The spread of COVID-19 will continue until herd immunity is achieved either naturally or through vaccination, according to Dr. Krishna Reddy Nallamalla, Country Director, Access Health International (AHI). In an interview with The Hindu, he also says that fault lines in health systems have been exposed by the raging pandemic. AHI is a non-profit think tank, advisory group and implementation partner with a mission to provide quality and affordable healthcare to people. Edited excerpts:
What is the ACCESS Health International’s assessment of the COVID-19 situation in India at present?
Containment measures instituted in the beginning have been able to bring down the reproduction rate (R0), i.e., number of people each person can infect, from ~2.8 down to ~1.2. However, given the socio-cultural factors, we have not been able to bring it down below 1.0 in order to bring it under full control. Hence, it will continue to spread across the population.
What should be done in such a situation?
Continuing personal protection and social distancing measures (social vaccine) with extra protection of vulnerable population (elderly and those with co-morbidities) will maintain or slow the spread to manageable levels. At the current level of positive cases, public health system capacity is not sufficient for an effective containment in terms of isolation of positive cases and quarantine of primary contacts.
Will the virus spread subside over a period of time on its own or will it continue till a vaccine is available for its treatment?
Virus spread will continue until herd immunity is achieved either naturally or through vaccination. Percentage of population needed to be infected to reach herd immunity levels are given by the formula 1-1/R0. For example, if R0 is 2.8, 64% of people need to get infected to reach herd immunity. However, if R0 is 1.2, and containment measures are continued, herd immunity may reach when ~20% of the population is infected. Since asymptomatic infections are common, current testing for viral detection (RT-PCR or antigen methods) in symptomatic cases only will not give us an idea of population infection rate.
So, what else is being done to get an accurate rate of infection?
Serological studies (which detect antibodies against the virus after a period of ~2 weeks) will give more accurate picture of population infection rate. For example, serological studies in Spain indicated that 5% of the population (~23.5 lakh) were infected, while RT-PCR positive cases numbered only ~3 lakhs, suggesting that the asymptomatic cases may be 8 to 10 times more than the symptomatic cases. Hence, seroconversion studies being undertaken by ICMR will give an idea as to what proportion of population in a given area is infected and how close has the population come to the level of herd immunity at the current reproduction rate.
It will be interesting to know the results of recent seroprevalence study carried out in Delhi, as it is witnessing declining rate of new cases.
Besides seroprevalence, are there any other studies in the pipeline with regard to COVID-19?
Recent scientific evidence demonstrated presence of innate cell-mediated immunity, possibly due to exposure to other corona viruses which underlie common colds. It is not clear if it plays a role in infection rates and herd immunity level. It is not yet clear as to how long the immunity is protective against a second infection. This also has relevance in effectiveness of vaccines. There are multiple ongoing studies that are studying existing antiviral drugs. Early treatment with effective antiviral drugs will also influence the spread of the virus.
What are the shortcomings of the current practices by the Central and State government in tackling COVID-19 in the country?
Major fault lines in health systems have been exposed by the raging pandemic across the globe. The hard choice between lives and livelihoods has also constrained the public health response. One of the major shortcomings, both at the Central and State levels, has been poor public communication in the face of misinformation flooding every communication channel. We need a clear, consistent, persistent and transparent communication in a way people can understand.
Second was in case of testing. There are two aspects to testing – one, as part of epidemiological response (triad of test, track, and treat) and two, to manage individual case. However, if an analysis is done of a given State, district, town or ward, the picture is entirely different. Adequate testing tailored to an area would have helped in calibrating the response. In addition, testing, not conjoined with isolation and quarantine of primary contacts, will not serve the purpose of containment. While guidelines issued by ICMR are applicable for public health epidemiological response, managing an individual case either in clinics or in hospitals, require different approach to testing. Hospitals routinely screen for HIV and Hepatitis virus for every admission and procedure to protect health workers and other patients. The same principle applies to COVID.
Third shortcoming was in preparing the hospital systems to meet anticipated surge in cases. Most of the capacity was built in public healthcare facilities, while the people trust in these facilities has deteriorated over last few decades. Engagement of private sector right from the beginning of the pandemic in planning the response would have avoided the current situation, wherein people are flooding limited private healthcare capacity despite fears of unaffordable costs, while public facilities remain unoccupied.
Fourth is the response to non-COVID health needs of people. Since entire public health system has been engaged in COVID response, vaccinations, antenatal visits, tuberculosis and HIV treatment programs might have suffered to a large extent with long term consequences. Given the fear of contracting infection in clinics and hospitals, people need clear guidance on where they can safely visit for their non-COVID health needs. Telemedicine, helplines and mobile clinics will be of great help.
Last shortcoming has been the response from the payer system (Public and Private Health Insurance). Beneficiaries are not aware whether their health card/ policy covers COVID-related health needs. Similarly, there has been no dialogue between payers and empanelled hospitals on the subject to arrive at a mutual agreement. Governments have an option to extend health coverage through existing schemes (PMJAY, Arogyashri etc) to all COVID-affected people to avail treatment at the empanelled hospitals.
Have the Central and State governments adopted any of AHI suggestions so far to address the spread of virus?
AHI has shared a study comparing the response of various countries in tackling the epidemic. It also submitted a note on engaging private health system in joint response to COVID, and participated in a collaborative report on managing testing supply chains. It has been providing support to State health agencies administering PMJAY in addressing steep drop in claims for non-COVID health needs, in ramping up testing capacity in Uttar Pradesh by identifying private facilities with capacities to undertake these, and in addressing various concerns of PMJAY empanelled hospitals. Basic principles of epidemic response remain same. It is the capacity of the government to implement these that determines the outcome of the epidemic.
You said fault lines in health systems have been exposed by the raging pandemic. What is AHI doing in this regard?
We are tabulating health system response to COVID-19 across its various pillars (governance, payers, providers, public health, and health information) in order to come up with policy briefs in strengthening health systems and making them more resilient. While we struggle to contain the virus, the learnings should not go waste in future.
