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A Gambit of 3 Vs: Virus, Variants and Vaccines

The COVID-19 situation in Jammu and Kashmir has taken an ugly turn though there has been a lag time from the national surge. The reasons and patterns for the surge have followed the national scenario.

Post by on Thursday, May 20, 2021

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The COVID-19 situation in Jammu and Kashmir has taken an ugly turn though there has been a lag time from the national surge. The reasons and patterns for the surge have followed the national scenario. 

Sequencing data of sera from patients with COVID-19 of 2021 from J&K (UT) showed that around 25% of patients had several types of variants. These were classified as VOC (Variants of Concern), or VOI (Variants of Interest), and /or important mutations and included single mutations, two mutations, and multiple mutations in varying numbers. The variants in these samples were classified: i. B.1.1.7 (UK variant), ii. Variants similar but not exactly like the UK Variant, iii.B.1.617 (Indian variant), iv. Variant without a linage number but have a signature to have increased infectivity, and v. Variant without a linage number but with a signature have immune evasion. Thus, circulating variants in J&K (UT) including those with mutations that have a potential for increased infectivity and those mutations that have a potential for evasion and can cause breakthrough infections in persons who had COVID-19 disease earlier and recovered or who have been fully vaccinated by any of the vaccines available in India.

Nature-of-COVID-19-2021-Surge:

SARS-CoV-2 viruses circulating now in India including J&K have shown significant mutations and several variants are circulating in the population. These variants give advantage to the virus at multiple sites of attack which include: Increased infectivity, Immune evasion, Diagnostic test evasion, Possible changing mode of transmission, change in age-related prevalence, Change in clinical profile, and Possible increased morbidity and mortality. I would prefer to call it a new-COVID-19-virus-2021 with a new-COVID-19-disease-2021. 

So as of today, the following features of COVID-19-Disease-2021 J&K are being observed due to the introduction of these variants: 

i. A massive surge of cases due to increased infectivity, 

ii. The Super-spreader phenomenon is shown by the fact that infection in one member in a family/office/establishment spreads to all and spares none. This phenomenon has a major implication on the ‘stay home policy’ as elderly people who stay home can yet get infected. The advice on ‘mask and social distances indoors’ (reverse quarantine) needed to be practiced to save the elderly from getting infected, 

iii. Aerial mode of spread especially in congregations in ill-ventilated areas. In such a situation masks may become less protective and viruses circulating in the air spread for extended distances. The basic mode of spread by droplet continues to be a major factor, 

iv. As of today, disease occurs more often in young people than seen in 2020 and a significant percentage developed moderate to serious disease and even die, 

v. A higher percentage of infected patients developed lung disease and get hospitalized and cause pressure on resources including space, manpower, drugs, oxygen, and ventilators, 

vi. A significant percentage develops disease outside the pulmonary system including GIT, cardiac disease, neurological disease, and whatnot. Such patients lack pulmonary symptoms and are difficult to detect unless suspicion of COVID-19 among the public and medical fraternity is enhanced, 

vii. There is a suspicion that COVID-19 as of today in J&K has higher mortality and morbidity.  

viii. Immune evasion phenomenon: Unfortunately, people who are vaccinated, partially or fully or those who have suffered COVID in the past can get breakthrough infections due to variants in the community. The breakthrough infections may be mild or asymptomatic in a large majority of cases. However, some patients may get lung disease, need hospital admission, or even die.  

ix. Diagnostic test evasion: Due to major mutations in the spike proteins, otherwise sensitive test ‘rt RT-PCR may show false negative results delaying therapeutic interventions at crucial times. 


Fighting COVID-19-Disease-2021 Surge in J&K


To face such a huge challenge, a heightened state of emergency has been called for and all state machinery has been geared to act and face the pandemic. Several actions namely the creation of inpatient beds, extending hospital space for COVID-19 patients, manpower at all levels, supplies including Oxygen and drugs are considered and implemented.  Looking at the epidemiology of COVID-19, the incubation period, and modes of transmission, any effective measures to stop transmission at an early stage of the surge of pandemic make gains in a matter of days to few weeks. However, as of today, we have missed the bus as there is obvious community spread and the infection has spread through society like a wildfire. 

Even highly effective measures to block the transmission at this stage namely ‘Mandatory-masking, Social distancing, Avoid-crowds/gatherings, and hand-washing policies ‘shall take from 6 to 8 weeks to initiate benefits. In such a situation, there is only one crash major to tame the beast: the so-called Lockdown. Of course, the administration has to evaluate the economic impact of the lockdown and use highly dedicated measures to support those who are badly hit namely daily wagers, small-scale vendors, unskilled and skilled workers. An effective economic package needs to be implemented to mitigate the economic suffering of lockdown. Also, free ration, fuel, and other supply items can be distributed to persons below the poverty line under national programs existing in J&K (UT). 


While we believe Lockdown is mandatory as of today to save lives, few observations are important: i. Lockdown may not be as effective as for COVID-19 of 2020 as the transmission of disease now happens within the household setting. The majority of the elderly get infected within their houses rather than from outside. Additional measures to curb this spread within houses need to be implemented. ii. The virus as of now and its variants are extremely infectious and evasive. Lockdown measures for virus with such behaviour have not been well worked up. Time will only tell how effective the Lockdown will be and how much time it will take to start working. 


To fight the pandemic, highly coordinated and effective measures need to be implemented in society. These have been practiced by all countries including India while fighting the 2020 surge. However, additional measures need to be done to block the altered behaviour of the variants and their additional mode/mechanism of transmission. The virus/variants often show super spreader phenomenon and are transmitted rapidly in household settings and a major threat to the elderly population who are otherwise housebound. 

Secondly, the airborne transmission may play a significant role in the transmission and can spread in close spaces beyond 6 feet distances and for a longer period. Mask wearing in such a situation may not be as effective as otherwise in such a setting.  Because of the variants, medical personal who may be vaccinated are at risk for breakthrough infection. There is evidence that such infections may not come from patients only but from the spread of infections in cafeterias and canteens and from washrooms where masking practice cannot be fully implemented. The medical fraternity needs to be made aware of this phenomenon. Persons who are partially or fully vaccinated or have had COVID in the past and recovered can have breakthrough infections due to immune evading variants. So, such people should not reduce their protective guards against the virus and continue to take all precautions to protect themselves. As elderly people often get an infection while staying indoors from young who move out, advice of reverse quarantine should be advised to block such a spread. So, the use of face masks inside the houses needs to be advised under such a setting to protect the vulnerable. All forms of a gathering of diverse nature need to be identified and clear guidelines for their COVID status need to be circulated among the incumbents. The testing program for vendors, barbers, receptionists, butchers, and other people who interact with large groups of people. This will reduce transmission of disease at such points.Hospitals, nursing homes, private clinics have become a big source of crowds and virus transmission. Surveillance at such centers by intensive testing needs to be done. 


Testing and tracing policy should be intensified and made more realistic. Rapid testing should be limited to specific circumstances as recommended by the committee and the RT-PCR facility made more available and quicker. The impact of variants on testing needs to be studied as more and more cases are being identified with classical COVID disease and RT-PCR negative.  A concentrated effort should be done to study the changing disease pattern with the Variants so that proper therapeutic interventions can be introduced. Vaccine hesitancy needs to be fought and the vaccination program must be strengthened and its expanded role implemented with full force. This shall reduce infections and further mutations. 


Vaccines

With variants that are more infectious and have immune evading properties, and can infect those who are partially or fully immunized, the role of the COVID-19 vaccination program in society needs to be redefined. It is believed that vaccination programs should continue with full strength and forces even with such variants are circulating in the community. The fact is that vaccine-induced immunity may not give sterilizing immunity but can safeguard you from getting infections that need hospitalization and/or serious lung disease and death. Also, the doctrine to fight RNA-virus-variants as of the SARS-CoV-2 virus is to stop or reduce viral replication in the community. So, implementation of COVID appropriate behaviour and vaccination shall reduce the occurrence of infections. Once virus replication is reduced occurrence of variants is also inhibited. 


PROF. MOHAMMAD SULTAN KHUROO
MD, DM, FRCP (Edin) FACP, Master American
College of Physícíans (MACP, Eméritus)
Dr Khuroo also heads the newly constituted committee to tackle possible third Covid-19 wave in JK.
• Former Dean & Director SKIMS and Ex-officio Secretary to Govt.
• Former Professor & Head Gastroenterology and Chairman Dept. Medicine, SKIMS.
• Former ConsultanT & Head Gastroenterology and Liver Transplantation.KFSH&RC, Riyadh.
• Member, Governing Body SKIMS.
• Chairman. Apex Level Advisory Committee to Govt. of J&K (or COVID-19.
• Director, Dígestive Diseases Centre, Dr. Khuroo's Medical Clinic, Srinagar.





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