A Jab To Block An Uppercut

Round 2 Back in the middle of the ring, squaring off against an opponent whose moves are only too well known. That first round was gruelling. But it eased up a bit towards the end, enough to get off the ropes and spar—the defences had apparently worked. Now, however, the opponent’s punches are once again flying in fast, feet shuffling just as swiftly—in between ducking and parrying the blows, an unmistakable sense of déjà vu.

Haven’t we been through this fight before? Exactly a year after the word lockdown clanged down on everything that moved, there’s a COVID-19 resurgence in various regions in the country. Lockdown is still an option that nobody wants—but night curfews have made a comeback in Maharashtra;  protests, rallies and parties have been banned in Bangalore; and Delhi is keeping an eye on headcounts at open-air events. Tighter curbs because clusters of infection are popping up—in apartment complexes, hostels and workplaces. Here’s what the macro picture looks like—daily new cases climbed to 72,330 by the end of March, most of it coming from eight states. On the other side, around 430 districts haven’t reported a Covid case in the past 28 days.

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To get your bearings, look back at the downward curve we had been coasting on till recently—since mid-September the daily fresh case count had fallen from a peak of nearly one lakh to a nadir of just over 8,000 new infections a day, as recently as February. That latter scenario, most public health experts believe, led to complacency as people tried to return to something that passes for normalcy, though a second wave was always in the reckoning. Hence, the sombre tone of V.K. Paul, Niti Aayog member who heads the National Expert Group on Vaccine Administration for COVID-19, at this week’s press briefing, as he laid out the cards: “If it is business as usual, we will continue to be chased by the virus rather than the other way round.” What he was referring to were the simplest yet most effective interventions that were being neglected—wearing a mask and maintaining physical distance. As Paul put it, the situation is going from bad to worse.

But unlike the previous bout, there’s a new metric to keep note of as well—vaccination. India’s biggest yet inoculation drive targetting all adults aged 45 and older began on April 1. Again, for comparison, look at the recent vaccine run rate when healthcare workers and the elderly were being immunised—in the past fortnight, the daily tally of doses administered has averaged more than 20 lakh. In fact, on March 22, it even clocked 30 lakh doses, nearly nudging the US single-day record of 32 lakh that same week. The US is leading the global vaccination tally so far but even authorities in that country are warning citizens against complacency setting in. Cases in the US too are around 60,000 a day and there’s the growing concern of another spike.

Where, then, is this battle headed? Will vaccination help control the surge? How fast can India immunise its most vulnerable? And what about virus mutants? The questions, as usual, are many.

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The recent daily rate of vaccination in the country is “very, very good”, says virologist Shahid Jameel. “But you realise that it will take nine months even to administer two doses to the three crore people in the target group of 60-plus and the healthcare workers.” Vaccination, says Jameel, director of the Trivedi School of Biosciences at Ashoka University, will have to be ramped up quickly if the situation has to be brought under control. India’s vaccination drive started in mid-January, targetting, in stages, healthcare and frontline workers and the general public above 60. The total numbers by end-March were 5.3 crore people having received one dose and 85 lakh getting both doses. “These amount to 3.9 per cent and 0.6 per cent (of the country’s population) respectively,” says Jameel. Indeed, the health ministry is pushing the districts witnessing a surge in cases to aim at saturation coverage of the vulnerable age groups—the 45-plus group, as data shows, accounts for 88 per cent of the disease mortality. The ministry also noted that the most affected districts had been slipping up on the basics—testing, tracking and isolating.

Prof. N.K. Ganguly, former chief of the Indian Council of Medical Research, says he would recommend vaccinating people in the 29-40 age group in states which are seeing the biggest surges. Provided supply isn’t a constraint. “Because that is the main workforce which travels and they spread the infection the most. They themselves don’t suffer as they are more asymptomatic in that age group,” he says. Secondly, Ganguly says more vaccines could be offered. “I would allow all the vaccines which have been approved by the US FDA and European Medicines Agency because these are mature regulators,” he says. Besides, recent studies from the UK and US show that even single doses of some vaccines protect against severe infection, he says. Last month, a Public Health England pre-print research paper said vaccination with single doses of either the Pfizer or Astrazeneca vaccines used in the UK was associated with a “significant reduction” in symptomatic positive cases in older adults.

The early days of vaccination were slowed down by hesitancy—some experts point out that of an estimated one crore healthcare workers, only about 52 lakh have received their second dose so far. By most accounts, uptake is still an uphill battle, given the lingering fears. But the delivery system has been streamlined. “I have been in public health for almost 45 years and I have never seen a simpler and functional mechanism than this one,” says Rajesh Bhatia, former Director of Communicable Diseases at the World Health Organization’s regional office. He expected long queues when he scheduled his first jab at a nearby hospital but it took him just over an hour—including travel time and post-vaccine observation. “The facilities are available, but where are the people.”

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A health official in Uttar Pradesh’s Moradabad district explains that there are six vaccinations sites in his block whose daily target is to inoculate 100 people each. “However, if I can give you an average daily vaccination figure, it would be around 30 at one centre. So, you can say out of 600 daily targets, we are achieving only 180,” he says. “Fear and distrust is the reason for that, he adds. “People read all sorts of news about side effects and deaths and they don’t come forward to get vaccinated.” Both vaccines currently in use in the country—Covishield and Covaxin—have been through controversy. The homegrown Covaxin faced initial scepticism over its hasty approval until interim results announced in early March pointed to 81 per cent efficacy. Meanwhile, the concerns abroad over rare cases of blood clots in people who received the AstraZeneca vaccine were allayed by the European Medicines Agency and the WHO. The shot’s “proven efficacy in preventing hospitalisation and death from COVID-19 outweighed the extremely small likelihood of developing” conditions relating to blood clots, the European agency said. It explained that of the roughly 20 million people in Europe who received the vaccine, it had reviewed only 25 cases.

Last week, Ashwini Kumar Choubey, the Union minister of state for health, told Rajya Sabha that 89 deaths of vaccinated people had been reported till March 16 but “none of the deaths so far have been causally attributed to COVID-19 vaccination as per current evidence”. The surveillance system to monitor Adverse Events Following Immunisation (AEFI) is robust and measures such as providing anaphylaxis kits to vaccination sites and immediate referrals to AEFI management centres are being done, he said. This has been met with some scepticism, however. “I’m not very sure the investigation into causes of death is done adequately, although the government has said they are not related,” says Amar Jesani, editor of the Indian Journal of Medical Ethics. “We need not stop the vaccination but we need to be aware of this, so that people are followed up thoroughly and provided medication if adverse events occur. If you don’t do it, there will be less people coming forward to take a vaccine.”

Between January—when case counts were falling and vaccine acceptance was low—and now, the scenario could have changed, reckons K. Srinath Reddy, president of the Public Health Foundation of India. “Cases are going up rapidly and people are worrying about the mutants. So I think given that situation, we must increase our ability to vaccinate more people by recruiting and training more vaccinators and getting more centres active.” Private sector participation in the drive is still low—of the 43,182 vaccination sites, only 5,630 are private.

The principal purpose of current vaccines, Reddy explains, is to reduce severity of infection, if a person is infected. There’s isn’t trial evidence yet about vaccines reducing disease transmission, but it stands to logic that if a person doesn’t get very sick, then he/she is not coughing out a huge amount of virus particles to infect others, says Reddy. “Therefore, the transmission is likely to be reduced. There is some evidence now coming, not from trials but post-vaccination studies, that transmission is also reduced,” he says. “So while we must step up vaccination to protect as many people as possible, we cannot bank only on that for reducing transmission. We must do everything to contain transmission by way of physical distancing, masks and preventing large super-spreader events.”

At the moment, the 10 top districts for active cases comprise eight from Maharashtra besides Bangalore and Delhi. As epidemiologist Jayaprakash Muliyil explains it, the surge means that the coronavirus has found new hosts to spread to as people move about and mix freely.

Then, there’s the natural process of mutations to reckon with—so far, out of around 11,000 samples that have been genome sequenced since December, the UK lineage has been detected in 807 samples, the South African strain in 47 and only one Brazilian variant was found. The recent discovery of a “double-mutant” virus in samples analysed in Maharashtra has triggered fresh concern, though authorities say there’s no evidence to correlate it with the surge in cases in the state. “A virus, when it multiplies, makes errors in replicating its RNA. And these errors happen at random,” explains Shahid Jameel. “Most of those errors are bad for the virus and then you don’t ever see those viruses again.” But the ones that persist give the virus some selective advantage. The double mutant, Jameel says, can be potentially worrisome because of two mutations in the spike protein that allow the virus to bind strongly to cells and, therefore, transmit efficiently (a mutation named L452R) and secondly evade an immune response (E484Q).

Muliyil reckons there probably isn’t yet cause for alarm on account of mutants—the clues to that, he explains, will come from the rate of repeat infections, i.e. people getting infected a second time. “Remember, crores of people all over the world have been infected and only a handful of cases we know are repeat infections,” he says. “At the moment, we have no evidence to show there is any excessive number of repeat infections.” There are studies planned to capture repeat infection, he adds.

Srinath Reddy believes it is possible to stem the surge, given the health service’s experience of dealing with the coronavirus over the past year. “We have the knowledge and the tools to control it, if we want to,” he says. “There are two elements…one is transmission and the second is protecting against severe infection. The vaccine achieves the latter. But for the former to be achieved, we have to definitely maintain discipline.”

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‘Better That We Run Fast And Catch Up’

Chairman of the Empowered Committee on Covid Vaccination, Ram Sewak Sharma, says the Co-WIN platform has been ramped up for 50 lakh vaccinations a day.

Vaccinating 45-plus

There are two parts—the vaccine and the capacity to vaccinate. Both these things are completely ramped up, in the sense that there is no shortage of vaccine and, obviously, no shortage of vaccinators. And we have now roped in the private sector people also—the combined capacity should be more than 50 lakh (doses) certainly per day. That is one part. However, it will depend on how people respond and how people come forward. My sense is that we have done about 30 lakh (doses) on some days in Phase 2, beginning March 1. We think that we will be doing more than 50 lakh going forward.

The challenges

Let me put it in perspective. If you have an eight-hour slot, then 50 lakh translates to about 6 lakh per hour. It’s a pretty high figure. We are recording hundreds of concurrent events per second—recording the vaccination and generating certificates. We have tested this infrastructure at the rate of 10,000 concurrent events per second. So, it can take up an even larger number than 50 lakh per day. But the distribution is always bell-shaped. For example, in one particular hour on April 1, we had 3.13 lakh vaccinations.

Analysing data

Hesitancy is no more there, I suppose. One still sees a difference between rural and urban areas. The demand for vaccination is lower in some rural areas. We emphasised to state governments that wherever there is demand, increase the speed because there is no constraint on vaccine supply. Ultimately, we are running against time. Better that we run fast and catch up.