Vaccines, Data, Public Healthcare: 3 Challenges Before Third Wave

Unless India acts swiftly, we will be condemned to cyclical surges and the inevitable lockdowns.

There will be a third COVID-19 wave in India, and a fourth, and a fifth and these will be caused by new hyper-virulent, hyper-transmissible variants. Super spreader events when superimposed on new emergent ‘variants of concern’ will supercharge the surge.

We can never have enough oxygen, adult and pediatric hospital beds, drugs, ventilators, and clinical staff. Unless India acts swiftly, with strength and coordination, we will be condemned to cyclical surges and the inevitable restrictions, containments, and lockdowns that follow with their devastating consequences on our lives, our livelihoods, and our crippled economy.

Infection is Inevitable: Not a Question of ‘If’ But of ‘When’

SARS-CoV-2 is here to stay and as long as the virus is prevalent it will continue to spread, replicate, and mutate in unvaccinated and under-vaccinated population groups in our country.

Each of us, adult and child will get infected and reinfected with this strain, or the next. It’s not a question of ‘if’, it’s a question of ‘when’. We have to adapt to this virus just as we have come to live with ‘flu’ viruses including adenoviruses and other coronaviruses.

The outcome we should be working towards is to down-regulate SARS-CoV-2 from a pandemic to a seasonal infection that has outbreaks with lower number of cases, morbidity, and mortality, allowing us to safely keep our economy open.

We have to stop mopping the floor and turn the tap off. To achieve this outcome, India will need to overcome two colossal challenges.

Vaccinate, Vaccinate, Vaccinate! But Can We?

The first is to immediately purchase, procure, and partner with domestic and international manufacturers to produce enough vaccine doses to enable mass, rapid and repeated vaccinations of a billion Indians every pandemic season.

To meet this challenge, the Indian government announced on 13 May its ambitious plan of producing 2.16 billion doses of vaccines against SARS-CoV-2 in India over 5 months starting in August 2021.

However, vaccines do not save lives, vaccinations do and mass, rapid, and repeated vaccination is the only way to prevent the next pandemic cycle. Up to 23 May, only 10.9 percent of our population had received 1 dose and only 3 percent had been fully vaccinated with two doses. On an average, 1.54 million Indians have been vaccinated every day since the vaccination program started on 16 January.

If we achieve our moonshot of procuring and producing two vaccine doses for 1 billion Indians, the next Herculean task will be to administer these doses in five months. We will have to vaccinate 14.4 million citizens per day, over ten times the current rate of vaccination and many decision-makers forget that vaccinating the nation is not a one-off.

We lack the infrastructure to administer the produced vaccines at the scale and speed this pandemic requires and will fail in this critical task unless we mobilise our armed forces, our railways, our network of pharmacies, primary health workers and paramedics so that a produced vaccine gets into the arm of an Indian overnight.

Unless every Indian is protected either by vaccination or herd immunity, India will remain unprotected.

This is a Battle, And It’s Our Economy (And Lives!) on the Line

India will be unable to end the economic crisis until we resolve the health crisis. All vaccines are not equally effective and investments in higher efficacy vaccines results in higher economic benefit. We are currently rolling out vaccines in India without full knowledge of efficacy against original and current ‘variants of concern’.

Manufacturers must be held to account to meet efficacy targets reported at the time of receiving ‘emergency use authorisation’ and be fully transparent about their clinical trial and phase-4, post roll-out analysis.

A central, national vaccine agency must purchase vaccines, now, as the first part of the technology transfer and licensing deals. Decisions must be based on high efficacy and ability of the platform to quickly re-engineer and update vaccines against emergent strains.

SARS-CoV-2 has caused more death and destruction of our economy than all the wars post-Independence India has fought. The battles against emerging infectious diseases will not be fought over our skies or at our borders. We need to radically rethink how best to defend ourselves against this new, invisible enemy.

Whilst India’s military expenditure as a percentage of general government expenditure at 8.8 percent is strangely comparable to that of the USA at 9.4 percent, India’s current healthcare expenditure as a percentage of GDP at 3.5 percent is shockingly a fifth that of the USA at 16.9 percent. This resource allocation has to change, our public health systems and infrastructure are now our new defence forces.

India Needs a Public Health Agency, Now

The second and equally crucial challenge, therefore, is to revamp our central health agencies and fund a ‘Public Health India’, on the lines of the other governmental public health agencies like the US Centers for Disease Control and Prevention (CDC) and UK Public Health England (PHE).

Without a national, networked, proactive and hyper-vigilant, hub and spoke public health agency we cannot battle this or future epidemics. Nationwide, this new agency must continuously surveil, detect by gene sequence an emerging virus and its mutations, define the transmissibility and virulence, and correlate to the severity of clinical illness.

This agency must monitor the ability of the variant to evade existing vaccine or infection induced immunity and this actionable intelligence must be passed on to vaccine manufacturers who can re-engineer their platform and produce effective and updated vaccines.

We cannot effectively manage what we do not measure ! We cannot re-engineer vaccines if we do not know exactly which variant is prevalent and causing disease. Sadly, only 1 in 1886 positive cases in India undergo viral genomic sequencing.

Data from the Global Initiative on Sharing All Influenza Data (GISAID) indicates that since the start of the pandemic India has shared only 14,063 (0.05 percent) viral genomic sequences, less than a tenth of one percent of our total reported cases.

Do We Really Believe Our Fatality Rate is Just Over 1%?

India has reported over 26.75 million cases of SARS-CoV-2. Given our population of 1.4 billion, is it plausible that only 2 out of every 100 Indians tested positive over two surges? The total reported deaths in India are 3,03,751, which works out a case fatality rate of just over 1 percent, very impressive even by Western healthcare standards! These numbers are decoupled from the all too painful reality we witnessed. They are a gross underestimation and experts believe that the real morbidity (disease) and mortality (deaths) could be at least five times higher.

It is ruinously sad, but the only meaningful metrics that might indicate we have turned the corner and that this surge is easing across our country will be the absence of the tragic images of oxygen shortages, inadequate ventilators, overflowing hospitals and ICU beds, exhausted clinical staff, and most heart-rending of all, the number of burning funeral pyres.

If the virus has taught us anything, it is that irrespective of the divisions and differences of wealth, education, religion, station, and location, all our lives are even more inextricably connected. This is India’s crucible moment. We have to transform not just the healthcare of an individual Indian but the public health of a nation.

(Joseph Britto is a former consultant and honorary senior lecturer in Pedaitric Intensive Care at Imperial College at St Mary’s Hospital, London, UK. He can be reached by email on [e-mail] or on Twitter @JosephBrittoMD. This is an opinion piece, and the views expressed are the author’s own. The Quint neither endorses nor is responsible for them.)