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With Covid cases once again registering a comeback, we invited two doctors to take stock of what we have experienced over the last few years and provide us Covid insights. Dr J Amalorpavanathan, a doctor with a distinguished record in public health intervention including in setting up the organ donor registry in Tamil Nadu, and Dr Trivadi Ganesan, a medical oncologist with an international reputation in research, had a freewheeling discussion. Below is a summary of their discussion.
Dr Amal: Sir, you are a professional researcher. At this point, I want to play the devil’s advocate and ask you some questions.
Two things were discussed initially in Covid. One was community spread. It was said that when that happens, the virus will spread like wildfire. Deaths and diseases will be more. Then it will be doused like how a wildfire is doused. The second thing that was talked about a lot was that if more than 70% are vaccinated in a community, that community will get herd immunity and the community will be relatively safe. In the three years, what has been the learning? Should there be a re-education on these aspects. What are the current Covid insights?
Dr Ganesan: As far as India is concerned, in 2020 there was a wave. In 2021 there was a big wave. Again January of this year, there were more cases. There was infection but not too many people went to hospital. We note that some 50% to 60% have taken vaccination, both doses.
Dr Amal: In Tamil Nadu, first dose coverage is 90% approximately and second dose is 70% approximately, if I remember right.
Dr Ganesan: So there is some protection. And many have already got the infection. I got the infection last year. I checked my antibodies level which is high. This is due to a combination of vaccination and infection. This means the first concept of wildfire spread is not quite applicable to India. At that time, we didn’t know much. Also, hospitals were not quite prepared. Last year, we were better prepared. But still we had oxygen and bed deficiency. If 70% to 80% vaccination is there, the disease will be less. But it will be always be in the population just like flu. My assessment is Covid will also become like that.
‘Covid again: Likely no lockdown, no wave either’
Dr Amal: There have been many cases, even clusters. Hospitalization is less, antiviral drugs need is less, monoclonal antibodies need is less, prone ventilation is no more considered. What is coming is two-three days of infection. For this, should we go for vigorous vaccination such as vaccinating all school children? In light of decreasing virility of the infection and decreasing transmissibility, how do you see the relevance of mass vaccination today? What are the current insights on this aspect of Covid?
Dr Ganesan: We don’t know how many people need to be vaccinated to prevent this disease. Some diseases like measles need more than 90% of vaccination.
Dr Amal: But the cases are relatively mild. Should we go after the unvaccinated in a mass camp? Shouldn’t we target immune-compromised people and so on? Don’t we have better insights on controlling Covid?
Dr Ganesan: That’s true. Older people, ie, those more than 60 years old, and patients with kidney failure and heart failure can be vaccinated. They are vulnerable. It is not required that everyone should be vaccinated. In foreign countries, the stress is not there. My own personal opinion is that vaccinating children is not really required now. Government policy is to vaccinate and the Indian Academy of Pediatrics has supported this move for 2-18 years of age. A lot of thinking and minds have gone into this and this is the consensus.
The reason for vaccinating children was that they can catch infection easily. Since they are younger, they may not get diseases. But if they go home, they can infect older family members. If older people are vaccinating, then children need not be vaccinated. Focus should be on older, vulnerable people.
Dr Amal: This raises an ethical question. Why vaccinate a child saying his father or grandfather will get a disease?
Dr Ganesan: Individually, it is unethical. But this is public health policy. Now we have drugs but at that time they were not there. Only vaccination was there. We should focus on vulnerable people.
The reason for vaccinating children was that they can catch infection easily. Since they are younger, they may not get diseases
Dr Amal: Our understanding during the beginning of Covid was that children and adolescents have fewer ACE receptor cells so they have fewer chances of getting the disease. What is our understanding now?
Dr Ganesan: Children do get the disease. Only one in 100 who get it become serious. They could get Covid pneumonia or blood clots on their legs. To some extent this depends on the immune system. But we still don’t know for sure why only some children get it.
The other aspect is viral load that determines how much of the virus is attacking. We don’t know this fully. Not much research has gone into children’s infection because from the beginning they did not get the disease much. In foreign countries and India, there is an emphasis on vaccinating children. But in my opinion this is not required. The logic is not there anymore. This is among the new insights on Covid.
In school, while playing, they will get infection. In colleges, we have seen this. They sit together and eat. Nothing can be done about it.
Dr Amal: Some vaccines were released without the same rigourous procedure used for release of other vaccines. Are adverse reactions to these vaccines being documented adequately pertaining to India? Any research being done on this? Is the data in the public domain?
Dr Ganesan: In the beginning, when the first vaccine was introduced, the drug controller website had these. When delta came, the side effects got sidelined. In India, there is no data. In foreign countries where there is better data, complication cases are quite low. One out of 100,000, maybe. In India, this data is not there as far as I know.
In India, we have taken two vaccines mostly. I have not seen many adverse cases barring one or two to these vaccines. So I would say the adverse reactions are quite rare. Even in other drugs, we do prescribe without knowing fully the side effects.
Dr Amal: But vaccine and drug are different. In vaccine, the person is not a patient but a normal person. We don’t know fully the adverse reactions. We don’t have a system for compensation. So we should be more careful, I feel. I have seen cases of vaccine-induced thrombosis. I have seen palpitations. But these are all sporadic, as you say.
Dr Ganesan: As far as thrombosis is concerned, there is some documentation.
Public health is the only reason for these vaccines. The greater good is the overriding concern. Six million people have died. And that is likely an undercount.
Dr Amal: We have three defenses against Covid. We have pharmacological, non-pharmocological and third is vaccines. How muchever the virus mutates, it only goes in through the nose. So masks, social distancing are continuing to be relevant. Would you say masking and social distancing and handwashing are more relevant now than vaccination?
I advise vaccine to my patients saying it’s not just for a three-day fever. I don’t advise vaccine just because they will spread it to their family. The important reason is Long Covid syndrome.
Dr Ganesan: Masks are good. Those who have sneezing etc should wear masks. In hospitals and high-risk areas like cinema theatres, wearing masks is necessary. Even the surgical mask is good enough although N95 maybe better. The virus keeps mutating and infection keeps happening. It is not going away. Non-pharmocological intervention should not go away therefore.
Better drugs are there now, for instance against serious illness developing if a patient is found positive. These drugs have been introduced only this year through research. They can be prescribed for suitable patients, not necessarily young patients.
Public health policy says vaccine. We simply don’t have the beds. Zero Covid policy such as in China is difficult to implement here. Every three days, everyone should test is not practical in India.
Dr Amal: I advise vaccine to my patients saying it’s not just for a three-day fever. I don’t advise vaccine just because they will spread it to their family. The important reason is Long Covid syndrome. It’s an unmanageable symptom that is prevalent among some 20% to 30% of those who get Covid. The symptoms are sometimes bizarre and we don’t know if we can scientifically link them. For instance, I have seen borderline diabetics becoming full-fledged cases. We don’t know if we can link them. After three-four days of Covid fever, other symptoms start to kick in sometimes. We don’t have any medicines for Long Covid. So, if it’s a question of vaccine or drugs to fight infection, I will advise vaccine.
Dr Ganesan: Long Covid is a real problem in India. In Tamil Nadu, in MMC and Stanley we have launched Covid clinics. We don’t have the data yet for Long Covid. ICMR is looking at it, apparently. In the US, the Veterans Administration has put out data. Instead of Long Covid, I call it Post Covid Sequelae. It’s a real entity. Only some get it after infection. It’s like post viral syndrome.
Fatigue, tiredness, pain in the knees and hands and legs, diabetes – these are worrying manifestations in Post Covid Sequelae.
The virus is not going away. We test only through throat swab. We don’t know if the virus is there in the kidney or pancreas. In the US, during post mortem, they found the virus was clearly present in the organs. During endoscopy, they found viral fragments. We don’t know if it’s attacking the immune system. Long Covid is a genuine reason to avoid infection. This is among insights on Covid vaccination now.
Dr Amal: More than just 20% individuals, this means 20% of our workforce is affected. That’s a major impact on family earnings. This figure provides insights into the long term impact of Covid.
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