Dr Harsh Vardhan says coronavirus patients deserve compassion. (Sanjeev Verma/HT PHOTO)
In the middle of the coronavirus disease (Covid-19) crisis, Union health minister Dr Harsh Vardhan spoke to Amandeep Shukla about “flattening the curve”, the importance of the lockdown period, aggressive testing, community transmission, and the quest for a cure, among other issues. Edited excerpts:
India has crossed 1,500 Covid-19 cases. When do you think the curve will flatten?
All public health measures are being put into place to mitigate the rise of the epidemic curve in India. The upcoming few days are critical. Our experience from the global response tells us that even with stringent lockdowns and public health measures, the transmission dynamics of Covid-19 is such that it takes about 2-4 weeks to bend the curve.
We recommended quarantine for 14 days, based on the incubation period of the infection. Incubation period is the time between acquiring the infection and manifestation of the symptoms. So, persons who acquire the infection prior to the lockdown will keep manifesting symptoms and be reported as cases in the first 10-14 days of the lockdown period. Only after this incubation period is over can we expect a change in the trajectory of the epidemic curve.
How important is the lockdown period?
It is an important intervention, as it delays the peak of the epidemic, slows the growth of the curve, and provides the health and social systems the time to mount a response. However, despite the lockdown and all public health measures being in place, it will take some time for the caseload to reduce, because individuals exposed just prior to the lockdown may take some time to manifest symptoms. Assuming that the lockdown is effective in ensuring social distancing, it will be important to see how the epi curve looks after two weeks.
It is vital that we initiate community-led interventions to ensure social distancing, quarantining, and isolation of symptomatic persons to augment the scale of the lockdown.
Do you think the lockdown should be extended?
The situation is still evolving. No doubt, the lockdown and quarantine has tried to contain the spread amongst clusters, still we have a long way to go till every contact of a confirmed case is rendered safe.
I would like to convey to your readers through this interview that they must honour the lockdown protocol. Staying at home is the only way of staying safe.
There is a lot of discussion or speculation as to whether the country has reached stage 3 or not. Have there been cases of community transmission?
There is no clear globally accepted definition for community transmission. Right now, India has mostly cases related to international travel, or such contacts. There have been only a few sporadic cases, which do not indicate a wider communitywide spread of infection at the national level. There are a few clusters of cases, which are being managed through cluster containment strategies. With the information at our disposal, it appears that there is no widespread transmission of Covid-19 in the community at the moment. However, we are far from being complacent, and we are maintaining stringent adherence to social distancing measures, ensuring a tight lockdown, and motivating the communities to own the social distancing strategies.
How close or far are we from finding a cure? Is a vaccine still a distant possibility?
There is no definitive cure for Covid-19 at the moment, and management is mostly symptomatic and supportive. However, a lot of investigational therapeutics are being researched, and India is part of international efforts to find a cure, such as the multi-country “Solidarity Trial” of WHO. Several treatment alternatives are also under trial; however, a definitive cure is not yet on the charts. Some of the agents under investigation include remdesivir, favipiravir, hydroxychloroquine plus azithromycin, lopinavir/ritonavir, to name a few. Some of the recent trials have indicated that the last two options may not be very effective. However, new evidence is emerging every day.
According to WHO landscaping, there are over 40 vaccine candidates under investigation. However, most of them are in the pre-clinical evaluation stage, and only two have progressed to Phase 1 clinical trials. The availability of the genomic details has accelerated vaccine production, but still we are unlikely to have a vaccine ready to scale up in time to staunch the current epidemic.
Around 100 cases have been declared as recovered? What are the lessons learnt from those cases? Are there any patterns which give us hope?
Most cases of Covid-19 are mild to moderate. Around 80-85% of cases are likely to be mild. Hence, we expect a significant proportion of infected people to recover without any significant sequelae. Our focus remains on preventing deaths. The most vulnerable groups include the elderly, or those with other conditions such as lung diseases, heart diseases and other chronic diseases. It is important to protect these high-risk individuals first.
What is the biggest challenge in countering this virus?
The timely dissemination of critical public health information down to the last man is the challenge. The other challenge is the misinformation about Covid-19 that is spread through social media or because of certain myths. We are constantly strategising on how to meet and counter both these challenges. Central and state infrastructure is pressed into action to ensure critical information related to precautions, social distancing norms, lockdown and self-quarantine protocols is available to the common public. Official channels of information are being constantly updated and monitored.
Similarly, steps are being taken to prevent spread of misinformation that can otherwise give rise of panic amongst the people. The third challenge is to get the communities to own the process of ensuring social distancing and self-enforcing these measures so that transmissibility is reduced.
My biggest challenge is to ensure that affected people are treated with compassion, and not stigmatised. This is also applicable for the health care workforce, which is working hard to counter this epidemic. It is through concerted, community-owned efforts, supported by the policies put in place by the government that we can contain this disease.
A lot of people feel that India is not doing sufficient testing. The example being given is of South Korea. Are we going to increase testing, especially in rural areas?
India has scaled up the capacity for testing in a massive way. As of April 1, 2020 there are 124 government laboratories across the nation that have been supported by ICMR. Further, 49 private laboratory chains have also been approved for testing. In order to ensure that we have reliable and accurate results, and the laboratory staff are also not exposed to undue risks of acquiring the infection, all labs have to meet a set of minimum standards. However, we have pan-India testing capacity, and are testing more samples every day.
Further, in initiating the testing work, we have to keep in mind the Indian context as well as the state of propagation of the epidemic in India. While indiscriminate testing is discouraged to ensure optimal use of resources available to us, targeted testing of higher risk groups has been the strategy to identify and contain the cases. In the near future, however, we will be scaling up testing to reach out to a wider population.
When will we widen testing and make it more aggressive?
India has scaled up the capacity for testing in a massive way recently. Collection centres are located in over 16,000 places across India. At present, we are utilising only 43% of our capacity to test in public laboratories. As of April 1, 2020, 8pm, we have tested a total of 53,605 persons. The figure for today alone is 5,654 persons, who have undergone testing.
Further, serologic testing is also under consideration, However, presence of antibodies indicates either past or currently active infection. They appear late in the natural history of disease between 5-7 days or so. Though these tests can be used for persons under surveillance, they cannot be used for early diagnosis. These laboratories are expected to offer tests to those who are eligible to receive the test based on the Covid-19 testing guidelines. These testing guidelines are appropriate for the level of the outbreak and avoid indiscriminate testing.
What is your strategy for areas where the spread is more? NCR is one such area. Kerala and Maharashtra have almost over 200 cases each.
A differential strategy needs to be adopted for areas depending on the extent of infections being reported. While it is important to protect the districts where no cases have emerged, it is also important to limit the spread of infection in districts where cases have been noted. To do this, we are focusing on multiple strategies.
At present, 10 states are contributing more than 80 per cent of the total number of Covid cases in India. Maharashtra and Kerala have the highest number of confirmed cases. Also, Maharashtra, Kerala and Karnataka have the fastest-growing incidences.
Only 16 districts account for 80% of the cases that have occurred in the last three days. Quite obviously, we work in a very focused way to contain the further spread of infection in these districts and employ multiple strategies for doing so. The central government works in very close coordination with the states to ensure that the rate of growth of new cases is contained.
Testing of eligible populations remains a focus area. Self-reporting of symptomatic persons, either through mobile apps or helplines is also being undertaken in some places. The lockdown needs to be supplemented with sustenance and relief operations through provision of food or other benefits to ensure that people are incentivised to adhere to the lockdown.
COVID-19 specific healthcare facilities need to be identified at district level, starting with the COVID-19 affected districts first. These facilities should be provided with the resources needed to combat the clinical workload.
How cooperative have the states been?
There is perfect coordination between the Centre and the states. I have been in regular touch with the state health ministers right from the beginning of this battle. I must commend them for the excellent work done by them in helping us control the spread of this epidemic either in the form of contact tracing, enforcing lockdown, providing isolation and quarantine facilities, ensuring smooth flow of supplies of critical equipment and supplies, boosting the morale of health workers, etc.
There is a continuous dialogue that I hold with the states. Just recently, I asked them to request retired doctors to volunteer proactively for battling this disease. Similarly, I requested the states to sort out issues related to health workers transportation on priority so that there is no shortage of doctors, nurses and other staff. We have asked them to issue directives that no landlord can evict doctors, nurses and other health workers. We are ironing out all difficulties together.
What is your message for the medical community?
This is an unprecedented crisis that is facing humanity as a whole. My heartfelt gratitude to all our health workers and support staff taking care of patients across the world. They are the ones who are leading this battle from the front. I call them “Corona Warriors”. Their selfless service at this juncture is unparalleled. The health of the nation is in their hands, they are placing the needs of the patients before their own. My request is to provide them with safe and respectful working conditions.
On March 22, Hon’ble Prime Minister Shri Narendra Modi ji told the nation to observe a day-long Janta Curfew and come out on the balconies at 5pm in large numbers to honour all the medical, nursing, paramedical, sanitary workers and other staff engaged in the hospitals. He asked the nation to stand up and in unison clap for our Corona Warriors and clang thalis. The air reverberated with the pious sounds of ‘Thali Bajao, Thali Bajao’ that evening. I felt moved by the commitment that people across the country showed, and I personally know many who cried that evening.
My message to the community is simple – the nation shall never forget your sacrifice. We are grateful to not just you, but your families as well.
What are the most important things to keep in mind during this crisis?
I would like to reiterate the importance of remaining calm, ensuring that there is no spread of misinformation, and ensuring that there is adherence to the policies and advisories which are being provided by the government from time to time. ‘Precaution, and not panic’ is the need of the hour.