U.S. Moves Forward on COVID as Other Parts of the World See Surges

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The U.S. has hit a new COVID-19 milestone — not a grim one, but one of hope — experiencing the lowest case and death counts since early on in the pandemic.

Around the world, a different picture is emerging as countries like Brazil, India, and Malaysia are experiencing devastating surges and shortages of critical supplies. India recently reported seeing more COVID deaths in a single day than any other country at any time during the pandemic.

Globally, more than 3.5 million people are estimated to have died from COVID-19 — however, researchers at the Institute for Health Metrics and Evaluation at the University of Washington School of Medicine believe that number is vastly undercounted and the real death toll is likely two to three times higher. Even as 9% of the world’s population have gotten vaccinated, half of those manufactured doses have gone to wealthy countries, whose supply is starting to exceed demand.

Krutika Kuppalli, MD, vice chair of the global health committee at the Infectious Diseases Society of America and assistant professor of medicine in the division of infectious diseases at the Medical University of South Carolina, joins us in this week’s episode to explain why the longer cases spread uncontained in any part of the world, the worse it fares for all of us.

The following is a transcript of her interview with “Track the Vax” host Serena Marshall:

Marshall: Dr. Kuppalli, thanks for joining us here at “Track the Vax.” Here in the U.S., we’ve now seen that more than half the population of adults have been vaccinated, mask mandates are lifting, and deaths are going down; but overseas it’s a really different story. So let’s start with why Americans should be concerned, outside of the simple humanity of it all?

Kuppalli: Sure. That’s a really wonderful question. As we have seen repeatedly throughout this pandemic, viruses don’t have any boundaries or borders. And you can trace that back all the way to the beginning of the pandemic, which started in China. You know, at that point a lot of us thought, “oh, well that is an outbreak over there. That’s not going to affect us.”

But lo and behold, a year and a half later, we are still battling that outbreak here in the United States. And so, just because things are starting to “look better” here in the United States, doesn’t mean we should forget about what’s happening in other parts of the world.

One of the things we’ve had to worry about this year is the rise of variants: the B.1.1.7 variant in the U.K., the B.1.351 variant coming out of South Africa, and now the B.1.617 variant that’s driving the epidemic in India. And so, you know, it’s very important that we get the outbreaks under control so we don’t have the development of other variants and also so we can help curb further infections.

It’s really important for not just what’s going on in those local areas, but also again, so we don’t have those variants take over other parts of the world.

Marshall: I’m really glad that, Dr. Kuppalli, that you brought up the variants. Because the variant that came out of India, B.1.617, it’s already spread to, at least, you know, 50 other territories worldwide, according to the World Health Organization. In the U.S. it’s still relatively low, but can that change even though in the U.S. we’re seeing such high vaccination rates?

Kuppalli: Yeah, absolutely that can change. If you look at the fact that we do only have about 50% of people vaccinated, that is concerning. We don’t have high numbers of people vaccinated, so we still need to get people vaccinated. And we know that this particular variant tends to be a bit more transmissible.

And from what we’re seeing and hearing on the ground, it’s that people who are getting it seem to be sicker. That data hasn’t been proven yet, but it’s definitely something that we are concerned about. And so, the concern is, if we don’t get it under control and it gets a foothold here in the United States, we could have another surge of people who haven’t been vaccinated who could get sick.

Marshall: When you talk about what you’re hearing on the ground, that’s hearing on the ground in India?

Kuppalli: Yeah, absolutely. So, I have a lot of connections and contacts with people in India that I’ve been talking to. A number of us have formed a nonprofit group called India COVID SOS, and we’ve been working to try and help the situation in India.

Marshall: So what does it look like on the ground for those who might not be familiar with what’s happening?

Kuppalli: The situation on the ground is very frightening and it is an urgent public health emergency. It does seem things are moving a little bit now, but it’s still very bad. Hospitals are at capacity, particularly in parts of Northern India. There still is a limited supply of oxygen. Oxygen is a very hot commodity. Other things like testing are still being ramped up. We really need to get an understanding of the different types of sequences that are being seen throughout the country.

And I think probably the hardest part right now is that it’s really beginning to get a foothold in the rural areas of the country. Those are very difficult populations to engage. These are populations that still don’t necessarily understand what COVID is, that don’t understand the appropriate precautions that need to be taken, so really helping them understand how to protect themselves.

And then, you know, finally, we’re beginning to see a lot of cases of what people are calling the “black fungus” or what is known in the medical community as mucormycosis. And that is very frightening. This is a very aggressive and deadly fungal infection that can happen in people. And we’re not quite sure yet why we’re seeing such a high incidence in India, but that is also very concerning.

Marshall: When someone looks at India, they might think, “well, it’s one of the most populated, if not the most populated nations in the world. And so this was expected.” But was it expected to have such an outbreak of this magnitude in such a highly densely populated country? Or were there protocols in place that we should have been able to prevent this from happening?

Kuppalli: Well, I think that it depends on who you talk to. So I will say that at the beginning of the pandemic last year, I was always concerned that India would become the epicenter of the pandemic. I wasn’t quite sure when, but I was always concerned that it was going to happen just because of the things you talked about: the complicated socioeconomic challenges there. The population density. All those things make it really a ripe area for an outbreak of this magnitude to have happened.

That being said, when they underwent their first surge, they really locked down and were able to institute these important public health measures and, compared to the rest of the world, they did relatively well.

And I think one of the things that has hurt India is that when they came out of the first wave, there was this narrative that people in India had been spared. They had “beaten” COVID. And there were lots of stories that were done to try and understand why India had not been so decimated by COVID-19. And I think there was a false narrative out there that, you know, India had beaten it. And because of that people maybe weren’t as vigilant.

Marshall: Was that false hope?

Kuppalli: False hope, but really just a false narrative that for whatever reason India had beaten it. And so they were not as vigilant as adhering to the public health measures that we’ve all been talking about for the last year and a half — so wearing face masks, maintaining physical distance, which in and of itself is very difficult in India. Anyone who has been there knows that’s almost near impossible. But I think that was a real challenge. And then on top of that, during the first wave, I think that the government really did not use that time appropriately to scale up resources and capacity to be able to properly flex in a situation like this.

So, I think we’re seeing the repercussions of that now, during this wave, where the healthcare systems are so overwhelmed. There’s a shortage of numerous supplies. And that’s now adversely affecting the population.

Marshall: When we look at the vaccines that are available, we know India has the Serum Institute of India and it produces the most vaccines globally, not just for COVID, but previously measles, tetanus, diphtheria. And so, you would think that they had the systems in place and the experience to do a mass vaccination campaign to really tamper this down before it got to this level.

Kuppalli: Well, I think there’s a couple of things. Number one, there’s been a shortage of raw materials. And so hopefully that will be getting better now that the U.S. has lifted the ban on that. Secondly, when the Serum Institute made a pledge to [global vaccine sharing facility] COVAX, they had planned on distributing a certain proportion of vaccines to COVAX, and then there’d be a certain amount of vaccines going to India. They didn’t plan for a second surge. And then the government said that there’d be no more vaccines that could be sent out.

So this is also going to cause a problem in terms of COVAX getting the vaccines that they need to vaccinate the rest of the world. So it is a really challenging situation right now, as they try to ramp up production of vaccines not just for people in India, but also for COVAX.

Marshall: Yeah, a real ripple effect. I mean, the cases in Malaysia have been surpassing those of India and if they can’t get those vaccines out there, what do we expect to see more globally, especially with this particular variant?

Kuppalli: Ultimately the key is going to be a couple of things. Number one, we do really need to hammer home the importance of these public health measures, which, I don’t see people talking about as much, but they’re very important. The face masking. The avoiding crowds. Maintaining physical distance and adhering to good hand hygiene.

I think the other part of it is also going to be really pushing on the countries that have a surplus of vaccines to really step up and be a role model during this global crisis. Those are the countries in the West that are doing well and have a large amount of vaccines. We need to really help out the rest of the world.

If we really truly believe what we say — that this pandemic isn’t over until everyone is safe — then we need to really show that we mean that and really try to help other countries vaccinate their own people.

Marshall: You brought up, Dr. Kuppalli, the vaccine distribution. I want to come back to that in just a second, but before we talk about that, how effective are the vaccines that we have against this new variant? The B.1.617?

Kuppalli: So far, the information that we have shows that the vaccines work against the new variant. That again is still data that’s being looked at. So I think that I would keep your eye out and see what information comes out in the next few weeks about it. But it does look like the vaccines are working, but you do need to get both doses of the vaccine.

Marshall: And when you’re talking about the vaccines, is that Pfizer and AstraZeneca?

Kuppalli: The Pfizer vaccine, the AstraZeneca vaccine. Covaxin, which is used in India. Covishield, which is also used in India.

Marshall: The research is showing that those do protect against these variants?

Kuppalli: It is. Yes.

Marshall: What are the factors that, outside of the public health measures that we talked about, will continue to contribute to spread and the rise of the new variants?

Kuppalli: Unfortunately, I do expect to see more variants. The variants occur when we have high amounts of circulating virus. And we know that that’s the case right now in places like India and other places in Southeast Asia, and so unfortunately, that likely will happen.

If it’s a variant — a variant of interest or a variant of concern — that we’ll be seeing, a variant of concern is obviously the one we’re most worried about. But I think we’ll have to just wait and see what we find out, and the best way we can prevent these is by working to get the levels of circulating virus in the community down.

Marshall: What location are you watching now as an area that could lead to a variant of concern? Would that be still India? Still Brazil? Or countries in Africa, perhaps?

Kuppalli: I think I’m looking at all those areas, right? I think, unfortunately the things that we need to do to determine if we’re going to have other variants still need to be done. One of the things that we need to scale up in all these areas is genomic sequencing. And so India is working on that.

They still need to work on that in Africa and in Latin and South America. So, I don’t think that you can predict where the next variant is going to come from. That’s why we do so much genomic sequencing.

Marshall: And so when you’re talking about genomic sequencing, that’s to identify the variants. But to stop the spread, you have the public health measures that we talked about and the vaccines — but they have to get the vaccines. You would think that many of these countries are no strangers to mass vaccination programs?

Kuppalli: Right. But the COVID vaccine is a very different situation. Most of them, except for the Johnson & Johnson vaccine, which is a one-shot vaccine, you’ve got the cold storage components. Then you’ve got the situation where we are trying to vaccinate the entire world. We’ve never tried to do that at one time. So there are a lot of challenges with this vaccine rollout.

Marshall: I read one estimate: 11 billion shots to hit 70% globally. I mean, even the ones we’ve seen the U.S. donate, that’s just a drop in the bucket.

Kuppalli: Yeah, it is. And so that’s part of the reason why it was important that we had the development of numerous different vaccines because you can’t have one vaccine supplier trying to vaccinate the whole world. That’s been important, but it’s also important to upscale the manufacturing and production of resources. And all those things are important and you need the manpower to be able to scale up these vaccine campaigns.

And I think the thing that a lot of people don’t think about sometimes is, you don’t just need the vaccines, but you need the things to administer the vaccines, so, syringes, needles, Band-Aids — all those things that are really important, as well.

Marshall: How do we ensure equity in distribution? Right now we know that the high-income countries are the majority of where the vaccine has been distributed. How do you ensure that it doesn’t come down to a situation where lower- and middle-income countries are essentially begging for help from the high-income countries?

Kuppalli: Well, essentially now that is the situation we’re in, right? I mean, we’re here in the United States. How many of us are seeing people talking about a post-pandemic period? And, you know, quite frankly, we’re not in a post-pandemic period. We won’t be in a post-pandemic period until we’re able to get the entire world vaccinated.

And I really worry that this is going to become a disease of those who are economically and socially disadvantaged. That concerns me. And so I think when you think about vaccine equity, you really need to think about how we can make sure the vaccine gets to those in a fair way. I really encourage the United States to work with WHO and donating to COVAX because COVAX is very much focused on vaccine equity.

I think it’s unfortunate that in some countries you’ve got frontline healthcare workers who still have not been vaccinated, whereas, you know, here in the United States, look at how far we’ve come. So I think we need to think about those things.

Marshall: How do you solve some of those problems? Especially when it comes to things like trade disputes and proprietary information?

Kuppalli: Personally, I think we’re in a pandemic and we’re talking about lives. And I think that things like trade disputes and proprietary information goes out the window in this type of situation. I understand there’s a time and a place for those types of discussions, but we’re in the middle of a global pandemic that has killed millions and millions of people, that’s devastated the livelihoods of millions more people, and will continue to do so if we don’t stop it. So, to me, having discussions about trade and proprietary issues seems a little bit unnecessary at this time.

Marshall: To play devil’s advocate, Dr. Kuppalli, though, those in the industry do say to relax the rules, open patents could cause panic in the industry, and to create an environment that changes the rules in the midst of a pandemic would create chaos in some ways.

Kuppalli: I guess I just disagree. I think if you’re limiting it to the vaccines, I have a hard time seeing that. I think that we need to figure out a way to, again, upscale the production of vaccines and the resources needed to get them out there and we need all hands on deck in order to do so.

Marshall: So, how should we be preparing and getting them enough vaccines? Is it simply taking the entire U.S. surplus and donating it to COVAX? Is it getting personnel in place? What do you see as the solution?

Kuppalli: I think there’s a lot of different things that can be done. I think leveraging public-private partnerships is one way to do it. I think that the U.S. has figured out how to upscale our manufacturing, so are there ways that we can work with other countries to help them?

I do think the release of the TRIPS waiver will be helpful. Not immediately, but I think in the medium- and long-term range, it will be helpful because places like India and South Africa will be able to scale up production of vaccines. So I think that there’s a lot of different ways that this could be done and be done effectively.

I also think partnering larger pharmaceutical companies with smaller ones that can maybe help with production would also be very helpful.

Marshall: What do you say to those cynics who say, “well, it’s U.S. taxpayer dollars that paid for the development of many of these vaccines, paid to purchase them. Why should we worry about other countries when we still have the highest death rate in the world?”

Kuppalli: The U.S. taxpayer dollars went to develop Moderna. It did not develop Pfizer-BioNTech. Secondly, if anything, again, as I’ve said before, this pandemic has shown us that we are all globally connected and what happens in one part of the world affects the rest of the world. And third of all, early on in the pandemic when the U.S. was struggling, other countries came to our help. We should repay that favor. It’s the right thing to do. It’s the humanitarian thing to do.

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