Fewer cases mean fewer mutations, says AIIMS director Dr Randeep Guleria

Ahead of festivals, you have warned of a possible rise in Covid-19 cases and asked people to remain vigilant. If all Covid protocols are observed, will that help prevent a third wave?If we look at the current situation, we have good vaccination coverage. And serosurvey data also suggests that more than 50 to 60 per cent of our population, including children, have antibodies. Therefore, against the current circulating Delta strain, a good amount of our population is protected. We have some numbers—it could be 30 per cent or less—that are still susceptible, and if we want to protect them... it would be very imperative that we have Covid-appropriate behaviour.

When you don't have a festive season, Covid-appropriate behaviour is easy to follow. During festivals though, there is a higher chance of developing super-spreader events that have a snowball effect. The chance of transmission becomes less when a majority of us have achieved the target rate of 80 to 90 per cent of protection. You could, therefore, be in a safe position, which would happen in the next two months or so only if Covid-appropriate behaviour is observed.

So we are looking at a low-grade third wave?
I feel that we may see a third wave in number of cases. But in terms of hospital admissions and deaths, it probably won't be that bad.

There is no likelihood of a new strain developing in the third wave?
One of the variables which is unknown is the virus. Will the virus mutate to become more infectious? No one can predict that. But we do know that when cases are less, viral replication is also less and so chances of mutation become less.

It has been more than 12 weeks since Bharat Biotech released their Phase 3 results. But why is the scientific community not convinced of its efficacy? The results are yet to be published in a peer-reviewed journal. What is lacking?

I don't think there is anything lacking. The data is all there. The detailed publication happens based on what the journal wants in terms of editing and things like that. The data has also been given to the WHO, so one is hoping that soon we will have their approval. There are also people who have done studies on Covaxin, which are not industry-sponsored. For example, we have looked at our own group of health care workers who got Covaxin. We found that there was very good protection in workers who had got the vaccine as compared with those who were not vaccinated, especially after two doses. We are now sending this data for publication. So I am very hopeful that in the next few weeks, data not only from the company but from various other institutes where Covaxin has been given will come out to give more strength to the efficacy and safety of the vaccine.

Is a third booster dose likely for the adult population in India?
We will probably need a booster, but there are still a lot of unanswered questions. First of all, at least everyone should receive one dose of the vaccine, ideally two, before we start talking about a third dose because you still have a large susceptible population that needs to be vaccinated. Secondly, we don't know what are the correlates of protection in saying that now this person needs a booster dose. Just a decline in your antibodies is not good enough because we already have other ways of protection in terms of cell-mediated immunity. Our memory cells can immediately produce antibodies whenever there is an exposure.
Then the other issue is which vaccine should be given as a booster.... Some data does suggest that if you got Covishield first and took a different vaccine later, for example, Pfizer, you had a better immune response. There is more data required, but at some point in time we will need a booster—depending on how things evolve in the long run.
For a possible third wave, what kind of preparedness are we looking at in terms of oxygen output capacity, hospital beds, medicines?
So, there’s been a lot of work done at the government level. I am aware that many groups have been formed which are working on this. Both for oxygen requirements in terms of having oxygen plants, storage capacity and trying to develop good distribution in terms of a dashboard, and similarly, how to upscale our beds—ICU beds, hospital beds. It is there both at the regional and the national level. So, a lot of preparedness has gone in, both from the adults and the pediatrics' point of view.

There was a spike in cases in Kerala which is now declining and then Mizoram is seeing an upsurge, specifically in the under-18 category. There is Ahmednagar district in Maharashtra where a lot of villages are now under lockdown. So will this qualify as the beginning of a third wave?
I think this is part of the tail of the second wave and we are still seeing some areas where we did not have that many cases in the past. So if you look at the overall numbers in India, they are showing a decline. But there will be pockets, as we are seeing in Kerala and the northeast where there will continue to be cases and that will happen for quite some time. We cannot say that we will reach a figure of zero for the country. We will continue to have few areas where small, localised outbreaks will happen but that will gradually become less and less.

There was a spike in cases in Kerala which is now declining and then Mizoram is seeing an upsurge, specifically in the under-18 category. There is Ahmednagar district in Maharashtra where a lot of villages are now under lockdown. So will this qualify as the beginning of a third wave?
I think this is part of the tail of the second wave and we are still seeing some areas where we did not have that many cases in the past. So if you look at the overall numbers in India, they are showing a decline. But there will be pockets, as we are seeing in Kerala and the northeast where there will continue to be cases and that will happen for quite some time. We cannot say that we will reach a figure of zero for the country. We will continue to have few areas where small, localised outbreaks will happen but that will gradually become less and less.

People who have taken Covaxin are an unsure lot. It's been more than 12 weeks since Bharat Biotech released their phase three results, but why are journals, the WHO and the scientific community at large still not convinced of its efficacy? The results are yet to be published in a peer-reviewed journal. What is lacking?
I don't think there is anything lacking. The data is all there. For Covaxin, the preprint is already there but the detailed publication happens based on whatever the journal wants in terms of editing and things like that. The data has also been given to the WHO, so one is hoping that soon we will have their approval. There are also people who have done studies on Covaxin which are not industry sponsored. For example, we have looked at our own group of healthcare workers who got Covaxin and then tried to see how many of them got infected. We found that there was very good protection in healthcare workers who had got the vaccine as compared to those who were not vaccinated. Especially after taking two doses. So we are looking at our data which is not company sponsored. We are now sending our own healthcare workers' data for publication. So I am very hopeful that in the next, let's say, few weeks, data—not only from the company but from various other institutes where Covaxin has been given—will come out to give more strength to the efficacy and safety of the vaccine.

With all the negative press around Covaxin, do you feel the perception of other upcoming homegrown vaccines like Zydus Cadila: ZyCoV-D will also be affected?
I do not think so. Ultimately, the vaccines which are being researched and produced in India are the ones that will be able to really provide vaccination for the world. Because our vaccines have two advantages. One is that they can be stored at two to eight degrees and therefore the cold chain is easy to maintain. And it is what has remained the standard in the past for vaccination of children or pregnant women. So for most of the world, it is easier to translate vaccines which are currently being manufactured in India. Secondly, in terms of the pricing, it will be much more cost-effective and easier for various governments to look at. And thirdly, we are the ones who are manufacturing vaccines at a very large scale. And once we reach a stage where we have enough for our own country, we will be in a position to supply vaccines for a large number of other countries which do not have vaccination plants and are not producing them. The strength lies in our own country.

Do you feel this delayed EUA approval for Covaxin and also UK's reluctance to recognise India's vaccine certificate are part of the same problem?
So UK's reluctance is a little bit paradoxical because of the fact that the vaccine (Covishield) was invented in the UK, Cambridge, given to AstraZeneca which is also partly based in the UK. The UK company gave the Serum Institute of India the license to manufacture it and also SII is going to manufacture Covishield for the Covax program which is backed by WHO to supply vaccines to the rest of the world. So their reluctance to give it a green signal seems a little paradoxical and hard to explain.It is difficult to understand why this is happening. Because currently, every country is in this pandemic together. What the pandemic has really shown us is that the “western” world or the “developed” world or the “developing” world don't live in isolation, they live together. And if you have a variant which develops in one area, it will travel to the entire world. So therefore, it does not matter whether you are here or there.

India is thought to have the largest adolescent population in the world, according to UNICEF figures. So what are some of the challenges likely to come up while inoculating this population group? Will the method to register continue to the CoWin app?
Yes, most likely it will remain the CoWin app. One is, of course, to have a strategy where we can now have this group also on the Co-Win platform. So the Co-Win platform is very robust, and it can easily have more people on board, especially children less than 18. The second challenge is, of course, to see how we can do it in a manner that may be easier to deliver. For example, can you look at vaccination, let's say, which could be done in a community setting like a local school? One has to look at strategies where they can be made simpler, especially for rural India.

When can we hope to rid ourselves of lockdowns, masks, social distancing? Gradually, once this becomes endemic. That means there is a good amount of immunity in the population and most people who get COVID-19 will get flu-like symptoms like fever, cough, cold. There is no need for a 14-day isolation except for the few whose immunity is very low like the elderly or the ones with comorbidities. But, by and large, the majority will have a mild self-limiting infection. To some extent that is already happening. If you look at data from Kerala, you have cases but hospitalisation is not that high. It means that already you are seeing cases where people are getting a mild infection and becoming alright unlike what we saw in the second wave. As to when India can get to the endemic stage, that is a difficult question. I am hopeful that it happens sometime early next year. But let's see.