NATIONAL SNAPSHOT
TEST POSITIVITY NUMBERS HAVE REMAINED STUBBORNLY HIGH IN THE SECOND WAVE, WITH INDIA REPORTING OVER 300,000 NEW CASES PER DAY FOR THE PAST THREE WEEKS
The folly became evident in the last week of March when a tidal wave of infection hit India leaving its citizens gasping for life. From around 11,000 cases of new infections daily, it skyrocketed to over a lakh, rapidly doubling every week till by April end and early May, the numbers infected crossed 400,000 daily. It was a world record in daily cases for a single country, the highest such figure since Covid-19 was declared a pandemic by the WHO in March 2020. When Mukherjee warned India of the coming wave, the country had 11 million active cases of Covid infection. In just two months that figure more than doubled and stood at 23.3 million on May 12. Among those infected was Mukherjee’s father who finally took his first dose of the vaccine only in mid-April and is now recovering from the disease. India is second only to the US in terms of number of infections caused by Covid-19. The death toll has gone up from an average of 1,000 daily in the first wave to a numbing 4,000 daily—and still counting. The big question on everyone’s mind: when will the nightmare end?
WHEN WILL THE WAVE PEAK?
To answer this question, it is important for the central government to get a good estimate of when the wave will peak and the factors that could cause its decline so as to put a strategy in place to halt the pandemic. Research models that make projections based on certain statistical criteria and assumptions are of great help. In mid-April, Mukherjee and a group of researchers at the University of Michigan, who have set up a special model to track the progress of Covid-19 in India, projected that the second wave could peak by mid-May at an alarming 800,000 to 1 million new cases daily and 4,500 deaths by May-end.
Mukherjee still stands by her prediction that India would turn the corner by mid-May though new cases in
India, averaging around 350,000 a day currently, have not hit the levels her team had projected. She admits the height of the peak is debatable since “the model rests on the edifice of new case counts…but because of the bottlenecks in testing in India there are a large number of undetected infections happening which makes the actual figure of the infected nebulous.” Meanwhile, the Institute of Health Metrics and Evaluation (IHME) in Washington University, which maintains a database of worldwide statistical reports of Covid-19, also predicted a mid-May peak for India. It projected that, in the worst case scenario, by August 2021 India would record a devastating 1.04 million deaths. But if the country followed a universal masking policy, IHME predicted the mortality numbers would drop by 250,000 to around 880,000. This is still frighteningly high, given that the current death toll stood at 254,000, as of May 10. (The IHME estimates that actual Covid related deaths in India are double the official figure.)
MEANWHILE, two groups of Indian data modellers, who also maintain that mid-May will see a peak in infections, are more circumspect in their projections of infected cases and deaths. One of them is the Sutra Group consisting of M. Vidyasagar, distinguished professor, IIT Hyderabad, Manindra Agarwal, professor of computer science and engineering, IIT Kanpur and Lt Gen. Madhuri Kanitkar, deputy chief of Integrated Defence Staff (Medical). The group has been tasked by the department of science and technology (DST) to work out a ‘supermodel’ to predict the progression of the pandemic. In early April, the Sutra Group first projected that the second wave would peak at around 120,000 cases daily by April end. But by mid-April as the cases grew relentlessly, the group
reworked its numbers and said that the second wave would peak at a moving average of 400,000 cases between May 8 and 15. Vidyasagar says their simulation model is robust because it is built around several key parameters including rate of infections, mobility of people, virus variants, recovery rate, geographic spread and the ratio of detected cases to undetected ones.
OTHER MODELLING experts like Gautam Menon, professor of physics and biology at Ashoka University, however, criticise the DST supermodel for constantly “shifting the goal posts” and call it a “stupid model”. (The DST itself has admitted that the Sutra model had underestimated the impact of the second wave.) Menon points out one of the big issues in getting authentic data to make calculations: “In India, for every positive case that is revealed through testing, there are 20 others who have not been tested. Mortality figures are usually completely forged and many Covid deaths are not registered. Any model is only as good as the data you feed it.” The model that Menon developed along with a consortium of scientists, called INDSCI-SIM (Indian Scientists’ Response to Covid-19), factored in these inconsistencies and projects that the second wave would peak in mid-May at around 500,000 to
600,000 cases daily.
WHERE WILL IT SPREAD?
The real worry, though, is that the pandemic that first struck on the west coast of India and has now moved to the east and south shows no signs of abating. Health ministry statistics reveal that 26 of the 28 states in the country have a positivity rate of 15 per cent and above—much higher than the positivity rate of 5 per cent that the WHO set as a benchmark of sorts, below which the pandemic could be deemed under control. Currently, India’s national average is a high 21 per cent positivity rate with some states like Goa registering as high as 49.2 per cent—which means that every second person tested here is found to be positive. The states that are a worry now are West Bengal, Haryana, Karnataka and Rajasthan, for they are showing positivity rates of 30 per cent and above.
Worse, the Second Wave is now spreading rapidly to rural areas and may upset the projections of those carefully constructed models. Health ministry statistics show that on May 10, 533 of the country’s 718 districts had a case positivity rate of over 10 per cent. In Madhya Pradesh, 45 of the 52 districts had a positivity rate of above 10 per cent. In Uttar Pradesh, the country’s most populous state, 38—or half—of the 75 districts have high positivity rates. In Bihar, as many as 33 of the 38 districts are similarly impacted and in Tamil Nadu a majority of the 38 districts had high positivity rates (see graphic: National Snapshot).
The worry for experts is that in rural areas there is very little testing being done and no proper record of deaths. So the pandemic may rage on without reflecting in official statistics. The reports of growing numbers of the sick and dead in rural areas are the only indications that the situation is fast getting out of hand. Recent reports of a rapid fall in positivity rates in states like Bihar and UP are viewed with much scepticism by experts. As one of them said, “Figures don’t drop like the Niagara falls –[the decline] either indicates that the states are doing extraordinarily well, which seems hard to believe given the condition in the rest of the country, or their testing numbers have dropped drastically.”
Giridhar Babu, professor and head, life-course epidemiology, Public Health Foundation of India (PHFI), believes that both cases and deaths are being “undercounted” across India and that the numbers impacted could be anything “between 3 to 7 times” what is actually being revealed. His own estimates are that instead of the official figures of an average of 350,000 cases, there are actually around 500,000600,000 being infected daily. Shahid Jameel, director, Trivedi School of Bioscience, Ashoka University, adds, “The only saving grace is that the population density is not so high in rural areas so the transmission will not be as fast as it is in cities. But the negative point is that healthcare in villages is poor.”
Meanwhile, Dr Balram Bhargava, director-general, Indian Council of Medical Research (ICMR), which governs the testing regime, says in order to ramp up the current 1.9 million tests daily, it has altered its policy to allow more rapid antigen tests (RAT), especially in rural areas (earlier it had been insisting that 70 per cent cases must be tested through the RTPCR route). ICMR is pushing for deployment of mobile vans in rural areas to increase the number of RAT tests done. While RAT has a much higher rate of false negative results, it would at least give some idea of the spread of the pandemic in rural areas.
WHEN WILL COVID 2.0 SUBSIDE?
Experts differ on the question of how long the second wave will take to subside and infection levels to hit manageable levels. Would it drop rapidly like a cliff or taper off gradu
THE ICMR-NIV STUDY SHOWS COVAXIN NEUTRALISES SARSCOV-2 VARIANTS. IT CAN ALSO PREVENT SERIOUS INFECTION THAT COULD LEAD TO HOSPITALISATION AND POSSIBLY DEATH” DR PRIYA ABRAHAM
Director, Virology, National Pune Institute of
ally in a series of rolling hills? Vidyasagar says, “If you looked at the first wave of infections last year, it was a very gentle climb which almost went unnoticed and so was the decline. We believe the decline will not be a sheer drop but a benign process which will take a month-and-a-half before it stabilises. There would be a rapid decline from the peak till you get down to around 50,000 to 60,000 cases daily which would be the intersection point where the disease slows down.” Menon agrees with that conclusion and says “it will not balloon down as fast as it took off, so we have to be very watchful as there is a risk that new variants may come in and queer the pitch.”
TO COMPLICATE these predictions further, Gagandeep Kang, professor of microbiology at CMC, Vellore, points out that “it’s very hard to think of an Indian peak because we are seeing multiple peaks, starting with Mumbai, then Delhi and now in the south where the peaks are just beginning. Also, you may continue to have bumps in the downward curve depending on the containment measures or the lack of them by a particular state”. Mukherjee agrees with Kang that India experiences “cascading peaks” across major cities but points out that “Maharashtra has always been the driving factor in terms of number of cases and outbreaks. India’s curve follows the Maharashtra curve with a bit of a lag. What we are now seeing is a slowing down in the big cities.” She believes the declining curve would be symmetrical to the increase as infectious diseases do have a predictable pattern that can be statistically estimated. The curve, she believes, would follow the contours of a Mexican sombrero. The good news is the Union health ministry announcement on May 10 that it saw the early trends of a plateauing of cases and a possible decline in some major cities. But this decline has to be sustained for weeks before it can be recognised as the waning of the second wave.
WHO chief scientist Soumya Swaminathan, however, discounts projections that the Second Wave “will come down sharp just as it went up sharp”. She believes the diminishing of the Second Wave will be a prolonged affair (see interview: “I am worried about a prolonged second wave...”). Swaminathan points out that “predictions also depend on how interventions are being done. If there is a national lockdown for a couple of weeks, it will help bend the curve”. To illustrate her point, she cites how waves behaved in countries like the UK, US and Brazil. The UK, for instance, experienced several clear waves that subsided when the government implemented a lockdown but rose again when it opened up the country. In January, the UK imposed a prolonged lockdown and backed it with speedy vaccinations that covered much of its population. Swaminathan believes these measures will help
the UK in staving off huge waves next time around.
For the US, when the second wave came, the numbers shot up really high and even when it came down it settled at a much higher level of daily cases. But because of the recent massive vaccination drive, both hospitalisations and deaths are going down. Brazil, on the other hand, lacked a clear national policy and continues to experience peaks and troughs even in areas where it thought herd immunity had developed. A clear warning for India not to follow the Brazil ‘model’.
WORRY OVER MUTANTS
There is a known unknown that could upset the best of pandemic progression models. It is the ability of the virus to mutate into variants that can break through a person’s hard-won immunity even if he/ she has been vaccinated. While no major study has yet established that the newer variants were the cause of the Second Wave in India, they certainly played a large part in swelling it. The world over dozens of variants have evolved from the original Wuhan virus. Only four of them—originating in the UK, Brazil, South Africa and India, respectively, have been labelled by the WHO as ‘variants of concern’, capable of causing global havoc (see graphic: Understanding Covid variants).
In India, during the second wave both the UK variant and the so-called ‘Indian double mutant’ have been found in significant percentages in samples tested. While the UK variant was found active in Punjab, the Indian variant was widely prevalent in Maharashtra. Studies so far have shown that both these strains are far more infectious than the original virus. But in terms of mortality, ICMR’s Bhargava says so far there is no evidence to show that these variants caused a higher number of deaths or more serious illness. What they do show is that the use of oxygen for treating patients is higher by 6 per cent, as compared to the first wave.
Apart from the progress of the infection, the biggest concern raised by the new variants is whether the two vaccinations India is using, Covishield and Covaxin, are effective against the virus. This is especially because these vaccines, like many others, were designed and developed to combat the original Wuhan virus and not its variants, as such. The worry has grown after many people who had taken either the first dose of the vaccines or the second one subsequently got infected. Researchers across the world are studying how effective the vaccines are against the newer variants of Covid-19.
In India, ICMR’s National Institute of Virology (NIV), in a recent study, showed that Covaxin is effective against both the Indian and the UK variants. NIV director Dr Priya Abraham says, “The ICMR-NIV study shows that Covaxin neutralises variants of SARS-CoV-2 including the double mutant strain found in India. What this means is that while the vaccine may not always stop a person from getting infected it can prevent serious forms of Covid infection that could lead to hospitalisation and possibly deaths.”
There are reports from international laboratories that Covishield too is effective in neutralising Covid variants prevalent in India. As Shahid Jameel puts it, “The cat and mouse game between humans and the virus will continue for awhile. The second wave will go down only when a sufficient number of people get exposed and develop immunity by various means, or through stringent containment measures. The virus then stays in a reservoir of people, usually acquires a mutation to evade existing immunity and then attacks again.” He adds: “It is imperative that genomic surveillance is in place all the time in India. It can’t just be there by hindsight. The value of sequencing emerging variants early, before they start circulating in large numbers in the country, should not be underestimated. It will give us the capability to identify and handle the surge before it is too late.” With K. VijayRaghavan, the scientific advisor to the Indian government, stating that a third wave was now a given, Jameel’s advice becomes all the more pertinent.
DEALING WITH THE THIRD WAVE
Even as concerns about an imminent third wave grow, the strategy to combat it remains the same as in the second wave. The best way to get a wave of infection to subside quickly is to break the chain of transmission both through universal masking and by stringent lockdowns that mini
mise contact between individuals. Already 26 states in India have some sort of lockdown in place. This is beginning to bend the infection but the trend has to be sustained. Swaminathan says, “It is difficult because India is a very huge and heterogenous country. To put the whole country into a lockdown has lot of implications on the livelihoods of people. We need a nationally coordinated strategy that is based on clear, transparent criteria as to when to lock down and when to lift restrictions. These must be made publicly available, apart from establishing district-level monitoring of cases and ensuring adequate health infrastructure.”
Lockdowns do exact a heavy price in livelihoods, especially in India where the informal economy dominates and work from home is suitable for only a small percentage of the workforce. Gagandeep Kang says, “I am very reluctant to advocate lockdowns because of the human costs involved. But the wave has reached a stage where we have no choice but to stem the transmission by interrupting mobility and preventing people from coming in physical contact with others. It is important that during this period the government, NGOs and civil society support the most vulnerable sections. “
Experts say the strategy is the same as it was in dealing with the first wave: beef up medical oxygen supply and beds for patients with serious symptoms, apart from ensuring availability of key medicines to treat the disease. And ramp up the vaccination programme to cover as much of the population as soon as possible. Mukherjee says, “You have to solve the virus problem to revive the economy–ignoring it would the wrong thing to do. We have to a clear-cut strategy to rescue India. The government must candidly admit its mistakes and reassure the public that they are not going to drop the ball. That they are not going to shut down Covid care centres, oxygen production or be sluggish with vaccination. These may cost money but will in the long run prevent the economy from getting crushed and we’ll not have to see the humanitarian crisis we are now facing.”
EXPERTS ALSO advocate ramping up the vaccination strategy as a most important preventive measure against future serious Covid outbreaks. Giridhar Babu says that given our reputation of being the world’s largest vaccine manufacturer, the government should now go all out to invite international companies to come and manufacture Covid vaccines at Indian facilities, and to not just supply to India but export to the world. Babu says, “This is the opportunity for the Modi government to create a turnaround story and push the Make in India campaign more vigorously. It must pull out all the stops, spend money to get the best companies to come here, utilise our existing manufacturing capabilities and also set up new ones.” Gautam Menon says the top priority in the coming months must be to aggressively vaccinate the above 44 years age group where Covid mortality is highest as are serious illnesses.
Shahid Jameel is clear that “the third wave will come but no one can predict when. Its impact will depend on how many people are vaccinated, what sort of mutation the virus acquires between now and the third wave and how much we have improved our health infrastructure to meet the crisis as well as educate the people to adopt Covid-appropriate behaviour”. Kang agrees and says the key is to build surge capacity in health infrastructure that acts as an insurance policy against future waves. “That we will get multiple waves after this is certain,” she says. “But we don’t know if it will be a larger peak, and it could happen if the virus undergoes huge changes. But, in general, most viruses adapt after several years to becoming something like influenza which spreads easily but is less virulent.” Till such time, she says “India must never let its guard down again”. Sound advice. ■
EXPERTS CALL FOR A NATIONAL COORDINATED STRATEGY BASED ON TRANSPARENT CRITERIA AS TO WHEN TO IMPOSE AND LIFT RESTRICTIONS. RAMPING UP VACCINATION IS ALSO CRUCIAL