How to brace for the coming third wave of coronavirus

The government warns of a third coronavirus wave. India is not ready. 
A Covid-19 victim's body at Nigam Bodh Ghat crematorium in Delhi
A Covid-19 victim's body at Nigam Bodh Ghat crematorium in Delhi

Long Bets is a philanthropic website built with funds from Amazon billionaire Jeff Bezos. Anyone can post a prediction and a challenge the winner donates the money to charity. Lord Rees, the prominent British astronomer, placed a bet in 2017 that “bioterror or bioerror will lead to one million casualties in a single event within a six-month period starting no later than December 31, 2020.” His friend and Harvard psychologist Steven Pinker took up the wager and lost. All bets are off as the pandemic cuts widening fatal swathe in India because of no trials and many errors.

In a podcast, Niall Ferguson, the author of The Ascent of Money: A Financial History of the World, scoffed at projections by investment banks and governments of a V-shaped recovery sometime in 2021: “If you believe that, I’ll sell you a bridge... because there’s no way this is going to be a V-shaped recovery.” The pandemic in India shows a bridge that will not be crossed anytime soon, thanks to government confusion, ignorance, lack of expertise, unscrupulous data fudging, slow vaccination drives and misplaced Vaccine Maitri.

Experts warn of an imminent third Covid-19 wave even before the nation has a chance to recover. Delhi Chief Minister Arvind Kejriwal has declared that the national capital is in the grip of a fourth wave. Experts in the US are debating the existence of a fourth wave. The Washington Post saw a rise in cases that equalled the crest of 2020. Every day, India is breaking the previous day’s records.  “We kept warning that the pandemic was not over but no one was listening,” Rakesh Mishra, senior principal scientist and director of the Hyderabad-based Centre for Cellular and Molecular Biology told National Geographic last month.

What is a wave during a pandemic?
It is the curve of any outbreak that reflects the rise and fall of the number of cases over a defined period. For example, the common cold crests in winter and drops in warm weather. A wave ends only when the virus has been contained and cases have fallen exponentially. A sustained rise in infections indicates a second wave, which is what has happened in India and is spreading to other countries. Research in the US and elsewhere shows that the common cold virus is usually active between December and March. Annual epidemics like influenza are accelerated by social factors like schools opening.

Two Oxford University scholars who studied respiratory disease epidemics in the past 150 years found that the peaks of the waves differ. For example, the 1889-92 influenza epidemic had three waves with different degrees of virulence. Like with the second Covid wave in India, the second stage of the 19th century outbreak was worse for young adults. This was the case during the influenza pandemic in 1918 and 2009, the former being compared to the current contagion. Epidemics have the maximum impact on a country’s future; reports suggest that the third wave puts children at the risk of a higher rate of infection.

A patient waits for his admission outside Delhi's Lok Nayak Hospital
A patient waits for his admission outside Delhi's Lok Nayak Hospital

“Right now, we know that post the current wave the most vulnerable group would be the children. The adults are all being vaccinated on priority. We do not have the authorisation to vaccinate those under 18 years. This could pose a problem later,” says Upasana Kamineni, founder of URLife, a wellness platform, and Vice Chairman CSR, Apollo Hospital.

Experts like Ferguson are predicting many more waves, though their magnitude is not certain.

Dr Sanjay Rai, Principal Investigator of Vaccine Safety and Efficacy Trial at AIIMS, Delhi, is also a professor at its Centre for Community Medicine and part of the development team of Covaxin. Rai told The Leaflet, a news website which has on its advisory board economist Kaushik Basu and Kalpana Kannabiran, Director, Council for Social Development, Hyderabad, that it is difficult to predict the number of Covid-19 waves in India with the available scientific evidence. Like Ferguson, Rai is of the opinion that the human race will have to live with the virus for a long time to come.

"The Spanish Flu hit the world in three waves; it affected 2/3rd of the world’s population before it disappeared. But does this mean coronavirus will disappear after the third wave? No, there is no guarantee. We may see a few more and distinct waves in the coming years. After that, the virus will run out of evolutionary options and settle down as a more benign, endemic pathogen," explains Gauri Chaudhari, healthcare industry expert and author of The Perfect Pill

Why do these waves occur?
The well-known reason for multiple waves is the mutation in the genetic code of the coronavirus. A slow vaccination pace gives it more time to mutate and find ways to evade or trick antibodies. This "accelerates the appearance of new variants as the continued spread of the virus allows it to get 'trained' to detect and bypass antibodies, since the immune system merely looks out for the original strain," Brazilian virologist Renato Santana told the media. Fitch Ratings has warned that this delay would cause more epidemic waves in the future; the only silver lining is its prediction that the economic damage of Wave Two will not be as severe as in the first.

Vaccinations in India dipped even as two-thirds of all districts reported a 20 percent climb in infection. "Scientists and public health experts believe that herd immunity is impossible because the virus is changing too quickly. New variants are spreading fast. We have to do mass vaccination as early as possible," says Dr Varsha Phadke, Dean, KJ Somaiya Hospital and Research Centre, Mumbai.

The Brazil variant is today considered its most dangerous form, which researchers confirm is a combination of 18 different mutations that includes Brazilian, British and South African variants. Deadlier and more infectious than the original coronavirus, this new scourge is a genetic combo of around two-dozen previously known mutations. "It is as if these variants were evolving," Santana reportedly said.

Three triple mutant viruses were found circulating in India last month. Of these, two were found in Maharashtra, Delhi, West Bengal and Chhattisgarh. Genome scientist Vinod Scaria in New Delhi had tweeted that one of the new mutants has specific genetic and immune escape variants and first appeared in West Bengal in October. But the government, flush with success over the first wave, did not act.

What makes variants lethal?
Variants can override vaccines and unleash severe diseases, according to the US Centers for Disease Control and Prevention. They are fast movers. The D614G mutant can spread more rapidly than the original coronavirus by infecting human respiratory epithelial cells. Death is common after infection. Moreover, the mutant can resist monoclonal antibodies effectively. "For various mutant strains, a booster shot of the vaccines will be required to protect against variants, yet the protocols are not yet in place," says Phadke.

According to the Institute for Health Metrics and Evaluation (IHME), an independent global health research centre at the University of Washington, daily deaths in India will peak at 5,600 in mid-May. It has projected 665,000 Covid deaths by August 1, 2021. "Without drastic measures to decrease social mixing and increase effective face mask use, the situation currently looks quite grim in India," the briefing said. The institute estimates that universal mask coverage could prevent 70,000 deaths and that if the vaccination target for every Indian above 18 is met on schedule, another 85,600 lives would be saved by August 1. The Indian government is confident that the current wave will peak soon and the crisis is due to different states experiencing different peaks.   

A medical professional wearing PPE coveralls inside a quarantine centre
A medical professional wearing PPE coveralls inside a quarantine centre

The Modi government had contained the first wave with a draconian lockdown. Then what happened?
Cases came down. Morality rates receded. Economic activity was resumed in a phased manner. If it was not for complacency and self-congratulation, India would have indeed been a viswaguru.

Dr Antony Fauci, one of the world’s foremost infectious diseases experts, has advised repeating the lockdown. The government is weighing its options.

Principal Scientific Advisor to the Prime Minister K Vijay Raghavan had warned earlier in the month that even after infection rates subside, a third wave is coming. "We can’t predict the timing, but it seems inevitable. We must prepare ourselves and be ready for it,” he told the press. But he is not clear on its timescale. "We should prepare for new waves," he cautioned.

Because of low testing capacity and an opaque data policy, medical experts put India's actual tally at five to 10 times the official number.  Over 10 million cases have been added in over four months, though it took more than 10 months to reach 10 million in the first wave. At a Supreme Court hearing in the first week of May on oxygen distribution, Justice DY Chandrachud ordered, "We may enter stage three and if we prepare today we may be able to handle it. Whatever stocks procured needs to be sent to hospitals. It’s not about allocating it to the state but also the logistics to see that it is distributed to hospitals."

The situation is so dire that atmanirbhar and anti-China rhetoric is in the bin; Indian companies have placed orders for more than 60,000 oxygen concentrators with Chinese medical equipment manufacturers to meet the shortage of medical oxygen in India. The Centre, however, refuses to accept any outside advice, especially from experts who are critical of its Corona effort. The Indian Medical Association (IMA) asked the Union health ministry to "wake up from slumber" and expressed shock that its suggestions are "put in to the dustbin" and that the government is making decisions without understanding ground realities.

Is India ready to meet a third wave?
Sadly not. According to an IIT-Kanpur study, Wave Three is projected to rear its head in October. Government incompetence, especially the tortoise pace of bureaucratic decision-making, has much to answer for the Covid-19 mess. Even as the vaccination drive falters, the Sputnik vaccine from Russia was stuck in the Central Drugs Laboratory where it was being tested for efficacy and other factors - 10 days after its arrival. Only about 9.2 percent of the Indian population have received the first dose at least. Daily vaccination targets are just about past the four-to-five million mark.

On April 5, India logged the highest number of jabs as 43,00,966 recipients got vaccinated. But on May 9, the rate plummeted by 84 percent. If the Wave Three has to be countered, 60 crore Indians in the 18+ population category must get 120 crore shots in five months, starting now. But shortage is plaguing many states. Glitches in booking slots on the CoWin platform have prevented aspirants aged above 45 from getting their jabs. Fortunately, states are evolving their own containment policy. Delhi, Odisha, Maharashtra, Uttar Pradesh, Karnataka, Telangana and Andhra Pradesh have decided to float global tenders to procure vaccines.

a relative with a critical patient in Delhi
a relative with a critical patient in Delhi

Though there is every need to be prepared for possible mutations in the future, genome sequencing of Covid-19 is hardly on track and almost petered out after Wave 2. People are casual about social distancing and wearing masks, be it at super-spreader events like the Hardwar Kumbh Mela or Friday prayers in Hyderabad. “The only way forward is to follow Covid-appropriate behaviour religiously and keep on vaccinating as fast as possible. Some more vaccines are expected in India in the next month or so which would address the vaccine shortage adequately,” says Dr Namita Jaggi, Chairperson-Lab Services and Infection Control, and Chief-Education & Research, Artemis Hospitals, Gurugram. Since viruses mutate rapidly, vaccines have to be modified accordingly.

There are lessons to be learned in slow political will and red tape marring the dismal way India’s second wave is being handled, thereby causing unimaginable agony to the population. To meet the third wave, the government will have to hugely ramp up the availability of oxygen. Despite receiving emergency medical aid from the US, UK and Europe and Oxygen Express deliveries, the country has reached nowhere near oxygen sufficiency levels. There is no centralised coordination of oxygen supply and distribution. Red tape hampers timely deliveries; marooned equipment at Customs depots was released only after the media broke the story. Foreign aid languished in airports because SOPs for distribution were delayed. Ventilators bought with PM Cares funds were found faulty in states such as Delhi, Rajasthan and Punjab. Media reports claim that hundreds of ventilators purchased using the same fund lie unused in states, including Madhya Pradesh, Uttar Pradesh, Maharashtra, Bihar.

India does not possess the capacity to store liquid oxygen at very low temperatures. Kept in cryogenic tankers, it is transported to distributors, who convert it into gas for filling cylinders. The number of cryogenic tankers in India is alarmingly low. Wave 2.0 is devastating rural India; the infection rate in Uttarakhand went up by 1,800 percent after the Kumbh. Madhya Pradesh’s BJP government found that 99 percent of returning devotes tested positive. Health infrastructure in small towns and villages is moribund.

According to a research paper ‘Covid-19: Challenges and its consequences for rural health care in India’ in ScienceDirect, "There is currently a shortfall in health facilities: 18 percent at the Sub-Centre level, 22 percent at the PHC (Primary Health Centres) level and 30 percent at the CHC (Community Health Centres) level (as of March 2018). Although the number of facilities has increased over the years, the workforce availability is substantially below the recommended levels as suggested by the WHO. Rural India has 3.2 government hospital beds per 10,000 people. Many states have a significantly lower number of rural beds than the national average."

In this bewildering scenario, unless India's rural healthcare and oxygen capacity and storage are ramped up massively, Wave Three will be more devastating to life, livelihoods and the economy. "The doctor-population ratio in India is 1:1,456 against the WHO recommendation of 1:1,000. There's a sheer shortage of healthcare support even after recruiting medical students from other streams, so the pressure is enormous. In fact, the frontline healthcare workers are the most at risk of infection. So, we have to do all we can to also protect them," demands Alok Sharma, CEO, Bengaluru-based Shycocan Corporation, manufacturer of a one-of-its-kind "virus attenuation" device called Shycocan.

The paucity of credible experts jeopardises discussion and the formulation of an effective future Covid-19 strategy, which takes into account the rural reality. "The reasons for the surge are many. How quickly the authorities, who are at the helm of affairs, learn lessons, accept the shortfalls and start taking steps to mitigate the effect of the next surge will make all the difference. We encountered challenges in managing the first wave due to systemic faults in our society, healthcare services, and governance," says Dr (Prof) Gautam Sen, Chairman & Founder, Healthspring, a leading primary healthcare solutions provider in India. The IMA has been calling for a planned, pre-announced lockdown to curb the virus spread. They say the lockdown will give medical infrastructure and medical staff crucial time to prepare for the coming wave.

What is keeping victory back?
The government is playing coy on data. Policy formulation is impossible without it. Official numbers regarding infection and mortality are undercounted, due to low testing and image paranoia since seven states will go to the polls next year. In an open letter to Prime Minister Modi, 400 scientists sought wider access to the granular testing data collated by ICMR since the pandemic struck. "The ICMR database is inaccessible to anyone outside of the government and perhaps also to many within the government," the appeal stated. The Union health ministry has an aversion to sharing Covid data. Information is not dynamic and is restricted to once a day.

Regular press updates were discontinued. And the information available concerns only state-wise cases that are active and discharged, and about deaths on a given day. There is no data on the age-group or risk profile of Covid patients in ICU or on ventilators. The number of asymptomatic or pre-symptomatic patients is a secret. No findings on Covid deaths by age in different regions exist. The full serological data remains in ICMR's sole custody. Such censorship hampers the assessment of the viral spread and estimation of Covid-19's fatality rate which should be a priority for preparing for Wave Three.

Covid 19 patients inside a Covid ward of GTB Hospital in Delhi, parveen negi
Covid 19 patients inside a Covid ward of GTB Hospital in Delhi, parveen negi

Desperation marks the actions of a government that is on the back foot. Emergency clearance has been given to a DRDO-produced anti-Covid-19 drug. Dr Surya Kant, Professor and Head Department of Respiratory Medicine, King George Medical University, Lucknow, says, “We have revisited some of the old molecules and have found ivermectin, originally introduced as an antihelminthic, to be an effective, safe and affordable therapeutic option in Indian settings for prevention and treatment of Covid-19."

However, explains a World Bank official based in Delhi, “There is no medicine extant to cure a virus, you have to sit until it runs its course. Like with HIV, antiretroviral drugs can only contain the virus from replicating. SARS-Cov-2 is no different."  

What is stirring the pot?

Fake news, politics and irresponsibility, of course.

In any great crisis, superstition has a field day. During the Black Plague, people in England tied live cats and dogs under their clothes to ward off the disease. That was centuries ago, but India has not deviated from the path. The gentle cow finds itself in the middle of a raging controversy. The Covidiot is a product of the times.

Medical professionals are distressed about cow dung cures - in Gujarat, people are visiting cow shelters to gather dung and urine to smear on their bodies and later wash them away with buttermilk. Last week, media reported a Covid-19 hospital in Gujarat where patients would be exclusively treated with cow piss, ghee and other bovine products. A UP MLA not only prescribed cow piss as a Covid cure but also demonstrated how to drink it. US officials confiscated the bags of an Indian passenger which contained cow dung cakes.

A Union minister tried to solve the pandemic crisis by shouting the slogan ‘Go Corona, Go!’ The Union Health Ministry paid money to examine the efficacy of the Gayatri Mantra to curb the coronavirus. Research shows that superstitions have a healing role to play during a crisis, like a pandemic.

"Superstitions are normal and in some cases may help relieve stress in times of crisis, for instance during a global pandemic," Emily Balcetis, a social psychologist and associate professor of psychology at New York University, told AARP, a US–based interest group focusing on issues of people over the age of 50. "You can’t stamp out Covid, but holding a rabbit’s foot in your purse might feel like it brings some control,” she says. “A magical trinket that keeps me safe—it’s an illusory sense of control,” is her opinion.

Her theory has found support in Jane Risen, a professor of behavioural science at the University of Chicago. "In these times when life feels more out of control, research suggests that those are the moments that people turn to magical thinking and superstitions more," she says.

BBC researchers did 1,447 fact checks on five Indian websites, where 58 percent of posts were mostly related to false cures, lockdown rumours and conspiracy theories about the origins of the virus. Some other posts said meat prevented infection, while chicken and eggs caused it. WHO labelled as false a video that attributed a prediction of '50,000 Covid-19 deaths by April 15' to the health body. More recently a fact check by a news website proved that the pictures and videos about corpses being flung in the river in Bihar were not all of Covid cases, because the cause of death could not be verified.

Sheer confusion over medicines has thrown health response into disarray. In spite of no medical evidence about remsedivir's efficacy, the clamour for it led to black marketing and imports. Dr Vijaya Raghavan and a few colleagues wrote to the government warning that 'irrational and nonscientific' plasma therapy has no validity to save lives. The fear of forced quarantine has forced many villagers to seek help from quacks. Many fake doctors have been caught operating from tin sheds, orchards 
and even a truck. 

ALSO WATCH: India's COVID situation hugely concerning, says WHO | Expert Talk

It seems that the spiraling death rate is perceived by many state administrators as a performance report. Pandemic politics has worsened the endemic confrontation between the Centre and Opposition states. On April 29, Delhi High Court asked the Centre why it was giving various states more oxygen than they had demanded.

Vaccine politics has got worse. Last month, the Centre released 350 lakh Covishield doses for distribution of which Maharashtra, one of the worst-hit states, got only 17.43 lakh doses while the BJP-ruled Uttar Pradesh (44.98 lakh), Madhya Pradesh (33.76 lakh), Karnataka (29.06 lakh) and Haryana (24 lakh) received more.

Vaccine wastage by states is another issue. Tamil Nadu, Haryana and Punjab have the highest wastage of the coronavirus jab. Kerala, West Bengal, Himachal Pradesh reported zero wastage.  

"Unity is strength. The fight against the pandemic will have to be collaboratively fought by all the people of the democracy. Effective participation from all the people will ensure that the pandemic can be curtailed and will not overburden the healthcare system which is relentlessly working to ensure the safe well being of all the affected people," says Dr Nanditha, Consultant General Medicine, Apollo TeleHealth, Hyderabad. 

The government needs to adopt a transparent and non-partisan approach in treating Covid-19 to contain Wave Three and beyond. Honest data collation and exchange, accelerating vaccination, equitable distribution of aid, setting up more Covid facilities with beds, oxygen supplies and staff and expanding and empowering rural infrastructure will go a long way in meeting the challenge. Or else the pyres will keep burning late into the night of another year, or perhaps more.

Mumbai Shows the Way

Last week, the Supreme Court recommended the Mumbai Model to the Centre to manage oxygen supplies. The lessons learned during the first wave were applied by the Brihanmumbai Municipal Corporation (BMC) to prepare for the second. There are 31,695 Covid-19 beds, including 12,754 oxygen beds and 2,929 ICU ones, in the city. 

The BMC conducted a survey of oxygen demand to identify vulnerable areas and entered into agreements with nearby private plants to procure liquid oxygen daily. Protocols were evolved to prevent oxygen waste. Experts trained medical professionals to achieve minimum consumption by monitoring saturation and leakage. Hence, 275 metric tonnes of oxygen were enough to satisfy the requirement of Mumbai’s 90,000-odd active patients.

During the first wave, the BMC stopped refilling cylinders and opted for jumbo liquid medical oxygen tanks that can store 13,000 kilo litres, a 10-fold increase in capacity. Two of these cylinders each were installed in large hospitals to provide three to four days of oxygen supply. BMC has in reserve old cylinders which can supply patients for one to two days in case demand rises.

Cities like Bengaluru are taking cues from Mumbai. The Karnataka government has asked the Bengaluru city corporation to set up Ward Decentralised Triage and Emergency Response (Ward DETER) committees to ensure emergency medical care to critical Covid patients. A list of available hospital beds and oxygen resources will be updated in real time. 

With inputs from Medha Dutta Yadav and Ayesha Singh

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