manner.

Q: Do you think lockdown is one of the useful options?

Dr S.K. Sarin: Once you finish two to four weeks of lockdown, people tend to think that the virus has gone and they start doing multiple times the level of activities they did earlier; so lockdown sometimes is not a very positive way of managing such things.

As Dr Padma said we have to get things like hospitals, ICU beds, drugs, protocols and healthcare workers in order; however, testing and tracing has to be as strict as possible. Lockdown has to be self imposed–you have to see that you actually lock yourself down compared to others to stop the transmission of the virus. The virus is like a villain, it will go away and then show up again and again.

We need to vaccinate our population faster; we have just done 7% vaccination of our population which is much less, especially with respect to areas where the virus is spreading fast like in Maharashtra or maybe Karnataka and Delhi. I think the age bar should be removed and mass vaccination is required as fast as possible. In the history of medicine, there has never been an occasion when the whole world has to be vaccinated and that too fast. So, there are challenges, challenges of making vaccines available, challenges of side effects, challenges of getting people to vaccinate and most importantly, getting people to accept a vaccine. Having said that, through the media, it is very important for us to communicate that there are two types of vaccines available: one is your mask and the second is the available vaccine and we have to employ both of them. Get your shot, do not be hesitant because there are advantages of getting a vaccine. Some people say he got two shots of vaccines, still he got infection, so what is the use of getting vaccination? But it is important to understand that if someone got vaccine shots and even then that person got infected, the infection will be milder. The severity of the disease is reduced as also the severity or possibility of transmitting the virus to others.

The other advantage of vaccines is that you will have antibodies which will at least last for six months to a year; but that should not make you abandon all the Covid-appropriate behavior. Also, once you have a vaccine, you can become and work like a frontline worker. No doctor, nurse, or healthcare worker should work if they have not received both doses of the vaccine. In fact, if there is a possibility, there is a support, we should test the immunization because vaccination is not equal to immunization; immunization means we have a high level of protective antibodies; we have not come to that stage yet. If you are over cautious that a certain vaccine may have side effects, we will lose more lives. Take whichever vaccine is available; they’re safe as millions have taken them.

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COVAXIN PRODUCTION TO INCREASE TO 10 CRORE DOSES PER MONTH BY SEPTEMBER

Shalini Bhardwaj

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New Delhi: The Centre on Friday said that it is taking steps to boost production of indigenous Covid-19 vaccines, and the production capacity of Bharat Biotech’s Covaxin will increase 6-7 times by July. The government is taking steps under Aatmanirbhar Bharat 3.0 Mission Covid Suraksha to accelerate the development and production of indigenous vaccines. The Centre’s Department of Biotechnology is providing financial support as grant to vaccine manufacturing facilities to enhance their production capacities, a release said.

“The current production capacity of indigenously developed Covaxin vaccine will be doubled by May-June 2021 and then increased nearly 6-7 fold by July-August 2021 i.e increasing the production from 1 crore vaccine doses in April 2021 to 6-7 crore vaccine dose/month in July- August. It is expected to reach nearly 10 crore doses per month by September 2021,” it said.

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DR HARSH VARDHAN REVIEWS HEALTH FACILITIES AT AIIMS TRAUMA CENTRE

Shalini Bhardwaj

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Harsh Vardhan

New Delhi: In the wake of a massive spike in Covid-19 cases during the second wave, Union Health Minister Dr Harsh Vardhan visited AIIMS to review the facilities available at its Trauma Centre, including the availability of oxygen for the Covid patients. In the review meeting, AIIMS director Dr Randeep Guleria and other doctors were present.

“The implementation of Covid-appropriate behaviour is the biggest challenge before us. People have become casual during the second wave. We are doing everything to speed up vaccination and bring more vaccines into the country. We have already given ventilators to the states and they are not demanding more because they are not able to use the current ones because of lack of space. In the last week we took many decisions to strengthen the supply of oxygen on the same dynamic pattern as we did last year,” Dr Harsh Vardhan said.

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NINE COVID TIPS TO KEEP IN MIND THIS NAVRATRI

Dr Deepak Gupta

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The ongoing Navratri celebrations in India are nine holy days when the nine incarnations of Goddess Durga are worshipped. In the spirit of the occasion, senior neurosurgeon at AIIMS Dr Deepak Gupta shared nine important tips to remember during the current Covid-19 ‘wave’ so people can be better equipped in the fight against the infection.

DON’T TAKE STEROIDS FOR MILD CASES

Steroids dexamethasone, hydrocortisone and MPA may have some benefit, but they are only useful for patients who are on oxygen therapy or ventilator support. Don’t give the patients steroids early or in the first week of the course of the infection. More importantly, don’t use them for mild cases as they might do more harm. Avoid steroids in case of asymptomatic and just RT-PCR positive cases.

REMDESIVIR CAN BE EFFECTIVE IF GIVEN EARLY

Remdesivir with or without Baricitinib can be effective if administered within the first ten days of the illness for patients on ventilator support, non-invasive ventilation or HFNC. It can speed up the time taken for recovery but has no effect on mortality.

WHEN TO USE ANTICOAGULANTS

Anticoagulants (LMWH) followed by oral anticoagulants (Apixaban for three weeks) are useful if D-dimer is high.

PLASMA THERAPY MIGHT NOT BE AS BENEFICIAL

Plasma therapy has no benefits. If at all, plasma must be given within the first three days of the infection from a donor who has very high antibody titers.

OXYGEN THERAPY IS RECOMMENDED

Oxygen therapy, HFNC or ventilator support is highly recommended, if levels of oxygen saturation fall in a Covid patient.

KNOW WHICH MEDICINES MAY BE USEFUL FOR COVID

Inhaled nebulised interferons may be useful, if available. Favipiravir can also improve time taken for clinical cure and help in the cessation of viral shedding by two or three days in mild to moderate cases. MoAb can be used in mild but high-risk cases as it helps in recovery but it is very expensive.

TAKE NOTE OF WHAT DOES NOT WORK FOR COVID

Antibiotics like azithromycin and doxycycline, antivirals like lopinavir, HCQS (chloroquine), ivermectin, and vitamins are not useful for treating Covid-19. Tocilizumab (IL-6 antagonist) is not effective for preventing death in moderate or severe cases and has a risk of sepsis. If one does use it, take only one dose of 400 mg (but only in select cases).

YOUR IMMUNITY MIGHT BE ENOUGH

A majority of patients are improving on their own and developing body immunity, without any treatment. In India, with over a million cases being reported in the last year and the vaccination drive running at its best, people might be likely to achieve natural herd immunity soon.

OPT FOR THE VACCINES

The vaccines available for Covid-19 in India—Covaxin and Covishield—are recommended for all. Two doses are to be taken with a gap of minimum four weeks between them. The Sputnik V is also in the coming, while the Pfizer and Moderna vaccines are available elsewhere.

The novel coronavirus is going to keep spreading and infect everybody it possibly can, until the vaccines can protect everyone or the population develops natural herd immunity. Until then, it would be wise to practise Covid-appropriate behaviour like wearing masks (preferably the N95 kind) washing hands, distancing from each other, and avoiding any unnecessary travel.

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