THE SECOND WAVE
As the coronavirus returns in a more infectious variant, a beleaguered nation struggles to cope with the challenges and keep up the fight
On April 13, when former district judge Ramesh Chandra, a resident of Lucknow’s Gomti Nagar, and his wife Madhu had a bout of fever and a sore throat, they got themselves tested for Covid-19. The report found both of them positive. As Madhu’s condition deteriorated over the next two days, the former judge made frantic calls to city hospitals for ambulances and, when none came, called up and pleaded with the district magistrate and even officials in the chief minister’s office—to no avail. His wife died on the morning of April 15. But the ordeal was not over yet. Chandra spent a harrowing time trying to get a hearse to take her body to the crematorium. A weeping Chandra says he spent four hours calling friends in high places before one was sent and he could perform her last rites. Chandra is not the only one facing this nightmarish collapse of medical infrastructure. And it’s not just in Lucknow but across major metros, cities and even smaller towns, in the wake of a monster second wave of Covid-19 infections that has swept the country. So rapid has been the spread that an average of 260,000 people were infected in the week ending April 18—2.5 times the number at the peak of the first Covid wave in September 2020. Worse, it shows no sign of waning. The rate at which active cases are doubling is an alarming 11 days as compared to the 49 or so days at the peak of the first wave. While the World Health Organization recommends bringing the positivity rate down to 5 per cent or lower in order to prevent a surge of the pandemic, our national average has been a high 13.5 per cent, and was an astounding 33 per cent in Delhi on April 20. Eighty per cent of our active cases are confined to 10 states (see accompanying report, Dread and Despair)—Maharashtra, Uttar Pradesh, Kerala, Tamil Nadu, Karnataka, Gujarat, Chhattisgarh, Delhi, Madhya Pradesh, Rajasthan—where the sudden surge in demand for treatment has overwhelmed the medical system.
The country is, no doubt, paying a severe price for the complacency shown both by the central and state govern
To prevent a THIRD wave, we need to MONITOR the progression of the various mutant strains in India
ments. Declaring premature victory over Covid early this year, they had begun scaling down Covid-19 containment and prevention measures. It lulled the public into discarding Covid-appropriate behaviour, shedding their masks and participating in mass events such as the Kumbh Mela in Haridwar and election rallies in five states going to assembly polls. “In a country of a billion people, a pandemic cannot go away so quickly,” says Dr Virendar Singh Chauhan, director of ICGEB (International Centre for Genetic Engineering & Biotechnology) in Delhi. “There was always the chance of a second wave if we were not careful. We were lucky to have had 3-4 months of calm, we shouldn’t have become complacent.”
The challenges of the second wave aren’t limited to just coping with the mammoth number of infections, there are concerns about newer, more infectious variants and a wider variety of symptoms. Then, there are the massive shortages in testing, tracking, treating and vaccinating. Not to mention enforcing strict Covid-appropriate behaviour among people. It is a humongous task. Tackling the immediate medical crisis should, of course, be the first priority, but it will also be worthwhile to learn from the huge mistakes we have made so far and avoid repeating them in order to prevent a third wave from striking us.
STOP FLYING BLIND
Experts knew a second wave was lurking. After all, a national serological survey (which uses blood tests to detect antibodies, a sign that an individual has been exposed to Covid) conducted by ICMR (Indian Council of Medical Research) indicated that 80 per cent of the country had still not been infected by December 2020. This meant there were still a billion people who could fall sick. It was around this time that various scientific institutions in the country began reporting Covid variants—from Brazil, South Africa, the UK, as well as a fourth Indian strain (B.1.167) that had two mutations. All these variants showed modifications in their spike protein, which helped them bind more easily to human cells and therefore become more contagious. From barely any cases of double-mutant Indian strain infections last year, today it can be found in 10 states and 60 per cent of the samples sequenced in Maharashtra in early April. Anurag Agarwal, director of CSIR (Council for Scientific & Industrial Research), says US studies have found that the L452R mutation in the Indian strain makes it 20 per cent more transmissible. According to Rakesh Mishra, director of CCMB (Centre for Cellular and Molecular Biology), “It is a more infectious Covid this time around, and we could soon see it [the double-mutant strain] become the dominant variant in India.”
However, despite global warnings from the
WHO about the new variants of concern, it was only in January this year that the government formed a consortium of 10 labs called INSACOG (the Indian SarsCoV2 Genomics Consortium) to hasten the pace of gene sequencing. The slow pace can be attributed not only to the lack of funds but also to the lack of clear direction. While INSACOG has been asked to sequence 5 per cent of the samples, with 250,000 cases a day currently, it would mean 12,500 samples. India is currently doing barely 1 per cent. “Not knowing how much these variants are affecting our population has been disastrous,” says Dr K.K. Aggarwal, public health expert and former chairman of the IMA (Indian Medical Association). “As we can see, it isn’t just that the virus has spread more this time, but the demand for oxygen too has been far more. By not keeping track of the kind of clinical symptoms the new mutations show, we could not prepare for
the new challenges.” Experts say that to prevent a third wave, India should monitor the progression of the variants across the country and take appropriate steps to fortify the medical infrastructure to handle any breakout.
NEW THREATS
ICMR has now begun monitoring the Indian variant more closely. Based on national data so far, ICMR chief Dr Balram Bhargava says that, in terms of mortality, the second wave so far seems “less severe”. Its death rate of 1.2 per cent is slightly lower than in the first wave. However, in absolute numbers, the number of deaths is much higher, given the higher number of infections. On April 20, India lost 2,000 people to Covid—the highest number of deaths in a single day.
Also, unlike the symptoms of dry cough, severe joint pain and headache that people were reporting in the first wave, the second wave has more people complaining of breathlessness. This is exerting extra pressure on the healthcare system. ICMR’s National Clinical Covid-19 Registry shows that 47.5 per cent of symptomatic patients this time are reporting breathlessness compared to 41.7 per cent last time. “This, in turn, has impacted the demand for oxygen; there is significantly more demand for it,” says Dr Bhargava. According to the government’s task force report on April 19, hospitalised patients’ demand for oxygen this time has been 54.5 per cent, an increase of 13 percentage points from the Covid peak in September 2020,
going by data from 40 centres across the country. This has caused a massive nationwide shortage of medical oxygen, with both Maharashtra and Delhi sending out SOS signals to the Centre to replenish stocks across major hospitals, as many of them were left with supplies insufficient to meet even the day’s needs.
However, Dr Bhargava points out, the rise in demand for oxygen does not necessarily imply that the new wave is more lethal. The requirement for ventilators, for instance, which are needed for serious lung infections caused by Covid, was 37.3 per cent last year and is 27.8 per cent in the current wave. The number of hospitalisations for symptomatic cases has also come down from 87.4 per cent in the first wave to 74.5 per cent in the current one, going by the National Covid-19 Registry data. (Last year, 80 per cent cases were asymptomatic while 20 per cent required hospitalisation, of which 5 per cent needed ICU and 1 per cent ventilator care.) While specialists believe that the second wave may finally even out to similar statistics, the absolute
numbers have been much higher in a shorter span of time. Dr Rommel Tickoo, director of internal medicine at Max Hospital in Saket who has been treating Covid patients for over a year in the ICU, confirms that. “The symptoms are similar,” he says. “In some cases, there is early lung infection but the overall proportion of people who are advancing to severe lung infection is the same as last year.” However, he goes on to add, “Last year, we saw around 8,000 cases. Now, we are seeing 25,000, because the virus is more infectious—entire households are getting infected at one go.”
Another challenge in the second wave pertains to the age group of those getting infected. National data may show a variation of only 1 percentage point over the 31 per cent cases among the under-30-year-olds in the previous wave. However, when broken up further, there is a slight increase of around 2 percentage points in the number of cases among 0-19-year-olds and a similar spike in infections among 20-39-year-olds. There are also variations across states. In Maharashtra, for instance, 88,827 children up to the age of 10 have tested positive from January onwards, and those below 40 comprise 52 per cent of the state’s total active cases (683,856 as of April 21). The national capital Delhi faces a similar situation. “The Delhi spike has infected a lot of young people, even infants,” says Dr Randeep Guleria, head of the All India Institute of Medical Sciences in Delhi and a member of the government task force on Covid. “Most of them develop mild symptoms, but they are capable of infecting others. It is important for the young to be responsible as they can spread it to vulnerable groups who can develop serious symptoms.” Clinical management, he goes on to say, has remained unchanged, and a lot depends on early diagnosis and treatment.
A BIG TEST FOR TESTING
As cases surged exponentially in April, testing centres found themselves unable to cope with the demand. India currently has 2,449 test labs with the capacity to conduct an average of 1.3-1.5 million tests daily, compared to 1,623 labs that could do a million tests daily in the previous wave. The main difference this time, say lab owners, is that test
ing criteria for Covid was limited last year. Today, ondemand testing is possible in most states. This has led to panic testing even amongst those with no symptoms and a consequent spike in demand. The average wait time for a test result, which was 24-48 hours a month ago, has now lengthened, with some states taking as long as four days for results.
Take Delhi, for example. It tested 180,000 samples on April 18 and 19 at its 18 public and 23 private labs. The state government has also ordered for large offices to test their employees every fortnight. Many labs say they are testing thrice the number of samples daily and are close to running out of consumables such as gloves, flasks, swabs and other safety equipment. The National Institute of Cancer Prevention in Noida, which has a contract with the government to collect 4,000 samples daily, is now receiving 6,000 per day. Dr Dangs lab has seen a 150 per cent increase in tests, with test slots getting filled within 20 minutes of the online portal opening. Thyrocare, which tests in both the capital and in Maharashtra, says the demand for tests came down to 20 per cent of its capacity in January, but has grown by 100 per cent every week since mid-March. “The positivity rate in the city has gone up exponentially,” says Harsh Mahajan, founder of the Mahajan Imaging Centre, one of Delhi’s most prominent testing labs. “But our infrastructure is limited. It cannot be ramped up overnight either, as a lot of the testing machines are imported and it takes a few weeks to set it all up. Investments by private players will also
be limited as there is a price cap of Rs 800 on tests in the city.”
There have also been concerns over the efficacy of the RT-PCR tests, with many wondering if they can detect the newer strains of the virus. Dr Bhargava is reassuring when he says, “The test kits being used are designed to detect more than one gene of the Covid virus and are reliable against all new variants as well.” As for the false negatives that many tests are throwing up, Dr Arjun Dang, CEO of Dr Dangs Lab, lists two main reasons why this could be the case. The first is poor sample collection. The second is testing being done in the wrong time period. “Covid shows up in the test on an average 5-6 days after exposure. If people come to test immediately after meeting a positive case, it will be a false negative, leading to a false sense of complacency. Labs should ensure their kits are approved by ICMR and are detecting the correct genes for SARS-CoV-2.” Dr Tickoo adds that if someone has all the symptoms of Covid, a second test should be done to ensure a person is indeed Covid negative. A third reason could be the test kits themselves.
While you need testing to treat individuals, this was followed up last year with robust contact tracing to ensure that the virus did not spread. MoHFW (the Union ministry of health and family welfare) rules state that 80 per cent of a positive case’s contacts should be isolated within three days. In UP, contact tracing was the reason why the state managed to avert a huge first wave—nearly 93 per cent of contacts in 75 districts were traced and then tested last year. This required the effort of 70,000 workers. At its peak, the state had 60,000 active cases last year. The cases this time are thrice the number and sources say the manpower for contact tracing needs to be ramped up urgently. Most states have fallen short when it comes to contact tracing and confinement of the afflicted. With the delay in results of tests, the efforts to contain the rapid spread of the virus are failing. “Close contacts do not mean only family members but anyone the person has come in contact with,” says Rajesh Bhushan, health secretary, MoHFW. “Districts had become lax and were only tracing family members while the virus was spreading by those the positive case had met.” States need to ensure proper contact tracing to avoid the other, bleaker option of lockdowns to stop the chain of transmission.
LOSING SLEEP OVER BEDS
In the previous wave, the Centre had stratified Covid treatment into three categories—Dedicated Covid Hospitals (DCH), Dedicated Covid Health Centres (DCHC) and Dedicated Covid Care Centres (DCCC). On paper, the statistics look impressive: there are 18,800 Covid facilities across the country, which together have 1.8 million isolation beds, 155,168 oxygen beds and 75,867 ICU beds. The Centre has also given out 6,303 new ventilators in the current wave. The number of beds is roughly 300,000 more than last time when the active cases and daily new cases were half of today’s count. Yet what these statistics don’t reflect is that the epicentres of the second wave are woefully short of beds and don’t have appropriate Covid treatment facilities. In fact, treatment has become a logistical nightmare for many states from April onwards, with Maharashtra and Delhi facing acute bed shortages. This is largely because these states have been adding cases faster than the time taken for people to recover. On an
average, a person requires a 14-day hospital stay, which could become longer if they develop severe symptoms. On April 20, Delhi had only 33 ICU beds and 2,627 treatment beds, while the city has been recording close to 23,000 new cases daily. Even if 20 per cent, or 4,600, of these cases require hospitalisation, the current availability is woefully inadequate. Interestingly, the Centre had promised 6,000 ICU beds for Covid in Delhi in November 2020. Today, the current capacity has increased by just a thousand to 4,500 beds. “This brings to mind scenes from Delhi’s last wave. Why haven’t we prepared since?” asks Malini Aisola, a public health expert. The crisis is not restricted to the national capital. On March 31, Madhya Pradesh said it had provision for 20,139 isolation, oxygen and ICU beds and there was no need for concern. The state then had only 2,332 new cases and 17,096 active cases. Within two weeks, the state had 68,576 active cases of which 12,248 were new infections and the total number of afflicted overtook installed bed capacity in the state. Indore and Bhopal have the bulk of the cases. Every second hospital in the cities, including paediatric hospitals, has now been converted into a Covid facility, yet bed capacity cannot meet the galloping demand. To ease the burden, doctors are advising mild patients to opt for home isolation or a homecare package with a reliable hospital.
GASPING FOR OXYGEN
Shortage in oxygen supplies also assumed critical proportions in hospitals across major cities, including Delhi, where some of the largest facilities reported dangerously low supplies. The Centre and states were forced to take emergency measures to stem the crisis. The country has a capacity to produce 7,287 MT of oxygen per day. On April 12, for example, it used only 3,842 MT, or 54 per cent, of the daily production capacity. As demand has been projected to rise further, most states have banned industrial use of oxygen. Meanwhile, the Centre has roped in new manufacturers to increase capacity to 50,000 MT and also issued a tender to import an equivalent amount. The Centre has also issued 4,880 MT, 5,619 MT and 6,593 MT to the top 12 Covid-affected states to meet their projected demand as on April 20, April 25 and April 30. The railways has been roped in to run Oxygen Express trains with dedicated green corridors to ensure quick supply.
Nowhere is the situation as bad as in Maharashtra, where the consumption of medical oxygen has already reached the state’s full production capacity of 1,250 tonnes per day. The state has 638,000 active cases, and 10 per cent of them— an estimated 60,000-65,000—are on oxygen support, more than in any other state. Maharashtra is now taking 50 tonnes from Chhattisgarh and another 50 tonnes from Gujarat daily. It is also expected to receive another 100 tonnes from Reliance’s plant in Jamnagar, Gujarat.
States have also been issued guidelines for rational use of oxygen. “Oxygen alone cannot save a patient,” says Dr Farah Ingale, internal medicine specialist at Fortis Hiranandani Hospital in Vashi, Mumbai. “Many people are stocking up cylinders at home. It is pertinent that oxygen is used at the right time alongside medical care and supervision.” Ventilators, too, are in short supply in the cities that need them the most. Gujarat-based Max Ventilator, a company that can produce 1,000 ventilators a month, has received six times the number of orders this year that it did in the same period last year. “There are hospitals in Ahmedabad and Surat that are facing ventilator shortages. I have already delivered 600 ventilators and have pending orders for 800-1,000 more,” says Ashok Patel, director of the company. Most state governments, he adds, prefer ventilators that can also be used for non-invasive oxygen supply. However, simply ramping up infrastructure will not be enough without personnel trained in its use. For a 10-bed ventilator-equipped ICU, you need 48 nurses, six technicians and nine doctors every 24 hours, the cost per patient is estimated to be Rs 5.02 lakh. In Maharashtra, to meet the demand for more manpower, Pune has fasttracked approvals for new recruits. Around 16,000 frontline workers have also given up a day’s salary to incentivise better salaries for quicker recruitment.
DEFICIENT ON DRUGS
Indiscriminate use of Covid drugs across the country have become another area of concern. Cities like Lucknow, Bhopal, Mumbai and Delhi reported shortages of Remdesivir and a waiting time of 24-72 hours for other Covid drugs such as FabiFlu, Azithromycin and Paracetamol. The Remdesivir shortage was particularly acute. Currently produced by six companies in India which, according to a Rajya Sabha report, have a production capacity of 3.88 million vials per month, the supply would have been enough under normal circum
stances. But these companies also have export commitments, which the Centre has currently halted. The government will also fast track approvals for manufacturing the drug, so that production can be doubled to 7.8 million vials per month by the middle of May.
However, doctors say there is no cause for alarm. It is not a drug essential for Covid treatment, with the WHO still saying there is no concrete data as to its efficacy. “Remdesivir is an experimental drug, it must be administered at the right time by a trained professional,” says Dr Tickoo. All viral diseases are self-limiting, which means the body can fight them off by itself. The drug can help the body only if the viral infection is moderate or severe. Moreover, administering steroids during the first 5-7 days actually aids viral replication. With more and more cases of people buying drugs using false prescriptions coming up, states have been ramping up efforts to advise against self-medication and hoarding of essential Covid drugs.
In Telangana, for instance, where Remdesivir is in short supply, a few pharmaceutical companies have constituted a task force to streamline distribution by checking a patient’s Aadhaar identity to end the rampant abuse and black marketeering of the drug. Health authorities have also sensitised hospitals against prescribing it for every case as it was meant for restricted use. “During the first Covid wave, the powerful steroid Tocilizumab was administered irrationally to a large number of Covid-positive patients. They suffered due to the use of this drug. The same mistake is being committed with Remdesivir which is not meant for all Covid patients,” cautions Dr G. Srinivasa Rao, Telangana’s director of public health. “At present, it is being misused everywhere, from homes to hospitals.”
THE GRIM BATTLE AHEAD
In his address to the nation on the evening of April 20, Prime Minister Narendra Modi, who imposed one of the world’s severest lockdowns last year in March, ruled out that possibility this time around, even though the number of cases is far higher in the second wave. Asserting that the health of the economy was as important as that of the nation, he made a case for micro-containment zones and selfdiscipline to break the chain of the virus transmission. This is essential to reduce the load on hospitals and resources, say experts. An average doctor at LNJP Hospital in Delhi now works nearly 12- 14 hours a day. Over a year of Covid care has left them fatigued. “The decision not to impose localised lockdowns is important,” says former IMA president Dr Aggarwal. “Even if you get more beds and ventilators, manpower will remain limited. You can’t create a million doctors, nurses, technicians overnight.” Alongside lockdowns, the Centre continues to urge states and districts to create micro containment zones. First used successfully in Bhilwara, Rajasthan, last year, the strategy allows authorities to isolate positive cases while limited movement in a cluster keeps the infection from spreading. In Delhi, there has been a 507 per cent jump in the number of containment zones from April 1 to April 18, 2021. According to health secretary Bhushan, even as states saw a marginal rise in cases in February, the number of containment zones didn’t increase. This is another factor that has contributed to the current surge.
The Centre is also hoping that mass vaccination will help reduce the spread of infection or, at the very least, bring down the severity of cases. With central control over production and delivery stifling the effort, so far only 128 million vaccine doses have been administered, with a mere 17 million or 1.28 per cent of the population fully vaccinated. Last week, in a series of welcome measures, vaccination has not only been opened up to those above 18 from May 1 onwards but states have also been allowed to procure vaccines on their own. The liberalisation of the vaccine programme will hopefully increase demand and distribution. However, there are concerns as to whether the supply will be able to meet the demand of 400 million-odd additional people that the opening up the vaccination to above 18-year-olds will generate.
However, the most important step the country still needs to work on is Covid-appropriate behaviour. The PM exhorted the youth of the country to form local committees to spread Covid awareness and enforce Covid discipline. He also urged children to tell elders in the family to go out only if absolutely necessary. According to WHO, wearing masks and social distancing of 6 feet cuts down transmission by 85 per cent. That is a higher efficacy rate than either of the vaccines available in the country. India, however, has a serious gap in mask literacy. “There is no cotton cloth in the world that can keep out a particle as small as the Covid virus,” says Jai Dhar Gupta, founder of clean air solutions firm Nirvana Being. “One needs an N95 mask at the very least. Moreover, people haven’t received awareness on how to wear the mask—it must cover your nose and chin. Thirdly, not having a breathable mask is disastrous for health as breathing your own carbon dioxide is poisonous.” Europe has standards for community masks to ensure quality and efficacy. India has yet to introduce something similar for one of the pandemic’s most essential defences. While selective lockdowns may work to reduce our current case load, vaccination and mask coverage on a war footing are crucial to pre-empt a third wave. Meanwhile, states must focus on handling the medical crisis precipitated by the second wave. Covid is here to stay. You can ignore it at your own peril. It’s a lesson we are learning the hard way right now. ■
The IMPACT of govt freeing up VACCINE supply will be felt later. Currently, it has to deal with the 2nd wave crisis