In January 2021, there was a self-congratulatory mood in India, as the steady fall in case and death counts after September 2020 appeared to signal a ‘final’ victory over Covid-19. Many politicians and public health experts gushed about herd immunity having been acquired by the country, even as other regions of the world were battling second or third waves. International experts too opined that the virus appeared to be blocked by a ‘human wall’ of persons who had gained the protective armour of immunity even before the vaccine roll out. The ever-sceptical international media, which previously attributed India’s low case and death counts (per million population) to undercounting, suddenly started enquiring with wonderment as to how India had pulled off a miracle.
There were some voices of caution which questioned the breezy assumption that the magic cloak of herd immunity had descended on India. Their pleas for continued discipline in observing public health measures to curtail viral transmission had few takers. Technical experts in the government too pointed that much of the population was still susceptible. However, the fatigue of pandemic restrictions and the urge to return to normal life made politicians, public figures, traders, travellers, sportspersons, shoppers, religious groups and revellers galore want to believe that the virus was vanquished and all of India was liberated.
The wily virus had other plans. Not only did the wild virus strike back but it also brought in a brood of mutant progeny to run around with great speed as kids do. Relaxation of international travel restrictions made it easy for mutants first reported in the UK, the US, Brazil and South Africa to enter. It is currently stated by the authorities that only the British intruder is spreading fast and far while other variants of foreign origin have only a minimal presence (an eerie repeat of India’s colonial history). Variants have emerged from within India, too, though their menace is yet to be measured. A ‘double mutant’ has been reported in some states, combining mutations observed earlier in California with those previously noted in India and some other countries. These spike protein mutations appear to confer the virus added ability to enter human cells.
Whether they enhance or reduce its virulence (causing severe disease) remains to be seen. Higher rates of genomic analysis of isolates from positive tests are needed to better estimate identities and transmission characteristics of the variants .
Alarm bells have been sounded as the daily case counts, test positivity rates and hospital admission rates are rising. Death rates are not rising as fast, suggesting that either the virus is less virulent now or case management methods are more efficient. It is also possible that more young persons are being infected now, with less severe manifestations than among the elderly who may have accounted for a higher proportion of patients during the first wave. Only age and gender disaggregated data on cases, hospital admissions and deaths will provide better insights. Geographic spread is faster than in the first wave, both because of the variants and less rigour in containment methods.
Our response has to be informed by the lessons we have learnt over the 14 months since the virus first landed in India in end-January 2020. It has to be shaped also by the current context. Broadly, we need to frame and effectively implement our strategy across four areas: containment of transmission; care of the infected, immunisation of the population and protection of the essential functions of society. These have to proceed in tandem, which requires us to draw on all our reserves of resolve and resilience. This resistance has to be sustained over the next six months without premature proclamations of victory and vacating space for the virus.
For effective containment, we need to prevent new infections and quickly detect infections that do arise. Public health mandates on masks, physical distancing, avoidance of crowded events and mass gatherings must be enforced with unwavering political will and unrelenting administrative skill.
Elections can be conducted with local canvassing instead of mega rallies, along with intelligent use of mass and social media. Indian democracy flourished even in the early decades after our Independence, without the razzmatazz of (dis)organised crowds. If ‘work from home’ is possible, prayer from home too can be a pious personal offering of devotion, which should surely please an all-knowing deity. People must be mobilised and motivated to protect themselves, their families and others too, through messaging via both mass media and closer to home community networks. The role of civil society organisations, largely ignored in the past response, must be greatly enhanced.
Detection of cases can’t depend only on viral detection tests, which we now know have many false negatives (especially in the rapid antigen tests) and some false positives (attributed to nucleic acid residues from ‘dead viruses’). Symptoms suggestive of Covid-19 (a long list by now) should also be used for early case detection by primary healthcare teams visiting homes and also for promoting awareness to stimulate voluntary isolation and self-referral for testing. Clinically suspected cases must isolate and use masks at home, even if they test negative. Repeat tests, during the course of the illness, reduce the false negative rate. Genomic analysis of a sizeable fraction (around 5% or more) of all positive test samples will help to identify and track the spread of variants. However, the mainstay of defence against any strain of virus remains the combination of masks, physical distancing and avoiding crowds. Testing alone won’t help, if we don’t adopt contact tracing and other public health measures. The US led in tests per capita but failed with contact tracing, isolation and masking, resulting in a public health tragedy that continues to shock the world. While it is usually argued that contact tracing is no longer useful when community transmission is established, every new variant needs to tracked and curbed through energetic contact tracing, testing and isolation before it becomes the next don of the virus clan.
Clinical care of infected persons is now better informed by research, which has shown the benefits of home-care to many and of prone positioning, oxygen, steroids and anti-coagulants for hospitalised patients. The need to mobilise both public and private hospitals and upgrade district hospitals was recognised during the first wave. That should cut response-time in the current surge.
Vaccination must pick up speed and spread across the country. We must aim to vaccinate all persons above 35 years of age and others with associated disease conditions by August 15 this year. Even as more vaccines get regulatory approval, we must train and engage more vaccinators and get the private sector to offer stronger support to the public sector across the country. Vaccine confidence must be promoted at the community level, by building trust in public health advisories and clearing misconceptions through local networks.
The test this time won’t only be meeting the challenge of the virus through a smart, strong and sustained strategic public health response but also ensuring that the vulnerabilities of our economic and social structures don’t get exacerbated. Both livelihoods and educational opportunities have to be protected. Lockdowns and laxity can’t become a perpetual see-saw of our society. We have to make a determined and disciplined commitment on a long-haul fight and not view every skirmish won as the end of the battle. That is the variant we need for our strategy if we have to overcome the variants the virus hurls at us.
The author, a cardiologist and epidemiologist, is president, Public Health Foundation of India (PHFI)
Views are personal