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Keynote: What the world's worst pandemic taught us, and where do we go from here

Jun 24 | 1:55 PM

Every challenge is a learning opportunity. Let's see what have we learnt from over a year of battling the pandemic, treating over 2.94Cr cases and dealing with 3.7 lakh deaths. One of the learnings is that a country of 1.4 billion can not flourish with only 1.8% of the GDP being spent on healthcare. To find the others, Join us.

good evening professor and valeria and all the delegates it gives me immense pleasure to welcome you all on this covicon it give me means pleasure to welcome and introduce professor randy galeria mule rasa has been conferred with the highest civilian award administry in 2015 by government of india professor guleria has also been the recipient of the highest award in the medical faculty in the form of dr b 0 award sir has been the institute director of oil density of medical science and by training he's a pulmonologist sir has been involved in the task force as an expert member and has been the sheer force for the implementation of the national policies as well as the formulating the guidelines for the management of kobit 19 and as we have seen that the guidelines kept on changing as the new evidence kept coming from various parts of the country as well as the globe sir has also been the co-author of one of the book called the title was till we win the india's fight against kawaii 19 pandemic along with dr chandra kant laheria and another famous dignitary professor ragandeep kaur from cmc valor the netflix is a new app developed by plexus md who has been in the forefront for medical education and almost 2 lakh 80 000 members are already registered with plexus md today is the first launch of this app which is a mobile only app at this moment and we are going to have many clubs where the members can join as per their interest kovicon has three sessions every day for three days starting from your keynote addresser and we request the viewers to choose the topic of their choice and enjoy and learn the most sir we cannot have a better person than you to inaugurate the netflix as well as the kovicon may i request you to raise your hands thumbs up your hands as a mark of inauguration of the netflix as well as the conference thank you very much sir and with your blessings we go ahead and i invite you to deliver your keynote address sir platform is all yours thank you very much and i'm really grateful for the invitation and for asking me to inaugurate uh this session as far as covicon is concerned on netflix um the topic that you asked me to really talk briefly on and then we can have a discussion is on the world's biggest pandemic and what it really has taught us if we talk of covet 19 then it has uh as of now affected almost 180 million people and we have almost 400 4 million deaths which have occurred because of covet 19. so it has caused huge impact on every impact in every areas of life whether it be healthcare whether it be education for the young students or whether it be trade economy travel even the holidays have all been affected for the entire uh population because of covet 19. as we move forward there's a few things that i think we must understand uh one is that this virus is here to stay so we must basically learn how to be able to manage as far as covered 19 is concerned and therefore we all talk of this new normal because that is something which is very very important it has also helped us in some ways that technology has come into medicine in a very big way because of the challenges that we had to face over due to covert 19 and it also told us how humans and mankind if it comes together can be resilient and really move forward in tackling a lot of challenges now what have we learned and what are the major lessons first of all we must understand that this century has been a area where pandemics will happen and this is something that we've been seeing since i've been involved in this for quite some time we had an outbreak of uh what we call bird flu or avian flu which is caused by an influenza virus h5n1 way back in 1998 when a number of poultry died and there were some humans all human nets also after that we had sars in 2002 2003 we've had number of outbreaks after that we've had mers coronavirus we had another pandemic which was h1n1 known as swine flu which was not that severe but that was there in 2009 2010 and the game caused a lot of panic in various parts of the world and then they've had other outbreaks like zika ebola and other outbreaks in different parts of the country even a nipa virus outbreak was seen in our in this part of india now the issue that comes up is why is this happening why in the last 20 years are we seeing so many outbreaks and what should we do as far as the future is concerned it's important for us to understand a few things one is so what why are we seeing so many districts in the last 20 years and what is the reason for that one of the reason is that the world itself has become a global village we're able to now move from one part of the world to the other part in a very short period of time and we can try and as we move infections travel this is something that we saw also in the sars outbreak one canadian citizen who was in hong kong he was there and while he crossed the corridor and some one other person who had sars infection was coughing and not wearing a mask he got the infection and he took the evening flight landed in canada no one knew what problem he had and he caused a huge outbreak of stars in canada with large number of debts as far as health care workers are concerned so we are becoming a global village the other issue is that there is a lot of crowding which is happening we need to just see the marketplace the airports the railway stations there is a lot of crowding and this is a fertile area for respiratory viruses to spread urbanization is also happening we are having a lot of urban development and encroachment into what was usually the natural green environment for various other species and because of that what we are seeing is that infections are happening the jumping species and lot of infections which are seen in other species whether it be bats whether it be birds the virus is jumping and is causing infection in humans and this is what we've seen in the last 20 years and therefore it's important for us to understand that as we move towards global warming change in our environment urbanization deforestation pandemics will continue to happen and i think this is one learning that we've had from this pandemic and that is why it's very important to also concentrate concentrate on what we call one health when we talk of health it's the health of not only humans but of animals plants and environment which is important and unless we have a holistic view we will not be able to really come out of the pandemics like this or decrease pandemics and that is why it's very very important for us to keep that in mind people will travel travel has become so common and viruses and infections will travel with that we've had patients who had ebola we would never see ebola coming out of africa but now that is happening because of air travel and infectious disease then even travel faster the other important challenge that we have is how do we really meet the pandemic and what is the public health awareness that needs to be done and i think that is very important because as we move forward what strategies should we have in place and i think three or four things are very very important one is surveillance we need to have a surveillance so that we pick up any outbreak or any increase in number of cases or any new uh outbreak that we see for example if we had a very good surveillance with global partnership if we had picked up that this is something which is so dangerous in gohan more than a year ago 18 months ago we could have really clamped down out there done a lot of restriction and not let the virus respect to other parts of the world and we may not have had such a bad pandemic as we've had right now so surveillance system which is robust which is global and which is partners with the entire global community is very very important along with that there have to be laboratories with biosafety systems so that they can pick up any new infection which is happening and we have to have trained healthcare workers who are able to really manage manage this and have an uh training as far as outbreak is concerned along with this there has to be a good coordinated research whether it be drugs whether it be vaccine whether it be other things that also needs to be done we need to focus on what i would say is public health measures or what is known as non-pharmacological measures because non-pharmacological measures are the most important thing that we can do in any pandemic before we have any drug available before we have a vaccine available we saw this 100 years ago in the flu pandemic and we did not really learn much i in 2018 i wrote a small paper that 100 years after the influencer pandemic india is still not prepared for a pandemic and that is something that we really need to keep in mind so what can we do as we move forward one is aggressive coed appropriate behavior masking washing your hands trying to maintain as much physical distancing as we can all of this would really help in breaking the chain of transmission if you have a surge of cases in any area a strict lock down in that area limited lockdown will really help and the third important thing is to really ramp up our vaccination drive and monitor to see whether the vaccine is effective against the new variants which are coming up it has been shown not only this time because whenever there was a lobby or not finally what else has been the learning as far as the pandemic is concerned and i would really focus on two areas one is research this is the first time that we've had vaccines at such high speed developed in the world and so many vaccines currently over 60 vaccines are undergoing clinical trials we're using new platforms the mrna platform is a new platform that is being used and has been shown to be successful so many other new platforms which are otherwise being used only in terms of its research are now coming into clinical trial so i think this is the year of vaccinology and driven a lot by this pandemic and we have now developed so many new vaccines and india is also developing almost 7 8 vaccines india was the hub of manufacturing white seeds but we are now becoming the hub for research in waxing also and this is something which is very very good so i think this is another very important point and the second important or final point that i would like to make is the fact that we are also discovering that we can provide health care through what we call delhi health and telemedicine and that is going to be very useful because in areas like a rural india or areas where there is a shortage of doctors telemedicine and telehealth can really help in augmenting healthcare facility in those areas we have areas where doctors are scarce you can tie up with a district hospital or a medical college or a tertiary care hospital and with that provide quality care by using telemedicine and tele health tele health is also something that we don't use that much all of us have fake bits or devices on our hands which tell us our pulse which tell us our sleeping pattern we can use this in a simpler manner to really monitor patients who have having chronic diseases it could be diabetes it could be hypertension it could be chronic respiratory diseases it could be a chronic heart disease and using telehealth and telemedicine be able to predict any outbreak that may in any worsening of the symptom that may happen and therefore by provide treatment and preventive treatment so you could prevent heart attacks you could prevent worsening of chronic respiratory diseases or prevent someone's sugar from going very high because of tele health and telemedicine so this is another learning that we've had and the government of india now has come out with the guidelines as far as telemedicine practice is concerned and they will regularly be updated but i think this is also an important learning so i'll stop here and take questions but i think the points that i wanted to make were three or four one was pandemics are here to stay and we need to really see the reasons why pandemics are here it's related to urbanization travel uh deforestation and the fact that viruses are jumping species and causing more and more of uh outbreaks as far as humans are concerned second issue that i wanted to put forward was that how important it is to have non-pharmacological measures in an outbreak over appropriate behavior how science has really progressed rapidly in terms of vaccinology and we've got vaccines at breakneck speed with high quality and no compromise on safety and efficacy and finally the role of technology especially telehealth and telemedicine which is actually making will make a big difference in the coming years in way in terms of how we will provide health to large parts of our citizens especially where health care facilities are not available thank you very much and i'll be more than happy to take a few questions thank you so much sir customarily we don't have the question answer session but it is your modesty and greatness that you allowed us to exchange some of the questions uh on this podium thank you very much sir sir first question on your personal note uh what do you enjoy the most pulmonologist in you or the administrator in you and how to balance the both so at heart i'm still a clinician and i love seeing patients and enjoy the time that i spend either teaching students or looking after patients so i enjoy more of my clinical work both in terms of patient care and teaching administration is something which is not that something that i enjoy but it's a responsibility and i feel that maybe you can make a bigger difference if you're within administration than you can by seeing patients but in terms of your own satisfaction nothing like curing a patient and seeing a smile on a patient's face that gives you much more satisfaction than any administrative work that you do right sir sir as i said earlier also that country could not have asked for a better person than pro reserve professor guleria as a pulmonologist heading this aims and the kovid pandemic but what are the difficulties that you change because probably you also it must have come as a surprise that you are in the cockpit and you are not signed up for the same so your initial experience in mobilizing all the resources and formulating the policies and the guidelines i had a little bit of an advantage since i was a pulmonologist and i had been involved in outbreak management by the government of india what was known as a joint monitoring group and also during the h1n1 pandemic but the the uh the way this pandemic came was unexpected and we did a lot of things because we realized that we have to do something for our institute but also at a national level and therefore for the institute we started various committees a covert task force for our own institute every day in the morning i have meetings with the entire faculty our residents our nursing officers our technicians and we try and resolve problems that we were facing every day and last year there was so many problems and by working together whether it be shortage of ppe's whether it be converting overnight uh an area into a covered labor room or go with ot or developing dawning and doffing areas or moving an entire trauma center to one area and converting the trauma center into a covet hospital these were challenges that we faced so these it wasn't very prying time but i must say that i am very proud that our entire staff the entire ames family and i would say that is true for the country also we all came together and really took up this challenge and were able to really manage the huge surge in cases that we saw both in the first and the second wave right sir well said professor guleria we know that for as far as the kovid 19 pandemic is concerned everything is unpredictable whether it's a virus behavior or it's a clinical picture uh from first and the second wave or it's a diagnostic criteria or the management so can you some throw some light on the do's and don'ts of the different aspects of the kovid 19. i think we are learning more and more about the virus and what we really thought in the beginning was this is a virus which is causing a predominantly respiratory problem but it's now becoming more and more clear that this virus is basically cause causes a systemic problem and therefore we need to make point of view that i think is also becoming clear so if that is becoming clear so it's very important for us to manage and change our strategy in a manner that we are able to do this i think that is very important and the other thing that we should remember is no matter what be the virus no matter what we the variant if we are able to follow appropriate behavior the non-pharmacological methods that i mentioned we will be able to prevent the spread of the virus it's a human to human transmission so most respiratory viruses can really be the spread can be stopped by having physical distancing wearing a mask and hand washing so i think the learning that we've had is that this is something that is very very important and that we need to do at the same time i would just like to stress that also what i have realized over the last one year is that as the virus is unpredictable human behavior is also unpredictable there has been last year people were very scared they would follow covert appropriate behavior they would stay inside but things have changed gradually and human behavior is now changing and it's becoming a couldn't care less attitude as far as the covert is concerned and this actually led to this huge surge in the cases that we saw in the second wave with a very high mortality so i think it's important for us to really understand everything holistically the virus human behavior and how we can really move forward in terms of interventions which are doable at a ground level right sir and sir over over one half years also we have not been able to come out with each and every practitioners levels the number of investigations we should be doing it in the mild moderate or severe cases so can you give us some guidelines about the investigations required or the investigations we should not be offering in the very early part of the infection become a big issue and i'd like to just say two or three things one is that you have to treat the patient and not the investigation sometimes you really panic because of the investigation and i'll give you an example if you have fever and you have mild covet you will have a rise in your crp you have it is a huge phase reacted so any person who has a fever even has a sore throat there will be a rise in crp but because people you get all these tests done then they get a you know a panicky situation and start steroids and other drugs because crp is high so i would say that don't really over investigate look at the patient and in the early stage if someone has mild illness he needs just supportive treatment and there is really no need to do any of the tests that are required people are getting ct scans done on day one which again is not required so my argument is that let's not over investigate because that creates a problem yes if you have more severe disease moderate disease or you are now wanting your are hospitalized then regular investigations have to be done but in my cases in my opinion really no tests are required and you can really get away without doing any tests that's what my opinion so what i was but as many cases if a person has mild illness saturation is well maintained really no tests are required if you have moderate to swear illness or you are you're having fever which is persisting other symptoms then only should you get your test done otherwise you don't really need to get too many tests done and i think in mild cases actually we should just avoid a lot of testing right so uh often we see that people get investigated for ielts sakes or serum ferritin and ldh and all are they really required in the mild cases so none of these are required in mild cases you don't need to get serum ferritin done you don't need to get il6 done and many very often they may be otherwise also elevated i'll just give you one example there are studies which have looked at il6 levels in icu in covet positive patients and non-covated patients and what they found was that it was much higher in non-covated patients as compared to covate patients so il-6 will be high in a large number of patients who have inflammatory syndrome and therefore it is not an indicator to start high dose steroids or drugs like tosses holy mac please look at the patient ultimately you are treating the patient not the reports and therefore remember that this is one of the very important rules in medicine that remember to your patient and do no harm so if you start panicking by looking at the blood reports you may land up giving your patients drugs which are really not required right so that is reminding your primal non-nausea that is do no harm yeah same applies to hrct order also sir do we when do we need hrct so again hrct is not required early in the disease and i've mentioned this a number of times faced a lot of criticism because of that but i would really say that you must understand two things one is getting a hrct done early may give you a false sense of security because you may feel now my ct score is only two or three but your changes in the lung may occur much later on secondly if you have changes in hrct and this has been shown that even if you got a ct done in people who are covet positive and asymptomatic their ct will show a few changes and it resolves on its own it doesn't need any treatment so doing an hr ct may cause more of a panic situation thirdly you are exposing yourself to some degree of radiation and it's important not that we don't do that in the younger age group because there can be a cumulative effect you may get ct scans done later on also so cumulative exposure to radiation can lead to or have a higher chance of developing cancer in later life which we should try and avoid right uh earlier in the early part of the pandemic uh there are not rtpc facilities at every centers and the smaller centers might have reserved it to hrc and that has led to the behavior or habit formations but now that rtpcr is available almost at every centers that district place i think your point is well taken that chassis should be reserved only to the essence where we are suspecting that he might be heading for inflammatory syndrome or ards correct so in patients with moderate to severe illness there is a role and i remember in the early days i had even gone to gujarat and many uh in one place in a city their doctors said that their habit their rtbc report was taking almost three four days and because it was taking so long they were resorting to a clinical radiological diagnosis and then there was a lot of debate with with me in terms of if you have a ct which is suggestive of covet but your rtpcr report is negative can you give steroids can you give rem disappear because the diagnostic criteria the gold standard is rt pcr so it has other issues uh medical legal issues also because i remember in one case there were classical features suggestive of covet but rtpcr was repeatedly negative a bronchoscopy was done and that actually showed legionella pneumonia and the patient responded to treatment for legionella rather than for covalent so since you mentioned about steroids i'd like to again uh inform our audience about your exact advice for the steroids then how much we should start so again two or three things one is the recovery trial and data after that clearly shows that steroids are useful only in moderate to swear illness when your saturation is falling and when you have infiltrates appearing on the chest x-ray in mild diseases when your saturation is all right there is really no role of giving steroids because of the simple reason that it has been shown to be more harmful the recovery trial showed that in early stage when steroids were given there was higher mortality because of secondary super added infection both bacterial and fungal and we've seen that in from our data also so therefore steroids in early stage can be more harmful and there is some data which came early that steroids in early stage may actually promote viral replication and the viral virus may be actually replicate much more causing more severe disease therefore in the early stage steroids should be avoided in moderate to swear illness steroids can be life-saving and they should be given but here it's important to remember two or three things one is high dose steroids or pulse steroids have no role and you have to give low dose steroids or moderate dose steroids at most in these cases secondly it's no point in giving them for a very long duration most steroids in the trials were given only for five or ten days and were stopped after that so in most patients you can do that in some you may need to continue strivers for a longer period if they have ongoing inflammation but i would say giving high dose steroids giving them when they're not indicated and giving them for a very long time actually predisposes to more side effects sir where do you suggest inhale corticosteroids in the management of covidonite so there is there are now two papers which have looked at midocinite as inhaled cortical steroids and showed that it may be useful and therefore it has to come into the guidelines indian guidelines also recommend that that in moderate to severe cases you can give it or patients who have intractable cough we also found that it's useful in patients who have cough which is not resolving in here butanite sometimes helps in resolution of that so there is no role of giving inhaled uh medicine uh and that has been shown to be of some use sir one of the part delegates asked about the role of monte lucas so monte lucas is usually not given because there is no it's an anti-allergic drug so unless someone has symptoms like sneezing running nose sore throat then we would give an antihistaminic and often on some some physicians do give monte lucas along with levocitroxine or flexophenidine but for kovit19 there is really not much data to suggest that this is uh useful and should be given sir next we move on to the complications uh we we saw with covet infections especially my core mycoses we don't see so much of my core more causes elsewhere so are there any specific factors specific to our country or geographically we are predisposed that's what we would like to have your opinion so if you look at the data and there is some studies which are looked at global data seventy percent of all nuclear mycosis cases have been reported from india so we are seeing a large number of mucour micros much more than what is being reported from other countries the issue is why is that being seen and there are two papers one which looked at the first wave which has come recently been published and another paper which is looked at 200 patients from our own center what it found was that one of the risk factors which was definitely there was underlying diabetes and we know that india is known as the diabetic capital of the world what we found that many patients who had swear covet either had very high blood sugar which was not picked up or they were not even aware that they were diabetics and came with high blood sugar so it's important to keep that in mind the other of course important factor was the high use of steroids in the second wave because of a panic situation where steroids were used much more so it seems that possibly because of diabetes being high in our country and not being controlled properly or not being diagnosed properly along with a lot of mysql steroids we saw a lot of mucur which was not used seen that much in other parts of the world so moving on to the next hot topic which every headlines topic would give you is the variant of delta that that is now what we are considering to be maybe one of the factor for bringing the third wave so your comments about this so the delta plus which is the new uh variant which has been reported it's the same lineage as delta that has one mutation at the spike protein which is a cause of concern k417 n which is basically also been reported or also has been seen in the in the beta and the gamma variant and that has been shown to make the virus more infectious it binds more closely to the ace receptors and some studies suggest that it can also cause more infection in the lungs currently we have 40 odd cases in our country and we need more data there is a worry that this may make the virus more infectious and it may spread more rapidly the data is not there because the cases are very few there was a concern that this may also cause higher mortality but of the 40 odd cases that are there in our country that has not been borne out most of these cases have had mild illness and they have not had severe illness so it doesn't suggest that they will that this strain causes a more severe illness but i think it is something that we need to observe very closely because as the virus mutates we may have changes which may affect not only the virus the infectiousness of the virus but may also develop some degree of what we call immune escape mechanism and that may also be a cause of concern so the biggest question in everybody's everybody's mind and it may not be a straightforward answer is will there be a third wave when will it be and will it be a milder or more severe form so and will the children be affected more in that third wave two or three questions one is will we have a third wave why we know that respiratory viruses come in waves we saw that in 1919 we've seen that in the influence of the swine flu pandemic also so waves will happen and that is related to the behavior of the virus and behaviors of human being so if we look at will we have a third wave we are likely to have a third wave will that third wave be large or small a lot depends on our own behavior if we are able to have strict covert appropriate behavior we don't allow the virus to spread the third wave will come later on and it will not be much of a wave because by that time we will also be able to vaccinate a large number of people on the other hand if we don't follow covert appropriate behavior for the next few weeks and by the time large number of people have not been vaccinated we will definitely have a third way which will cause significant mobility and mortality i feel that the third wave will not be as big as a second wave but we will definitely have a third wave and i don't think there is any data to support that it will affect children more it is children are having a milder disease and if you look at data which we've accumulated both from zero surveys and actually looking at children who came to us for getting vaccinated as part of the trial almost 50 to 60 percent of them when we enrolled them to the vaccination trial and tested them for antibodies they had antibodies that means they had had infection mild infection had recovered i don't think children will actually get more severe as far as subsequent wave is concerned since you touched the topic of x in a sensor more than 30 crore people have already been vaccinated in india but still there are so many misinformations and complica about the vaccines so could you throw some light about the efficacy of the vaccines and the need for vaccinating as many people as fast as possible so i think we must understand that vaccines are the way out from this pandemic there is no other way out as far as coming out of this pandemic is concerned but the important issue to remember is vaccines as of now protect us mainly from disease they do protect us from infection but mainly from disease and we must understand the difference between the two you may still get covert infection after the vaccine you may still be rtpcr positive and you may still be infectious to others for some time but because of the vaccination you will not be able you would the virus will not spread multiply that much in your own body and thereby it will not be able to cause severe disease it will decrease mortality and will decrease hospitalization that is already being seen as far as the vaccine is concerned and therefore it's important for people to understand they should not go into the info demand the false things coming in social media but understand how important it is to vaccinate each everyone vaccines are never going to be 100 protective so people say that so-and-so got vaccinated and he got covered and yet swear forward there will be some people but there are huge number of people and we have data from our own health care workers who got vaccinated and had much milder disease as compared to those health care workers who did not get vaccinated and actually had more severe disease sir one very pertinent questions related to the pandemic but non quebec was that because we have been all focusing on the kovid issues many of the non coercives are also being tracked and they are almost a time bomb to explore so what are your comments about yes yes i think there are two these are very very important and we have to balance out the two for example there has been a lot of suffering as far as the immunization program is concerned the immunization program has actually come to a halt because of the fact parents are scared and doctors are not willing to give them immunization the national tuberculosis program tb is a disease which requires regular medication the dots program needs regular uh drugs to be delivered there's also the issue of sputum testing all of this has actually gone into a little bit of a problem and therefore our whole aim of eliminating tuberculosis by 2025 is becoming a big challenge so a lot of programs have suffered lot of other diseases have suffered and this is something that we have to aggressively work on to bring them back on track sir one of the delegates want to know because we as healthcare workers have taken the second rows immediately after 28 days so do we need the third dose and will vaccination of the 19 infection would be an annual event yes more related to kobe shield rather than for vaccine because co-vaccine is to be taken after four to six weeks but the the overshield duration has been changed but the data still suggests that even if you take the vaccine after four to six weeks it is going to be effective to some extent but yes you're right the immunogenicity tends to be better if you take it later on and therefore we will need to follow up and see how things evolve over a period of time my own feeling is that definitely we will need to take a booster dose or have some degree of regular vaccination for some time i am hopeful that as we do research and like i said there are more than 16 60 clinical trials going on we may have a vaccine which is available which gives long-lasting immunity and also covers for any new or emerging variants so that we don't need to be worried about it it can look at the site of the virus which does not change and it does not mutate and can be effective against mutant so i am hopeful that with the research that is going on you will have a vaccine with long lasting immunity and which will be able to cover for all the mutants or the variants which will emerge in the in the near future sir we almost consume all the time that you are allotted to us but can i ask you one or two questions more sir one of the one of the question is about the mix and match vaccines so will that be the order of the day for the better efficacy and covering the variance so this is something that is being looked at this is known as heterologous prime boost that is you give a different vaccine to as a prime and you give a different vaccine as the booster dose now there are studies which are being done and there were some studies which have come by inadvertently for example in certain parts of the world especially with astrazeneca the first shot was given as astrazeneca and then because of some fear of side effects the vaccine was withheld and therefore the second shot was given of another battery and in uk there have been trials of around 600 people who have got astrazeneca followed by the pfizer vaccine or astrazeneca followed by sputnik vaccine what data we have currently suggests that you can have a little bit more reactogenicity and side effects may be slightly more in terms of fever body eggs when you mix the vaccines and some data suggest that it may lead to a better immune response so when we will i think in the next few weeks get more data and it may become a routine that we mix the vaccines this has also been done in the past for the ebola vaccine which is a heterologous prime boost vaccine strategy so it may happen in the coming months that we may be able to look at a mix and match of vaccines and that may be more effective ah sir the time would not permit us to take more questions but if i am allowed to some of what that you have stress one point was that the pandemic is here to stay and we have to be prepared for pandemic ourselves instead of more facilities for the laboratories the bio safety facilities we should have more research oriented science development and we have to ramp up the vaccinations and we have to have more public awareness and the non-pharmacological treatment and probably we can say that mask is one of the important as good as vaccines and with combining vaccines and mass really we can face the any variant because the vaccines may not cover all the variants but mass will definitely prevent a variant sarcoid virus also thank you very much sir for your time and all these advices that you have given and we would like to call you again on our platform for the discussion of the this topic as well as many of the topics of your interest thank you so much and the viewers we also thank you very much for joining with us and it has given us a boost for the launch and we'll have few more sessions to come and i wish that you will join with us thank you so much [Music]

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dr. Randeep Guleria

Dr. Randeep Guleria

Director - AIIMS, Delhi

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dr. Mahadev Desai

Dr. Mahadev Desai

Senior Consultant Physician | Ahmedabad

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dr. Randeep Guleria

Dr. Randeep Guleria

Director - AIIMS, Delhi

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dr. Mahadev Desai

Dr. Mahadev Desai

Senior Consultant Physician | Ahmedabad

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