Speeding up of vaccination process and strictly following masking and social distancing norms are the only ways India can avoid seeing a third wave of the COVID-19 pandemic, according to epidemiologist Dr Eric Feigl-Ding.
India has been reporting record number of new COVID-19 cases over the past few weeks which has led to the healthcare system crippling under the pressure. The emergence of mutant variants of the SARS-CoV-2 virus has led to faster spread of the disease in the country.
"These variants will keep rising unless we stop it with either the masking which works just as before, vaccines which works just as before but we have to keep on doing it and distancing. But the difference is the virus will grow faster than we can vaccinate because for every person infected, the virus will infect five or six or eight more people," Dr Feigl-Ding told BOOM.
Dr Feigl-Ding is an epidemiologist, health economist and Senior Fellow at the Federation of American Scientists who used to be a Faculty and Researcher at Harvard Medical School.
"Testing alone is not enough, testing works. It is like a big rake, that will rake out most of the cases, but it's not perfect. It will miss some cases. This is why we need a mask, why we need distancing and of course the vaccines whenever they can come," he added.
Dr Feigl-Ding believes that India and other countries need to learn lessons from the second wave, study the mutants further and prepare ahead of time to ensure they have the upper hand when the virus eventually mutates and makes a comeback.
"The main reason we think it will slow down is it will infect just too many people. As it keeps infecting potentially 10 million people more day, eventually it will run out of people and then it will slow down as it has less people but the number one lesson is, it can come back.
"The more millions of people it infects, it will learn how to adapt and out of millions who will learn, which are most successful in evading previous infection and it could theoretically come back once it learns how to evade the immunity of our current built up immunity against it," Dr Fiegl-Ding said.
Edited excerpts follow
Govindraj Ethiraj: How are you seeing the progression of the virus at this point of time, even as it abates in some parts of the world and is moving much faster in countries like India?
Dr. Eric Feigl-Ding: The virus is obviously going wherever there is minimal mitigation and minimal vaccination. Vaccines, of course, are in some ways, a luxury in this world where there is such a limited supply but even without vaccines, we can mitigate the spread of the virus and we have to mitigate by realizing that this virus is an air-borne, aerosol virus.
It stays in the air and can float long distances and it builds up concentration indoors and wherever people fail to learn that the dangers of indoor dining or indoor meeting places with poor ventilation, that is how the virus spreads the fastest and of course, whenever given the chance of super spread in mass rallies, whether religious or political or sports games, the virus gets further ahead.
Unless we learn from these lessons, we are not going to be able to stay ahead of it because this virus is a very pernicious virus. It will stay in the air for 20 minutes to 4 hours without any other changing conditions and this is why this virus has taken over the world because even when you are infected, 30 or 50 percent of all infections are due to asymptomatic transmission. You think you are healthy, no symptoms whatsoever but the virus will still transmit and that's what has been so frustrating in stopping it.
GE: In a country like India, the infectiousness that we are seeing today is much greater than what we saw in the first wave and that perhaps is what led to us being more complacent as well. How do we understand it at a very broad level, the nature of mutations and how they will or are likely to spread?
EFD: There is definitely the variant now driving the second wave in India and variants, just like any evolutionary driven factor, they basically arise when they have selective pressure to arise and so, also when there are even more warm bodies, more hosts to infect, that is also when it will thrive and learn to adapt and over the many, many months, over a year, the virus has learnt to adapt in many ways.
There is the South African variant that has a lot of reinfection risk and the South African variant has the greatest immune escape. It does not mean the vaccine won't work, it's just much weaker against it. There is UK B.1.1.7. This is more contagious and 60%, more severe. B.1.1.7, also infects kids more and the India variants B.1.6.17 and B.1.6.18, the double and triple mutants as some call it, it is worrisome because it has properties of some of the worst variants we have seen elsewhere.
We don't know the exact contagiousness but we do know that generally the more warm body the virus has, the more it will mutate and the virus, think of a virus like a pole-vaulter, the virus that is most successful and able to jump over a fence of people who have previous mild immunity, that is the virus that is going to survive and then further proliferating spread and obviously India has given a lot of chances for it to mutate before.
So, these variants will keep rising unless we stop it with either the masking which works just as before, vaccines which works just as before but we have to keep on doing it and distancing. But the difference is the virus will grow faster than we can vaccinate because for every person infected, the virus will infect five or six or eight more people. Well, for everyone vaccinated, I cannot just immediately give them five or six vaccine syringes to syringe or vaccinate the next person.
We just don't work at the same pace of the virus. So, this is why we have to mitigate at the same time we vaccinate. Mitigation, masks and especially double masks or premium masks I think is really key. That is what a lot of European countries now mandate for any public activity, Premium N95 Grade masks and of course distancing.
Distancing in India is much more difficult but there is also technological solutions such as, like in a simple classroom, Hepa filter. Hepa filters costs around $200 in the west, but that's a one-time investment and it's only less than $10 per child per classroom, and obviously, in India, we could probably make it even cheaper but if we put this in every classroom, every meeting room, we can have greater, huge reduction in cases and have some return to normalcy, but we need all of these solutions, not for relying on just one.
Testing alone is not enough, testing works. It is like a big rake, that will rake out most of the cases, but it's not perfect. It will miss some cases. This is why we need a mask, why we need distancing and of course the vaccines whenever they can come.
GE: Given your own understanding of numbers as are visible, do you see the second wave in India peaking shortly?
EFD: Yes. So, the problem in India is there is a huge under-diagnosis. There is a lack of testing as you know, and that's partly seen in the positivity rates. In some places in Kolkata, it is near 50 percent but overall, it is 25 percent in many parts of India right now.
That means, for every four stones you turn over, you find the virus underneath them and that means that in the forest there are a lot more other cases that were not turning the stones over to find the virus. So, the problem is we don't have a good grasp of how many total cases. The testing is not exponentially increasing like the viruses.
So, there are some estimates that were under counting by 10X but the one latest estimate by IHME, Institute of Health Metrics and Evaluation, the Epidemiology firm, Institute in University of Washington says, there is 58X underdiagnosis. For a quarter million daily cases confirmed in India, there is actually 13 to 14 million daily new cases. That is obviously a very high number.
They believe that hopefully the cases will stop increasing this coming week. They will start dropping, but the mortality will keep going. That's the problem. Mortality is a lagging indicator and mortality obviously goes up whenever you have lack of oxygen but mortality will keep increasing for about two more weeks into mid-May. It will slowly come down, but not that quickly and IHME predicts that by August, there could be potentially be a million deaths.
Whether or not that number is true, we know the reality of the funeral cremations. There is so much and we do not have enough testing to actually be an effective measure right now to fully stop the virus because if you have enough testing, you can use it as a tool to stop the transmission but if you don't have enough testing right now, we can't even use it as a tool to slow the transmission and we don't even have any sense of how many cases.
That is why we are literally driving in the middle of a pandemic at midnight with no headlights and that's the scary thing because we don't know how many true cases there are. We don't know how many true deaths there are. In many countries, we can eventually see the excess deaths, but we don't know how many excess deaths there are being burnt a day and we don't really know what is the true extent and this is so scary because would you drive down the road at 100 miles per hour in the dead of midnight, with no lights on. That is what we are facing right now and that is why India's situation is so scary.
GE: Assuming that we have lockdowns in many parts of the country, there is vaccination going on, we will see cases peeking out and then dipping down as we've seen it earlier. So, what happens after that? Is this likely to be a stable state for some time or could we will see another resurgence, after a few months?
EFD: We could very much well, see another resurgence and to be clear, the reason, only reason we think it will slow down, is not that interventions in India are currently really working, because clearly India is only 1.6% fully vaccinated, 8.7% single-dose vaccinated.
The main reason we think you will slow down is it will infect just too many people. It will infect, again, this is a dangerous type of herd, there is vaccine herd and then there is natural infection herd and as it keeps infecting potentially 10 million people more day, eventually it will run out of people and then it will slow down as it has less people but the number one lesson is, it can come back.
The more millions of people it infects, it will learn how to adapt and out of millions who will learn, which is most successful in evading previous infection and so we think that it could theoretically come back once it learns, how to evade the immunity of our current built up immunity against it.
This is why we are playing this yo-yoing, up-and-down roller coaster, because the first wave, the old Wuhan 1.0 virus has almost disappeared. It almost does not exist anywhere in the world anymore, other than a few pockets that has never seen many cases. It's the new surge, the B.1.1.7 UK variant, the South Africa variant with high reinfection, the Brazil P1 variant with really, really fast 2X, 2.5X transmission, faster transmission and large reinfection fraction.
It's these faster spreading ones that have reinfection potential. Those are the ones that are now thriving around the world and I do not think that South African variant or the Brazil variant will be the last variant and I am worried about the India B.1.6.17, B.1.6.18 variants; could also be kind of like the South Africa variant and the Brazil variant that they are very evasive, towards pre-existing immunity to the old virus. So, we could be entering a new pandemic and that's the worry.
GE: You said in some cases, a vaccine may not be as effective. Where do we stand on that today? Either way, where is all this lined up or likely to land up, given our demand?
EFD: So first of all, the US is planning to share 16 million of its excess AstraZeneca vaccine doses, because US has enough of the other ones. The issue I want to clarify is, first of all, there is no ban on exports of raw materials from the US, the CEO of Serum Institute India even said.
So, what they are lacking is some materials for Covovax, which is not even approved in any country, US or India. So, they are just trying to stockpile and the US has something called the Defence Production Act. It basically says during an emergency, you have to, these companies have to prioritize US production and if the company has extra, beyond the US requirements for production, then yes, it can also ship to other countries.
So, it's not a ban, it's more of a prioritization and it does not affect Covishield, the CEO of Serum Institute too says the raw material shortage doesn't affect Covishield per se, and the US will also send more materials for Covishield as well. Also, India, in terms of yesterday, I think announcement was the Federal government of India will not buy more, import more vaccines.
They will develop more internally and there are letting States and Private companies buy more but my sources say, that is a very bad plan, having states purchase it using their own non-Central Government's budget to do it is not very feasible in the long run and companies to do it will lead to eventually price gouging and that's not the best way. The vaccinations should be free, should be done and ordered in the hundreds of millions and only at the federal level can they do that. So, it's very frustrating to see that.
Altogether, I think vaccines are coming, the US will definitely share more and the first batch of US vaccines actually could not be shared because Trump's Operation Warp Speed contracts prohibit those early batches of vaccines from being shared with any other country and used outside the United States but the new batches of Biden-ordered vaccines can be shared with the world and the Biden Administration is going to ramp up production of a lot of these vaccines for the world. So, look forward, the second half of the year, there will be much more in addition to the US donating 16 million AstraZeneca and four billion dollars to Covax.