VT Padmanabhan and Joseph Makkolil
After a brutal second wave of Covid-19 pandemic, Indian people are anxiously waiting for the third wave, which is expected to arrive in about 6 to 8 weeks in August-September. The first wave was driven by two variants Alpha and Delta, which were more contagious than the ancestral strains. Recently a new variant – Delta Plus – has been seen in four Indian States and this is likely to drive the new wave. Here we try to focus on the main features of the second wave, to see if there are any lessons for facing the third wave.
This article is in three parts. The first part looks at the infection rates in Indian states. The second part is about death and recoveries. The third part deals with variants, vaccines and vaccine adverse events reported so far.
The wave between two mathematical models
During the first half-month of September 2020, there were 1.33 million new covid-19 cases in India. This was the peak of the first wave in India About a month later, the Government of India’s National Supermodel Committee promised a “victory over Corona in 21 days” and assured that the pandemic in India would be “ending in February 2021’. Celebrating the model, the Prime Minister of India said during the video conference of the World Economic Forum’s Davos Dialogue on 28 Jan 21 that India managed to beat the Covid-19 crisis despite predictions for the worst. The pandemic did not end in February. But during the first half February 2021, the number of new cases declined to 167000, which was less than 15% of the September peak. This marked the end of the first wave. The curve started rising again dangerously leading the second wave.
On 09 May 2021 the Science News reported that India’s covid surge will peak sometime between early and mid-May and daily case numbers could rise to anywhere between 800,000 and 1 million. This was based on the model prepared by Bhramar Mukherjee, a biostatistician at the University of Michigan. The first part of the prediction turned out to be true; the second wave in India peaked during the first half May 2021. However, the average of new cases per day was 325,000, which is less than half the lower bound of Mukherjee’s estimate, Now that India is on the last lap of the second wave, the experts are preparing for the third wave which is projected to begin around August 2021.
The Global Scenario in a Nutshell
As on 31 May 2021, the cumulative caseload of covid-19 In 220 countries and territories of the world was 171.5 million. Of these, 169 million cases were reported from 104 countries, each with a total caseload of 50,000 or more, with 5.3 billion people. On the date, India (1370 million populations) had 28.2 million cases.
The infection rates
For comparing a pandemic across space and time, the absolute numbers are of no use. They need to be converted into rates- – number of cases per thousand or million population. In this paper we will use the rate per 1000 population. The infection rates in the world and 104 countries are 22 and 32 respectively. Andorra, a territory with 77,000 population has the highest infection rate of 178, and Tanzania (population 61 million) has the lowest rate of 8 per 1000. With a rate of 103/1000, the USA holds the 14th rank in the world. India’s rate is 21 per 1000 and rank is 107th. Figure 1 shows the infection rates for top 8 places in the world and of India. Lakshadweep Island which holds the seventh position in the world is a union territory of India with a population of 73,000.
Figure 1: Top Covid Places in the world
The first Peak in India and the World
The pandemic in India saw its first peak in September 2020 as against December in the rest of the world. The second wave started in India and the rest of the world simultaneously in March 2021.The trajectory of the pandemic in 104 countries (Global 104) and India during 16 Mar 2020 -15 June 2021 is in Figure -2. The vertical axis has half-monthly new infection rates.
Figure 2: Half monthly Infection Rates in India and 104 Countries – Apr 20- June 21
As on 15 June 2021, there were 29.6 million RT-PCR confirmed cases of Covid-19 in India, 95.8% of whom recovered and 1.3% died. The US had the highest number of cases – 34.3 million. Figures 2 shows the half-monthly data for India and the US for the period 16 Mar 20 to 15 June 2021. The number of cases and rates per 1000 are shown in the left and the right panels respectively.
Figure 3: Half-Monthly Cumulative Caseloads and Infection Rates in the US and India- Mar 20- Jun 21
Trajectory of pandemic in India
India attained a cumulative infection rate of 1 per 1000 during the second half of June 2020 and 5/1000 during the first peak of September 2020. The total IR as on 15 Jun 2021 was 21.5. The maximum half-monthly infection rate was 4.1 during the first half month of May 21. Figure -4 shows the half monthly cumulative infection rates in India during April 20 – June 2021.
Figure 4: Half monthly cumulative infection rates in India during April 20 – June 2021
Figure 5 shows the trajectory of the pandemic in 36 Indian states during Apr 20- June 2021. Surges can be seen in a few states even during the first wave.
Figure 5: Panoramic view of the pandemic in Indian States.
Now, at the end of the second wave, 65% of the people live in states with infection rate below 10, while 5% live in states with rates above 50. (See Figure 6)
Figure 6: Percentage of population and infection rates
The infection rates as on 15 June 2021 in Indian states ranges from 6 in Bihar to 128 in Lakshadweep. Though India’s global covid ranking is 107th, six states and territories –Lakshadweep, Goa, Puducherry, Delhi, Kerala and Ladakh – have infection rates above 65/1000. Figure 7 shows the total infection rate per 100 people and total death rate per 100 Cases In states and territories as on 15 June 2021.
Figure 7 Infection rate per 100 people and death rate per 100 Cases: Indian States 15 Jun 21
The Delta wave in Indian States
The Alpha and Delta variants were driving the second wave in the UK and India. In India during the week 14-20 Jun, there was a 29% decrease of cases relative to the earlier week, as against a 32% increase in the UK.
We have placed the Indian States into 4 groups on the basis of their total infection rate. The half-monthly infection rates of these groups are presented in Figures – 8 -11. The total population of the States is given as text box in bold red. The numbers before the states’ name in the legend shows the total infection rates of the states as on 15 Jun 21.
Figure 8: Indian States with Very Low infection Rates
Figure -9: Indian States with Low Infection Rates
Figure 10 – Indian States with Medium Infection Rates
Figure 11 – Indian States with High Infection Rates
We have analysed the progress of the pandemic in four phases as follows:
- Jan – Sep 2020 – The beginning of pandemic and the first peak
- October 20- February 21 – Declining Phase
- March- April 2021- – Beginning of the second wave
- May – June 2021 – The second and the decline.
Figure shows that only few states with the highest infection rates visibly experienced all the four phases. Lakshadweep, which has the highest infection rates, had experienced only the third and the fourth phases. Phase-wise average monthly infection rates in 36 Indian states are given in Figure-12.
Figure 12: Average monthly infection rates during four phases in Indian States
The Declining Phase
India had registered the peak half-monthly infection rate during 01- 15 May 21. However, 10 states experienced their peak 15 days earlier and 4 had it 15 days later. In India, there was a 29% decrease in the infection rates during the second half of May 2021, in comparison to the first half of May 2021. Not all states and territories were on the fall; 14 of them registered an increase.
The ups and downs are normal in a pandemic. Covid-appropriate behaviour of the people, lockdowns and the vaccinations and several unknowns like the behaviour of the virus might be behind the fall. Let us now see if vaccination had any impact on the changes.
Did the Vaccines contribute to the Fall?
Both vaccines and prior infections protect the people from future infections. The people in India started receiving their jabs against covid-19 since January 16. On 30 April 2021, 9.1% and 1.9% of the population had received their first and both doses respectively. Besides, 2% of the population had RT-PCR confirmed infection. We have estimated the susceptibility percentages in the states by deducting the vaccinees and infectees from the population. As on 1 May 2021, 87% of Indians were susceptible, the range among the states is 64% in Lakshadweep and 94% in Uttar Pradesh.
Figures 13 shows the increase in infection rate during 16-31 May in relation to the previous half month. Figures 14 shows the decrease in infection rate during the same period. All the states that reported increase in infection have lower susceptibility and those with reduced infection have higher susceptibility.
Figure 13: Increase in infection during 16-31 May and Susceptibility
Figure 14: Increase in infection during 16-31 May and Susceptibility
This does not imply that vaccines or prior infections do not prevent Covid-19. Firstly, India or any of the constituent territories is nowhere the herd immunity. Secondly most of the vaccinees have received their first dose only’, the efficiency of the first dose of AstraZeneca vaccine is 33%; and the duration of antibody protection among the infectees is not known. Besides, break-through infections have been reported among fully protected people. Urvashi Singh and colleagues from the All India Institute of Medical Sciences (AIIMS) report that the Alpha and Beta Variants are responsible for cases surge in April-May 2021 in Delhi, and they were the predominant lineages among breakthrough infections. Quote from the pre-print: “Of the 63 cases of vaccine breakthrough infections, 36 had received two doses, while 27 had received one dose of vaccine. Almost all cases presented with high-grade unremitting fever for 5-7 days. Ten patients received AZD1222/Covishield while 53 received BBV152/Covaxin.”
Surges during the Third Wave
Sweden, Slovenia and the US have infection rates above 100 as on 15 June 21. Goa, Lakshadweep, Delhi, Kerala and Puducherry are the top ranking states in India. The curves for Slovenia, Sweden, the US and India and three Indian states during the first and the second waves can be seen in Figure– 15. The infection rate is Slovenia was above 10/1000 for continuous eight half-months of October – January… The rates were above 5/1000 in the US and Sweden during November- March. India’s high-covid places registered short-lived steep surges with rates 15 and above per half-month during the second wave. These surges were reminiscent of Wuhan in February 2020 and Italy in March-April.
Figure – 15: Surges in High Covid places and India
There were surges in low infectious states also, but they had infection rates below 3. See Figure – 16.
Figure – 16: Surges in Low Covid States in India
Did the pandemic hit India as it did in other major covid countries? During the first 15 months of the pandemic, the States with high rates today experienced surges. Few states which saw The extraordinary surges seen in few states were of extremely short duration. The second wave affected almost all states in India, but the impact was minimal in most of them.
The second wave has shown us unprecedented levels of surges in Lakshadweep, Goa, Delhi and Kerala, not seen in any other country so far. The infection rates increased across all states in India, but the surges there were less than 3/1000/half-month. But the health services in these states were also over-whelmed due to the poor infrastructure and shortage of care-providers. What happens if the transmission dynamics of the virus in the third wave in the low-infectious places of India are similar to those of Goa or Lakshadweep in the second wave? There are 258 ICU beds per million population in the US. India has 26, a little over 10% of that in the US.
Did India learns her lessons from the Second Wave?
Some reports show that the UK is already in third wave of the pandemic. While the Government of India anticipates the third wave 4-6 weeks later (during early August), the experts in Maharashtra think that the State is already in the third wave. As the world is inching towards the end of the second wave, a new variant called Delta plus, first seen in England during April, has been identified in Maharashtra, Kerala and Madhyapradesh. Besides the mutations seen on Alpha and Delta have mutation that increases the transmissibility. While Alpha is 60% more transmissible than its ancestor, Delta is 50% more transmissible than Alpha. Delta Plus has an additional mutation – K417N, believed to help the virus dodge the neutralising antibodies, which mean it can render the vaccines less effective, and increase the risk of re-infection.
Dr Randeep Guleria, director at All India Institutes of Medical Sciences (AIIMS) says “we don’t seem to have learnt from what happened between the first and the second wave. Third wave is inevitable and it could hit the country within the next six to eight weeks… may be a little longer. It all depends on how we go ahead in terms of Covid-appropriate behaviour and preventing crowds. The government aims to vaccinate 108 crore of over 130 crore people in the country by the end of this year.”
Innoculation Against Thrid Wave
Dr Guleria is talking about vaccinating 80% of India’s population within six months. Is this possible? India officially launched its COVID-19 vaccination drive on 16 January 2021 and so far (21 June ) 288 million doses have been. That is equal to full vaccination of 144 million people in 5 months. The availability of the vaccine and the infrastructure for its delivery are two main constraints in India. There are about 65,000 vaccination centres in India, one centre for about 21,000 people. During the covid-19 vaccine season, maximum number of doses administered was 3.8 million on 14 June 21. That is about 60 doses per centre per day. For vaccinating 1080 million people (with 2160 million doses) 12 million doses per day will have to be administered during 180 working days. If 4 million doses are given per day during next 70 days, about 140 million people can be fully vaccinated before the beginning of the third wave. That is a little over 10% of India’s population. It may be possible to buy the doses from the global market, but who will administer them? An article published in Down to Earth quoted Dr Sunil Kumar, secretary of Indian Medical Association (IMA), Bihar, who said:” At the current speed, even after availability of vaccine doses, it will take at least two years to inoculate everyone.”
Conclusion
If one looks at the health care infrastructure and the number of care-givers, India is somewhere near the bottom. Seriously and critically ill patients also require intensive care units, ventilators and oxygen supported beds, which are all in short supply in India. The second wave in Lakshadweep and Goa has shown how big the surges can be. If the states with low covid rate during the first and the second waves experience surges seen during the Delta wave, there will will be nothing much to do. That is why the covid-19 command of the country now talks about Covid-Appropriate Behaviour. This is what all regimes do in the face of defeat in a war. Turn to the people and make it a people’s war. And the people have the oldest medical “weapon” –Yoga, claimed to have been invented in India. But Yoga is not war; it is peace, stillness and impermanence. Yoga does not go with war rooms and war thoughts and talks like defeating the virus. The virus is not out there, it is inside us all.
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VT Padmanabhan has done his Masters in Community Health from Jawaharlal Nehru University, Delhi. His team conducted genetic epidemiological studies of children exposed to high background radiation, children of Bhopal survivors, workers of Indian Rare Earths, Aluva and Gwalior Rayons Nagda, MP. He also reviewed the genetic studies of atom bomb survivors in Hiroshima and Nagasaki. He has also studied radiation and safety risks from the Kudankulam Nuclear Power Plants (KKNPP) and Madras Atomic Power Station (MAPS). He and his colleagues have published several articles in countercurrents. All his works can be seen on ReeearchGate.
Dr Joseph Makkolil did his PhD in Physics and Chemistry. He specializes in nanosciences. He is the founder of the Inter-University Centre for Nano-Devices at the Cochin University for Science and Technology. Besides his academic research, he has guided VTP’s environmental studies.
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