India’s current covid situation: how it came to this and what needs to happen

As of 10th May, 2021, India registered about 400, 000 new positive cases of COVID-19, with nearly 23 million total COVID-19 cases in the country since the beginning of the pandemic, with nearly 80% cases occuring between March and May of 2021. At the time of writing this, the surge in the number of cases continue (see Figure 1, data source: https://ourworldindata.org/coronavirus/country/india).

Daily new covid cases in India, source: Ourworldindata.org

India covid cases

In parallel with this rapid surge in the number of cases, India has also experienced about 4000 deaths per day between March and May of 2021 and the surge in the number of people dying from COVID-19 continues. It is believed that these numbers are under-reported on the order of about 5–10 times of what has happened in India (Figure 2). Altogether, since the beginning of the pandemic in about February when India was first hit, nearly 250, 000 people have died due to COVID-19. Between February of 2020 and January of 2021, about 150, 000 people died, and about the same number of deaths were registered in three months since then, such is the ferocity of the new surge or wave of the infections.

Daily covid deaths

India’s first cases were in February 2020 and for a relatively long time, the number of cases were low and so were the deaths attributed to COVID-19 although it was known by then that India was not conducting enough tests and were possibly under-reporting the deaths. The first uptick in the number of cases started in the middle of March 2020. Around that time, the Indian government announced a sudden country-wide “lockdown”, apparently without much advanced preparation or allowing people enough time to adjust their lives. Mass transit facilities such as airports were closed, and train and bus services were suspended for a month, as happened with offices, banks, and markets were closed. People were advised to work from home; most worksites were closed for business, and work in construction sites were halted.

Thousands of migrant workers in the country found themselves out of work and source of income; with practically no social support provided and employers laid off these temporary workers with no compensation. Desperate for survival, these workers breached the lockdown conditions and started moving out of cities and started heading home, most people started marching long distances from North Indian cities such as New Delhi to reach their homes in villages of Haryana, Uttar Pradesh, and Bihar, often walking for weeks. The crisis came to a pass that the United Nations Human Rights Chief warned India and the world on his blog. This was beyond a humanitarian crisis, serious as it may, it also resulted in an unprecedented series of events that may have further augmented the spread of COVID in India within months.

COVID-19 is a disease caused by sars-cov-2 virus, a virus that belongs to coronavirus family marked by spikes around the capsule of the virus giving them an appearance of crowns surrounding its body; several features of this pandemic are notable and unique that makes it particularly lethal. First, the virus, unlike its previous avatar SARS that ravaged much of East Asia in 2003 leading to about 8000 deaths, has a long incubation period and infectious period within which a person can spread the infection even though the person themselves may not show signs of the infection; in this stealth phase, which can last up between 48–72 hours, the person is referred to as asymptomatic or presymptomatic; it is believed that roughly 40–45% infections are spread by asymptomatic or presymptomatic individuals: second, this virus spreads through fine particulates, namely aerosols and respiratory secretions (cough, phlegm, spit) in closed confined spaces, crowded conditions, and among closed contacts. As a result, “social distancing” or maintaining a distance of at least six feet between individuals, good ventilation of the buildings, avoiding overcrowding, avoiding closed proximity of individuals, and wearing of masks are recommended preventive measures. Third, a significant characteristic of this epidemic is that, it is overdispersed as suggested in this paper by the Epidemiologists Akira Endo, Adam Kucharski and others. Overdispersion refers to the fact that about 10–20% individuals can account for 80% of the infections and the pandemic spreads via superspreaders and clusters of high infections that get connected; that is, while some individuals and events result in a large number of secondary infections (superspreading events and superspreaders), a vast majority of the individuals can infect at most one or two people. This has been known since the beginning of the pandemic; therefore funerals, weddings, and public gatherings have been known superspreading events: for example, a wedding in Bluff led to a cluster of 87 cases in March 2020 in New Zealand, and a woman in South Korea (patient 31) was known to be a superspreader leading to about 60 secondary infections around the same time. As a result, not only it is necessary to trace contacts to map out those that the newly diagnosed COVID-19 positive persons might infect or come in contact within a 48 hour window (known as forward contact tracing), it is equally necessary to trace the network of all people that the infected person came in contact with in the past several days and identify who might be a superspreader that are missed. This is why lockdowns to limit human movements and activities have been traditionally part of COVID-19 prevention strategy. Therefore, widespread testing of individuals to identify possible COVID-19 positive individuals, contact tracing, and isolation of such individuals, including lockdowns have been widely adopted.

However, as Adam Kucharsky has argued in his prescient book “The Rules of Contagion”, when a virus spreads in an epidemic, human beings react to it in one of the two ways: either they flee or they hide. In the summer of 2020, when the Indian government clamped down stringent and sudden lockdown conditions, the workers fled the lockdown restrictions, and in the process, those that were asymptomatic or presymptomatic, carried with them the infections to yet unseeded areas. Several others in India did not report or did not get tested and hid their symptoms and signs. The testing rates in India were among the lowest in the world for a long time. As a result, even with low testing statistics, and under-reporting of cases, India nevertheless registered a steady increase in the number of new cases of COVID-19 throughout the summer of 2020 despite repeated lockdowns and variations of lockdowns and stringent measures enforcing social distancing measures, and restricted movements of people. Over time, the testing rates increased, people became habituated to wear masks all time, travelled less on public mass transits, maintained social distancing. Starting middle of October and continuing November of 2020, the number of COVID-19 cases started dropping in India. Some hailed it mysterious, and international media hailed the phenomenon as puzzling. Many experts tried to explain that India reached herd immunity — a concept in epidemiology where when a certain percentage of the population reaches a level of immunity either through infection or vaccination, the rest of the population is protected as the infection cannot anymore propagate — at least in places like Delhi, experts claimed, on the basis of community surveys that suggested certain levels of antibodies to COVID. But the story was far from over yet, as subsequent events unfolded, even as experts and India’s habitually glib political leaders and ministers basked in vainglorious claims of early success.

Around December, when the cases started reportedly dropping in numbers in some parts of India and showed up in the statistics charts reported by the country, worldwide new variants of sars-cov-2 virus were emerging. This was nothing new, sars-cov-2 virus is known to mutate roughly twice month, and these mutations are tracked and a database maintained by GISAID as part of global influenza tracking system. However, these new variants were reported from Southwest England in late December and soon it rapidly spread to other countries. New, more virulent strains were reported within the Indian state of Kerala as well and cases were rising even as cases were reported to drop in India overall and this drop dominated the news. Reportedly, by the end of 2020 and into 2021, India’s testing levels slowed down, people seemed to “drop their guard”, wearing of masks became less frequent, people started travelling in mass transit more, and the government allowed and actively encouraged large mass gatherings in religious festivals and large multi-phased elections in three states of the union. Airports were open and air travel was allowed between India and other countries. There was no provision of mandatory quarantine in the airport or at the borders, such as the system that exist in New Zealand, where majority of the new cases in the country were reported in managed isolation and quarantine facilities and among people entering the country from overseas. In India, on the other hand, any visitor could walk through the border security with routine tests and questions, there was no provision for mandatory isolation and quarantine was in place.

The first COVID vaccines were approved for usage in India was the Oxford-AstraZeneca vaccine that was manufactured by the Serum Institute of India under the trade name of Covishield, and India started administering the vaccines on 16th January, 2021. India approved two vaccines for general usage, one was developed within India by the Hyderabad based Bharat Biotech, referred to as “Covaxin”, and the other, the aforementioned “Covishield”. On first of May, 2021, India received a third, a Russian Sputnik V vaccine for distribution. It is reported that while India exported about 66 million doses of vaccine to 72 countries, she was not prepared with enough doses to cover her entire eligible population with two doses of the vaccines.

Even as the covid cases from new variants started increasing in various parts of the country, the Indian government mismanaged vaccine distribution, and people dropped their guards, India’s political leaders and rulers were even more reckless. Despite neither planning nor implementing a vaccine programme that would be adequate to vaccinate eligible at-risk people in the country, with no established forward and reverse contact tracing programme in place, relatively low levels of testing, upon observing a reportedly reduced level of COVID positive cases in the community in the country ignoring the rising cases in the states of Kerala and Maharashtra, not only did a sense of overconfidence and recklessness set in, Indians seemed to declare a premature victory over COVID. On 28th January, 2021, India’s prime minister Narendra Modi proudly declared at the World Economic Forum Davos Dialogue via videconferencing that “India’s stats cannot be compared with one country as 18 per cent of the world’s population lives here and yet we not only solved our problems but also helped the world fight the pandemic”; if this was a sign of overconfidence, about the time when the so-called COVID tsunami about to hit, India’s health minister Harsh Vardhan declared at a medical conference in New Delhi in India on the fourth of March that “We are in the end game of the COVID-19 pandemic”; as he declared this, India were able to vaccinate at that point about less than three percent of their population.

Beyond this, the government of India abetted and orchestrated large gatherings of millions of people in India in the middle of COVID-19 pandemic: between March and May, multi-phased elections were organised in three states of the country. The prime minister, the home minister and other political leaders addressed large gatherings of voters in political rallies and gloated on social media about the enormity of the crowd they addressed in thier political rallies. Photographs of such gathering revealed that hardly anyone wore masks on such mass gatherings and these ended up as superspreading events, and followed by further escalation of cases in the country. A second large gathering of people happened in Haridwar, a city in the state of Uttarakhand. Kumbh Mela is one of the largest religious fair among Hindus that draws millions of people from all over India. In 2021, March, more than three million pilgrims from all over India converged in the town of Haridwar in the Uttarakhand state of India, where mendicants and pilgrims converge on the banks of the river Ganga for bathing for several days; people live in small, poorly ventilated tents. Both these events were marked by hundreds if not thousands of people huddled over closed areas, large crowds, and infected people in close proximity to susceptible people: three conditions that lead to uptick in the probability of COVID-19. It was little wonder then that, soon after, the number of new cases increased to well over 300,000 every day.

As a result, between the end of February 2021, when the leaders were basking in their tall, if not somewhat vainglorious claims of having solved the world’s problem of COVID and helping the world, and middle of May, India was hit by a so-called “tsunami” of COVID-19 pandemic of new variants never before seen before. As the old strains of sars-cov-2 started declining in the country, the variant B1617 rose steadily and underwent other lethal mutations. Even with allegedly under-reporting on the total number of new COVID positive individuals, as can be seen from the reports, nonetheless, a near vertical steep rise in the number of new infections of COVID-19 were seen from India. In parallel, a similar steep, nearly vertical rise in the number of people who have died from COVID-19 in India every day were observed and continues at the time of writing. On an average, everyday in India, more than 350, 000 new cases of COVID-19 are reported, and about 4,000 people die from the disease. As this march of death of COVID-19 continues unabated across India, not a family is spared where death and covid has not touched yet in this massive country of over a billion people. India has vaccinated about 2.6% of total population, which regardless of the total number of people vaccinated, is still far short of what would have been useful or even comparable with countries of similar size and population, such as China, that were able to vaccinate about 30% of their population. The vaccines are in short supply, oxygen are depleted in the country, people literally begged on social media in search of oxygen and medicines and hospital beds. Hospital beds have overflown; streetside cremations were observed in a never before occurrence in India: in a hundred-years’ time, dead bodies were set afloat in the Ganges river in hundreds. India is a sad place right now, shattered and devastated.

This is beyond a humanitarian emergency and disaster of unprecedented proportion only for India, and now it threatens to spill over to the rest of the world. Surge of cases in Nepal, Bangladesh, and Pakistan are already been reported. As I write this, the World Health Organisation has announced that the variants of the sars-cov-2 virus, B.1617, that has run rampant through India are variants of concern. These variants have already spread to more than 30 other countries. India’s problem therefore goes beyond a mammoth public health emergency and disaster within South Asia but it has now touched the rest of the world significantly, and perhaps no country is now immune from the impending viral spread.

What may have happened and what can be done? In summary, a pervasive misunderstanding and failure to communicate among the general people, but also among leadership in India about the characteristic of the virus and its spread seems to explain the response pattern and rise of infections and deaths. COVID-19 follows a pattern of overdispersion with isolated clusters where a few people spread the disease among many and most people spread the disease to one or two and the disease spreads rapidly when the clusters merge and grow. Therefore, lockdowns need to be carefully planned and timed with eye to allow appropriate “ring-fencing” of the infections. This was not achieved in India in the first place. India continued to under-report the extent of the infection and death rates in the country and this led to a false sense of complacency among the leadership and the mass. Personal practices such as wearing of masks waned in the wake of an observed drop in the infection rates. The infection rates abated but did not go away completely and there were clusters that remain hidden or people with infection that were never reported who later led to more clusters leading eventually to the outbreak. The rollout of vaccination has been very slow in India and the pandemic was fuelled by the massive crowd gatherings.

In the next few weeks, India will need to address these issues. Vaccination rates will need to be ramped up. While on the one hand, those who are suffering will need to be taken care of, equally, targeted lockdowns that can ring fence clusters with reverse contact tracing to trace out the network of cases need to be urgently established. A map of superspreading events and circumstances may be helpful in forward planning to prevent further escalation of this pandemic in India which is already very fragile is necessary. A long summer awaits India and the world will need to come together to solve the crisis. None of us are really safe till all of us are safe from COVID-19 is a mantra well worth remembering. One hopes that the Indian experience has taught the world this lesson.

Associate Professor of Epidemiology and Environmental Health at the University of Canterbury, New Zealand. Also in: https://refind.com/arinbasu

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