COVID-19 cases in India may peak by April end if current trend continues: Dr Srinath Reddy
Dr K Srinath Reddy, president of the Public Health Foundation of India and member of the National Task Force on COVID-19 management, speaks to The New Indian Express on the government's approach to the crisis, the herd immunity theory, random sampling and more. Excerpts:
The government's approach so far has largely been on containment of the COVID-19 outbreak through measures like lockdown and social distancing. How do you think the outbreak pattern has been in India so far? Can we avoid going the US, Italy or Spain way? Is there an estimate on when could the outbreak peak in India and what kind of numbers are we looking at?
The measures taken so far were intended to markedly slow down the transmission, even if the chain is not completely snapped countrywide. It appears from the hospital admission records of serious acute respiratory infections that there has been no surge. Given the lag time between viral entry into the body and death, this cannot entirely be attributed to the impact of lockdown.
However, the rate of new cases doubling has slowed down markedly, despite the number of tests increasing. These are positive signs. If this trend continues, we can expect the epidemic to peak by end of April. To avoid going the way of the high-toll countries you mentioned, we need to continue social distancing and contain spread from high case density zones to low case density zones.
The government in India has reposed a lot of faith in anti-malarial drug hydroxychloroquine, possibly in the absence of a more targeted therapy for COVID 19 -- recommending it both for very serious cases as well as prophylactic use in specific cases. However, the evidence of its efficacy against the disease seems to be mixed. Are there new therapies/drugs we could see being tried in India in the coming days?
All drugs being tried out for the treatment of COVID-19 are under investigation, as no definitive evidence of benefit in clinical outcomes is as yet available. Several clinical trials are underway, testing the impact of hydroxychloroquine, antiviral drugs used in other conditions and passive immunity through infusion of plasma from recovered patients. The results of these trials will provide the needed evidence. Till then treating clinicians can use their best judgement to choose therapeutic agents which are already approved for use in other conditions.
What in your view are the key tools and systems that India needs to fight the outbreak and are we prepared enough to be able to deal with the crisis?
Every health system in the world was challenged by this virus and found to be facing barriers in mounting a ready and rapid response. We too have faced difficulties but are rallying our limited resources to provide an effective response.
We need to step up our community-based surveillance, combining symptom-based syndromic surveillance and lab testing to the extent resources permit. We need to provide needed personal protection equipment to all healthcare providers and support staff who come into proximate contact with a virus-affected person. For this, we cannot depend on imports but must quickly ramp up domestic production by mobilising innovators and industry, while snipping away regulatory red tape.
We need to expand the health workforce with the addition of retirees, trainees and auxiliaries. We need a nationally coordinated policy, state-level planning and decentralised district-level implementation which permits context relevant flexibility. We must gear up our rural and urban primary care systems, as 80-85% of patients and contacts will need to be assessed and managed in those settings.
Risk communication and health advice to communities and destigmatisation are needed, to make the community receptive to guidelines and encourage its participation in implementation. Social solidarity must be promoted to supplement multi-sectoral coordination and enhance health system impact. Kerala is a great model.
Now there is growing evidence from some countries that SARS CoV 2 could be reinfecting some people or getting reactivated again in same hosts? If true, won't that be a big worry?
We do not know what parts of these are to reinfection, reactivation or inaccurate test results. We still do not know how long acquired immunity lasts with this virus. We also do not know if the clinical impact is less severe in these patients. We will have to deal with this challenge, with further intensification of our public health response and augmenting our clinical care systems. A fresh lockdown will not be needed. To use a cricketing analogy, if you have your target unexpectedly altered by the application of the much detested Duckworth- Lewis rule, we still have to go full steam to win the match.
Some epidemiologists in India have suggested that herd immunity against the virus--with or without vaccine--could be only way to stop the storm? What are your views on that?
Herd immunity arises when a large proportion of the population, between 60-70%, is infected, recovers, frees itself of the virus and thereby stops viral transmission to others. Actually, it is herd protection, because the uninfected person has no acquired immunity. If such a person goes to another community where only 20-30% have been infected, he or she becomes vulnerable too.
Herd immunity will have to be acquired over time rather than as a sudden exposure of large numbers to the virus. That will trigger a rush to hospitals which will be overwhelmed. Even if you want the cricket stadium to be filled for the big game, you still have to control and regulate entry at the gates. Otherwise, there will be a stampede. You can't let the herd stampede, even for branding with the stamp of immunity.
The Indian Council of Medical Research has been gradually expanding the testing criteria and is now allowing all symptomatic people in hotspots to be tested as well but some public health experts feel that it still might not be enough and random testing among symptomatic as well as asymptomatic people could be crucial to assess the extent of the outbreak. Your views?
Random sampling is needed and we must get district-wise profiles through such testing. Testing in asymptomatic cases is fraught with a higher risk of false positives but we must still perform such surveys to profile the status of each district. This must be supplemented with community-based syndromic surveillance and hospital-based statistics of severe acute respiratory infections. We need a three-dimensional picture.