India has been witnessing a steady decline in Covid-19 cases since mid-September despite gradual withdrawal of lockdown restrictions and increased testing. Compared to many OECD countries, the case fatality rate, has been low at around 1 percent. Mobility of people has reached pre-Covid levels. The economy is showing a ‘V’-shaped recovery trend. The population in Delhi is inching towards natural herd immunity with a seroprevalence rate of 50 to 60 percent. Based on the last two rounds of seroprevalence studies, it is estimated that there are approximately 40 to 50 asymptomatic infections for every positive case detected. Emergency Use Authorization (EUA) has been granted to two vaccines and nearly three million frontline health workers have received the first dose of the vaccine within the first two weeks of the nation-wide vaccination program.

It is important to have a realistic assessment of the behavior of the pandemic in India, to be able to plan ahead in a pragmatic way. It is evident that the infection has spread to a sizeable number of people despite containment measures. It is also clear that the case fatality rate at ~1% or 1 in 100 Covid-19 positive cases and the infection fatality rate at ~0.025% or 1 in 4000 infected cases (asymptomatic and symptomatic)has been low compared to many high income countries. Since India has had the same strains as the rest of the world, virus related factors may not explain the low fatality rates. Host related factors are more likely to be the reason. Similar behavior is being witnessed in low-to-middle income countries (LMIC) in South and South-East Asia and Africa, while the behavior is quite different in South America.

Simple measures like the use of face masks, hand washing, and social distancing have convincingly demonstrated to be effective in reducing the spread of infection. They may also reduce the number of symptomatic cases. We do not have comparative data on compliance to the above measures across countries to explain the difference in the pandemic behavior. The role of immunity is being studied extensively to explain the differences. It is known that people living in crowded and unhygienic habitats may have more robust innate immunity. Immunity is the body’s first defense response to any pathogen irrespective of prior exposure. The BCG vaccine is known to enhance non-specific immune response to various pathogens. Research evidence on the role of BCG has been mixed so far. Corona viruses are responsible for nearly one third of common colds. It is demonstrated that people do exhibit both antibody and cell-mediated cross-immunity to SARS-CoV 2 virus that causes Covid-19 illness. Despite the above pointers, the behavior remains a puzzle!

The world has witnessed unprecedented global collaborationsamongst researchers to come up with diagnostic tests, repurposed drugs like steroids and remedesivir, innovative therapies like monoclonal antibodies, and a variety of vaccines within one year of the pandemic. Not unexpectedly, the virus too has been undergoing many mutations to evade these human efforts. The World War III – the one between humanity and the SARS – CoV2 virus, continues! Vaccines are only one more weapon in our armamentarium.

India must be cautious against many unknowns at this stage of the pandemic. Behavior of the new variants originating in different countries is a cause for concern. Uncertainty about the duration of immunity gained through natural infection and vaccination is another area of concern. Whether the new strains evade existing immunity is yet another concern. Given these concerns, India can adapt the following strategies to remain ahead of the curve.

India should continue with its proven mantra of ‘face mask, hand wash, and social distancing’. Relentless public messaging should continue on these measures. It should maintain border controls as per emerging data on new strains. It should continue with its surveillance system to spot reinfections, emerging spikes or even slowing of declining case rates. Existing and emerging vaccines should be continuously tested against new strains for their efficacy. Efforts should continue on developing novel antiviral drugs.

In addition to the above, India should focus on strengthening its weak health systems. The recent economic survey makes a strong case for increased public health spending to reduce impoverishment caused by catastrophic out of pocket health expenses and to improve economic productivity overall. The focus on existing health issues should remain strong. India should also leverage its strength in pharma and vaccine capacity to help people across the world. The Covid-19 pandemic has forced reluctant health systems into the rapidly changing world of digital and molecular technologies. Healthcare is likely tomove towards genome based precision medicine. India has an opportunity to prepare itself for the future of personalized health care. Two of the major policy reforms – National Digital Health Mission (NDHM) and National Science, Technology and Innovation (NSTI) Policy – announced during the pandemic are apt to make this possible.

The post-Covid world will go through a massive geo-political, economic, technological and socialchange just as the change the world witnessed after two world wars. India has an opportunity to regain its rightful place in global affairs. Great leaders see opportunity in every crisis where others falter!

Dr Krishna Reddy Nallamalla

President, InOrder

Regional Director (South Asia), ACCESS Health International