The Delta variant of the SARS-Cov-2 virus continues to drive surges in COVID-19 infections across the world. Back home in India, following weeks of gradual decline in cases, the recent data on COVID-19 is beginning to present a mixed picture. The slowing down of the rate of decline of average daily cases and the uptick in the ‘R’ value are becoming a growing cause of concern. Experts are worried about complacency setting in as people resume social and economic activity. Despite the general public perception of low risk levels, experts and authorities have warned that the second wave has not yet waned at the desired pace and the fear of the third wave continues to loom. 

Senior government officials and experts have repeatedly stressed upon the increased risk of transmission attributed to the Delta variant that drove the deadly second wave in the country. While the national weekly positivity rate as on August 3 dropped below two per cent for the first time in three months, an upward trajectory in terms of new cases of infection is being seen in certain geographies. As of the week ending July 26, a total of 54 districts in 12 states continue to report a positivity rate of more than 10 per cent. A week earlier the number of districts having a positivity rate greater than 10 was 46. Eighteen districts in the country have been reporting an increasing trend in cases over the last four weeks and now account for 47.5 percent of all new cases. These include ten districts in Kerala, three in Maharashtra and the remaining in north-eastern states. Despite this, the daily positivity rate for the country has remained below 5 percent for 58 consecutive days now.

With 42,625 new coronavirus cases reported on Aug 04, India now has registered a total of 3,17,69,132 COVID-19 infections across the country. This includes 562 new deaths which have taken the total death toll to 4,25,757. The total number of coronavirus cases also includes 3,09,33,022 people who have recovered and 4,10,353 who are currently being treated. A majority of the fresh cases have been reported from Kerala, which is battling a surge over the past few weeks. Out of the total current active caseload, 49.85 per cent were reported from Kerala. It is now the only state with more than 1 lakh active cases, followed by Maharashtra with 78,000 and Karnataka with 24,000 active cases. According to the Kerala state government, the test positivity rate is at 11.87 per cent now as against the national rate of 2.37 percent. Kerala is one of the eight states where the reproductive number, an indicator of how fast the Covid-19 pandemic is spreading, is greater than 1.

Upward trajectory of the R-value 

Authorities have attributed the recent increase in cases to a rise in the R0 (R-naught) which is the effective reproductive number of a virus. R value denotes the number of people an infected person will pass on the virus to. Public health experts use this number to understand the movement of a virus in a geographical area during a specific period. Knowing the R-Value is a critical first step in curbing the spread of any virus.

In times of a pandemic, public health authorities target an ‘R’ value of less than 1. If the R value is higher than one, then the number of cases keeps increasing [1]. But if the R number is lower the disease will eventually stop spreading, because not enough new people will be infected to sustain the outbreak.

On July 27, the ‘R’ value of the COVID-19 virus in India crossed 1 for the first time since May 7, as per the findings of the Institute of Mathematical Sciences in Chennai. The estimated average R value over the period from July 28 to August 3 period was 1.03 as against 0.89 between July 1 to 7. Eight states in India are currently reporting an increase in ‘R’ value, including Himachal Pradesh, Jammu and Kashmir, Lakshadweep, Tamil Nadu, Mizoram, Karnataka, Puducherry and Kerala. The ‘R’ value for Delhi, Chennai, Bengaluru and Kolkata also exceeded 1 around the same time[2].

The government has called the rising R value a significant problem. While some experts believe that the R value becoming greater than 1 may just be a temporary event and it is possible for it to go back to being less than 1 in a few days, the fact that R has risen in several states around the same time may suggest that this rise in active cases is not entirely disconnected and may be more than just a transient event.[3]

Is the third wave really coming?

Even though the rise in new cases is restricted to a few states, it has renewed fears that a third wave could be imminent. With a large unvaccinated population, India is not immune from the possibility of the third wave. Non-compliance to Covid-appropriate behaviour after the first wave led to a massive second wave. Recent sights of overcrowded public places without adequate enforcement of Covid appropriate behaviour point to the possibility of increased transmission. The Indian Medical Association (IMA) recently issued a warning about the consequences of inappropriate behaviour, especially with the festive season being round the corner.

The mathematical models of various institutes have forecast that India may witness a spike in infections as early as the end of August. A silver lining in most such projections is that the third wave is likely to be less severe than the second wave.  According to a study conducted by IIT researchers, the third wave is likely to hit India in the month of August and the daily infections are likely to clock between one lakh to 1.5 lakh during its peak in October[4]. The research was conducted by researchers at IIT Hyderabad and IIT Kanpur, who developed a mathematical model to predict the rise in Covid-19 cases during the third wave in India. The researchers had previously accurately forecasted the tapering of the surge in Covid-19 cases earlier this year. 

The Indian Council of Medical Research also recently estimated that the third wave would not see the same magnitude as that of the second wave. The ICMR models used parameters such as fading immunity and the potential rise of a new, more transmissible variant that can evade immunity. At the same time, scientists have warned that the looming threat of the Delta variant may also surge the wave. As per the Indian Sars-CoV-2 Genomic Consortium (INSACOG), eight out of every ten infections between May and July 2021 were caused by the Delta variant.

The global context

Even before the second wave of Covid could recede completely, cases have started to shoot up in many countries, indicating a global third wave. In parts of the world where large numbers of people are yet to be vaccinated, the Delta variant has led once again to surging death rates and hospitalisations. Daily new cases globally rose to a weekly average of 5.71 lakh on July 30 from 3.62 lakh on June 21.

Russia, United Kingdom, South Africa and Mexico are some of the countries that have been hit by a significant surge in cases.  A number of countries, including the US, Australia, Finland, and Canada, are reporting an uptick in the R-value. The global R-value rose from a low of 0.86 in the first week of June to 1.12 on July 13[5]. This means that the pandemic is far from over and measures must be taken to further contain the spread of infection. Though cases are rising in many parts of the world, the situation is particularly worrisome in Southeast Asian countries such as Indonesia, Malaysia, Vietnam, and Thailand.

Indonesia, the world’s fourth-most populous nation, overtook India and Brazil in the number of daily cases last month, becoming the new epicenter of the pandemic. Hundreds of children in Indonesia have died from the coronavirus in recent weeks, many of them younger than five, a mortality rate greater than that of any other country and one that challenges the idea that children face minimal risk from COVID-19. More than 800 children in Indonesia younger than 18 have died from the virus since the pandemic began, but the majority of those deaths have occurred only in the past month. Just 16 percent of Indonesians have received one dose, and only 6 percent have been fully vaccinated.

The US Center for Disease Control recently stated that the global war against Covid-19 has changed because of the highly contagious Delta variant. It stressed the need for clearer messaging by governments, mandatory vaccines for health workers, and a return to universal masking. It added that the Delta variant required a new approach to help the public understand the danger, including making clear that unvaccinated people were more than ten times more likely than those who are vaccinated to become seriously ill or die. While vaccinated people were less likely to become infected, once they contracted such breakthrough infections from Delta, they might be just as likely as the unvaccinated to pass the disease on to others, unlike with the previous strains.

Renewed push towards infrastructure ramp up

To accelerate health systems’ preparedness for potential future waves of COVID-19, the Government of India last month approved a Rs 23,123-crore package for improving health infrastructure. As a part of this budgetary allocation, around 2.4 lakh medical beds and 20,000 ICU beds would be created with a special focus on paediatric care. The funds release comes as the second phase of the Emergency Response and Health System Preparedness Package. The Central government had given Rs 15,000 crore earlier under phase one for setting up Covid-dedicated hospitals and health centres across the country.

Under the new package, the Centre would provide Rs 15,000 crore and states will collectively put in Rs 8,123 crore. The plan would be implemented jointly across all the 736 districts to improve medical infrastructure at primary and district health centres. Under the proposed plan, support will be provided to Central government hospitals for repurposing 6,688 COVID-19 beds. 

The National Centre for Disease Control (NCDC) will be strengthened by providing Genome Sequencing machines, apart from sanctioning scientific control room and epidemic intelligence services (EIS) facilities. Support will also be provided for implementation of hospital management information system (HMIS) in all the district hospitals of the country. Presently, it is implemented only in 310 district hospitals. 

Funds will used for expanding the national architecture of eSanjeevani tele-consultation platform to provide upto 5 lakhs tele-consultations per day from the present 50,000 consultations per day. Assistance will also be given for the central war room at department of health and family welfare (DOHFW), strengthening COVID-19 portal, 1,075 COVID-19 help lines and CoWIN platform.

To tackle the third wave, the scheme will aim to create paediatrics units in all 736 districts and establish paediatrics centre of excellence (PaediatricCoE) in each state/UT. Of the 20,000 ICU beds in public healthcare system to be augmented, 20 per cent will be paediatric ICU beds. The scheme will also help strengthen  the existing feet of ambulances—8,800 ambulances will be added under the package. 

Under the scheme, funds will also be available for short-term HR augmentation through medical  students (interns, residents, final year) and nursing students; increasing oxygen supply at central, district and sub-district level; availability of equipment, medicines; and enhancing testing capacity and supportive diagnostics.

Vaccination rates pick up

Amid the rising cases and the possibility of a third wave, the improving pace of vaccination in the country presents hope for a reality where the pandemic is truly brought under control. According to the Health Ministry, a total of 48.89 crore doses of Covid-19 vaccines have been administered across the country as of August 4. These include 37.80 crore first doses and 10.71 crore second doses.

As per MoHFW data, the increase in the pace of vaccination is seen by the reduced number of days it has taken to administer the last ten crore doses as against the very first ten crore does. The first ten crore doses were administered over a period of 85 days, the next 10 crores vaccinations were achieved over 55 days, further more 10 crore doses over 29 days, followed by 24 days for the next ten crore jabs and just 12 days for administering the latest 9 crore doses. 

Despite the increased pace, the vaccination drive needs to pick up further. India will need to administer an average of 92 lakh doses a day if it is to meet the year-end target of fully vaccinating the estimated population of 94 crores of those aged 18 and above (2021 Census office estimate).  Supply constraints and vaccine hesitancy that have been behind slow vaccination rates in the past months may become less of factors in the months ahead. The government has stated that it expects increased supplies from all vaccine manufacturers in the weeks to come.

Conclusion

The recently concluded fourth national sero survey by the ICMR showed that 67.6 percent of the population has been exposed to the coronavirus till now. This means that at least 40 crore people in the country are still vulnerable to contracting the virus. It also means that breakthrough infections or reinfections may also be a reality though not enough data is available on it currently. 

As of now, only 57 districts in the country today are reporting more than 100 new cases of infection each day, compared to 279 districts on June 1. Moreover,  sixty per cent of active cases are being reported in limited geography. Despite this, the simultaneous local rises across different geographies signal the need for governments, the healthcare system, and citizens to continue remaining cautious. States must pursue contact tracing and set up containment zones wherever clusters are identified. It is important to suppress the chain of transmission locally which is the only way the virus will not spread. The current scenario underscores the need for India to accelerate its vaccination campaign, reinforce Covid appropriate behaviour among masses, deploy surveillance methods to catch emerging hotspots and stay vigilant through genome sequencing given the potential for new variants to emerge.

Photo Credit: Neha Kulkarni for Reuters

[1] https://www.bbc.com/news/health-52473523

[2] https://www.indiatoday.in/coronavirus-outbreak/story/india-covid-cases-corona-third-wave-r-value-factor-r0-1835876-2021-08-02

[3] https://www.indiatoday.in/coronavirus-outbreak/story/india-covid-cases-corona-third-wave-r-value-factor-r0-1835876-2021-08-02

[4] https://www.thequint.com/news/india/iit-researchers-see-third-less-brutal-covid-wave-peak-october

[5]  https://systems.jhu.edu/research/public-health/ncov/

Other References:

https://www.indiatoday.in/coronavirus-outbreak/story/covid-pandemic-raging-india-delta-variant-dominant-positivity-rate-r0-1836292-2021-08-03

https://www.indiatoday.in/coronavirus-outbreak/story/india-third-covid-19-wave-august-forecast-daily-cases-1835644-2021-08-02

https://indianexpress.com/article/world/no-longer-hidden-victims-children-are-dying-as-virus-surges-in-indonesia-7423421/

https://www.theweek.in/news/india/2021/07/08/centre-announces-rs-23000-crore-to-strengthen-health-infrastructure-to-battle-covid-19.html

https://www.indiatoday.in/coronavirus-outbreak/story/cdc-calls-for-new-response-to-delta-variant-1834971-2021-07-31