After a short-lived respite, India’s Covid-19 graph is on the upward rise again.
The second wave of Covid-19 has hit India, causing a widespread increase in infections and deaths. On April 8, the number of new coronavirus cases in India hit a record daily high since the outbreak of the pandemic last year, with over 1.26 lakh new infections being reported in a span of 24 hours. This pushed the nationwide Covid-19 tally to close to 13 million cases of which 1.66 lakh cases resulted in death, as on April 8.
As governments begin to restrict citizens’ movements in several parts of the country, experts worry that the second wave could possibly be much worse than the first one, compounded by several factors such as non-adherence to appropriate precautionary behaviour and the spread of deadlier variants of the virus. The second wave, that hit India in February, is seen to be spreading at much higher intensity.
In September 2020, India was reporting almost 100,000 positive cases a day. This was seen as the first peak of the pandemic in India. After this, cases started to decline steadily and with a few region specific exceptions, we were seeing fewer than 10,000 new cases a day towards the onset of the new year. In February, however, the numbers started to rise again, more exponentially as compared to the first wave. The doubling rate of infection, that is the amount of time it takes for the number of Covid-19 cases to double, was down to less than 170 days on 30 March, from a high of 590 days on 28 February. The last time infections were doubling in less than 170 days was in November last year.
Despite seroprevalence studies showing the presence of antibodies in large proportions of population in Mumbai Pune and Delhi, these cities continue to show an upward trajectory of cases in the second wave. It is feared that the given rate of the spread of the virus may result in the need to reimpose extensive restrictions across several parts of the country.
Even as the rate of increase is rising in almost all states, the surge has been pronounced in a few select states. Maharashtra, Chhattisgarh, Karnataka, Uttar Pradesh and Kerala cumulatively account for 74.13 percent of India’s total active cases. Maharashtra alone accounts for 55.26 percent of the total active caseload of the country. Along with the above states, Delhi, Madhya Pradesh, Tamil Nadu, Gujarat, and Punjab have been showing a sharp rise in Covid-19 cases in the past few weeks, together accounting for more than 60 percent of the cases recorded since February. A high test positivity rate is seen in Maharashtra (25 percent) and Chhattisgarh (14 percent). The steep rise of cases in the above states have caused the national weekly positivity rate to increase from 2.19 percent in the first seven days of March to 8.40 percent during the first week of April. The Ministry of Health and Family Welfare has noted that since February 2021, these states have witnessed a steep increase in cases, majority of which have been reported in the younger population of 15-44 years. Also, it was pointed out that majority of the deaths have been reported among the elderly of age more than 60 years.
Experts have warned that the new strain of the novel coronavirus is highly contagious and because of its characteristic of high infectivity it can quickly enter the lungs and cause severe illness and complications. According to information emerging from hospitals across India, people testing positive for the virus are now reporting different viral symptoms. As per doctors in Gujarat, patients are now exhibiting unusual symptoms of the virus, including abdominal pain, nausea, and vomiting. The absence of typical symptoms, such as fever and cough, is causing doctors to caution patients to get tested even in the absence of the classic symptoms as were seen under phase one of the pandemic.
A major worry for the country at present is to ensure that the health infrastructure can keep up with the sudden surge in cases. Many hospitals in cities are running on full capacity and the wait for a bed for Covid-19 patients is becoming longer, especially within the private sector. Beds and ICUs with ventilators are filling up much faster than expected. Even with a shorter peak last year, the country had struggled to meet critical care, owing to the skewed distribution of care facilities. If the second wave continues rising up the way it currently is, urgent action will need to be taken to ramp up critical care, while maintaining enough resources required to continue and fasten the pace of the vaccination drive.
What is fuelling this second wave?
A major reason for the surge in new coronavirus cases was people becoming lax towards following Covid-appropriate behaviour. Many attribute the spike in cases to the indifference and casual behaviour among people. After several months of lockdown and spending extended periods of time at home, when the spread of the pandemic finally started seeming under control, many Indians began socializing and congregating at crowded weddings and family functions without taking enough precautions.
The opening of cinema halls and gyms, and the large political rallies in five states where elections are due, have become super spreaders, contributing to the steep rise in cases. In addition, more and more sectors have been seeking exemptions from following the required regulations in preventing super-spreader events. Experts believe that India wasted the window of opportunity it had in January and February when cases were at the lowest, making it the ideal time to ramp up vaccinations while continuing with restrictions and reiterating the need to follow Covid appropriate behaviour.
Several variants of the novel coronavirus have been discovered in different parts of the world over the past months. These have been established as being more contagious and more fatal. While there is no evidence to suggest a direct link between the surging cases and the new variants yet, many experts believe that the variants have a significant role to play in the current rapid spread of infections.
Why are variants a cause of deep concern?
Like in the case of all viruses, natural evolutionary changes in the novel coronavirus are normal and expected. When a virus is widely circulating in a population and causing many infections, the likelihood of the virus mutating increases. The more opportunities a virus has to spread, the more it replicates and the more opportunities it has to undergo changes.
The mutations of the novel coronavirus have rendered it more transmissible than its previous strains. The variants originating from the United Kingdom, Brazil, and South Africa are being seen as wreaking the most havoc. These variants are said to be stronger, causing more symptoms while attacking the vital organs more profoundly.
The health ministry recently released data on genome-sequencing conducted by a consortium of ten labs, called the Indian SARS-CoV-2 Consortium on Genomics (INSACOG).Of the 10,787 samples analysed from 18 states, 771 cases of known variants were found; 736 of the UK variant (B.1.1.7), 34 of the South African variant (B.1.351) and one of the Brazil variant (P1). There were 336 samples from Punjab that tested positive for the UK variant. A new variant of concern with two mutations (E484Q and L452R) was found in 206 samples from Maharashtra. Officials also reported this strain in samples from Punjab, Delhi and Gujarat. In late March, India’s National Centre for Disease Control (NCDC), a division of the Ministry of Health and Family Welfare, announced this new variant and called a “double mutant”.
Of all the variants that have reached India, the UK variant is seen as being the most worrisome. This variant virus’ mutations make it up to 60 percent more infective. It has been identified in 125 countries worldwide and is now the dominant variant in the UK. While this variant has been reported from across different parts of the country, it has been found extensively in some parts. As per a statement by the Punjab government, eighty-one per cent of the 401 samples sent by the Punjab government for genome sequencing have tested positive for the UK variant of Covid-19.
The health ministry has stated, however, that variants have not been detected in numbers sufficient to either establish a direct relationship or explain the rapid increase in cases in some states. But the proven infectious nature of these variants and the inadequate evidence around the efficacy of existing vaccines against the variants is reason enough for us to exercise all caution, as genomic sequencing and epidemiological studies continue to further analyse the situation.
Will the ongoing vaccination drive help bring cases under control?
Nearly three months into the nation-wide Covid vaccination drive, the cumulative number of vaccine doses administered in the country crossed 90 million on April 8. These include 8.9 million healthcare workers who have taken the first dose and 5.4 million healthcare workers who have taken the second dose. During this time, 9.7 million frontline workers have taken the first dose, while 4.4 million frontline workers have taken the second dose. In the age group of above 60, 36.3 million beneficiaries have taken the first dose while 11.3 million have taken the second dose. Between the age group of 45 to 60, 2.36 million people have taken the first dose and 0.46 million have been administered the second dose.
Even as these numbers may seem encouraging, experts and critics say that the pace of vaccination coverage needs to progress much faster if we are to effectively control the rapidly spreading infections under the second wave. The current pace of 90 million doses in three months out of the total population of over 1.3 billion may have little effect on slowing the spread of the virus in the near future. It is also believed that when the cases were at the lowest in January and February, the government should have gone into overdrive in terms of the vaccination coverage and ensured that larger proportion of the population gets covered during this conducive time period. However, the government alone is not to be blamed for the slow pace of vaccination coverage as there was much hesitancy among citizens about the safety of the vaccines which led to a slow uptake in the initial weeks. As of April 1, jabs are available to anybody above the age of 45.
Another pertinent question is about the efficacy of the vaccines against the variants. While there has been no study of Covishield’s and Covaxin’s efficacy against different variants in India, these vaccines are expected to provide at least some protection against new virus variants. The vaccines have been designed to create antibodies which target the spike protein of the virus specifically. However, the worry is that if a mutation changes the shape of the spike protein significantly then the antibodies may not be able to recognise and neutralise the virus effectively. Given this scenario, sincere attempts should be made to assess the efficacy of existing, approved vaccines against the new variants.
Are we doing enough to tackle the second wave?
In order to curb the resurgence of the pandemic, the health ministry has advised states to strengthen their public and private healthcare resources. Limiting social and public gatherings is also critical and being stressed upon. The implementation of “Test, Track, Treat” strategy with a 70 percent RT-PCR ratio, quarantine of positive cases, contact tracing of positive persons will need to continue with renewed rigour.
Fifty high level multi-disciplinary public health teams have been deployed to 50 districts across Maharashtra, Chhattisgarh and Punjab in view of the large numbers of daily new cases and mortality being consistently reported by these states. The teams will monitor the overall implementation of Covid-19 management, especially in testing, surveillance and containment operations, Covid appropriate behavior and its enforcement, availability of hospital beds, sufficient logistics including ambulances, ventilators, medical oxygen, and to track the vaccination progress.
In addition to the above steps, experts believe that there is an urgent need for India to step up genomic surveillance to track down variants and to ramp up vaccination in areas of high transmission and in states where elections are being held to prevent the virus from spreading. A revised control strategy accelerating containment efforts with strict prevention of crowds needs to be adopted immediately. This must also include a revised communication strategy to ensure everyone follows Covid appropriate behaviour.
As the dramatic upward trajectory of the virus continues, there cannot be any delays in our response. In a recent report, the health ministry has highlighted that the next four weeks, till the end of April, are critical for controlling this surge. The responsibility of controlling the spread lies not just with the government and establishments but also with people at large.The five-fold strategy of Testing, Tracing, Treatment, Covid-appropriate behaviour and Vaccination if implemented well, will alone be effective in curbing the further spread of the pandemic.