Governments and citizens interested in politics, cricket than science, quips Dr Jacob John
Diphtheria and Rabies have not been controlled, neither have Cholera, Malaria or Tuberculosis in India. Only Polio and HIV control programmes succeeded in India, says Dr T Jacob John
The world has pinned its hopes on a vaccine to help us return to a state of normalcy. Dr T Jacob John demystifies for lay readers what the vaccines may or may not do and how they work. Dr Jacob John is retired Professor and Head, departments of clinical virology and microbiology, Christian Medical College (Vellore), and was Director of ICMR’s Centre of Advanced Research in Virology. He has conducted pioneering research in the fields of infectious diseases, clinical virology, and epidemiology.
Edited excerpts of an interview he gave to Ashlin Mathew
It’s been nine months into the pandemic and we are going to touch one Crore cases and 1.5 lakh deaths. Where do we stand? Are the cases likely to increase?
The pandemic is beginning to slow down everywhere, India included. The one crore documented number is a gross underestimate – by how much no one knows. India’s peak was in September and since then numbers are declining almost in all states, Union Territories, cities, districts. Cases will continue till first quarter 2021, which is my personal opinion. It is unlikely to increase significantly.
Could we have reduced the number of deaths? How?
The answer is given by Kerala. In spite of being diabetes capital of India and in spite of maximum number of people above 65 in the country, case-fatality was always 0.5% or lower. If other states want to imitate, they have to go back 20 years and build primary/secondary health care under public-private cooperation. Literacy made people learn fast. These legacies are not easily replicated.
Do you think the Central government and several Indian states have completely given up managing the pandemic? They seem to be now only interested in optics...
You mean politics. It seems to me that both governments and citizens are more interested in politics, cinema, cricket, music etc and least interested in science. This is reflected in Padma awards. Science is not well understood by people from top to bottom. Logical thinking; clear understanding of cause and-effect; and faith inhuman ability to change natural path of physical events – these are the elements of faith in science.
People had to be taught to modify behaviours in the wake of the pandemic and healthcare workers had to be trained. None of these happened in India. The Central government did not release enough guidelines and procedures to follow. State governments did better. We are still in the midst of an epidemic and all kinds of false information is being spread. It must be taught to people and the best person to teach Indians is the Prime Minister. That means he has to learn it first.
Is India going through the continuation of the first wave as in India the numbers never really went down? When do you think COVID-19 is likely to peak in India?
India’s gross numbers are cumulation of a thousand epidemics. They were asynchronous and spatially disparate. The sum total is a statistical construct. That national epidemic curve peaked by end-September and since then it is slowly declining. I do not expect a second peak any time soon – by second quarter 2021 the infection will be “endemic” – low numbers constantly present. Only countries that “flattened” the first curve – Italy, Germany, and Kerala in India, have the second wave. We may have seasonal ups and downs. These are my opinions based on my understanding of both theory and available facts.
There seem to be five vaccines which are top contenders. Which one do you think will be best for India? Why?
No one can answer that now. My guess is that mRNA vaccines may be safest and most efficacious. Both Moderna and Pfizer vaccines are using this method. Here, vaccines make use of messenger RNA molecules to tell the body’s cell what proteins to build to fight the virus.
But, both Pfizer and Moderna are out of reach for Indians, so ‘Killed virus’ vaccines may be equally safe though efficacy needs to be measured. I expect very high efficacy, equal to mRNA vaccines. In a “killed virus” vaccine, a chemically-inactivated virus is used and it does not infect, but it retains the spike protein. Covaxin by Bharat Bio is an example of this kind of vaccine candidate. We do not have data, but I am guessing from a safety point of view, neither the mRNA vaccine, nor the killed virus vaccine will introduce alive virus into the body. Hence, likely to be quite safe. Many killed virus vaccine such as for Hepatitis A, Polio IPV, rabies, influenza have been highly successful.
Adeno-vectored vaccines such as AstraZeneca/Oxford vaccine and Sputnik V vaccine, are introducing a virus into the body. At the moment, we are unclear about safety and efficacy. Here the safety has to be documented.
DNA vaccines, such as the vaccine candidate from Zydus Cadila, may be safe but probably less efficacious than others. Many DNA vaccines have been tried, but they don’t do quite well. Efficacy has not been up to the mark. Proof of the pudding is in its eating. Let the cooking of the pudding be over.
The regulators continue to maintain silence about the adverse event in the AstraZeneca trial; why do you think they have maintained silence?
I have no idea. Apparently, the volunteer was not fully informed. The legal action was one and a half months after the event – plenty of time for counselling, putting information in public domain etc. Lack of promptness in informing the volunteer himself, even if it was not vaccine-adverse reaction, eroded trust.
A volunteer, in the AstraZeneca trials who faced a severe complication, has sued Serum Institute of India. SII has said they would file a counter defamation suit. Their response came even before the regulator spoke about the issue. What should have been their response?
If I were to advise, I would suggest to ramp down emotional response, anger, accusation – but provide facts, logic, cause and effect sequence and build trust through kindness, factual information, transparency, humility regarding delay in letting everybody including the public informed.
By when can most people, realistically speaking, expect to be administered the vaccine? Will the vaccine be just one of the measures to control the spread of COVID-19?
India cannot “control” in the absence of the second intervention and public health surveillance. Either the vaccine can be used for personal protection or it could be used on a national level in a planned programme to control the epidemic.
‘Control’ is a technical term. We must have a baseline level – suppose it is 1,000 people getting infected in a day and based on this baseline, we must say that it must be brought down to 10 infections in a day. That is my ‘control endpoint’. We then introduce the interventions to get these results, then monitor these interventions to see if the level has been brought down to our definition within the specified time. This is called ‘control’ in epidemiology. Control is reduction in burden to pre-determined level from the present level proving that the decline was due to the intervention.
Decline can also happen naturally. It needs to be proven what would have been the numbers if the intervention had not been applied. Polio was eradicated with extreme control, HIV was reduced immensely; here control meant no increase in infections and the numbers should reduce. Now, HIV numbers in the country have reduced and our intervention has been accepted around the world.
There is not a third control that has succeeded in India. Diphtheria has not been controlled; it has come back again and again in the twenty first century. Rabies has not been controlled, neither have Cholera, Malaria, Tuberculosis, Typhoid, Leprosy, Hepatitis B or C been controlled.
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