Hydroxychloroquine: In coming days, you will see a scaling up of testing capacity for Covid-19 across the country: Union health minister

As Union health minister,
Dr. Harsh Vardhan is at the forefront of India’s battle against Covid-19. In an interview with
Prerna Katiyar, he discussed key themes at the heart of this battle, including testing strategies, availability of protective equipment (PPE) for healthcare workers and lifting of the lockdown.
Edited excerpts:

India has been lauded by WHO for taking proactive action in the face of the Covid-19 pandemic. You are at the centrestage of managing this crisis. How do you assess our efforts?
There is no doubt that India was extremely proactive in handling this entire crisis. Without sounding complacent, I can say that so far we have a much lower incidence of confirmed cases as compared to other countries. We are working to ensure that we are able to mitigate this virus.

Given all constraints, India handled this very maturely—with speed, scale and determination. The WHO has also appreciated the capacity-building scale and which was commendable for a developing nation like ours.

The world is appreciating the determination of our medical personnel and everyone who was involved in the disease management. I want to thank the national team of frontline health workers who are performing their duty to the nation in an exemplary way and who have shown utmost commitment.

Why have we been testing below our capacity?
We have the capacity to test 20,000 samples every day, and we have been scaling up this capacity in a sustainable manner. So far, as on April 7, we have tested 1,04,764 cases. On April 6 alone, we tested 11,795 samples. We have utilized only a portion of our testing capability. Thus we continue to have a huge capacity to test which is at the moment underutilized.

It is important to address the following issues before we talk about scaling up of testing: Quality assurance of testing kits, so that we can reliably identify the cases. The impact of deploying a test which misses actual cases (false negatives) or labels cases wrongly (false positive) are very high.

Protection of lab workers is also vital, to ensure that testing sites do not become nidus of spread of infection. Not overwhelming the labs so that quality and lab safety measures are side tracked, is important.

Testing strategy should be appropriate for the given phase of COVID-19 transmission that we are in, availability of testing kits and judicious deployment of available resources to ensure optimal testing, beginning with the highest risk groups first to ensure that we have a higher yield of cases and can clamp down on infection transmission. In the coming days you will see a planned scaling up of the testing capacity across the country.

Do you feel it is necessary to extend the lockdown?
A country-wide lockdown has socioeconomic implications, in addition to health-related issues. Given the diversity of a country like India, it is essential to use the lockdown strategy judiciously. As the epidemic evolves in the next few days, it will become clearer as to how we should proceed.

The progress of the epidemic at the district level in the country, use of serology-based strategies to identify the hotspots, and if required, calibration of lockdowns and strategies targeting these high-risk areas will be deliberated in depth. The data generated in the next few days will help us develop an ideal way forward.

There have been reports about the stigmatisation and ostracization of families under quarantine? Are there steps being taken by the ministry to stop people from doing this?
I feel pained that there is so much stigma being attached to this disease and people who are self-quarantining or those who are being quarantined are facing the unnecessary wrath of the public. There is no need to stigmatise families whose members are being quarantined as suspect cases.

We are making continuous efforts to reach out to the masses on this issue of stigmatization. I appeal to all your readers that there is no need to stigmatize or ostracize any person suffering from the disease or healthcare workers treating such patients.

Do we have enough ICUs and ventilators to handle the situation? By when can we expect India-produced ventilators in bulk quantities? And what steps are being taken to train staff for operating ventilators?
Every effort is being made to augment the availability of ventilators by another 48,000 in the coming weeks, about which we are very hopeful that we shall be able to achieve. For this, the health ministry is continuously in touch with a number of domestic manufacturers.

There have been reports of anti-malarial drug Hydroxychloroquine getting wiped out from drug stores after ICMR said it could be given to healthcare workers as a precaution. What steps are being taken to stop the hoarding of this essential drug?
To prevent hoarding of Hydroxychloroquine, the government has moved the drug to another, stricter ‘schedule’ of the laws i.e. schedule H1 drug, and now it can be sold on prescription only. In this regard, the health ministry issued a gazette notification on March 26, 2020.

There have been several reports of doctors reporting on lack of PPEs especially beyond big cities. What is the ministry doing for its adequate supply?
Availability of PPEs has been a problem worldwide during the Covid19 outbreak. The problem was even more acute in India because they were not manufactured locally.

With the help of the Ministry of Textiles, all the potential domestic and foreign manufacturers, based in India, were contacted and provided handholding support to make good quality PPEs. The Health Ministry along with the External Affairs Ministry and the Textiles Ministry have identified several other foreign sources, which are being pursued.

A total of 164.45 lakh PPEs have been ordered or pledged already against a projected requirement of 153 lakhs in a three-month period ending June 2020. Further, in this regard, several foreign suppliers have been roped in through philanthropic contributions from the Indian corporate sector and Red Cross. They are starting supplies of around 31.30 lakh PPEs soon. As of now, hospitals in the country have around 4 lakh PPEs available with them.

Are you concerned about the recent attacks on doctors and healthcare professionals during contact tracing in some localities? The Delhi government has made provisions for the stay of doctors at prime hotels. Are there similar plans by the Central government?
I have outrightly condemned the recent attack on doctors and healthcare professionals. I consider it most unfortunate. They are the ‘Covid Warriors’, putting their life in danger to serve the nation and all of us.

On the issue of ostracisation, I must tell you that our government stands fully in support of frontline health workers. Time and again, Modi ji has spoken out against the violence against doctors and appealed to the nation to protect our medical personnel. Modi ji has equated them with God!

The Home Ministry has taken cognizance of such incidents and advised the authorities to take stringent action under the National Security Act. Now our doctors and health warriors should work without fear as the government is standing in all its strength with them. Doctors, nurses and the healthcare workers deserve our respect, support and cooperation to keep the fight going.

We have advised all state governments to take appropriate action against those who are indulging in violence, be it landlords who are evicting doctors and their families.

I am happy that the Delhi government is taking appropriate actions to raise the morale of this workforce. They have already directed that penal action must be taken against all those landlords who are force evicting healthcare workers.

Do you feel that countries that have universal vaccination for BCG have fared better in controlling Covid?
I am aware of the study suggesting a link between BCG vaccination and COVID-19 caseloads. However, we need to study the evidence critically before leaping to conclusions. First, it is an ecological study, which means that the analysis is done with country-level data.

What may hold true at the aggregate or population level, may not hold true when the individual level heterogeneity is considered. This is a hypothesis generating approach, which needs more careful consideration before making sweeping policy decisions.

Secondly, this is a correlation study, and we must remember the epidemiological adage – correlation does not imply causation. Thirdly, we need to consider the biological plausibility of this assertion. BCG confers protection against a bacterial disease, and that too against more severe forms of the disease. The idea of a vaccine which protects against a bacterial lung disease also conferring protection against a viral lung disease might seem like a tidy connection, but till the pathophysiological pathways are clarified, these assertions will remain hypothesis generating rather than policy-altering. It is also important to remember that BCG is known to be an immunomodulator.

However, we provide it as soon as a baby is born. It is unclear whether immunomodulation continues to be present even if we grow older and for how long. One must at least remember that even if we have received BCG, we should not be complacent in practising the well-known preventive measures.

What percentage of COVID patients in India have needed critical care?
A very small fraction of COVID-19 patients have required critical care support in India. As of April 7, 2020, 9:00 am, we have had 4,421 cases overall, out of which 3,981 cases are currently active, 325 have recovered, and 114 have succumbed.

With such a small number of cases under consideration, it would be premature to look at proportions and base decisions on them. Our focus should remain on two aspects—preventing the cases from becoming severe and landing up in the hospitals; and preventing deaths from COVID-19.

Are there plans to start serological tests in India for diagnosis of antibodies?
The Task Force on COVID19 is considering the issue of undertaking serological testing for screening of people, and an advisory on this matter will be issued shortly.

What’s the best and worst-case scenario for India?
The best-case scenario is we can keep ahead of the curve, and keep the curve flat, and slow the spread of the infection in the country by reducing the doubling time.

This provides our health systems time to respond and develop the clinical service capacity to deal with the surge in cases. The worst-case scenario is that there is an explosion of cases, with high mortality, and tertiary healthcare needs which overwhelm the available clinical services capacity. This nightmare scenario is the one we need to avoid.

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