The reproductive number for India as a whole is more than 1.53, which means that 10 people will infect 15 more persons. This is more than 2 in Jharkhand, Uttar Pradesh and Bihar. India currently has 8,41,083 active cases and without any intervention, it could reach 12,86,857 by April 20. Simultaneously, the doubling time has decreased to 30 days at the national level. If the same trend continues, India will have 16,82,166 cases by May 6. However, the numbers could be 10-20 times higher considering underreporting.
Estimates by Professor Bhramar Mukherjee and team at the University of Michigan suggest that COVID-19 second surge could witness 1.8-3 lakh cases each day with daily deaths between 1,500 and 2,200. Also, several mathematical models suggest serious projections in the short-term. The forecasts predict the total cases and deaths will increase faster than what the country had witnessed during the first wave.
Whichever model one chooses to believe, the misery induced by the case surge is scary. Even if we assume that only 10 per cent of people suffer from severe infections, at some point in the short-term, we would require 20,000-40,000 critical care beds for admissions each day. At this rate, the health system is glaring at a crisis in the near term.
Learning from others
Despite the lack of endorsement by official agencies, there is no doubt that variants of concern (VoC) are spreading in India. With less than 1 per cent of samples processed for sequencing, we simply do not know how many of these variants are more infectious or how many have the capability to escape the immune system. This is corroborated by the surge in cases in areas that had presumably reached the threshold levels of population immunity. The more the virus replicates, the higher are the chances of newer mutations and development of more variants of concern. And, more variants will certainly emerge due to the ongoing high circulation.
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India is not alone in witnessing such resurgence. Evidence suggests that many other countries are reeling under uncontrolled rise in cases. It is concerning to see higher ICU admissions among the younger people in some parts of Canada. Compared to the Indian response, they have an advantage—their policies are well-informed by evidence. Thanks to the excellent concurrent epidemiological investigations coupled with genomic sequencing, Canadian agencies have identified the P1 strain is creating havoc in their country. To gain upper hand in combating the virus, the need for efficient data systems are not only necessary but essential.
The global experience from managing the second wave suggests that stronger public health measures are needed to control the epidemic growth. If unchecked, the country cannot bear the disastrous consequences. To prevent any tragic consequence, the next four weeks are the defining period in terms of how successful India’s COVID-19 response will be. Here are some actions that require immediate attention.
Five things India must do
First, the ongoing uncontrollable surge in COVID-19 transmission should be controlled to manageable levels. We have argued elsewhere too that lockdown is a lazy policy option and should not replace the much-needed enhanced containment measures. Crowding of any nature should be immediately banned. To achieve some respite from the onslaught of rising cases, we urge central and state governments to initiate and enforce ‘3Cs’—coverage of vaccines, containment efforts to limit the spread and continued genetic sequencing in the strictest form. The governments should implement strict guidelines to enforce the 3Cs’ to tackle the crisis. Minimizing spread in closed spaces, especially with poor ventilation, preventing gathering of any kind of crowd will limit the spread in groups of people. Currently, several exemptions allow gathering of crowds in closed spaces, such as cinemas, colleges and officers. All these should be immediately stopped. Preventing the transmission in close-contact settings like one-on-one conversations should be ensured through strict enforcement of wearing masks.
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Second, without proving the impact of VoCs, fighting the virus blindfolded will not yield results due to lack of appropriate strategies. Strengthening concurrent epidemiological and genomic surveillance is needed to ensure that contagious variants are limited to few regions. Wherever present, the more contagious and immune VoCs should not be allowed to spread to other areas. In addition to this, we need to enhance our efforts in stepping up isolation and quarantine facilities to cover maximum proportion of cases and contacts, especially as the infection is spreading to tier-2/3 cities and rural areas. Unless this happens, the real chances of preventing the spread are slim.
Third, the country will have to step up resources for building sufficient public health capacity at all levels. Although the government has stated repeatedly that we need to test, trace and track, the country needs to address the inequities in access and affordability. Limiting the availability of such resources to combat each wave will be futile and not cost-effective. Instead, strengthening the public health infrastructure and building resources and laboratories should be done at every block and district to augment disease control programmes, including fighting multiple waves of COVID-19. The Government of Karnataka improved infrastructure at district and block levels by increasing the number of ICUs and oxygenated beds. Similar efforts should be replicated across the country to ensure sufficient healthcare capacity exists, including substantial clinical care capacity to respond to surges.
Fourth, it is important to ensure that comprehensive risk reduction measures are in place for populations that are at high risk. It is now proven that vaccines can prevent deaths due to COVID-19 in nearly 100 per cent cases. Preventing deaths among the vulnerable population is top priority. The proportion of people vaccinated is an important indicator in terms of how effective we will be in reducing overall mortality.
Accelerating the pace of vaccination can prove to be more cost-effective in the long run by preventing several deaths in the country and boosting economic activities.
Finally, data should be available to enable researchers and modellers to help the government provide better options for implementation of disease control programmes. Systems promoting data transparency can help in many ways, including timely forecasts and ensuring people’s health is prioritised.
We need to check crowding in public spaces and postpone all celebrations. Desperate measures are needed to tackle this unfolding crisis.
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