Omicron Update Diagnosis Treatment Vaccination and Future by Dr. G C Khilnani

Interview of Dr. G C Khilnani on India TV on Omicron Update

Interviewer: What really is the exact situation on the ground both in India and abroad when it comes to the Omicron variant?

Dr. Khilnani: Number one the Omicron percentage is rising consistently. It has gone up to 86% to 84%. Number two, we have to understand that from the international data we know that Omicron causes mild illness in the sense that it is a short-lived illness like common cold which is presenting with, you know, blocked nose, scratchy throat, running nose, a little bit of fever, no loss of smell, no loss of taste. Generally, it is not causing pneumonia and so the patient becomes alright in 3 to 4 or 5 days and recovers fast, but we need to understand that it is highly contagious. The viral load factor is 3 times more than what we have in Delta and Delta was 2 to 3 times more than the Alpha, so it is spreading very fast. So, before we become complacent about this virus, we need to understand that our population is very large. We have a large population that is immunocompromised can be because of age, can be because of diabetes, hypertension, heart diseases.
This virus, which is supposed to be causing very mild illness, we know that can cause serious illness in patients who are immunocompromised, elderly, hypertension patients, diabetes so we need to understand from the data from South Africa. In South Africa, the patients who were admitted were 43% who came to the emergency, 43% got admitted in the Omicron wave as compared to the 69%, 31% were in the acute respiratory failure as compared to 91% before and 17% required oxygen as compared to 74% before and the deaths were to the tune of 2.7%. Why I am telling you all this data is that we should not take it lightly. The numbers are rising like Delhi has seen 22,000; Mumbai has seen more than 20,000. The numbers are rising so, therefore, we need to do, very good community medicines or epidemiological practices to control this menace. Otherwise, we are going to be in trouble because if you see the USA the death rates are 1500 to 1800 per day, UK the death rates are high. A small country like Poland has 800 to 900 deaths. So, we should not be sitting idle thinking that this disease is very mild, and will not cause any trouble. Having said that there is no need for panic. If you have any symptoms, my advice would be to please go for testing and isolate yourself. You have a responsibility towards your family and neighbors and other people. Do not go to parties, gatherings, avoid unnecessary travel. Always use your mask properly. Follow social distancing to the extent as possible. Keep on practicing hand hygiene. This is the only way to minimize the spread of the disease. We also know that a large number of healthcare workers are affected. So, if we don’t control this, our medical system will be overwhelmed, and we will not have healthcare workers to provide you services. So, therefore, it is the responsibility of all the citizens of this country to be vigilant about this Omicron and follow the COVID-appropriate behavior.

Interviewer: Community medicine and epidemiological intervention, what do you mean by that? If you could explain that in layman terms?

Dr. Khilnani: So, the epidemiological as we were taught in our MBBS, there is agent, host, and environment. Now agent we know is the Omicron virus. The environment we know. It is the question of controlling the environment. That means agent means that we know the character of the virus. It should be diagnosed. Another part is the case finding. Case finding is part of the epidemiological tool for controlling the disease. So, India is very, very competent and we have the amazing capability of testing and there are two types of tests which are available. One is of course the RT-PCR test. The other test which has become quite popular is the home test that is the self-test which we do. We need to understand that RT-PCR remains the gold standard for diagnosis, but you know it is expensive. The availability is there, but it is not available in small towns or villages, sometimes it may not be available. The sensitivity of the RT-PCR test at best is about 80%. That means if there are 100 cases of Corona, 80% will be detected, 20% will still become negative. Other than that, rapid antigen test or home test as it is also called is a very good test which is easily available, is inexpensive, can be done by a person at home but its sensitivity is something like 50% to 70%. It is less than RT-PCR, but we must understand that once the home test is positive that means positive. So, the study was done in Canada with 9 lakh samples and found that the false positivity was 0.015% meaning thereby if the home test is positive, it should be considered as positive. So, coming back to the point, the case finding is important. After the case finding, isolation is important, but we have to understand the difference between quarantine and isolation. Isolation is done for the people who have got the disease or are suspected of having the disease. Quarantine is done as a preventive measure if the person is exposed or if they are high risk. Now once the person gets a runny nose or sore throat or fever or if he feels feverish, then it is his responsibility to isolate himself while being tested and if the test comes positive then he should be isolated for a minimum period of 7 days as per the Indian guidelines, the minimum period of 5 days as per the guidelines by CDC Atlanta, United States. After 7 days, without testing this person can go out and use a mask but be conservative for another 5 days in going out and traveling. So, controlling this disease has got two facets. One is case finding, other is isolation. The third most, most important is the vaccination in which I think India has done amazingly well by, you know, 1.5 billion dosages have been given, 90% of the Indian adults have already received at least one dose. Now we must understand that vaccination does not necessarily prevent infection. Well, you and I all know that so many of us have got infected despite being have received two dosages so they should not think that they were not benefited by vaccination. Now we are the people, suppose we get an infection after vaccination, the disease is very, very mild and internationally we know from the data, from South Africa also the severe disease occurs in people who were not vaccinated. So, my advice would be that people who have had hesitation for vaccination which is minuscule in India as compared to the UK and USA, should go for the vaccination. Those who have received two dosages of vaccination whenever their turn comes should go for an additional dose or whatever it is called. So, we follow these things. Case finding, preventing transmission, enhancing vaccination. These are the three tools that are with us for preventing.

Something if I don’t say I will be deficient in my this that there have been significant advances in the management of COVID in the last 2-3 months and that has been minimizing the severity of infections. Nobody is bothered about running nose or, you know, blocked nose or sore throat or scratchy throat, a bit of fever, you take paracetamol, you become alright, but important thing is that severity of the disease which leads you into the ICU and requiring oxygen and going on ventilators and it should be understood that it is not 100% cases of COVID are Omicron. If that was so, we wouldn’t be worried. 80%, 90%, 95% in the United States, UK, and other countries are also struggling with a small proportion of Delta and other variants, which cause more severe disease. So, what has happened during the last 2-3 months that newer therapies have come. One of them is popularly called cocktail therapy or antibody therapy. What it does is they have pre-formed monoclonal antibodies which are geared towards the virus. Now, this has got a proven value, but it is recommended not for everybody. Not that everybody who gets COVID should go for antibody, but those who have got severest of immune deficiency because of transplant or cancers or who are 70+, 80+, who are severely diabetic those people can consider getting cocktail antibodies. Besides that, there has been a consistent effort in finding antiviral therapy. We know that hydroxychloroquine, Ivermectin, azithromycin, doxycycline nothing worked during the first and second wave and they have been given up and also favipiravir also did not show benefit, but the newer drugs called molnupiravir and Paxlovid, these are the two drugs which are approved by FDA and other international agencies and the Indian government is also frequently meeting to look into this whether they would be beneficial. These two drugs of which molnupiravir has been approved by DCGI of India is an oral drug which if taken 5 days of start of the illness it reduces the severity of illness and as per the one international study, the death rate also was 9 as against 1 is controlled and cases group and also the severity of the disease reduced by 30% to 50%. So, this is a silver lining. Only time will tell how much it will benefit but currently, this drug is approved. So, this is another armamentarium to protect our vulnerable group.

Interviewer: So, Dr. Khilnani, you say molnupiravir is approved by our regulatory authority. Who should take this drug? Of course, it should be taken on medical advice after consulting your doctor, but who are the people who should take this drug?

Dr. Khilnani: That’s an amazing question, you know. So, molnupiravir is not approved for young people who are immunocompetent, who have got the mild disease, and have less chance of getting severe disease. This drug was actually tested in people who are unvaccinated but has shown amazing results and those people did not have Omicron virus. Those cases which were tested had Delta, Alpha, and Beta viruses, but these are an antiviral drug. So, answering your question, this should be given to people who have got a high risk of severe disease and death, and we all know that you know elderly, elderly, the diabetic, and those with immunocompromised conditions, those who are on cancer drugs, those who are transplant patients, those who have got severe heart disease, these are the people if they get COVID positive within 5 days if you come to know about this, if you give molnupiravir, there is at least one study published in New England Journal of Medicine, which is one of the top journals, which has shown significant benefit in reducing the severity and death.

Interviewer: But you saying that this has not been tested for whether it works for Omicron so what if somebody gets positive and has all that, you know, comorbidities, diabetes, etc., and are senior citizens what would the doctor do? He would ask them to go in for genome sequencing to figure out first whether they have Omicron.

Dr. Khilnani: There is no time to do that and since it is not an antibody, it is an antiviral drug, it worked for Alpha, Beta, and Delta variants, it is proven and it will take a lot of time to conduct the study on Omicron, the scientists feel that there is no reason that why it will not work against Omicron variant also and another thing which I must say that when you get the RT-PCR positive report, you cannot find out whether it was… as of now, whether it is Alpha variant or Delta variant or Omicron variant.
Interviewer: That you will only find in whole-genome sequencing.

Dr. Khilnani: We have to save the life. If I was to treat my patient who has got a high risk of getting severe disease and death, I would prefer to treat it with the antiviral drug so that to prevent it. Till the time we get a test, which at the outset can detect Omicron virus and the test is in the pipeline. I think in a week’s time we may have a test where the RT-PCR will tell us whether it is Omicron or any other variant. Till that time, this policy to my other physicians should follow.

Interviewer: You are saying that there is testing going on to figure out whether the RT-PCR can reveal what variant you have because right now it only reveals whether you are COVID positive or COVID negative, so you are saying in a week’s time we would have an RT-PCR which would tell us that which variant are we suffering from?

Dr. Khilnani: So, ICMR scientists have already come out with the RT-PCR test. Actually going a little more technical, this S gene deletion if it is detected by RT-PCR it indicates that it is Omicron and this has been tested in the laboratory testing and it is being discussed and being considered for approval as a test for finding out Omicron and I have the information, not official though, that in a week’s time we may have a test which will detect Omicron by the RT-PCR at the outset. The gene sequencing takes 3-7 days which is not practicable as far as the patient care is concerned because by then it becomes too late.

Dr. Khilnani: So, whenever we get an infection or we vaccinate, there are two types of immunity that we develop. One is humoral immunity. Humoral immunity is exemplified by antibodies and second is cellular immunity, which is popularly called memory cells. So, when we get the first dose of the vaccine, the antibody is formed. When you give a booster dose, which we all have got, the antibody level further rises. These antibodies are like the infantry of a battalion. As the infection occurs, these antibodies are ready in the blood to attack the virus so that infection does not occur. However, the level of the antibodies gradually over a period of time reduces, and sometimes they become undetectable. However, the cellular immunity or the memory cells remain active for the lifelong majority of the time. These are the memory cells that will mount immunity on recognizing a known enemy, which has been memorized by the vaccination or the previous infection and it will act but it takes a little longer than the antibodies take. These are the ones that lead to reduced severity of disease because they come a little later into the action. Now what was found with COVID as the first and second dose was given in the Western world and in India also, the majority of studies came from the United States and Israel and other developed countries that over a period of time especially by 5-6 months the level of antibody was waning off. Subsequently, the study came from Israel that breakthrough infections were becoming common. Now breakthrough infections are the ones which occur in people who are completely vaccinated, even then they get an infection which we are seeing nowadays. So, Israeli people were one of the first to start the third dose what we call an additional dose and they called it booster dose. Israel people also found out by their community studies that the longer the gap between the second dose the higher were the chances of the breakthrough infection. So, if the two months have passed by after the second dose, the chances of breakthrough infections were lower. If six months have passed by, then the chances of infection were getting higher. Therefore, the question came that booster should be done, in our country is called as additional dose or preventive dose. Now booster dose is nothing new to mankind. Like flu vaccines, we take them every year. Similarly, you know, we have taken boosters in our childhood all the time to boost our immunity. Now as far as COVID is concerned whether this booster should be given six-monthly or it can be given yearly, no one knows, but since this is a pandemic situation and the breakthrough infections started occurring in the United States and in Israel and other countries, they started their third dose 5 months or even 3 months after the second dose. Now probably only the time will tell, and I must tell you normally development of vaccination takes 10 years. Where in the pandemic situation, the scientific community were able to give us vaccine within a period of 12-15 months, that’s commendable. So, therefore, some questions are unanswered and one of the questions that are unanswered is what should be the gap between the second and third dose, what should be the gap between the third and fourth dose. So, over the course of time, they are consistently reducing the gap between two dosages because it is a lethal disease. Currently, the Indian government has said that after 9 months of the second dose you go for the third dose. This will… and also I must tell you that…

Interviewer: After nine months of the second dose…

Dr. Khilnani: Between the third dose, they were able to reduce the rate of breakthrough infections. So, therefore, it is very important for those who have received a second dose and they are due for the third dose they must take the third dose as and when their time comes. Thank you.

Dr. Khilnani: So, you are making questions more difficult now. So, we need to understand what is endemicity. As we are living with chickenpox, we are living with measles, we are living with hepatitis, we are living with so many viral infections, and what is the endemic situation. An endemic situation is one where a particular infection remains in the community at a relatively fixed slow rate and that is what… and the endemicity will be determined by the host and also the immune status of the community. So, what we are trying to achieve? Suppose imagine a situation if the whole world is vaccinated, the whole world means children, adults, and everybody so, therefore, the transmission will be slowed down and now the immunity can come either by vaccination. Immunity can come by getting a natural infection as we got during the Delta wave and the vaccination was not so much percentage we had achieved but our seropositivity was 67% including children. So, therefore when the community is well vaccinated or well immune to the infection, then infection transmission slows down to a level which becomes almost fixed and it does not take a pandemic or outbreak form that is what is called endemicity and what I expect that as the vaccination is going on at a very high rate not only in India or developed countries but developing countries, if the vaccination process will be complete all over the world and the boosters will be given periodically as would be determined by scientific studies there would be a time that we would be away from COVID in the form of outbreaks or pandemic, it will become endemic, and I am very hopeful and I always say one phrase no one is safe till everyone is safe and we actually saw that. While the UK and USA had vaccination rates of 60%, 70%, 80%, South Africa was very low at vaccination, and we saw the outbreak of Omicron in South Africa. So, my thinking is that the world has to be vaccinated and I think the developed countries and rich countries have a responsibility towards the poorer country to provide them sufficient vaccination so that everybody gets vaccinated and we all can become safe.

Interviewer: Absolutely. Vaccine equity is a dire need of the hour and hopes the world comes out of their small-term interests and realizes as you are saying that unless everybody is safe nobody is safe. Well, Dr. G. C. Khilnani at that point we leave it there. Thanks for joining us on the show and sharing your insights with us.

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