As we try to piece together the full extent of the devastation caused by the second wave of the Covid-19 pandemic, that some have called an “apocalypse,” the focus has now shifted to vaccination. India, however, is facing a major vaccine crisis, with massive shortages being reported across the country, and people’s desperation for that elusive jab is growing. Experts, while emphasising the urgent need to vaccinate citizens, are also warning of the impact of a third wave on India, especially in view of our vaccine challenge. According to Our World in Data, only 3.2% of India’s population has been fully vaccinated, and 12.1% have received one dose.
We spoke with one of the country’s leading virologists Gagandeep Kang, a Professor of Microbiology at the Christian Medical College, Vellore, to understand why things went so horribly wrong that people died while their families cried out for beds and oxygen, and how to avert a similar crisis in the coming months.
On why the second wave of the pandemic hit India with the ferocity that it did, Kang said that the Covid-19 variants are to blame.
“Viruses have several waves of infections. It is well known. The ferocity of the second wave in India has been because this was a different set of viruses. If we had not had variants, I don’t think the second wave would have been as bad. These variants are much more transmissible. Also, many public health precautions were not being taken,” said Kang.
Kang also pointed to India’s failure in responding to the challenge in time. “The increased infections are something we should have seen, recognised and acted on, latest by the beginning of March, which we didn’t do. So, the second wave is at least partially our responsibility.”
The increased infections are something we should have seen, recognised and acted on, latest by the beginning of March, which we didn’t do.
Kang warned that this isn’t the last pandemic we’re going to see, and that the biggest challenge for a country like India would be the mutation of the virus leading to newer variants.
“I hope we will pay heed to the lessons we’ve learnt and also understand that this is not the last pandemic we’re going to see. We need good primary health care and a referral system. We’ve focused so much on hospital based medicine. We need to be working on what keeps people out of hospitals. Prevent disease before it reaches the stage of hospitalisation. We need to worry about variants. We need to decrease virus circulation, replication and mutation which lead to variants. Until we do that, we won’t have a handle on what’s going on and the chances of future large waves still exist.”
We need to decrease virus circulation, replication and mutation which lead to variants. Until we do that, we won’t have a handle on what’s going on and the chances of future large waves still exist.
On future waves, Kang said, “We should not be thinking about the third wave. We should be thinking about the third, the fourth, the nth wave of this pandemic. If we continue as we’re going, we’re going to see continued circulation of the virus. And then it might wind up being a seasonal virus where we see one or two waves every year.”
We should not be thinking about the third wave. We should be thinking about the third, the fourth, the nth wave of this pandemic.
Addressing concerns about whether the third wave could severely impact children, and whether this demographic needs to be urgently vaccinated, Kang said, “I don’t see children being disproportionately affected by the third wave. We might see less severity of the disease in older people because many of them would have been vaccinated. We should think about vaccinating children only once we’ve finished vaccinating older people and people with comorbidities because the risk of severe disease in children is much lower. The proportion is much lower than any other age group. Children should be vaccinated but later.”
I don’t see children being disproportionately affected by the third wave. We might see less severity of the disease in older people because many of them would have been vaccinated.
On reports about Vietnam discovering a new coronavirus variant which is a hybrid of the strains first found in India and the UK, Kang said, “Vietnam has a really good public health system. And if they say they are worried, I’m worried too. I would really like to know more about this strain and what it means in terms of transmission.”
Vietnam has a really good public health system. And if they say they are worried, I’m worried too.
On the new antibody cocktail drug launched recently in India, Kang said it is useful for those who can afford it.
“If the antibody cocktail is given early in illness, it prevents severe disease. It has shown to prevent hospitalization in the US. If you have the resources to get this drug, it is a safe drug and works. But at its current price, it is not a public health solution in India. Not a wonder drug but useful for some patients at the right time.”
Kang expressed skepticism about the DRDO’s (Defence Research And Development Organisation) anti-Covid drug, saying, “As far as I’m aware, the DRDO drug is being evaluated in only a few hundred patients. To me, that is not reassuring. I’d like to see a much larger number of people using it. We currently don’t have information about what its impact would be”.
Kang says that Bharat Biotech’s nasal vaccine and Zydus Cadilla’s DNA vaccines, both of which are in the pipeline, could be game changers not just for India but the world, provided their efficacy is proven.
“A nasal vaccine could be a game changer if it shows efficacy in the phase 3 trial. I’m skeptical only because I don’t have an example of a nasal vaccine working better than an injectable vaccine. Similarly, we don’t have any DNA vaccines for humans yet. If Zydus Cadilla can make one, that would be outstanding science where India would be the first country to deliver a DNA vaccine to the world. But we need data.”
On the Centre’s recent announcement that India would undertake a study on mixing and matching of vaccines, Kang said it could be the answer to India’s current vaccine woes.
“In India, we’ve seen vaccine shortages and people running around desperately looking for the same vaccine for their second dose. I think, in India, we should be doing a mixing and matching study and we should do that for every vaccine we bring into the country because that gives people more options to complete their vaccination schedules appropriately without having to necessarily wait for the same source of vaccine as they had used previously. We also need to think of mixing and matching boosters for the longest lasting protection against a range of variants.”
On India’s current vaccine crisis, Kang said, “Right now, the situation is about as bad as it can get. We have a lot of people waiting for vaccination and there aren’t enough vaccines available for them. But the situation should ease a lot towards the end of the year. Other countries which have filled the order books of vaccine manufacturers were taking a risk by ordering vaccines five or 10 times their population. The question is will those countries be willing to donate or sell their surplus vaccines after they have finished vaccinating their populations. I’m hopeful that many of the Indian vaccine companies that are now in clinical trials- Zydus Cadilla, Biological E, Genova- will be able to produce a large amount of vaccines for the country.”
Right now, the situation is about as bad as it can get. We have a lot of people waiting for vaccination and there aren’t enough vaccines available for them. But the situation should ease a lot towards the end of the year.
On the government’s claim that the entire Indian population will be vaccinated by December, 2021, Kang said, “The delivery can be done. Supply of vaccines is another story. We’ll have to see if we have enough vaccines for our entire population. We will have to depend largely on manufacturers in our country.”
Kang said that she did not agree with the new UK study, which claims that a single dose of vaccine offers only 33% protection against B1617.2, the predominant variant in India.
On concerns about the increased gap between doses recommended by the Indian government, Kang said that she too had recommended 12 weeks in February, but the situation had changed since then.
“In February, when we had far fewer cases, I was recommending a 12-week gap between doses of vaccine. The real world data available then told us that was a safe approach. But since then, the situation has changed a lot. The UK data is based on symptomatic infections and not on severe disease and mortality. So, we should not think that protection against severe disease and mortality with a single dose will only be 33%. We don’t know how much protection there is against severe disease. We should get that data in India. The UK decision to have an eight week gap between doses is not based on real world data. It’s based on an interpretation of the whole picture. It’s a logical decision for them because they have vaccinated a bulk of their population with one dose already.”
On the WHO (World Health Organisation) not endorsing Bharat Biotech’s Covaxin yet, and the world body being somewhat skeptical about the efficacy of existing vaccines against the B1617.2 variant, which is said to be responsible for most of the recent infections in India, Kang said “Lab studies done in India with Covaxin and Covishield tell us that the vaccines are performing well against B1617.2. But lab data doesn’t give us the information that real world data provides. So, I hope India will try to gather real world data sooner rather than later. The vaccines are working but maybe working less well against this variant. And going by the UK data, it seems that the Pfizer vaccine is working better than the AstraZeneca vaccine.”
“The interim analysis for Covaxin shows the vaccine is working really well. The first efficacy result was 81% , the second was 78%. Interim results are strong indicators of what the final results are likely to be. So that efficacy level is pretty good,” she said.
On the ongoing debate over India’s actual Covid-19 death toll and allegations of under-counting, Kang said, “There is an under-estimate. The factor by which there is an under-estimate, we’ll know only after the fact. The real scale of the pandemic will only be known when we have nationwide surveys.”
On the controversy over the origin of the Coronavirus and growing demands from scientists and countries around the world for a further investigation, Kang said we may never know the entire truth.
“There has been a lack of sharing of information with the WHO on the part of China. The teams that went there the first time and the second time did not get the information they had sought. Is this a virus that was a direct animal spill over? Did it leak from a lab? Was it engineered to be the gain of function experiments that are being reported, to make the virus more infectious? Those questions will continue to circulate and I’m not sure we’ll have clear answers.”
There has been a lack of sharing of information with the WHO on the part of China.
On India’s future preparedness, Kang said, “We have the Swiss cheese approach. That means, no intervention is without holes. But if you have enough slices, you can ensure that the holes don’t line up. And you can protect people against illness. Vaccines are one of those slices of cheese. Masks are another. Social distancing is another. Ventilation is another. Staying outdoors is another. We have many options to protect ourselves and we need to use those until we can get a significant proportion of our population vaccinated.”
We have the Swiss cheese approach. That means, no intervention is without holes.