IS THE WORST OVER?
The Covid graph may be falling and vaccines are cause for cheer, but the pandemic is still with us
AAs India enters Unlock 9—almost a year after first going into lockdown on March 24, 2020— and reopens its cinema halls, malls and swimming pools, it may be a good time to ask where we stand in our fight against Covid-19. The official statistics look encouraging. According to health ministry figures, India recorded less than 9,000 new cases in 24 hours on February 9, a massive drop from the 90,000-odd daily cases it was recording in November. Its total cases as on February 9 stood at 10.8 million and deaths at 155,195, compared to the 27 million cases and 465,000 deaths in the US. And they are a country of 320 million people. On a per capita basis, the number of infections in the US was 12 times that in India.
Of course, many doubt the accuracy of India’s official Covid data, citing underreported cases and deaths. Others attribute the low Covid count to the large number of asymptomatic, and therefore untested, individuals. Even so, there is general consensus that India has done better than the US and some European countries, and that its Covid curve is now declining. “The virus seems to have run its course in India,” says noted virologist Jacob John, “and the epidemic seems to be coming down naturally.” And even if one concedes that the official figures do not capture the real extent of the pandemic, the fact that our health infrastructure remains uninundated suggests we might have escaped the worst of the pandemic. “We are not seeing the kind of hospitalisation demand that was there last year,” Dr N.N. Mathur, director of the Lady Hardinge Medical College in Delhi, points out. “Those coming in are either the elderly or those with comorbid conditions.” Two months ago, private hospitals in the capital were asked to keep aside 80 per cent of their beds for Covid patients to meet the growing shortage. Today, that figure stands reduced to 25 per cent; yet, there are over 6,000 beds available in the city.
The decline in the number of cases and deaths, indicating either herd immunity or the success of the government’s Covid management measures, coupled with the rollout of its vaccination programme, beginning January 16, have inspired hope that perhaps India is past the Covid crisis. It’s evident in the public laxity in mask and social distancing protocols and the return to business as usual. However, the risk of a second wave remains, as in some European
countries. Already, Mumbai recorded a 39 per cent spike in cases between February 10 and 14 (compared to the first nine days of the month) as soon as public transport and large gatherings were permitted. Kerala and Delhi, which had flattened the Covid curve by July, saw a massive resurgence in November. “It is a highly infectious, clever virus. Just as you let your guard down, it will resurge,” says Dr Om Shrivastava, head of the infectious diseases department at Mumbai’s Jaslok Hospital.
With gyms, swimming pools, movie halls, malls, offices and even schools opening up, the biggest challenge before public health experts is to keep the virus from travelling. Fresh mutations of the virus, as recorded in the UK, South Africa and Brazil, threaten a renewed, more virulent outbreak (see The Mutant Covid Virus). The hope vaccines offer remains untested in the absence of sufficient data on their efficacy and length of protection (especially against the newer mutations), not to mention the vaccine hesitancy among a large number of people.
As India finds itself on this critical cusp in the Covid graph, it must ensure that it negotiates the next phase with care to prevent a relapse. Not only do we need to assess our situation realistically, we should also learn from the experiences of other countries while continuing to maintain a vigil against the pandemic.
HAS INDIA ESCAPED THE WORST OF COVID?
Serological surveys have long helped researchers assess the prevalence of an infection and whether a majority of the people have developed immunity. This involves testing blood samples in a given set of people to detect antibodies that can indicate the extent of an infection.
In India, ICMR or the Indian Council of Medical Research, the apex body for biomedical research, has conducted three national serological surveys since the pandemic began in March 2020. While the first of these surveys in May 2020 showed that 0.73 per cent Indians had been exposed to the virus, the number went up to 7 per cent in September 2020 and is now 21 per cent, according to the latest version of the survey, released on February 7. It means one in five Indians has been exposed to the virus. Of course, there are regional variations and this is not enough to test the theory of herd immunity, but the sero survey does indicate that a lot more people (20.8 million) were
infected but did not get tested because they did not exhibit any symptoms. As a result, the official figure of Covid cases remains restricted to 10.9 million.
Yet, as Dr Randeep Guleria, director of the All India Institute of Medical Sciences in Delhi, points out, “Sero survey results are very significant in understanding the nature of the pandemic in India. They show that a majority of the cases in India were mild and mostly asymptomatic.” He attributes this to some sort of “inherent immunity”. There is a belief that poor hygiene and exposure to a lot of pathogens leaves low and middleincome countries, including India, less susceptible to the severe effects of Covid. A study by the Dr Rajendra Prasad Government Medical College & Hospital in Kangra, Himachal Pradesh, notes that per capita Covid deaths are lower in countries where people are exposed to a diverse range of microbes and bacteria. “Most of Southeast Asia has some sort of immunity against Covid, which the western world does not have,” says Dr Guleria. Others believe India’s young demographic—more than half its population is under 25 and hence has a stronger immune response to the virus—has played a role.
Yet, one cannot rule out the possibility of asymptomatic individuals being carriers of infection. The young and socially mobile age group can themselves get away with milder symptoms but pass on the infection to more vulnerable groups such as the elderly and those with preexisting diseases, who may suffer more serious consequences.
In fact, several studies offer conclusive evidence that the elderly and those with comorbid conditions, in India and abroad, continue to be at risk from Covid. According to health and family welfare ministry data, a staggering 88 per cent or 8 out of every 10 Indians who died of Covid were above 45 and 70 per cent of those who died had comorbidities. However, in terms of those who actually contracted the virus in India, the figures are the other way around: only four out of 10 people diagnosed with Covid were above 45. This is in line with the trend prevalent in the US, where 97 per cent of those who died were above 45 but only 47 per cent of those who were infected were from this age group.
“We don’t see the kind of hospitalisation demand that we did last year. Those coming in are mostly the elderly” DR N.N. MATHUR Director, LHMC
India has 835 million people below 45. Letting the virus run unchecked puts 188 million of the country’s above-45 population at risk.
FRESH STRAINS
Then, there is the threat of fresh mutations. “Every single time a virus transmits,” says Dr Rakesh K. Mishra, director of CCMB (Centre for Cellular and Molecular Biology), Hyderabad, “it has a chance to mutate. So, if you think nobody is falling sick from Covid and you are safe, you are mistaken. You might not be sick from the current strain of Covid, but if you continue to let it spread, you stand the risk of getting infected by stronger variants. At the end of the day, the virus is a living organism; it wants to survive.”
The new mutation in Brazil is said to require 10 times as many antibodies to fight off as the strain of Covid prevalent in India. “Covid can change any time and we don’t know in what manner,” says Dr Mishra.
Till last year, only four labs in the country were sequencing Covid infections to check for variations and mutations. After the UK caught the new variant of Covid, which triggered the same symptoms as its predecessor but was more infectious, it became abundantly clear that the only way to red-flag mutations was through constant surveillance. Today, 10 labs across the country are poised to sequence around five per cent of all samples in India.
Fortunately, Covid seems to be mutating at a rate slower than most viruses. This is evident in the low number of reinfections. Reinfections are usually a sign that the resistance built up by the body is no longer adequate against a disease. This usually happens as a result of viral mutations. “You keep getting a common cold because the virus mutates extraordinarily fast. Your antibody memory is against a certain type of virus, but the virus that infects you the second time might be different and you fall sick again. With Covid, this has not happened. Reinfections are rare, and our own genome sequencing shows that its mutations are slower than the common cold,” says Dr Mishra. Having said that, around 5,000 mutations have been mapped in India. The threat of mutation remains and grows with every new infection. And so, while India may be seeing a declining Covid curve, we are still not out of the woods.
INDIA’S VACCINATION TRAJECTORY
The coming year will be critical, says Dr Guleria. “People are still dying from Covid. The virus is also mutating. We have to do surveillance, invest in vaccine research and stay ahead of the Covid virus.” And vaccination will be key in that endeavour.
India had vaccinated almost 7 million people in 24 days since the rollout of its vaccination programme on January 16. The US took 26 days to achieve the same target and
“Sero surveys help us understand the nature of the pandemic. They indicate a majority of cases were asymptomatic” DR RANDEEP GULERIA Director, AIIMS
the UK 46 days. However, despite the widespread availability of the two vaccines— Covaxin and Covishield—only 65 per cent of those who registered for the vaccination came forward to get it and, by February 17, 37.5 per cent of those who took the first dose had returned for their second. This figure was even lower in the early days of the vaccination programme. The Serum Institute of India is already sitting on close to 55 million doses of its vaccine and has temporarily halted production till the existing stock is exhausted. Meanwhile, the WHO-led coalition Covax has pledged close to 97 million vaccine doses for India.
“Last year, everyone was asking about the vaccine—when is it going to be available, will we have enough? And now that there is supply, there is widespread hesitancy. Where did we go wrong?” asks Delhi-based public health expert Chapal Mehra.
With almost 9 million healthcare and frontline workers vaccinated, there is already widespread acceptance, says Dr V.K. Paul, member, NITI Aayog and chairperson of the expert committee on vaccines. It is the rest, he feels, who need persuasion. “These people
“Every time a virus transmits, it has a chance to mutate. You may be safe from one strain but at risk from another” DR RAKESH MISHRA Director, CCMB