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DR. J E PARK MEMORIAL ORATION
Year : 2022 | Volume
: 66
| Issue : 4 | Page : 403-406
Looking back to move forward: A travel rule underlined by the current pandemic
Samiran Panda
Distinguished Scientist, Indian Council of Medical Research, Dr. AS Paintal Distinguished Scientist Chair, New Delhi, India
Correspondence Address:
Samiran Panda
Indian Council of Medical Research, Dr. AS Paintal Distinguished Scientist Chair, New Delhi
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijph.ijph_1513_22
Abstract
Learning from the past – is easier said than done. In this narrative, “travel” refers to the forward movement of the society at large on the path of health and development. It is suggested that looking back and learning from the lived experiences of the past outbreaks could help generating public health insights and incorporating them in planning for a better future. In the process, a country may choose to revisit what took place in the recent past during the COVID-19 pandemic within its boundary and beyond. However, unfolding of events in the past, which is not as immediate as COVID neither too far as the flu pandemic of 1918, also has lessons to offer. Recognizably, a few alarms, that rang in the recent past and cried for mass attention towards beefed up public health preparedness, were missed. It is therefore necessary now to critically examine the past-efforts to eradicate, eliminate or control diseases such as small pox, polio, HIV, tuberculosis, leprosy, measles or malaria. Results of such evaluation could inform the future courses of actions around disease elimination science and health (DESH) and help develop better nations.
Keywords: Community preparedness, innovation, regulatory framework, vaccine
Background 
The year 2022 is on its last legs. Public opinions in discussions around COVID-19 in today's world, at times take the following narratives; 'here now almost nobody wears mask' , 'the virus is going to stay with us', 'life and economy slowly coming back to normal', 'the possibility of further waves is remote', 'the virus is yet changing itself', 'we do not know if the new variants will turn out to be variant of concern', 'scare tactics', 'masks protect not only against COVID but also against other respiratory viruses and pollution - so why not use them'. They reflect people's reading of the course of the COVID-19 pandemic and accompanying change in behavior, which is very different from what most of the human civilization braced for during COVID-19[1],[2] since December 2019 onward. Within a months' time of the announcement of this global outbreak by the World Health Organization[3] as a public health emergency of international concern, travel and transportations in almost all the countries came to a screeching halt except for those involved in essential services such as frontline workers and health-care professionals. The busiest of the marketplaces became quiet and even international flights stood still on ground for months.
India: unfolding of Events with Time The first case of COVID-19 in India was reported by end-January 2020.[4] With the number of cases gradually escalating, the peak of the first wave became evident after a period of 8 months in September 2020 with about 100,000 symptomatic cases being reported from the country per day. However, the spread of infection was not uniform across the country; about 70% of the case loads were reported by 8 states. Evidently, cities with higher population density witnessed a faster spread of infection compared to the sub-urban areas or rural settings. This was followed by a sharp decline; the number almost touched the baseline of a few hundred active cases being reported per day during the last quarter of 2020. This was the time when hopes of moving ahead of the pandemic were rising high. Some commentators even hinted toward the possibility of protective level of herd immunity being attained at the population level; however, the findings from the three rounds of the national serological survey (the last one taking place during December 2020 – January 2021)[5] stood in contrast to such assertion. Importantly, the vaccination program against COVID was rolled out on January 16, 2021, in India in a phased manner; health-care staff and frontline workers were prioritized to go first. While vaccination program was gaining pace, the second wave made its appearance in March 2021 with fierce intensity[6] and domination by delta variant.
The heterogeneity, in terms of the affected states, during the second wave, almost mirrored what was observed during the first wave with addition of only a few more states. Although different states in the country had experienced the peak of the second wave at slightly different time points, overall, the infliction point for India was evident by early-March 2021. At the peak of the second wave, the daily reported number of symptomatic cases was about four times higher compared to the number recorded during the first peak. This surge of the second wave waned within about a month's time by mid-April and the transmission of the virus SARS-CoV-2 causing COVID-19 disease was maintained at a low level across the country.
As with the rest of the world, December 2021 onward, a highly transmissible variant of SARS-CoV-2, named omicron,[7] swept through India. Importantly, the peak of the resulting third wave evident by end-January 2022 (due to symptomatic infections) did not reach a height similar to the immediately preceding one. This was unlike the scenario of the second wave unfolding about 8 months ago. Although the elderly and the people with co-morbidity had greater brunt of the third wave compared to other population groups, ongoing vaccination program appeared to be an effective protector[8] and the demand posed on India's health-care infrastructure (requirement of human resource, oxygen, hospitalization, and ventilation) was significantly less.
COVID-19: Through Health Lens The wide range of impact of a pandemic, such as COVID-19, demands attention of the leadership of a country towards various aspects of the society. International issues also become important and relevant as a pandemic of such magnitude moves beyond borders and spreads through the globe. However, as per the scope of this narrative, the following discussion focuses only on some of the biomedical aspects of pandemic management; experiences, from India, have mostly been referred to.
Diagnosis, prevention, and care were upheld as the three core considerations for effectively managing the aforementioned waves of the COVID-19 pandemic in India. A sense of urgency to find out solutions under each one of them drove most of the responses, on many occasions delivering what was required and at times giving rise to angst and a sense of despair. What prevailed in the society at large was a mixed sense of urgency for remedies and panic.
Looking Back on COVID-Time In its effort to develop appropriate care and management guidelines for COVID-19 patients and modify them as and when needed, the national task force in India met regularly to critically examine the evidences emerging from various countries. Concurrent measures, as follows, characterized India's public health responses: (a) national level lockdown with phase-wise extension (end-March to end-May, 2020) followed by slow-release and state-level restrictions, (b) enhancing in-country production capability of personal protective gears (mask, disposable gown, face shield, etc.), (c) rapid scale up of diagnostic facilities, and (d) harnessing in-country modeling capacity to project the impact of smart vaccination plan rather than mass vaccination[9] and probable health infrastructure requirement in case of a third wave.[10] Lockdown and other restrictive measures including closure of schools[11] and higher educational institutions had their positive as well as negative impacts. These impacts were far reaching and disproportionately harsh on daily wage workers and other unorganized sectors of labor force as evident through the ordeal faced by migrants.[12]
During January - March, 2020, with the increasing number of reported SARS-CoV-2 infections from India, the whole of government quickly got into action. For example, the production of naso-pharyngeal swabs went up to 200,000 pieces a day within a few weeks of identification of licensed companies. They were supported through grants released by the Ministry of textiles, Government of India. Despite the lockdown, the production of viral transport medium, in which the clinical specimens (nasopharyngeal swabs) are carried from sample collection site to laboratory, was successfully scaled up from 500,000 units per year to 500,000 units per day.[13] Similarly, the diagnostic laboratory network was expanded across the country, which was steered by the Indian Council of Medical Research (ICMR) through regular online interactions, troubleshooting with the laboratories and establishment of quality assurance and quality control programs. At this interface of service provision and research, expectations from ICMR also grew, while some of the investigators coming across preliminary promising results wished for uncritical and quick incorporation of such findings in public health practice guidelines. What, at times lacked appreciation, was that conducting research during outbreak situation had their intrinsic challenges.[14] Lengthy startup period before one could carry out observational research during pandemic time is one of these hurdles,[15] and the others are reactive approaches, sociopolitical pressures to approve repurposed or promising drugs[16] or diagnostic tests,[17] and urgency felt by the researchers to inform public health decisions.
Vaccine, Vaccination, and Regulatory Framework Debates around COVID vaccines unearthed a range of tensions worldwide as well as nationally in India. Globally, the dangers of “vaccine nationalism,”[18] where deals were being struck between powerful countries and manufacturers to garner the initial and major shares possibly, of doses being produced, were heard. In such a scenario, how India could safeguard its own interests,[19] revisit regulatory framework,[20] and yet remain responsive to the needs of the world,[21] were critical Importantly, an innovative regulatory approval process, drawing upon the new Drugs and Clinical Trial Rule, Ministry of Health and Family Welfare, Government of India (dated March 19, 2019), offered a crucial support to vaccine roll out program with considerations around “life threatening situation,” “serious disease conditions,” “rare diseases,” and “drugs intended to be used in the diseases of special relevance to Indian scenario or unmet medical need in India.”
Nonetheless, the community voices recorded during the same time underlined that it was necessary to engage more with the society at large and execute evidence-based information dissemination strategy.[22] This qualitative inquiry further identified that it would be imperative to sensitize and train media professionals on how to report side effects related to vaccines. Responsive communication strategies would thus be a key public health approach for future pandemic preparedness.
Bells that Rang – Not Far in the Past Coronaviruses (CoVs) were known to infect a wide variety of animals. They are present throughout the world and CoVs that infect mammals (except pigs) belong mainly to two genetic and serologic groups: Alpha- and Beta-coronavirus genera.[23] Unlike influenza virus and respiratory syncytial virus, CoVs did not enjoy much attention till 2002. However, in this fateful year 2002, a super-spreading pneumonia (later known as severe acute respiratory syndrome), that clinically seemed like swine flu but was not diagnosed so virologically, drew attention of the bio-medical researchers. Scientists and public health professionals recognized that SARS-CoV, the virus causing severe acute respiratory syndrome (SARS; akin to COVID-19 situation in today's world), traveled from Guangdong province to Hong Kong and then to Vietnam, Singapore, Thailand, and Canada. Finally, it was reported from 33 countries. This was the first pandemic threat posed by a novel coronavirus and by the time of cessation of its journey in June 2003, a total of 8098 cases were reported globally with 774 deaths (case fatality rate 9.6%); most of the infections were nosocomial.[24] Close to the heels of this event, an article published in Science in 2005 reported certain species of bats as natural host of CoVs closely related to those responsible for the SARS outbreak. These viruses, termed SARS-like CoVs (SL-CoVs), displayed greater genetic variation than SARS-CoV isolated from humans or from civets. The human and civet isolates of SARS-CoV nestled phylogenetically within the spectrum of SL-CoVs, indicating that the virus responsible for the SARS outbreak was a member of this coronavirus group.[25] Two years later, a review article in 2007 summarized the explosive nature of the first SARS epidemic with high mortality, its transient reemergence, and economic disruptions leading to a rush on research of the epidemiological, clinical, pathological, immunological, virological, and other basic scientific aspects of the virus and the disease.[26] Further, the review reiterated the findings of horseshoe bats being the natural reservoir for SARS-CoV-like virus and civets being the amplifier host to highlight the importance of wildlife and biosecurity in farms and wet markets, which could serve as the source and amplification centers for emerging infections. This was almost prophetic. Finally, the authors of an article published in 2013 in Nature announced – “here we report whole-genome sequences of two novel bat CoVs from Chinese horseshoe bats (family: Rhinolophidae) in Yunnan, China: RsSHC014 and Rs 3367. These viruses are far more closely related to SARS-CoV than any previously identified bat CoVs, particularly in the receptor binding domain of the spike protein. Most importantly, we report the first recorded isolation of a live SL-CoV (bat SL-CoV-WIV1) from bat faecal samples in Vero E6 cells, which has typical coronavirus morphology, 99.9% sequence identity to Rs 3367 and uses angiotensin-converting enzyme 2 from humans, civets and Chinese horseshoe bats for cell entry.”[27]
Moving Forward If future conditions appear fit for introduction, mutation, amplification, and transmission of a pathogen to occur, either from animals to humans (zoonosis) or from humans to animals (reverse zoonosis), it would occur. While such spread may remain localized with a high case fatality as seen with Middle East respiratory syndrome, a viral respiratory disease caused by the Middle East respiratory syndrome coronavirus, first reported from Saudi Arabia in 2012, some of the pathogens may sweep through several countries or the world as seen with the SARS or COVID-19. Although, such possibilities exist, they are not inevitable, provided the lessons learnt from the past (in efforts to eradicate/eliminate or control small pox, polio, HIV, tuberculosis, malaria) are used to pave the path for future. During such efforts, political, will community engagement, strengthening of public health infrastructure, surveillance, research, dedicated resource investment and ability to scale up effective multi-pronged interventions - all will play critical roles.
Acknowledgment
This article is based on Dr. John Everette Park (March 20, 1928 – October 6, 1989) Memorial Oration delivered at the 66th Annual Indian Public Health Association Conference held on September 25, 2022, at Pune, Maharashtra.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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