What is driving India’s second Covid-19 wave?
We have seen miracles, and we have seen disasters. In September 2020, India came close to 100,000 Covid-19 cases a day, and it seemed an inexorable rise. And then magically, the cases started to dip, and with a few blips here and there in specific cities, by January, we were seeing fewer than 10,000 new cases a day. In February, the numbers starting heading up again, and we have now breached 100,000 new cases per day, the second country in the world to do so.
Why did this happen now? Why did the numbers escalate beyond what India had at its peak the first time? For the Sars-CoV-2, it does not take a lot of virus to infect another person. When people mingle, speak, shout and sing, they unknowingly spew out infectious virus. This clear mode of transmission is what makes masks, distancing and ventilation so effective. In September, we cared about prevention, and emerging from severe restrictions, were willing to do what it took to keep spread down. From then on, week by week, we have been slipping, first in some regions, then others, with some activities and then others. Crowding on public transport, in markets, at festivals, at family celebrations and during elections are back to being acceptable. The communication from the government and of experts seem to go unheard.
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This lack of appropriate behaviour that could prevent the virus’ spread has increased, and potentially been amplified, because of viruses that are more transmissible than the ancestral version of the virus that we had last year. We are still not clear about the proportion of B.1.1.7 or the United Kingdom variant, which spreads more easily and may cause more severe disease, and which has badly affected Punjab, and possibly other states.
The new Indian so-called “double mutant” variant is now the global lineage B1.617. But is this virus more transmissible? Does it cause more severe disease? Will vaccines work? These are questions that we will be able to answer if we can interrogate our health data and back it up with standardised laboratory investigations as in other parts of the world.
We have two vaccines that work well against Sars-CoV-2. Covishield had the advantage of large-scale clinical trials being conducted elsewhere that generated efficacy data quickly, requiring small scale studies in India. But it also has a disadvantage — the initial messy data about doses, intervals and age groups and miscommunication by AstraZeneca have led to confused messaging about how to use the vaccine. Covaxin has the advantage of tremendous support from the government of India but the disadvantage of needing to do large-scale clinical trials in India, never an easy task, given the lack of clinical research experience at many sites.
But the roll-out of vaccines, despite the fast-tracking of approvals, prioritisation frameworks, central procurement, efforts at preparedness for vaccination sites and sessions, establishment of process and development of the CoWin app, has been slow. The government originally planned to immunise 300 million people by June-July (later July-August), and this appears very unlikely if the pace of vaccination does not increase several-fold.
Are we in the same position that we were in during the rapid increase of the first peak in India? If not, what makes it different? From the serological surveys, between a quarter and one-third of the population has been infected but this is not evenly distributed by place and stratum of society; so those who had the ability to isolate last year and are not yet vaccinated, are more likely to get infected. But given that vaccines work much better than expected, it is not unreasonable to suppose that our immune systems are capable of handling this virus well. This means that previously infected people should expect some protection against severe disease for several months.
Additionally available vaccines provide some, not complete, measure of protection against most viral variants. If one-third of the population is already protected at least against severe disease, and we can ramp up vaccination quickly while continuing the measures that we know restrict the spread of the virus, then control is feasible, even with the new variants.
We know what works, but to use the tools we have most effectively, we need more detailed data. We are not in the same situation today that we were in last year, so control measures cannot be one-size-fits-all.
We need to know more about the people who are getting infected. Where are they from? Age? Gender? Vaccinated? Previously infected? Disease severity? If we have this information and can tie it together, we can achieve more tailored strategies for control instead of strategies that have an uncertain effect. What does a night curfew prevent and how effective is it? We don’t really have the data.
Yet, on the other hand, we are bombarded by news that affects vaccine uptake, for instance, “Doctors infected after vaccination”, “Healthcare worker in XX dies two days after vaccination”. Conveying both truth and uncertainty is important, as is explaining with facts that vaccines are not perfect, that care continues to be required when there are high numbers of cases in our communities, that we have a surveillance system for picking up vaccine side-effects, but it may not be always able to assess the relationship with the vaccines.
This is a challenging time, but we have the science to help us get through this pandemic and future ones. We need to use it, together.
Gagandeep Kang is professor, Christian Medical College, Vellore
The views expressed are personal