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Decoding India’s COVID-19 crisis

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Dr Mehul Mehta, Chief Medical Officer at Albright Stonebridge Group (ASG), discusses the factors that led to the current crisis in India and the efforts that are underway to help the country emerge from this situation.

Currently, COVID-19 is continuing to wreak havoc in India. According to a recent World Health Organization (WHO) report, hospitals in India are fighting for beds and oxygen in response to the deadly surge in infections and the country is accounting for nearly half the coronavirus cases reported worldwide and a quarter of the deaths.

To make sense of the situation in India, we sat down with Dr Mehul Mehta, Chief Medical Officer at Albright Stonebridge Group (ASG). Dr Mehta draws on decades of global healthcare, medical education and life science research systems experience to advise on the development and implementation of health care, education and research systems around the world.

Dr Mehta discussed the factors that led to the current crisis and the efforts that are underway to help the country emerge from this situation. Excerpts:

How did things go so wrong for India? Is the new double mutant variant the reason behind the surge in cases?

In any pandemic, the spread of the disease is contingent on a balance between the infectivity of the virus and the resilience, or the receptivity of a population to get infected. If you looked at the early part of the year where the entire world was talking about India’s success, and the country itself felt that it had gotten over COVID-19, the virus had reached a balance between its infectivity and the people's resilience against it. And that came from multiple angles. Number one, the nature of the virus has changed. The virus has mutated and what we saw before and what we see now is a very different strain.

The second dynamic that shifted was that since people felt that the pandemic was over, they let down basic public health measures. When you let your guard down, you expose yourself. The body has not seen this virus before, so these basic public health measures are critical to protecting individuals. People stopped wearing masks properly, crowds started forming and social distancing was not being followed. This created an environment that resulted in an opportunity for a mutated virus and mutations spread much faster. This results in two things – the contagiousness increases, and they also do what's called an immune escape.

The third thing that happened is that vaccinations had not taken root. Even now, vaccination numbers in India are very low. Therefore, you had a combination of multiple factors – a virus that is much more infective, a more susceptible population, and basic public health measures that were being broken down that resulted in super spreader events.

What measures should have been taken to avoid the situation?

The first measure is prevention. If all the preventive measures had continued – wearing masks properly, not allowing crowds, it would have contained the virus. Once you have a spread, contact tracing is important, because that's part of public health measures, but then identification and isolation are equally important.

Contact tracing is important because few people infect everybody else. So, it's not a homogenous spread that everybody infects everybody else. Therefore, you have to find those super-spreaders who are highly infective and infecting the rest. This gets accentuated much more when you have a mutation because it can spread much faster.

The biggest thing to understand about what is causing the spread is the New Mutants and genomics. In January, India pulled together a genomics network. The country looked at all its national research laboratories that had genomics facilities and capabilities. They then tried to connect them through the help of external entities, such as certain genomics manufacturers to create, with their expertise, a national genomics system.

The important thing about genomics is that when you see positive patients, you do the genomics and have to correlate that to the clinical picture. Many mutations are non-relevant and there are some that are relevant. If you don't correlate a mutation with the clinical relevance, you miss the picture, as just looking at a mutation has no value. If you see the clinical relevance, then you know, which mutation is causing a different clinical picture, if it's spreading more or if younger people are getting more affected. This is how the B.1.617 mutation was found in Maharashtra. Therefore, we need a much stronger genomics network and big cities where this is spreading fast need their own genomics infrastructure.

The vaccine rollout has been quite slow in India, despite being the country having the highest vaccine manufacturing capacity in the world. Why is this the case?

The two vaccine manufacturers of India (Bharat Biotech and Serum Institute of India) are constrained due to global supply chains being highly stretched. They can’t manufacture vaccines in the absence of vaccine supplies, which are overstretched because of multiple factors. Firstly, these are specialised materials, and their demand has skyrocketed. We want to see vaccinations expand dramatically all over the world. But along with that, we have to figure out how do we make sure that that expansion is possible by going upstream in the supply chain and making sure the supply chain also can flex up. This is a global problem that needs to be addressed now

What would you say has been the impact of COVID-19 on mental health?

This is a very important topic in which I am very involved as I am on the board of trustees of the American Nurses Foundation, which is part of the American Nurses Association. Frontline workers all over the world and in India have reached a point of total burnout. Their mental health and physical health, and the risk they put on themselves and their families has been untenable and relentless.

Globally, burnout is a massive issue among all health professionals. I want to call out nursing in particular, as from the recent data gathered in the U.S., higher rates of burnout and loss of trust in the systems were observed. There has also been financial burnout.

It is very important to tackle this, for nurses in particular, as they are facing patient's 24/7 and require different forms of interventions, whether it is counselling, or finding different ways to reduce the pressure, finding financial support, and providing them with the right information. There has to be a strategy that's equally important to make sure your core workforce, the ones who are battling this for the whole world, are supported.

How is ASG helping support the fight against COVID-19 in India?

My physician colleagues and I came together as a volunteer group and had the support of the leadership of the firm. The first area is trying to push the dialogue and talking with different entities about how to increase vaccine supplies for manufacturing. I reached out to manufacturers and tried to find out what are their pinch points? Can we have a global dialogue? If by intervention and our facilitation and raising awareness, we get more vaccines out by a few days, we are saving many lives. This is what I call an amplification intervention.

The second is to enhance India's genomics surveillance capacity because we are doing less than 1 per cent of genomic assays on positive samples. We need to ramp that number up by a large factor and we're working on that and are getting a lot of positive traction.

The third is education, which is our relationship with Informa and leading academic centres of the United States. We believe that if we can help physicians keep patients at home, and help patients stay safely at home and get over COVID and reduce the pressure even by a fraction of a percentage in hospital beds, this will have a cascading effect on everything.

What are the next steps that India should take to survive this?

India needs to build up the infrastructure and the ability to prevent the fourth wave because we can’t afford it. Factors such as testing, tracing and containment need to be ramped up. People have talked of lockdown, but it is what I call a huge blunt instrument that causes a lot of consequential damage. But at some stage, it is the only thing that you have. We have to move rapidly to contain the current crisis and then prevent or prepare with the greatest strength for the next wave so that it is more muted or contained way.

The wave is spreading, so while Mumbai may be seeing a drop in numbers now and is in a better place, COVID is spreading to other parts of the country. Each of the states has seen what's happening and has to prepare. They have a lead of a week-10 days before it hits and need to be well prepared in advance.

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