A slow and steady surge across six states in India over the last two weeks has raised serious concerns of a possible second wave. Maharashtra reported 8,807 new cases on Wednesday, inching back to its worst phase, with high positivity rate and the highest number of active cases in the country.
What is causing this rise in states across Maharashtra, Chhattisgarh, Madhya Pradesh, Punjab and Jammu & Kashmir? Kerala has slowly and steadily started showing a downward trend.
Are new variants behind the surge? What are these new indigenous variants and how concerned should we be? How is India faring in its genomic surveillance? To discuss all this and more, we spoke with a scientist who was the face of Indian Council of Medical Research in the initial months of the pandemic, Dr RR Gangakhedkar, former head of Epidemiology and Communicable Diseases at ICMR.
Where do you see India’s position vis-a-vis the virus? Are we actually seeing an emergence of a second wave?
It’s too early to say whether there is any emergence of a second wave. We need to understand that because of a successful and prolonged lockdown, the epidemiological curve that we generally see started pretty late. We had an advantage of almost five or six months. The result now is that it is on a decline but there are small pockets where you are seeing some resurgence of this particular infection. Is this perhaps indicative of second wave? We cannot say with certainty as of now and the reason is very simple, ours is a very large country.
If you look at this pandemic, you need to look at three drivers – population density, mobility and migrations. Now when we talk of these, you will find that different geographical area will have different factors related to vulnerability. Since such variation tends to exist, you will find some increase in small areas, where the lockdown is being lifted. Unless there is a consistent trend, you should not say that this is an emergence of a second wave.
But this is a moment where we have to issue caution to people that they need to continue to follow COVID-appropriate behaviour, because if we don’t, we will end up having a second wave.
World over, the virus is on a decline. Even in Brazil, in a month’s time, the virus will be on a decline. We should make sure India doesn’t become a place where the second wave has started, then people have to worry about whether or not it will spill over the rest of the world.
The genomic consortia has detected two new variants in three states that are significant among the various mutations that they have discovered. Can you explain the significance of ‘N440K’ and ‘E484K’ variants?
Today we don’t know much about the ‘N440K’ variant and if it has clinical significance. For it to be significant, either it should impact the transmission efficiency or it should lead to severe disease. We don’t know anything about this.
With variant E484K, you find that there is some evidence that perhaps even the normal immune response that tends to produce antibodies against the virus may not be sufficient to take care of this, which would essentially mean that it is likely that if you have this variant around, reinfections would also be seen.
I don’t think we have sufficient evidence to say that all those new cases are occurring because of the new variants. We need to recognise that it’s convenient for us to blame the virus for the spread, rather than looking within and understanding that you are not following COVID-appropriate behaviour.
Why has India not seen enough cases of the UK, South Africa or Brazil variants? Is it because we haven’t found them and they are quietly spreading?
These are my personal opinions. I could be proven wrong by the virus, as well as science. This is how science evolves. But the fact is, one of the first things that the government did was ask for RT-PCR negative tests done 72 hours before travel from international passengers. You quarantine them, isolate, test and contact trace. Now when you have such a strategy, it's more likely to work because this virus is short lived.
But this doesn’t rule out that these variants won't spread. We have to understand that we got a few cases from Wuhan which led to one crore people getting infected. So, we have to pull ourselves up, pull up our socks and try to strengthen our COVID-appropriate behaviour.
How satisfied are you with the pace of genome sequencing and surveillance? We want to be able to test at least 5 percent of all samples; are we nowhere close?
This is a tough, because I tend to have arguments over it. See when you pick up 5 percent of the samples, you will pick up five out of a hundred that come to you. Now when you take 5 percent, you need to remember that the probability of picking up a variant continues to be lower. What we should be concerned with is not just picking up any variant, but a variant of interest.
To find out variants of clinical significance, we need to look for variants that have changed the spike protein so much, that they can escape the immune response that a vaccine could generate. How do you do that? One of the best ways is to look at the RT-PCR test and in the RT-PCR, when the patient actually has COVID infection, but his spike protein genes don’t light up, then you need to worry. This way you minimise your work but maximise your output.
The second significant issue is that there is no known anti-viral against this particular virus. So, why this virus mutates is an enigma. Perhaps the reason lies in the immune pressure that tends to come over the virus. The immune pressure comes when I infuse an individual with convalescent plasma repeatedly. The virus will have to face a challenge of multiple neutralising antibodies which are coming from different human bodies because of their past infection, and now the virus will try to find weakness in the same. You will find that the virus will mutate to take care of at least those that it can negotiate with.
What is important is that we know convalescent plasma is not useful at all. We know if at all we have to give it, it has to be given in the first two or three days. So let us refrain and ask everybody not to use convalescent plasma unnecessarily, irrationally, and at least multiple times.
When we know that plasma therapy is not useful, why not just remove it from COVID clinical protocols issued by the Health Ministry? Why cause this confusion?
See, we saw this first with HIV. When you keep changing the protocol periodically, often people don’t read the fine line. The only recommendation was if you have to use the therapy, use it within the first two to three days. But we forgot that two to three days period. I think, we need to disseminate that fact.
As someone who has closely seen the evolution of this virus, how do you see it ending?
That’s a very tough question, it is possible that I may be proven wrong by the virus and by the emerging evidences that may come. But I strongly feel that ending this epidemic is in our hands. It is eventually going to become an endemic infection. But it won’t have the kind of outbreak which was seen across the world in 2020. To ensure that it doesn't, that opportunity lies with us. In a month's time, even cases in Brazil will come down.
After a month, you will perhaps have your most opportune moment to ensure that no new cases occur. If we do stick to our COVID-appropriate behaviours, we would be lucky to avert this particular disease. If we don’t do that, then yesterday we were speaking about the UK variant, South Africa variant and Brazil variant, it could suddenly become an India variant.
(The article was first published in FIT and has been republished with permission.)
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