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 Table of Contents  
Year : 2021  |  Volume : 6  |  Issue : 5  |  Page : 95-97

India between the waves

President, Public Health Foundation of India, New Delhi, India

Date of Submission08-Aug-2021
Date of Decision02-Sep-2021
Date of Acceptance12-Sep-2021
Date of Web Publication19-Nov-2021

Correspondence Address:
Dr. K Srinath Reddy
President, Public Health Foundation of India, Plot No. 47, Sector 44, Institutional Area Gurugram – 122002, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2468-8827.330657

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How to cite this article:
Reddy K S. India between the waves. Int J Non-Commun Dis 2021;6, Suppl S1:95-7

How to cite this URL:
Reddy K S. India between the waves. Int J Non-Commun Dis [serial online] 2021 [cited 2023 Mar 26];6, Suppl S1:95-7. Available from: https://www.ijncd.org/text.asp?2021/6/5/95/330657

From a premature celebration of the epidemic's permanent end after the first wave of the COVID-19 pandemic to premonitory predictions of an imminent third wave, even before the second wave fully subsided, 2021 has brought contrasting moods to India. The challenges of universal adult vaccination now lie along the journey between these waves.

India weathered the first wave of the pandemic relatively well. Even though cases and deaths were undercounted, the numbers of persons with severe infection were not large enough to overwhelm the healthcare system in 2020.[1] A prolonged lockdown from late March to late May gave time to organize a coherent and coordinated countrywide response. Younger age of the demographic profile, with only 6% above 65 years of age, kept the population-adjusted mortality rates low. Two-thirds of the population being rural helped to slow down transmission, while high crowd density and travel intensity of large urban areas made them vulnerable to high rates of infection. Though adherence to public health advisories on COVID-19 appropriate behavior was partial, the observance was evident in most cities. Even the festive season, during October to December, was muted in celebration, though cases and deaths had declined from mid to late September, respectively. Coordination between federal and state governments was smooth.

By early January 2021, the daily counts of cases, deaths, and test positivity rates declined to levels that gave rise to erroneous assumptions of final victory and misleading mathematical models, which confidently ruled out a second wave.[2] This was welcome news for all who longed for normal life to resume, from public to politicians. Caution sounded by some, that the arrival of B.117 (later called the Alpha variant) from the United Kingdom (UK) could cause a second wave, went unheeded.[3] Instead, attainment of herd immunity was cited as a near certainty.[2]

While the Alpha variant initiated the second wave, the emergence of the Delta variant resulted in a sudden and severe surge that dwarfed the first wave.[4] The states that were most affected in the first wave again bore the brunt, indicating that a large section of the population was still susceptible. Other states were not spared, and rural areas were now laid open to viral invasion through multi-level elections, political rallies, and religious congregations. The highly transmissible variants were offered a fast track to travel across the country, even as vaccination levels were too low to offer resistance.

The numbers of those affected are disputed and are still being corrected, as in many other countries.[5] Given India's large population, per million estimates of diagnosed cases and deaths were much lower than in Europe, North America, and many parts of South America but exceeded the rates of many Asian and African countries. The Delta variant-driven surge inundated the hospitals that ran short of beds, oxygen, and medicines in some cities. States which had invested inefficient health systems over the years coped better. The lesson was clear, that a swift and strong surge response to a public health emergency can be provided only by health systems which are assuredly effective and equitable in their performance prior to the challenge.

The second wave crested in May and displayed a varied pattern of decline across India in June and July. Around 80 of India's 734 districts continued to show high test positivity rates till mid-July as states like Maharashtra and Kerala showed a plateauing rather than a sharp decline.[6] However, some states relaxed restrictions rapidly, resulting in crowded markets and rush to the cooler climes of tourist destinations in the hills.[7] Fears of a rapid rebound in cases have drawn warnings from public health agencies, and government leaders in Delhi, but fickle resolve and frail memories seemed to the bane of human behavior even as the virus went on to introduce a Delta Plus variant.[8] This was from the AY. 1–3 series, with the addition of the K417N mutation to the already existing mutations of the Delta. Since the new mutation is also present in the Beta variant, which displayed considerable finesse in reducing the efficacy of many vaccines, the behavior of the Delta Plus is being keenly watched.

Since high rates of vaccination are needed across a population to secure safety from severe disease and slow down transmission, India's vaccination rates and vaccine production capacity have attracted international attention.[9] India did not preorder international vaccines but commenced domestic production of the licensed AstraZeneca vaccine and an inactivated virus vaccine developed by the Indian Council of Medical Research and Bharat Biotech. These were provided emergency use authorization in early January 2021. Since a second wave was not anticipated, the pace of planned vaccination was intended to cover up to 280 million persons in priority groups till September 2021. Only those aged >45 years were eligible to receive vaccines initially. By September, several more vaccines, indigenously developed or licensed for manufacture in India by international firms, were expected to be available for universal adult vaccination. Confident of this strategy, India even supplied India manufactured vaccines to over 80 countries between January and March.

This plan was altered when the second wave hit with an unanticipated ferocity. The central government provided approval to vaccines already cleared by the United States of America, UK, European Union, or Japan, waiving the requirement of a prelicensing bridge trial in India.[10] Attempts are being made to ramp up domestic production and speed up imports. Export of COVID-19 vaccines was stopped, leading to disappointment in countries and international initiatives like COVAX, which had placed orders. In April, the central government unexpectedly opened up vaccination to all adults aged over 18 years, in the belief that the highly mobile young are likely to be super spreaders.[11] State governments, private hospitals, and large employers were asked to buy the vaccine directly from the manufacturers. Complaints from states about differential pricing and the low availability of vaccines led to the central government partially reversing the policy.[12] It agreed to procure for the states, but private hospitals and employers could still directly procure from a quota decided by the central government. Lower than anticipated vaccination rates by the private hospitals led to warnings by the government, even as some states were closing vaccination centers, citing nonavailability of vaccines.[13] By July 15, 23% had received any vaccine, while 5.71% had received two doses. Still, the government has been assuring that all adults would be vaccinated by the end of 2021.[14]

Not to be caught unprepared, central and state governments are ramping up resources to counter the third wave. The central government has announced a special emergency response package of 3.12 billion USD.[15] Many states are making additional investments. Since it is apprehended that the third wave may affect more children, as many adults would be immune by then from infection or vaccination, central and state governments alike are investing in the expansion of pediatric care facilities in hospitals, including pediatric intensive care. Oxygen supplies are being augmented, to hospitals across the country. Medical and nursing students are being readied to support hospital services as auxiliaries. Uninterrupted drug supplies are being assured to hospitals with buffer stocks.

India has seen the pendulum swing from a coherent and competent response in 2020 to a confused and inadequate counter to the second wave. It witnessed the resignation of the federal health minister in July 2021 as national and international criticism mounted.[16] However, it is trying to script a better story for the sequel that is expected to release soon as the third wave. The future will tell us if we can act better and bring down the curtains on this pandemic. No encores please!

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Conflicts of interest

There are no conflicts of interest.

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Uttarakhand: Nearly 8,000 Tourist Vehicles En Route Mussorie, Nainital Sent Back. Mint; 13 July, 2021. Available from: https://www.livemint.com/news/india/uttarakhand-nearly-8-000-tourist-vehicles-en-route-mussoorie-nainital-sent-back-over-weekend-11626155011200.html. [Last accessed on 2021 Jul 16].  Back to cited text no. 7
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