COVID-19 in India: False positivity amidst declining second wave?

The current trend of declining COVID-19 cases and deaths and the positive outlook the government is projecting on the pandemic situation in India are no guarantee that the nation will not confront another grim phase of the pandemic in 2021, especially since it is lagging behind in vaccine production and administration.

Mansukh Mandaviya assumes office as the Health Minister, in New Delhi on July 8.

AMONG the Union Ministers dropped from Narendra Modi’s Cabinet was Health Minister Harsh Vardhan, a doctor by profession. Mansukh Mandaviya, a relatively junior politician from Gujarat with no specific experience or qualification in health matters, replaced him. Such a drastic change in the midst of a pandemic could reflect several things. It was either an expression of the Bharatiya Janata Party’s unhappiness with Harsh Vardhan’s performance during the second wave of the pandemic or it was simply that he was made the scapegoat for the government’s abysmal failure to deal with the pandemic. It could also reflect some combination of a lack of seriousness about public health and a feeling that the possibilities of a serious challenge as posed by the second wave emerging again in the near future were extremely low. However, the pandemic is unlikely to give Mansukh Mandaviya the time to enjoy an easy settling down into his new role.

The positive outlook the government is projecting on the COVID-19 situation in India reflects an optimism not shared by the World Health Organisation (WHO). With the global death toll crossing four million, and Tedros Adhanom Ghebreyesus, the WHO’s Director-General, stating that these figures might be an understatement, the WHO does not believe that the last word on the virus has been said yet. In his biweekly press conference on July 2, Ghebreyesus said that “we are in very dangerous period of the pandemic” and that the Delta strain first identified in India was becoming the dominant strain in many countries.

In a briefing in the last week of June, he said that the variant had the potential to make the epidemic curve rise exponentially. Present in as many as 98 countries, the strain accounts for more than half of the new infections in countries such as the United States that have a relatively high vaccination coverage. At the July 2 briefing, Ghebreyesus also said that it was spreading in countries with “low and high vaccination” coverage. At the same briefing, Maria Kerkhove, the WHO’s technical leader for COVID-19 response, said that the virus had been evolving ever since it emerged. There were sub-lineages of the Delta variant that experts were tracking, she said, and urged countries to expand their genome-sequencing efforts.

Soumya Swaminathan, the Chief Scientist of the WHO, had said that a full course of vaccination was essential for immunity against the Delta variant. A multi-author peer-reviewed paper published in Nature on July 8 found that a single dose of either the Pfizer or the AstraZeneca vaccine was either “poorly or not at all efficient” against the Beta and Delta variants. It was only after the second dose that both vaccines generated a neutralising response that sufficiently targeted the Delta variant. The study assumes significance in the context of countries such as India where only a small proportion of the population is fully vaccinated.

The positive overall picture of the ebbing of the second wave of the pandemic appears to be continuing even as two months have passed since the daily case numbers peaked. In the latest full week (Monday, June 27, to Sunday, July 4) for which data was available at the time of writing, the total number of test-confirmed cases reported countrywide was 3,05,898. This was just over 11 per cent of the 27,36,971 reported in the week in which the weekly total had attained its maximum level (Monday, May 3, to Sunday, May 9).

The seven-day average of officially recorded COVID-19 deaths stood at 804 on July 8, under a fifth of the high of 4,190 touched on May 24. According to the July 6 media briefing of the Health Ministry, the number of districts in the country reporting more than 100 cases has dropped from 531 in the week ending on May 4 to 91 on July 4. These districts are mainly concentrated in Maharashtra, the southern states, Odisha and the north-eastern region. Only 73 districts reported a test positivity ratio in excess of 10 per cent. All of these trends are being interpreted to mean that the pandemic is now concentrated in a limited geography requiring “focussed attention”.

Behind the story of limited geography are fairly wide variations across States in the speed of both the rise and the reduction in numbers during the second wave of the pandemic. In Gujarat and the Hindi heartland States, including Delhi, the number of cases being reported daily is now minuscule. In most of them, the numbers in the week ending on July 4 were less than or around 1 per cent of those in the week ending May 9. Further, their weekly numbers of reported cases are already back to and even less than the very low levels they had recorded in the second and third weeks of February, which is when the second wave began. In other words, these are States or regions that saw sharp rises and falls in COVID cases, and their current low numbers may say very little about how high the next spike may go. In contrast, States such as Maharashtra and Kerala, despite their higher absolute numbers, had seen a second wave in confirmed cases increase at a lower rate and have also seen a slower rate of decline since the peak.

The southern States in general have shown a more moderate pace of decline since the peak than northern India. In all of them and in Maharashtra, the number of cases being reported is still some distance away from returning to its mid-February levels. Odisha and the north-eastern States are the parts of the country where the sharply rising trend in cases set in later than in other parts, and this lag is being repeated in their downward trend phase too. They are, therefore, even further from returning to their mid-February levels.

Pattern in variations

These variations across different parts of the country are following a pattern that was seen even in the first wave. There is also clearly another overall or aggregate pattern that is being repeated in the second wave: the downward graph in number of cases is not a complete mirror image of the rising part. During the first wave, the early declining phase of daily cases lay below the corresponding part of the mirror image of the rising graph but after a point of time it moved above. This has happened in the second wave too (see Figure 1). What this means is that while initially it appeared as if the number of cases would return to levels seen at the start of the wave faster than they rose, this did not last. In the first wave, this eventually meant that more cases were reported in the same duration of time after the peak than were reported before. The same appears to be the likely fate of even the second wave as the numbers after the peak have already crossed 86 per cent of the cases between February 8 and May 6, and the daily numbers are more than double the corresponding numbers in the mirror image.

A revealing comparison can also be made between the weekly totals of number of cases in the second wave from February 8, 2021, onwards and the first wave figures from June 8, 2020, onwards. As Figure 2 shows, the second wave numbers stayed close to the corresponding figures of the first wave for about six weeks and then started rising much more steeply. The second wave peak was more than four times that of the first wave but was reached in a period that was two weeks shorter. After another five weeks of moving downward, the second wave numbers once again resumed tracing the corresponding first wave path. If this pattern continues, it means that it will take a few more months for the numbers to come back to those in early February.

What these two graphs reflect are the similarities and differences in the movement of the rate of change in cases from one week to the next in the rising and falling phases of the second wave. As the table shows, initially the rate of increase in February and the first week of March 2021 was relatively slow, but there was a sharp acceleration thereafter and it again slowed down considerably in the last two weeks of the rising phase. In contrast, the downward journey from the week ending on May 16, 2021, was marked by a relatively stable rate of decline, but a sharp deceleration set in in the last two weeks. The midweek picture for the week that will end on July 11 indicates that the rate of decline could be even lower in this week. In other words, the numbers are not coming down as quickly as they rose and even at the pace at which they initially declined.

Therefore, even if no third wave sets in before that, it is likely that the second wave will take some time to play itself out. More generally, if past experience is taken into account, the current trend of declining cases and deaths and the supposed limiting of the geography of the pandemic in India provide no reassurance that the nation will not confront another grim phase of the pandemic in 2021. This is all the more so because the vaccine coverage of the Indian population does not appear to be destined to reach adequate levels quickly enough and there is the possibility of new variants reducing its effectiveness.

The third monthly update of the Global Commission for Post-Pandemic Policy on the worldwide production of COVID-19 vaccinations shows that India continues to lag behind in vaccine production. The country’s production increased to 120.5 million doses in June 2021, after having dropped to 62.6 million doses in May 2021 from the 76 million doses produced in April 2021. Yet, India’s share in global vaccine production in June was just 9.8 per cent and its share in worldwide production since the beginning dropped further to 11.8 per cent from over 13 per cent a month ago. The total of 397.6 million doses produced so far in India until June 2021 would not have been enough to administer even one dose to 45 per cent of the adult population even if no part of it had been exported. With 66 million doses having been exported before the ban on them came into effect, the vaccines available for administration in India until the end of June 2021 would have been around 332 million, or 33.2 crore. This is close to the figure of 33.6 crore vaccine doses that, according to the Health Ministry data, were administered until the end of June 2021.

In contrast to India (which has almost 18 per cent of the world population), the European Union (with a population less than a third of India’s) and the U.S. (with a population less than a quarter of India’s) had produced 598.8 million doses and 409.5 million doses respectively by the end of June 2021. It is not surprising, therefore, that the number of vaccine doses administered in India per 100 population stood at just under 26 as on June 7, while the E.U. and the U.S. had reached levels of 87.8 and 99.17 respectively, and the world average stood at 42.61.

Yet, on July 6, health officials were at pains to show how India had the largest and fastest vaccination drive in the world. Fallacious comparisons of absolute numbers in India were made with countries with much smaller populations. The fact is that as a percentage of the population the number of people in India who had received two doses of either Covaxin or Covishield was less than 5 per cent (4.8 per cent according to the latest data from Our World in Data), whereas in the U.S., 47 per cent of the population had received two doses. In terms of absolute numbers, the number of people who had received two doses in India was 66.89 million, whereas the corresponding figure for the U.S. was 157.91 million.

What is left out in these “international comparisons” are the figures for the only country with a comparable population size to India’s, namely China. With 59.3 per cent of the global production of vaccines in June 2021, 49.1 per cent of the total global production so far, and with 93.26 doses administered per 100 of its population, China appears now to be key to the vaccination of the world. Its exclusion from official Indian presentations may be on political grounds insofar as relations with China are strained and there may be a desire to avoid an unfavourable comparison with a “strategic rival”. However, it contributes to the distortion of the story of Indian vaccination that the government wants to indulge in for its own domestic political purposes. China, of course, has made a significant contribution to pushing the Asian average of vaccine doses per 100 population to 44.56, above the average for the world. In addition, other countries in the region—such as South Korea, Malaysia, Japan and Australia—that had been slow starters in vaccination compared with India have overtaken India in vaccine coverage per 100 people.

Mimicking the trends in monthly production, the number of vaccine doses administered in India rose in June 2021 after a dip was observed in May in comparison with April. If one takes changes in the total number of vaccines administered since the beginning in any period as the number of doses administered in that period, 11.97 crore doses were administered in June 2021. This was considerably greater than the 8.99 crore administered in April 2021 and the 6.11 crore administered in May. However, the entire difference between the April and June figures was on account of the vaccinations carried out in the last 10 days of June. The numbers increased suddenly when the Centre’s new policy came into effect (that is, it would procure 75 per cent of vaccines and the private sector would procure 25 per cent). These levels, however, have not been sustained. From a high of 6.23 million doses in the week ending on June 27, the seven-day average of vaccines administered a day fell to 4.1 million in the week ending on July 4 and looks set to drop even further in the week after that. It is clear that India could have vaccinated many more people by now, and if the vaccination drive has lagged, it is because the production and availability levels have been inadequate in relation to requirement. Unless this is addressed quickly, vaccinating the entire population will take a long time.

According to Anil Goswami of the Rajasthan Nagrik Manch, a non-governmental organisation working in the State, the 25 per cent vaccine allocation to the private sector was bad enough, but corporators were disbursing even the government-routed quota in favour of their constituencies and specific caste and religious groups. Camps were being organised in temple complexes, which led to people being excluded. Primary health centres and community health centres were not getting adequate quantities of vaccines, he claimed. People who had received the first dose 90 or more days earlier were not prioritised for the second shot.

Said Anil Goswami: “The ideal thing would have been to organise the camps in government medical colleges, schools or government community centres and not in places identified by corporators. Neither should religious communities be given charge of organising camps. A lot of favouritism is taking place as a consequence. The government ought to publicise information on vaccine availability and vaccine centres in newspapers, especially for the benefit of rural folk.”

The question of number of the dead arises again

The cataclysmic second wave prompted severe criticism of the government by the judiciary and the active intervention of courts in matters of pandemic management that would normally be in the domain of the executive. On June 30, a bench of the Supreme Court directed “the National Disaster Management Authority [NDMA] to recommend guidelines for ex gratia assistance on account of loss of life to the family members of the persons who died due to COVID-19, as mandated under Section 12(iii) of DMA [Disaster Management Act] 2005”. The Centre pleaded fiscal reasons for not giving compensation and also said that COVID-19 was not envisaged under the DMA.

The apex court ruled that it could not be disputed that COVID-19 was a disaster under the DMA and that the Centre had also deemed it a “notified disaster”. The court held that by not recommending any guidelines for ex gratia assistance on account of loss of life due to COVID-19, the NDMA had failed to perform its statutory duty. The court also ruled that deaths due to COVID-19 had to be stated as such in death certificates and official documents to enable the kin of those who had died from the disease to claim any relief they were eligible for. In addition to the financial implications of the Supreme Court’s judgment, compliance to it will once again bring into focus the question of the wide discrepancies between the actual number of COVID-related deaths in India and the official death figures.