After touching an all-time high of 4.14 lakh newly reported cases on May 6, the devastating second wave of Covid-19 in India has been on a consistent downward trend ever since. Daily recoveries are outnumbering new infections for over two weeks now. The recovery rate as a percentage of total cases has also improved, from 82.2 percent on May 9 to 93.7 percent as on June 6.

Four weeks ago, the positivity rate (percentage of positive cases to total tests) was 22.7 percent. On June 6, this number has come down to 6.6 percent. It is important to note however, that the number of tests done has also increased during this period as a result of ramped up testing capacity.India’s effective reproduction number for Covid, an indicator of how fast the infection is spreading, dropped to below 1 at 0.98 (seven day average) on May 11, for the first time since February.[1] As on June 6, this number is 0.74. However, there are significant geographic variations in the R value with some high case load states continuing to exhibit higher value than the national average.

While the absolute number of daily deaths have come down from 4092 on May 9 to 2677 on June 6, the fatality rate (i.e deaths as percentage of total cases) has increased from 1.09 percent to 1.20 percent during the same period. This is because the decline in deaths was not consistent, withthe number hovering around the 3500-4500 mark till May 26 even as the total cases were on a steady decline. In the week ending May 30, nationwide fatalities dipped by 17 percent for the first decline in 12 weeks. The daily death toll dropped below 3,000 on June 1 for the first time in 34 days.

Even though the number of new reported cases has reduced, India still contributed to approximately 45 percent of the new cases detected globally and nearly 34 percent of the deaths globally during the third week of May, 2021.[2]

The dip in official numbers has led governments to gradually begin easing lockdowns and other restrictions. Cities, especially Delhi and Mumbai, which were hit hard during the second wave, have been reporting sharp drops in new infections and deaths. On May 31, Delhi lifted restrictions on manufacturing and construction followed by limited opening for malls and shops a few days later. Even though the declining numbers come as a relief for citizens, governments, and the healthcare provider system alike, it is absolutely imperative that the mistakes made post Covid’s first wave in India are not repeated as life slowly returns to normalcy in the country. With the easing of lockdown, even a small opening poses as a risk of spurt in cases if required protocols are not followed and appropriate Covid behaviour is not adhered to. Experts predict a third wave while cautioning that the lull in cities like Mumbai and Delhi may be just a respite, and not the end of the second wave.[3]

Moreover, while cities may be showing sharp decline in cases, there isn’t enough evidence yet to rule out the possibility of the virus spreading through non-urban areas across the country. Because of limited health infrastructure and public reporting, the state of the pandemic in rural areas is largely unknown. For instance, the downward trend of the second wave is obvious in big cities like Mumbai and Pune but in parts of Maharashtra, the infection is still spreading. As per a report, there are at least ten districts in Maharashtra where the spread is still happening at a worrisome pace. [4]

Moreover, there is a lack of clarity on the future threat from virus variants, especially the Delta variant B.1.617 that now has three sub-types and the dominant one, B.1.617.2, is estimated to be 50 percent more transmissible than another variant of concern, Alpha or B.1.1.7. The surge of cases during the second wave in the country in the last two months shows a correlation with the rise in the B.1.617 variant, according to INSACOG, a grouping of 10 national laboratories. The WHO said recently that one strain of the Covid-19 Delta variant first detected in India is now considered “of concern”, while two other strains had been downgraded. “It has become evident that greater public health risks are currently associated with B.1.617.2, while lower rates of transmission of other lineages have been observed,” the World Health Organization said in its weekly epidemiological update on the pandemic.

As per the official data, around 162,000 people in India had lost their lives to Covid-19 till March-end. Within just two months that followed, the death toll more than doubled, taking the total number of Covid-related fatalities to over 340,000. The exponential rise in Covid cases during the second wave overwhelmed the country’s health infrastructure, leading to shortage of oxygen, beds, medicines and medical professional across hospitals.[5]As the second wave recedes, it is important for governments, healthcare establishments and most importantly for citizens to not let their guard down. With only a small portion of the population being  fully vaccinated so far it is important that adherence to Covid-19 appropriate behaviour is reiterated and reinforced frequently and extensively.

Rising incidence of Mucormycosis

As India continues to gain stability and control over the second wave, another imminent threat has emerged in the backdrop.Worsening the woes of patients and doctors, a small percentage of recovering and recovered Covid-19 patients in the country is being afflicted by a rare but dangerous fungal infection called Mucormycosis. Commonly known as ‘Black Fungus’, it is caused by exposure to the mucor mould that is commonly found in soil, air, plants, manure, and decaying fruits and vegetables.

Mucormycosis mainly affects people on medication for other health problems that reduces their immunity to fight environmental pathogens. People with uncontrolled diabetes, immunosuppression by steroids, prolonged ICU stay, and other comorbidities are among sections of the population that are more susceptible to contracting this virus. It can be life-threatening in diabetic or severely immunocompromised individuals, such as cancer patients or people with HIV/AIDS. Their sinuses or lungs get affected after fungal spores are inhaled from the air. This aggressive infection affects the nose, eyes, and sometimes the brain.Patients suffering from the fungal infection typically have symptoms of stuffy and bleeding nose; swelling of and pain in the eye; drooping of eyelids; and blurred and finally, loss of vision. There could be black patches of skin around the nose.

Black fungus is being believed to get triggered in Covid patients because of the irrational use of antimicrobials, antibiotics and immunosuppressants such as steroids, uncontrolled diabetes, and a dysregulation of the immune system due to Covid itself. Steroids are a treatment for moderate-to-severe Covid cases for reducing inflammation in the lungs. However, they also end up reducing the overall immune response and significantly increases sugar levels in both diabetics and non-diabetic Covid-19 patients.

The black fungus crisis in India may also be driven by the overuse of zinc supplements according to doctors.[6]Doctors cite that fungi thrive in zinc-rich environment.Other hypotheses suggest the use of iron and the failure to use sterile water in oxygen concentrators as other plausible reasons.

At least 14 872 cases of the rare disease have been reported across the country as of May 28, 2021. [7]The state of Gujarat alone contributed to the highest number of cases, with at least 3726 cases of mucormycosis in patients with active and recovered Covid-19, followed by the state of Maharashtra. Since May 19, 2021, there have been 90 deaths attributable to mucormycosis in Maharashtra. Other states such as Rajasthan, Andhra Pradesh, Karnataka, Haryana, Madhya Pradesh, Uttarakhand, and Delhi have also shown a steady rise in the number of mucormycosis cases and deaths related to it; with multiple states already having declared it as an epidemic and a notifiable disease to the national health authorities.[8]

Various state governments have taken quick measures to control the spread of black fungus by setting up special task forces, issuing guidelines, arranging separate wards in hospitals, and procuring the drugs required for treatment. Approximately, 1.1 lakh vials of amphotericin B, the drug used in the medical management of mucormycosis, were distributed to the states by the Union Ministry of Health as on May 27, following the shortage of amphotericin B being noticed in multiple states. [9]In addition to ramping up domestic production, different methods of importing the drug are currently being explored by the Union Ministry of Health.

Where does the vaccination coverage stand?

Presently, there is an urgent need for India to carry out mass vaccination of its 1.3 billion people to reduce the potential impact of subsequent waves. Despite being one of the largest vaccine manufacturing countries globally, India has not been able to ramp up its vaccination efforts in alignment with the current need. To rapidly increase the pace of Covid-19 vaccination in the country, India is looking at both, boosting its domestic manufacturing capacity as well as easing the import of foreign-made vaccines into the country.

Recently, in amove to clear the way for foreign vaccines the drug regulator has done away with the requirement of India-specific trials. Foreign vaccines approved by specific countries and WHO for emergency use will no longer need bridging trials in India, the Drug Controller General of India (DCGI) has said in an attempt to fast-track the import of doses needed to bolster vaccinations. The government has further decided that customs duty on import of Covid vaccines will also be exempted for the time being.

American pharma companies Pfizer and Moderna were among the companies that had requested the government for waivers like indemnity and for post-approval local trials. The government has yet to take a final decision on indemnity or liability from compensation for any severe side effects..

Meanwhile, Dr Reddy’s Laboratories which had received over two lakh Sputnik V vaccines from Russian Direct Investment Fund early last month, recently tied up with Apollo Hospitals for piloting the vaccine. Earlier this month, a consignment of three million doses of Russia‘s Covid-19 vaccine Sputnik V arrived in India. Dr Reddy’s Laboratories is in a pact with the Russian Direct Investment Fund to sell the first 125 million people doses (250 million vials) of Sputnik V in India.Dr Reddy’s Laboratories has received approval from the Indian drug regulator for restricted emergency use of SputnikV.The DCGI has also granted permission to the Serum Institute of India (SII) to manufacture Sputnik V vaccine in India for examination, test and analysis with certain conditions, The company had submitted an application to the DCGI in this regard.

The SIIalso recently informed the government that it will be able to manufacture and supply nine to 10 crore doses of Covishield in June, amid complaints by states about the shortage vaccine jabs.In the month of June, SII will manufacture and supply nine to 10 crore doses of our Covishield vaccine to the country as compared to its production capacity of 6.5 crore doses in May.

Similarly, the monthly production of indigenously developed Covaxin will also be increased to 6-7 crore doses in July-August from one crore doses in April. The production capacity of the vaccine being manufactured by Bharat Biotech is expected to reach nearly 10 crore doses a month by September. [10] Additionally, the Union health ministry has finalised arrangements with Hyderabad-based vaccine manufacturer Biological-E to book 30 crore Covid-19 vaccine doses, set to be manufactured and stockpiled from August to December this year.This is the first such order for unapproved shots.The vaccine, which is currently undergoing phase-3 clinical trials, is likely to be available in the next few months

Biological E., which also has a separate deal to produce about 600 million doses of Johnson & Johnson’s Covid-19 shot annually. Earlier this month, it signed a licensing agreement with Providence Therapeutics Holdings to manufacture the Canadian company’s mRNA Covid-19 vaccine in India.Biological-E will run a clinical trial of Providence’s vaccine in India and seek emergency use approval.

Vaccination Coverage:

The country has administered more than 23 crore Covid-19 vaccine doses as on June 5. [11]Of this, close to 18.5 crore people have received their first dose while 4.61 crore people have received both jabs. Cumulatively, 2.76 crores persons in the age group of 18-44 years across 37 States/UTs have received their first dose and a total of  1,60,406 have received their second dose since the start of Phase-3 of the vaccination drive on May 1. In the age group of 45-60 years, 7.06 crore people have received the first dose while 1.12 crore people have received both doses. In people above 60 years of age, 6.05 crore have received the first jab while 1.91 crore have been fully vaccinated with both jabs.

While the central government has asserted that all eligible person will be able to get vaccinated by the year-end, analysis has shown that India’s inoculation drive will need to be accelerated manifold to achieve the target.The pace of vaccination has, however, dropped by 34 percent in May from April because of a supply crunch. [12]

The Way Ahead:

Despite the seeming end of the second wave of Covid in India, experts have warned about a possible third wave, given that only around 3.2 per cent of the Indian population has been fully vaccinated against the infection so far. To limit the damage that future waves are likely to cause, India will need to be prepared with better health infrastructure and rigorous vaccination. Coupled with strict adherence to Covid-19 appropriate behaviour, the above two factors could lead to a significant decline in severe Covid cases and deaths in the future waves.

Like many other countries, India needs to prioritize vaccination in a better manner, going beyond just priority age groups. It should use data on region specific infection rates from the first and second waves to prioritise vaccinating populations residing in these high caseload areas. India’s former health secretary K. Sujatha Rao suggested in a media report[13] that that states must: a) conduct seroprevalence studies to see the level of antibodies in different regions, b) analyse the socio-economic characteristics of individuals in these areas, c) recognise the at-risk population from these groups and d) prioritise regions that have more share of at-risk population. The report also quoted Dr K Srinath Reddy of the Public Health Foundation of India saying that states must also focus on areas of higher population density first to limit the case count and deaths.

The Lancet Citizens’ Commission has recommended establishing central systems to procure and distribute Covid-19 vaccines free of cost instead of the current policy of decentralised procurement through state governments. This is among the eight-point recommendations proposed by the commission in response to Covid-19 in India. The reportalso highlights the need for transparency in government data collection and modelling to enable districts to proactively prepare for the likely caseloads in the coming weeks. Additionally, it emphasizes the need for surveillance to include an urgent investment in genomic sequencing, adequate institutional capacity, and trained personnelto provide real-time alerts of SARS-CoV-2 variants, hot spots, and breakthrough infections.

While localized, calibrated lockdowns should and will continue, measures to shut down everyday activity without adequate reason will lead to panic, and leave the economically weaker sections, the disabled, migrant workers and many single individuals unable to cope. It would work to shut non-essential sales, encourage remote transactions and home deliveries, actively monitor compliance with Covid-19 protocols in public places and vaccinate workers in services, including domestic workers, on priority.

The time has come to take a fresh look at the pandemic policy and transform it into one that relies on scientific evidence, promotes safe public behaviour through effective and persuasive communication, monitoring, and, includes appropriate medical interventions to curb the spread of the disease.

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