Coronavirus Outbreak: India is in Phase 2; if we don't stop transmissions, country could slip into Italy-like situation, says top virologist

Sibi Arasu

Dr. Shahid Jameel is a former group leader of Virology at the International Centre for Genetic Engineering and Biotechnology, New Delhi. He is now the CEO of Wellcome Trust/ DBT India Alliance, an independent public charity that funds research in health and biomedical sciences in India. He is the Fellow of all the three Indian Science Academies and a recipient of the Shanti Swarup Bhatnagar Prize for Medical Sciences (2000) for his work on the Hepatitis E virus and HIV.

In this exclusive interview, Dr Jameel addresses some of the questions that are on everyone's mind regarding the novel coronavirus pandemic. He said, "If we don't stop the transmission, we should brace ourselves for an Italy-like situation, perhaps even worse, considering our healthcare infrastructure."

Here are the edited excerpts from the interview:

Q: What do you think about the processes of self-isolation and government-mandated quarantine? How effective are these actions in mitigating the spread of the coronavirus, given that widespread tests are not yet a reality in India?

I think they are extremely effective, if done well. Singapore and South Korea are examples of this during the current pandemic. It is best for each one of us to consider ourselves as infected and do whatever is being said to protect others. This is the only reliable tool available with us today to defeat the virus.

Q: Would you like to compare the COVID-19 pandemic to previous pandemics/ epidemics?

The swine flu pandemic of 2009 was similar. But there are also important concepts for us to understand. In the swine flu pandemic, every country in the world reported cases. The World Health Organisation (WHO) estimated that 11-21 percent of the world population, i.e. 700 million to 1.4 billion people were infected with an estimated 1,50,000 to 5,75,000 deaths, which would be a fatality rate of about 0.02 percent.

We don't yet know how many people have been infected with the COVID-19 virus since there is no suitable test for population screening so far. What we do know is that by today there are over 4,70,000 confirmed cases and more than 21,000 deaths reported from 174 countries. This puts the current case fatality rate for COVID-19 at about 4.4 percent. But one must also understand that this is not the same as population fatality rate.

Going by these numbers and a 7.8 billion world population, only 0.006 percent of the world population is confirmed to be infected with the COVID-19 virus. Again, these are underestimates since we are measuring only cases not population infection. The actual numbers will become clearer in times to come. The alarming think about COVID-19 is that cases are doubling roughly every 6 days. In places like USA, this is happening about everyday. Even in India, the rate of appearance of new cases has picked up in the past two weeks, now doubling in about 4 days. We had 200 cases on 20 March and reached 400 cases on 24 March.

Q: Should India be attempting to mitigate the spread of the virus or contain it, as things stand now?

It is impossible to contain it now, we can only restrict it. We can't make sure the virus doesn't spread (contain) but we can try to reduce the spread as much as possible (restrict). The approach that the government is using right now is the correct one. The entire emphasis is to slowdown the spread of virus so that the number of people requiring quarantine, hospitalisation and ICU admissions do not cross the capacity available in the country.

Q: Is there evidence of community transfer of coronavirus in India so far? What stage of the pandemic are we in?

There is no clear evidence yet presented yet, but if you look at the rate at which numbers are increasing in India (see the graph), that must be the case. I have said this earlier as well. As of today, officially we are still in Phase II.

Q: What are your thoughts on the timeline with regards to this pandemic? Can you comment on the near-term and long-term scenarios with regards to the COVID-19 pandemic in India? What should we brace ourselves for?

Viral pandemics such as this, or even large outbreaks, are very hard to predict since viruses spread due to human behaviour, which itself is highly unpredictable. So it's best not to attempt this prediction. I think what is more important is to follow advice and guidelines that are widely circulated. Maintaining discipline and following rules will surely help us overcome this. But if we don't follow rules and don't slow down and eventually stop the transmission, we should brace ourselves for an Italy-like situation, perhaps even worse, considering our healthcare infrastructure.

I will appeal to people with all my might to please follow rules and be disciplined. This is the only tool available to us.

Q: We are hearing a lot about vaccines, what are the chances of finding a successful vaccine? What does the timeline for this look like?

The WHO has stated that there are at least 40 different candidate vaccines for the coronavirus that are currently in development in labs across the world. The Serum Institute of India based in Pune is working with Codagenix, an American company to develop a vaccine as well. The one that has the most buzz is the mRNA-1273, an experimental vaccine developed by Moderna, a US biotechnology company, which has gone into Phase 1 trial. This vaccine has caught the world's attention because it is the first time that a candidate vaccine has been developed so quickly. They began testing it in just 63 days from the time the virus sequence became available. To compare, the SARS vaccine took 20 months to reach that point in the last decade.

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It takes a long time to develop and test vaccines that are safe and efficacious in humans. This is because the proof-of-concept needs to be shown in labs, then a manufacturing process is developed to make a stable and a highly pure product. This is then tested in animals and finally in humans, in three phases with increasing numbers of volunteers. All this takes time and money. From proof-of-concept to a successful vaccine takes at least 2 years, generally more.

The Moderna vaccine has been fast-tracked into humans without prior testing in animals given the urgency of the situation. Despite this, it may still take one or even two years for the clinical trials to be over. Also there is no guarantee that this or any other vaccine currently in development will work. To increase the probability of a successful vaccine, one must have numerous candidates, and that is what we have for the coronavirus.

Q: Can you elaborate on how global medical community is coming together (or not) to develop vaccines or any anti-viral for COVID-19?

There is unprecedented cooperation in the global research and medical community in this time of crisis. New knowledge on medical interventions, etc. is openly shared. There are over 300 research papers and reports related to coronavirus in MedRxiv, an open source medical sharing platform. New knowledge on the virus is openly shared on various openly accessible research platforms such as bioRxiv, preprint.org and others. The sequences of viruses from around the world are shared with the Global Initiative on Sharing All Influenza Data (GISAID) repository and openly modelled at Nextstrain.org. This helps greatly in tracing how the virus is evolving. Information on drug trials is openly available on the websites of the USFDA and Chinese Clinical Trials Registry as well. And, of course, as I mentioned earlier over 40 vaccines are under development as well.

Q: What are the other treatment options available until a vaccine is ready to be deployed?

As of now there are only experimental treatments using existing drugs or combinations. There is no approved treatment yet but drugs such as chloroquine / hydroxychloroquine are approved as experimental drugs as they undergo proper clinical evaluation. For most people the treatment is symptomatic to reduce fever etc. In critical cases, it is best to ensure ventilation and oxygen supply in case the lungs are compromised.

There is a lot of misconception in India, even among educated people, that chloroquine can be taken as a preventive to protect from infection. There is no evidence for it, but there is sufficient evidence that wrong use of chloroquine can cause various other health problems. Don't self-mediate and use it as a preventive for coronavirus.

Q: How effective are anti-virals for COVID-19? Can they be a viable solution to deal with the pandemic? Are any anti-virals already available or nearing deployment?

As things stand now, some anti-virals have been tried in limited experimental and emergency situations. It is important to note that none of them have been approved so far. The control of this pandemic through antivirals is not yet an option.

Q: There is little to no information regarding the numbers available or the supply and manufacture of coronavirus tests, can you shed some light on this?

The Ministry of Health and Family Welfare (M0HFW) has said many times that they have one lakh tests, and have ordered another 10 lakh. We should believe them. Recently, testing is also being opened to government research labs and private sector diagnostic labs. This will help improve the numbers of tests conducted as well.

Q: In your opinion, what are we doing right to deal with coronavirus? What should we be doing differently?

I think the 21-day lockdown and earlier travel restrictions are correct decisions and will prove effective if adhered to properly. But we should even be prepared for a longer lockdown if the situation requires, after these three weeks. Widespread messaging for reducing spread is also urgent and is being carried out well. It is up to us to make it successful by being disciplined and following guidelines.

Having said this, if we had started all of this a few weeks earlier, it we could have done better. The delay is definitely something that could have been avoided. I also think testing should have been much more aggressive. Better collaboration between the Indian Council for Medical Research (ICMR), public institutions and private sector would have also made handling this situation easier. There was a lot of mixed messaging earlier with doubtful AYUSH products and now with chloroquine. Such erroneous and conflicting messaging should at all costs be avoided.

We must remain vigilant yet sensitive to the needs of others. We have a very large poor population in our country, which is going to be hit badly with the lockdown and economic downturn. While following all precautions, please help people in your area with food and other needs to the best of your ability. Those who can afford should reach out with a helping hand to those who cannot.

In the end, we will overcome this if we use common sense, be disciplined and follow orders. This challenge is also an opportunity to win friends through compassion.

The author is an independent journalist based in Bengaluru. He tweets @sibi123

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