COVID: Too soon to say the worst of the pandemic is behind us

The number of cases and deaths due to COVID-19 may be low at present, but it is too soon to conclude that the crisis is over. There remain at least three issues of concern: the durability and the nature of the immunity that exposure to virus has conferred on people and what future variants will be like.

Outside a vaccination centre at Tilak Nagar in New Delhi on April 10, the day the option of a third dose of vaccine, officially termed a “precaution dose”, opened for the 18-59 age group but entirely through the private sector, meaning on payment.

WITH the war in the Ukraine grabbing most of the headlines, the COVID-19 pandemic has clearly ceased to be the number one news item at the global level as it had been for a lengthy period of time until recently. Much the same can be said of India too where in addition to the military conflict several hundreds of kilometres away, many domestic matters have started occupying the attention of the media. An important factor in this has of course been the course of the pandemic itself.

The World Health Organisation’s (WHO) COVID-19 Weekly Epidemiological Update published on April 12 states: “[D]uring the week of 4 through 10 April 2022, the number of new COVID-19 cases and deaths has continued to decline for a third consecutive week, with over 7 million cases and over 22,000 deaths reported, a decrease of 24 per cent and 18 per cent respectively, as compared to the previous week.” The declining trends are notably a feature shared by all regions of the world. The WHO, however, warned, that these figures should be interpreted with caution as they may reflect a reduction in the number of tests being conducted as countries are changing their testing strategies. However, the following additional statistic inspires confidence: the average daily COVID-19 deaths being reported worldwide are lower now than they ever have been in the past two years.

The Indian situation, too, had been looking positive in the past two months, better than it has been in a long time. The all-India numbers of confirmed cases and deaths had been consistently declining during this period. In the week that ended on April 10, the daily cases averaged around 1,000 and the deaths at just above 5. Although the number of tests being conducted has dropped considerably, the positivity ratio has remained at very low levels, so reduced testing may be more an effect than a cause of low numbers. The current levels of confirmed cases and deaths have, in fact, not been seen after April 2020.

The numbers have dropped to such low levels that the scope for them going down any further is almost non-existent. It is because of this that it is a little hard to interpret the latest figures from some States/Union Territories such as Delhi, Gujarat, Haryana or Ladakh, Manipur, Meghalaya and Sikkim where the number of confirmed cases in the week that ended on April 10 was higher than in the previous week. At this stage it cannot be said with any degree of certainty that this marks the onset of another wave. As the numbers are still very low, it is entirely possible that the higher figures are just some fluctuations around a rock bottom–like average. However, there is at the same time no reason to dismiss this trend as a false flag. In other words, any conclusion at this stage would be premature.

The recent rise in cases in some parts of the country comes against a background of a growing feeling that the odds are in favour of the worst being behind us and it is only a matter of time before the pandemic is consigned to history. There has been no indication from the WHO that it is on the verge of declaring the pandemic over and neither have Indian authorities put out anything officially to that effect. Yet, no serious effort seems to be under way to dissuade people from underplaying the threat from the virus. This is important because at least three issues of concern about the future course the infection will take continue to linger in the absence of any conclusive evidence to settle them in one direction or the other.

The first is the question of the durability of the immunity acquired through exposure to the infection or vaccination: if it is something that lasts for a long time, most Indians today can be said to be reasonably safe as they have not one but two sources of immunity. In many parts of the world, particularly in the West, the recorded number of confirmed cases of COVID-19 infection since the beginning of the pandemic has reached very high levels, close to or more than 25 per cent of their populations. By this metric, the incidence of the COVID-19 infection in India would be among the lowest even in Asia, with total test-confirmed cases standing at a level of just over 3 per cent of the population.

About 99.5 crore Indians vaccinated

However, the sero-surveys the Indian Council of Medical Research (ICMR) conducted before the vaccination programme reached a large number of people estimated that 67 per cent of Indians had acquired antibodies through exposure to the infection by the middle of 2021. It would be reasonable to surmise that this number would be considerably greater by now. The vaccination programme has also reached a large section of the population. About 99.5 crore Indians across all age groups have received at least one dose of a COVID-19 vaccine. Of them, 84.1 crore have also received their second dose and about 2.5 crore have received a third precautionary dose. If the immunity acquired through this combination of infection and vaccination is something that lasts, then much of the concern going forward will primarily be with the post-mortem of India’s experience with the pandemic. This would include counting accurately the losses incurred and to derive public health lessons that would help prepare the country better for the future. However, if there is any serious danger of the immunity waning, then immediate attention has to be focussed on boosting immunity through additional vaccination and on deciding the question of what should be the appropriate vaccine for this purpose.

Unfortunately, the Indian government still seems to be pursuing the approach of hoping for the best and being reactive rather than proactive. The recent decision to open up the option of a third dose of vaccine, officially termed a “precaution dose”, for the 18-59 age group reflects this. It was not too long ago, in November 2021, that Dr Balram Bhargava, ICMR Director General, asserted that the evidence did not warrant administration of a booster dose to fully vaccinated people. Since then, experts from ICMR bodies or institutions have said that evidence indicates that immunity wanes in six to eight months, and therefore all adults should get a booster dose.

Results have been presented suggesting that mixing vaccines produces better results than the homologous approach (the same vaccine). The government’s final decision announced on April 9, however, ends up being neither here nor there. Only a homologous administration of the precaution dose has been recommended, and these are to be done entirely through the private sector, meaning on payment.

That the precaution dose is not going to be available free of charge through the government’s own system introduces a fundamental inequity in the programme. Any protection through vaccination will be available only to those with the ability to pay for it. Moreover, the limited reach of this round of vaccination, where many are not receiving the dose, may not even make sense from a public health perspective. Yet, without offering it free of charge, the government is in no position to go around encouraging people to take the precautionary third dose.

Future outbreaks cannot be ruled out

The second issue relates to the nature of the immunity. That vaccination has been protective more in the sense of preventing severe illness rather than in preventing infection and transmission seems to be the generally accepted proposition now. Instances of people getting infected more than once are no longer as rare as was originally thought to be the case. Thus, that there will not be any major future outbreaks of COVID-19 because of some kind of “herd immunity” is not a conclusion that can be made. This does beg the question which combines with the possibility of waning immunity, can individuals be assured of protection from severe illness in the future if they have been vaccinated earlier or suffered the infection? No one can answer emphatically in the affirmative. Whether a third dose of the same vaccine will make any difference is also not certain. As vaccination is being extended beyond the standard strategy of two doses each to the entire adult population, it is entering greyer and greyer areas.

The third source of great uncertainty is the likely direction that the evolution of the COVID-19 virus through mutations will take. According to the WHO, it is the Omicron variant that is now the overwhelmingly dominant strain of the virus across the world. The Weekly Epidemiological Update says that this variant accounts for 99.2 per cent of the 3,79,278 sequences reported to the GISAID (Global Science Initiative that provides open access to genomic data of influenza viruses) from samples collected in the past 30 days. The organisation is also monitoring several descendant lineages of the Omicron variant of concern, including the recombinant form XE, to assess their characteristics and public health significance. In addition to this is the danger reflected in the history of the Omicron variant itself.

Writing for the Global Commission for Post-Pandemic Policy, the economist and physicist Dylan Barry points out that the Omicron variant is not a direct descendant of the previously dominant Delta variant, and one of the hypotheses about its origin is that it developed from the original variant over a long time in an immunocompromised patient in Africa with a chronic infection (which is why it had so many mutations). One implication of this is that the fact that the Omicron variant has been less severe in its effect cannot be seen as evidence of the COVID-19 virus evolution moving into a stage where it is becoming benign. On the other hand, the possibility of new and more dangerous strains developing through the same kind of process exists, especially since a large part of Africa remains unvaccinated and it does not seem that this situation is likely to change soon.

The COVID-19 pandemic exposed chinks in the armour of the world community. A terrible price has already been paid because of the inability of political leaderships across the world, including our own, to unite their own societies and other countries in the struggle to vanquish a dangerous and common enemy. With the Ukraine crisis further exposing the fault lines in the “world order”, the prospects of a common struggle against COVID-19 have become even less likely. In India, complacency about the pandemic coexists with the government promoting an increasingly strident and virulent version of its polarising politics. The COVID-19 virus is not a conscious being that will smell in these circumstances an opportunity to mount a fresh and decisive assault, but no one can rule out the possibility of another round of suffering at the hands of this “weapon of mass destruction”.