Ramp up your vaccination to permanently control this virus: Dr Faheem Younus

Hundreds of mucormycosis cases have been reported in India and prompted the Centre to ask states to declare the life-threatening Covid-19 complication notifiable under the Epidemic Diseases Act. Faheem Younus, the chief of infectious diseases at the University of Maryland, spoke to Sunetra Choudhury about the disease, Covid-19 vaccination, etc. Edited excerpts:

Why have mucormycosis or black fungus numbers multiplied?

...we have seen Covid ravaging through Europe and North America, but I do not think we have seen that degree of increased cases of mucormycosis. Now, why a higher incidence in Nepal or India or Pakistan. There are some hypotheses and of course, there is a tri-factor. ...the fungus is in the environment and the soil and what predisposes a human being is diabetes, steroids, or immunosuppressive drugs. Covid by itself... I do not think predisposes anyone to mucormycosis. But it is the treatment of Covid. If steroids are being used in very high doses or if patients have immune suppression or they are having cancer, dialysis, or those situations and also depending upon what kind of environmental exposure they get... if they get a big dose of soil that is carrying this fungus and they are immunosuppressed, then there are chances that they are going to have a higher risk.

Watch : Will children be impacted in next Covid wave? Dr Faheem Younus answers

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Those conditions prevail more in the subcontinent as compared to Europe and America. ...the focus should be on the appropriate use of medications and the

early diagnosis. ...what I am hearing is people are just using steroids like water. ...it is precision that matters. When you are a good clinician, do not do more, do not do less. A good clinician does just right and as long as you do just right, you will not do harm.

Are doctors jumping the gun or people are self-medicating?

Both could be possible because... when they first talked about steroids [in the UK], it only helped in people who were hypoxic, meaning they needed oxygen support or were on a ventilator. If you are home, do not require oxygen, your pulse oximetry is over 94, then you are going to actually do harm by taking the steroids. That is what was shown in the [UK] trial. And what I have seen is that even doctors feel compelled to write eight or nine things in regular patients who typically are going to get better by routine paracetamol. ...[Patients] feel good when you give them three or four medications. So, I get that. But as clinicians, our job is to do the right thing. And I think once again, it could be both that the doctors are over-prescribing and that the people are self-medicating.

What else should be done to curb the disease?

...good action will lead to good results. We are in control, not the virus. So, I absolutely believe that it needs to be stopped. It can be stopped, and you have to give a multifaceted strategy. The best strategy is to prevent it which means that you, first of all, tell people that this does not go from a person to person. This is not contagious like Covid. ...you need to quell the panic around it. Then you need to educate people about good hygienic practices. You tell them, in soil, this fungus prevails, so anything that you are doing that is bringing you closer to that soil may increase your risk. So, first is public education. The second is quick diagnosis... mucormycosis...is a rare disease. Early diagnosis is really the key. [It] is not just Amphotericin, the drug that typically gets used, but a lot of these patients require aggressive early surgery. Sometimes the eyeball has to be removed. Much of these infections happen in the face and head and neck area. So, prevention, early diagnosis, aggressive treatment. But at the end of the day, this is going to go away.

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There is a lot of confusion that if you have been infected with Covid, when should you go in for vaccination? The government has said people must wait for three months. But many are saying that India now has a shortage of vaccines which is why people are told to wait...

There are some broad principles for this whole pandemic that we need to first keep in mind. Number one is that science will change all the time. ...every day we do things and there are different results, and we are always changing our strategies. So, changing information is nothing new to the world of medicine. Number two is assuming good intent. Yes, if you do not trust someone, do not listen. But once you trust a physician, then surrender your opinion because otherwise, you are really going to have a lot of anxiety. And number three, there can be more than one right answer in this situation...many areas are grey; some are black and white, but not all. ... the current [United States] CDC [Centers for Disease Control and Prevention] recommendations, which will be globally applicable... is once you fully recover from Covid, you can go for the vaccine shot. After that, there is pretty ample and strong data that you are not likely to get reinfected for three months. That immunity is going to last for three months... maybe six, 12 months.

...We cannot go and buy everything. We must make choices. The government must do the same thing. So, if the government is saying three months because of a shortage, I see nothing wrong with it. I would be very transparent.

But the government has not admitted that there is a shortage...

That is why I am a doctor, and they are politicians. That is why we have different professions. But I would simply tell people and I will also reassure them that for three months, your risk is minuscule. It is not like you are increasing your risk. ...whatever the reason is, I think three months is Okay.

You have talked about one month being ideal to vaccinate after Covid. Suppose you have had the first dose of the vaccine and you get infected, is there an outer limit for the second dose?

I have seen many patients, who had one dose and then got infected ...which means that their exposure was just a few days before the first dose, meaning that they were completely not protected. That happens to be a tricky area. After you get Covid, there is significant science developing that just a single dose of vaccine is enough because Covid essentially was your first dose and your first dose of the vaccine becomes your booster, I mean your second dose. So first, people should know that if they got the first dose, then got infected after that ...they have up to three months to get their second dose.

Doctors in India were the first to get vaccinated. The Indian Medical Association recently said that 260 health workers had died in India. How is this happening?

...last I checked 40 million people in India have been fully vaccinated. If 400 people died, that would be 0.001% of them. That is the context. ...now you compare the risk with Covid... I think nobody understands that better than the US and India because these two countries have been just ravaged by this virus. ...we do not know the baseline mortality rate out of a large population. People will die at random times.

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You know, there is random mortality going on that we call baseline mortality. Unless you can say that your baseline mortality has gone up, it is very difficult to once again attribute something to a vaccine. ...we do not know the confounding variables. I do not know the ages of these doctors. I do not know that how many of them were obese, how many had immunosuppressive drugs, how many had diabetes. We do not know any of that. As a scientist, I always keep that final option open. Maybe there is an X factor. Maybe there is something different with this variant that is going on. ...I think the headlines, the raw numbers can be very misleading... The vaccine right now is a thousand times less risky because people need to understand if they refuse the vaccine, what option they have.

What should I do if I do not get the vaccine?

There are two choices. Stay in your home, locked up for the next year, or go out and take the risk of Covid. And both of them are horrible choices. This idea that somehow not getting a vaccine gives us a safer option. No. There is nothing safer than that [vaccine]. You are exchanging a much bigger risk. If there was a better option, I would love for people to present it, provided it is data-driven; it is published.

In India, there is a feeling that despite the vaccine, it does not an assurance that you are going to be fine. What would you say to this?

This is just like saying that I was wearing my seat belt but then why do people die despite the seat belts? See, they are going to prevent a lot of deaths, but they are not going to prevent every death. That does not mean we should not wear a seat belt.

Where is your stand on naming variants with regard to their countries of origin, given the racist and other connotations?

I stand on the side of the patient. The patient who is in the ICU either trying to get on a ventilator or trying to avoid a ventilator or looking at death. Does that patient care what you call this? I do not think so. I have seen hundreds of those patients; they do not care what you call them...They are looking at the horror of Covid. They have never experienced something like this before. They feel like they are drowning in their own fluids inside their lungs. So that is where I stand as a physician. To me, it does not matter. I think whatever gets the patient immediate help is important.

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...when you name a variant after a country, it will impact the economy. At least there is a fear that it will impact the economy and your image. It will impact travel and all those things and for some people, it is just a matter of political pride, national pride. I get all of that.

Our top scientists have said children are likely to be impacted in the next wave. Do you agree?

That is very irresponsible to say with all due respect. I would not make such a statement in the midst of a pandemic when there are so many bigger real challenges that India is facing. ...there is no scientific data that it is true. It is somebody’s personal projection. ...we have not defined what a child is or what young means. People throw these terms out but as physicians, we have very clear definitions. Are you talking about people between the ages of 18 and 35? Is that what the young are? Is under 18 a child or is under 10 a child? What do you really mean by these terms? What is clear is more younger people are getting impacted. But look at the elephant in the room. Is not it likely that the first wave infected a lot of the elderly? Now they are probably immune, and their immunity is still lasting, and they are somewhat resistant to reinfection. Now you have added another 40 million, though a small number, who are fully vaccinated. ...you have a lot of vaccinated people who are also likely to be elderly. ... the elderly may be a little bit as well staying home, staying out of trouble. Young people may be living a little bit more through a high-risk lifestyle, going out to offices, work parties, etc. There are so many reasons which are much more likely to explain why younger patients are getting infected now. It is concerning if they are getting bad outcomes, but the way to make these assertions is to publish them.

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... folks like me can look at real data rather than learning from the media. No disrespect to the media, but I do not think science works that way. I cannot look at a media story that does not answer my questions and then draw a conclusion. Till today, I have not seen it, and if somebody has, please let me know... If you think there is good data out there to suggest that children are at risk in India, send it to me and I would be happy to review it. But I have not seen good data to make such a conclusion. Children can get this virus. They can get infected, no question. This is more transmissible, and we are likely to see more infections in youth and children because it is more transmissible. But are we truly at a point where we should be afraid for the life of our children or worse outcomes? I do not have that information and I do not think we should say that.

Are more waves inevitable?

This is a tough one. Once this virus gets holed in a country like it has in India, think of it as a flat tyre, like a punctured tyre, you can push air into it and go another few miles, but you will lose air again. You can keep pushing air, but unless you fix that puncture or you change the tube, you are not safe. Every lockdown is like you are just pushing more air in the tyre. It is going to give you some time. But the permanent solution is to fix that puncture by vaccination. ...ultimately, you have got to get up to 70-80% [vaccinated]. But once you get to 50%, chances are you will at least not see big waves anymore... Unfortunately, we are not in control and the virus is driving us the way it wants. You get to switch seats around that 50% mark. That is what we are seeing here in the US. ...The only factor that has changed is about 60% of the country is now vaccinated. So, I think that is the key thing. ... You want to permanently control this virus, ramp up your vaccination. There is no other shortcut, no other treatment.

CDC has said if you have been vaccinated, you can take off masks. How convinced are you with that? In the subcontinent, that seems to be years away...

CDC is doing the right thing. They just did so a little abruptly. I would have preferred this to be slowly communicated in a little more gradual fashion over a couple of weeks. People felt that jolt of just complete freedom. But yes, more than 95% of transmissions occur indoors and more than 60% of the country is vaccinated. Another 10 to 15% may be Covid recovered. So, you are already at 70 to 75%. As far as other countries are concerned, it is just not possible to stay in lockdowns. It is perfectly fine to just accept the fact that a good quality mask for the next foreseeable future, perhaps the rest of this year. I do not want to say years and years. I think I always think in three-month increments. ...I think in the next three months, it is very likely that you will need a good mask mandate and then from there on reassess.

Umar Sofi has contributed to the story