One year of Covid-19: How India fought the virus
There are several ways to look at India’s Covid-19 year. On the face of it, it’s the story of a country battered by the world’s second-highest number of infections. The country’s 1.3 billion-plus people spent more fatigued weeks in a hard lockdown than most others and, in turn, faced one of the sharpest economic contractions seen anywhere in the world.
At least 11 million have contracted the virus, and close to 160,000 died due to it.
But, it is also a story of intrigue and, often, surprise. It has one of the lowest deaths rates seen in any large country and, leaving out trends that have become visible only in the latest fortnight, gone through only a single, gigantic wave of infections that appeared to be well-controlled by the country’s precarious health infrastructure.
In March of 2020, when the world first caught a glimpse of the devastation that the coronavirus would go on to unleash, experts feared India would suffer heavily as well. Tried-and-tested epidemiological models predicted 97,000-1.3 million infections by mid-May, to perhaps even 300 million infections by the end of the year.
But, largely, the worst of the fears did not pan out. During the highest of the infection peaks, hospitals appeared to be on top of the situation – unlike in New York or Milan. The season of festivals, which touches almost every region, religion and custom in the pre-winter months of October-November, led to spikes, but not of the nature seen in other parts of the world. “Reported cases mean very little in India. The estimated number of true infections from models as well as sero surveys is huge and point to about 20-25% of the adult population being infected. That is nearly 170-200 million infections,” said Bhramar Mukherjee, the chair of biostatistics at the University of Michigan School of Public Health.
Even if one takes this into account and looks at fatalities to calculate what is known as the infection fatality rate (IFR), she added, India’s story seems different. “Even if you believe not all deaths were reported, this points to a low IFR compared to the rest of the world,” she added.
India’s IFR is 0.1% and this number may be a better measure of an epidemic since deaths are more likely to be recorded than infections, particularly in the case of a disease like Covid-19, which infects many without symptoms. But, Mukherjee added, “41% of India’s population is in the age group 0-18, in which the infection rate is really low -- so the age-adjusted mortality does not look as low as the overall one.”
In the week beginning March 2, there were nearly 50 cases. The infected were not only those who had history of recent international travel, but, for the first time, were also people who picked it up locally. The month of March is crucial – not only because this is when the nationwide lockdown would come into force later – but because the most critical first step of a scientific response to an epidemic was missing: Testing.
It would not be until March 20 that authorities would allow a person without a travel history to take a Covid-19 test. But people would still be eligible only if they had symptoms, travel history or high-risk contacts – a condition that was relaxed in September.
The most effective intervention, then, was a crude one: the hard, 68-day lockdown that began on March 25. It was also unique since India was the only country that shut down while cases were still low, and actually surmounted the peak while reopening.
According to Mukherjee, the lockdown did not help stop transmission in the end but it “really helped us scale up health care”. “Testing became accessible and affordable, and isolation beds, ICUs, Covid care centres were set up. That helped reduce mortality. After opening up when cases surged and hospital beds were filling up, we were much more prepared,” she said, while adding that the hard lockdown also helped send a message of seriousness from authorities, “which was not the case all over the world.”
SK Sarin, the director of Institute of Liver and Biliary Sciences, headed Delhi government’s first committee on Covid-19 control and management. Having been on the frontlines in the fight in the Capital, he identified several things that helped eventually, but the first was to plan for infection surges: “Even in the initial days, we planned for situations in which 1,000 or even 5,000 cases were reported in a day.”
Then, he added, protocols were defined to manage the various ways in which the disease manifested. “We also worked on scaling up testing. ILBS had one of the biggest labs at that time with a capacity for conducting 1,000 RT-PCR tests a day. And Delhi was the first to set up the flu clinics in hospitals to check patients coming in for symptoms of Covid-19.”
But this was the story of Delhi, the country’s capital. An analysis of infection and fatality trends suggests India’s rural regions reported similar fatality trends as more urbanised regions, where health infrastructure is arguably better.
Mukherjee, who was among the dozen-odd researchers from three American universities who collaborated for the Crisis of Virus in India (COV-IND) study group, identifies the trends in rural India as particularly surprising. “I spent quite a bit of time in my parents’ farmhouse. In the villages they do not wear masks, and yet there were no severe cases that they could report. Our fear seemed like an urban myth or fiction to them. What happened there?”
The second question of intrigue is the dramatic drop in infections in India. The Indian Council of Medical Research (ICMR) in February released the latest nationwide sero survey that showed roughly four in five Indians was still vulnerable to an infection. Mukherjee described the end of the first wave as something that struck her, in addition to big festivals like Diwali and Dussehra not triggering major outbreaks. She notes that, as reflected in the sero surveys, which found higher exposure in cities compared to rural areas, the receding of the pandemic may perhaps be due to separate characteristics in these areas.
“I think the antibodies in metros/urban areas are still protecting us from massive surges, but we cannot wait too long. Rural India is a mystery to me. I believe it is a confluence of cross-immunity, genetics, lifestyle, lower obesity and heart disease prevalence and also a more outdoor lifestyle with natural air ventilation that helped villages,” she said, while adding: “I really want to understand why despite tourism and travel by migrant workers, the number of infections remained low in rural areas.”
Lalit Kant, the former head of epidemiology and infectious diseases at the Indian Council of Medical Research saw much progress in how India’s government and citizens have learned to manage the pandemic. “We have come a long way. This time in 2020, we did not know much about the virus or the treatment. There was an acute shortage of masks, PPE kits, sanitisers, and, when cases started rising, hospital beds. Many permutations and combinations of medicines were tried out and it took doctors some time to standardise the treatment, and this was happening across the globe.”
But now, he added, “testing has since improved, including the quality of tests available and people’s awareness about the disease and how it spreads has increased, even if precautions are not followed all the time.”
As the country turns the page on its first year of Covid-19, it will begin to open up the vaccination drive to its general public.
Experts see this as the most crucial objective now. “It has been a year of challenge, but it has also showed the power of science. But, the virus is likely to persist. While there wouldn’t be big outbreaks like we saw last year, summers in India is when there is indoor time (staying indoors increases the risk of transmission) and if we do not take precautions there could be an increase in the number of cases, said Anurag Agarwal, director, CSIR-Institute of Genomics and Integrative Biology. “Also, by the time the peak summers come, immunity will decline from last years’ outbreak leaving more people susceptible. Over the next six months we just have to vaccinate, vaccinate, vaccinate.”