Explained: New Variants & India’s COVID Surge with Dr Gangakhedkar
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, slowly 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, Chattisgarh, 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 second wave. We need to understand that because of successful lockdown, prolonged lockdown that we had, the epidemiological curve that we generally see started pretty late. It was almost five or six months advantage that we had. The result is now 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. And since such a variation tends of exist there would be small areas where you are lifting lockdown you will find that there would be some increase. Unless there is a consistent trend you should not say that this is an emergence of second wave.
But this is moment where we have to issue caution to people that they to need to continue to follow COVID-appropriate behaviour, because if you don’t, we will end up in second wave.
World over the virus is on decline, even in Brazil, in a months time, the virus will be in decline. We should make sure India doesn’t become a place where second wave has started, then people have to worry whether it will spill over in rest of the world.
The genomic consortia has detected two new variants in three states that are significant amongst the various mutations that they have discovered.
Can you explain the significance of N440K and E484K variants?
See today we don’t know much about N440 variant, whether it has some kind of clinical significance. 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 it 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 in that particular area.
I don’t think we have sufficient evidence to say that all those new cases that are occurring are occurring because of 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 the 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 the cases?
These are all my personal opinions. I could be proven wrong by the virus as well as the science. This is how science evolves. But the reality is one of the first things which the government tried to do was they said now every international traveler who comes, he has to undergo RT-PCR test 72 hours before. You quarantine them, isolate, test and contact trace. Now when you have such a strategy, this strategy is more likely to work because this virus is short lived.
But this doesn’t rule out these variants won’t spread. We have to understand we got few cases from Wuhan and that led to one crore people getting infected. So we have to pull ourselves up, pull up our socks and try to strengthen our own 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% of all samples, we are nowhere close?
This is a tough one because I tend to have arguments over it. See when you pick up 5% of the samples, you will pick up five out of hundred that come to you. Now when you take 5%, you need to remember that the probability of picking up a variant continues to be lower. Now what we should be worried about is not finding out only the variations, but variations of interest.
To find out variants of clinical significance, variants that have a change in 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 to do that, just try 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 outputs.
The second issue which is also important is there is no known anti-viral against this particular virus. So why does this virus mutate is an enigma. Perhaps the reason lies in the immune pressure that tends of come over the virus. Now how does the immune pressure come? The immune pressure come from a fact that if 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 virus will try to find weakness in the same. You will find that the virus will mutate to take care of at least those which it can negotiate.
What is important is we know convalescent plasma is not useful at all, we know if at all we have to give it has to be given in first two or three days time, so let us refrain, let us 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 clinical protocols? Why cause this confusion?
One of the things that is typical, see we first saw it in HIV, when you keep changing the protocol periodically, often people don’t read the fine line. Since we know convalescent plasma is not effective every time, the only recommendation was if you have to use, use it within first two to three days time. But we forgot that two to three days period, we thought we not saying no to convalescent plasma. 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, by the emerging evidences that may come. But I strongly feel that ending this epidemic is in our hands. It is going to become an endemic infection. But it won’t have the kind of outbreak which was seen across the world. That opportunity lies with us. In a month’s time even Brazil cases will come down if you look at their curve.
I feel 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 UK variant, South Africa variant and Brazil variant, it could suddenly become India variant.
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