Q & A on COVID-19 with a Public Health Perspective: A chat with Dr. Amrita Misra

first_imgThe Corona-virus disease (COVID-19) started in the Wuhan city of China in December 2019 and was declared a global pandemic by WHO in February 2020. It is a highly infectious disease caused by a new virus and spreads primarily through contact with an infected person’s cough or sneeze. There are also chances of spread when a person touches a surface/ object that has virus contamination and then touches his/her eyes, nose or mouth.It is not an easy task to protect ourselves from an enemy we cannot see and therefore each one of us needs to follow the advice of experts to protect ourselves and our community. Since March 2020, many countries all over the globe, including India, have urged citizens to maintain social distancing, which means keeping a distance of at least one meter from each other. Some countries have locked down, which means the closure of all workplaces and most businesses.To understand how this is being seen from a Public Health perspective and what should be the next course of action during and after the pandemic in a diverse county like India, I chatted with Dr. Amrita Misra, of course through WhatsApp and e-mail, since we are all lockdown at home; I tried to understand & to get some questions answered through the situation; not more not less but the real facts from a real Public Health Expert.Dr. Misra, a medical doctor with an MD and two decades in Public health, leads multiple projects in a Public Health Consulting Organization, providing technical inputs and programmatic leadership to a multitude of projects on Maternal, New-born, Child, Adolescent Health and Tuberculosis. She had also worked for almost a decade with the United Nations. What are the easier alternatives to Lockdown? The global picture shows that Elderly people, above 60 years of age, who have pre-existing diseases usually get more severely affected and have a higher chance of death, up to 14%. Those with compromised immune systems, such as HIV positive or those on immune-suppressants are at higher risk for severe disease. People who are working in the health care system in the facility and community are also at a higher risk. What’s the further projection of the epidemic? For latest update and information kindly visit https://www.mohfw.gov.in/&   https://www.who.int/emergencies/diseases/novel-coronavirus-2019        ] Coronaviruses are a large family of viruses that can cause illnesses ranging widely in severity. The first known severe illness caused by a coronavirus emerged with the 2003 – the Severe Acute Respiratory Syndrome (SARS) epidemic in China. A second outbreak of severe illness began in 2012 in Saudi Arabia with the Middle East Respiratory Syndrome (MERS).The SARS-CoV2, which is the name of this virus is a Zoonotic virus, which means that it originally infects animals, particularly bats. This is the first time this virus has been isolated from humans.Gene mutation simply means that a being can change some of its characteristics over time. Viruses multiply rapidly so gene mutations among them can occur rapidly to adapt to new environments. They undergo subtle genetic changes through mutation and major genetic changes through a process called recombination. A mutation occurs when an error is incorporated in the viral genome. Recombination occurs when co-infecting viruses exchange genetic information, creating a novel virus. The infection rate and the death toll depend essentially on the effectiveness of personal control measures and preparedness of the health system. Do we have enough drugs, beds, ventilators to care for the severely sick? Will we be able to isolate cases effectively? Are we actually maintaining social-distancing? There are so many parameters to consider.Because we have no previous experience with this virus, we take action based on current data which changes by the hour. Rate of infection, the severity of the disease, death rate varies not only from country to country but also with time, as doctors become better at managing cases. So, it is extremely difficult at this point to make any projections. But one should keep in mind that this virus has changed our way of living completely and is here to stay, till we find a very effective vaccine or medication and eradicate it like Small Pox was eradicated from the earth. I am quite hopeful that these dark times will end soon and we will learn from this situation to invest in our public health personnel, build better public health infrastructure and systems so that we can protect ourselves from future pandemics. [Author’s note: Some YouTube videos have been created in some Indian languages which can be viewed through https://www.youtube.com/playlist?list=PL19xiNr5KR1BzVhr3Yhkqw44Oi5jDd5SV Why is this called a novel virus and what is gene mutation? Who is more vulnerable? India is unique, in the sense of its size and population. The number of people migrating to other areas for work is possibly the largest in the world. To control and take care of this huge migrant population is posing a big challenge, especially for larger cities like Delhi, Mumbai, etc. Secondly, social distancing is not really part of usual human behaviour, so teaching people to keep distance or self-isolate requires behavioural change, which is always a long-drawn and time-consuming process. In larger cities, 40-50% are known to live in urban slums, in cramped and unhygienic conditions. How would they manage social distancing?Another challenge that the Indian public health system faces at all times is that the most severely sick people reach hospital facilities, so it is more difficult to save their lives, often leading to a higher death rate among hospital patients. This has to do with poor access, lack of resources and weak referral systems. In the case of COVID-19, it means that only the more severe cases will reach health facilities and several-fold milder will be missed. Due to ignorance, the milder cases will keep spreading the infection causing substantial loss of life and morbidity.center_img To stop and to take control of the massive epidemic, the only option available to the country’s administration is an enforced lockdown. This will give the health system time to prepare for the cases that will arise when the lockdown is lifted. Large scale preparations are needed, such as isolation hospitals, wards, testing kits, ventilators, drugs, personal protection kits for health workers and these are being prepared. It is also encouraging to see several State governments take proactive steps to equip the health systems, maintain supply chains of essential goods like food and medicines, provide food, shelter and cash packages to the poor. What should be the strategy to overcome this pandemic situation? Hoping for the best and preparing for the worst is the best strategy. While we go through this lockdown, the Government, the Indian Army, and all associated bodies need to make a collaborative, concerted effort towards managing the patients when they come. The virus is likely to spread rapidly when it reaches rural areas. There is speculation that due to environmental conditions it may not affect Indian populations as much as other countries, it is also speculated that Indians and neighbouring country populations have some level of cross-immunity to the virus. But there exists no scientific proof of these ideas and hence, one should assume that there will be a surge in cases in the next few months in rural India too.At a personal level – social distancing, avoiding crowded areas, washing hands frequently with soap & water is the best protection. Having said that, a recent study shows that each day 20 litres of water is being used per person, which can create an acute water shortage in the upcoming summer season. Therefore, while washing our hands we should try to save water by slowing down the flow a bit or may think of turning off the tape after wetting and during rubbing since it takes 20 seconds to properly clean the hands.Masks reduce the chances of getting infected if you are in a crowded area where the chances of infection are high, such as a hospital. But, in normal circumstances, masks are not required. Masks are a must for health workers, those providing health care services and those who are already infected. Till date, there is no medication for COVID-19. Several efforts are ongoing for vaccine development. As of 26th March, 2020, the phase I trial of a vaccine called mRNA-1273 has begun at Seattle (USA) by a private company, Moderna in which 45 volunteers are participating. They will go through 2 more phases of trials to check for side effects and for efficacy before the vaccine can be deployed. The process will take at least a year’s time.India has a robust supply chain system for Routine Immunization and for other Vaccination campaigns. These are meant for a specific age group i.e. for children. Once a COVID-19 vaccine is introduced, experts may consider vaccinating the most vulnerable first, as vaccinating the whole population will require several months and resources. Vaccine logistics management, reporting and analyses of adverse effects to make needful corrections in the vaccine will further prolong the process for a successful large-scale vaccination campaign. Widespread testing available to people will help to identify many more cases who should then be isolated. Studies are needed on drugs/ antiviral treatment and the development of an effective vaccine. Learning from other countries, the Govt has developed several travel advisories, Guidelines and Standard Operating Procedures for the community and for the health care professionals. These should be adhered to. What are the challenges being faced by countries like India? What should be the public health interventions? Once the Coronavirus was introduced among humans, due to its high infectivity, COVID-19 cases rose rapidly in many European countries, particularly Spain, Italy, and the UK. China, where the epidemic started managed to control it to a large extent with its stringent lockdown policy and isolation of infected populations and subsequent spraying of public places with disinfectants. South Korea managed it differently by testing and isolating a very large number of people. India, on the other hand, has a very stringent testing policy – testing only very high-risk cases, making it difficult to say how many cases exist in the community. But, there is an increasing trend of confirmed cases at the rate of 20-25% per day. There is speculation that in a few months there will be a tsunami of cases but there is no need to panic. It should be kept in mind that even among confirmed cases, the severe disease affects few people. To illustrate this, have a look at the data from a study in China; the large majority of cases 70-80% had mild symptoms, severe disease with breathing difficulties in 14%, critical disease in 5% and death of 2.3%. Some countries have not locked down and were hoping to develop ‘Herd’ Immunity, which means that they wanted to wait for many people to develop mild infection and develop immunity, so that the transmission chain of the virus breaks. But, as we see, this policy is not working, as everyone does not develop immunity so easily, and by the time Herd Immunity develops, scores of lives would be lost. What’s the current situation of the COVID-19 outbreak?last_img read more