Gagandeep Kang, Director of Translational Health Science & Tech Institute has been discussing everything we need to know about India’s fight against coronavirus. As the disease is spreading rapidly across the world, governments, health agencies and pharmaceutical companies are making concentrated efforts to root out the virus.
In an exclusive interview with CNBC-TV18’s Archana Shukla, Kang decodes what measures are being taken in India to ensure patients are treated in a timely manner and how research institutes are working with authorities to curb the spread of the virus.
Below are unedited excerpts from the interview:
Q: Currently when it comes to the coronavirus outbreak, the Indian Council of Medical Research (ICMR) says we are still in the local transmission phase. But there are certain states like Kerala and if we look at the revised guidelines they have come up with, it suggests that at least for those states they are moving into a community spread phase. What is your assessment?
A: I think without availability of testing data it is very difficult to know what is and is not happening. I think that community transmission in India is likely very feasible to have happened and if we test more, we will be able to find the extent of that. So, in terms of the approach that we have taken so far, we have only done risk based testing, testing travellers and their contacts. That is never 100 percent so it is good to think about some level of community testing as a backup to inform you whether community transmission is happening or not.
In the absence of any approaches that allow us to look at communities and whether there are infections going on, it is very hard to say where exactly India is on the epidemic curve. We do know that once transmission starts locally, things start moving very rapidly in terms of numbers of cases and particularly severe cases coming into hospitals.
If we look at the countries that have controlled transmission and the once that have not, the difference is in the testing. The ability to make wide testing available as quickly and widely as possible.
Security guards check bags and offers hand sanitizer to the visitors as a precautionary measure against COVID-19 in an almost empty shopping mall in Kolkata, India, Sunday, March 15, 2020. For most people, the new coronavirus causes only mild or moderate symptoms. For some, it can cause more severe illness, especially in older adults and people with existing health problems. (AP Photo/Bikas Das)
Q: In your assessment community transmissions in a country like India could have already happened. Any assessment as to what level and would it be confined to the places where we found positive COVID-19 patients, those who have travel history and their family members or will it be beyond those regions as well?
A: If we are to look at whether community transmission is happening or not, there are two ways to do it. One way is to look at testing people and finding out whether people who do not have a travel history and do not have a history of contact of infected or not. The other approach is to follow syndromic findings and see whether the patterns this year are different from other years.
So, in New York, they have tracked the influenza surveillance patterns, looked at admissions and visits for respiratory infections and shown that the levels that they are seeing are greater than are expected for influenza alone. So, that would allow you to estimate what proportion of respiratory infections with fevers that come in, that fit sort of influenza like illness case definition could be COVID-19.
In the absence of such data in India on a country wide scale or by state, it is very difficult for us to use that approach to estimate whether or not there is community transmission. So, essentially if we want to know whether there is community transmission or not, we have to test.
Q: India has also started using influenza surveillance tests that we have and the network that we have under the integrated disease surveillance programme. How useful will that be? Is that a step in the right direction?
A: It is absolutely a step in the right direction. The symptoms of flu and the symptoms of COVID-19 overlap so much that it is very difficult at an individual patient level to tell the difference between the two. So using the influenza surveillance network is a good way to go, but unfortunately the influenza surveillance network is not representative of the whole country. The locations where their network is located or the laboratories in the network are located don't really have the kind of distribution that would tell us that this represents a good picture for the entire country. It is a great start, but the numbers are limited and it is not representative, so we should be thinking that what is it that we do beyond the influenza surveillance network.
Passengers undergo temperature check as a precaution against a new coronavirus at Chhatrapati Shivaji International Airport in Mumbai, India, Tuesday, March 10, 2020. For most people, the new coronavirus causes only mild or moderate symptoms, such as fever and cough. For some, especially older adults and people with existing health problems, it can cause more severe illness, including pneumonia. (AP Photo/Rafiq Maqbool)
Q: Statistically if you look at a situation like this where we aren't doing enough testing but we know that there is a community transmission with 125 currently reported positive cases, statistically what would be the reference points for the number of people?
A: This is a little difficult to say. I can speculate but until we have more data, it is just speculation. If you look at other countries that have good contact tracing, testing activities they have been able to control infections with a lot more than 120 inflections coming in. However in our case we know that the testing and the tracing of contacts has not been perfect which makes me think that we really need to check on community transmission and whether that is happening or not.
Again I would emphasize that this is to inform better decision making. Bulk of patients who get infected are not going to be the ones who will get really sick, 80 percent do well. We are looking at doing this so that we protect the most vulnerable in our population and that is people who are older and people who have co-morbidities. This disease is spread by younger people, people who have a lot of social mixing, people who are professionals who go to work and people who travel. So even though they are not going to get the severe disease, they are the ones who are spreading the disease and our responsibility is to the most vulnerable in our population.
Q: In that regard you spoke about the need for testing and how we are not doing enough, let me take your perspective on some of the government decisions in the last 2-3 weeks. We have closed our borders to most of the European countries, to some of the Middle Eastern countries and some of the South East Asian countries. Slowly, we have added more countries to the compulsory quarantine list. The band was recently extended to UK, France and two other countries in the European Union and we also extended the compulsory quarantining to four of the Middle Eastern countries. We still have people coming up and saying that while they travelled from a country X they did not show symptoms.
A: I think when someone doesn't have symptoms what can you rely on? You can look at a travel history and say you come from a place that has a lot of disease and therefore you need to be quarantined or followed up very very rigorously. So in that sense this is the right kind of thing to do. Does closing borders help? Every little bit that you do that allows for people not to mix with each other is a good step. Is that step going to completely control spread of infection? No it's not because we know that people can share it before they are symptomatic. There is a small proportion that is also asymptomatic infections and that's what makes this particular infection very difficult to control transmission. What seems to work best is using every approach that we have available to increase separation between people, restrict movement of people, restrict gatherings, restrict travel, these are all helpful steps but none of them is really perfect because as long as you have some people coming in contact with others, transmission will happen.
Agra: A CISF officer, wearing protective face mask, stands in the backdrop of the Taj Mahal, in Agra, Tuesday, Feb. 4, 2020. India on Sunday temporarily suspended e-visa facility for Chinese travellers and foreigners residing in China in view of the coronavirus outbreak that has killed more than 300 people so far. (PTI Photo)(PTI2_4_2020_000132B)
Remember we are not trying to eradicate this infection from the world, what we are trying to do is too slow transmission down. A lot of people are talking about flattening the curve and flattening the curve does not mean that you will have fewer cases, it just means that you will have fewer infected people at any given point in time. So you are spreading transmission instead of completely stopping it. If you did stop transmission right now what would happen would be essentially when you restricted all these measures you might get a second wave where people who had not been exposed previously would now come up in large numbers. So what we need to do is to see how much do we stretch transmission out and as I said every action that separates people from each other will decrease transmission.
Q: In terms of criteria of testing people who have travelled from a foreign country back into India, a lot of people have put themselves into individual isolations and home quarantine, but every single call they make to the authorities for testing, they are asked whether they have symptoms, have you travelled from this country? If not we won't test you even if you have symptoms. In terms of the criteria of testing that we have as of now, do we need to add certain more criteria and expand it beyond this point?
A: I think anyone with symptoms should be evaluated. We know people are coming from many countries but airports themselves are a source of transmission, so you may not have come from a country that is very badly affected but you will have transited and been in contact with people who have come from many other places as well. So anybody who is an incoming traveller looking at symptoms and then testing them irrespective of which country they came from is a good thing to do. I also think that we need to do syndromic surveillance, the influenza network is doing a proportion of that but it is a proportion, I don't see why we can't expand that to severe cases to less severe cases and come to a point where we can do the kind of screening and testing that China and South Korea or Singapore have done, which is not risk based testing but testing for anybody who might potentially be infected. In fact in Singapore they were allowing doctors to order tests even if a person did not fit the case definition and in a small study over 10 percent of all the infections that they found was because the doctor had a suspicion and ordered the test.
Q: In India particularly on the testing side, is it a matter of not having enough capacity that we are not testing or the government is thinking that we are in the local transmission stage, we don't need to do a community level testing or expand testing to every single person who may have travelled from a foreign country in the last 20-30 days?
A: I think the government is thinking about expanding testing. We have seen that they are now going to allow accredited laboratories to test. I think we will see testing expand greatly and it is not a question of resources at this level. We have heard from the ICMR director general that even the laboratories in the ICMR network are not functioning at capacity because they are getting very few samples to test at the moment. So I think we should be expanding the pool of people that we are testing.
In terms of laboratory capacity if you look at private labs, we could expand testing a 100 fold with no problems at all. We need to be able to do real time PCR to specify what the protocol is and provide those laboratories with the primers and probes. So in terms of laboratory capacity this is doable.
In terms of identifying patients and collecting samples from those patients this is something where we really need to expand how we decide whom to test. As I said earlier, I think we should be moving well beyond travellers, travellers from everywhere if you want to do that but it has been shown that traveller based screening is not the perfect way to detect all infections that are imported. However I think we need to look to see about what's happening in communities. If we find that there is nothing, that's great. Unfortunately I don't think that we will find that but this time I would be very happy if I am wrong.
In terms of looking for community based testing, I think that is essential. I think community transmission may already be happening and the only way we are going to find that out is if we test. This is one time where I would be really happy to be proved wrong if there really is no community transmission going on, that would be very reassuring and give our health systems plenty of time to prepare.
FILE - In this Jan. 30, 2020 file photo, a man wears a face mask as he stands along the waterfront in Wuhan in central China's Hubei Province. Arek and Jenina Rataj were starting a new life in the Chinese industrial center of Wuhan when a viral outbreak spread across the city of 11 million. While they were relatively safe sheltering at home, Arek felt compelled to go out and document the outbreak of the new type of coronavirus. Among his subjects: the construction of a new hospital built in a handful of days; biosecurity check points; and empty streets. (AP Photo/Arek Rataj, File)
Q: In terms of private laboratories, we know that at least in Mumbai, one or two private laboratories have been approached to get their capacities. How much time will private laboratories take and is there a policy that in this sort of an outbreak only government centres will be testing and will there be some policy revisions on this or it is just a matter of saying “yes” to private labs?
A: Yesterday, it was announced that accredited private laboratories that have national accreditation board for laboratories accreditation would be allowed to test and I think this is a great move on the part of the government because it stresses the government system a lot less. When we share the workload then there will be less work, we won't be overwhelming the government system.
Q: South Korea particularly has made all testings free of cost for every individual. Is something similar possible in India?
A: I think we should be thinking about providing much greater free testing. We could do it as a way of saying that if you have symptoms and you meet this case definition or if your doctor thinks that you require testing then testing will be done for free and that would be great to do.
I think there are a lot of people who are very worried particularly if they have elderly individuals in their families or someone who is undergoing chemotherapy, has diabetes, has hypertension etc, where even people who have believe that they have come in contact with somebody who might be infected, might want to get tested, in that case I see no reason why they shouldn't get tested if they pay for it because it is really for their own reassurance rather than to solve a public health problem. However in terms of where it affects public health, I think we should be thinking about making it free or making it greatly discounted.
Q: There have been certain companies like Roche that have come up with fast testing kits for coronavirus, they are in the testing stage of the kit, but does India have this sort of capabilities? I remember last when we spoke you had mentioned that the Department of Biotechnology was working on a mass scale screening tool which would help screen multiple people at the same time. Where are we as far as the development of these testing kits and screening kits are concerned?
A: Roche Cobas system that has been approved by the FDA for testing is something that a lot of Indian clinical laboratories already have. It is just question of buying the kits from Roche and running them on the machine. However to do that we need permission to import and that would require for Roche to apply to the Drug Controller General of India for permission to bring the kits into the country. Then the laboratories that already have the Cobas system could test.
In terms of developing new diagnostics, there is work that is ongoing but in order to do that work you need access to both different kinds of reagents as well as samples from patients who have tested both positive and negative and that is something that the department of biotechnology is working on.
In terms of being able to test at the population level, doing PCRs for patients is the first step but we really should be thinking about transitioning to assays that allow us to assess exposure which are antibody-based tests and department of biotechnology is working on those. Those usually take a few months to develop and we will need well characterized samples from patients where we know what the outcomes have been to both develop and then validate those tests.
Q: You said you are still looking at samples, are there enough samples for you to do your testing for the screening kits and by when could we have indigenously developed screening kits?
A: I understand that there are already India-developed screening kits available. There is a company in Hyderabad that is making kits, there is another one in Ahmedabad that has just had its kit made and they are applying to DCGI for approval. A company in Delhi has a PCR kit that has already been sent to the National Institute of Virology for validation. So there are multiple manufacturers in the country that are making these kits and now want marketing authorisation to be able to sell these kits in the market.
In terms of being able to do the testing as opposed to having commercially available kits, the primers and probes that are required were published by the CDC but they got some things a little bit wrong and the WHO and other researchers around the world that Chinese protocols are available to everybody. So in terms of kits there are some that have been developed and in terms of testing protocols there is a lot that's already available. It is a question of synthesis of primers and having the right probes to be able to get testing off the ground.
In terms of samples to be able to validate these tests that is important but remember when you are doing a PCR based test, confirmation is relatively easy because you can amplify multiple parts of the genome and sequence the virus. So even if you don't have a positive control in your test you can still get confirmation of the result by using another technique which is sequencing.
Q: Now that the government is also expanding the testing stage and we know that there would be community transmission of the outbreak, everyone has been talking about flattening the curve and you did explain what it means but are we on the right track as far as flattening the curve is concerned, are we doing the right things and what in your sense more needs to be done so that the transmission is arrested and the curve is flattened? If we go out on the streets for the larger crowd life is as usual. We in our offices are sanitising everything and we are working from home etc but the larger crowd they don't have the liberty to work from home, they are traveling in public transport, they are meeting people especially in cities like Mumbai or Delhi the density of population is so high that even if you want you may not avoid the infection.
A: That is true. Where ever you have people in contact with each other, there is a risk of transmission of infection. One infected person in a mix can transmit to a lot of other people - between 30 and 60 percent are the estimates. So the risk of acquiring infections anytime you are in a crowd, anytime you are spending prolonged periods of time with people are there. However we are constantly acquiring other respiratory infections of various kinds. As I said earlier what we are trying to do with flattening the curve is trying to stretch out the time it takes for people to get infected. It is important to remember that every action that you do can potentially help decrease that risk. We have seen a lot of discussion around washing your hands, obviously that helps, if you look at not touching your face that helps, opening a handle with a paper towel, wiping down a pole that you hold on the train before you hold it with a sanitizer would help. Is it possible when you are pressed up against each other to avoid having someone breathe in your face? You can't.
It is important to remember that there are things you can control and things you cannot control. Where ever there is something that you have control over, do that. It is important also to remember that it is the younger people, the fitter people who are going around and traveling, so when these people come home and you have somebody who is more vulnerable to severe disease, that is where you have control of the precautions that you can potentially take - take off your outside clothes and put them aside for washing, make sure that you have a shower or bath when you come in if there is enough water but if not at least change your clothes, wash your hands, wash your face before you go close to somebody who might be at risk of having severe disease if infected.
So every action that we do, that we can control, that decreases risk of transmission is a good one. It will decrease risk for this Coronavirus and it will decrease risk for other infections as well.
There are things as I said that you cannot control and then I think it is very important to not beat yourself up about it, to not get into a panic if you could not control the situation. If you did have somebody cough in your face, it is definitely a risk but it is not your fault, you couldn't have done very much about it. So it is important as I said to stay aware, do what you can, limit interactions as much as possible and if you cannot limit those interactions, it is very important not to go into a negative spiral and feel guilty about these things.
Q: Have we not been able to also provide a good level or good infrastructure at the quarantine facilities, a reason why some of the suspects or positive people who have been quarantined have actually slipped out of those quarantines? What more can be done there? I understand it is an outbreak, it is like an emergency situation so whatever best is available is being done, but what more can be done? Like the Delhi government was talking about hiring some of the hotels and converting them into quarantine facilities for people who want to pay and live there and not live in a government quarantine facility. But is the infrastructure and the level of quarantine facility good enough in India right now?
A: Right now it is not. The Delhi government has notified three hotels as potential places in Nehru City where people could undergo quarantine if they can pay for it. But what actually worries me is I do not think our quarantine facilities are good enough and there is a lot being said around how you must accept that this is for the public good and therefore put up with poor circumstances for the period of time it takes for you to be quarantined. That is correct, but I also think that it is possible if we decide to go for it on a war footing to build better bathrooms for people.
It must be remembered that this is a virus that transmits through the respiratory tract and multiplies in the gut. We have currently no evidence that it is transmitted fecal-orally but severe acute respiratory syndrome (SARS) certainly was. One of the ways of transmission was because sanitation was not good. There was a toilet breakdown that led to a lot of people being infected.
So, when you put people in quarantine, the fact that you are putting people in quarantine when you might have an infected person there and this is a respiratory infection, you are in fact increasing the level of risk that the group that is quarantined might potentially have. So, that is through respiratory route. If you can do something about preventing that by putting people so that they are housed at great distances apart instead of what we have seen which is where the beds are actually quite close together for people who are being held there as well as by improving the bathroom and toilet facility, I think it would go a long way in helping people stay in quarantine.
It is easy to say that if you are being told to stay in quarantine, then stay there, but there is a lot of support that needs to be provided to people who are actually quarantined and it should include reasonably decent conditions in which people are held.