Second surge of COVID-19 rocks IndiaApril 10, 2021
A fresh wave of SARS-CoV-2 infections is pushing the case counts across India to record highs even as the authorities vehemently deny the role of any mutant variant behind the sudden surge.
The country’s COVID-19 case numbers are peaking at an alarming speed after five months of continuous decline.
The daily case numbers rallied past the 72,000 mark on the final day of March, setting new records for single-day spikes while doing so. The daily national infection number had been hovering around 10,000 till the 2nd week of February when all of a sudden, the numbers started to rise.
Initially led by Maharashtra, other states too have joined the trend. Punjab and Gujarat have already registered their highest single-day numbers ever. Chhattisgarh, Madhya Pradesh, Tamil Nadu, Karnataka, and Delhi also started showing noticeable increases.
However, the numbers are still modest in some of the most populous states like Bihar, Uttar Pradesh and West Bengal as of March. What is worrying is the fact that several states are gearing up for legislative assembly elections, including West Bengal, Kerala, Tamil Nadu and Assam, and huge crowds can be seen attending political rallies.
What concerns experts the most is the much faster pace at which the infection is spreading. This time, it has taken hardly ten days to double the case count from 30,000 to 62,000 per day, while it had taken more than four weeks during the first phase.
Looking at the faster rise in infections, experts fear that the new wave could be fuelled by more virulent strains of the SARS-CoV-2.
Last year, the UK saw the rise of a new variant, B.1.1.7, at a time when the number of new COVID-19 cases was shrinking by as much as 4% a day. The strain is said to be up to 70% more transmissible than the previous strain. First seen in Britain in September, it already accounted for 62% of all COVID-19 cases in London by December.
Similarly, last December, when South Africa declared a second wave, over 95 percent of the reported incidences were caused by a variant called B.1.351.
In Brazil too, the second surge in March this year has been attributed to P.1, a more contagious variant of the virus, also known as the Brazil variant.
All three mutants — considered variants of concern (VOC) — have been reported at various places in India as well.
Recently, Indian SARS-CoV-2 Consortium on Genomics (INSACOG) has reported a new “double mutant” variant.
According to an INSACOG statement, an analysis of samples from western Maharashtra showed an increase in the E484Q and L452R mutations compared to December 2020. These mutations, which may confer immune escape and increased infectivity, were found in 15-20 percent of the samples.
E484Q mutation is known to be similar to E484K – a mutation seen in the B.1.351 (South Africa) and P.1 (Brazil) variants, which have emerged independently several times. The L452R mutation found in the “double mutation” was first identified as part of B.1.427/B.1.429 lineage in the US, also known as “California variant”.
From a total of 10,787 COVID-19 positive samples across the country, INSACOG detected 771 VOCs. Among these VOCs, 736 samples were positive for the UK variant of the novel coronavirus lineage; 34 samples were positive for the South African (B.1.351) virus lineage; and one sample was positive for the Brazilian (P.1) virus lineage, according to the Union Ministry of Health and Family Welfare (MoH&FW).
Even though many reports claim that the new “double mutant” variant may be driving the new surge in COVID-19 cases in India, experts see no tangible evidence to substantiate that the double mutant is causing the new surge.
“We do not have a definitive link between the double mutants and the rise in cases,” comments Dr Gagandeep Kang, Professor, The Wellcome Trust Research Laboratory Division of Gastrointestinal Sciences, Christian Medical College, Vellore. She points out that we will require much more detailed sequencing data and careful local epidemiology to establish that. However, she adds, the finding that 80% of Punjab sequences contain the UK mutant is worrying.
Dr Kang’s view is also shared by Dr Vineeta Bal, former Staff Scientist with the National Institute of Immunology, New Delhi. While there is a very rapid increase in the number of COVID-19 cases across India, the exact reasons for such an increase are hard to state, despite the discovery of a double mutant.
“Firstly, these cases are mostly NOT of reinfection, but first-time infection. Most of them are also not vaccinated, so there is no real vaccine failure so far. Thus, the virus is affecting the susceptible, naive population, “ she avers.
Secondly, while there are reports in tens and hundreds of various mutants of SARS-CoV2 reported officially, the numbers are very, very small to start talking about any direct cause-and-effect relationship. From a public health perspective, a much higher frequency of the virus variant needs to be reported based on an epidemiologically sound sampling. So far, such details are scanty, at least in the public domain, she points out.
The third reason, according to Dr Bal, is the abysmally low vaccine coverage of the population so far, even though the number of vaccine recipients is increasing. India is a highly populated country and the solid infrastructure needed for carrying out a mass vaccination programme to cover 40-50% of the population is a very, very tall order. It is not clear whether the inability of the government to procure and supply adequate dosage of vaccine to every place in the country is also contributing to low coverage, she says.
India’s health authorities have also denied that the spread is due to double mutations. But experts are of the view that it would be difficult to establish or negate this fact without testing.
“Because the testing is low, it would be difficult to definitively say that the spread is because of the mutations,” opines Dr Shivkumar Utture, President, IMA, Maharashtra.
What you have to understand, he says, is that for every positive patient, we are missing out on nine to ten positive patients who are asymptomatic or have minimum symptoms and are roaming about. Hence, the mantra of maximum testing remains, he asserts.
However, according to Dr Utture, what we have to achieve is a test positivity rate below 5%. The rate has been as high as 20% in the past. It remains around 13% even today. That has to come down and for that, we have to do enough testing, isolation, quarantining etc and break the spread of this disease somewhere.
But Dr A M Deshmukh, President, Microbiologist Society of India has a different take on this. He says the government is holding back its comments because until now, no study has been carried out to understand the correlation between the new double mutant strain and the spread of the disease. At present, there is only probability. So, the government is not making any comments. “We cannot also come to any conclusion, but surely there is a strong probability that it might be due to it,” he says.
Clearly, as of now, there is no data to confirm that the double mutant, or any other, variant is causing the rapid rise in cases.
“It is still early to attribute this second wave to the double mutant strain reported from India,” concurs Dr V Anil Kumar, Clinical Professor & Head, Microbiology, Amrita Institute of Medical Sciences, Kochi.
The double mutant reported from India — harbouring E484Q and L452R mutations — has already been classified as a “variant of interest” (VOI) and an increase in transmissibility and virulence needs to be documented to make it a “variant of concern” (VOC) like the UK variant, he clarifies.
Leading microbiologists like Prof Anil Kumar favour the view that the current surge in infections may be due to multiple factors like poor adherence to COVID-19 protocols. The original SARS-CoV-2 virus is infectious enough to spread like wildfire when high-risk activities like elections, political gatherings, and mass religious functions like Kumbh Mela are conducted without COVID-19 restrictions, he points out.
The priorities of the state and central government have also changed from controlling the COVID-19 pandemic to retaining power by winning elections. The state of Kerala has seen two back-to-back elections, and therefore it is expected that COVID-19 cases will continue to rise for the next few months. “Only time will tell whether the mutants are more infectious or can escape the immune system or not. Till then, humans can blame the mutants for their failure to adhere to COVID-19 protocols,” quips Prof Anil Kumar.
Among other factors working behind the current spike, epidemiologists also see what they describe as ‘pandemic fatigue’ playing a crucial role.
Life during the pandemic is brimming with tasks requiring control and mental effort. People are constantly adjusting to new rules and policies. Everything from working to getting groceries to holiday shopping involves new rules and protocols. So, it is not surprising that people experience mental exhaustion.
This pandemic fatigue might be causing people to start ignoring social distancing measures, particularly when combined with ongoing vaccination efforts which may also be encouraging people to relax a bit too much.
Common citizens seem to have lost the fear of the virus and more and more people are not following the protocols set by the government. We are seeing crowds everywhere, rues Utture.
Laxity sets in at different levels. At the individual level, COVID-19 precautions are abandoned in the form of masks that are not worn, crowding, too much moving around, and holding risky celebrations in enclosed places.
Following the unlocking process and the resumption of economic activities, a large number of people are now together for a long period of time — in offices, factories and on public transport. The authorities are also not enforcing the rules strictly. Political meetings and rallies are being organised. Large political and religious gatherings have been permitted, throwing all precautions to the wind.
If people do not follow the protocol, he adds, cases will definitely increase, and we may again see a second increase in the number of cases. Just like in Western countries, we may see a much higher peak compared to the first one and we are not fully geared with health infrastructure to deal with such a surge, especially in small towns and villages where the number of cases is increasing day by day.
Such a surge can happen all of a sudden, rather inexplicably.
Finally, says Dr Kang, we need better, real-time data to prove that the double mutant strain is causing the surge, and as we build that up, we should do our best to ensure reduced travel, higher masking and distancing, and increased vaccination to avert another surge.
—With inputs from Prapti Shah, Mumbai
Maharashtra: The worst hit
As the biggest contributor to India’s COVID-19 case tally, Maharashtra continues to claim the lion’s share of the total reported cases. In fact, the state has upped its share by at least 20 percent this time compared to earlier. Never did the daily contribution of the state come down below 40 percent during the second wave, figures indicate.
The western state, which accounts for over 60 percent of the registered active cases in the country, has registered a 10-fold jump in active cases in just 43 days. The last time, it had taken more than 110 days for the active cases in Maharashtra to rise from 30,000 to three lakh. At this pace, the state’s healthcare infrastructure is likely to be overwhelmed, experts point out.
“The number of patients that are being affected is going to be very large and when we see such a large number of people getting affected, the health infrastructure is going to come under tremendous pressure,” remarks Dr Shivkumar Utture, President, IMA, Maharashtra.
Over the past few months, the state government and the municipal corporation have ramped up the number of beds which would be available for patients of COVID-19, especially in cities like Mumbai. Meanwhile, case numbers are increasing exponentially. The per-day numbers have gone beyond what was recorded even during the height of the first wave of COVID-19 infection. Naturally, as the numbers increase, more infrastructure would be needed. The biggest problem is almost one year has passed and fatigue is setting in among the frontline workers. When fatigue sets in, the enthusiasm to work also goes down. So, it is important to decrease the number of cases in order to effectively combat and cope up with the existing infrastructure, observes Dr Utture.
‘Reduced adherence is to blame; but possibility of a new variant is real’
The second wave of SARS-CoV-2 infections could be attributed to relaxation and reduced adherence to COVID-appropriate behaviour by the general public. However, the possibility of reinfections by a different and new variant of concern is very much real, says Dr Chandrakant Lahariya, a medical doctor and leading expert on public policy, vaccines and health systems.
Several India-specific mutant strains are also circulating, but the limited genomic sequencing data is an obstacle to saying anything conclusive. Epidemiologically, we know from the experience
of other countries that the second wave could have a higher number of cases, though fatalities have remained proportionately lower.
However, as the absolute number of cases increases, even relatively low fatality could mean a higher number of deaths, according to Dr Lahariya who is also the lead author of the recently published book “Till We Win: India’s Fight Against The COVID-19 Pandemic”.
In any case, whether second wave, re-infection, or new strain, the approaches to tackle the pandemic remains the same: hand washing, face mask and physical distancing.