To beat the second wave, understand it
India needs better public data on testing, variants, vaccination, case trajectory and more
It would be comic if it were not so deathly serious. The homegrown variant B.1.617 was visible in the United Kingdom (UK) in February, when here, it was claimed surges were not due to new strains. Cabinet ministers derided an Opposition politician for suggesting an expanded vaccine portfolio, labelling him a broker for pharmaceutical firms, before expanding the portfolio three days later. Apparently, there is no shortage, but states are shutting down vaccination centres. An empowered group of senior officers says there is no oxygen shortage, but the Prime Minister’s Office cancels a meeting with a key international visitor to review the situation.
All these point to tightly controlled information, unhelpful to transparent and collective pandemic management. What information can be released to help combat the pandemic?
First, the share of antigen tests available with Indian Council of Medical Research (ICMR). This is an imperfect measure of missed infections, due to the nature of the test. Cities and districts with higher share of antigen tests need more attention because it’s likely that they may be missing infected people, who go on to infect others.
Second, the reasons for testing (also with ICMR) — of self-testing, surveillance (e.g. fever clinics) contact tracing, etc — some indicate underdetection. A high share of contact tracing is better than high self-reporting, which depends on an individual’s intent to test.
Third, the proportion of different variants (from the Indian Sars-CoV-2 Consortium on Genomics, hopefully better-funded now). Punjab reported a high share of the UK variant, B.1.117. This does not have an immune-escape mutation and is thus more responsive to vaccination. In Maharashtra and other states with a high share of B.1.617, immunisation may reduce the severity of infection but it may not stop the infection itself, as it has a possible immune-escape mutation. This has implications for disease management and how the benefits of immunisation are communicated. If a large number of people get infected after immunisation, then vaccine hesitancy may rise, affecting the expansion of vaccination.
Fourth, the location of cases (from analysis of ICMR data and states’ administrative reports). Whether it is big cities, small towns or rural areas matters for the spread and plans to move people and materials to manage the pandemic. Sketchy data from Maharashtra seems to indicate a move away from the bigger cities, but it is unclear whether it is to smaller towns, peri-urban areas or villages. This can also matter for the geographical prioritisation of vaccination.
Fifth, the age structure of cases (from ICMR) and deaths (from states). We are assuming that younger people are less likely to have severe disease and this underpins our vaccination strategy. It seems that young people are getting infected in this surge, but not much. Numbers from Mumbai indicate that the share of those below 50 is now around 65%, whereas previously it was around 57%. Is this related to vaccination or the variant?
Reports from Pune, Mumbai, Delhi, among others, indicate that hospitals are filling up. While the case fatality numbers from Mumbai seem lower, it is higher in many districts which needs attention. High hospital occupancy and low fatality indicate that more people are coming in for treatment but are also getting cured, even for older persons. This, with the age structure, affects how patients are prioritised and open communication would reassure families running around for oxygen and remdesvir.
Sixth, are vaccinated people in hospital with severe infection? With 11 million health care and frontline workers fully vaccinated, and nearly 90 million people above 45 getting at least one jab, a substantial proportion
of the age group, especially in urban areas has been vaccinated. If they are not showing up in hospital, even if they are infected (which could be determined if the ICMR form captured vaccination status, as recommended by the Lancet Commission Task Force), it is good news.
Seventh, there is need to build vaccine-confidence by reporting adverse events following immunisation (AEFI), currently not released with the vaccination data. Some cases of blood clots from the AstraZeneca (Covishield) and the Janssen vaccine (which share a common viral vector platform with Sputnik V) have been reported internationally. With over a 100 million vaccinations in India, it is unusual not to see such reports here. This does not breed vaccine-confidence — rather, it increases the likelihood of misinformation increasing vaccine hesitancy because the government is seen as trying to conceal negative information.
Eighth, recognise vaccine shortage and modify our strategy. We can release vaccination information by rural and urban and formally prioritise
by geography, given the disease’s spread. The initial favouring of urban areas may have helped. We can redefine frontline workers to include construction and manufacturing workers and street vendors in cities, who, even if sick, are likely not to test, to avoid losing income. The geography and age profile of infection will help in this decision.
Ninth, we need to mitigate the spread from large gatherings like the Kumbh, as with returning migrants last year, with quarantine and testing. The will not work in election states, where it is prudent to expect a sharp rise in cases and be prepared to combat the surge, by moving patients if needed. We will be lucky if it does not occur, but won’t be caught napping if it does.
Tenth, the media must ask far more questions and not accept “trust us”. If governments are pushed to answer, they may be forced to think. It is time for them to trust us.