Dr Krishna Reddy Nallamalla
Mutations in genetic coding, like spelling mistakes, are common. The frequency of mutations depends on stressors in external milieu, just as a stressed person is more likely to make spelling mistakes. Some mutations give an organism a survival advantage, while some are detrimental to its survival.
Unlike bacteria, viruses need a host cell for their proliferation. The SARS-CoV2, which is the virus causing the Covid-19 pandemic, is an RNA virus that gains entry by binding to the ACE-2 receptor present on cells through the receptor-binding domain (RBD) of the spike protein. It is like a key to open the lock. Evolving mutations of the virus may make the key fit into the lock more perfectly, thereby facilitating guaranteed entry. Such mutations tend to increase the infectivity of the virus.
The human immune system recognizes a foreign protein and counters it by synthesizing antibodies that bind to the grooves of the key thereby blocking it from opening the lock. However, when there is a change in the groove due to a mutation, the antibody may not be able to bind the groove needed to prevent unlocking. These mutations will allow the virus to evade the immunity developed earlier either due to natural infection or vaccination.
Some mutations may allow the virus to infect and damage a greater number of cells across various tissues and organs. This may result in a higher number of infected people becoming sicker and eventually losing their lives. This was the case with the corona virus underlying the Middle Eastern Respiratory Syndrome (MERS-CoV) that had very high lethality.
The above facts are common scientific knowledge. They are the basis for many public health measures. Across health systems, public health has been relegated to backyards, as they evolved more to take care of individual’s health than that of the population. Strong disease surveillance is the foundational response to any epidemic. A good surveillance system monitors the epidemiological behavior and clinical behavior very closely. Many countries today have highly evolved genomic surveillance systems.
The issue of variants was brought to the fore by the mink-associated variants in Denmark in November 2020. On December 14, 2020, UK and Ireland reported the new variant (B.1.1.7) which subsequently became dominant across many countries. The variant isolated in South Africa (B.1.351) raised concernsregarding the efficacy of the Astra-Zeneca vaccine Covishiled in providing immunity against it. The P.1 variant was first detected in Brazil in January this year. California reported two variants (B.1.427 and B.1.429) in February. India reported a double-mutant variant of concern in March.
Could we have prevented the second wave?
We need to analyze the response and preparedness of various branches of the Indian health system in particular and the whole of social systems in general as the first wave was waning and news of new variants began cropping up across the globe.
Response of the Governance System
Governance of health systems is multi-level, starting with the WHO at global level, the ministry of health at national and state levels, and going down to district, mandal/ taluk, and village level governance bodies. Since the pandemic affected every section of the society, the decision making happens from the highest level of the Prime Minister’s office, aided by expert advisors and evidence. Institutions entrusted with generating scientific evidence must be competent, should have enough resources, have a fair degree of autonomy and independence, and should be free of the fear of reporting the truth. The Indian Council for Medical Research (ICMR), National Center for Disease Control (NCDC), Department of Health Research, National Health Systems Resource Center (NHSRC) etc., are some of the key institutions responsible for providing scientific evidence to guide decision making. Whether the government was provided the needed evidence and scientific guidance towards emerging variants is not clear. Evidence was provided, but the government might have been constrained in its decision making by various other factors, especially those concerning economy and livelihood.
If the threat of new variants was well understood, the government could have taken a few practical, but effective steps to stop their spread. It could have increased its cross-border surveillance of incoming people from other countries, includinga preventive blockage for people from countries reporting new variants. It could have ramped up genomic surveillance of positive cases to detect not only the entry of new variants from abroad but also to identify new variants arising within the country, given its huge capacity across various public research labs. It could have continued public messaging on the perils of relaxing Covid appropriate behavior, given its reach to every person in the country. It could have put a system in place to test various vaccines and diagnostic tests against the new variants so as to prepare itself better. It could have put effective restrictions on political, religious, and social gatherings. It could have planned better to vaccinate more people as fast as possible, given the manufacturing capacity of India.
Two factors might have lulled the decision makers – one, the decline of the first wave despite nation-wide unlocking, and second, the high percentage of people having evidence of prior infection through sero-prevalence studies leading to a belief that the decline of the first wave was due to herd immunity. It was forgotten that the percentage of immune people needed for achieving herd immunity depends upon the prevalent containment measures. If a majority of people follow Covid appropriate behavior, herd immunity may be reached once ~25 percent of the population has immunity. However, for a variant with high infectivity rate (like the UK variant which had 40 to 70 percent more infectivity), coupled with people letting down their guard by going back to pre-Covid behavior, you may need ~70 percent of people to have immunity for achieving herd immunity.
Even as the central government has been taking appropriate measures against the threat of new variants, state governments seem to have failed to understand their future threat or might not have had the resources to continue the battle, or were more focused on preparing for the vaccination drive. Even if governments at various levels have taken appropriate measures, people and other branches of health systems (providers, payers, public health professionals, producers and health information and communication systems)might not have given enough thought to the threat of the variants. Unless every actor plays their role, systems will not be able to function effectively.
Response of the People
People started heaving a sigh of relief as the first wave came down from a high of 100,000 positive casesa day, to a low of less than 6,000 cases per day. Energy consumption came back to pre-Covid levels. Families started celebrating long postponed marriages and other functions. People started visiting hospitals and clinics for their other health problems. Restaurants and movie theatres started opening. Air travel came back to 70 percent of pre-Covid level. People with properly positioned masks became a minority. The arrival of vaccines boosted everyone’s confidence further. Markets were booming like never before. In the absence of a credible individual or institutional messenger, the public health message got drowned by the cacophony that exists in regular and social media. There were more debates on vaccine approval processes than on the new variants. Vaccine hesitancy witnessed till recently started giving way to the demand for vaccines. Public behavior is also changing with regards their choice of vaccine.
To communicate the threat of the new variants and the second wave, India needed a figure like Anthony Fauci, who became the source of credible, consistent, and scientific public information in the United States. To shepherd liberated masses of people, we could have used legal measures to enforce masking, just like we did to ban public smoking. Political and religious leadership should have been educated on the looming future threat. We, the people, people’s representatives, and public activists, are to be blamed for letting our guard and vigil down.
The role of the Public Health System
We have a weak public health system, from years of neglect. Many districts do not have formally trained public health professionals. Most of the public health response today depends on frontline health workers (ASHA, ANM etc.,), who did a commendable job during the first wave of Covid, despite meagre resources available to them. As the public health system was relaxing from the rigors of the first wave, it was activated again in preparation for the nation-wide vaccination program. It is unthinkable for the existing public health system to undertake both containment of the second wave and vaccination jobs simultaneously. Bringing the private sector on board for vaccination will not only ramp up vaccination, but also release public health professionals to focus more on containing the second wave.
Has the Provider System learnt from the first wave?
The public provider system created sufficient beds to manage Covid patients during the first wave. However, given the low trust and confidence people have in public healthcare, many beds remained unoccupied while there was a shortage of beds in the private healthcare system. With advances in medical knowledge, medical treatment protocols are getting standardized. People now have free access to diagnostic tests. Many patients are being managed at home, including receiving oxygen therapy. Use of tele-consultations has increased and there is a general acceptance towards it. More than access, people are more apprehensive of medical bills. There is no shortage of masks and PPE kits within the provider system anymore. A majority have built their capacity to ramp up vaccination subject to supplies. Compared to other branches of health systems, provider system learnt much faster from the first wave and are reasonably well prepared for the second wave, provided the surge does not overwhelm the capacity.
How has the Payer system changed?
During the first wave, the fear of financing unforeseen medical expenses was far higher than contracting the virus itself. Even people with health insurance protection (either public or social or private) were subjected to hardships both by the insurers and the providers. While insurance regulator (IRDAI) stepped up oversight, it was not enough to give succor to people. Few state-level public health insurance programs (like Arogyashree in Telangana State) refused to cover Covid treatment, thereby defeating the very purpose of preventing catastrophic health expenses for which these programs were designed and rolled out. As non-Covid health needs declined dramatically, claims went down significantly thereby benefiting health insurance companies. As people recognized the need for protection against unexpected health expenses, there has been a significant jump in health insurance policy holders, even overtaking motor vehicle insurance. Overall, while the payer system hasn’t learnt from the first wave experience, people are learning how to prepare for future health expenses better,
Producers seem well prepared for the second wave
By the time the first wave ended, India had witnessed an amazing turnaround in the production of various goods required for Covid diagnosis and management. We were in a position to use the excess capacity created to supply to rest of the world. Despite having the capacity to produce vaccines, we erred in anticipating the second wave. We didn’t finance the manufacturers in anticipation of the need for faster vaccination. However, given the capability to ramp up, we still can correct the mistake.
Diagnostics and vaccine companies are working out strategies to deal with the variants. Sensitivity and specificity of existing diagnostic kits may have to be reassessed against the new variants. Genomic data can guide the process. Similarly, it becomes imperative to generate data on continuing efficacy of the existing vaccines against the new variants. Information being shared across the world can be leveraged to take appropriate and timely action.
Health Information System – is it coming to the rescue?
The first wave triggered the announcement of the National Digital Health Mission (NDHM). Digital technology has been of immense use in disease surveillance, mobility data analysis, vaccination logistics, communication, direct benefit transfer, telemedicine, homecare, andrapid training among others. The second wave is expected to sustain this momentum towards achieving the ideal state of standards based, interoperable health records systems. Digital Health can bridge some of the existing chasms in health systems. Bioinformatics, for example, has taken a quantum leap due to Covid.
Response of the system as a whole
A health system is an open, adaptive system with interdigitation with other social systems. The first wave disrupted almost every social system. Most of the systems were recovering back to pre-Covid levels, albeit in a state of new normal. Energy consumption and GST collections exceeded pre-Covid levels recently. The learnings gained from the first wave will be leveraged during the second wave to blunt its impact. The education system that was hoping to come back to normalcy will have to go back to remote learning. Working from home has become the new normal. Companies will likely make arrangements to prevent labor migrationin the real estate and manufacturing sectors. Online services will get a second booster dose to propel to a new trajectory. Economic recovery may not significantlyimpacted. However, inequity may further widen. Policy measures should address this issue on priority.
Covid variants will continue to evolve. Covid appropriate behaviorshould continue despite vaccination, until the WHO declares the end of the pandemic. Ill-informed lockdowns may not be of help. Public messaging should improve. Direct benefit transfers may mitigate people slipping into poverty. Health systems will continue to learn and adapt. People should be well aware and wary of the unintended consequences arising from decisions that are not based on scientific evidence and pragmatism.
Dr Krishna Reddy Nallamalla
Country Director, ACCESS Health International.