Will the chain of transmission of the coronavirus outbreak in India be broken in 21 days? To understand the thinking around the COVID-19 outbreak and efficacy of lockdowns and social restrictions, I sat sat down for a Skype interview with Dr Dhruv S Kazi, Associate Director, Richard A. and Susan F. Smith Center for Outcomes Research and Director, Cardiac Critical Care Unit, Beth Israel Deaconess Medical Center, Harvard Medical School.
We spoke about how the US social restrictions have differed from India, how isolation policies have to be driven by testing and data and on whether heat will kill the coronavirus.
Q. My first question to you is, if we are serious about stopping pandemics, what’s the role of lockdowns?
Ans: India got into the business of controlling this pandemic early. The steps they have taken are very good. But at the same time India has not done testing. And if you don’t test, and not just symptomatic patients but also within the community, you won’t have a clear idea about the prevalence of the disease. In this setting with limited testing and resources, lockdown is important. But the challenge is that for disease control, we are not just talking about 21 days. Politicians are talking about it. But the truth is we need 6 weeks of social isolation and maybe even beyond that. For the older population, those who have heart disease, we are looking at 6 months of isolation.
Q2. In fact even in the US, the restrictions in place are very flexible. In terms of response to the disease, how has US and India differed?
Ans: One of the interesting things about the US is that the governance is different. There is a central government but most of the power is with the states, which is very different from India. In the US each state is doing a different thing. You are right that in India, restrictions are more severe, but India’s health system is also more fragile. So I think India’s restrictions, almost curfew like, are appropriate.
Q 3: Can you explain the virus behaviour to our audience, so we know why this 21 days is not the end all for the virus.
Ans: Ya, I want to say that the idea that we would have beaten this virus in 21 days is rubbish. It reduces contact, it does not eliminate it. In a world that we live in, the virus has very good ways to continue to spread beyond 21 days.
Q 4: That’s another thing that the WHO chief has said, test, test, test. Why is testing so crucial and to say ‘we are now in local transmission stage so we don’t need to test everyone’ Can you talk to us about that.
Ans: So it is very clear that when the history of pandemic is written specially in the US it will start with a paragraph that not testing enough Americans for SARS-COVD-2 which is the virus, was the biggest mistake from health standpoint. In India, with all epidemics, information is power. So if you don’t test, how do you know how much the disease is spreading. If you test and you see that after 21 days infection rate has gone down, then you can relax the social distancing norms. Testing is critical at every stage of this epidemic. In India, the testing rate is among the lowest in the world.
Q5. It is believed that the virus only impacts the older population. But in the US a number of young people have got the more severe disease. Can you explain why this would be the case.
Ans: Initial finding was that the older population and those who have diabetes, heart disease, which by the way is a large part of India, diabetes, blood pressure, about a third of all adults, they are more at risk. In the US, that is not true. We are seeing that a lot of young people get mild disease, but also young people with no other medical problems, who have no other issues, who are not on medication, healthy young adults, 20s, 30s, 40s are getting a very severe disease.
Q 6: I want to know your opinion as a doctor and as a public health expert on the use of hydroxychloroquine as a prophylactic.
Ans: Data supporting the use of hydroxychloroquine is very very weak. So all these people who are talking about it, it is very frustrating from a public health point of view. It is not a very safe drug. Dosage of the drug can impact the heart, we have one person die in the US after taking hydroxychloroquine after hearing about it in the news. For the diseases from which the drug is used, like malaria and rheumatoid arthritis, lupus, there will be a drug shortage. As far as using hydroxychloroquine for prevention, as ICMR has recommended, there is absolutely no data to support it. For treatment at least there is bad data, for prophylaxis, there is no data and I would not recommend it.
Q 7: I want clarity from you on who should use the full PPE kit and for whom should we save it?
Ans: PPE is more beneficial for doctors and nurses, and not for those in the community. So if you have a stock of masks somewhere, give it back to the community. There are two types of masks. Surgical masks and N 95 masks. What we have started doing is every healthcare provider here has a surgical mask. You cannot walk into the hospital without a surgical mask. It is a little excessive. But at this time we cannot tell who is infected and who is not and so we have to protect all our providers. N95 masks we use in the ICU and when there is a risk when there are a lot of virus particles in the air, for certain procedures, for ENT procedures or for intubation or if a patient is in the ICU. So we also trying to understand what to do with the PPE. It will do well for the Indian govt to use these 21 days to build up their supply. For individual practioners, it is important to understand how to use PPE correctly, if you use a mask, and with your bare hand you touch the mask then you are infecting your hand. If you use a raincoat, and you take your raincoat back home, you are at risk of taking the infection back home. We know that the virus lives for 3 and 7 days on surfaces. So its important to know how to protect yourself, but also how you handle those PPEs. In the community people having N95 masks is a wasted mask. You might as well give it to those who know how to use it and are at higher risk. In the community, wash your hands with soap and stay away from people.
Q 8. There is a lot of conversation about heat, and how heat impacts the virus. There is a lot of conversation on how in April, May June, the virus will not survive. Can you explain how this works?
Ans: The short answer is, it is wishful thinking. Many cold viruses decline in the summer. But this one is different. And we don’t know anything about this virus. So while we can hope that it comes down, to assume that it will come down in April or May, we have no idea. While it’s okay to say it is possible, coronaviruses in particular are notorious for spreading in summer and winter. We haven’t seem this virus before so there is no immunity in the community, so it is very hard to say how this virus will change over the summer. We should be prepared for six months.
This is a real epidemic, it is life threatening, it is already having major effects on the economy. But if we don’t get it right, the effects on the economy will be even larger, so listen to the instructions of your local governments and public health experts and take this threat seriously, whether you are 14 or 40 or 80, take this seriously.