'Mumbai, Delhi Have A Third The COVID Deaths Per Million Than DC, Madrid'
Mumbai: Even though India has about 19% of the world’s COVID-19 cases, it has 10% of the deaths, data show. A younger population, experience and the benefit of global knowledge on COVID-19 helped India keep deaths low, said K. Srinath Reddy, president of the Public Health Foundation of India (PHFI).
Currently, India has about 7.4 million cases of COVID-19, the second-most after the US, with 8 million cases. Nearly 6.5 million have recovered in India and the virus has killed about 113,000 so far. The US has a much higher rate of death with over 218,000 deaths, data show. Within India, Maharashtra has the maximum number of cases and deaths from COVID-19.
IndiaSpend spoke to Reddy, formerly the head of cardiology at the All India Institute of Medical Sciences, on the current trajectory of COVID-19 cases in India, treatment and vaccines for the disease, and how India has managed to keep deaths lower than western countries.
How do you see the current trajectory of cases and what are your conclusions based on that?
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 could be due to the kind of tests that we are employing--rapid antigen tests, which have a lower sensitivity. So there may be more false negatives. Despite that, the trend of falling case numbers is encouraging.
But because of the problem we have about the kind of test being employed, with the number of tests being performed and the criteria for testing--particularly now that on-demand testing is permitted in private labs--there can be a fair amount of confusion about whether the actual case numbers really reflect day-to-day trends accurately. Overall, it appears to be encouraging--no doubt about it. I believe, and I have said this repeatedly, that it is the number of deaths that matters quite a lot.
Tell us a little more about the tests. If the test numbers are confusing, can that throw the COVID-19 numbers completely off? For instance, we are seeing 55,000-60,000 cases per day now compared to the September peak of 96,000 per day. Could it be that these numbers are completely or 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 that the decline in case count is very encouraging but to actually keep track of the daily cases with the kind of tests being employed, the number of tests being done, [and with] the criteria of tests varying, it is not the most precise way of tracking an epidemic. But despite those limitations, this is definitely an encouraging trend.
Are you able to triangulate from any other data such as hospital admissions to tell us where we are?
Triangulation with hospital admissions is certainly helpful. Again, there the indications are varying. Previously, we used to admit everybody who would test 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 because 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.
Therefore, looking at the trend in deaths, it is very encouraging to find that over the last 10 days, deaths have been coming down and we have hit 638 deaths yesterday, which is a quite remarkable decrease. We must recognise that deaths actually follow cases by about almost 10-15 days. The fact that the deaths have been steadily decreasing for about the last 10 days means that the cases are also decreasing at least for about 20-24 days before that, which means that for nearly a month, we have been seeing substantial improvement. So if we take the cases and deaths into account, I definitely see an improvement.
Why are the numbers of deaths and cases coming down, particularly when contrasted with the UK, Europe and the US, where cases are still rising?
All through, our deaths have been much lower than in Europe and the US. 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 in the West with those in India. If we do that, Delhi is about three times less in terms of deaths per million [so far] than Washington DC. And Mumbai, which has the highest number of deaths, is about three times less in terms of deaths per million than Madrid. So also is the case with a Chennai and London comparison.
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. 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 like with like--big cities with big cities--we have done much better than the West.
Why is this happening? Is it because our treatments are working better or because we, as a population, 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. 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.
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 and management. We knew oxygen was helpful and ventilators were not really necessary in very many people. We also know about some other [techniques] 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.
Are you getting a sense in any way that we are responding differently or better to treatment? The same medicines 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. [There has been a] 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 estimate these numbers? For instance, of 100 patients maybe X number are turning up late, but if those X turned up earlier, then so many could be saved?
Our case fatality rate itself shows that over the period of the last few months, we have had initially anywhere between 3-5% case fatality rate and now it is about 1.5%. The situation has also changed with milder cases being asked to take treatment at home and severe cases being rushed to 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.
We are continuing to unlock, opening up movie halls, schools are not yet opened but it is likely they will, 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?
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. We 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--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 the epidemic trends in our population much better. 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. With the festive season coming up there is always the danger of superspreader events. We know--whether it is Europe or elsewhere and in India too, we have evidence now--that it is the superspreader events that are the most dangerous. 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 whether, at this point, we are able to manage with the kind of treatment available in smaller towns and villages? A lot of people are coming to cities for treatment, but that is always the case, with many diseases.
That is a challenge. But one of the things that actually distinguishes it from the other emergencies when 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 if there is a sense of breathlessness, it is 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 intensive care units for most patients that have been used in the larger city hospitals. I know we are having challenges with oxygen supply. That is something that must be overcome. If we can equip our district hospitals and even our smaller hospitals well and use the primary healthcare teams much better, you do not necessarily have to rush everybody to a big city hospital.
How do you see our treatment protocols? Do you see any further innovation--for the lack of any other word--which could help alleviate the problems?
Firstly, being a new virus, trials need to 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 and 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 have cut short the treatment period, but do not have an effect on saving lives. Other trial results are expected soon on some of those drugs too.
We also are now looking at not only new drugs but monoclonal 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 really flares up. But again these require trial evidence. Trials have started but on compassionate grounds people are being given these in many places, including India. [US President] Trump has received it. But actual trial evidence is not available.
We do have some drugs that have some evidence behind them, some drugs which have some rationale behind them, but evidence is still awaited. It is likely that in the next few months, we will get much greater clarity.
What is the time-frame for a vaccine to be available in India, and how do you see it rolling out?
I think we have several candidate vaccines which are developing, most of which, if systemically administered, 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 those still have to enter clinical trials.
Those that have entered clinical trials are likely to protect, after the infection, from it developing into a severe illness. Some of those are now reaching the stage of phase 3 trials being completed at the end of the year. At least a few of the vaccines are in fairly advanced 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 this is safe, efficacious and has reasonable immunological evidence of duration of protection at least for a few months. It cannot be an evanescent 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 on our mask, physical distancing and avoid crowding.
You said that 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, it appears that it is the earliest when things could settle down?
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 it is when winter will end in most of India and we are not sure what winter is going to bring. 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. The 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.
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