As this piece is being written, the COVID-19 global infection numbers have crossed the million mark and deaths are inching close to 60,000. In India, the numbers provided by the Ministry of Health and Family Welfare is 2,650 infected and 68 dead. There has been a massive spike in infections and deaths since mid-March. On March 16, the infected case load globally was 182,414 – which, has crossed the million mark and stands at 1,118,559 with 59,226 deaths.
There are 44 vaccines in early stages of development, but still no cure. Meanwhile, the world is latching on to any and every glimmer of hope. First, it was the anti-malarial drug hydroxychloroquine, which resulted in some doctors self-prescribing and stock-piling hydroxychloroquine. Now it is the Baccilus Calmette-Gue’rin (BCG) vaccine.
A study by researchers at the New York Institute of Technology (non peer-reviewed, pre-print, open for public scrutiny) hypothesises that countries like India, China and Brazil have lower COVID-19 cases and even lower fatalities because of their universal BCG vaccination programme.
The NYIT study
The study led by Gonzalo Otazu compares 56 countries’ COVID-19 infections and fatalities and proposes the BCG could be the answer to combatting the deadly coronavirus. BCG is a century old, very cost effective vaccine which is given to prevent meningitis and TB in children.
Low and middle income countries which have continued with the universal immunisation programme of BCG, have shown lower incidence of COVID-19 infections while high income countries like the United States, Netherlands and Italy, which discontinued the vaccine (and administered it in a targeted manner in some TB burden localities) have a much higher case-load.
The study also tries to explain the anomalous case of Iran – which has a universal immunisation programme for BCG which started only in 1984, unlike India and China, whose programmes go back to the late 1940s. Hence most deaths in Iran are of the elderly, who would not have got the requisite BCG shot.
The NYIT researchers, while offering BCG as a possible answer to combat COVID-19, are circumspect in their conclusions and call for controlled trials to test their thesis.
Contrarian take on the NYIT study
The world, desperately waiting for hope, rushed to follow this advice. The Netherlands, Australia and United Kingdom’s National Health Service (NHS) mandated their health workers be administered with BCG shots and many doctors (epidemiologists, pulmonologists and even the non-practicing variety) commented on the study and even “hope” that BCG offers.
But some Indian doctors and public health practitioners have been much more cautious. Dr Swaroop N, public health specialist, who manages large-scale primary healthcare initiatives at the Karnataka Health Promotion Trust (a leading non-profit in the health and equity space), shares his skepticism about the study and the research questions which beg answers:
1. The countries selected are arbitrary. Even Australia and Germany have a much lower morbidity and mortality from COVID-19 and have no universal BCG immunisation programme, hence BCG solely cannot be the answer
2. Health systems’ capacities, infrastructure, staffing, ICUs, ventilators, are all confounding factors which have not been taken into consideration
3. The innate immunity of people in low-income countries exposed to dust and grime also needs to be factored in. The Indian Council of Medical Research (ICMR) is poised to under-take a large-scale serological study to understand the innate immunity of Indians (if any) and settle the debate, once and for all, if Indian innate immunity is an urban legend or a reality
4. Though inconclusive, weather and temperatures also play a part in the spread and containment of an epidemic. That needs to be researched too, since most tropical countries have had low case loads
5. Also the stringent lockdown in India (when the nodal ministry claimed, the country was in stage-2 of the pandemic) could be a deterring a factor
However, Dr Swaroop does agree the BCG has been an effective vaccine in protecting children from TB and meningitis and might have residual immunity in adults to combat other diseases.
More words of caution
Dr Gagandeep Kang, executive director, principal scientist at the Translational Health Science Technology Institute, advocates similar caution.
Dr Kingshuk Poddar, molecular biologist and serial health technology innovator, emphasised the need for large-scale epidemiological study on the correlation between COVID-19 and BCG before drawing any conclusions.
He also red-flagged similar research which might have distracted the scientists’ attention from finding that cure for COVID19.
One example is the International Centre for Genetic Engineering and Biotechnology (ICGEB) study that stated the version of Coronavirus (SARS CoV2) that has hit India is merciful and less virulent. And this “merciful virus theory” gained a lot of traction, because of tweets by the right-wing ecosystem. It got so much traction that it featured in a television discussion with Dr David Nabarro, the WHO Director General’s special envoy.
So while home-remedies and pseudo-science are being peddled as corona-cures, there is also the danger of scientific papers indulging in lazy arm-chair research. As a public health expert, Dr Ranvir Singh, assistant professor at Jammu Central University, put it, “The world is so desperate for a cure, that if Baba Ramdev’s churan can be packaged in a sophisticated paper and published in Lancet or PLOS Medicine, we would lap it up. That is why science, transparency in methodology, replicability of results is so important. We should not mistake coincidence as causality.”
But while the BCG’s connect to combatting COVID-19 is yet to be fully explored, there are lessons about the BCG vaccination’s coverage which should not be lost
India is combatting COVID-19 with an extremely deficient health system. There are 600,000 doctors and two million nurses missing, according to the Centre for Disease Dynamics and Economic Policy, and the clamour for ICU beds, ventilators and personal protective equipment (PPE) has been too loud to miss. Yet, the BCG vaccination, one of the oldest vaccinations in India’s Universal Immunisation Programme has had one of the best coverage performances next to the polio vaccine. According to Dr Pradeep Haldar, deputy commissioner (immunisation) in the health ministry, the coverage of the BCG vaccine is at 95%. Even in states with very low health indicators, the coverage is 85%, while the average performance of the universal immunisation programme has flat-lined at 62% for all the vaccines combined, as per the National Family Health Survey-IV (2015-16).
Dr Meenakshi Jain, an expert working in maternal child health, explains, “BCG is administered during delivery, hence missing a child is impossible if the mother has had the delivery at a healthcare institution. But if the child is missed during the delivery, there is a sincere attempt to track and administer the dose within the first one year of the child. The entire frontline health-workers system, of ANM, ASHA and Anganwadi workers are geared towards this……….The importance of the vaccine is well-communicated, its access is free, both in terms of free of pricing and not causing opportunity costs to parents for accessing this vaccine for their children. The polio vaccine also goes door to door for administration, so the access is free of any opportunity costs. But the same cannot be said for many other vaccines in the universal immunisation programme.”
This assessment is echoed by the WHO 2018 study “Explorations of Inequality: Childhood Immunization”. Income inequality, mother’s education, birth order of the child, child’s sex and intra-country disparities go a long way in determining the immunisation coverage. Inequality as per the WHO is the most important determinant. This requires the last mile delivery be strengthened, the advantages of vaccination be properly communicated, and the marginalized, poor communities not be subjected to additional costs to access health care in general and vaccinations in particular. Finally, the frontline cadre of health and nutrition are as essential as the doctors.
Need systems approach now more than ever
Policymakers familiar with the healthcare scenario in India warn against the idea of an easy silver bullet
Amod Kumar, principal secretary for planning in Uttar Pradesh says, “That, the national capital Delhi has a 10 degrees Celsius difference within the city limits in the same season (which is perhaps the maximum range in any capital city), is an indicator of inequality. That every year 5.5 crores people fall back into poverty because of out-of-pocket expenses, is a direct impact of under-funded health sector, which fuels inequality. That, the same successful BCG vaccination notwithstanding, India continues to have the largest global burden of TB is a direct outcome of inequality and resource allocation. Because TB is a social disease, where, poverty, malnutrition, exposure to polluting conditions are all force-multipliers… If there is need to pick one point from the hyper-excited discussions on the use of the BCG in combating COVID-19, it has to be about combating inequality while challenging epidemics, taking a health systems’ world-view and foregrounding the poorest in the plans, and not as an after-thought.”
Once you strip off the privilege of physical distancing in middle-class homes with their well-stocked refrigerators, the policy failures, the bad programming that a poor migrant worker encounters, trudging hundreds of kilometres home during the COVID-19 lockdown, manifests itself every single day.
And since this is open season on the WHO’s own shortcomings in handling the COVID-19 pandemic, here’s a question: Why did the WHO disband its ‘Task-Force on Social Determinants on Health’? If the WHO doesn’t remind us that health planning for combatting pandemics requires a “systems approach” and “social-determinants to health” world-view, then who would?
Biraj Swain works on international development and human rights. She has been a fellow of International Centre for Journalists Washington DC and Senior Fellow of Kalam Institute of Health Technology. She can be reached at biraj_swain@hotmail.com