By May 17, India would have been in a nationwide lockdown for over almost two months. With the lockdown to contain the spread of COVID-19 extended for the second time, questions that loom large are – what next? With the infection still prevalent, how will we go about our lives? What does India need to do to deal with this long term? And what will be the trajectory of the pandemic hereon?
TNM asked three experts – Dr Priya Balasubramianiam, senior public health scientist at the Public Health Foundation of India (PHFI), and director of the PHFI-RNE Universal Health Initiative; Dr Jacob John, former head of Indian Council of Medical Research and emeritus professor at Christian Medical College (CMC), Vellore; and Dr Jayaprakash Mulyil, a renowned epidemiologist. Here’s what they had to say.
The experts say that physical distancing and wearing protection gear – such as masks – frequent hand washing, coughing and sneezing etiquette will be a must in the time to come. Shops and other public places will likely make hand sanitizing a norm for anyone who comes and goes. Adapting these hygiene practices will require a behavioural change to some extent. Dr Priya estimated that these will likely have to be practiced till the end of the year, at least, or until we have herd immunity, treatment or a vaccine.
When it comes to movement, Dr Priya said that some inter-state and inter-district movements would continue to ensure supply chains are not affected.
Aviation experts already estimate that air travel will become quite expensive, as flights are unlikely to be able to operate at full capacity to maintain physical distancing. Experts had earlier told TNM that air travel may not resume till September 2020 at least. You may also be required to show a doctor’s certification for your fitness for air travel, carry their own protective gear like goggles, and also prepare for a longer boarding time, aviation experts had told TNM.
Dr Jayaprakash pointed out that when it comes to flattening the curve of the virus, the lockdown can do that – but temporarily. “It won’t make the virus go away, even if we remain in lockdown for two years. We have to resume some activity so that livelihoods can continue,” he said.
Dr Jacob agreed, “’Relaxations must restart economic activities […], yet if infection control is not good, we will go back down as if in a snakes and ladders game. Lockdown was necessary for infection restriction, but economic standstill resulted. Now doing the reverse - economic revival - should not increase infection.”
“It cannot just be left to the people; states will have to put in place checks to ensure physical distancing as well. They will also have to take the onus of frequent sterilization, disinfection of public places and providing personal protection equipment (PPE) to healthcare workers,” Priya added.
Dr Jacob also said when it comes to ‘normalcy’, he does not expect that to mean the absence of SARS-CoV-2, the virus that causes the COVID-19 disease. “Normal travel can resume perhaps with rapid testing of passengers, when SARS-CoV-2 is pan-endemic or universally endemic. Things will return to ‘true normal’ after a vaccine comes in wide usage.”
According to Dr Jacob, developing a vaccine for COVID-19 will take a minimum of nine months; other estimates suggest a minimum of a year or more. For the vaccine to come into widespread usage across countries will take even more time.
One key concept to understand the trajectory of the infection and the subsequent response is herd immunity i.e. the immunity of a population at large to a disease. This does not mean that everyone in the population is immune to the disease, but simply because most of them are, it can reduce the chances of the minority who are not immune contracting the infection. Once a majority of the population has been affected and has recovered, it breaks the chain of transmission as less people are susceptible to the pathogen, thereby slowing down, or ending the epidemic. This can be achieved in two days – either when a majority of the population is infected by the virus, or through vaccination.
According to Dr Jayaprakash’s estimate, India’s threshold for this is 60%, that is, when this proportion of its population has been affected, COVID-19 would slowly subside by itself. “I believe that if we open up and allow movement with precautions and protective gear, we will achieve herd immunity in around six months. We can slowly start to reopen schools after this,” he said. According to Dr Jacob, this herd immunity will be achieved at 70-80% threshold.
Herd immunity does not mean that we can let our guard down forever though. Dr Jayaprakash explains that every few years, due to the birth of new children, and the death of people with immunity, the proportion of population susceptible to the disease in a country increases. This gap, where a population remains protected from the disease, is the inter-epidemic gap. “German measles used to come back as an epidemic every seven years. Similarly, COVID-19 will also take some time to come back. However, its inter-epidemic gap should be a couple of years, which should give us time to come up with a vaccine,” Dr Jayaprakash said.
A vaccine and its universal administration would ensure continued herd immunity.
TNM also spoke to experts about what the trajectory of COVID-19 is suspected to look like from hereon.
Several educated estimates from epidemiologists and virologists globally suggest that the novel coronavirus is unlikely to disappear, and will probably become like the seasonal flu, spiking in some seasons. According to Dr Jacob, this appears to be the only possible trajectory. He referred to his write up in Current Science dated March 25, where he takes the example of the flu H1N1 pandemic and how it has become “perennially seasonal” and evolved as “pan-endemic” or globally endemic. He believes that SARS-CoV-2 will behave similarly.
Many global experts have similar views. According to experts quoted by Bloomberg, because the virus causes many people infected to be asymptomatic for two weeks or so, it is difficult to identify everyone who is affected and control transmission. Therefore, it is likely that the virus will continue to co-exist with humans.
Experts are also saying that it is likely to peak in the winter season – it will show more prominently in the southern hemisphere during winter, and then move to the northern hemisphere during the next winter. If the virus does behave in this way, experts are hoping there will be some respite in between, allowing for time and research into a treatment and/or vaccine.
The trends so far reveal that it is the elderly who are most vulnerable to COVID-19. According to health ministry data on April 30, the mortality rate in India is highest for ages 60 and up (51.2%), followed by 40 to 60-year-olds (34.8%), and least in those below 40 years of age (14%). 78% of the people who died also had co-morbidities.
Dr Jayaprakash said that by and large, a majority of the people affected will have a good immune response against COVID-19. However, given the vulnerability of senior citizens, he suggests that in the coming time, we must ask our elderly to stay at home, maintain a distance from their own family members who are venturing out. “We should allow the youth to work – with precautions and protective gear. We should make sure that our hospitals are well equipped and the staff have good PPE. When the most vulnerable populations stay indoors, we can avoid overcrowding at hospitals, and further infections.”
Dr Priya said that India also needs to be pre-emptive, and carry out rapid antibody testing and cluster testing among these vulnerable populations, like those living in shanties. “We should be able to isolate ahead of time, before the infection becomes symptomatic,” she said. That being said, it would also require India to ramp up quarantine and isolation facilities. Dr Priya recommends using large public spaces for this, like Singapore is using an expo hall to house recovering patients, who may still be infectious.
At the heart of India – and the world’s – long fight against COVID-19 is the healthcare system. And experts say that India must provide financial support as well as PPE to its frontline workers in order to emerge victorious against the pandemic.
One of the fallouts of the pandemic has been that most doctors and healthcare workers have been pulled away from treating patients with other chronic illnesses. There have been reports of HIV positive persons facing difficulty in accessing antiretroviral treatment, blood shortage, struggling dialysis patients, among others. Dental clinics have been shut as well. Dr Priya stated that this needs to be remedied soon so as to not make more of our people vulnerable.
She also said that India needs to strictly co-opt private hospitals into its fight against COVID-19, wherein private doctors will work in concert with state and district level counterparts to standardise guidelines for COVID-19 control. “Public hospitals need to be supported by the state as well as the Centre. Sterilisation, disinfection and PPE need to become priority. There also needs to be a long-term norm for investing in healthcare and its facilities, and research and development,” she added.
Experts also say that it should become a norm to test a person who comes to the hospital for COVID-19 to increase detection.
Dr Jayaprakash said that while in the initial period it was important to test to identify people affected and isolate them, the focus should now shift to providing PPE and to rapid antibody testing. The latter for it will tell authorities how many people are already affected on the basis of the presence of antibodies in their systems. “This could help gauge how many people in the community have already achieved immunity, and could help identify when we have reached the threshold level.”