HYDERABAD: Handwashing isn't as effective as wearing a mask, when it comes to curbing the spread of COVID. Fact.
Flying in an aeroplane is a surefire way to contract COVID because it is a closed air-conditioned space. Myth.
Six months of on-again, off-again lockdowns later, the average Indian still has a whole load of basic questions about the COVID-19 virus — and all he/she has to contend with is a glut of news stories that often offer contradictory viewpoints about what is safe, and what isn't.
To best understand the hard (and constantly evolving) scientific knowledge that we have about this virus, The New Indian Express Editor G S Vasu spoke to renowned gastroenterologist and Padma Bhushan awardee Dr D Nageshwar Reddy.
The Hyderabad-based Chairman of the Asian Institute of Gastroenterology spoke about the need to dial down the panic, while not getting into 'crowd' mode yet, the possibility of us getting an affordable vaccine by early 2021 and why India's numbers are likely to be 5x higher than we think. Excerpts from TNIE's The COVID Debate:
India has recently seen the highest ever spike in a single day in any country since the beginning of COVID. Scientifically speaking, how would you say things are different from four months ago?
On the face of it, it looks a little alarming but I will explain why it's not. There's been a huge explosion of knowledge in this area. In the last few months, over 20,000 papers have been published. No other disease has seen such a humongous amount of research published in such a short span of time. It is now clear that the virus has undergone a mutation. The virus that is now present in India is called A2a. One of the most important mutations that have occurred is the position 614 spike protein. What we have understood is that this mutation is not changing the immunogenicity of the virus, — which means that the efficacy of the vaccine will not change due to the mutation. Overall, it looks like this mutation is not too dangerous but still, studies have to be conducted.
From a medical standpoint, why are the increasing numbers in India not alarming?
If you look at the number of infections in our country even 77,000 is an underestimation — it will be five times more, in my opinion. The number will depend on how much we are testing in a day. What is more important is the fatality rate. If you look at that, the case fatality rate in our country is the lowest in the world — 1.8-1.9% compared to 10% in Europe. Not just that but the actual mortality rate is quite low. Even people dying of cardiac problems, malignancy are reported as Corona deaths. In my opinion, there is no underreporting in our country. Through our research, we came to know about the immunological dark matter, which may be related to past infections. People who have had past exposure to other Coronaviruses also seem to have some preventive antibodies that work against this virus also. All these facts are now coming out and so we should be optimistic.
Is it possible for people to have been infected by COVID and not realise it?
To say that 30 lakh people in India have the virus, I think, is an underestimation. I believe that 1 crore people may be having this, but what is vital is that double or five times those people will actually have antibodies. Which means they would have had it silently and not realised it. These antibodies are going to decrease the way that the virus is spreading. But will it happen by the end of September or October? We cannot predict that. As we go forward it will come down.
There have been fears about reinfection. Can someone who has recovered from COVID still be affected by it?
People are misunderstanding this. With reinfection, it is not the disease, but only the presence of the virus in those patients. He/she developed antibodies the first time but the second time it might have been only in the nose and then disappeared. We don't have to worry about reinfection as the body's immunity is good enough to fight it off. It is hopeful that the same thing will happen. It's very clear that there is another protection in the body from T-Cells, which has a memory. The Oxford vaccine has also shown that along with these antibodies the T-Cell is also activated and thus, the protection may be long-term.
There has been a lot of discussion on aerosol transmission. Can the COVID virus be transmitted through the air? Or is that restricted to A/C rooms?
Aerosol transmission is larger in closed rooms as the virus stays for three hours whereas outdoors if you maintain physical distancing, it transmits less. Initially, we were worried about the Air Conditioning systems in flights, but if the air goes from top to bottom and is sucked out and new air comes in frequently, you have laminar airflow which is safer. Many hospitals are adopting this method now. Truth be told, airports are more dangerous than aeroplanes!
We now have a lot of repurposed drugs, how useful have they been in treating the patients?
We know the virus attaches itself to the nose, lungs and even intestines and from there it enters the bloodstream. It's called viremia, it produces fever, body pain etc. When the virus enters the bloodstream the body tries to react against it by producing antibodies. If it still fails to remove the virus then it begins to produce chemical weapons called cytokines that not only destroy the virus but have a harmful effect on the body. All these antiviral drugs should be used in the first week, only then are they effective. Remdesivir is very useful. We have found that even for somebody who is above the age of 60 with comorbidities, high fever, administering the drug in the first week leads to the illness being remarkably controlled. Other drugs such as FabiFlu and so on still not much data is there.
Now, we have developed a very compartmentalised therapy — first, we begin with Remdesivir, to which the majority responds. For those who don't, we give plasma therapy early on. Just taking plasma from someone who has recovered is not right, we have to study the patient's neutralising antibodies before taking it. Oxygen therapy is equally important. We are unnecessarily putting patients under ventilation which is wrong. What we are providing is high flow nasal oxygen and we are able to save more patients.
From a layman's perspective, how do you explain this — a 70-year-old is recovering but a less-than-50-year-old is succumbing to the virus?
Most of the deaths we are seeing are in the patients who are coming to us in the second week, after 10 days, once the cytokine storm has come. We have very few things to keep it in control at that stage and our capacity to alter the disease becomes less. That's why we are suggesting that people who are symptomatic should within 3-4 days see the doctor.
In this global rush to produce a vaccine, there is a view that we are short-circuiting normal checks and balances that doctors and scientists go through to get a vaccine in the market. Do you feel that is happening?
We should not rush for a vaccine. It, unfortunately, has become politicised with every country saying we are getting out a vaccine faster. There are 231 vaccine candidates of which 25 have been approved for clinical trials and of which 19 are in Phase 1 and 2 and six are in Phase 3. It is only Phase 3 that will tell us what happens when the vaccine is given to a large population, in different age groups. With the Dengue vaccine, we had a very bad experience, where it was found to produce dangerous activational disease in those who took it. Despite all this, we are hoping that by the beginning of next year we will get a definite vaccine.
Has there been any advancement in the diagnostic methods to detect COVID? Test results still seem to be taking days in India.
Saliva is becoming a big diagnostic tool. Saliva is as good as a blood test in the detection of the virus. When it becomes a question of merely asking someone to put his spit in a bottle and send it, this can become a major tool for the government to increase testing. It is the same RT-PCR procedure that takes 6 hours, but the other logistics of taking a nasal and mouth swab by a technician in a PPE suit are avoided.
Do you think people are less panicky now compared to what we have seen in April, May? And is this is a reason for the spike in cases?
We don't want them to be more panicky or less panicky. As you said, what happens is that people will disregard physical distancing and evidence suggests that when markets are open some people will resort to crowding. Although we are optimistic, we should follow the regulations which are extremely important. Initially, people were talking about the importance of handwashing but now we know they are less important than wearing masks. One study has said that if masks are put on properly and if physical distancing is followed, it is equivalent to 90% effect of lockdown. Instead of lockdown, the same effect can be achieved by people wearing masks and maintaining distance.
What is your advice to the people of India now?
Kindly don't panic but at the same time don't become too lenient. A balanced approach is important. We have decreased the mortality rate, effective treatment is coming, still, masks and physical distancing is important. A lot of mental issues are coming up. Be optimistic, continue working from your homes or offices with safety protocols in place. We will overcome this. This will be a small blip in the history of mankind.