IN the first week of November, even as India recorded 47,000 new cases within 24 hours and the total active cases stood at 500,000, the country’s health establishment let out a collective sigh of relief. This was the first time since the pandemic began that the all-important R0 (pronounced R-naught), a measure of how contagious an infectious disease is, had dropped below 1 (it was 0.88 on November 6). In a pandemic, an R0 value of less than 1 indicates that the virus is going to eventually stop spreading since it cannot infect enough individuals.
India’s R0 value in November had foretold the eventual fall in Covid cases. Active cases began to drop steadily and the pandemic curve turned downward for the first time. As more people recovered from Covid and fewer got infected, states began to lift restrictions. For a while, it seemed the pandemic was nearing its end. But come February 11, and the curve turned the other way. The number of new cases per day began rising by the hundreds. By early March, roughly 1,500 more cases were being added every day than during the lows in February. With most cases being reported from Maharashtra, health secretary Rajesh Bhushan declared the state was experiencing a second wave of Covid. Soon, similar spikes hit several other parts of the country.
Between March 14 and 22, Covid cases in India jumped 150 per cent. Around 130,000 new cases were added in three days alone and the daily count of 47,009 on March 21 was the highest yet in 2021. India’s daily cases are now the third-highest, after the US and Brazil; the ‘R’ value of 1.32 is the country’s highest since April 2020. The positivity rate is also rising, from 1.6 per cent of samples testing positive in February to 5 per cent on March 22. The positivity rate in 13 states is higher than the WHO scare benchmark of under 5 per cent. It is 13.6 per cent in Maharashtra and 8.7 per cent in Kerala.
Data from the Union ministry of health and family welfare (MoHFW) suggests a fresh surge across the country. Since March 1, 70 districts have seen an uptick of about 150 per cent in their case load. Delhi’s daily Covid count of 800 on March 21 was its highest this year, just as the 1,640 cases in Gujarat the same day were the highest ever to be recorded in the state in a single day. Tamil Nadu’s 1,385 cases on March 21 were the highest since December 14; the same day, Rajasthan saw 602 cases, the highest since January 1.
The surge has but naturally left the government apprehensive. On March 17, Prime Minister Narendra Modi called the rise in Covid cases as the start of a ‘second wave’ and urged all states to step up testing, create micro-containment zones, and step up the vaccination drive. “Our confidence should not become overconfidence. Our success should not turn into negligence. We have to stop the second wave,” he said.
Where are the masks? Shoppers at Delhi’s Khari Baoli market
MUTATIONS to blame?
Two broad reasons are being cited to explain the surge in cases. First, Covid variants from the UK, Brazil and South Africa, which are known to be more infectious than the previous strain of the virus in India. The possibility of a new homegrown variant is also not being ruled out. After a UK variant was detected in January, the Indian government increased genome sequencing. Ten institutes, including the Hyderabad-based Centre for Cellular & Molecular Biology (CCMB), were tasked with sequencing about 5 per cent of all samples in India. Around 7,000 variants, with 24,000 mutations, have so far been found in India, but none of these mutants increases infectivity or the severity of symptoms.
On March 23, an analysis of 401 samples sent from Punjab to the National Centre for Disease Control (NCDC) found 81 per cent of them testing positive for the UK variant of the virus. Punjab, as on March 24, had the third highest number of active cases in the country and the highest case fatality rate (CFR), the proportion of deaths among total individuals infected.
A study by the Imperial College London found the new strain in the UK to have an ‘R’ value of 1.45, while it was around 0.92 for the previous strain. The new strain is far more infectious, and those infected by one strain can get re-infected by another and transmit it. In all likelihood, a second infection from a different strain will result in mild to moderate symptoms. According to CCMB director Dr Rakesh Mishra, mutations by themselves aren’t causing the spike. “We need to study a larger number of samples over a longer period to ascertain if the new variant or a homegrown variant is causing the infections,” he says.
Several health experts, including virologist Dr Gagandeep Kang and AIIMS Delhi director Dr Randeep Guleria, have emphasised the need to scale up India’s genome sequencing capacity. According to Dr Kang, there is no other way to rule out another big wave in the future triggered by more infectious Covid variants. Adds Dr Mishra: “All new strains can be kept at bay if people adopt Covid safety measures, mask, social distancing and hand hygiene.”
The spike in Covid cases could also be due to sheer public complacency. From attending large weddings and crowded public functions to heedless crowding in malls and marketplaces, the general public has been quite lax about adhering to basic safety protocols. It’s a mistake made by several countries, such as the UK, the US, Brazil and Germany. “States are no longer following the test-track-treat strategy. People are also roaming around without their masks on, and there’s little social distancing,” says Dr Guleria.
At New Delhi’s Max Super Speciality Hospital, beds in the Covid ward have again started to fill up. “The young are getting more infected this time around. This is largely due to the opening up of inter-state travel and the slack in following Covid precautions,” says Dr Vivek Nangia, head of pulmonology and respiratory medicine at the hospital. “Vaccines have also given people a false sense of safety.”
Health experts caution that the Covid virus is too resilient to risk laxity. “Just when you think you have defeated the virus, it makes a comeback. Covid is infectious; if you do not take precautions, it will continue to infect,” says K. Srinath Reddy, president, Public Health Foundation of India (PHFI), New Delhi.
WHY IT’S WORRISOME
Although India’s Covid death toll remains one of the lowest in the world, doctors say the surge in cases alone is cause for worry. “Covid cases reported in the past few weeks have been mild, leading to the notion that the viral symptoms have reduced. Since more young people are getting infected, the symptoms are less severe,” says Dr Nangia.
He adds that the clinical management for moderate Covid remains a combination of remdesivir and steroids, and the latter in particular leads to blood sugar and blood pressure complications if the use is prolonged. “Treating someone with Covid is tricky. The virus isn’t to be taken lightly at all. You may not die from Covid but can get very sick,” warns Dr Nangia. “Inflammation is a huge problem. A patient of mine who got infected in April 2020 returned for treatment of blood clots in January this year.”
More recently, the Max Super Speciality Hospital had to restart treatment for blood clots for a patient who had been discharged, apparently fully cured, two months earlier. “One needs to constantly monitor certain indicators of inflammation in the blood. Blood clots if not spotted are extremely dangerous as they can travel to any organ and cause stroke, heart attack and so on,” says Dr Nangia.
Those who survive the severe symptoms may have to live with scarred lungs. “Even climbing stairs becomes difficult once your lungs are compromised. So it isn’t just about surviving Covid. It impacts your quality of life, causes stress and [can add to your] financial burden,” says Amrita Singh, a 43-year-old Noida resident who recovered from severe Covid a month ago.
Those with mild symptoms have to grapple with ‘Long Covid’, or the protracted effects of the virus, even long after recovering from the initial illness. In the latest medical studies examining Covid’s impact on the respiratory tract, Oxford University and Sheffield University researchers studied 10 patients with no lung damage in conventional health scans, but eight of them suffered from shortness of breath and extreme fatigue. MRI scans found that three months into recovery, these patients had signs of lung damage that traditional scans could not have spotted.
“Lung tissue is extremely delicate and takes time to repair. Once Covid impacts the lungs, it damages vital tissues and cells, even if your body has fought off the virus and you have survived,” says Dr Rajesh Chawla, a pulmonologist at Apollo Hospital, New Delhi. “In Covid treatment, it is important to ensure that diagnosis and treatment happen on time.”
CAN VACCINES SAVE THE DAY?
As cases rise, the government is ramping up its vaccination programme. From April 1, all individuals above 45 years of age will be eligible for the Covid shot. As on March 23, more than 48 million people had received at least one dose of the Covid vaccine. But logistical, safety and dosage issues remain. For example, at the Rajiv Gandhi Super Speciality Hospital in New Delhi, despite increasing their vaccination booths to six, each capable of administering 200 doses a day, the hospital received enough vials for just 200 doses on March 22. Authorities have noticed that a dearth of trained vaccinators is resulting in a lot of wastage. “A trained vaccinator can draw the right number of doses from a vial. Those nervous while administering the dose end up wasting a large amount of the vaccine,” says a vaccinator at the Lok Nayak Jai Prakash Narayan Hospital in Delhi.
Meanwhile, around a dozen European countries have said they will resume administering the AstraZeneca vaccine (Covishield in India) after the European Medicines Agency (EMA) declared that its initial investigation of possible side-effects had shown the vaccine to be ‘safe and effective’. It is hoped that the move will have an encouraging effect in India where vaccine hesitancy remains high.
The Indian government has increased the gap between the two vaccine doses to 6-8 weeks, from 4-6 weeks earlier. An analysis of phase 2 results in the UK, Brazil and South Africa found vaccine efficacy improving to 59.4 per cent, from 54.9 per cent, if the second dose was given 6-8 weeks after the first one; to 63.7 per cent if it was given 9-11 weeks later and 82.4 per cent if given after 12 weeks. However, a government panel said there wasn’t enough convincing data to increase the gap between the two doses to more than 8 weeks.
Two months into the vaccination drive, cases have emerged of recipients getting infected. Dr Farah Ingale, an internal medicine specialist at Fortis Hospital in Navi Mumbai, had taken both doses of Covishield. She developed high fever and bodyache on March 26 and tested positive for Covid. “I was surprised to find myself infected even after vaccination. It is important to realise that it is still too soon to stop taking Covid precautions. The vaccination drive is still too slow to give the kind of protection needed,” she says.
In Germany, which has already seen two sharp waves of Covid, a third one is now beginning and leading to fresh restrictions. In India, a similar situation was observed on a smaller scale in Delhi last Diwali. Health experts caution soberingly that the only things that will keep the Covid curve down are following the safety norms, wearing masks, hand hygiene and social distancing.
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