Prabhat Jha is founding director of the Centre for Global Health Research at St. Michael’s Hospital in Toronto. As Endowed Professor in Global Health and Epidemiology at the Dalla Lana School of Public Health, he is regarded as one of the most influential epidemiologists in the world’. Jha is a lead investigator of the Million Death Study in India, which quantifies the causes of premature mortality in over 23 million people from 1997-2023. A man with a sharp eye on India, this Ranchi-born former Rhodes Scholar, who has held senior positions at the WHO and the World Bank, talks to -Moneycontrol in a wide-ranging interview about the biggest public health issue of the day.
What do you make of this second wave of pandemic in India, which appears to have caught the authorities by surprise?
I had always warned that a large repeat wave was possible. It’s very likely driven by variants, which are more infectious and seems to be affecting younger adults. Allowing large scale political and religious gatherings in February and March and the hubris that India had beaten the first wave, have contributed to complacency.
The optimism that India might have beaten the COVID-19 pandemic has given way to pessimism from the sharp increase in new cases and deaths from the disease. Maharashtra seems to be particularly affected, but nearly all states are reporting increases. The epidemiology of COVID-19 is poorly understood, but some early understanding of the transmission of the virus can enable a more effective science-driven response.
How does a vaccine work?
A vaccine works by mimicking a natural infection. A vaccine not only induces immune response to protect people from any future COVID-19 infection, but also helps quickly build herd immunity to put an end to the pandemic. Herd immunity occurs when a sufficient percentage of a population becomes immune to a disease, making the spread of disease from person to person unlikely. The good news is that SARS-CoV-2 virus has been fairly stable, which increases the viability of a vaccine.
In your estimation, how long will this second phase last in India?
It is difficult to say. Usually declines take twice as long as reaching the peak. We still don’t see a peak yet in India.
Given the poor socio-economic conditions in the country, its lack of mass awareness coupled with poverty and ignorance, do you see the pandemic lasting longer here than in other countries?
We don’t know. Intergenerational transmission within households and crowding are the key drivers of the increase. It was, and remains, wishful thinking that India had achieved ‘herd immunity’. The patterns of infection in India clearly suggest multi-generational transmission, with younger adults the engine of transmission into the elderly. Various serosurveys have consistently found that half or more of tested urban populations have antibodies to the virus. However, this high level of infection is not the same as a markedly reduced level of transmission, which is what is required for herd immunity.
The Indian Council of Medical Research’s ICMR) national serosurvey had design limitations such that it probably underestimated the true national prevalence. A far larger and better set of serial surveys is required. Finally, we need to understand better why some populations are not affected.
How successful has been vaccination? In India, it has mixed reports. People have been infected even after getting their second dose.
The AstraZeneca/Covishield vaccine has strong efficacy against the original strain (about 80 percent or so) and we await evidence on how well it works against the recent Indian variants (it should work). Most of the complaints and reports of repeat infection are of the Covaxin, for which insufficient scientific evidence was released.
Would you say, as some are saying, that coronavirus has been on the decline in some countries in the world? If so why?
Usually declines take twice as long as reaching the peak. We still don’t see a peak yet in India
Most countries affected by variants have shown a third peak, even some states in the US. The UK and Israel have mostly avoided such a third wave due to vaccination efforts. But not so for most other countries. Portugal is interesting – only a modest third wave thus far. Thailand had avoided any major peak but is seeing one now. We don’t know the reasons for the widespread variation.
Some leading authorities in India are saying that this second wave, by most accounts more contagious, could last for as long as the end of 2021. Do you agree?
We don’t know.
Could there be a third wave in India and the world at large?
Much of the world is already in a big third wave.
If the answer is yes then what shape could it take?
We don’t know.
What should be of public interest in India at this point of time?
India must ramp up its science response, which it has not done. Without science, it will be harder for India to walk out of the pandemic. India needs to increase the quantity, quality, and public availability of actual data to guide decision-making. Theories or mathematical models are hugely uncertain, particularly early in the epidemic. Better understanding of the unique patterns of Indian viral transmission has a few pillars, which can be achieved quickly.
First, collection of anonymised demographic and risk details (age, sex, travel, contact with other COVID-19 patients, existing chronic conditions, current smoking) on all positive cases on a central website in each state, remains a priority.
Second, greatly expanded sequencing of the viral genome is needed from many parts of India, which can be achieved by re-programming sequencing capacity in Indian academic and commercial laboratories.
India must ramp up its science response, which it has not done.
Third, far better reporting of COVID-19 deaths is needed. Daily or weekly reporting of the total death counts by age and sex by each municipality would help track if there is a spike in presumed COVID-19 deaths. The Registrar General of India’s verbal autopsy studies are invaluable but must be reactivated to review deaths occurring in 2020, given that the last available results are from 2013!
What, according to you, is the roadmap needed for India?
COVID-19 could well turn into a seasonal challenge and thus, the central government should actively consider launching a national adult vaccination programme that matches India’s commitment and success in expanding universal childhood vaccination. The Disease Control Priorities Project estimates that an adult national programme would cost about Rs 250 per Indian per year to cover routine annual flu vaccination, five-yearly pneumococcal vaccines, HPV vaccines for adolescent girls and tetanus for expectant mothers.
Per year, vaccines for one billion adults might save about 200,000 lives from the targeted diseases. Annual flu vaccination reduces the risk of influenza pandemics and perhaps even COVID-19 infection. Indeed, we might already be in the era where major zoonotic diseases are not once-a-century events, but once a decade. Thus, adult and child vaccination programmes are essential to prepare for future pandemics.
