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Behaviour Change, Not Lockdowns, Will Quell India’s Epidemic: Gagandeep Kang

Behaviour Change, Not Lockdowns, Will Quell India’s Epidemic: Gagandeep Kang

Photo: Twitter/UKinIndia.

The following is the transcript of Karan Thapar’s interview of Dr Gagandeep Kang on November 17, 2020 (conducted entirely online). The video of the interview is embedded below. The transcript was prepared by Zobia Salam, and has been lightly edited for clarity.

Public health

Karan Thapar: Hello and welcome to a special interview for The Wire, supported by Glenlivet. As we cross Diwali and enter winter, what is the big coronavirus picture facing the country; and secondly, as vaccines get ready to come on the market, are there one or two that give particular hope to India that could in fact be the miracle that we’re waiting to happen?

Those are the two key issues I shall explore today with a professor from the Wellcome Trust Research Laboratory at the Christian Medical College at Vellore – Gagandeep Kang. Prof Kang, let’s first start with the big COVID-19 picture facing the country. The daily increase in cases, calculated as a weekly average, on November 15 was 41,679. But a month earlier, on October 15, it was 65,956. Similarly, the daily increase in deaths, once again calculated as a weekly average, on November 15 was 494; on October 15 it was 803. So, quite clearly, India has crossed the first peak, but the question is, are there more peaks ahead?

Gagandeep Kang:  If we are to look at patterns of disease from other parts of the world, there are drivers of infections, and therefore of disease, that vary with seasons. So one of the things that is emerging is that colder and drier weather, rather like for influenza, does protect this virus as well. And it’s likely that when you have dry, cold weather, the number of cases will go up.

In India, I think, we have in some ways an advantage – in that we’ve had very, very high levels of virus circulation in crowded areas up until now and we’ve achieved a level of seropositivity that we have not seen from many other parts of the world. Now, this is not country-wide. It is in locations that are densely populated and that have had a high incidence of disease. So the data – if you look at it – from Karnataka, Pune, Mumbai and Delhi, showing a relatively rapid increase in cases in the two rounds of seroprevalence surveys that they published, and the third just done, shows us that a large proportion of our population has already been exposed to infection.

If you have many people exposed to infection, it’s likely that they will have protection against subsequent disease, which means that the fact that we are on a downward trajectory is good news – but also that if we see subsequent waves, those waves might not necessarily be as high as what we are seeing in the USA and Europe, where a much smaller proportion of the population was exposed in the initial peak and they had a larger proportion of the population to be infected in subsequent weeks.

KT: I’m just going to ask you to clarify – because you began by saying, in dry cold weather the spread of the infection is likely to increase and as far as north India is concerned, into dry cold weather. In addition, there’s pollution and also now, because the festive season has begun, people have dropped their guard. But then you also went on to say that the subsequent waves may not be as large or as worrying as they are proving to be in Europe [and] in America. So if I take the two halves of your answer together, I’m saying there will be subsequent waves but they will not be as large as the first in India and not as worrying as the second and third in America [and] Europe. Is that a correct understanding of your answer?

GK: I think the possibility of a second wave certainly exists as long as you have people who have not been infected. A lot depends on our behaviour, a lot depends on the climate and we’ve seen both of those operating together in a festival season that also has cold, dry weather.

KT: Let me pick up on something that a panel of seven experts – you were one of them – put together by the Department of Science and Technology headed by Professor [M.] Vidyasagar of IIT Hyderabad concluded in mid-October. That was exactly a month ago. That panel said that if preventive guidelines were followed, the disease will run its course by February 2021. Do you believe we are on track for that conclusion or now – a month later – do you think the panel might revise its conclusion?

GK: I don’t think the panel will revise its conclusions because the predictions are based on a mathematical model that was developed by collating a number of different models that were built by Indian investigators – mainly physicists, mathematicians – who work in these areas. That group was put together to create what is called the ‘supermodel’, and my role in that group was to advise on certain aspects of the virus because most of the people on the panel, other than Madhuri [Kanitkar] and I, did not have a medical background…

KT: Does the panel stand by its finding that if preventive guidelines are observed, then by February the disease will have run its course? That’s the critical question that gives people a great deal of hope. So, is this a credible finding which the panel stands by?

GK: Okay, I will caveat this answer by saying that the model is built on publicly available data. It is not built on necessarily all of the data that is available with the government. So… since it relies on data that may be incomplete, there is a possibility that the model might not be perfect.

In general terms, looking at the patterns that the supermodel is predicting, I think it is reasonable to say that the first peak will be done by February next year. But the peak being over, the number of cases declining does not mean that we will have no infections and no disease beyond February. It means that we will not see the rates of infection that we are currently seeing today. Now, should behaviours change, should our understanding of how the virus is behaving in our setting change, then the model might need to be revised…

KT: I take the point you’re making that when you say the disease will have run its course – it’s not that the disease will have disappeared, but it will have moved from a pandemic state to becoming an endemic state. So although infections will continue, they’ll be at a much lower rate.

But the reason I’m questioning this finding is because this assumes that by February, India will have reached a total of 106 lakh cases. At the moment on November 15, we’re at 88.45 lakh cases. And if you look at the weekly average of daily increases, we’re increasing at about 40,000-41,000 a day. So, are you really confident that we can come in under that 106 lakh number? It’s not very far away from here we are at the moment, which is why I ask.

GK: No, I agree with you. But if you look at it, it’s actually a further declining trend at the moment and the prediction was based on the situation that we were in about a month and a half ago. Now, if behaviour has changed –and we’ll see the consequences of Diwali really two weeks from now. So if you look at the pictures that have been shown about what’s happening in Delhi, and what’s happening in other places during the festival season, it’s possible that those interactions are going to drive a peak that we might see in November, which would then negate this currently declining trajectory.

KT: Ah!

GK: So, I will have to wait and see…

KT: This is very important. You’re saying that the sort of behaviour – the way people dropped their guard during the festive season; congregated in marketplaces, shoulder to shoulder, without any care for physical distancing – all of that would actually end up negating the conclusion that the disease will have run its course by February. There may be, as a result of the behaviour during the festive season, more peaks that lie ahead. That possibility you’re saying is very much there?

GK: Absolutely! This virus depends on people spending time with other people who might potentially be infected. The more you do of that, the more the chances of spread.

KT: In which case, let me put this to you: in summer, when Europe thought they had crossed the first peak, they were much more relaxed. People began meeting, they began meeting in houses they began meeting outside, restaurants opened up, cinema halls even opened up (although a lot of people didn’t go) and the same thing happened in America.

As a result of people dropping their guard in Europe, Europe is going through a severe second peak which seems to be worse than the first. America seems to be going through a third which is worse than the first or the second. You’re saying that the same laxity on the behaviour of people could lead to a similar outcome in India too. There’s no guarantee it won’t.

GK: I think any time people let their guard down without sufficient people in the population being infected, the possibility of a second peak exists. You could call it a peak; you could call it a flare up – whatever it is, until behaviour changes, you’re going to continue to see these infections happening. Now, if we look at what happened in Europe and the US: their way of living is very different from ours. The level of ventilation in many of their buildings is very different from ours.

It’s been shown recently in papers that have looked at mobility – that have looked at locations of individuals, that about 80% of all infections are acquired indoors. So if you’re meeting outside or you’re meeting in very well-ventilated spaces, your chances of infection are lower. And among all the places that could potentially be hotspots, what’s been shown outside is that it’s restaurants and gyms that have really driven infections in many Western cities.

KT: I take on board your caution that there is a significant difference in the lifestyle and the living conditions in the West and here. They live in closed rooms… Winter drives them into closed rooms and central heating. Our environment, our homes are different.

But that said and done, aren’t you also, Prof Kang, saying that whether that forecast – if I can so call it – by that expert panel that come February, the disease could have run its course provided preventive guidelines are followed – whether that forecast is realised or missed depends very much on the outcome of the way people behave during the festive season and also on other connected things like pollution in northern India and the impact of the dry cold on respiratory illnesses. All of that will determine whether that forecast about the disease running its course is met or not.

GK: You’ve nailed it, Karan.

KT: So, what was a moment of great hope, that by February the disease would have run its course, now has question marks hanging over it. And those question marks arise out of our behaviour.

GK: Absolutely! A lot of control of transmission is in our hands. We’ve seen that in hospitals, for example. We are actually seeing lower levels of infection in healthcare workers than you’re seeing in the outside community, even though healthcare workers have greater exposure. This is because we are handling the availability of PPE and the practice of how you see patients very, very differently from how we did before.

KT: Absolutely, I saw the corollary – and I’ll mention it before I move to another subject: the corollary is that if we miss the forecast made by the expert panel and the disease hasn’t run its course by February but continues with further peaks, the fault will be ours because we let our guard down; because we didn’t wear our masks; because we met without physical distancing. In other words, if that forecast is missed, we are to blame, largely, at any rate.

GK: I think, for every infectious disease that spreads by the respiratory route, there is a lot of control that is in our hands. Where the model itself is concerned, it’s always important to remember that models are models. Whether it is February 1 or April 30 doesn’t really matter. What models predict are trajectories and the accuracy of where that trajectory lands can vary a little bit. But if the shape changes then something has to change for that shape to change. A second peak would be driven by a difference in our behaviour or a difference in the behaviour of the virus.

KT: In which case, how do you interpret what’s happening in Delhi at the moment? Delhi is going through its third peak and we know, quite clearly, that the third is worse than the second and the second was worse than the first. In fact, the situation in Delhi has become a matter of national concern. How do you interpret this – how we got to this dire situation… Particularly when the rest of the country seems to be coming away from the situation and improving. Why is Delhi deteriorating at precisely the same time?

GK: So, I think one of the differences with Delhi is mobility of people. What has been happening in Delhi is that restrictions on mobility are practically non-existent. So if you have public transport, you have people moving around for employment. Delhi is a magnet for surrounding states’ people, who come in for work or just as economic migrants. I think there is a lot more movement in Delhi; a lot more interaction in Delhi, and the pollution really does not help when it comes to severe disease.

So, while infections might be there in many places, the severity of disease I think is driven by the fact that pollution compromises your lung function and people with compromised lung function are more likely to have more severe disease. It’s been calculated at several times that people in Delhi lose years of life because of pollution and the first effect that you see is on what is called vital capacity – the ability [to take] air into your lungs – which can be significantly compromised.

KT: In which case, did the Delhi administration make a mistake in allowing buses to travel full, as opposed to the earlier rule which said the seat beside you must be empty? Secondly, have they made a mistake in allowing the number of people who gather for weddings to increase to 200 from the earlier limit of 100? They’ve done both these changes just when Delhi is hitting its third peak! Was that a mistake?

GK: I think, when you’re in administration, you probably have to balance economic drivers, the idea of COVID-19 fatigue (which is very real) with the risk of disease. If you focus on one, you damage all of the others. So in your balancing game, you have to make a call on what you’re willing to accept and what you’re not willing to accept. Obviously, increasing the number of people who travel on a bus is going to increase the risk of infection; increasing the number of people who can attend a wedding is going to increase your risk of infection. So what are the risk minimisation steps that you can and should be taking? These could be among some of the…

KT: ‘These could be among some of the’ and I lost you at that point…

GK: If we were to think about what all the actions that you could take are that could limit people getting infected – keeping a bus at 30% [capacity] is better than keeping it at 50%. Keeping it at 50% is better than allowing a bus to run full. If you look at weddings, 10 people is better than 50 is better than 200.

KT: Given what you’re saying, which is very straightforward, let me repeat my question. When you’re hitting the third peak and the situation is escalating – Delhi as we now know is running short of ICU beds; it may be running short of coronavirus beds, even the simple ones without ventilation of oxygen – at that point, to have made these liberalising changes so buses can travel full and the number of people at weddings can increase to 100, was it a mistake? Was it the wrong point at which to liberalise and relax the situation?

GK: I think a lot of decisions should be planned in advance and you should have indicators for making those decisions. To make a call on if our trajectory is heading upwards, we are not going to relax any recommendations and we may tighten them when our trajectory is heading downwards or we reach this rate of increase of cases, then we can afford to relax these interventions. Much of this can actually be informed by modelling and it is a risk-benefit analysis.

KT: Absolutely.

GK: I don’t know that the Delhi government has done that.

KT: Ah! You’re not aware that the Delhi government has done a risk-benefit analysis, but what you’re pointing out is a very interesting thing. Normally, you relax on the way down. Delhi has chosen to relax on the way up. And that might be the wrong moment to do it. Let me go one step further. Given the concern about ICU beds; given the fact that paramedics from the Central Reserve Police Forces and doctors are being flown into Delhi; given the fact that the central government is intervening to help the Delhi government – is there a need for a limited circuit breaker-type lockdown in Delhi?

After all, Delhi now is an exception as far as the rest of the country is concerned. Tamil Nadu’s cases have gone down below 2,000 a day; Delhi is fast hitting 7,500-8,000. Is there a need for a limited circuit-breaker-type lockdown?

GK: I think one of the things to think about is whether you need a circuit breaker or you need to change practice across the entire city. A circuit breaker could be a limited lockdown in defined areas. But I think if we are in this for the long haul, we really need to be thinking about changes that are sustainable, which will slow the spread of infection.

What is it that we can do to make sure that we emphasise mask-wearing? What is it that we do to ensure that crowding is limited, whether that is in markets or on public transport? These are the kinds of sustained behaviours that are going to be required for a long time to come and it’s better that we focus on beginning to implement those instead of a process that is, you know, random lockdown, random lifting, random change [of] policy…

KT: Can I point this out? The government has been messaging repeatedly that mask-wearing is essential; physical distancing is essential. During the festive period, particularly the days before Diwali, we’ve seen hundreds, thousands congregating shoulder to shoulder in markets like Sarojini Nagar and Lajpat Nagar, without any concern for physical distancing and even while they’ve had masks, they’ve been standing cheek by jowl with each other. So clearly good sense isn’t working; the communication isn’t being heard or heeded. Hence my question: is there a need for a short circuit-breaker?

GK: I’m not sure that a circuit breaker would work because if you don’t change behaviour you’re going to wind up with the same situation in another location.

KT: Okay.

GK: Why would you want to do something that you cannot keep going over a long period of time? I think one thing that we don’t do well in public health is look at behaviour change – what are the drivers of behaviour change across the population and [of] sustained behaviour change? That actually requires a lot of effort and there are many people who are specialised in doing that. It requires an investment in investigating what matters to people and crafting your messages around making sure that this is shown to be a benefit to you. We are not doing that.

KT: Prof Kang, I am interrupting because what you are saying, no doubt, is absolutely correct, but changing people’s behaviour is very difficult. It doesn’t happen quickly. And secondly, you’re suggesting we should have started this process a lot earlier by getting in experts who know how to do it. We didn’t get in the experts. We didn’t start early enough. We now have this daunting task to do and it’s not going to happen easily or quickly, and yet the numbers in Delhi are going up.

In fact, a government committee headed by [V.K.] Paul has even predicted that by December-January, we could be increasing by 15,000 cases a day! Given that we can’t change behaviour quickly or easily and given, in fact, that we haven’t even started to try and do it, what then? What do we do in Delhi? Just sit and wait for the numbers to come down eventually?

GK: No, I think there is a lot that can be done around monitoring and making sure that people are not allowed to do certain things that go against public health. For example, entering into a shop beyond a certain density; allowing X number of people into a market area… Allowing only so many people onto a bus – these things are doable in the short term while we still look at making sure that behaviour changes.


KT: Okay, this is not a circuit-breaker but it is certainly a restriction on people’s activities in terms of how many can enter the marketplace; how many can enter a shop; and you even said, how many can travel together in a bus. You’re thereby even conceding that the decision to allow buses to travel full at this particular time may have been a mistake, although you haven’t said it upfront.

Let’s leave Delhi aside. Let’s leave aside the big COVID-19 picture facing India as we enter winter and come to the second big issue I want to discuss with you: vaccines. The government has identified four priority groups who will be the first to get a vaccine when it’s available. These are health care professionals, police and the armed forces, those above the years of 50 and those below 50 with comorbidities. But if there’s an insufficient supply of vaccines, as almost certainly will be the case when vaccines first come on the market, how then do we prioritise between these priority groups?

GK: I think WHO and the government have done a fair amount of thinking through the principles on which these allocations will be made and the sequencing of these allocations. In most places, the decisions are that frontline healthcare workers will be prioritised, followed by other age groups.

My worry really is – how well we are going to do on identifying people and then ensuring the right kind of sequencing among them. If you were to look at healthcare workers, for example – there are many healthcare workers who are patient-facing; other people within the healthcare system that are not, strictly speaking, healthcare workers; and healthcare workers who are not patient-facing. So among those, do we have a priority list? I have not seen one.

We have private healthcare and we have government systems. If you were to look at that – who would get it first? Would it be all government hospitals before you give it to private hospitals? Will you sequence, as has been done for many other vaccines, by state? Saying that if there is a really limited supply, these are the states that are going to get it first for their healthcare workers? And how would you decide which those states would be?

So it would be great to see a much more detailed plan even among health care workers, and these are actually people who can be identified by the occupations. When you move from that to age, that’s another point but still doable. But how do you identify people with comorbidities and how do you prevent fraud there? So, I have a lot of concerns.

KT: You raised a lot of issues about how the government will actually implement the prioritisation. When these issues are handled – because they have to be; the government may delay handling but it can’t avoid doing so – should the government, at that point, bear in mind the characteristics of the vaccines that are available? After all, some vaccines are better suited to younger people than elders. Some vaccines, because of their logistics, are easier to handle in urban India than the rural. Should that also determine how these decisions are made?

GK: Absolutely, and so should cost! If we do look at which vaccines are better suited for what kinds of populations;,if we are going to deliver a vaccine in the public health system, we have to look at how the public health system can handle that, even if there is a public-private partnership.

For example, if we were to look at the new vaccines that require -70º C storage, such as the Pfizer vaccine… I think that would be a very challenging vaccine to use outside of urban areas, even though Pfizer has developed its own cold chain and says that it can provide, you know, with its partners, a reasonable degree of confidence that their vaccine will stay at the right temperatures until it reaches the last cold-chain point. I don’t think that this is going to be feasible for the 28,000 cold-chain points that India has.

KT: Let me pick up on Pfizer because it’s one of the two vaccines that has attracted not just a lot of attention but given people a lot of hope. As you pointed out, Pfizer may be 90% effective, as the company itself claims, but it requires storage and transportation at levels of -70ºC. Then I’m told, after it thaws, its shelf life – depending upon what you read and which paper you go by – varies between 24 hours and three to four days. It’s not a very long shelf life. Are you saying that given these problems, Pfizer is not a feasible solution for India?

GK: I think at the current cost and the current logistic requirements, it’s very unlikely to be a solution for India. I know that the government will be in discussion with all of the vaccine companies to figure out what can be done, but I think we have to remember that the vaccination program should be tailored to what can be done in which places and for which people.

You pointed out the issue with the elderly as well. There are some vaccines that are showing reduced immunogenicity among the elderly and it’s possible that they may have reduced efficacy as well in the elderly. So do we have a benchmark for what level of efficacy we will accept?

If you remember, not so long ago, there was WHO coming out with a recommendation saying that a good vaccine could get 70% protection and the FDA willing to accept a 50% protection, and the European Medicines Agency saying well, we’d even be willing to go lower. Now that we have a readout that is 90% and 90%+plus for some of the other vaccines, I think we’re going to be a lot more ambitious about what we can do with these vaccines. So delivery becomes even more important.

KT: Let me now come to the second vaccine, details of which were announced only yesterday: the Moderna one, which is said to be 94.5% effective. And in the case of the Moderna vaccine, it only needs -20– C temperatures for transportation and storage. And secondly, once it’s thawed, the company claims it has a shelf life of up to 30 days. The problem in the case of the Moderna vaccine is that it’s very expensive. It’s something like $37.50 per shot. So even if Moderna is easier and more feasible for India, is it too expensive for a country that’s already coming close to promising a free vaccine for every Indian?

GK: I don’t think we can afford a vaccine if it is sold at the price of $37 a dose, but that’s not what will happen when a market like India comes calling. I think most vaccine companies would be very willing to drop their prices if we were to commit to a substantial supply of those vaccines. I think with Moderna, the price may be $37 a dose initially, but what we’ve seen with other vaccines as well is that once they get beyond the point of recouping their investment in R&D – and we have a situation here where much of the investment in R&D has not really come from the companies themselves – after that, their prices drop.

The RNA vaccines have an additional advantage, in that setting up a facility to make these RNA vaccines is not expensive. But the reagents that go into making these RNA vaccines is going to be a rate-limiting step if we want to make billions of these vaccines. So Moderna [is] much better suited to the cold chain that we currently have, but a very expensive vaccine. India has never had a vaccine in the programme for which we have paid more than $3 a dose and that [is] only for a portion of the country. So, I think we are looking at huge challenges.

KT: India has never had a vaccine for which it has paid more than $3 a dose? That’s a tenth!

GK: Yeah.

KT: In the context of our discussion about Pfizer and Moderna, let me bring up the Oxford AstraZeneca vaccine that only requires temperatures ranging between -2º C and -8º C which, I believe, a normal freezer can quite easily handle. Even if Oxford AstraZeneca is a little later than happening, should India lay its hopes on this? Secondly, of course, because Serum [Institute of India] – a company based in India – is heavily involved in making it.

GK: It’s actually [that] AstraZeneca’s vaccine can be held at 2º C to 8ºC [positive, not negative], which is your regular refrigerator and not a freezer at all. This fits in again very nicely because most vaccines that we use are held at 2º C to 8º C. So there will be a question of shelf space, but storage temperatures are appropriate.

KT: So are you suggesting that perhaps we should patiently wait until Oxford AstraZeneca is ready for distribution and use – or is that a bit of a risk that we can’t afford to take because we don’t know when it will happen, if it will happen?

GK: I think we should be excited about the Moderna and Pfizer-BioNTech results because they are giving us proof of principle that vaccines work. Vaccines work better than we had ever thought they would work. I think most of us were predicting about 60%-70% efficacy; 90% plus is phenomenal.

Now, all of the vaccines that are being developed, including the AstraZeneca vaccine, are based on the spike protein. In the case of the mRNA vaccines [Moderna and Pfizer] – the mRNA encodes the spike protein, gets inside cells, the cells make the spike protein, the body responds. In the case of the AstraZeneca vaccine – essentially, you have an adenovirus that does the same thing that the mRNA does, which is carry the sequence into the cell, make the cell make the spike protein and the body responds.

Now…, the chances are very, very high that the AstraZeneca vaccine is going to work. And given what is happening in the rest of the world, I think, for AstraZeneca we will likely have a readout by the end of the year. In any case, it’s important to remember that having a readout from these interim analyses does not mean that we will have the vaccine tomorrow.

KT: Can I then then draw the conclusion that seems to be hanging in the air in that answer of yours? Are you suggesting that if the chances that AstraZeneca will work are very, very high; and secondly, AstraZeneca is so easy to store that it can be kept in an ordinary refrigerator, not even a freezer; and thirdly, given that it will be made in very large quantities by Serum in Pune – are you therefore suggesting that rather than put our money into Pfizer [or] on Moderna – which are either very difficult to handle or expensive – we should wait until AstraZeneca is ready?

GK: Absolutely! I think we should wait and see what is a good vaccine that fits our systems.

KT: Okay.

GK: Whether that is the AstraZeneca vaccine or the Bio E vaccine or the COVAXIN that is being developed by Bharat Biotech. I think the security of supply is important. I think the price is important. I think the practicality in terms of delivery is important. Maybe Pfizer and Moderna will end up being products that could be used in the private market, but for a public market right now, I’m not sure that we are ready for them.

KT: That’s very important. For a public market where the government is giving the vaccine free to every Indian – that’s the promise they made in Bihar, [and] I assume they’re going to have to make it nationwide; they’re not going to treat Bihar as an exception… Therefore, for that sort of environment, AstraZeneca is better suited than Pfizer and Moderna. Maybe Pfizer and Moderna can be kept for the private market, where people pay for their own vaccine.

Let me at this point ask you briefly what your thoughts are about Sputnik, the Russian vaccine, and the Chinese one, which seems to have run into trouble even in China, although the Chinese won’t admit it. Very quickly tell me: do you see Sputnik [and] the Chinese vaccine in the same light as Moderna, Pfizer [and] Oxford AstraZeneca? Or do you see them as different entities?

GK: I think they have the potential to work but in order for us to place the same level of reliance on those vaccines, we’ll have to see a lot more data than we’ve seen up to this point. Vaccines must be safe and effective and of high quality. It’s the responsibility of a regulator to ensure that, so that vaccines are trusted and vaccines are used. Without data, we can’t decide.

KT: Two or three very quick questions about vaccines. Practically all the vaccines we’re talking about – Pfizer, Moderna, Oxford AstraZeneca – require two shots. Is that going to be a problem in India or have we mastered the art of double vaccinations one month apart, because of our experience of polio and measles vaccines?

GK: We are pretty good at giving vaccines. There is a percentage of our population, particularly children, that are not reached, so about 10% of our kids can be very hard to reach. And I think when it comes to adults we have additional challenges of getting to and giving adults vaccination and then making sure that a person who received the first dose also got the second. So this is going to be a … difficult task for the government and for all partners, but it is something that we can do. We already have the largest immunisation programme in the world. It’s a good starting point, we have a long way to go.

KT: Let me then ask you another question about vaccines. How long is the immunity these vaccines – Pfizer, Moderna, Oxford AstraZeneca – will confer? Are we talking about immunity for five-six months, which is what the antibody immunity seems to be? Are we talking about immunity for a year, which may require a booster shot thereafter? Or are we talking about lifetime immunity, as comes with the measles vaccine?

GK: We don’t know. We will find out. We are working on it. I think this is the million-dollar question for SARS-CoV-2 vaccines. It would be phenomenal if we wound up with a situation where if you took one shot – and the Janssen vaccine is going to be a one-shot vaccine – if that works and gives you lifetime protection or two shots or three shots, as with some vaccines, give you lifetime protection, that would be fabulous! But we are not going to know until we have people who have been vaccinated getting reinfected.

That’s why our investigation of vaccines does not stop with phase three trials. We are going to need to continue this post-licensure to make sure that we can define whether boosters are going to be needed and if they are, [then] how frequently.

KT: My last issue, Prof Kang, and it’s somewhat of a moral issue, but it’s one raised by Ugur Sahin, the co-founder of BioNTech, one of the makers of the Pfizer vaccine. In an interview on Sunday to the BBC, he said – and I think I’m quoting him correctly – that “if all the vaccination and immunisation approaches are accomplished before next autumn, we could expect a normal winter next year” – that’s winter, December 2021.

Now, that may be true of Europe, but is it likely to be true of India? And if it’s not – because these countries are relying on Moderna and Pfizer, which we may not be able to use – then are we going to end up with a two-speed recovery in the world, with the richer countries of Europe and America recovering faster and poorer countries like India, South Asia or Africa recovering considerably more slowly?

GK: I think Ugur is being incredibly optimistic even about the Western world. I think, in the West, they have problems to face at a much larger scale than we do in terms of vaccine hesitancy. So a lot of people are not going to be willing to take the vaccines and when it’s a public health issue – which depends on a large proportion of your population being vaccinated – that is a significant concern and recovery will hinge on that. I also don’t think that it is appropriate to equate rich and poor countries because I think the patterns of disease that we are seeing, and will continue to see at least for the first few years, are going to be very different. The levels of seropositivity that we have seen in our country are not being seen in the West and that’s going to shape our response to future infections and disease.

KT: I take your point that one of the checks on a two-speed global recovery is the fact that in the West, there’s a greater resistance to vaccine-taking. A lot of people refuse to take vaccines and that could be a problem ensuring that a sufficient number of people in the West are vaccinated and therefore this two-speed recovery may not quite happen.

One last question – it’s an issue raised by the Business Standard in one of their recent leads. They said that if we do end up with the two-speed recovery, where Pfizer and Moderna have taken control and checked the spread of the virus into richer European and American countries, is there a danger that other vaccine makers may lose the profitability motive and incentive and slow down their work, even though their vaccines are much better suited for countries like India and Africa? Is there a danger there that the success of one or two vaccines in Europe could retard the development of others?

GK: I don’t think so because vaccines that are in phase-three clinical trials will be seen through to completion and if they are in regulatory geographies that are outside of the US and Europe, those regulators have a responsibility to see these vaccines through to licensure.

I think the modulating role played by the WHO in making sure that there is access to vaccines around the world will ensure that programs aren’t slowed down. The ACT [Access to COVID-19 Tools] Accelerator, CEPI [Coalition for Epidemic Preparedness Innovations] and GAVI [Gavi, the Vaccine Alliance] are very, very invested in making sure that there are as many products as possible that suit different geographies and they are supporting the development of many vaccine candidates that go beyond what is being developed solely in the US and the European region.

KT: Prof Kang, thank you very much for this comprehensive interview where you helped put in perspective, first, the nationwide big COVID-19 picture that we face as we enter winter; and secondly, you’ve answered many critical questions about the vaccines that are almost ready and which would be more suitable for India [and] which would be perhaps a little bit more difficult to handle because of the logistic requirements. I’m deeply grateful for this. Take care. Stay safe.

GK: Thank you.

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