Dr Shashank Joshi, member of the M aharashtra COVID Task Force and a consultant endocrinologist at Mumbai’s Lilavati Hospital, describes the pandemic situation in Maharashtra as “grim” but also says he is “optimistic about containing it”. The pandemic has exposed the poor state of the public health system. Dr Joshi cautions against complacency and irresponsible behaviour, all of which are promoting the second wave, which he says is more pernicious than the earlier one. Excerpts from an interview he gave Frontline .
Give us a medical perspective on the current situation: Is the virus following a typical path or is our behaviour promoting its spread?
COVID started in March last year, and by November we say that more or less it had curbed out. In geographies like Mumbai, we always had a thick tail [a fat or thick tail is when a single person appears to infect six or more people, thereby sustaining the pandemic], but in the rest of Maharashtra and India, we saw that by November, more or less, the numbers were at their lowest point. We were scared, as this is a cold virus and common cold viruses often go up in winter, but that winter peaking didn’t happen. In December and January, we thought COVID was over. Social gatherings started and people stopped following COVID-appropriate behaviour like masking, distancing, sanitising, avoiding crowds. Then, sometime in early February, there were local body elections in Kerala and in some parts of Maharashtra, like Vidarbha.So, what is very typical of the second wave which we are in is that the less exposed population to the virus in the first wave has started picking up the virus in the second wave. This virus which came to Akola, Amravati, Yavatmal saw a very unique clinical pattern. It was spreading in clusters and families. Formerly, one member of the family got COVID and got isolated at home and came into contact with a few family members but not everybody got COVID. But in this [second] wave, we saw that even after casual contact with that person almost eight to ten people were getting affected. So, this was a more infectious strain which was rapidly spreading, but probably people were [making] a very good recovery and [it was] a less fatal and less virulent strain. That time some genomic data was analysed by the Microbiology Department of Pune’s B.J. Medical College, which found that there was a potential mutant but of course the genomic scientists did not attribute it [rapid spread] to the genomic mutant and unfortunately it became like a mini tsunami in Vidarbha, Marathwada and then gradually across whole of Maharashtra. And now we have cases swarming because of the fast-spreading strain. You saw a similar pattern occurring in Punjab and Delhi.
Was it the same strain in Punjab and Delhi?
No, it’s a different strain. So, the genomic scientists from the CSIR and the ICMR found there was a British strain variant in Punjab and Delhi, and they found a double mutant strain in Maharashtra: E384Q and L452R. Unfortunately, a correlation between this strain and the current pandemic is difficult to establish and is currently being studied. Week after week, we saw a geometric rise [in the number] of cases. At the same time what happened is that the government ramped up testing both in Mumbai city and the rest of the State. So, the 3,000 to 5,000 tests a day in Mumbai and 30,000 tests a day in the State suddenly went up to almost 50,000 in Mumbai and almost 2.5 lakh in Maharashtra. Therefore, we are seeing numbers of 60,000 plus in Maharashtra every day, and more than 10,000 in Mumbai alone.
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What strain is there in Mumbai?
We don’t have genomic data in Mumbai still, but we are reasonably certain that whatever the strain, it is a fast-spreading one. Mumbai’s already started plateauing out now, but the numbers in the rest of Maharashtra are going up and overwhelming the health care infrastructure. This is the challenge. Fortunately, the case fatality rate is low, but we are seeing a younger population, even children, getting affected, and there’s a fast spread of the virus because this is a working population.
Beyond this, what we have seen in Maharashtra is that the test positivity rate has crossed 20 per cent in many places and there is a large invisible pool of asymptomatic people; 70 to 80 per cent of this current strain is asymptomatic. And the right public health strategy is to micro-contain this invisible group. But to track and trace this invisible pool is a nightmare for public health [workers].And so, we have community spread.
One more thing we observed is that compared with the last time where we had the slums of Dharavi being affected in a very big way… they all have developed some form of immunity, but this time it is the people from a better socio-economic status being affected, and the problem we are facing with this is that they all want to go to a private hospital.
Tackling asymptomatics has been a nagging issue, has it not?
We need to isolate asymptomatics for a good 14 days because the COVID timetable is two to three weeks. Now, an asymptomatic person starts getting restless at being contained at home by the third day. After all, in the second week, he could get hypoxia and collapse and succumb. It’s vital to micro-contain and macro-contain these invisible asymptomatic patients.
Is this where a lockdown would be good?
Last year, when the first lockdown was done, it helped to build health care capacity. What we need rather than a lockdown is to have restrictive measures and zero tolerance for non-adherence to COVID-appropriate protocols. We need to make people responsible and not dismiss COVID lightly. We’ve taken COVID too casuallyWe have to stop reckless and mindless behaviour. And for that, the measures have to be restrictive. We have to have a behavioural change. This can be achieved by cooperation or by coercion. Ideally, the cooperative approach is best, but this doesn’t seem to have worked.
So, I think restrictive measures are required. Ensure that crowds and social gatherings are contained and there is zero tolerance for those who don’t follow the COVID code. If we don’t follow this, we will be at square one, and there will be a third or a fourth wave. It happened in France. We have to see that whatever restrictions we put in now, when we un-restrict them, there has to a be punitive measure for violating them.
Is this the advice you are giving the government as a Task Force member?
As Task Force members, we are looking at caring for patients and at ramping up testing and containment. We look at protocols to ensure that there is a two-to-three-week timetable, how to manage patients at home and what the red flags are to move them to a corona care facility or to a hospital set-up. In a hospital set-up, what should the therapy protocol be so that lives are saved. Our primary objective is care. And our second objective is how to ramp up testing, and containing the virus.
As far as restrictions and lockdowns are concerned, it’s a decision for the administration to take. Our advice is restricted to medical care.
Do you have any data or anecdotal evidence on whether the vaccine is offering protection? For instance, front-line workers have all received it. Has any infection or reinfection been observed among them?
A very relevant question. First, whatever vaccines we have are all emergency authorisation vaccines and are first-generation vaccines. We will get newer and newer vaccines in the next couple of years. Usually, a vaccine development timetable is five to seven years. We have super-fast tracked our vaccine development. All the vaccines are effective in preventing deaths and severe disease. However, vaccines may not prevent infection. So, many a time we see that vaccinated people may get a mild infection or an asymptomatic infection. We have not done any systematic study of health care or front-line workers who have been vaccinated. Also, remember that many people have harboured the virus asymptomatically when they got vaccinated. Vaccinations will not impact the current surge. Vaccinations will offer protection to mitigate and to take out the sting of the third wave. When the U.K. went into the second wave, the vaccination helped reduce the deaths of people above 65.
Also read: Lessons from the first wave
Apart from vaccination what are the other strategies to control the spread?
Vaccination is a future strategy. Current spread and future spread have only one strategy and that is double mask, sanitise and maintain distance, avoid crowds. And avoid poorly ventilated spaces.
Do we have to learn to live with COVID-19? Is it going to become a part of our lives?
COVID will get endemic in some geographies of India. And you will have to be masked in 2021 and 2022 whether you are vaccinated or not, whether you have antibodies or not, whether you have COVID or not.
Is there a shortage of vaccines in Maharashtra?
It’s all sorted out. There were two challenges. The rise of vaccine programmes in some parts of Maharashtra was very fast because as the rate of infection spread the rate of vaccination also increased very fast. This probably depleted the stocks from centres, and now they have been replenished, and I’m sure all stakeholders are taking care that the supply-demand ratio is adequately maintained.
Will the pace of vaccination step up now?
We are already stepping it up.
