Posted on April 8, 2021
Publication for Observer Research Foundation
India is squarely into its second wave of COVID-19. Will it be able to manage it better compared to the first wave? That will depend largely on the lessons it draws from those experiences.
The second wave
The number of new daily cases registered has increased more than ten-fold from below 9,000 on 1 February 2021 to over 103,000 in the first week of April. During the first wave, the peak was in mid-September when India crossed 97000. This time, despite far more extensive diagnostic and monitoring capabilities, the rate of increase has been much faster.
The number of related deaths has steadily risen from below 90 in early February to over 440 but there is invariably a lag between rising cases and related mortality numbers. These numbers are likely to rise further in coming weeks. Medical facilities, especially intensive care unit (ICU) beds are increasingly coming under strain in Maharashtra where the second wave has hit hardest.
Mutated variants of the virus with a higher infection rate, pandemic fatigue and increasing Covid-inappropriate behaviour are cited as reasons for the second wave. The beginning of the vaccination programme on 16 January 2021 gave a sense of complacency. The government’s message of not letting the guard down is diluted by the huge election rallies in recent weeks with nobody wearing masks and the Mahakumbh in Haridwar that is drawing 30 million visitors daily, convinced that their faith will protect them from the virus.
Lockdown is not an option
The first wave was during a period of complete uncertainty about the virus. The central government quickly took control. Though health is a state subject, decisions were centralised and often announced without adequate consultation with states. On 24 March 2020 a nation-wide lockdown was announced when India had 525 cases and had suffered 11 deaths. The lockdown was lifted on May 31, after 68 days, with the number of cases standing at 190,606 and the death toll at 5,408. The pandemic spread slowed but then quickly gathered pace, reaching a peak in the second half of September, before the numbers began declining from November.
However, even with a more rapid second wave, nobody is talking about a repeat of the national lockdown. That Brahmastra was used and the belated realisation of its economic downside means that there is no appetite for such measures. Delhi would rather let individual states take that call and face the fallout. In fact, the central government is desperate to get the economy back on track.
The only solution is a rapid increase in vaccinations. In January, before the vaccination programme was launched, the target was to complete vaccinating Indians in the priority category numbering 300 million (consisting of 10 million healthcare workers, 20 million frontline workers, 140 million above 45 years and suffering from co-morbidities and 130 million above 60 years) by July (later extended to August) 2021. Since the vaccines need two-doses, this meant 600 million vaccinations in five months, over and above the normal vaccination drives covering children, pregnant women and for other infectious diseases.
India has a large immunisation programme that has led to its emergence as the largest vaccine producer in the world. Annual immunisation against nearly a dozen infectious diseases and the natal and neo-natal immunisations number 400 million doses annually covering about 60 million people. This means nearly 34 million monthly doses and the Covid-19 drive would add another 100 million to it. However, this target needs to be revised in the face of the second wave.
Ramping up vaccination
It is clear that the COVID-19 vaccination rate is far too slow. In the first phase, beginning 16 January for healthcare and frontline workers, the offtake was lukewarm. Confusion was generated by statements about Covaxin (developed and produced by Bharat Biotech) use in “clinical trial mode” even as Phase III trial data was awaited while Covishield (developed by Astra-Zeneca and Oxford and produced by Serum Institute) was given “emergency use authorisation”. In Europe, there were reports about Covishield not being given to age group above 60 years because of suspected blood clot developments. On 1 March, the government opened vaccinations for those above 60 and also for those above 45 years suffering from co-morbidities and on1 April, to all above 45 years.
Demographic data indicates that the above 45 year cohort accounts for only 22 percent of the population. While it is true that this age group accounts for 60 percent of the cases of infection and 88 percent of COVID deaths, the second wave is also hitting the younger age groups hard because they are back at work, in fields, shops, factories and offices.
To date, 80 million vaccinations have been given; the current rate is approx. 3 million daily. At this rate, the target of 600 million doses for the priority population by July cannot be met. If it is assumed that for the 800 million Indians above 18 years that need 1.6 billion doses, at the current rate, vaccinations would continue till November 2022!
Currently, there are about 50,000 vaccination points with a target of 100 vaccinations each. However, because of reluctance and lack of effective communication strategies, the offtake is much less at many centres. In addition, there is a wastage of vaccines, estimated at 7 percent nationally and reflecting wide variations among states. Some wastage is inherent in such a large scale exercise but in a war-footing, every vaccine ought to get used. This has added to anxieties, especially among states worst impacted. It is therefore hardly surprising that Maharashtra, Delhi etc have started demanding that the government open up vaccination to all ages or allow the states to set their own rules to protect their populations and control outbreaks in most affected districts.
It is clear that the second wave is moving faster and according to preliminary calculations, 1.7 times faster than the first wave. At this pace, it could go beyond 150000 daily cases before it peaks. Second, the idea that the case fatality rate (CFR) is lower this time is turning out to be a fallacy because the delayed-CFR (using an 18 day lag) indicates that it is as deadly as the first wave. This means that we may soon see rates exceeding the peak of 1200 deaths daily during the first wave.
The first requirement is to open up vaccination and accelerate vaccinations to 10 million doses a day; in a manner that retains priority to those above 45 years, but below 45 years would also be accepted for vaccination, according to local situation and suitable guidelines. This requires delegating authority to states for establishing vaccination points and opening up vaccinations to age groups below 45 years. Guidelines for monitoring the vaccinations would continue to be prescribed by the Indian Council of Medical Research (ICMR).
At three million-plus vaccinations daily, the government’s monthly demand of 100 million doses already exceeds the current production capacity of Serum Institute (SII) and Bharat Biotech (BB) that currently stands at 65 million and four million doses a month respectively. According to a report tabled by Department of Biotechnology in Rajya Sabha on 8 March, 2021, SII capacity is to go up to 100 million and BB to 10 million by mid-2021. Beyond that, the two companies have asked the central government for financial assistance to undertake scaling up production.
The central government has no choice in this matter. It had established a national task force to expand vaccine production under the Department of Biotechnology last year that has helped in development of diagnostics and promoted R&D for vaccine development. But the requirement now is different. The first priority is to fund an immediate expansion of production of the two approved vaccines, Covishield and Covaxin.
The second priority is to move forward on the approvals of the Russian vaccine Sputnik V for which the Russian company, Russian Direct Investment Fund (RDIF) has tied up with five Indian vaccine manufacturers to produce a total of 850 million doses in 2021. There are at least five other vaccines in the Indian pipeline, being developed by Biological E, Zydus Cadilla, Gennova Biopharmaceuticals, SII and BB’s nasal vaccine.
Meanwhile the single shot Johnson and Johnson should also be considered for early use, especially if Biological E is going to produce it in India. If the government finds it too expensive, its use can be allowed for the private sector. Large corporates will be glad to take on the responsibility for their workers and their families if they can be certain that their schedules will be spared the Covid outbreak disruptions.
The national wastage levels are estimated at 7 percent, with considerable variation among states. Opening up vaccination will put an end to this avoidable waste.
Current testing levels need to increase rapidly. The current level of 1.1 million tests daily is less than the 1.5 million tests conducted daily last September-October. With prices being much lower now, there is no reason why the testing numbers should not go to 2 million or even higher.
Finally, India has only undertaken sequencing of 11000, a fraction of 900000 genomes sequenced, of which nearly half are by US and UK. Large scale sequencing helps in early tracking of variants so that the mutations can be analysed. The ICMR labs are best suited to address this shortcoming. This will also help the Indian vaccine developers.
Finally, the most important lesson of the first wave is the need to change the mindset-from centralising control to delegating responsibility. In order to have a whole of government approach, the central government needs to focus on what only it can do and rely on the state governments to manage the ground situation. Local authorities are also better able to tailor communication strategies specific to demographic groups to ensure higher vaccination rates.