The Union Health Ministry, on October 17, 2020, said that India has one of the lowest COVID-19 deaths per million population in the world with less than 1,000 fatalities registered daily since October 4. The fatality rate of 1.52% on October 16, is the lowest for India since March 22. India now has 7.49 million cases of COVID-19 and 113,000 have died of the virus.
Experts now point out that India has fared better in terms of fatalities as compared to other countries with a higher count of cases like the USA with 8.19 million cases and 220,000 deaths.
Dr K Srinath Reddy, President of the Public Health Foundation of India, says there are multiple reasons for India registering a lower mortality rate, starting with the fact that India is a younger country as compared to the west. According to Reddy, this also translates into having a population under the age of 60 with a lower rate of co-morbidities. India also benefited from the ascent of the disease much later than Europe, so that it could gain knowledge of how to handle the disease.
The onset of the disease in Europe was in February and March, while India's peak for the disease was reached in May when doctors had better knowledge on how to manage the disease and therefore could save more lives. In an interview with Databaaz, Dr Reddy spoke about the course of the COVID-19 pandemic in India.
How are you seeing this current trajectory of cases and what are the conclusions, if any, that you are drawing at this point?
Firstly, when we look at the cases, of course we must be quite happy that despite the increase in testing numbers, the case counts are coming down fairly steadily now. Part of this problem could be also due to the kind of tests that we are employing--the Rapid Antigen Tests, which actually have a lower sensitivity. And therefore they may be having more false negatives. Despite that, the trend of falling case numbers is encouraging. But because of the problem that we have with the kind of test being employed, with the number of tests being performed, the criteria for testing--particularly now on-demand testing is permitted to the private labs--there can be a fair amount of confusion about whether the actual case numbers really reflect the day to day trends accurately. Overall it appears to be encouraging no doubt about it. I am saying this repeatedly that it is the number of deaths that matter quite a lot.
Tell us a little more about the tests. If you are telling us that the test numbers are confusing, is that something that can throw the numbers that we are seeing completely off? For instance, we are seeing 55-60000 cases today versus the September peak of 96000. Could it be that these numbers are completely off, partly off?
I am not saying that the numbers are off. They are going in the right direction. But with a foggy light. The light is not absolutely crystal clear to tell us exactly how the road conditions are. What I am saying is the decline in the case count is very encouraging but to actually keep track of the daily cases, when the kind of tests being employed, the number of tests being done, as well as the criteria of tests are varying, this is not the most precise way of tracking an epidemic. But even despite those limitations, this is definitely an encouraging trend.
Are you able to triangulate from elsewhere Dr Reddy, looking at any other data from hospital admissions, any other data , any other indicators that are telling you where we are whichever way.
Ok the triangulation with hospital admission is certainly helpful. Again there the indications are varied. Previously, we used to admit everybody who was tested positive. Now, in several cases we are advising home care for mild cases. So, again that is not necessarily a very reliable indicator. However, deaths are the best indicator as other ones have this kind of a variable noise to signal ratio. Even if the deaths are undercounted, the noise to signal ratio is relatively more constant in the case of deaths. So therefore looking at the trends in deaths, it is very encouraging to find that over the last ten days, the deaths have been coming down and we have now hit 638 deaths yesterday.Which is a quite remarkable decrease. Also we must recognise that deaths actually follow the cases by about almost 10-15 days. The fact that the deaths have been steadily decreased over the last 10 days means that the cases are also decreasing at least about 20-24 days earlier, which means that for nearly a month we have been seeing substantial improvement. So if we take the cases into account and deaths into account, I definitely see an improvement.
And deaths are a far more linear way of looking at where we are rather than looking at tests, and positive tests.
Well the cases are an important element and when you actually do not have the same types of tests being performed on a regular basis, the same number of tests being performed, criteria for testing varies, there is a certain degree of fuzziness that is introduced. Whereas with deaths we are dealing with a much greater level of certainty of the signal.
Let's talk about why this is happening and what is changing? What are your understanding and key conclusions at this point? Why are 1) deaths coming down?2) Why is the number of cases coming down, particularly when contrasted with the UK, Europe broadly, particularly in the United States where the cases are still rising at fairly high proportionate levels?
All through our deaths have been much lower than in Europe and the United States. In our case, if you actually look at where the epidemic started and progressed substantially it was in the big cities. And our rural population is fairly high, where the spread of the virus has been later and probably slower. So let us just compare cities with cities in the West with those in India. If we do that Delhi is about 3 times less in terms of deaths per million than Washington DC. And Mumbai, which has the highest number of deaths here is again about 3 times less in terms of deaths per million than Madrid. So also Chennai and London comparison...
Dr Reddy, are you comparing at this point? Or you are talking about the peak?
I am talking about the total deaths so far. So in a sense, if you compare the like with likes, which are the big cities with big cities, India has done much better than Europe and the United States. Now in Europe, you are seeing the second wave starting. You do not know what the numbers are going to be there. We too will have to brace ourselves for a possible second wave. Also, I do not think that our first wave is complete because now we are seeing the virus moving into smaller towns and we will have to try and control the transmission as well as ensure that the death rates keep going down. We still have these challenges, but comparing the likes with the likes, the big cities with big cities we have done much better than the West.
Why is this happening Dr Reddy. Is it because our treatments are working better? We as a population, as a race are more receptive to these treatments or something else?
I think there are multiple factors. Firstly, we are much younger than the West. Therefore the level of co-morbidities is also much lower under the age of 60 than above the age of 60. Therefore, if you have many more people above 60 like in the West, the likelihood of having more severe disease is definitely there. Something like overweight and obesity is much more common in the West, though we do have a problem of diabetes and hypertension even in our middle-aged population. But definitely age is a protective factor for us. Then, it is also possible that we experienced the wave of ascent much later than in Europe, which really started getting into serious trouble in February and March, whereas our problem started much more in May, after the lockdown eased. And by that time we had a lot more knowledge of what to do. Not only in terms of prevention, but in terms of treatment, management. We knew oxygen was helpful and ventilators were not really necessary in very many people. We also know about some other …...like proning--making people lie flat on their belly--improves oxygenation. There were so many other things that were happening around that time, we gained from our own experience and also from global knowledge. So I think particularly age, and also we happen to benefit from elsewhere in the world because of a slightly later onset of an epidemic wave helped us.
Are you getting a sense in anyway that we are responding differently to treatment better to treatment? Same medicines I guess are being used everywhere?
I think basically our own treatments have been very effective in the way people have managed it in the big cities in the hospitals, and fatality rates have been lower ( partly because as I said the global knowledge has been accumulating). Very energetic response in terms of treatment modalities. So we have to give credit to both. Firstly, the lower risk itself of our population because of the age and also earlier and more prompt treatment. We are still losing cases because we are not detecting cases as early as we should but nevertheless despite that limitation, energetic treatment gets started when people do get to the hospital, and that is where lives are being saved.
Is it possible to put a number on that Dr Reddy. For instance, today you say of a 100 patients maybe X number are turning up late, but if those X turned up earlier then so many could be saved?
Well our case fatality rate itself shows over the period of the last few months, we have actually had initially anywhere between 3-5% of case fatality rate, and now it is about 1.5%. The situation has also changed with the milder cases being asked to take treatment at home and severe cases being rushed to the hospital and being taken care of much earlier rather than having to move around searching for some hospital, getting rejected at some and getting admitted after much delay. So I think our systems are much better prepared. I cannot put a fraction on that. Obviously, there is a much better system operating now in terms of earlier detection and earlier admissions.
YWe are continuing to unlock, opening up movie halls, schools are not yet opened but are likely there is a lot of pressure, there is pressure in the state of Maharashtra to open up temples, and there might be similar pressure elsewhere. How do things look going forward in terms of transmission?
Well I do not think we can take anything for granted.We are fortunate that we have managed to gain some level of control right now and I hope that it will continue despite the fact that the virus is now entering new territories. It is entering small towns, villages, so we cannot say that the battle has been won. Far from it.See have to also make sure that in cities and districts where the numbers have started going down, we do not have a second wave because of our carelessness. This we have seen in Europe, in UK, in the US and even in Spain, France where after very rigorous control and considerable amount of success, suddenly there was an air of relaxation and that we must celebrate the summer, before we enter into the winter, and we have seen how the virus has now spread rapidly; they are going into second lockdowns. We have to make sure that we continue our vigilance at least till next April or May, till we understand this epidemic trends in our population much better and for that...We do not know, large parts of India may not be having such a severe winter but some parts of India will have a severe winter. We do not know how the virus will behave when the weather turns cold and whether there is going to be a resurgence and with the festive season coming up there is always the danger of super spreader events. And we know whether it is Europe or elsewhere, in India too we have evidence now, that it is the super spreader events that are the most dangerous events. The moment we have large crowds going in whether for religious or social reasons, political rallies, we are going to have this problem anyway. I think vigilance has to be particularly maintained during the festive season. And we have to exhibit a great deal of restraint, we can celebrate joyfully at home but not necessarily crowd in public places.
Are you getting a sense at this point whether at this point we are able to manage numbers or the kind of treatment in smaller towns and villages. I do know through my conversations with doctors a lot of people are coming to cities but that is always the case. That is not a new trend in itself.
That is a challenge. But one of the things that actually distinguish it from the other emergencies that people come to cities is that most cases do not require very sophisticated management. Mild cases can actually be managed at home. As long as their oxygen is monitored with a pulse oximeter, temperature is monitored with a thermometer, and a sense of breathlessness, if it is there will be an indication of admission to the hospital. Even in the hospital, we know that a majority of the patients will improve on oxygen alone if they need it, if they are very sick.
Firstly, proning, lying on the belly, improves oxygenation. Then oxygen itself, if it is high flow oxygen continuously administered that helps. Therefore you do not require the ICUs for most patients that have been used in the larger city hospitals. So if we can actually manage these facilities well, I know we are having challenges.with oxygen supply. That is something that must be overcome ….If we can equip our district hospitals and smaller hospitals well and use the primary healthcare teams much better, you do not necessarily have to rush everybody to a big city hospital.
Two questions, partly related--treatment protocols, how are you seeing the treatment protocols, the way we are applying the treatment protocols…..do you see any further innovation-for the lack of any other word--which could help alleviate the problems? Secondly, vaccines, what is your understanding of its introduction into India, what is the time frame and how do you see it rolling out?
Firstly being a new virus and demanding trials be completed to generate the evidence for treatment, we are still searching for the answers though we do have one clear cut trial evidence that in very sick patients who require intensive care, steroids are very helpful. Not to be given in mild cases but in moderate to severe cases, particularly those who are on oxygen, and on ventilators it is very helpful. But beyond that we do not have clear cut evidence of a life saving drug. We are looking at various drugs some of which may cut short the treatment period but do not have an effect on saving lives and other trial results are expected soon on some of those drugs too. But we also are now looking at not only new drugs but mono-clonal antibodies, which are likely to help boost whatever immunity our body is producing and hopefully act as a supplement to that to quickly overcome the virus. Now these monoclonal antibodies can be used either as part of treatment, or as part of prevention immediately after exposure before the actual infection actually flares up.But again these require trial evidence. Trials have started and on compassionate grounds people are being given in many places including India. Trump has received it. That we do have some drugs that have some evidence behind them, some drugs which have some rationale behind them but evidence still awaited but likely that in the next few months we will get much greater clarity. But as far as vaccines are concerned, I think we have several candidate vaccines which are developing, most of which are systemically administered and will reduce the risk of severe infection even though they may not be able to prevent the infection entering the body. For that you require a different kind of vaccine called sterilising vaccine, which is a mucosal vaccine which does not allow the virus to even settle in the nose. Those are under development and they still have to enter clinical trials. Those that have entered clinical trials, which are likely to protect against the virus after the infection from developing into a severe illness those are now reaching the Stage of Phase 3 trials being completed at the end of the year, atleast in a few of the vaccines that are in fairly advanced in trials, others are still in Phase 1 and Phase 2. We are likely to see some clear cut results in some of the vaccines by the end of the year. But by the time the regulatory scrutiny and approvals are completed it will probably be the first quarter of the year that we may have a vaccine but with a caveat that we still have to absolutely have the proof that it is safe, efficacious and has reasonable immunological evidence of duration of protection atleast for a few months. It cannot be an xxxxxxxxxx protection then it will be of no use. All of this needs to be rigorously studied in terms of the evidence the trials produce. We have a considerable amount of hope but nothing should be taken for granted. And therefore we have to keep up our mask, physical distancing, and avoid crowding.
That was in a way my last question to you Dr Reddy. You said in a way we have to be vigilant and alert till March-April next year. Is that the way you see the whole curve either plateau out completely or die down. Or is it just that from where we are today that it appears that it is the earliest when things could
SR: Well whether it is because of the vaccine coming in or the virus becoming less virulent because of evolutionary biology, it is probably going to take upto that time. But the reason I said, March April is that is when winter will end in most of India and we are not sure what winter is going to bring to us. So till the winter ends and the spring of hope comes in we will not be able to say for certain that we have conquered the virus. Conquering the virus does not mean that we have completely eliminated the virus from us. Threat will continue to stay with us and we have to maintain a fair amount of protective measures after that but by March April we will be much clearer about what are the instruments we have at hand to beat it back.