"The only thing I would say is that lockdown is not a solution, it is not the answer to the present problem. You know there are important side effects of a lockdown," says Dr Pradip Awate on Nagpur lockdown
Dr Pradip Awate is the state surveillance officer for Maharashtra, in charge of monitoring epidemic-prone diseases in the state as part of the Integrated Disease Surveillance Programme of the Health Ministry. He is one of the most crucial players in designing intervention and response strategies against the Covid-19 disease in Maharashtra.
Anuradha: In this pandemic, Maharashtra has consistently been the worst affected state, but in between the cases had begun to decline. Does the current trend of rising cases qualify as a second wave?
Yes. What we are looking at currently does appear to be a second wave.The magnitude and speed of new cases are comparable to the first wave.
Anuradha: Why are the cases rising so rapidly again, and mostly in Maharashtra? What has gone wrong in Maharashtra?
Nothing, actually. There are different epidemic curves for different states depending on the geography, weather pattern, and even international connectivity. If you remember, the first case in India was detected in Kerala, about one and a half months prior to Maharashtra. But after that, cases increased very quickly in Maharashtra, while Kerala had very few of them. After a few months, Kerala began to grow while Maharashtra slowed down. Now Maharashtra has picked up again, while Kerala has started to see a decline. In other states, the curves have been different. It just goes to show that local conditions play a big role in the spread of the disease. There are lots of such local variables that influence the spread.
Manoj: Nagpur is going into a week-long lockdown from Monday. Is lockdown the solution?
As an epidemiologist, and a person who has been observing the trends, I would say that lockdown is not the answer to control this surge that we are seeing. In fact, even the central team that visited Maharashtra a few days ago said lockdown is not the answer.
Lockdown is basically a pause button. Its importance is mostly in the initial phases when there is a need to build up capacities in terms of hospitals, surveillance, laboratory network. One has to expand the existing infrastructure keeping in mind the expected rise in cases. At that time, lockdown certainly has a very important role to play.
But in the current situation, I think, surveillance should take prime importance. May be, partial lockdowns are useful in so far as they force people to adhere to Covid-appropriate behaviour. But total lockdown is not very desirable at this stage. This Friday, we had a review meeting in Pune, and some restrictions were placed on the timings of restaurants, hotels, markets and malls, and schools and colleges were asked to close down. But everyone agreed that there was no need to implement a total lockdown in Pune.
Manoj: Then, why do you think Nagpur opted for a lockdown? Is it only a district government decision? Is the state government not consulted on this?
Currently, the disaster management act and epidemic act are in place. The district magistrate and municipal commissioners have been empowered to take decisions dictated by the local situation. The state government definitely is kept informed. But, the district administrations are empowered to take their own decicsions on an assessment of local situation.
Manoj: Would you say it was a wrong decision to impose a lockdown in Nagpur?
The only thing I would say is that lockdown is not a solution, it is not the answer to the present problem. You know there are important side effects of a lockdown. It has major social and economic impacts, some of which are worse than the impacts of Covid. So, we do need to factor in the social and economic impacts of a lockdown.
Tabassum: Is there some something special in the virus circulating in Maharashtra? Have we found any specific mutation in the virus here?
Looking at the surge in Maharashtra, particularly in Amravati, Nagpur and Akola, and also in Buldhana and Washim regions, many have been of the opinion that there must be a different variant of the virus circulating in Maharashtra. We have sent many samples, almost 100 samples each from Amravati, Akola and Yavatmal, and about 50-60 samples from other districts also for gene analysis. So far, over 900 samples have been sent to National Institute of Immunology and National Centre for Cell Sciences for genome sequencing. Till now, there have been no reports of any new or special variant of the virus from Maharashtra, except for the 15 people with a travel history to UK who had been found infected with the UK strain.
But it is a fact that many of the samples that have been sent are still being analysed, and their results are not yet available. So, it is possible that in the coming days we might discover that some new variant is indeed present in the state.
Tabassum: What are the lessons learnt from this pandemic, so that we are better prepared for future?
There are quite a few important lessons. First of all, public health was never a top priority issue in India — not for politicians, not for general public, not even for doctors, and certainly not for the media. It had never happened that a public health issue was regularly flagged on the front pages of a newspaper. Covid19 has changed this. This pandemic has told everyone that public health cannot be treated like a backbencher. It should be on the front benches of public policy. That is the first lesson.
The second thing is in terms of infrastructure. I work for the Integrated Disease Surveillance Programme, or IDSP, which was started in the wake of Surat plague of 1994. Compared to the present crisis, it can only be considered a small outbreak. There were about 700 cases, but the almost half the population in Surat had to leave the city. The economic loss was huge. The IDSP was created to detect early warning signals of any such pandemic in future, and control local outbreaks.
While the objective of the programme is very good, there are several infrastructural issues. Look at Maharashtra, for example. It is one of the more developed states in the country, with almost 50 per cent of the population residing in urban areas. But apart from cities like Mumbai or Pune, many parts of the state do not even have basic health facilities. Newer municipal corporations like Parbhani, Latur, Chandrapur, or Jalgaon do not have basic capacities to deal with a crisis like this. State would need to build public health infrastructure. There are weaknesses in the rural health programme as well, but at least there is a structure. There is a sub-centre for every population of 5,000 population, then there are primary health care centres above that. A similar structure needs to be built in the urban centres as well, especially in the newly-developed areas.
There are some other lessons which might seem to be outside the domain of public health, but are important ingredients of public health. Like, affordable housing. What we have observed is that most of the deaths have happened in the slum areas, where the population density is high. It is not just about Covid19, even the prevalence of tuberculosis is much higher in these areas. The quality of housing is an important determinant of your health. That is why providing affordable housing can be a very good intervention from the point of improving public health as well.
Also, in Maharashtra, whenever such a crisis emerges, like at the time of swine flu, or the emergence of Zika virus, all the focus is centred on only two hospitals – the Kasturba Gandhi hospital in Mumbai and Naidu hospital in Pune. These infectious disease hospitals were built in the British era. In the last few decades, we have not built enough infectious disease hospitals with state of the art facilities. We need to do that. Kasturba and Naidu alone would not be sufficient for future requirements. There should be at least one good infectious disease hospital in every district of the state.
Partha: When the cases were declining, there were suggestions that India was approaching herd immunity. But the cases have begun to rise. Clearly we are far away from herd immunity. What is the percentage of population that needs to get infected for herd immunity to kick in?
Herd immunity is a very important process, and its attainment depends on the basic reproduction number, or how fast the disease is spreading in the population. For Covid19, it was considered that if 60-70 per cent of the population got infected then it would be sufficient for herd immunity to settle in in that particular population group.
There are two ways to achieve herd immunity, through natural infection and through vaccination. Natural infection is a painful process, because it also involves mortality. There would be many deaths on the way to achieving herd immunity.
The proportion of population that needs to be infected for herd immunity to kick in is different for different diseases. For measles, it may be more than 85 to 90 per cent, because the disease spreads at a very fast rate. The results of the serosurveys conducted by ICMR show that there is at best only a 25 per cent seropositivity in the population. So, it is very clear that herd immunity has not been reached, even though in some pockets of dense populations, more than 50 per cent people have been found to be infected.
Herd immunity does play a role when the disease prevalence reaches 50-60 per cent. The transmission slows down considerably in that area. Even now, in Pune, for example, we are noticing that areas that had high prevalence rates earlier are not showing a surge. The new cases are coming up in areas that previously did not have very high number of cases. This time, most of the cases are coming not from the slums but from the middle-class localities, and high-rise buildings. These areas had remained shielded earlier.
Partha: Should we not open up vaccination for all?
We definitely need to bring the vaccines for everyone. But remember, currently the vaccines are being used only under emergency use authorization.
Though the trial results of these vaccines have been very positive, we only have data for a short time. With vaccines for other diseases, we do not allow it to be used unless we have data for several years, and we are absolutely sure that it is entirely safe and efficacious. These vaccines have been developed within a year. Naturally, scientists, and even topmost experts, are very cautious. Everyone is being very very careful.
That is why we are doing, what is called AEFI surveillance, or adverse events following immunization. Every recipient is being monitored, every side effect is being investigated. The data is being collected and analysed. But that does not mean that vaccines are being restricted. We have already seen that private sector has also been roped in. And in a month or two, I guess, vaccinations would become open for all.
Partha: But currently a lot of paperwork is required for Covid-19 vaccination. We do not have this for other vaccines, pulse polio for example? When do you think the delivery of Covid19 vaccines would become as simple as the pulse polio?
There are important differences, actually. One is in the delivery of the vaccine. Polio drops are oral vaccines. Any lay person can administer these. It is easy. Second, pulse polio is a time tested vaccine. It was developed in the 1950s, and since then millions and millions of doses have been administered. Its safety and efficacy is beyond doubt.
The Covid-19 vaccine is new, has been developed in a rush, and therefore requires a closer monitoring, and scrutiny. That is why records have to be maintained. Documentation is necessary to keep track of any adverse events. This is called pharmaco-vigilance. It is standard procedure whenever a new drug or vaccine is introduced.
Alifiya: It seems that pandemic fatigue has set in because of which people are not strictly following Covid-appropriate behaviour. What is the government doing to deal with this?
Our initial response to the epidemic was hospital centric. We tried to upgrade the infrastructure, provide more hospital beds, oxygen cylinders, ventilators, critical care facilities. This was all essential. But to break the chain of transmission, and bring down the numbers, we need to focus on surveillance as well. Right now, our approach should be field centric, rather than hospital centric.
That means we need to have more robust field teams to do influenza-like surveillance, to do aggressive contact tracing, to monitor the patients who are isolated at their homes. Even today, on an average, 35 to 40 per cent of the infected cases are under home isolation. It is necessary to ensure that they are following all the prescribed norms at home, and not violating those protocols. In many areas of Maharashtra, like in Amravati, it has been noticed that entire families are testing positive. Whether that is because of increased transmissibility of the virus, or due to the fact that people did not take proper care during home isolation, is being investigated.
At the same time we need to increase our testing numbers. But these tests have to be targeted and not on random people. We need to identify people with higher chances of getting the infection, and for that we need to have a network of fever clinics. We do have these fever clinics in all the districts, but this fatigue that you talked about, has set in not just in the general public, but also in the public health system probably. The fever clinics have stopped functioning in many cities. We need to have at least four to five fever clinics per lakh population. These clinics can screen people for symptoms like fever, common cold and sore throat, and those cases can then be tested. If such cases are identified at an early stage, and then tested and segregated from the rest of the population, including their families, this will help in breaking the chain of transmission.
Alifiya: One of the big casualties of the pandemic has been education. There have been lots of concerns about online exams. Is it possible to conduct exams offline, like in earlier times? How real is the danger of the disease spreading if such exams are conducted?
I think it is possible to conduct exams offline, but meticulous planning is required. Looking at the size of the students who appear for these exams, and the effort that would be required to prepare the test centres, I don’t think it is an impossible task. In fact, for our own public health department, we conducted a recruitment drive recently, and had an offline exam for theory paper, for which nearly 50,000 applicants appeared. It can be done, with proper preparations and precautions.
Dipanita: Initially, there was a lot of hesitancy amongst people regarding the Covid19 vaccine. But that slowly seems to be going away? What role do you think has social media played in convincing people?
When the vaccine was new, people did have apprehensions, and that is not unexpected. But now you see, people are posting their selfies after taking the vaccine. It is helping to convince the fence-sitters. Plus, some time has passed since the vaccination started. Almost everyone knows someone who has already taken the vaccine, and is doing fine. So, it is spreading through the word of mouth as well. It is good.
Ajay: What proportion of the population would we need to get vaccinated?
As you know, vaccination would build the immunity at the individual as well as community level. It will help us in attaining herd immunity. So at least that many people, which are required for herd immunity to kick in, must be vaccinated.
But we do not really know how long the immunity gained from the vaccine would last. There is an uncertainty there.
Nirupama: What would be your advise to people who have received both doses of the vaccine? Can they resume their normal activities?
No vaccine is 100 per cent effective, and Covid19 vaccines certainly are not. It is not that everyone who gets the vaccine would gain immunity. Some of them might not. But that probability, of not getting immunity, is quite low. Also, even after the vaccination, the immunity takes time to build. It would develop only after a gap of a few months. The third thing, as I mentioned earlier, we do not know how long the immunity will last. So, considering all these factors, it is strongly advised that people continue to engage in Covid-appropriate behaviour even after taking the vaccine.
Nirupama: In the current wave of infections, we are seeing that most of the cases are not as severe as they used to be, or are asymptomatic. What conclusions can we draw from that?
That is true. Even as the cases continue to rise, we are observing that these newer cases are much less virulent. And while the cases are rising, the CFR, or the case fatality ratio, is declining. The monthly CFR rate for Maharashtra, for example, in December was 2.19 (219 deaths per 10,000 infections). This came down to 1.66 in January, 0.83 in February and 0.46 in March till now.
The virus circulating right now does seem to be less virulent than earlier. But we are keeping our fingers crossed, because the behaviour of the virus in many other locations outside India is very different. Brazil, for example, is reporting more than 1,500 deaths every day.
But if the cases continue to rise, and hospitals get overburdened once again, then it is possible that the death rate may increase again due to lack of timely medical care. We are trying our best to avoid that kind of situation, and working towards breaking the chain of transmission.
Atikh: At the Friday meeting in Pune, it was suggested that at least for the city, the vaccination should be opened up for everyone, and more stocks of vaccines be allocated. What is the rationale for this?
I was present in that meeting. The reasoning is that if Pune is indeed the worst affected district in the country, then why not provide more vaccine doses to the city, and ensure that everyone gets it faster, and the outbreak is contained. The demand is coming in from the elected representatives as well.
Amitabh: You said at the start of the interaction that the speed and magnitude of infections in the current wave was similar to the first. Are we then headed towards a similar peak, wherein Maharashtra would be reporting about 25,000 cases a day?
Maharashtra has already begun reporting around 16,000 cases a day. It does seem, right now, that we would touch the 20,000 a day mark very soon. Our aim is to prevent that from happening, but looking at the current trends, the 20,000-figure is a distinct possibility.
Amitabh: And how is this current wave different from the first one?
The most important difference, as I mentioned, is the fact that the virus seems to be weaker, and most people only have mild or no symptoms at all. The death rate in Maharashtra, except for three or four districts, is less than one percent. That is quite a hopeful sign for me. While the increasing cases are worrisome, it is reassuring to see that people are not dying. We are now monitoring the CFR on a weekly basis, district wise.
Amitabh: Do we have any possible reasons for why the Covid-19 trajectories are so different in different states. Because, the reasons being offered for the rise in cases in Maharashtra are not unique to this state.
This is a difficult question to answer, to be frank. We do not fully know. The trajectories of other countries are also very different. And you would notice, the countries with better infrastructure have experienced more deaths. The analogy might not be entirely accurate, but I think, Maharashtra is exemplifying this same kind of trend within India. It is one of the more developed states, more urbanized, with better facilities. And it also has the highest number of cases and deaths.
Anuradha: Is there any change in the age profile of people getting infected?
We have been looking at the time, place and person analysis of the current surge. And, there is no stark difference in the age profile right now. People in the 30-60 year age group comprise 60-65 per cent of the infections. This number is similar in the second wave as well.
Tabassum: How long would we have to continue wearing masks, and practice physical distancing?
This again is a very difficult question to answer. There are lots of variables that are unknown or uncertain. Emergence of new variants, the effectiveness of vaccines against them, the duration of immunity gained through vaccinations are all factors that would decide how long do we need to wear masks, practice physical distancing and follow Covid-appropriate behaviour.
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