‘With COVID-19 infections contained, hospital capacities up, we’re in a good position’

Union Health Minister Harsh Vardhan tells DH’s Sagar Kulkarni that so long as the mortality rate in India due to COVID-19 remains low and the recovery rate high, there is no reason to panic even as cases spike. Excerpts from an interview:

Q1. COVID-19 cases have crossed one lakh mark and have been on a sharp rise. Are there any lapses in the strategy?

A. Yes, it is true that the number of COVID-19 cases crossed one lakh-mark and there has been an increase in cases per day during the past few days. But I don’t see any reason to panic especially in view of the hospital infrastructure that we have made available over these past few months.

Moreover, in terms of confirmed cases per lakh population, India has about 9.7 cases per lakh population as against global average 68.5 cases per lakh population, 479.4 cases per lakh population in the USA, 386.8 cases per lakh population in the UK and 6.1 cases per lakh population in China. Similarly, in terms of case mortality per lakh population, India has about 0.3 deaths per lakh population as against a global average of 4.4 deaths per lakh population; 28.7 deaths per lakh population in the USA; 55.2 deaths per lakh population in UK and 0.3 deaths per lakh population in China.

In India, we have focused on reducing mortalities and whatever mortality has happened, unfortunately, a majority of it has been primarily due to co-morbidities. As long as the mortality rate is low, and the recovery rate is high, there should not be any reason to worry. However, this does not mean that we throw caution to the winds.

We should continue to pay heed to our Prime Minister Narendra Modi’s well-thought strategy of physical distancing and complete lockdown, which along with, public health measures like screening and quarantine; testing, case detection & isolation; and optimal care of the cases has been of great success in containing the outbreak in the country.

As regards the gaps, I would like to tell you that we have been pursuing a dynamic-graded strategy based on the evolving situation since the virus is new and no tried-and-tested formula can be used to contain its spread. We have tried our best to ensure that our planning is fool-proof and every effort is made so that we are able to achieve the objective of containing the spread of the disease. That is why you see a number of circulars and guidelines being issued by the Central Government regularly so as to ensure that there is a perfect coordinated action between the Centre and all the States/UTs across the country to combat the disease.

Q2. What has been your message to state health ministers? One gets the impression that the Centre is now leaving decisions to the states.

A. SARS-CoV-2 is a new virus and no one knows how it will behave in a particular socio-cultural setting. There is also no specific treatment or vaccine to treat the people from the COVID except symptomatic treatment. Learnings from the experience of an outbreak in other countries as well as the capacity of our health system coupled with the guidance received from the teams of health experts decide our response to the disease.

Since the beginning of COVID-19 outbreak, I have been in regular touch with the State/UT Health Ministers primarily to understand the problems they are facing on the ground, identify the gaps in our approach when implemented in the field, the kind of handholding that the States/UTs require to combat the situation and also to familiarize them with the strategy devised by the Centre to handle the pandemic. These interactions have been rewarding. I must tell you that our States/ UTs have done excellent work in containing the spread. Each of the Health Minister that I have spoken to has been hands-on on the situation in his/her state and have been eager to contribute their insights as well as graceful to accept the recommendations given by the Centre.

Initially, at the start of the lockdown, we focused on the macro-management of the disease through demarcation of districts into green, red and orange depending on the number of cases in each district. Once the disease was contained to specific areas, we found that districts would be a larger unit if we had to start an economic activity. Commencement of economic activity was essential because livelihoods of a large number of the population were at stake and we cannot afford to let our economy slow down under Narendra Modi Government. So, if we have to move to micro-level management, the States/UTs are the best judge.

In this Lockdown 4.0, considerable flexibility has also been given to the States to identify red, green and orange zones and further demarcate containment and buffer zones in red and orange zones to provide appropriate relaxations.

As long as COVID-19 management principles are clear and unambiguous, it is better that the decision making takes place at the lowest level in a federal structure. With the hand-holding that Centre has done till date, through advisories, and by deputing Central teams, I am confident that our States/UTs will do a stellar job.

Q3. The prolonged lockdown has led to weariness. Would it be wise to make relaxations because we are now witnessing a spike?

A. We cannot afford to hold back economic activities for long. So there has to be a combination of economic activities coupled with the observance of fundamental principles of lockdown i.e. physical or social distancing. That is why even the lockdown in its various versions has evolved over time as regards the sectors that can be opened for economic activities. The Lockdown 4.0 presents a framework where both the social distancing measures as well as economic activities co-exist. We should remember that whenever our containment strategy changes, there is bound to be a spike in the number of cases. This is because every new activity will bring forth the stresses in the system generated due to lockdown. There may be slackness at a few places which would give rise to spike in cases. But this does get corrected over time. As long as we are prepared to handle the increase in cases and keep fatality rate low, there is nothing to worry.

Q4. How has the lockdown helped in tackling the outbreak?

A. The relationship between lockdown and the containment of COVID outbreak can best be explained in numbers. Prior to lockdown, the doubling rate was 3.2 when measured over a period of 3 days, 3.0 when measured over a period of 7 days and 4.1 when measured over a period of 14 days. On May 25, it stands at 13.1 over a 3-day window, 13.2 over a 7-day window and 12.9 when measured over a 14-day window. Similarly, the fatality rate stands at 2.89% while the recovery rate has improved to 41.57%. Clearly, the situation has improved due to lockdown.

Any change in the situation, be it due to gradual relaxations in lockdown or due to migrant workers, will definitely result in a spike of cases, but we are prepared to handle this spike. Let us remember that lockdown or physical distancing measures do not kill the virus but only prevent the spread of disease. I am satisfied that we have used the opportunity provided to us by this lockdown to augment and strengthen our health infrastructure.

Prior to lockdown, we had 39,504 isolation beds, 9,472 ICU beds and 8,391 ventilators. As on May 25, we have set up 952 Dedicated COVID Hospitals and 2,045 Dedicated COVID Health Centres having 2,81,661 isolation beds, 31,061 ICU beds and 19,958 ventilators, for patients with moderate or severe symptoms.

Also, in 7,071 COVID Care Centres, we have identified 6,45,053 beds for mild, very mild or suspect cases. This augmented capacity will keep us in good stead.

On the testing front, our present capacity of testing is 1,50,000 per day and we have done 30,90,590 tests as on May 25. Further, on 24 May, we conducted 90,963 tests.

Q5. How has India’s healthcare infrastructure improved over the past two months? Are we prepared to deal with a surge in COVID-19 patients?

A. As far as diagnosis capacity of COVID-19 is concerned, we started with one laboratory at NIV, Pune in the first week of February 2020, and on May 25, 2020, we have a total of 609 laboratories, which include 431 government labs and 178 NABL accredited private laboratories.

As of now, our present capacity of testing is 1,50,000 per day and we have done 30,90,590 tests as on May 25, 2020. Further, on May 24, 2020, we have conducted 90,963 tests.

Priority-based targeted testing for COVID-19 will be helpful in detecting more cases and curbing the disease. I feel that with the sustained, quality assured scaling up of the testing, it is envisioned that we shall reach optimal levels of case detection and contain the outbreak.

As regards the adequacy of facilities for appropriate care of cases, I would like to inform that 80% of the infections of COVID-19 are mild or asymptomatic, 15% are severe infections requiring oxygen and maximum of 5% are critical infections requiring ventilator support. The more important thing is oxygen supply which may be needed for 20% of the cases, 15% through masks or cannula and 5% for patients on a ventilator.

It is observed from the recovery data of May 25, 2020, that about 2.12% of all active cases under management require oxygen support; about 2.67% of the active cases under management require ICU support and 0.40% of the active cases under management require ventilator support.

As on May 25, 2020, the number of beds in Dedicated COVID-19 Hospitals is 2,49,150 and that in Dedicated COVID-19 Health Centers is 1,76,165 making a total of 4,25,315. In addition, several domestic manufacturers for ventilators have been identified and orders for 60,848 ventilators have been placed which will be received in phase manner in this month and June.

Many hospitals and medical colleges are increasing the number of ventilator beds. Several hospital owners in the private sector are also contributing their facilities for the cause of the nation.

As regards PPEs, as on May 25, 2020, 32.45 lakhs are available with States/UTs. Further with the help of Ministry of Textiles, 109 domestic manufacturers have been identified and orders have been placed for 2.23 crore PPEs of which 74.84 lakhs have already been supplied. Today we are manufacturing 3-5 lakh PPEs every day and distributing to States. Also, as on May 25, 2020, 46.11 lakh N-95 masks are available with states and orders for 2.29 crore masks have been placed and 95.22 lakhs have already been received. Further, ten domestic manufacturers have been identified for in-house production of N-95 masks.

With this infrastructure, we are adequately prepared to deal with the challenge of a surge in COVID-19 patients.

Q6. Is this the peak of the outbreak or is the worse yet to come?

A. As you know that COVID-19 is a new disease and the behaviour of this virus in evolving outbreak is unknown. The current outbreak is probably the most significant event of our lifetime with major socio-economic implications. We have isolated the virus and our scientist and epidemiologist are studying it with the help of gene sequencing. Not much data about the virus and the disease is available at the moment.

Right now, we have a steady curve which has never shown any exponential rise and now we are trying to bend the curve. It is very difficult to predict the future course of the outbreak as it is decided by a number of factors like pathogenicity and transmissibility of virus; availability of specific treatment, vaccine; and collective performance of all public health interventions undertaken to contain the outbreak like testing, early case detection, isolation, quarantine, contact tracing, optimum care of cases and surveillance.

There are so many mathematical models predicting so many scenarios but all these models are based on a number of assumptions and presumptions which may not match with actual ground realities because of diverse social structure. Therefore, it would not be prudent to base any decision on the mathematical projections and predictions about a future scenario of the disease. By now the predictions of all national and international mathematical models have failed and we have performed far better than predicted.

Q7. How are the efforts to develop a vaccine or medicines for COVID-19 faring?

A. Physicians, funders and manufacturers have come together as part of an international collaboration, coordinated by the World Health Organization (WHO), to help speed the availability of a vaccine against COVID-19. WHO has convened multiple public and private partners for mapping eligible candidate vaccines and is coordinating clinical trials across the world.

As far as India is concerned, it has been playing a critical role in global vaccine production, research and drug development and today supplies vaccines to more than 150 countries across the world. India has geared up COVID-19 vaccine research both in academia and industry through national and global collaborations. To fast track vaccine research, COVID Consortium under DBT-BIRAC has supported 14 vaccine projects in academia and industry.

Apart from this, the unique position of India, which none of the other countries has, is its traditional knowledge system, which the Ministry of AYUSH and CSIR are attempting to explore together. Along with the Ministry of AYUSH, we have launched inter-disciplinary studies involving AYUSH interventions for COVID-19 on May 7, 2020. I am hopeful that these studies would assist in the assessment of the preventive potential of AYUSH interventions for COVID-19 and also to assess the improvement in Quality of Life in high-risk populations thereby giving a global push to our traditional systems of medicine for prophylactic interventions.

Therapeutics and Drug development has been a focus area also, and we are funding initiatives for therapeutics including monoclonal antibody therapy. As regards drugs, based on evidence from laboratory, animal and clinical studies, the following four options are in various stages of the trial. This includes Remdesivir; Lopinavir/Ritonavir; Lopinavir/Ritonavir with Interferon beta-1a; and Chloroquine or Hydroxychloroquine.

Q8. A common refrain now has been that ‘we have to learn to live with the virus? Is physical distancing the new normal?

A. This is true that we have to live with the virus. The lockdown has been very useful for the containment of the outbreak and has given good results. But it cannot continue forever due to the socio-economic and psychological costs involved. Therefore, we have to start activities in such a way that their continuance does not interfere with the containment measures.

For this, each one of us has to bear the responsibility and follow all necessary guidelines and advisories issued by the Government from time-to-time in true spirit. We all should observe physical distancing and use face covers as prescribed. The practice of handwashing, respiratory etiquettes and use of sanitisers both at home and at the workplace regularly, is essential. Further crowded places and gatherings for any purpose need to be avoided. At the workplace, it becomes essential to provide a safe environment and make arrangement as per the prescribed guidelines to prevent the spread of disease.

True to what our Prime Minister calls ‘Jaan Bhi Jahan Bhi’, the country will continue the fight against the COVID-19 and simultaneously, will continue engaging in economic activities, with all public health measures in place.

Q9. Are we dealing with multiple strains of the virus in India?

A. This virus came into India through travellers from other countries and particularly China in initial phases. There are three clades of novel coronaviruses available in India. Our initial virus came from Wuhan. The travellers to Iran and Italy harboured founder viruses that were closer to viruses in different countries in Europe and the USA. Any predominant strain of this virus is yet to emerge in India.

A paper from China described two different variants of this virus S and L. L virus has been described to be more transmissible and pathogenic. However, the study had many flaws. The genetic make-up of the virus is not the sole predictor of the virulence of the COVID-19 virus. The transmission and pathogenicity could have been influenced more by many other factors that were not studied. The lockdown in China could have impacted transmissibility more than the viral strain. Similarly, better management of patients through learnings and experience could have impacted pathogenicity.

Let me tell you, the mortality depends on a large number of factors, like the stage of the disease in which the patient comes to the health system; the medical care received by the patient; the co-morbidities of the patients who succumbed to the virus, etc.

Q10. What is the status of testing kits? We are now testing almost one lakh samples per day? Are domestic units also supplying testing kits?

Total of 609 laboratories which include 431 government labs and 178 NABL-accredited private laboratories are involved in testing as on May 25, 2020. As of now, our testing capacity stands at 1,50,000 per day and we have done 30,93,981 tests till date.

As regards the availability of testing kits, it is a dynamic figure and keeps changing as per consumption and receipt. As on May 23, 2020, the number of kits available with the states across the country includes 6,73,069 RNA extraction kits, 3,73,962 VTM and 7,46,533 RT PCR kits.

Q11. Do you sense a kind of fear among people about COVID-19? Is it justified, particularly when we are now talking of ‘living with the virus’?

A. This is a new disease with an incredible rate of spread but with a low fatality rate. However, the experience of COVID-19 in the USA, UK, Italy, and other western countries has definitely created a sense of fear among the people. Timely decision taken by the Prime Minister for complete lockdown along with steps taken to augment public health facilities has placed India in a very good position.

There is nothing to be panicky about. I would like to repeat that 80% of the infections of COVID-19 are mild or asymptomatic, 15% are severe infections requiring oxygen and a maximum of 5% are critical infections requiring ventilator support. The more important thing is oxygen supply which may be needed for 20% of the cases, 15% through masks or cannula and 5% for patients on a ventilator.

Just like any other virus which remains in populations and ebbs over time, this virus too shall become part of our lives. However, unlike previous viruses, this one spreads through lack of observance of personal hygiene and maintaining physical distancing. So, these mannerisms should become part of our lives to check not only the spread of this virus but other similar infections in future. In fact, this would spur us further to develop innovative and safer ways of interacting with each other in society.

Q12. You have taken over as the Chairman of the WHO Executive Board? What would be your role in the global fight against COVID-19?

A. My main responsibilities as Chairman of the WHO Executive Board will be to give effect to the decisions taken by or policies formulated by the World Health Assembly. During the World Health Assembly meeting last week, the entire world’s Health Ministers shared the single-most-important concern of containing COVID-19. Clearly it remains the prime mover of WHO’s efforts. I will continue efforts to mobilize on multiple fronts to contain the virus.

My immediate focus is towards the development of vaccine and drugs for treatment. There is also a need to strengthen global disease surveillance systems so that such pandemic does not occur in future. Apart from this, it has also been my effort in India to ensure that there are adequate capacities in terms of human resources and physical infrastructure so that the health delivery systems are competent to sustain the increased load due to the disease. I will try to see how our experiences can be replicated amongst the needy countries across the world.

Last but not the least, dissemination of adequate amount of “information, education and communication” material to provide authentic information to the community, thereby, empowering them to fight with misinformation and stigma against COVID-19 is the need of the hour. We have to ensure that the vast knowledge pool of WHO health resources is put to the best optimal use of the world so that we can disseminate adequate information to the people of the world and make them capable of taking care of their health in a positive manner for delivering the goal of health for all for the world.