Omicron-fuelled third wave of pandemic

Omicron spread: Down but not out

Print edition : February 11, 2022

Balram Bhargava (right), Director-General of the Indian Council of Medical Research, with NITI Aayog member V.K. Paul at a press briefing on COVID-19, in New Delhi on January 5. Photo: PTI

A vaccination drive for those in the 15-18 age group, in Mumbai on January 22. Photo: PTI

During the weekend curfew in New Delhi on January 15. Photo: PTI

Data from metros show that the Omicron-led surge may be on the decline, but it is still too early to declare that the third wave has ended. It is time to exercise caution, and the government ought to study the issue in greater detail and prepare for the road ahead instead of congratulating itself on vaccination coverage.

The Central government’s response to the surge in infection caused by Omicron ever since the onset of the third wave, and communicating that response to the general public, has ranged, somewhat peculiarly, from absolute confusion to mild certainty. For weeks on end, its spokespersons and Health Ministry officials were reluctant to even admit that there was a third wave. They refused to categorise it as such and skirted questions from mediapersons. They were equally diffident in speaking against mass gatherings, given that representatives of the ruling Bharatiya Janata Party (BJP) and Prime Minister Narendra Modi himself were addressing rallies in the States where elections are scheduled to be held in February.

Balram Bhargava, Director General of the Indian Council of Medical Research (ICMR), was the only senior health official who was bold enough to state that “mass gatherings should be avoided”. On January 20, 2022, for the first time ever, the Union Health Ministry spokespersons referred proactively to a “third wave”, not once but several times. It was baffling that this was done after the third wave had progressed considerably and was expected to peak in the near future.

Declines in metros

Evidence from several metros suggests that the third wave peaked before mid-January and the number of daily confirmed cases of infection had begun declining almost as quickly as it had risen. Delhi, for instance, reported 28,867 “confirmed cases in the past 24 hours” on January 13, 2022, compared to the daily figure falling below 100 for several days around mid-December. This was the highest number of positive cases on any single day since the beginning of the pandemic, surpassing the previous high of 28,395 recorded on April 20, 2021, at the height of the second wave.

However, just four days after hitting this new record, on January 17, the number of positive cases reported in Delhi dropped by more than half to 12,527 and stayed around that number over the next three days.

The scenario in Mumbai was equally dramatic. According to the figures provided by the Brihanmumbai Municipal Corporation (BMC), the number of daily positive cases hit a high of 19,753 on January 7. On January 17 and 18, however, it reported only 5,892 and 6,064 cases respectively. The number rose to 7,717 cases on January 20, but this was after a dip on the previous day, a Sunday, to just 2,918 confirmed cases.

All-India rise

Notwithstanding such trends in some urban centres where the spread of Omicron was first seen, the all-India number of confirmed cases daily continued to rise, although the rate of increase appeared to have slowed down considerably. In the week ended January 16, India registered 16,72,526 cases, more than double the 7,84,845 cases recorded in the previous week. Further, in the first four days of the week beginning January 17, another 11,85,774 fresh cases were added to the country’s cumulative total; the number for January 20, 2022, was 3,47,254, the highest single-day number since May 11, 2021.

As Table 1 shows, while increased testing in January resulted in a rising graph, the trend is not a statistical artifact attributable to the increased number of tests. The number of tests has, in fact, lagged behind the spread of the infection, so the proportion of tests turning out to be positive has continued to increase.

The number of active cases, denoting the number of currently infected persons, has also been steadily rising, crossing the 20-lakh mark on January 20. Although this is a substantial rise from the below-1,00,000 figure that prevailed throughout December 2021, it is still only about 54 per cent of the highest figure reached during the second wave. The distance between the peak numbers of active cases in the second and third waves is still far greater than the one between the peak numbers of daily cases. For instance, the figure of 3.47 lakh on January 20, 2022, is almost 84 per cent of the all-time high ever reported in India: 4.14 lakh on May 6, 2021.

Also read: Omicron concerns rise in India

This difference illustrates that the rise in cases has been much faster in the third wave. The build-up of currently confirmed cases has consequently been over a much shorter time period.

If the number of new cases reported every day continues to rise, the active cases will also keep rising. However, if the number of new cases tapers off and starts declining soon, as several experts and models are predicting, then the number of active cases would also start dipping, with a lag, and will not reach the levels seen at the height of the second wave. The slowing down of the rate of increase at the all-India level appears to be consistent with such predictions. The implicit understanding behind these predictions is that the Omicron-driven waves record a sharp and swift rise in the number of people infected but the periods of “rise” are shorter in duration than those associated with earlier dominant variants such as Delta. Therefore, if these surges had started in different parts of the country at even slightly different points of time, there will be similar differences in the time when they peak, but soon enough each of them will exhibit the same pattern as seen in places like Mumbai and Delhi.

As soon as a sufficient number of regions start exhibiting declining trends, the all-India total will also head downwards and India has almost arrived at that point. However, there is still some uncertainty about how long the third wave will last.

Duration of the wave

Past experience shows that the downward journey of new cases takes longer than the upward one. The third wave could, therefore, still have some distance to go before the numbers return to pre-wave levels; and while that happens, a large number of new infections will still take place.

Secondly, there is the possibility of each surge being localised in relatively small and geographically concentrated clusters of the population but spreading to new and nearby clusters, a process that can stretch over a long time.

In the case of the Omicron surge, the upward trajectory of confirmed cases first showed up in other countries before making its appearance in India. In India, it started in some States and then eventually all States came within its ambit.

Health Ministry data shared with the media also showed that the number of districts showing test positivity ratios greater than 5 per cent also increased dramatically—from 78 on January 4 to 300 on January 11, and then from 335 on January 12 to 515 on January 19. .

This means that a majority of the country’s people are now in the variant’s ambit, but the extent of its spread or the percentage of the population exposed to it in these districts are not yet known.

In the case of the second wave, a sero survey conducted in June-July 2021 showed a dramatic increase in the proportion of the Indian population carrying COVID-19 antibodies: from 24.1 per cent estimated by the previous survey conducted in December 2020-January 2021 to 67.6 per cent six months later.

Moreover, it was also established that most of this increase could not be explained by the vaccination coverage achieved by then. The only logical explanation, therefore, was that the population infected during the second wave was very large. This also explained the cause of the eventual decline in numbers: the widespread immunity created by natural infections had reduced the proportion of population susceptible to the infection and this had also slowed down the transmission to the remaining vulnerable members. No such conclusion can, however, be arrived at regarding the present situation. There is no firm estimate of the actual spread and one must also reckon with the complexity of the changed situation compared to the Delta-led wave.

Also read: Understanding the third wave of the COVID-19 pandemic in India

On the one hand is the presumed higher transmissibility of the Omicron variant and on the other are the potential but uncertain counteracting effects of widespread immunity gained through past infection and vaccination, and potential differences between individuals with regard to the extent of waning of that immunity. The sharp and quick rise in cases could be an indicator of the Omicron variant being able to bypass that immunity by and large: if that is the case, there is no reason why the wave should end before it infects as large a proportion of the population as the second wave did.

It is well known that the numbers confirmed by tests are always only a tiny fraction of the actual number of people infected by the virus, but the magnitude of that discrepancy is not known. The ratio of actual infected numbers to those confirmed by tests during the second wave could be arrived at by a comparison of the confirmed numbers with the figures thrown up by the sero prevalence data.

No data on actual spread

However, whether the same ratio is applicable in the Omicron phase is not known. Adding to the lack of clarity is the fact that the government has not yet come out with any comprehensive data on how many of the new cases being reported are among those who are unvaccinated, vaccinated or with a history of past infection. It promised to present some data in this regard in the last week of January at its next press briefing.

There is reason enough to remain cautious before concluding that the third wave is coming to a quick end and there are additional indicators in support of maintaining such an attitude in the data itself. Gujarat was one of the earliest States where numbers rose in the Omicron phase while Kerala was one of the last to join that group. The number of daily cases, however, is still rising in both and has surpassed the highest numbers touched in the deadly second wave.

Apart from Gujarat, Kerala and Delhi, West Bengal, Assam and Tripura and the Union Territory of Jammu & Kashmir have already registered their highest number of daily infections since the beginning of the Omicron-driven surge. Several States are also close to that point. The number of cases being reported in Maharashtra is still some distance away from the peak of 68,631 on April 18, 2021. However, despite the waning of the pandemic in Mumbai, the State’s total numbers have resumed an upward trend after dipping for a few days, driven by the growth of infections in other centres.

In Karnataka, on the other hand, Bengaluru city has dominated the numbers throughout, consistently accounting for two-thirds or more of the State’s total cases. In the latest surge, unlike Mumbai or Delhi, Bengaluru has recorded a consistent rise in numbers, going past the second wave peak and pushing up the State’s total numbers (Figure 2). Most experts believe that the COVID deaths might have far exceeded official counts of mortality. A new study with epidemiologist Prabhat Jha as lead author, which was published on January 7, 2022, estimated the total number of COVID deaths in India since the outbreak of the virus in 2020 to be in the 31-34 lakh range, compared to the official figure of less than 5 lakh.

Reconciling mortality data

Globally, several countries have revised their mortality data, Peru being a leading example, but the Central government did not make any attempt to ascertain the real figures for compensation until the Supreme Court stepped in following a petition by a lawyer. It was after the second wave in April-May 2021 that the Supreme Court ruled that the family of anyone who had died within 30 days of testing positive would be entitled to ex-gratia compensation.

On June 21, it directed the National Disaster Management Authority to frame guidelines for giving compensation to the dependents of those who had died from COVID. On October 21, it further ruled that no State could deny payment to the kin of the deceased for want of a death certificate mentioning COVID as the cause of death. It directed the States to pay compensation to the kin of the COVID deceased within 30 days. In December, it reviewed the progress and found that several States had not paid compensation or that very few claims had been settled.

This indirectly brought to the fore the undercounting of deaths. Notices were sent to 17 States including U.P, Madhya Pradesh, Punjab and West Bengal for compliance reports. Since then, several State governments have been reconciling data. Kerala is the only State that has been regularly updating the backlog in its death toll, thereby resulting in an increase in the mortality numbers being reported daily by the State.

Compensation claims

On January 19, during a hearing of a petition (Gaurav Bansal & Ors), a bench of Justices M.R. Shah and Sanjiv Khanna pulled up Bihar and Andhra Pradesh for failing to disburse ex-gratia compensation to the families of the deceased. The bench expressed concern at the high rate of rejection of claims by Maharashtra, Gujarat, Tamil Nadu and Telangana. It directed that claims shall not be rejected on technical grounds, that claimants shall be given the opportunity to rectify their applications and that the reasons for rejection shall be sent to the applicants and to the grievance redressal committees that the court had earlier ordered to be set up.

The Bihar Chief Secretary told the court that the State had revised its mortality data and that the death toll was 13,250 as compared to the initial death toll of 3,737 compiled in March 2021. The State had received 11,095 compensation claims. When the court expressed surprised at the low number of claims as compared to other States, the Chief Secretary replied that it was because Bihar had the lowest positivity ratio during the two waves. The court did not buy this argument and observed that it was possible that the State had not reached out to the claimants or that the kin and family members of those who had died were not aware of the ex-gratia compensation. It directed the State to reach out to those claimants.

In the Supreme Court proceedings, it also transpired that while Kerala figured among the States with the highest settlement of claims, it was also the rare case of a State where the number of compensation claims received was less than the officially recorded number of deaths. The State’s counsel informed the court that the registered number of deaths in Kerala was 49,300. The government had received 27,274 claims, of which it had settled 23,652.

Also read: Omicron cases fuelling the surge in India’s third COVID-19 wave

The court recalled its previous orders where it had said that where the particulars of the deaths registered were with the State government concerned, the government ought to reach out to the families and make the payment. The Kerala counsel assured the court that such payment would be done within a week.

Maharashtra registered 1,41,885 deaths and received 2,17,151 claims. The government settled 1,02,771 claims and rejected 49,113 claims, for which it has to give an explanation to the court in the next hearing.

In Gujarat, there was a yawning gap between the official number of recorded deaths and the applications seeking compensation. Media reports had earlier mentioned the underestimation of COVID deaths and claimed that the death toll was almost 10 times the official figures.

Although the government had registered 10,094 deaths after the passage of the court’s initial order, it received 91,810 claim applications, of which 71,359 were approved and 5,169 applications were rejected. The reasons for rejection had been conveyed to the applicants and they were directed to approach the grievance redressal committee. Some 613 applications reached the committee.

As for Andhra Pradesh, as against 14,471 registered deaths, the government received 42,292 claims; of these 34,819 were found eligible while 6,400 were rejected. Of the total eligible claims, 23,835 claimants had received the payment while the remainder are to be paid in the coming days.

In the December hearing, the counsel for U.P informed the court that the State had registered 22,911 COVID deaths and received 16,580 applications. Of these, payment had been made to 9,372 claimants, less than half of the total number of official registered deaths.

A growing knowledge gap?

The limitations of India’s understanding of the pandemic’s trajectory in the country, an understanding that can probably guide future policy, are only getting exposed more and more at each stage of the pandemic. In addition to the uncertainties about the extent and nature of the spread of the Omicron wave among the Indian population are the uncertainties about the sources of its apparently less adverse effect compared to the second wave.

A total of 20 lakh active cases may not be as high as what was seen in May of 2021, but it is still a large number. When the same figure was touched in the third week of April of 2021, stories of people facing difficulties in getting hospital beds began emerging from across the country and the death numbers were also rising precipitously.

Nothing comparable has been observed this time, although hospitalisation numbers and deaths in January have both increased along with the rise in cases compared to December 2021.

At the Union Health Ministry’s media briefing, much was made of this very significant difference between the first and the second waves. The officials also highlighted the correlation between this difference and the difference in the extent of vaccination coverage—2 per cent fully vaccinated adults as on April 30, 2021, versus 72 per cent as on January 20, 2022.

Vaccination coverage

The government has been particularly self-congratulatory on its vaccination figures. The Health Secretary described the vaccination numbers as a “historic milestone”. However, many countries have vaccinated more than 90 per cent of their populations and are well on the way to administering the booster dose as well.

Also, the second dose coverage in several States is less than the national average of 72 per cent. They include U.P, Manipur and Punjab. Among the States where elections are due soon, only Uttarakhand has succeeded in giving both doses to 84 per cent of the adult population.

In an effort to dispel misgivings about the rising numbers, the Health Secretary shared data for Delhi during the January 20 briefing and said that even though positivity was high, bed occupancy was low.

NITI Aayog member V.K. Paul issued a note of caution in Hindi that the third surge was in full force and made special mention of certain States, mostly not ruled by the BJP, stating that they there witnessing a surge.

ICMR Director-General Balram Bhargava welcomed the trend of rising number of home tests, stating that the number had gone up from 3,000 in the second wave to 2 lakh in the third wave. However, it must be remembered that home tests were done by persons on their individual initiative and expense and were not the result of any screening or testing efforts by the government. Also, only those who were able to afford testing at home were getting it done.

The government has also not been able to provide an informed opinion on long term COVID-induced disability and morbidity. The government’s approach of pointing solely to vaccination coverage, while brushing under the carpet the public health system’s inability to prevent the quick spread of infection, also tends to overlook the difference between the nature of COVID variants. In fact, it is possible that the low mortality and hospitalisation rates in the current phase could be attributed to the less virulent nature of the Omicron strain itself. (Indeed, the supposedly ‘milder’ nature of this variant had even been a reason for the lack of urgency in taking measures to control its spread, despite the devastating experience of the second wave.)

The government has not been able to provide clear answers on these issues.

Two main scenarios

The answers are important to understand the road ahead, because multiple future scenarios can emerge out of the present. At one end of the spectrum is a scenario defined by a combination of two things. One, all future dominant variants of the COVID-19 virus will be mild even if they are capable of bypassing immunity and infecting large numbers of even the vaccinated. And two, vaccination will continue to provide a persistent high level of protection against severe disease.

If both of these hold, one can effectively assume that life can go back to normal soon and the only significant thing left to be done as far as public health measures are concerned is completing the vaccination programme. Achieving that target is only a matter of a few months, given that 72 per cent of all adults are fully vaccinated, and another 22 per cent have received their first dose, along with 52 per cent of those in the 15-18 age group.

Even a small change in this scenario, such as introduction of the possibility that immunity to COVID-19 is not permanent, may require major changes in the strategy to contain the virus; for instance, repeated doses of the vaccine.

At the other end is what might be called the worst case scenario. In this, future dominant variants more lethal than Omicron may appear and bypass infection and vaccine-induced immunity, in addition to the waning of immunity and its ability to reduce severity of disease.

Neither of the two elements of this scenario have been ruled out by experts.

Such a scenario will require a much more comprehensive response that involves advance planning, preparation and investment.

By evading the lessons of the pandemic and through our unwillingness to learn from the experience so far, we run the risk of repeating the failures of the past, possibly on a larger scale with even more devastating consequences in the future.