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Pathologists On The Pandemic Frontline: An Interview

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Dr Rifat Mannan is Assistant Professor of Clinical Pathology and Laboratory Medicine at the Perelman School of Medicine at the University of Pennsylvania. He was named among the world’s top 100 in the Pathologist’s 2019 Power List by the Pathologist Magazine (UK).

A native of Assam in Northeast India, Dr Mannan brings our readers the unique perspective of a medical practitioner in the US who has closely followed the outbreak and impact of COVID-19 in East, Southeast and South Asia (particularly Northeast India).

In this interview he speaks to The Eastern Link features editor Uddipana Goswami.

1.      Thank you for taking the time out. It has been a busy (and harrowing) time for many medical professionals since the outbreak of the virus. What role are pathologists such as yourself playing during the pandemic?

Thank you for providing me this opportunity to share my experience. Indeed, this has been a very unnerving experience for all of us, something entirely unprecedented that took the entire world by surprise. As a pathologist, I feel privileged and humbled at the same time, to be very much on the frontline of the coronavirus pandemic. For the last few months, as the pandemic is evolving, we are all increasingly hearing the word “testing” and how it is going to be a crucial component of our fight against the virus. This is where pathologists come in.

Testing, tracing and treating constitute the “3Ts” of a global strategy of combating the disease outbreak.  To explain it in simple terms, testing allows us to diagnose those who have the infection and lets us trace the contacts of this index positive individual and then subsequently treat those with the disease. 

With a little elaboration, we can better understand how testing forms the cornerstone of this strategy. Improved testing has a wide implication for the community/society. Once someone is tested positive, that individual is kept in isolation for the next two weeks. This is a very important first step in breaking the chain of disease transmission. Unless we detect those individuals who carry the infection, it is almost impossible to control transmission of infection in a community.

Till now, in many countries including India, testing is being offered to only those who present symptoms severe enough to be admitted in the hospital. That leaves behind a huge population in the community who either have milder symptoms, or no symptoms at all. With growing evidence, it is becoming obvious that nearly 20% of the coronavirus infected people are asymptomatic but are very much capable of transmitting the virus in the community.

With aggressive and widespread community testing, we will be able to detect those with the disease (but asymptomatic) and isolate them as well. Diagnosing this group of patients is more important as many countries/communities are preparing to ease social restrictions and open the economy. Without this knowledge, we will not have a clear picture of the disease burden and cannot contain transmission in the community.

This understanding has evolved over time, and currently most of the developed countries have enhanced their disease testing capacities. Only recently, on April 27, the Federal Government in the US has announced a National COVID-19 Testing Strategy aimed at enhancing testing capacity across the country.

With this somewhat expanded prologue about the importance of testing, I want to emphasize how important is the role of the pathologists during this pandemic. It rests with the pathologists, the virologists, and the laboratory staff who not only bear the responsibility of running these tests, but also have to look after all the details of the tests, including setting up new tests, validating them in the laboratory and also making sure test results are accurate.

Apart from testing, pathologists are also involved in treatment. Convalescent plasma therapy has emerged as a promising treatment option for coronavirus infected patients, in which plasma from those who recovered from the disease is used to treat new patients. The blood plasma collected from someone who has recovered from the disease contains antibodies, which can be used to treat a new patient. This entire therapeutic procedure comes under the jurisdiction of “transfusion medicine”, which again is a subdivision of Pathology.

Pathologists are also involved in performing autopsies in patients who succumbed to the disease. While the procedure itself carries a high risk of acquiring infection from the deceased, the results of the autopsies hold many keys  to understanding the pathology of the disease and how the virus is affecting different organ systems, which in turn will help formulate future treatment strategies.

Last but not the least, while the pandemic was at its peak and nearly overwhelmed the health care system in some of the worst hit areas such as New York, many of our colleagues have, in fact, helped manage COVID-19 patients in ICUs and emergency rooms.

2.      You completed your medical education in Assam, India. But much of your professional medical career has been spent in the US. You are therefore in a unique position to look at the progression, spread and management of the pandemic in both countries. What according to you are the similarities and differences in how the US and India’s responses to the virus? Do you think either country has anything to learn from the other?

The pandemic has proven to be a huge unifier, across the world, not just between the US and India. The world at large has one invisible enemy, the virus called SARS-CoV-2. We all have a lot to learn from each other if we want to effectively stave off this threat and free the world of coronavirus soon.

My personal view is that the pandemic has taught us many lessons, and those who paid attention and acted fast and smart were able to do better than those who relaxed and waited till the fire reached their fingertips. We can obtain a better perspective by looking at the timeline of the outbreak and how the world responded: 

On December 31, 2019, the first case of coronavirus was reported in Wuhan, China, and the first death was reported on January 11, 2020. The first case of COVID-19 in the US was diagnosed on January 20 in Washington state, where a man who returned from Wuhan tested positive.  On January 23, when the Chinese authorities sealed off Wuhan from the rest of the country, already 17 people had died with more than 500 others infected, including in neighboring Taiwan, South Korea, Japan and the United States. By late February, Europe saw its first major surge in the Lombardy region of Italy and around the same time, Iran emerged as the second hotspot. Meanwhile, several countries in Asia, such as Taiwan, Singapore and South Korea initiated aggressive social restrictions supplemented by enhanced testing and managed to bring it somewhat under control. 

On February 29, the first death from coronavirus was reported in the US. It was on March 3, the US officials approved widespread disease testing, at a time when coronavirus had already infected more than 90,000 people around the world with over 3,000 deaths. Another 12 days later, on March 15, the Center for Disease Control (CDC) recommended social distancing guidelines for the country. In the next 11 days, on March 26, the United States officially became the country hardest hit by the pandemic, with over 80,000 confirmed infections and more than 1,000 deaths. As of today, on May 2, 2020, in a span of just 4 months, the world has over 3 million coronavirus cases, with over 2,30,000 deaths, of which the United States alone accounts for over 1 million confirmed cases and over 66,000 deaths. This timeline and the statistics are a glaring example of our failure to learn and act promptly.

If we look at India’s timeline, the first case was detected in Kerala on January 30, 2020. Since then there has been a steady rise. As of May 2, 2020, India has over 37,000 cases with over 1,200 deaths. On March 24, the government of India announced a nationwide lockdown for 21 days, which is being extended for the second time, for another 2 weeks, till May 18. It may not be an overstatement to say that India had the rare advantage to follow the evolution of the disease elsewhere and to learn from others (both successes and the mistakes). At the same time, the country could also take advantage of the social and scientific developments in other parts of the world. Only time will tell how much the country could learn and effectively control the situation.

3.      What, according to you, is the trajectory that the virus is following in India? Is the administrative control the reason for its limited spread so far, or would you attribute it to something in the nature of the virus?

It is somewhat baffling to trace the trajectory of the outbreak in India. Despite a nationwide lockdown of over 30 days, there has been a steady increase in the number of cases, which seems to vary from state-to-state. As of May 2, 2020, Maharashtra has the maximum number of cases (11,000+  with 450+ deaths), followed by Gujarat  ( 4,700+ and 230+), Delhi (3500+ and 60+), Madhya Pradesh (2700+ and 140+), Rajasthan (2600+ and 60+), Tamil Nadu (2,500+ and 25+) and Uttar Pradesh (2,400+ and 40+). With a population of 1.3 billion, these numbers do appear meagre as compared to many other countries who are bearing a heavy brunt of the disease.

The nationwide lockdown definitely had a positive impact in controlling the infection by slowing down community spread of the disease. But again, if one wants to play the devil’s advocate, these numbers may not be telling the whole story. It is quite likely that testing has not been adequate, and we are very much under-reporting the actual scenario.  On the other hand, I am quite worried that despite the lockdown, new cases are on the rise in many states. This has forced the government to extend the nationwide lockdown.

With a population of over 1 billion, and majority below poverty line, lockdown cannot be continued indefinitely, with lasting and disastrous consequences for the country’s future. Health infrastructure in India is also not among the best in the world. While the developed nations like Italy, UK and the US have suffered so much, India cannot afford to overwhelm the health care facilities. It is in the country’s best interest to implement strict restrictions and at least try to control and avoid an exponential increase in the rate of infection. I would keep a close watch over the following weeks about how the pandemic behaves in India.

4.      What about Northeast India specifically? The eight states of the region seem to have handled the crisis especially well. Could there be anything pathologically different about the population of the region that sets it apart from the people of mainland India?

The Northeast Indian states seem to have done fairly well compared to the rest of the country, with barely 100 confirmed cases and only 2 deaths in the entire region (on May 2, 2020).  This is really encouraging. One important reason might be better preparedness and aggressive containment measures on part of the local administration in these states, and people following such norms.

However, we do not know the exact data about how much testing has been done in these states. Without that, it is hard to get a very accurate assessment of the real situation. At the same time, the situation is fast evolving and it would be imprudent to conclude that the region has effectively dodged the bullet.

On April 30, 2020 4 new coronavirus cases were detected from Bongaigaon district in Assam. This is a cause of concern that community spread is still underway. There must be an emphasis on aggressive disease testing, isolation and measures to trace contacts.

5.      I am curious about this because many Southeast Asian countries that are either contiguous with Northeast India or have people of similar ethnic makeup as Northeast Indian communities have also managed the crisis well. A lot could be owing to the social norms and cultural codes embedded in the communities. But I would also like you to weigh in here as a medical professional.

I am not sure if it has something to do with social norms. Rather I would relate it to good containment measures. This is quite true that several Asian countries seem to have managed the pandemic quite well. Taiwan is probably the best example so far; in a relatively small country of 35,808 square kilometers, with 2.3 million citizens, they reported only 429 confirmed cases of COVID-19 with 6 deaths and very negligible new cases (till May 2, 2020). This is indeed very commendable; we should learn how they achieved it.

There are other positive results from South Korea, Vietnam, Hong Kong, and also most recently from New Zealand, and Australia. As a medical professional, I can relate these results more to their strict adherence to highly efficient preventive measures, which would also include very capable leadership, and prompt and pre-emptive decisions. In fact, many of the countries who fared well in this fight against COVID-19 were affected by the SARS epidemic in 2003. They seem to have learnt their lessons well and were prompt to employ aggressive restrictive measures.

Another common thread that binds many of these countries is their strategy of aggressive testing, which helped them detect and isolate those with the virus and allows them to trace those who came in contact. This is a lesson for the rest of the world to learn from.

6.     What is your projection of the future? From your understanding of global efforts to address this unknown/unknowable virus, do you think we will see a vaccine anytime soon? Or at least some change in the currently very disturbing scenario worldwide?

The future is uncertain. While the curve seems to be past its peak in some of the worst-hit areas such as New York, or Italy, it is far from over. New pockets are still springing up. While the world is preparing to ease restrictions and re-open economies, there is always the possibility of sudden resurgence. Singapore is a very good example: cases were detected in the country in early February 2020. With aggressive containment measures and enhanced testing, it brought the spread under control and emerged as a “model state”. However, in the middle of March, new cases started pouring in and suddenly numbers went on an upswing, with at least 1000 new cases each day (17,100+ on May 2, 2020).

This should forewarn other countries about being cautious while planning to reopen businesses and the society. There is also the heightened probability of a second wave in the forthcoming fall and winter, in line with the annual influenza season.

The best scenario is to have an effective vaccine that will protect from the disease. Several candidate vaccines are undergoing clinical trials in a few countries. However, the task is arduous and if we trust the experts, we are at least a few months away, if not years. Nor do we know how effective the vaccines will be.

On the treatment front as well, several clinical trials are underway, which might herald fresh rays of hope. On May 1, the US Food and Drug Administration (FDA) authorized an antiviral drug, Remdesivir, for “emergency use” based on emerging evidence of its usefulness. Another treatment modality that has gained some momentum is the use of convalescent plasma, where the blood plasma from recovered patients (containing antibodies against the virus) is used to treat new patients.

In the far future, one expects that “herd-immunity” will take over, as more and more affected people will develop natural immunity from the virus. As we tread into this uncertain future, “cautious optimism” seems to be the only logical approach.

7.      Do you have any message for the readers of The Eastern Link?

We are all in uncharted territory. At a time when anxiety and panic loom large, the situation calls for staying calm and doing the right thing in the right and responsible way. While scientists across the world are working round-the-clock to find a solution, we all need to accept science, and pay attention to the experts’ advice. While we all wait with bated breath for a cure or a vaccine, let us all show restraint and continue to adopt health and social guidelines.

We should continue to follow physical/social distancing guidelines, make it a habit to wear a mask while going out, and continue hygienic protocols. We must adapt to this new normal.  I am confident humanity will triumph over this invisible enemy. But till the battle is won, we need to fight this together; keep our eyes and ears alert and learn from the success and failures of each-other.  Let us all stay united, while being physically apart. 

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