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Making waves: India heads towards the fourth wave of coronavirus

India is headed towards the fourth wave of the coronavirus, which could cause irreparable damage to its
population and economy. It can only be stopped by public awareness, sacrifice and cooperation.

Published: 18th April 2021 05:00 AM  |   Last Updated: 17th April 2021 12:39 PM   |  A+A-

India and the world are facing a vaccine crunch since the second and third waves are rising faster than the inoculation rate.

India and the world are facing a vaccine crunch since the second and third waves are rising faster than the inoculation rate.

The frightening truth is that we do not know.
We do not know why after over 13 crore recorded Covid-19 infections, 30 lakh deaths, nearly 700 million vaccine doses given worldwide, including in India, the waves of death and destruction keep coming, crashing on the rocks of fear and speculation, threatening to drown humanity in its worst nightmare.
We do not know why vaccinated people are getting infected or re-infected.
We do not know how long antibodies last in our body.
We do not know which mutation is next and which can bust the vaccine, like the South African variant, B.1.351, which has eluded the Pfizer shot.

We do not know about the scope, duration and efficacy of vaccines available in the world. We do not know which vaccine is the best either. Trapped in the middle of such apprehensions, India has plunged into a second wave, which is projected to get worse in the coming weeks. Experts say that Delhi, Mumbai, Pune along with many towns and cities in Maharashtra, Chhattisgarh, Kerala and Madhya Pradesh are in 3rd and 4th stages.

Stage One is the first stage of individual infections without a local spread, moving to Stage Two that begins with local transmission, followed by Stage Three when health professionals cannot trace the source of the infection on to Stage Four where the pandemic becomes uncontrollable with major clusters blooming all across the country. Currently, China is the only country to have reached that stage. Europe is in its third stage. Simultaneously, we are facing a big challenge of continuous mutations of the Covid-19 virus.

“Repeated mutation of the coronavirus is a matter of concern since it isn’t easy to predict for how long the pandemic will last or even slow down,” worries Dr Om Shrivastav, infectious disease specialist and consultant at Sir HN Reliance Foundation Hospital and Research Centre, Mumbai.

THE UNRELENTING WAVE
What we do know is that India has the world’s second highest number of Covid-19 cases after US. The tally was 1.39 crore cases, with a record spike of 1,84,372 cases by last Wednesday, according to the Union Health Ministry—the lowest number of active cases was 1,35,926 on February 12 or 1.25 percent of the total caseload in India. We also know that complacency and carelessness have pushed us into the Stage Two spiral, with mass gatherings like elections and the Kumbh Mela certain to become super spreaders, which would ravage India’s villages and small towns that have seen relatively low levels of contagion. Currently on an average, there are more than 1.5 lakh cases arising daily. AIIMS Director Dr Randeep Guleria has warned that India is fast approaching Stage Three. Should this trend continue, we are ultimately heading towards Stage Four, which the country is ill prepared for. Estimating a daily number of 100,000 cases, India would need 5,000-10,000 beds every day for critical care.

A PricewaterhouseCoopers survey found that India has only 1.3 hospital beds per 1,000 patients while the WHO mandate is 3.5 beds per 1,000 people. A conservative estimate of researchers at CDDEP India and Princeton University puts the current number of critical medical facilities at 1.9 million hospital beds, 95,000 ICU beds, and 48,000 ventilators. Most of these are in Uttar Pradesh (14.8 percent), Karnataka (13.8 percent), Maharashtra (12.2 percent), Tamil Nadu (8.1 percent), West Bengal (5.9 percent), Telangana (5.2 percent) and Kerala (5.2 percent).

However, India’s vaccination drive is in full swing. Its staggering population is the biggest detriment to a successful vaccine drive, even as efforts picked up following Prime Minister Modi’s call for ‘Tikka Utsav’—so far only 7 percent of the population has got at least one dose. The Washington Post reports that over three million Indians are being vaccinated daily. A senior health official stated that the Serum Institute that produces the Oxford-AstraZeneca Covishield vaccine manufactures about 60 million doses a month and Bharat Biotech 10 million doses of Covaxin. Scientists of IIT-Kanpur predict that the second wave will peak around April 15 to 20 and start receding within two weeks. They are hopeful of a sharp reduction in cases by May-end.

The required social distance used to be three to four feet but the new norm suggests five to six feet. Unless people take it upon themselves to overcome Covid fatigue and stop relaxation of pandemic protocols like wearing masks and social distancing, and effectively implement containment measures at the field level, the wave is certain to reach tsunami levels. There is good and bad news. The bad news is that the Health Ministry figures indicate that the current caseload is spiking at more than last year’s rate when coronavirus cases were at their peak. The good news is that the mortality ratio shows a downward trend. But viruses are unpredictable.

Experts, however, advise caution, warning unanimously that future casualty rates might go up due to unexpected viral behaviour and human response. Ageing, obesity, chronic renal failure, smoking and some genetic traits are responsible for a patient’s low immunity. Hence, sometimes the vaccine does not respond to its full extent. Two to 10 percent of vaccinated people fail to generate adequate antibodies, leading to inadequate immunity. Hepatitis B vaccine failure is noted as high as 10 percent, among the highest failure rates.

A SERIOUS MISUNDERSTANDING
After proving to be a world success story in Covid containment, how did the virus and its variants rise again as India’s fatal scourge? Associated Press reported that scientists have discovered a new Indian variant, which has two mutations in its spiky protein that it uses to stick to host cells. These variations can reportedly encourage faster and easier virus spread, and bypass the immune system. Take the case of Aarti (name changed), a 40 year-old banker in Delhi who contracted the coronavirus in October last year. She was admitted in Delhi’s Moolchand Hospital for 15 days.

But after recovering, she was careless, was not particular about social distancing, went mask-less and partied as before all in the mistaken belief that she had developed sufficient antibodies against the coronavirus. Soon she developed mild fever, diarrhoea and had sneezing bouts. She took a test immediately and found to her dismay that she was Covid positive again. Her physician Dr Srikant Sharma, Consultant, Internal Medicine, at Moolchand Hospital diagnosed that the possibility of Aarti having been infected by a new strain of virus is high, although the symptoms she developed were mild. She has also infected seven of her family members and three friends.

“If one member of a family is diagnosed Covid positive, the chances of every family member getting infected within a short period of time is high, since the new strains are spreading fast. Of 100 patients, almost 60 to 70 percent show a new set of symptoms,” adds Dr Sharma. Experts put the ratio between patients infected with old strains and freshly infected patients at around 40 to 60. Points out Dr A Sreenivas Kumar, senior cardiologist, Apollo Health City Jubilee Hills, Hyderabad, “Till now the mortality rate has been comparatively low, thanks to timely diagnosis and immediate treatment. But patients taking their infection lightly are landing up in hospital with serious complications.”

At the start of the second wave, the new strains were showing milder symptoms. It is also being observed over a period of time that not only are they more contagious than during the previous stage, they are proving more dangerous too. “After invading the chest and the lungs, the virus spreads very quickly,” says Dr Sharma. The double-mutated virus is showing serious and unusual symptoms among non-vaccinated patients. “More and more people are being put on oxygen support and quite many of them urgently need ICU facilities,” says Dr Ashesh Bhumkar, ENT Specialist at Bhumkar Hospital, Mumbai. Doctors do not deny the theory that every mutation makes the virus weaker and milder. But it has become more cunning, too. “Viruses act very intelligently, change their behaviour to survive longer by staying undetected. HIV and Hepatitis are examples where the viruses do not kill people within a short period of time; instead they stay in the body for years and years, damaging it slowly and gradually. We are noticing the same pattern in the coronavirus,” warns Dr K K Aggarwal, President, Heart Care Foundation of India and senior Internal Medicine consultant.

The question arises, why is the coronavirus wave pattern different in different states and cities? Infectious diseases spread or are contained depending on local and regional factors. According to Dr Aggarwal, the factors are: Behaviour (people not taking precautions like wearing masks and observing social distancing), Environment (too many public gatherings like weddings, political rallies, religious events and parties), Mitigation (government policies like increased testing, enforcing restrictions) and lastly Super Spreaders.

THE REINFECTION PUZZLE
Why are inoculated people getting re-infected? Take the case of 47-year-old Anuraag, a diabetic patient in Mumbai who got both his jabs in time. A month later, he got mild fever accompanied by sneezing fits and gastroenteritis. A Covid test found him positive, much to his distress. In spite of claims by governments and medical scientists that cases of inoculated patients being reinfected are rare, growing evidence proves otherwise. Anuraag is not a one-off example. Many doctors, nurses, paramedical staff, who were vaccinated at the beginning of the ‘Corona Vaccination Programme’, have caught the virus again. Credible information about immunity and the duration of antibodies in a recovered patient’s body is scant and sometimes even confusing.

For example, new research suggests that recovered coronavirus patients are developing blood clots. Such studies tend to be disquieting, but have comparatively small samples and are undertaken in short spans of time. The highly respected medical journal Lancet has alarming news. It reported a case study where the genome sequence of the coronavirus in the first infection and the reinfection differed significantly, suggesting that the fresh contamination was not from the same virus. The patient’s symptoms worsened, and he required oxygen support and hospitalisation. This is in spite of him having developed positive antibodies after the reinfection.

This clearly proved that existing immunity does not necessarily prevent recurrence of the infection. Why are the current reinfections mild? BMJ Case Reports, which hosts the world’s largest collection of case reports and other studies, notes that existing immunity could be preventing the patient’s condition from becoming severe. After the resumption of domestic and international travel with conditions, the new strains of virus that developed elsewhere have landed in India. But compare the coronavirus with its influenza cousin, which mutates every year. A new type of vaccine is produced accordingly. The flu vaccine’s protection is between 40 and 60 percent. Yet, it prevented an estimated 7.5 million influenza infections, 105,000 hospitalisations and 6,300 deaths in the 2019-20 flu season in the US.

FAST AND FURIOUS
A virus has no personal animosity towards people. Its karma is to replicate. Every time this happens, errors may occur in its genetic code; even within the body of the same host. If genome sequencing finds numerous such errors, it is a sign that a different pathogen from a different source has reinfected the patient. The chance of mutation during replication is high. BMJ Case Reports notes that new SARS-CoV-2 variants with the ability to circumvent immunity and increase the risk of reinfection have emerged. Scientists are keenly observing three rapidly spreading variants identified in the UK (B.1.1.7), South Africa (B.1.351), and Brazil (P.1). The first two are estimated to spread rapidly and easily.

Certain mutations of these could enable a variant to trick the immune system and thereby elevate the chance of reinfection. There are documented cases of reinfections with a new variant of the South African variant itself. The first and most important factor of India’s surge in coronavirus cases and the second wave is believed to be mutation. Two newly discovered strains of the (Double Mutation) virus seem to be more contagious. Many patients affected by these variants are below 45 years old or are small children—carriers who infect many people simultaneously. Their symptoms may be mild.

But they are spreading the virus rapidly. “It is hugely possible that the new mutation is evading antibodies developed post-vaccination and infecting inoculated persons,” explains Dr Aggarwal. Genome screening is imperative to understand a virus and its mutations. “So far it’s just an assumption that the new strains of coronavirus are probably rendering the vaccine less effective,” feels Dr Shrivastav. Different people have different antibody counts as well. Doctors are noticing new symptoms among patients, which they attribute to the new strains. Previously the common Covid-19 symptoms observed were fever, cough and weakness. Now a number of patients get diarrhoea, severe body pain, vomiting, giddiness and headache. “This indicates mutation and how new strains are reacting differently inside the body,” believes Dr Sharma. Dr Sreenivas Kumar supports the theory. He says, “The new virus is spreading fast. Gastrointestinal symptoms are appearing frequently, which was mostly not the case earlier.”

Currently during the second wave, in many parts of India, doctors are seeing four types of patients. A large number of them are newly infected with obvious symptoms of new strains. The second set has been vaccinated, and the third comprises reinfected patients. The fourth segment is believed to be infected by the old strain of virus. As research to understand this deceptive virus continues, medical experts are discovering neurological disturbances like anxiety and mood disorders all new symptoms. For answers to dealing with such complications, experts are comparing the patterns of Covid-19 with the Spanish flu.

“Since the Spanish flu pandemic occurred in three waves, experts are assuming a third wave that may last for a shorter period since the third wave of Spanish Flu was short,” reveals Dr M Wali, Senior Consultant, Internal Medicine at Sir Ganga Ram Hospital, Delhi. Called the Bombay Fever in India, the Spanish Flu pandemic, brought home by soldiers returning from World War I, claimed the lives of 17 to 18 million people, or about 5 percent of the population at that time. But it killed more Indians than British. The poorer sections of Indians lived, as they do now, in densely populated areas. Sanitation is India’s primary challenge in disease containment. Poor hygiene and sanitation systems cause diseases. What is more, both in villages and cities, humans and animals living in close proximity, allows bacteria and viruses to easily transfer from one to another.

JAB WE MET
On January 16, India kickstarted the world’s largest vaccination programme. Medical experts are certain that vaccination and adhering to safety measures are the two best protections from the coronavirus. However, both India and the world are facing a vaccine crunch since the second and third waves are rising faster than the inoculation rate. As with epidemics in India, politics and blame games are on despite the over 1.7 lakh deaths so far. Ten states have complained of facing a severe vaccine crunch, which the Centre strongly denies. The anti-BJP government of Maharashtra has threatened to stop Serum Institute trucks carrying vaccines unless New Delhi gives it the doses it needed. India, one of the world’s leading vaccine producers and suppliers to the UN-led COVAX initiative had noticed a flattening of the curve earlier this year and decided to embark on vaccine diplomacy.

The Modi government exported 64.5 million doses to many countries. Facing the second wave, it backtracked and began to ramp up production. Around 90 million doses of the AstraZeneca vaccine were not shipped because the Serum Institute of India began to reprioritise the domestic situation. The vaccine situation in the world is no different as vaccine racism and the rich-poor divide deepens in the backdrop of rising fatalities. The EU countries do not produce vaccines and have to depend on imports; to cash in on the misery. Pfizer has hiked the cost of its vaccine to the EU by 60 percent.

Leading influenza expert Klaus Stohr, who had influenced countries and companies to increase production of vaccines for avian flu, told Bloomberg recently that most of the world will not be able to get the vaccine and predicted a serious imminent wave. Most poor countries, like in Latin America and Africa, cannot afford the high costs of Pfizer, Moderna and similar vaccines, which leave them with Indian and Russian choices—China admitted its jabs were not potent enough to fight the virus. This puts pressure on India’s vaccine production, placing it in the middle of a conscience crisis.

The Covid-19 cure is the Holy Grail of the world pharma industry. Expected to get approval this year in India are five more vaccines, including Johnson and Johnson (Bio E), Zydus Cadila’s ZyCov-D, Serum’s Novavax and a nasal vaccine from Bharat Biotech. Russia has contracted five Indian drug companies to manufacture over 850 million doses of Sputnik V vaccines for export. Dr Reddy’s Laboratories will distribute 250 million of the doses at home later this year. A budesonide inhaler used to treat asthma has been cleared in the UK for patients in the early stages of Covid-19 infection.

A Munich-based tech company has launched a new Covid-testing app, Semic EyeScan, which identifies the virus in a photo of the eye taken with a smartphone, by spotting a symptomatic inflammation known as ‘pink eye’. It claims to have isolated the Covid-19 virus from over two million different shades of pink. Chinese company Sinovac and Janssen (owned by Johnson & Johnson) of Belgium begin clinical trials in the Philippines. But all is not hunky dory on the vaccine front. Both Pfizer and Johnson & Johnson vaccines are plagued by blood clot controversies, though the former is being used the world across. Gilead has halted remdesivir trials in high-risk Covid patients.

But the link between vaccine efficacy and infection is difficult to understand. Clinical trials showed that Covaxin has an efficacy rate of 81 percent. Does it mean that 19 percent of people who get it will be infected? No. Neither does it mean that vaccinated people have a 19 percent chance of getting Covid-19 or that 81 percent of people are protected. Vaccine efficacy is about reducing risk—hence those who get Covaxin jabs have a 81 percent lower risk of getting the virus compared to those who are not inoculated. While most vaccines, such as the ones by Pfizer and AstraZeneca, require two doses to attain complete efficacy, one may develop partial protection against the virus 12 days after the first dose. Though this would be short-lived. The second dose amps up immunity. The Australian Public Assessment Report states that no one is safe until seven days after their second dose of the Pfizer vaccine or up to 14 days after the AstraZeneca vaccine. This means that one can still fall ill prior to the dateline, despite being fully vaccinated.

FLAGGING A FRIGHTENING FUTURE
Some scientists feel that the coronavirus is a Malthusian intervention to correct the population and resources imbalance in the world. It is also believed to be just a drill for more invasive and deadly pandemics of the future. In the last 20 years, the world has faced six major dangers—SARS, MERS, Ebola, bird flu and swine flu. David Aronoff, director of the Division of Infectious Diseases, Department of Medicine at Vanderbilt University Medical Center, Nashville, Tennesse, US, and Priya Nori, associate professor of medicine (infectious diseases) at Albert Einstein College of Medicine, New York City, US, told Infection Control Today that the next pandemic is coming soon, which will be respiratory and airborne.

Covid-19 makes a strong case for vegetarianism. It is widely assumed that the coronavirus crossed over from a bat to a human in a wet market in Wuhan, China. WHO states that diseases originating from animals cause around one billion illnesses and millions of fatalities every year. Bats harbour over 200 viruses. Says Dr Aggarwal, “Many wet markets are operating in China and a few African countries. Most outbreaks of new viruses start from these markets.” Over the past 30 years, over 30 bacteria or viruses have been discovered that are capable of infecting humans of which, three quarters are believed by researchers to have emerged from animal populations. Ebola and Zika, like Covid-19, originated with species of bats, and are spread through coughing, sneezing or mosquitoes. Studies pinpoint that there are almost 80 types of autoimmune diseases that make patients vulnerable to catching viral and bacterial infections.

When hospital beds run out, the metal crematorium stands melt in the heart of funeral pyres and mourners are given numbered tokens to await their turn to cremate loved ones who died of Covid-19, the world stands at the threshold of a greater grief. The coronavirus has caused unprecedented chaos worldwide, critically affecting existing global power equations, economies, government actions and the nationalist spirit. Mankind has endured worse and prospered. Perhaps, Nature is giving a new crash course in survival. Otherwise, humanity’s crash is a matter of course, should the pandemic be the harbinger of more lethal man-made epidemics.

An Unknown Miracle

A small team of 10 researchers at the Walter Reed Army Institute of Research (WRAIR ) of the US, which had worked on vaccines for the Zika virus, Ebola and MERERS, has developed a new vaccine candidate. Lacking the resources of the big drug companies, they decided to take a different research route. This week, the first human trial of their vaccine candidate was completed. Should it clear the US Food and Drug Administration, it would strike fear in the hearts of pharma giants such as Moderna, Pfizer, Johnson & Johnson and their like.

Around 15 months ago, this unit from WRAIR ’s infectious disease branch quietly worked on a vaccine to zap all coronaviruses of which Covid-19 is only one. Traditional vaccines give directions to cells to manufacture the spike protein of the SAR S-CoV-2 virus. The body, which will remember the protein as a foreign body, develops antibodies to fight it should it return. The WRAIR vaccine has a different approach. It contains a nanoparticle with 24 spike proteins and an ingredient to enhance the immune response. Instead of resembling a part of a virus, the injected element actually looks like one, thereby allowing the body to recall more than one distinctive marker.

The subsequent immune response is strong enough to defeat any SARARS virus, including the numerous variants plaguing the world. Laboratory tests have found it effective against all Covid-19 variants and other coronaviruses. Since Armies everywhere take a pragmatic approach to solutions, the WRAIR -developed vaccine can handle all climate conditions. Giants like Pfizer and J&J were given massive US government contracts to make investments needed to get a vaccine off the lab in less than a year. They are expecting billions in sales. Whether a vaccine that can put an end to all coronaviruses stands a chance to reach the world market is anyone’s guess.

SHOTS OF PROMISE

mRNA-1273
Moderna/National Institutes of Health

Efficacy: Approx. 92 percent (WHO).
Protection kicks in 14 days after the first dose.
The new variants of SARS-CoV-2 do not alter the effectiveness.

BNT162b2
Pfizer/BioNTech/Fosun Pharma

Efficacy: 94.8 percent (The New England Journal of Medicine)
The protection circle begins 14 days from the first dose.
It has a high efficacy—92.1 percent—right from the first dose

Convidecia
CanSinoBIO

Efficacy: 90.07 percent (BioSpectrum Asia magazine).
It prevents the disease 28 days after single-dose vaccination.
It can be accessible by under-developed regions.

Sputnik V
Gamaleya Research Institute

Efficacy: 91.6 percent (BMJ).
Full dosage requires 21 days.

Janssen
Johnson & Johnson

Efficacy: 85.4 percent (WHO).
It comes into effect 28 days after inoculation.
The vaccine works against new variants of SARS-CoV-2 virus.

Covishield
AstraZeneca/University of Oxford

Efficacy: 63.09 percent (WHO).
The longer the dose interval 8 to 12 weeks range the greater the efficacy of the vaccine.

NVX-CoV2373
Novavax

Efficacy: 96.3 percent (Claims the parent company).
Additional efficacy: 86.3 percent, against the B.1.1.7 variant first discovered in the UK.

COVAXIN
Bharat Biotech/ICMR/Indian National Institute of Virology

Efficacy: 81 percent (Claims the company's official statement).
It has a 28-day open vial policy as a unique product characteristic, thus reducing vaccine wastage.



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  • Meet kamal Dwivedi

    very nice article
    1 year ago reply
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