 Hello and welcome to NewsClick. Today we are going to discuss the COVID-19 situation not only in India but across the world and what are the possible, what can you say, trends that we can talk about today. We have with us Dr. Satyajith Rat who has been with us throughout this pandemic and hopefully will stay with us till it is over. Satyajith, good to have you with us. Couple of quick questions that I know this is something a little painful for you because you ask this every time. Are we looking again at a fourth wave or not because we look at the world in some of the places we have about five, six countries and the numbers seem to have gone up fairly significantly 30,000, 40,000 has come down again and India numbers seem to be going up also but rather slowly in some of the cities and it seems to be that these are not really the kind of wave that we have seen earlier meaning very sharp rises but slow rises so maybe you would call it a ripple. So how do we differentiate when is it a wave likely to be a wave and when it is merely some numbers going up because of relaxation of norms, people not wearing masks, people party which is also what's happened not only here but in the US as you know even the leading lights of the establishment have been partying and have come down heavily with COVID. So how would you distinguish between what is a ripple and what is a new wave? So let's make two or three points clear. Firstly, as you implied, we're really not that interested in numbers alone anymore. What we are really asking is should we be worried all over again? And in order for us to answer that question, the three issues that make the answer uncertain is firstly, it's no longer clear if we are counting case numbers as reliably as we were a few months ago. This introduces enormous uncertainties into the counting game. Secondly, even though this uncertainty is there, the one factor that all of us seem to be ignoring is the fact that hospitalizations and what's more clearly COVID described death numbers are not rising even in the places where over the past three, four weeks there have been sort of case number rises. Death numbers are not rising, anecdotal reports say hospitalization numbers are not rising anywhere to the same extent, all of which would be expected if mild infection transmission is happening in primarily vaccinated communities with the many Omicron lineages. The last point that I want to make that rather than reducing the uncertainty compounds it is that in addition to not counting cases appropriately, we don't seem to be paying attention to mapping variants. So one of the few countries in the world which has been leading variant mapping has been South Africa. And as an unfortunate result, there are three variants that people are again referring to as South African lineages, which we should not, we should simply say they belong to the Omicron group of virus strains, but they are sort of descendants in the Omicron lineages, they're called BF4, BF5, etc. And those two or three descendant strains have some reason to carry potential for increased spread and or increased severity, none of that is proven anymore. It surprises me that countries across the world are not taking those lessons to heart and are not enhancing variant surveillance. Clearly in India, there is after a few weeks of fairly coordinated effort, the variant surveillance consortium has not provided any regular data output into the public domain. So we have no idea what's going on. And given that testing has now become sporadic, it won't surprise anybody if variant surveillance has become equally sporadic, because variant surveillance was dependent on testing. So on the one hand, there's a great deal of uncertainty. On the other hand, we do seem to be in the waning phases of the pandemic and therefore, numerical ups and downs are going to be local and frequent, but transient. As you noted, it's in Delhi, Bangalore, Mumbai, that case numbers are rising, they're not uniformly rising across the country. But on the other hand, hospitalization deaths and deaths don't seem to be rising. That's sort of a summary if you like. Saty, that's interesting what you're saying that effectively, when you look at numbers, these are, as I've said earlier, quoting you in some discussion, there are more ripples than peaks. And unless a new variant emerges, probably this is what we'll continue to see. And I don't know when the experts will say this is endemic from pandemic, that will leave for another discussion. But effectively, all bets are going to go off if you have a new strain. And then of course, we'll have to see all over again. And new strains can be descendants of the current strain. So as we have seen with Omicron, some old strain, a new lineage is arising from that against which we don't have that many in amount of defenses. So Omicron in that sense, had a population which already had seen various infections, vaccines and so on. So it didn't prove that dangerous. What would have done if it was completely to a naive population milling no immunity whatsoever, we don't know. So given all those caveats, one to the other issues which we are now talking about. And again, these are to some extent artifacts, I will say, of statistics, which you already referred to, how many were testing, what we are seeing. One interesting anomaly, if you will, that case fatality ratios are seen to be rising. While we are saying Omicron is a much, much less dangerous in terms of putting people in the hospital. So how do you account for this? So let's get again, the difference between numbers and ratios in perspective. Death numbers are not rising, particularly dramatically. They are pretty much low now all over the world. And while there is some noise, there is no sustained steady increase in death numbers anywhere that I'm particularly aware of. However, what is showing a great deal of noise, rise, whatever is case fatality rate. Now the rate is not a number, the rate is a ratio. The numerator is the number of deaths. The denominator is the number of cases, the number of cases meaning how many people tested positive for the virus. Now, how many people tested positive is going to be determined in large part by how many people were tested in the first place. Number one, and number two, how many of the people who were testing reported their test in the second place to the documentation process. Both of these have now become extremely unpredictable and sporadic. Total test numbers are dropping in various places. The groups of individuals who are being tested are shifting characteristics. Some people are getting tested only because they are sick rather than they are being statistically sampled testing. And there is a great deal of home testing from which no report is coming to the documentation processes. As a result of this, in the ratio calculation, the numerators are what the numerators are because people die in hospitals. The denominator, which is the total number of positive cases, is fluctuating all over the place as a result of these uncertainties. It's not surprising that in some places the case fatality rate is apparently rising. And I would suggest that we pay really no attention to the case fatality rate. And we simply dismiss it as a consequence of the fact that we are no longer testing and reporting even as systematically as we were doing a few months. In fact, a lot of the people who get tested is because they are already in the hospital for other reasons. And then of course it enters into the case fatality ratio because they came sick with some other disease which needed hospitalization. Incidentally, the tests show they have also COVID. And so of course that skews the case fatality ratio if they are as serious cases for other reasons or they die. So yes, the artifacts of all of this must be bought in mind because a lot of this is how you create the data that seems to suggest a result which is contraindicated to what really it is. And that's why you also have the statement the status lies, damn lies and statistics. And we have to be very careful about how you analyze it. Satyajit, another point that we also seem to have this vaccine debate going on. And that again is with respect to numbers that some vaccines are supposed to be more efficacious, some vaccines are not so good. And there is this concerted campaign coming from the West that how the Chinese vaccines are bad, the co-vaccine is not good, COVID shield somehow goes into a black hole, it's not mentioned. But what is mentioned repeatedly is the fact that mRNA vaccines have shown much more efficacy. And the quotes are like 90%, 93%, 87%, etc. Very high fingers compared to 53, 55, 65, 70 for other vaccines. Now the question is of course it doesn't take into account when you say this that you should only use mRNA vaccines because it needs cold chain which we know in a large part of the world is not possible. So what you do is of course create the demand that public health system should buy expensive vaccines, create a cold chain, essentially so that a few companies, pharma companies have monopoly. But how good is this so-called numbers of efficacy which are being trotted out of the drop of a hat that A is better, B is not so good. And also not taking into account how long the quote unquote antibodies from these vaccines last as another indicator for fighting against new variants that may emerge. So two questions really roll into one. Let's get a couple of issues on the table about this. Firstly, comparing protective efficacy of different vaccines has not been done and in general actually honestly cannot be done since it would have to be done in randomized clinical trials. So what everybody is doing is comparing real life protective effectiveness rather than efficacy. These two words in lay language mean the same thing but in technical language mean different things. Efficacies and controlled trials effectiveness is in real life. What all of us are comparing these percentages that you talked about is effectiveness in real life. And those are not from randomized clinical trials. They are results from different populations. There is an enormous amount of uncertainty and possibility of confounding. So a robust, rigorous comparison really cannot be made. Number one. Secondly, all of these percentages tend to set shifting goalposts. All vaccines have been formally rigorously tested and approved for usage on the basis that they protect against severe disease and death, not on the basis that they protect against infection and transmission of the virus. So asymptomatic and mild infection modification by vaccines has always been known to be modest. Severe illness and death has been well protected against. At the severe illness and death level, pretty much all vaccines do a very good job. Whether there is a real difference between 80% protection versus 90% protection cannot be clarified in the absence of well-designed trials, but they do very good jobs. At the other end, asymptomatic and mild infections are only very modestly protected against. Added to this is the next layer of confusion, which is that as variants shift, vaccines which are based on 2020 virus strains will inevitably, all of them begin to show some reduction in effectiveness. But again, over the past six, eight months, it has become very clear that reduction in the protection effectiveness for severe illness and death is relatively small. It goes down from 80, 85% to 75%. It's protection against asymptomatic or mild disease transmission, which goes down quite a bit from 50, 55% to as low as 35%. In all of this, therefore, there is a great deal of matrix of confusion that is loaded onto an already non-robust level of comparisons. Therefore, I think the WHO position, which does not practice vaccine discrimination, which clearly says that all COVID vaccines give very good protection against death due to COVID-19 and that protection against mild COVID-19 disease and transmission is much more modest with pretty much all vaccine strains is the only position that really needs to be taken serious. Now, as the last point, based on this background, it's very clear that very few of the claims made in public discourse that you are pointing out about COVID vaccines, even acknowledge any of these uncertainties, leave alone discuss them. So clearly, they read like tactics in advertising wars, whether the advertising is in support of purely commercial purposes or commercial political nationalist purposes. Therefore, what we should really talk about is the availability of the vaccine and the availability to be able to reach that vaccine to the people. Therefore, also the effectiveness of the public health system. And let's face it, mRNA vaccines are unsuitable in this context for large parts of the world, precisely because they need a cold chain, which most countries, most poor countries do not have. They already have been problems being able to provide vaccines. Africa, for instance, still has about only 12 to 14 percent of its people having two shorts, while rich countries have three shorts and some of them are also looking at four shorts. So, given this, I think this should be seen more as a pharmaceutical companies game rather than as a public health issue, because public health has to take availability and the ability to reach it to the people as well, not simply what is supposedly the vaccine efficacy. Last point, Satyajit, a bit of Indian health nationalism, if you will. Indian researchers have shown that Montelucast, which is used by a lot of my asthmatics like me, for instance, have some protective qualities against infection by COVID, by SARS-CoV-2. What is the evidence for that? Is it something which is interesting, but yet to be really validated fully? Where are we on that? So, it's an interesting research finding. It comes from the Indian Institute of Science in Bangalore, and the way that computational analysis has been put together with actual real wet bench experiments to show this is really very nice. That said, we have to keep in mind the past two and a half years of empirical evidence. In fact, the past many decades of antiviral drug research, but in the COVID context, the past two and a half years of empirical evidence, that so-called drug candidates which prevent virus growth in the test tube do not necessarily show clinical utility in real life, in patients. So, at this point, this is simply a very early phase interesting finding, and really nothing more than that. And I don't think anybody should be rushing out and buying Montelucast or drugs of that sort. Added to which is a point about antiviral drugs, which we've been making in these conversations for the past two years, which has been proven again and again in COVID cases. All the antiviral drugs in COVID-19 that have been shown to work, remdesivir, molnupiravir, Pfizer's combination called Paxlovid, the monoclonal antibodies, which is really the even more expensive versions that Roshan Regeneron are selling. All of these function as specific antiviral drugs that interrupt the viral life cycle, and they show clinical utility only if taken very early during the symptomatic phase of the disease. Meaning that if you've had symptoms for more than about three or four days, taking any antiviral drug is unlikely to increase your chances of changing your recovery trajectory. And as a result, the real issue with these drugs is not so much do we have drugs, do we need more drugs, but to be able to have oral drugs, drugs like Paxlovid, the Pfizer drug, and to be able to have them available in large amounts for early quick diagnosis and easy accessibility at affordable prices for everybody who's had 24-hour symptoms for COVID-19, if this is going to make any dramatic difference on the one hand to the epidemic. On the other hand, it is important for people with known immune compromised situations, people who are undergoing cancer therapy, people who are undergoing who've had transplants, people who are undergoing immune suppressions for auto immune diseases, rheumatoid diseases of a variety of kinds, that they should get tested for COVID-19 very early and at those very early stages, they should have access to these drugs. In none of this is the range of new antivirals the limiting factor. We already have adding more and more drugs is not the point. The implementation of a public health policy and program is the stomach. If modern the cost is off patents that the price would be much lower. So wouldn't that make it an easier drug to use? Yes, but I'm still arguing for the broader point. We are in the middle of a pandemic. Why on earth are we allowing commercial profiteering interests to trump public health needs? Whether the drug is an old drug or a new drug should make no difference to how we look at drug availability and implementation of public health policies. Which means we should break the drum decibel patent and make it widely available that we can do under the current Indian drug act that we have the basically the ability to do so and so as most countries because I think all countries have the provision during pandemic or epidemic they're allowed to break patents or do what is equivalent to breaking off patents. Exactly. Okay, so yes interesting but we have to see what happens but even if it does not prove efficacious there are other drugs which we can break patents make it cheaply available and Satyajit says why is it that we are not starting to do so in spite of the fact that India and South Africa have gone to WTO to say in this period of COVID-19 pandemic patents should not be enforced or they should be compulsory licensing should be followed and countries should be allowed to do so. Actually the countries have the power to do so. Why they haven't done so is still an open question and that's what Professor Rath is raising with us or raising with all and sundry including the drug authorities of our countries. Thank you Satyajit for being with us explaining to us the intricacies of looking at numbers of pandemic looking at how we should read these numbers as well as how the pandemic should be judged in its in its current course of development or waning whichever way it is at the moment and how should we look at the future not only for the pandemic but also for the drugs and the vaccines that have come in this period. Thank you very much we'll also be in touch with you discuss these issues with you as and when we think something new has arisen on the horizon which we need to address. This is all the time we have today for news click discussing COVID-19. Do log in to our website and do go to our YouTube channel.