How can India contain the second wave?

In a conversation I moderated, Dr. Gautam Menon, Professor of Physics and Biology at Ashoka University and Dr. Giridhara Babu, epidemiologist at the Public Health Foundation of India, Bengaluru and a member of the Karnataka COVID-19 Technical Advisory Committee discuss some possible options available to contain the second wave. Edited excerpts:

After daily new COVID-19 cases peaked on September 16, 2020, during the first wave, new cases and deaths in India began to increase from the third week of February 2021, marking the beginning of the second wave. The rise in daily cases and deaths has been steep since April 1. On April 14, India reported nearly 2 lakh cases. The seven-day average test positivity rate has also been climbing. What will it take to contain the second wave?

When do you think the second wave is likely to peak? And when we see such a peak, what do you think will be the number of daily cases?

Gautam Menon: That is very hard to say as you have to know what is the significance of reinfection, what is the level of immune escape that is happening. It’s clear that these new variants are spreading much faster and the reproductive ratio is significantly higher than the reproductive ratio in earlier cases. So far, there seems to be no sign of any point of inflection in the data. So, my guess is that it is going to get a lot worse before it gets better. We may be seeing around 2.5 lakh new cases per day. These are just guesses. The peak will be at the end of this month to the first week of next month.

There have been very few restrictions in the movement of people within and across States. Should we restrict such movement to contain the spread?

Gautam Menon: In my opinion, we will probably have to curb interstate travel at this point. But we can only make that decision when we know how much these new variants have spread. I think the rising cases everywhere are driven by the new variants. If they have already spread sufficiently, restricting inter-State travel would be pointless at this point. So we need data. Apart from that we need to do everything that we are currently doing, we need to worry about restricted closed spaces, we need to worry about masking, we need to worry about not reducing the intensity of religious events, political events, maybe forbid them altogether. But I think we will have to introduce restrictions on movement of people both within and across States.

Giridhara Babu: I think it’s a bit late. In the first to second week of February, we saw the reproductive number going up and we knew where the localised outbreaks were. That was the time we should have done concurrent genomic sequencing with epidemiological investigations. Even the results of the genomic sequencing were made available in the third week of March. So that won’t be useful in containing the transmission to a limited area.

I believe that there are many variants in circulation. It’s a pity that we are guessing that this variant might be there and so let’s restrict people from going from one State to another. This panic is not justified by data. The easiest thing to do right now is strictly enforce containment measures. If you fail there, especially in reducing the overall transmission trajectory in some of the places that have been hit the hardest, we will lose this opportunity also. It’s a bit late to restrict inter-State travel.

We see cluster of people testing positive in schools, colleges, offices or in apartments. Does this indicate that the new variant is more infectious? Does it defy the notion that 20% of people are responsible for 80% of infection?

Gautam Menon: I wish we had the information to answer that. But that’s certainly the fact that you see much more sort of person-to-person transmission in families in homes in restricted groups. That suggests that maybe it’s just more transmissible as well as it doesn’t satisfy the 80:20 rule that we don’t have super spreaders anymore. Everybody is potentially a super spreader at some level. And that we don’t know that yet. That’s very important to establish. And in principle by doing contact tracing, we can find that information.

Giridhara Babu: Earlier, after post lockdown we rarely tested in kind of settings where many people stay in the same place. But now we have the opportunity to test apartments, schools, colleges, and workplaces. In fact, we are testing more in clusters then we used to do earlier. So that is definitely a factor here. But the same kind of cluster investigation outbreak is not happening in the rural areas. So I think there is also a skewed testing which is the probably one of the factors. In addition to that, since the highest proportion is of asymptomatic in the among those were testing, probably this was similar earlier or so. But we have not just done similar testing earlier.

If it’s a new variant that is possibly responsible for the second wave, why do we see more cases in certain States and not in every State?

Gautam Menon: We are not doing enough genomic surveillance. Even now we don’t know how much Maharashtra has changed between March 24 and today. We know that this variant in Maharashtra has quickly spread to at least 10 States or so. But how those numbers have changed and how much of the spike is in response to that variant we don’t know.

What do you think are the reasons for States that went to the polls not seeing a surge compared to Maharashtra?

Giridhara Babu: If there is a newer variant in circulation, every State is at risk. Some are at higher risk than others depending on when the variant entered the State. Inefficient testing, especially an inefficient syndromic approach, and review and monitoring of COVID-19 responses getting second priority over elections are definitely the reasons why we might have missed it. But we cannot miss for longer, not at least with this second wave. The moment you miss for a week you already know that the cases are crossing the earlier peak.

Gautam Menon: In general, an outdoor activity carries much less risk than an indoor activity. And this, I think, is something that might account for the fact that even in election campaigns you’re not seeing the sort of large numbers of people who are accompanying that. In general, what we do outside and in open air carries much less risk than being in an enclosed space.

There’s hardly any distance between two people in these rallies or in religious congregations. So are the conditions not conducive for the virus to spread even though it is held outdoors?

Gautam Menon: From a modelling point of view the answer isn’t very clear. Whether if you have enough people have tightly put together what is the density of people, at which transmission between people become important? What they’re doing, are they shouting or not shouting is also important. So I’m just making a general qualitative point, not a quantitative point. It may depend upon the nature of the rally, how many people were there, were they super spreaders or not. But just qualitatively, an outdoor activity is much preferable to an indoor activity.

On March 24, 2020 we went into lockdown when the number of cases was less than 5,000. But now, when there are close to 2 lakh cases a day, we are seeing no restrictions even in closed spaces such as restaurants, theatres and gyms. Are we doing the right thing by allowing such businesses to operate?

Gautam Menon: In my opinion, no, this is a mistake. I mean, we know that the virus is transmitted efficiently in closed, badly ventilated surroundings. So anything that constitutes a closed, badly ventilated surrounding is something that you should not allow people to gather.

But let me just point out the other thing, what we have not done is to encourage people to go outdoors, all our messaging has been negative so far — do not do this, do not do that. And this, I think psychologically is a mistake. Because unless people understand or have a sort of framework of behavior in which they can operate or if you only tell them that they cannot do things. And if it is over a long period of time, it becomes hard for them to make decisions, and then they will finally throw caution to the winds.

Experts from different fields have to sit together and try to discuss this problem and see if we can alter the messaging a little bit, can we facilitate people going outside at low density in the open air, and thereby ensure that good COVID protocols are followed. You do need to give people some outlet somewhere and I think this has not been sufficiently discussed, and it needs to be done.

Giridhara Babu: I think there is more than science. These decisions are made based on how much power and influence these sectors have. For example, in Karnataka, there was a rule to allow only 50% attendance in theatres. Due to pressure, there was an immediate reversal of the rule and 100% attendance was allowed for a week. Taking a cue from this, people from other sectors also got relief. Now, if there is competition of sorts of how much relaxation each sector gets, this is not the way we can win over this virus. We’re giving more reasons for the virus to flourish. And then we say, we don’t want a lockdown.

Do you think we should go back to working from home wherever possible and have virtual classrooms? And similarly, should we reduce or restrict the public transport system, though the poor who rely on it will get affected the most?

Giridhara Babu: I think work from home option whenever and wherever it is feasible, I think should be the way ahead for managing not just COVID-19 response but also in terms of reducing the pollution and several traffic congestion related issues. That’s a good thing to do wherever possible. But when you look at online classes and public transport, limiting it will affect the people from poor socioeconomic status the most. Till now we don’t have the data in terms of sero prevalence in children. What kind of vaccines are effective in them? What is the severity of the illness in children? How are we going to manage schooling and their learning capabilities with one year not in school, and what kind of mental health issues they have. There is so much science that you are ignoring. If you say an evidence-based approach has to be taken, we have to take all of these into consideration more than the opinions of a few key people.

Gautam Menon: About public transport, I think what is key is really when understanding the nature of ventilation, it’s not clear that a bus with 50% occupancy well ventilated without air conditioning is a significantly worse option than just allowing people to walk around on the road. We can say that look we will not shut down public transport, but we will restrict public transport appropriately. We will increase the number of buses and make sure we don’t have AC buses and not have the full busload of people close up to each other.

Are we carrying out contact tracing and isolating those people who have been found positive in institutional facilities?

Giridhara Babu: There are too many generals and few soldiers. No additional manpower has been granted; we have not used the opportunity to step up preparedness but we want the same people to be tackling the second wave, which is more infectious. We need to have a complete relook at the way health manpower is managed in this country. You can’t expect global level containment efforts from a very weak system with very few people.

Gautam Menon: When there is large-scale community transmission, contact tracing becomes a bit irrelevant. The question is whether we should even divert resources to that. We have to really question whether the detailed type of contract racing of 10 or 20 people that we were thinking about doing is worthwhile anymore in those regions where the cases are growing rapidly; it may just not satisfy any cost-benefit analysis.

About genome sequencing, why is it that we aren’t doing the numbers that we are supposed to be doing? And why are the results not made public quickly?

Gautam Menon: I suspect that one issue may be the capability of doing five times more sequencing that we are doing now. INSACOG has to assemble a whole bunch of different institutions across the country to do the sequencing. I would guess that it is government’s decision to not publicize these results for fear maybe, of worrying people that the new variants are more infectious, these numbers are rising, etc. But that is probably not good public health policy to keep these secrets.  Beyond a point you cannot hide the reasons for this. So it’s far better, I think for government to be transparent in these to put this information out. Only if there is transparency can people understand why measures have to be taken and why measures are important now, as opposed to say in December 2020 or early January this year.

Is it fatigue or complacency that people aren’t wearing a mask or adhering to any kind of COVID appropriate behaviour in almost any State, at least not to the level that you would expect. What can be done to improve this?

Giridhara Babu: I feel this is mostly sort of psychological. People were wearing it when they were made to wear and the moment they think they won against the virus, like after the graduation you throw the hat, now people are celebrating by throwing the mask. But it’s unfortunate. And when you tell people that this is the right thing to do, the mask becomes an accessory either for the neck or for the chin. So in communication I think we have failed not just in ensuring COVID-appropriate behaviour, even convincing regarding vaccination.

The second is that there are all sorts of social media messages that are misleading and untrue. So unless you counter that in a more effective manner, these things are going to continue.

Gautam Menon: It’s been a whole year, so I can understand the level of fatigue, that has crept into some part of the population. The other thing is that campaigns work often because children tell parents and elders to behave in a particular way, for example, the anti-fireworks campaign in Delhi really succeeded because young children in schools decided that they would do this and then they went back told their parents we don’t want crackers. The schooling component has been absent and this sort of feedback that could in principle have maintained COVID-appropriate behavior and masking is absent.

Are States really prepared to handle the potentially huge inflow of patients to hospitals?

Giridhara Babu: There are huge inter-regional and intra-regional disparities in health system access and delivery. If you look at Maharashtra, the distribution of hospitals and healthcare workers in Mumbai is different compared to other districts. That’s why those districts face a greater strain on their health system compared to Mumbai. In Uttar Pradesh and Bihar, there is a very poor distribution of health system capacity both in terms of infrastructure and human resources. The worry is that with the reproduction number [R0] almost nearing three, these two States will probably have the highest number of cases. Even if you assume 5% of these people need hospitalisation, we have no beds in those States or in the nearby States. And this is what we need to prevent. We need to be very strategic in helping the States with poor resources.

More than 100 million doses have been administered in India. But we have vaccinated just about 6.5% of the population. What can be done to increase vaccine uptake? Is there vaccine hesitancy?

Gautam Menon: Vaccine hesitancy has now decreased. There are genuine vaccine shortages in multiple States which have seen a huge uptick in cases. There are many questions whether Serum Institute of India will be able to provide the number that it had promised earlier and how these will be divided between Indian and non-Indian recipients.

Giridhara Babu: Now, there can be many other problems, but vaccine hesitancy is least of the problems India has, whether it is COVID-19 vaccine or any other vaccine. It’s a convenient term. We have coined a complicated list of problems, which includes lack of micro planning, lack of mobilisation, lack of better communication, and a lack of a vaccination policy on how to go about in different phases. And most importantly, in every vaccination campaign, we have had a separate plan for social mobilisation of the minorities, and we don’t have that yet for COVID-19. So it’s incomplete preparation and the speed at which it is being expanded without these important aspects being covered. What has happened that we should start everything new in terms of learning to scale up this vaccination? We have done this for other vaccination campaigns.

The private sector has claimed that if allowed, it will exponentially increase the number of vaccines given each day. But it hardly holds 10% of the sessions across India now. What is the reason for this and how can this be scaled up?

Giridhara Babu: For nearly four or five decades now, it is the public health sector which has been the main player in vaccination programmes. So, if we are expecting the private health system to outsmart the public health system in coverage of vaccines just for COVID-19, that’s a wrong assumption. The private health system has a definite and clearly identified population that it caters to, but even that is changing both in terms of COVID-19 care and vaccination. There are government health facilities that are saying that for the first time they are seeing rich people coming to them. The kind of cold chain system in the government system is far superior. Even for oral polio vaccine, which has the vaccine well monitored to show the cold chain status, it will be in perfect condition in all the public health facilities. But if you go randomly to most private health facilities, this is not monitored well. It’s not their strength.

But if there are more vaccines, and people want to pay for these vaccines, then the public health system cannot get to it. That’s where the strength of the private health system is. I think we need to recognise the trends of each system and see which is the target population for those systems and work out mechanisms around it.

Unlike the US, which pumped in billions of dollars into each pharmaceutical company well before even the trials could begin, India did not. Neither did India give a firm commitment that it would take a certain number of doses from the two companies. Now that Serum Institute and Bharat Biotech are about to scale up production to meet the demand do you think it’s time that the government provides them financial support?

Gautam Menon: Absolutely. This is a time where we and every other country in the world needs vaccines in large numbers. So this is something where government intervention, government support can make a huge difference in the long term. We’re also going to serve to support Indian industry.

Public sector vaccine manufacturing facilities were shut down for various reasons. Do you think this pandemic and the shortage of vaccines is a wakeup call to build new public sector facilities considering that we have a large immunisation programme and COVID-19 vaccines would probably be required every year?

Giridhara Babu: I think it’s a combination of having independent public health facilities, and also more importantly, build partnerships with the private industry. Companies in India have done extremely well in providing most affordable vaccines or drugs of the highest quality, whenever it mattered, especially in public health emergencies. So I don’t think one new public health sector will cater to this need. What we really need is the trust and the collaboration between public and private entities. We need to have a policy for how we invite others to come manufacture in India, scale up to take care of global health. India is a manufacturer and supplier to most poor countries. But we need to change gears, we need to be a world leader in this. If you don’t use this opportunity, then it’s a loss.

Do you think the vaccine shortage will be eased now that Dr. Reddy’s lab can import Sputnik V?

Giridhara Babu: The shortfall in supply will be reduced to some extent. But I am not confident whether it will completely take care of the demand in terms of covering the eligible population above 45 years. I would imagine that at least 10 million doses are necessary per day to completely vaccinate 30% of the population in the next two months.

Gautam Menon: It’s also important to have a broad base of multiple vaccines, because we don’t know the answers to questions like which vaccine might be better against which variant. This may alter our policy in terms of where to send which vaccine at what time. In general, it will improve the availability of vaccines overall, and will strengthen our ability to at least meet the target of 300 million to be vaccinated by August, which is an important target.

Despite the fast-track approval, will India get access to Pfizer and Moderna  vaccines in the near future given that many other countries have already booked and are still waiting for supplies?

Gautam Menon: The sort of arrangements that vaccine manufacturers have with different countries are fairly complex. It’s not clear how much give they have in terms of their current abilities to sell vaccines, for example to India. But I think the impact of this is probably larger as it enables them to be able to manufacture within India, and to have a bunch of different arrangements with other Indian manufacturers. So you can do import of bulk, import of finished vaccines, and fill and finish. I don’t know if that might make a difference in terms of availability.

Giridhara Babu: I think the scale at which demand exists in India will definitely be a very attractive market for most vaccines. So the vaccine manufacturers have agreements based on their current manufacturing capability. But if Indian manufacturers show interest in partnering with these, the entire thing will change in terms of India becoming now the vaccine manufacturer for the entire world, not just the country. So I think it’s a great move.

Considering the high cost of the mRNA vaccines, do you think India can actually afford to pay over $30 per dose and make it available for free? Or will this lead to a situation where the government procures it and makes it available in the private market?

Giridhara Babu: I think there are too many assumptions right now in terms of what the pricing will be. I’m assured that whichever drug it is, India has been able to regulate the price mostly because of economies of scale. Once you manufacture for a larger number of people, then the cost will definitely go down. Plus there are also other countries who would require such vaccines from India. So that will allow India to have differential pricing, one for export and one for use within.

Gautam Menon: I think that the size of the Indian market for vaccines is large enough, that will certainly be a significant point in any negotiation. And already, there is differential pricing of various drugs that are available at much more expensive terms in the U.S. versus outside the U.S. by the same manufacturers. So it’s not unlikely that we would have an arrangement where the cost of these are not the same costs that would hold in the U.S., but they’re available for cheaper within India. It would not be a good system to have very expensive vaccines available only to the very rich who can afford it and the bulk of India not having access to that. So I hope some equity will be worked out in these negotiations.

Published in The Hindu on April 16, 2021