The UK government's move to institute mandatory 10-day quarantine on arrival even for fully vaccinated Indian nationals has no basis in science and is a political move say experts.
The UK government's new travel guidelines come in to place from October 4. According to the rules, the UK has recognised travellers who have taken two doses of the Pfizer, Moderna, or AstraZeneca vaccine, or one dose of the Johnson & Johnson vaccine. While Covishield was not included in the first list, the UK government included the Oxford-AstraZeneca vaccine manufactured by the Serum Institute of India (SII) after outrage from Indian lawmakers.
Despite Covishield's inclusion in the list of authorised vaccines, Indian travellers are still expected to quarantine on arrival in the UK.
Dr Vineeta Bal, Immunologist and Faculty at the Indian Institute of Science Education and Research (IISER) believes that the move is political in nature and has no basis in science.
"I see this ban on Covishield or putting forth quarantine as a condition as a political stance rather than any science-based stance. It is beyond me right now, but from what I see this is essentially a political stance, there is no science behind it. And in that sense, if scientists from the UK are involved in making this decision, then they should be embarrassed for making such a decision," Dr Bal told BOOM.
On the vaccination front, India needs to learn from the US' mistakes and ensure regions with low seroprevalence are vaccinated according to Dr Rajeev Jayadevan, Vice Chairman, Research Cell of Indian Medical Association.
A large section of the Indian population is fully or partially vaccinated while a significant portion has been infected by the coronavirus giving them natural immunity. However, there are pockets in the country where the seroprevalence is low which are highly vulnerable to the virus.
"Even a small percentage of a large number is still a large number. So, even if our country is nicely vaccinated and even if a large percentage of people seroconvert, there will still be a percentage of people who have had neither or the immunity has waned off.
"That is happening in the US. The US is a well vaccinated nation, 55 per cent are fully vaccinated and 60 plus per cent are half vaccinated. If you look at the wave now, it looks like it is worse than the previous wave. You may think superficially that it is a failure of vaccination. It is not. This pandemic in the US is almost exclusively affecting the unvaccinated and the same could occur in India as well," Dr Jayadevan said.
"There will be future waves but as Dr Bal said, they will more likely appear in regional forms rather than as a whole country as a whole. Looking forward we must definitely vaccinate as many people as possible and there is plenty of evidence coming out that if you give a dose of the same vaccine, it is still good against the variants," he added.
Edited excerpts of the interview with Dr Vineeta Bal and Dr Rajeev Jayadevan follow
Dr Bal, what is your sense on where we are in the efforts that we put into vaccination and the impact that it is having on the spread of COVID-19 in India?
Dr Vineeta Bal: What I would say is that India started late in terms of its vaccination programme implementation. And the availability of vaccine doses was extremely low. Even today for our population size and for the eligible population, we are still falling short of what would be considered as an ideal target. Even the targets that the Government had set up of giving the first dose at least to every eligible individual by the end of December, I think it may or may not be achievable.
But in the meantime because of the Delta virus variant that emerged from February, March, April onwards and it created a huge wave. It was much more of a vaccine requirement which was felt and in that sense partly, I would say that the impact of the second wave would have been much lesser if we were prepared and if we had vaccinated many more individuals even before March.
It seems that we have moved on quite a lot, there is still a positive impact of vaccination that we do see despite seeing breakthrough cases — the breakthrough cases are not as severe as they would have been otherwise. So, yes there is an impact but we are much shorter on what would have been ideal and desirable.
Dr Jayadevan, how do you see the impact of vaccination particularly from a state like Kerala that is reporting a substantial number of cases even today in contrast to the rest of the country?
Dr Rajeev Jayadevan: In contrast to the national average, the number of people who developed COVID-19 in the first year of the pandemic was quite small. It was only about 10 per cent, maybe an 11 per cent which means there were about 89 per cent of people who were shielded from the virus. Remember in 2020, there was no vaccine, there was no medicine available and there is still no antiviral. So the only method available was to shield in one way or the other. Wear a mask, social distancing and avoiding social gatherings as methods of shielding.
Now this worked for Kerala, a relatively small state, with a robust public health system, good communication network, and literate population and so people shielded enthusiastically. Now, the flip side of shielding is susceptibility or to use a more harsh word, vulnerability, which means that the 89 per cent of the people who were not exposed, in the first half of the pandemic, were subjected to an exposure as Dr Bal mentioned. It was Alpha variant at the beginning of the year; fortunately it did not create much of damage here.
But when Delta variant came, fortunately we went in for a lockdown and it saved the healthcare system from collapsing. It had come under a bit of strain but there was no overflowing. But as the lockdown was lifted, the Delta variant had not gone anywhere, was still here and as I mentioned, a large section of the people had never seen the virus before, and vaccination, as Dr Bal said, was just catching on.
So, around the middle of the year, this combination of events and humid, warm rainy conditions which are ideal for most respiratory viruses — the combination resulted in what we call a slow burn process, which is neither going up nor coming down dramatically but overall there is a gradual decline. So, as more vaccination kicks in and more people get naturally infected or combinations thereof, the impact felt will be lower and lower.
Covishield has been administered across the country. It is the major vaccine that has been administered as opposed to Covaxin. Now, some countries have concerns. One is whether those who present certificates that they are vaccinated are actually vaccinated or not, or there are actually some errors. The second is whether the vaccine itself is not effective or efficacious as it is being claimed. What do you feel when you look at the evidence both within the country and outside?
Dr VB: Covishield as we are calling, it is an Oxford University-AstraZeneca-Serum Institute vaccine if one wants to be precise about it. It is as good as practically any other vaccine. There are always a little bit of pluses, a little bit of minuses including mRNA vaccines and other vaccines that are available. But there is not anything much to choose or much to discard.
Certainly, Covishield is a very good vaccine, and in that sense the doses that we are recommending, as in the Government of India is recommending, initially it was after a gap of 4-6 weeks, now it is a gap of about 12 weeks. And even if there are some ifs and buts about this gap, whenever the 2 shots are given, 15 days after that even from the Delta variant there is a significant protection that is offered to Indians who have primarily received Covishield.
So I see this ban on Covishield or putting forth quarantine as a condition as a political stance rather than any science based stance and if there are other commercial interests involved in it, in the sense that the manufacturer has some interest in keeping people away and so on. It is beyond me right now, but from what I see this is essentially a political stance, there is no science behind it. And in that sense, if scientists from the UK, if they are involved in making this decision then they should be embarrassed for making such a decision.
Do you have any sense, any explanation to this effect. I have not seen any, so which is why I am asking you from the scientific community?
Dr VB: Explanation no. I mean I do not know whether Public Health England and scientists who are a part of that have put out any statement. But that is what I am saying: AstraZeneca vaccine is extensively used within UK; there are very many benefits of it which have been seen in the UK, and what we are seeing as Covishield in India manufactured by Serum Institute is essentially that.
So I do not see why in one country that should be an acceptable regimen and why from another country it should not be acceptable. That is why I am saying if scientists are actually recommending it, they should think twice about whether this is based on scientific evidence or as I am calling it a political drive. Rather than really any rational reason for it.
Dr Jayadevan, if I were to ask you to respond more empirically, when you look on the ground today, particularly post the peak of the second wave, what is your sense? How are Covishield and Covaxin working today? Is it making any difference in the hospital admission or the severity of the cases that are now coming in?
Dr RJ: Both vaccines that are widely used in Kerala have been excellent. Now, for our viewers, I think they would like to know that a vaccine protects on many fronts like a student is graded on different subjects, giving different marks for different subjects, likewise the vaccines can be graded for
A) their ability to stop you from being infected by the virus
B) their ability to prevent the symptoms from appearing
C) ability to prevent severe disease,
D) ability to prevent death
Now, what we know for sure is that all the mainstream vaccines used around the world are excellent at preventing severe disease and death. And our experience locally on the ground is exactly the same.
The vast majority of the people who have severe disease or are in the ICU or unfortunate enough to succumb to the illness are all people who have not completed vaccination. There are a few people who have received one dose vaccine, which may not be so effective in preventing severe disease.
Now, there is one other combination that I would like to mention because there are many people in our country who have been naturally exposed to the virus knowingly or unknowingly. We are aware that almost a half of these infections appear and leave without symptoms i.e., without the patient knowing about it. When these individuals receive one dose, they are essentially fully vaccinated because they have had two exposures to the antigen. So to someone who has not had such a prior exposure, when you receive one dose, it is called a priming dose, the second dose is the boosting dose.
So, basically, the point here is that there are several individuals in India who have received two doses of vaccine; two doses of vaccine in addition to past infection; one dose of vaccine and past infection; and combinations thereof. And there are very few people left who have not had either one dose of vaccine, or natural exposure infection. So I think as time wears on we will have fewer and fewer people who are unprotected.
The good thing that India did, even though our vaccine supply was somewhat sub-optimal in the beginning, we chose correctly to vaccinate. We chose the highest risk category, which is people who are constantly exposed to the virus — healthcare and frontline workers, they got the dose first and followed by the older segment. COVID-19 is a disease that I emphasise preferentially affects the older people, and cannot be emphasized enough; the risk of death in it for a 70-year old person is more than 200 times than that of a young adult.
Therefore vaccination, as they say, the juice is worth the squeeze in the older segment. If you vaccinate 50-70 efficiently, then you can prevent more deaths than if you use the same vaccine doses in the 20-40 group. That is my point.
Dr Bal, this is something that many public health experts are trying to compute. If you were to look at this equation that Dr Jayadevan has pointed out, those who have developed immunity because they have already contracted the disease or have been infected by it, those who have maybe got one dose and those who have two doses, where do we stand as population today in our likely susceptibility to future infections particularly in the near future.
Dr VB: We have ICMR serosurveys as a guide to areas with high and low seroprevalence. Kerala, where my colleague comes from, was one of the states that had very low seroprevalence. He explained the reasons for that. But many other, in fact big cities like Delhi apparently have very high, almost 80-85 per cent seropositivity. Which means that there are very few people left who are actually exposed and this seroprevalence also covers people under the age of 18 years.
So, all the population has been covered. If you want to really look at the averages — about 60 per cent but this is not uniformly distributed. This is distributed in patches and that is where the problem is. So, what we need to identify as a country from a public health perspective is areas where seroprevalence, seropositivity is low and that is where the vaccination should be concentrated.
Of course, that does not mean that others should not be given the vaccines, but the areas of low seropositivity are still a lot more vulnerable to catching delta or any other variant which might come our way. And that is the kind of public health policy strategy that needs to be evolved. But for that, one actually needs data —just as an example, in Belagavi what is the seroprevalence, in Pune what is the seroprevalence; even within Pune there are pockets where there are less seropositive and high seropositive individuals.
So, this kind of local studies or local picture is what is ideally required and that is how the vaccines should be channelised. Because there is no other way of preventing this and I do not think we have the wherewithal with whatever data we have and most of the cities are not smart cities, not enough data collected of this granularity and these problems will remain. As a result, wherever we understand that there is low seroprevalence, there is low seropositivity; it should be the target area from now on for sure.
When we travel, we are doing RT-PCR tests and only if you have a negative test can you board an aircraft and that goes for people coming into India as well. There is the double vaccination. What is your sense today, where we are today in the spread of Covid so far. What more could we do given the pace at which things are going to give people comfort that things are not as bad as they think they are, particularly in a large country like India?
Dr VB: Well, things are not really that bad and there have been many models who have predicted that a big wave is likely to emerge from now onwards in October and November. I disagree with that for the reasons that I mentioned that seropositivity status is so different in different parts of the country. So if there are outbreaks, they will certainly be there. Country wide in general, a huge wave is unlikely to happen. So that is one positive point.
The second apprehension that most people, especially with kids, is that they are not vaccinated and educational institutions have still not started. And I do feel that we know from this national level serosurvey, that even kids under the age of 18, at least 50 per cent of them, are already seropositive and almost all of them went without symptoms or illness. That should be an assurance and we should actually start the educational institutions by vaccinating every adult in the school or college because they are eligible and they should be vaccinated and they are more at risk.
These are some of the issues that will bring peace of mind, a sense of normality, because educational institutions are the ones where there is a complete stop. Some of these businesses and other professions have started functioning and there is some economic activity whereas educational activity has completely stopped. And we do need to begin that with precautions, slowly and steadily and I think that is an important point that we need to consider
And that itself is an indicator that we are not confident things are under control even at this point. Dr. Jayadevan, where do we stand and what more do we need to do?
Dr RJ: I would be a little on the cautious side simply because of a basic mathematical principle we sometimes forget when we look at large numbers. The principle says that even a small percentage of a large number is still a large number. So, even if our country is nicely vaccinated and even if a large percentage of people seroconvert — in other words get exposed to natural infection, there will still be a percentage of people who have had neither or the immunity has waned off.
That is happening in the US. The US is a well vaccinated nation, 55 per cent are fully vaccinated and 60 plus per cent are half vaccinated. If you look at the wave now, it looks like it is worse than the previous wave. You may think superficially that it is a failure of vaccination. It is not. This pandemic in the US is almost exclusively affecting the unvaccinated and the same could occur in India as well.
As Dr Bal said, we must selectively focus on these individuals or areas that are more likely to face future waves. There will be future waves but as Dr Bal said, they will more likely appear in regional forms rather than as a whole country as a whole.
In one sense what happened in India was the Delta 2, which was much faster spreading came and found that there were several pockets in every part of India that had not been infected and it was these people that primarily succumbed to the disease and that is still a large number. That is why the wave appeared to be huge. So, looking forward we must definitely vaccinate as many people as possible and there is plenty of evidence coming out that if you give a dose of the same vaccine, it is still good against the variants.
That is one of the fascinating aspects of our immunology. Our immunology, immune system has been under rated. You know, we have lived on the planet for almost 200 thousand years, our immune system has been exposed to these viruses and it knows how to fight these viruses and it knows what kind of changes can potentially happen in a virus.
That has been proven beyond doubt in more than one institution of excellence. You do not really need to have a vaccine for every variant. You do not need to do that and that has been shown. That is encouraging news. So, when the second dose comes in or a dose goes in after the natural infection, yes that person is well protected, again from severe disease but not necessarily very well from a repeat infection.
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