How To Stop Covid's Second Wave
India Today|April 19, 2021
A combination of new strains, vaccine hesitancy and Covid-denial among people at large has led to a potent second surge of cases in India. We must do more than step up the vigil and ramp up the ongoing vaccination drive
Sonali Acharjee

Covid was always an insidious enemy. In March 2020, it crept up on us without fair warning. In March 2021, just when we thought we had got the better of the virus, dropped our masks, shunned social distancing, opened up our offices, wedding venues, hotels, gyms, cinema halls and even swimming pools, it struck again, rudely reminding us that it hadn’t gone anywhere. From 1,000-2,000 new cases a day in the beginning of March, the number of daily infections/new cases reached 7,000-8,000 towards the end of the month. By April 1, active cases in the country touched 610,927, from 165,000 just a month ago. On April 6, India saw 115,312 new cases in 24 hours—the highest figure since the onset of the pandemic. Covid’s spread has always been exponential—starting as a trickle and turning into a torrent. It is something states like Kerala, Maharashtra and Delhi have seen happen at least twice before. It is something the rest of the country forgot.

“It is simple math—if one person infects another, you have one new case in a day. But when you have two people infecting two more, you get two new cases, then four, then eight, and so on,” says virologist T. Jacob John. Known as the reproduction number, or the R value, it is a key determinant of a pandemic. For cases to fall, the R value has to be below 1. On April 6, India’s R number was 1.3, having risen from 1.18 in just two weeks. The arrival of the second wave was swift, assisted by the slow clampdown on the rising infection rates at the local level. Individual states have it worse—Uttar Pradesh and Chhattisgarh have an R value of 1.6, while in Delhi, which is witnessing its fourth wave of infections, it is 1.5. The figures for all these states are the highest since the pandemic began. Maharashtra has an R value of 1.2 this week. The higher R value is what alarms virologists and doctors more than the number of active cases. “Covid has a gestation period of a few days. So, those who got infected yesterday will come out in numbers in a few days’ time,” says Dr Naresh Trehan, chairman of Medanta hospital in Gurugram. In other words, those who got infected before the state machinery sprang into action in early April have yet to be counted among Covid cases.

“We are going from bad to worse,” says Dr V.K. Paul, member, NITI Aayog. “Covid is still active and will strike back just when we feel we have it under control. No state should have been complacent when the numbers began falling, as the pandemic was not over.” He believes the whole country is now at risk even though 84 per cent of the cases are from eight states alone: Maharashtra, Chhattisgarh, Karnataka, Kerala, Punjab, Tamil Nadu, UP and Madhya Pradesh. “If cases continue to rise like this, it will overwhelm the system. If we don’t keep our guard up, we will never break the chain of viral transmission permanently. Masks, social distancing and hand hygiene must continue,” he says.

HYDRA-HEADED VIRUS

As India enters a second Covid wave, what is different this time is that it is battling not one but four variants of the original early China virus (D614G). “With every new person it infects, the virus has a chance to mutate,” says Dr Rakesh Mishra, director of the Centre for Cellular and Molecular Biology in Hyderabad. “These changes occur almost as tiny errors as the virus starts to take over a cell to copy itself. The natural selection compels it to pick those bits of its genetic code that help it survive. In most cases, mutations have very little effect. But, sometimes, they help the virus become more contagious, escape immune responses, even cause more severe disease. They then become an entirely new variant.”

India has recorded 7,000 variants so far. However, one strain, first recorded in December last year, has been especially successful in replicating itself. It was found in around 20 per cent of 1,600 samples (around 206 cases) in Maharasthra. While this may seem low in absolute terms, the fact remains that the strain is spreading faster than its predecessors. This is because it has two mutations in its spike protein that ease its access to human cells and increase its infectivity. Its ‘escape’ or E484Q mutation is similar to the South African and Brazilian strains and helps the virus slip past earlier antibodies. The L452R mutation, on the other hand, shares its characteristics with the Californian variant that make it more infectious. This mutated strain has become the dominant virus since November 2020.

Although the relevant authorities are monitoring the strain, it has yet to be labelled a ‘variant of concern’ by global health bodies such as the WHO (World Health Organization) or the CDC (Centers of Disease Control and Prevention, US). This is partly because the two mutations have also been found in 43 other variants of Covid-19. But it is certainly a ‘variant of interest’ as its mutation can potentially overcome antibodies previously generated against the early China variant either due to infection or vaccination.

This poses some concerns for the vaccination programme in India, where over 75 million have already been inoculated with a first dose and over 10 million have taken both doses of either Covishield or Covaxin. “The E484Q mutation is very worrying because it not only helps the virus enter cells easily but also helps it evade immune responses. If this variant spreads, it basically means we are back to square one in terms of all the immunity gained last year,” says Dr K.K. Aggarwal, noted cardiologist and former director of the IMA (Indian Medical Association). Indeed, the Brazilian variant, which has a similar mutation, reinfected thousands in the Amazon city of Manaus despite close to 75 per cent of its citizens having been infected by the early China variant.

Of equal concern is the fact that the foreign variants—from the UK, South Africa and Brazil—have also been found in India. There are 737 recorded cases of the UK variant (most of them in Punjab), 34 cases of the South African and one case of the Brazilian variant.

Yet, experts do not hold these variants alone as responsible for India’s second wave. Dr Sujeet Kumar Singh, the director of the National Centre for Disease Control, says that while these variants have been spotted, “data does not allow for us to make a direct correlation yet for the rise in cases”. Dr Mishra adds that since the Indian variant has been spotted for months now, it is certainly not the primary reason for the fresh wave. In fact, that it has taken this long to make its presence felt could also mean it is not more infectious than the early China variant either. “Gyms, pools, travel, schools—everything opened up this year and Covid precautions were discarded. Such complacency allows infectious diseases to thrive,” he says.

IS THE SECOND WAVE DEADLIER?

On April 2, India recorded 713 fatalities, the highest number of daily deaths this year. If Covid caused around 100 daily deaths in March, the figure reached 400 in the first few days of April. Experts say the increased deaths are natural given the rise in infections but the percentage of deaths against total cases, or the case fatality ratio (CFR), remains the same. In fact, our CFR at 1.3 per cent this month is lower than the 1.5 per cent last month. However, the CFR in Maharashtra (1.5) and Punjab (1.8), the two states with the highest number of rising cases, is higher than the national average. There has been no conclusive proof to link it to the new variants yet.

Dr Srinath Reddy, chairman of the Public Health Foun­dation of India (PHFI), says the virus may be changing its behaviour and becoming more infectious but it is not bec­oming deadlier. “It is still the same virus and still the same symptoms,” confirms Dr Vivek Nangia, the pulmonologist at the Covid ward of Max Hospital in Saket, New Delhi. “The infection has spread, we are getting more cases now, but the virus isn’t milder or deadlier. The disease’s progression and clinical management remain the same.” But doctors do say that just because hospitals aren’t overflowing and more people are recovering does not mean the viral transmission is less lethal. “Covid cannot be taken lightly. Even a moderate infection can lead to severe complications. The personal and human cost, too, is immense,” says Dr Farah Ingale, internal medicine specialist at the Covid ward in Fortis Vashi, Navi Mumbai.

HOW GOOD IS OUR FIVE-FOLD STRATEGY?

To combat the second wave, the Centre has devised a new strat­egy—test, trace, treat, public compliance and vaccinate. The first three elements of the strategy have already been in place for over a year now. Yet, the current surge is already overwhelm­ ing health infrastructure. Delhi, for instance, has asked private hospitals to reserve 30 per cent of their beds for Covid patients. Bihar, which has never faced shortages before, had 90 patients in the 80­bed ward at AIIMS Patna on April 4, while other city hospitals reported their beds were also fast filling up. Ma­harashtra, particularly Mumbai, remains the worst hit. The Brihanmumbai Municipal Corporation (BMC) has had to take the extreme step of discharging asymptomatic patients at the earliest to vacate beds for patients with more serious symptoms.

Meanwhile, there are also concerns over the city running out of crucial drugs such as remdesivir and steroids. Health­ care workers are back to working the kind of hours they did a year ago. “The situation has gone back to what it was last year.

‘WE NEED VACCINE SATURATION’

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