COVID-19: No endgame in sight

Amidst speculation of a third COVID wave, what remains missing are specific commitments to improve the quality of the public health response in India, and the periodic warnings seem like preparation for passing the buck on to the public should another wave hit the country.

Health workers aboard a ferry after a vaccination drive at an island in the Sundarbans area of South 24 Parganas district in West Bengal on June 25. At the rate of 87 lakh vaccinations per day, as India recorded on June 21, it would still take over 200 days to inoculate the adult Indian population.

OnJune 22, India’s official tally of COVID-19 cases crossed 30 million (3 crore) and the death toll reached close to the four-lakh mark. Set against the background of the loss to the economy, these figures point to the devastation the pandemic has wreaked on the country and a colossal public policy failure. Many experts are of the opinion that India’s GDP (gross domestic product) data may not even have captured the extent of the adverse impact of COVID on the unorganised sector. There is no official data indicating the loss of livelihoods or incomes in the unorganised sector because of the pandemic.

The serosurveys themselves reveal that testing in India has only captured a small fraction of the population infected by the virus. But the general consensus is that the data on test-confirmed cases indicate the trends accurately. However, official acknowledgement of the under-counting of deaths or its extent has not been readily forthcoming. ‘Excess deaths’ in many States compared with the pre-pandemic or 2020 levels, put together from the ‘official’ death registration data, are several times the official number of COVID deaths.

Contrast this with the situation in Kerala. On the face of it, Kerala has been one of the worst-affected States in India. It has the second highest number of confirmed cases in the country, after Maharashtra. Indeed, the number of confirmed cases per million population in Kerala is close to the levels seen in Brazil and European countries such as France and Spain, and higher than those in Italy or the United Kingdom. Yet Kerala has the lowest case-fatality ratio in the country and has recorded fewer deaths than most major States.

Further, it is one of those States which may be an exception to the trend of ‘excess deaths’. The mortality figures during the pandemic in the State have been lower than in the pre-pandemic period. In 2020, the death registration data revealed an 11 per cent reduction in all deaths compared with 2019. A more recent report on the situation in the capital Thiruvananthapuram during the second wave also shows a reduction in deaths compared with the pre-pandemic period.

What these point to is the high degree of accuracy of Kerala’s COVID figures, which is concomitant with the containment measures. The effectiveness of controlling the spread of the virus may have left a large number of people in Kerala unexposed and therefore vulnerable to the virus than in other parts of the country. This could explain the fact that the State has not seen a steep fall in the number of cases as elsewhere.

A large proportion of the population in India, many times more than the number of confirmed cases, has now acquired some immunity to the virus from the exposure to it. This might have naturally reduced the extent of the transmission of the virus, leading to a consistent downward trend in COVID cases in each of the six weeks from the week ending on May 9.

If such large-scale immunity has indeed been acquired, the downward trajectory in the number of cases is likely to persist even if COVID restrictions are eased. Along with increased vaccination over time, India could attain the threshold required to reach ‘herd immunity’ sooner than if it were to be dependent on vaccination alone.

Warnings of a third wave

Yet, no expert is optimistic of the future. Instead, almost all are pointing to the danger of a third wave. This could be because the course of the pandemic in India may in fact have created a situation where a large number of infected people coexist with a large population carrying antibodies. If the virus continues to sustain itself through transmission, even if at a lower scale than earlier, it will have opportunities to keep mutating. If this happens in an environment where a large number of people already have antibodies either through infection or vaccination, there is considerable scope for more transmissible strains or variants capable of bypassing immunity becoming dominant through natural selection. Any existing immunity from either vaccination or exposure to the virus need not be long-lasting and hence there is a great potential for a big home-grown outbreak or surge hitting India in the future. The risk is high because India will not be isolated from the rest of the world and the possibility of the transmission of infectious variants from or to India will remain.

Variants of concern

India has already seen the role of the Alpha and Delta variants, both categorised by the World Health Organisation (WHO) as ‘variants of concern’, in the making of the second wave. The Alpha variant (B.1.1.7), first discovered in the U.K. in September 2020, played a prominent role in the surge in cases in States like Punjab. The Delta variant (B.1.617.2) was first discovered in India in October 2020. The report on this variant on GISAID’s (Global Initiative on Sharing All Influenza Data) website records September 7, 2020, as the date on which the first of the 64,449 sequences of this specific lineage received from across the world until June 21, 2021, was found (in India). According to the site, it took several months before the Delta variant became the dominant strain in the country. In late March 2021, but more so in April 2021, the seven-day rolling average of the percentage of such variants in total sequences sampled climbed sharply. From 1 per cent in the beginning of March, it climbed to over 90 per cent by the end of April and the beginning of May.

The WHO’s COVID-19 Weekly Epidemiological Update, published on June 22, summarising the existing studies on the variant, notes that the Delta variant has not only greater transmissibility and a higher secondary attack rate, but makes the risk of secondary infections greater and lowers the efficacy of the existing vaccines.

The U.K., which is among the countries with the highest vaccination coverage (almost 110 doses per 100 population by June 21, 2021), has since the second week of May, been seeing a resurgence in the number of cases. Average daily numbers there have increased fivefold since then. This seems to be primarily driven by the Delta variant. Indeed, the 40,632 sequences of the variant submitted by the U.K. to GISAID during the end-May and June period are by far the largest number submitted by any country.

Significantly, according to evidence, the extent of the loss of efficacy of the currently available vaccines is not very large. However, this may not remain so as more mutations of the virus take place. Controlling the circulation of the virus and speedy vaccination of the entire population (not just in India but also elsewhere) are key elements to protecting India against another devastating wave. Neither of these appears to be happening to the extent needed.

A Delta plus variant has already made its appearance. According to a report released on June 23 by INSACOG (an Indian consortium of 28 laboratories conducting genome sequencing of SARS-Cov-2), the Delta variant with a particular mutation B.1.617.2.1 (AY.1) was identified in Maharashtra, Kerala and Madhya Pradesh. This variant included a K417N lineage of the virus which made it more deadly. This particular mutation was also present in the Beta variant (B 1.351 lineage), which had immune-evasion properties.

The report stated that even though the total number of Delta plus cases was low, around 40 so far, “its detection and distribution in various States over the past two months indicate that the B.1.617.2.1 (AY.1) is already present in some States, and States may need to enhance their public health response by focussing on surveillance, enhanced testing, quick contact tracing and priority vaccination in defined geographies where AY.1 has been detected”. The Delta variant was first detected in India and has been seen in nine other countries so far.

India’s COVID spread too is far from over. As many as 8.6 million (86 lakh) cases, or almost 45 per cent of the total number infected during the second wave until June 23, were reported after May 6, which recorded a peak of 4.14 lakh cases. The daily numbers reported now may look low compared with the peak level, but at over 50,000 cases a day, they are still higher than the numbers seen towards the end of March when the second wave was well under way. These were also the kind of levels seen in the third week of October 2020, a little over a month after the first wave peaked.

Unfortunately, with the number of cases dropping, efforts to control the spread of the virus are also tending to weaken. On the face of it, the number of tests done in the country has not fallen. The week that ended on May 2 recorded 12.33 million tests, the highest number in a week. The next week (ending on May 9) saw 12.10 million tests. In the subsequent six weeks, the number of tests reported countrywide were 12.67 m, 14.11 m, 14.33 m, 13.89 m, 13.22 m and 12.65 m, respectively.

It was only two months ago that people faced immense difficulties in getting tests done because of policy ineptitude and deliberate attempts to suppress numbers.

Vaccination story

India’s vaccination story is no different. On June 21, the first day on which the new vaccination policy came into effect, the government proudly reported that a record 87 lakh vaccination doses were administered on a single day. What this actually revealed was the yawning gap between the potential and the execution. Had India administered vaccines at this rate every day (which is still less than half the number being vaccinated daily in China), it would have taken just 154 days to administer 100 doses per 100 population. On June 22, 157 days into the vaccination campaign, the actual realisation stood at 21 per 100 population, reflecting the lack of availability of sufficient vaccine doses.

At the rate of 87 lakhs per day it would still take over 200 days to inoculate the adult Indian population. The first-day record has not been sustained thereafter and there is little reason to hope that vaccination in India will happen quickly enough to allow resumption of normal activities without the attendant risk of a third wave.

In a pandemic like COVID, it is important to study past and present experiences in order to prepare better for an uncertain future. In India, the failure to invest adequate resources or to enable the fullest use of data available has meant that its contribution to the global knowledge base on the pandemic, and particularly those parts of greatest relevance to shaping the response in India, has been woefully inadequate. It would prove costly if the country is not able to track properly how the pandemic is evolving and to nip in the bud the dangerous turns it might take.

The signals coming from India’s government, however, are mixed. On the one hand, it is unable to control its ‘euphoria’ about the ebbing of the second wave. Almost every official briefing is accompanied with the standard self-congratulatory note about how the private and the public had met the COVID challenge square on and how the percentage of “recoveries” was growing steadily and the decline in the positivity rate was nearing WHO norms. The 87 lakh vaccinations on June 21 were lauded as a “remarkable” achievement notwithstanding the fact that in the days that followed the numbers were nowhere near than figure.

V.K. Paul, member, NITI Aayog, and head of the national task force on COVID, admitted that if the virus mutated and changed form, no amount of planning could prevent that. Such mutations were “beyond our control”, he indicated.

There is a large body of evidence to suggest that vaccinations are a protective shield against the mutating Delta variants. Yet this aspect has been least emphasised in the government’s latest “five pillar” strategy: COVID appropriate behaviour, testing, tracking, treatment, and vaccination.

Caught off-guard by the devastating second wave, the Narendra Modi government is a little more reticent this time about declaring an early victory over the pandemic and is warning the public about the need to maintain vigilance. However, when a renowned pulmonologist from one of the leading medical institutions in the capital cautioned about the possibility of a third wave, another section of the medical establishment attempted to run him down, allaying fears of any impending wave. Apart from the problem of the mixed messaging this sends out to the public and increases the likelihood of deviation from ‘COVID appropriate behaviour’, what remains missing is specific commitments to improve the quality of the public health response in India. It is almost as if the warnings are just preparation for passing the buck on to the public should another wave hit the country again.