New Delhi: Dr Soumya Swaminathan, Chief Scientist at the World Health Organization, had a detailed conversation with Editor-in-Chief Shekhar Gupta at a digital version of ThePrint’s Off the Cuff Saturday.
She said a vaccine for Covid-19 could emerge in about a year, and called it ”unprecedented” that seven vaccines are in human clinical trials within three months of the discovery of a pathogen.
The discussion ranged from the spread of Covid-19 across the world, how countries were dealing with virus differently, and why the US President is angry with the WHO, to how long the development of a vaccine will take and how effective HCQ is in treating the novel coronavirus.
Read the full transcript of the conversation here:
You are sitting on the hottest seat you’ve sat on in your life, the whole world is looking at WHO, and I presume WHO is looking at you – because you have the scientific team. Can you give us, in 2 minutes, the science of what’s going on
We’re learning every day. What I say today, will be outdated tomorrow.
Let’s start with the 31st of December, when the local health authority of Wuhan notified through the Chinese authorities to WHO that they had seen an unusual cluster of pneumonia cases happening in Wuhan. That’s the first that WHO got to know about it. We set up immediately the incident management support team — a team that is immediately put in place whenever there is any hint of an emergency.
On the 4th of January, we supported on social media that something unusual was going on, and on the 5th we put out something called the disease outbreak news — this tells people that there is an outbreak somewhere and gives as much detail as available. On the 10th of January, we put out a technical package because on the 11th, we were informed by the Chinese authorities that this was a coronavirus and infact they had already sequenced the gene and had deposited the sequence in a public database. This is very important to note, as it sets the stage for many things that happened after that.
On the 14th of January, our technical teams did talk about possibility of human to human transmission knowing that the previous coronaviruses, the SARs virus and the MERs virus are the two ones that remember because they were rather serious but we must remember that there are four other coronavirus that infact cause the common cold, about 30% of upper respiratory infections in humans. This is the 7th coronavirus that is known to us, and so knowing the other coronaviruses we know this is how it’s likely to spread through droplet transmission and therefore all precautions should be taken and health workers should be particularly vigilant. And going on from there, the emergence committee met on the 22nd and 23rd of January. They were not convinced that it was an international emergency, because there were very cases outside of Wuhan or outside of China at that time.
But on the 30th of January, they were reconvened by the Director General and at that time they then declared it a public health emergency of public concern. That time there were only 82 cases in China, and the same day the first case in India was found positive in Kerala. That’s the highest level of an emergency threat that the WHO can make based on the international health regulations, at that time we had already called it high risk, possible threat.
We also put in place very quickly the research and development plan. On the 10th of Jan, before we knew very much about the virus, we convened an international group called the global coordinating mechanism of the R&D Blueprint — a mechanism set up after Ebola in 2015 in order to activate research and development for any new pathogens. We also started working on science and research and generating knowledge through our network of experts on the 10th of January.
Since then we have learning more and more. It has taken off in many countries, and explosive outbreaks in Europe and North America that have overwhelmed health systems. We have learnt much more how to diagnose it and how to manage it.
What do we know about this virus that we didn’t know three weeks back? Do you agree with people who say the virus is running faster than scientists, politicians and bureaucracies?
Yes. We had known such a thing would happen in the world, although no one imagined it would happen right in this moment and would take such shape.
If you look back at documents of the WHO, few things are important. We’ve known that the world will face a pandemic. The director general last year said it’s not a question of if but a question of when. Most people thought it would be an influenza pandemic, but it turned out to a coronavirus. The world was more prepared for an influenza pandemic. Secondly, we knew that it would be a virus and it would be a zoonotic infection, because we know that the majority of viruses jump from animals to humans which have occurred in the past century, many of them have predilection for becoming an epidemic or pandemic virus.
If you look at the history of HIV or Ebola, these all came from Nipa virus. Many of the viruses that are quite deadly in humans, they infect animals and they don’t kill animals. Many of them come from bats, for instance. This virus has been in some animals, has a very close similarity to bat coronaviruses. We don’t know how it moved from bats to humans, whether it came directly or through an intermediate animal and whether that animal was wild or domesticated animal.
But whatever it is, it made that jump, and we don’t know when it made that jump to human and whether the virus has actually been slowly evolving in humans for sometime. These are the studies that still need to be done. But it’s clear now this virus is able to transmit very easily between human being and luckily for us, it has less of a fatality rate than MERs or SARS, at 30% and 10 % respectively. MERS continues to show up from time to time in the Middle east, but SARS hasn’t showed up. But this is a virus that is related to the SARS coronavirus 1, which is why it is named SARS-CoV-2.
What is the chance that this will also one day disappear as a global threat like MERS or SARS?
It could take a couple of different trajectories. Early in the outbreak, WHO kept the pressure up for countries to contain it, hoping that like SARS it could have been contained and finished off in a few months. It now looks like it spread globally, and spread so widely that we can’t say with confidence that we can contain it. So what can happen? It could become a seasonal virus like influenza virus, it could have waves coming down or then coming up again once or twice a year we could see these waves happening in different parts of the world. Or it could become an endemic infection, in the sense that you end up with the virus causing disease in human at a low level, at a manageable level. And people continue to get sick, but we learn to live it.
Over a period of few years we don’t know what’ll happen. The virus may end up becoming less virulent, or enough of the population develops anti-bodies either naturally or through a vaccine and the virus really stops producing the kind of outbreaks that we’ve seen this year. Over time, either naturally or through vaccines, as immunity builds up it may not be so catastrophic. But for the next year or two, we should expect to see this virus continue to cause disease.
Why have the European countries like Britain, Italy, Spain and the US been so badly hit with such high fatalities?
There are a few reasons we could postulate, a combination of reasons. One of course, there is high travel. Most of these areas that have been badly affected have a lot of international travel and a lot of people with the infection could have travelled to these areas and seeded the communities there.
Secondly, we’ve seen that profile of people who’ve come into the hospitals has been mostly the ones who got really sick are the elderly, and these countries have a long life expectancy. The average age of the people who passed away in Italy was 81 years. Similarly, it’s been the same in other European countries. The older the people in the community, especially with other illnesses, these virus was able to really make them very sick.
The third reason is that countries did not take it seriously in the beginning. The WHO has been warning all countries saying this is not something to take lightly, put labs, testing, public health machinery set up. In many of those countries, that was not done. So they were suddenly overtaken by events when the number of cases were so huge that the hospitals could not cope. But we have also seen other countries that took the right steps and put in the right measures and were able to contain and control with very little mortality — mostly southeast asian countries.
People say it’s because of past experiences having been through SARS that countries like Hong Kong, Singapore are so prepared and the population knows how to handle a virus like this. It’s a combination of government and the public knowing how to handle a viral outbreak like this and also in some parts of the world, the public health infrastructure has crumbled. This shows us very clearly why the basic principles of public health are so important.
In the ranking of countries that prepared well and countries that took their eye off the ball, where would you place India?
I would say that India was one of the countries that took it really seriously right from the beginning. Last week we had a meeting, where once a month or so, we have all the health ministers of the 194 member states joining in for a discussion on Covid-19. The Health Minister of India, Dr Harsh Vardhan presented the timelines and it was quite incredible.
The 17th of January, he said, was the first meeting that was held at a high level, all of these different committees were set up. On the 30th of January, the day WHO declared a public health emergency, was when the first case was found which means that already states and cities had put in place screening of travellers, initially from China.
I’ve heard first hand from people who were travelling how they were called up by the health authorities, in different states. So they were actually tracked, if they had come back from a flight abroad they were called everyday for the next 14 days how they were, if they had fever etc. Those elements were put in place and we were able to limit and contain the number of infections that went into the community. But these screenings have limitations, temperature screening is not sensitive and therefore a few people with infections would have slipped in. A lot of people who came back from Europe brought in later waves of infections in late Feb-March, and then there were too many contacts.
But I think it was reduced by the actions taken, and that is why India’s been able to keep that line fairly fairly flat, and has not seen exponential growth.
Does WHO trust the data that the government of India is putting out, of testing, of positive cases, of fatalities?
Yes, absolutely. WHO does trust the data that we get from countries worldwide. We rely on countries to give us their data. Many countries have more or less developed systems to collect health information. Before, one of our priorities was how do we strengthen health information systems of countries , for instance a lot of countries in Africa and Asia, we get the basic data but there so much data that could be collected that could be really useful for planners within those countries, and of course for WHO to monitor the health of the world. Overall, I would say there’s a lot of scope for improvement.
Do you think fudging is possible in a country like India?
I don’t think so, because it’s a democracy and things are open and can be scrutinised. People criticise, everyone has a voice, so it’s very difficult to hide anything
You were heading ICMR institutionally, do you think ICMR as an institution would fudge or hide?
Never. I think ICMR really believes in science. I don’t think I’ve ever come across any incident where they would fudge or hide. Sometimes the quality is poor, or there are not enough labs, enough capacity. That is possible. But I don’t think there would be any wilful hiding of data.
The doubt comes from what happens in China, where suddenly overnight they upped their numbers in Wuhan exactly by 50%. These estimates don’t change in such round figures over night, so then you think the Chinese are getting away with it, so who knows what’s happening elsewhere.
When I was in the ICMR, one of the things I was really keen on strengthening was the cause of death of reporting. In India, almost 2/3rd of people actually die at home. We don’t know what they’ve died of. Even the third of people who do die in hospitals, the way the cause of deaths are recorded just say says ‘cardiac arrest’, ‘heart attack’. That doesn’t tell you anything. This is a weakness, not just because of Covid-19, but it’s the way you get to know the burden of disease.
In developed countries, they depend a lot on knowing the exact cause of death. This is an area we need to strengthen.
In terms of the death reports from China, what had happened was that they have now looked at all the deaths that happened in Wuhan at that time and have been able to reclassify. When the outbreak is happening, it’s very difficult to keep up with the statistics. If you see what’s happened in the UK, and other European countries, they’re finding now that people who are dying in care homes aren’t dying of Covid-19, but are being counted as Covid deaths.
All countries at some point are going to have to reconcile the statistics they get from sources and come up with a more accurate number of deaths.
Right now, do you trust China’s figures as well?
Yes, just as we trust every other country’s figures.
President Trump keeps saying many more people have died and gotten infected in China, and we know that Trump has been attacking WHO. So people tell us, why does Trump get so angry with WHO? Also Mike Pompeo, United States Secretary of State, has more specific comments about China not sharing data, research of the virus and what he calls WHO’s “inability” to get in from China and thereby, to get China to fulfill its obligations under the international health regulations.
There are two aspects to this question, and people must understand what the WHO can and cannot do. The WHO is a member state organization, and we are the secretariat here and we serve the 194 states. They govern the WHO, and they meet during the World Health Assembly, and there’s a board that takes all the decisions. We follow the instructions given by member states, who have the authority. We don’t have the authority to make rules and regulations. In 2005, they made a set of regulations called the international health regulations, and was done in response to SARS and to protect the world from exactly what we’re seeing now. All member states agreed that they would share data according to the international health regulations. To a large extent it’s been very good and successful, but it doesn’t give powers to WHO to take action. We have to work through cooperation, building consensus, by giving advice and persuasion. It’s not a body that can march into countries and can do inspections.
In terms of China, I shared the timelines of what happened.
When speaking about China, there are a few dates — middle of January WHO had put out a tweet saying there’s no evidence of human-to-human transmission. And then the third week of January, Dr. Tedros is in China, where no great concern is expressed, infact there is great appreciation of Chinese response. Then the 31st when America stops flights from China, then there is criticism of America. So when Dr. Tedros says Trump or America are politicising the pandemic, there is a counter that didn’t he politicise the pandemic to begin with.
Not at all. The Director General goes on the advice of technical experts, not only those who work in WHO but a network of experts from around the world. The emergency committee is made up of experts from different countries, they debate and decide when something is an emergency or not. The Director General can accept, or reject, the recommendations of the committees. On the 14th of January, our technical expert in her briefing said that it was very possible there is human-to-human transmission but we don’t have evidence of that, but knowing coronavirus we have to be very careful.
As far as travel and trade, this is part of our international regulations which talks about how travel and trade should not be restricted even when an emergency is declared because it leads to so many other unintended consequences. Therefore, what WHO recommends to countries is don’t restrict travel or trade but incase you put in place restrictions they should be temporary, measured and with good reason. We track what different countries are doing and why they are doing it. It’s a question of WHO putting out guidance based on either certain rules that have been developed or evidence that is available, and we update and change based on new evidence.
Countries that stopped travel from China early, like America, India, in retrospect do you think they did the right thing or not?
What we know about these viruses is that stopping travel does not stop the spread of infection. It is possible for a short period of time it could slow it down. Right from January, modellers said it would be delayed if you stop travelling, because in today’s world you cannot stop travel forever. So you could delay the virus from coming in, but not stop it.
We see in the US, the huge wave of infection in the East Coast actually travelled from Europe and not from China.
We have many audience questions. Question from Mukul Verma — when can the world expect a genuine vaccination?
We have over a hundred vaccine candidates, we are tracking it. What’s happening is unprecedented, there has never been a situation of within three months of a pathogen being uncovered that there are so many vaccine candidates that have come, including in India. Seven of them are now in trial. WHO hopes to help scientists from around the world, as well as private sector manufacturers, developers and academics to really come together and have open and frank discussions about different vaccines developed and come up with a prioritisation.
One, we are tracking candidates. Second, we are developing target product profiles — what kind of vaccines do we want to see for this infection? Third, we are developing draft clinical trial protocols for how such a trial could be run. We have also been developing animal models to test these vaccines before going to large scale human trials. We are in a good place. Yesterday, the Director General launched a new programme — ACT (Access to Covid Tools) accelerator calling on governments, public and private sector, to come together and get a vaccine in the shortest possible time. If everything works well, we could be there in 9-12 months, which would be an unprecedented scientific achievement because it usually takes 5 years.
A group in the UK says even as early as this fall. Do you think it’s possible?
They have launched their human trial which is going to be injecting 500 people. But then they have to wait to see how many of them actually get infections, because you have to prove the efficacy of the vaccine before it can be used. Efficacy and safety are two critical considerations.
This scientist from Oxford, Dr. Andrew Pollard, also said it’s a matter of luck.
It’s very hard to predict.
What about a therapy in the meantime?
In terms of therapy, it’s very challenging. Antivirals are difficult. In the beginning, it’s the easiest to look for existing drugs that have already been used on humans and known to be safe for other diseases. So that’s what people started doing, and came up with a few, like an anti-HIV drug, and hydroxychloroquine etc.
HCQ has also become popular and politicised. Our own science editors have questions regarding it.
The trials that are going on now are known as repurposed drugs, we don’t have results from any of the big trials. What we have is from China, where they did a large number of trials.
We’re waiting for results from the bigger trials to give us results. Meanwhile, there are people working on other drugs and monoclonal antibodies which are likely to be affected, but also need to go through phases of trial.
In terms of HCQ, it has a long history of being proposed as an antiviral drug, even for influenza. In the lab, it seems to have activity with the culture, but when you translate that into human beings, it has never been found to be protective against any other virus. Even the scientists who were advising us on the solidarity trial, were initially not very convinced that HCQ should be tested. But then there were some early studies and case series coming out of China that there could be some benefit in reducing the severity of the disease. So that’s why it has been included in the solidarity trial. But we’ll have to wait for results.
Other trials are looking at the preventive effect of HCQ when given to health care workers or other high risk populations. Only trials will give us the answers.
Do you agree with ICMR’s recommendations to health workers and high risk people to take HCQ as a prophylactic?
My personal feeling, and what WHO says, is that it’s better to test it in a research setting because we don’t have the evidence that it provides protection. There’s no harm in saying that we want to protect our healthcare workers, but do it in a setting where you can actually collect data and make an informed decision at the end of a few months.
You don’t see this as a reckless idea?
It’s a relatively safe drug. It’s been used for many many years, for malaria and autoimmune diseases. The dosage in which it’s being used for prophylactics, it should be safe generally. But it should not lead to a complacency, that you are taking HCQ so you are protected and you can be careless. PPE and other precautions are critical.
And what about remdesivir, that is part of your solidarity trial and Indian labs and centres will also be involved?
We’re very happy India has joined solidarity trials. Remdesivir was included because it’s a broad spectrum anti-viral and it acts against the polymerase enzyme of the virus — RNA polymerase, which is the enzyme that is needed for viral replication. So we’re happy that we were able to work with different drug companies for this large trial.
Recent study has indicated that sun rays and higher temperatures can kill exposed Covid-19 virus quickly. Is this true?
Sunlight does kill bacteria and viruses but they have to be exposed for quite some time, from two to three hours. There is no evidence to suggest that heat or humidity in India will result in the diminishing of the virus. Relying on the weather to control the epidemic wouldn’t prove to be a wise thing to do.
Is Covid-19 an airborne disease?
I think it is very important to clarify that when we say coronavirus is a droplet infection, what we mean is that when you cough or sneeze, droplets of different sizes come out of our mouth. These droplets can fall and settle on the ground. In case of close contact with a person, this can lead to droplet transmission. These fine particles can stay in the air for a long time and people run the risk of breathing them in. This poses a risk for healthcare workers especially. While incubating a patient, these particles can get aerosolised and can remain suspended in the atmosphere. The logic of wearing cloth masks is so that it prevents these droplets from coming into contact and transmitting. These masks are crucial to people who can’t physically distance themselves.
Another survey in New York revealed by the Governor showed that more than 20% of adults in the city have been affected by Covid-19 at some time. Doesn’t this show that this virus will keep infecting people and we will never catch those who are symptomatic?
There was another survey in Santa Clara, California which showed that they have found only 2.5% of adults who have been affected by Covid-19. New York has had an explosive outbreak. A large population is susceptible to the virus so it’s going to spread till enough people acquire it naturally and get protected through a vaccine. The world must now come down from a state of panic to a moderate and balanced approach. We must learn to manage the crisis especially because other health problems have now been put on the back burner.
Hypotheses claim that 22% of the world’s population has less than 2% of the case. Has been an outlier when it comes to the number of cases of coronavirus or is it just three weeks behind the western world.
There are many hypotheses around this but I believe that it is a combination of things. We have a younger population and if the infection was spreading, it is a very mild illness and people don’t even think about it. The proportion of people travelling abroad who might have brought the infection is lesser in India in comparison to countries abroad. India did heed to WHO’s advice and measures were taken to contain the virus. Social distancing in Europe is different from developing countries. A different approach could be pioneered by India and many countries in Africa. Moreover, community participation is very critical. Looking back at public health successes during the time of HIV AIDS or polio, eradication was only possible because communities cooperated and participated.
You don’t take the BCG vaccine very seriously. It deals with your favourite bug of all times, the Tuberculosis bug.
BCG is an interesting vaccine because of its non-specific effects on the innate immune system. Polio oral vaccine also has boosting effects on immunity. BCG is given for newborns in India and we know that its protective effect against TB wanes off in the first few years. To imagine that it will have a protective immunity for other bugs which last into adulthood doesn’t seem very likely. It is impossible to say whether it would have an impact on Covid unless trials are done.
No one is complaining, but why is the mortality rate low in India?
This is related to the demography of people who have been found to have infection within India. There are differences between states as well.
Why is it so that Covid-19 seems to kill more men than women?
It is linked to comorbidities. In most of the descriptions of patients who have had severe illnesses, the majority of them had hypertension, diabetes, cardiovascular disease, these were more common in men. There could be other biological reasons for the same, obesity being a risk factor for instance. WHO’s chief scientist also said that African Americans and the Hispanic community have seen higher cases of coronavirus. This is partly owing to obesity, hypertension and partly owing to a lack of access to healthcare. Moreover, smoking is a big risk factor for all respiratory diseases.
In case of statistics in India, percentages work but absolutes don’t. Where do we hide 13 crore people?
The first challenge is how do you reach everybody and protect the elderly. We have to be pragmatic and know what works in terms of how to prevent transmission so we have to be extra careful around the elderly. If anyone is sick in the family, they should try to isolate themselves. As lockdown is lifted and people go back to work, people with illnesses will have to be extra careful.
Was the virus created in a lab in China?
Absolutely not. There are detailed studies being conducted on the virus genome sequence. Scientists from around the world have looked at this claim and said that if this would have been genetically engineered in the lab, there would have been a particular marker that would have been difficult to hide. The scientists also found that this virus could be genetically linked to a natural bat virus. It also came close to the original SARS virus. However, studies still haven’t been able to find out how this virus jumped from the bat to the animal.
Do you think that the use by date of wet markets is over?
Yes, having in the same market wild animals as other animals that too when they are alive leads to a lot of mixing of these viruses and can generate these recombinant viruses. WHO’s guidance of these markets is clear that these should follow food safety standards and we discourage wild animals being sold.
Has time come for global pressure, pleading and persuasion with China to say please protect us from this?
There are regulations on wildlife trade and so on. A lot of what was happening was illegal trade. It is not good for biodiversity or human health.
US Secretary of State Mike Pompeo said that China is not sharing all the information that it should have as per the international health regulations. Do you buy that?
We have not come across any specific area of question where China hasn’t shared. In fact, an international team headed by a WHO expert visited China in February. This team included experts from the USCDC (United States’ Centers for Disease Control and Prevention) and USNIH (United States’ National Institute of Health). They travelled and met Chinese researchers and got data. They also went to Wuhan and saw for themselves. The experts produced a report by the end of it which described their observations and recommendations. China has been sharing their experiences as doctors across the world have bilateral dialogues and webinars learning from each other.
When you look at stuff coming from China, is there anything that makes you suspicious that they could be hiding something?
I haven’t seen anything that makes me or my colleagues suspicious. They are part of our committee’s work on vaccine development. They have been very collaborative in their approach. It’s not just China, we have seen global collaborations with the US. It is most valued not just in terms of resources but also in terms of the technical collaborations we have with their institutes. They have some of the best scientific institutes and this is a temporary problem we can get over.
Why is US President Trump so angry?
I cannot answer that question. At the level of scientists, the collaborations have been excellent. We work well with both NIH and CDC both in terms of our technical guidance and approaches. The part of the delegation that went to China, there is an element of administration that wants to evaluate how WHO works. One other thing is that WHO is very open and transparent to having a review. Director General has said that he would welcome a full audit, it is an opportunity to strengthen the organisation. However, right now the timing isn’t right, we are controlling a wildfire.
Does Ayurveda help with coronavirus?
We must have an open mind and we need to find out. China has put multiple trials in place. Ayurveda has a lot of potential to boost the new system. It should be looked at for both prevention and early cases for treatment.
Are Indians getting a virus that has mutated in such a way that its kinder to us?
We need genetic sequences from India to determine that. At the same time, all viruses mutate and this virus is mutating at half the rate of the influenza virus and that’s a good sign. Scientists could spot distinctions, clades were also forming. No one has been able to correlate that with difference in clinical presentation.
After this New York survey, do we all now accept the inevitability that all of us will get it. The only vaccination we now have is herd immunity. Should we let the younger generation come to work?
The word herd immunity is normally used for vaccination programmes. Getting herd immunity through natural infection is possible, countries toyed with the idea, like Britain and they quickly realised that they had to pay quite a heavy price and therefore put in place physical distancing measures. From what we have seen in the number of people in the population having antibodies, we don’t know whether these are protective antibodies. We think that over 80% of the population needs antibodies. To have any kind of herd immunity for this virus, any way of achieving this is through a vaccine and a sensible, valid data driven approach.
When do we get back to work?
The Indian government will weigh down on all these questions. The WHO provides the guidelines for the steps, the systems that need to be put in place and checks and balances. Mass gatherings are not going to happen for the next few years. Travelling will be cut down and other personal habits will change. There must not be a sudden opening of lockdown and everyone must abide by a graded approach. A lot of adjustments need to be made which will require people’s involvement and cooperation in order to sustain the world.
When you took up this role in the WHO, did you ever expect this to happen?
I was very reluctant to leave ICMR. But I also thought that not a lot of people would get an opportunity to serve at this level in an organisation that serves the world. At the time, Dr Tedros Adhanom had taken over. We have all been working 24×7. Dr Adhanom is the last one to leave the office. We have tried to be as technically informed. WHO doesn’t take sides and we praise where praise is due. He has often praised India for Ayushman Bharat. His heart in the right place. There could have been mistakes or human error in judgement but we are all learning something new.
Watch the full exchange of Off The Cuff here: