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With Covid’s Second Wave ‘A Nation In Distress’ – Why?

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If someone tries to see a silver lining in the disruptive Covid-19 pandemic, besides its vaccine rollout in some countries, there will be at least one. As of April 17, 2021- over 119 million patients (India – over 12 million), reportedly, have recovered out of 141 million (India – over 15 million) of Covid infected patients.

But this can’t mask the grim reality of over 18 million patients remain still infected, with over 3 million deaths (India – 175,673), since the beginning of the Covid menace. In the Indian perspective, this is the highest ever incidence of death – in absolute numbers – for any reason, so far. Now comes the Covid second wave with its more devastation onslaught on human lives and other consequences for the nation.

In this article, I shall explore this area, as apparently a Tsunami-like the second Covid wave starts sweeping across the India states, posing a greater danger than the first one, to the lives and livelihoods of millions of Indians, yet again. Let me start with a perspective, leading to the current situation.

No clinically proven drugs, as yet:

There aren’t any definite or clinically proven drugs after completion of Phase III studies, as yet, for curing patients from Covid infection. Nor are there any such well proven vaccines with fully known efficacy, safety, time interval between two doses, duration of prevention from Covid infection, in the future. All drugs and vaccines are currently being used under ‘emergency use’ approval by country drug regulators, based on interim results.

At the very onset of Covid-19 first wave, other than some attempts of repurposing older drugs, the world did not have any proven drugs to fight against this deadly infection. The old antimalarial drug Hydroxychloroquine – was tried first, followed by other medications, such as, Lopinavir/Ritonavir. Both created a huge global demand and subsequent shortages, including in the pharmacy of the world– India. Subsequently, W.H.O discontinued hydroxychloroquine and lopinavir/ritonavir treatment arms for COVID-19 based on interim clinical trial data. These results showed, hydroxychloroquine and lopinavir/ritonavir produce little or no reduction in the mortality of hospitalized COVID-19 patients when compared to standard of care.

At the beginning of the second wave of Covid-19, one of the latest repurposed drugs – remdesivir that is being widely used, especially for hospitalized patients, is also facing a shortage, even in the pharmacy of the world. Interestingly, even ‘Remdesivir has little or no impact on survival, WHO trial shows’.

Also – no clinically fully proven Covid-19 vaccines, as yet:

Possibly, the second-best antidote as of date, against rapidly mutating Covid-19 – after Covid-appropriate behavior by all, comes vaccines. All comes with ‘emergency use’ approval, based on interim results only, and with several challenges. These include efficacy against all mutating Covid-19 variants, exact safety profile, dosage interval and duration of protection. Interestingly, on April 16, 2021, Pfizer indicated that ‘Covid-19 vaccine recipients will “likely” need a third dose between six to 12 months after they’re fully vaccinated and suggested vaccinations for coronavirus could be needed every year.’ In this evolving scenario, Indian experts also acknowledge that - abidance to the defined health norms stays as a lifeguard, and will remain so for an indefinite period.

Several countries, including India, are making, and gradually expanding requisite arrangements to vaccinate their population. Whereas a large number of countries – mostly in the developing world, are still awaiting access to Covid vaccines. Meanwhile, another issue has started bothering many, which the April 10, 2021 issue of The Guardian had captured in its headline – ‘Global Covid vaccine rollout is threatened by a shortage of vital components,’ besides manufacturing capacity constraints compared to the current demand.

Global challenges with Covid vaccines in 2021:

As things have progressed with Covid vaccines, thus far, the year 2021 doesn’t seem to be a smooth run to vaccinate people across the world, deriving a significant outcome against the battle of this global menace. This gets vindicated by the following numbers, as published in the ‘Down to Earth’ magazine on April 13, 2021.

  • According to the Johns Hopkins University, United States, as of April 12, 2021, only 773 million Covid-19 vaccines had been administered across the world. This means, only a little more than 2 per cent of the world’s adult population, has been inoculated so far.
  • According to data analytics firm Airfinity, the world will manufacture 9.5 billion doses by the end 2021. Whereas immediate global need exceeds 14 billion doses to vaccinate the entire adult population.
  • According to Gavi – The Vaccine Alliance, this represents almost three times the number of vaccines the world was producing in the pre-pandemic period for other diseases.

In the midst of these, inoculation with, at least, two major Covid-19 vaccines – one from AstraZenecaand other from Johnson & Johnson, have raised safety concern in the United States and many European countries. These ongoing developments complicate Covid vaccine challenges further.

The Indian scenario – ‘a nation in distress?’

Despite building new and a workable emergency health infrastructure by several state governments to combat Covid-19 pandemic, the fierce attack of the second wave with mutating Covid-19 virus, has already made these bursting at the seams. The article - ‘A tsunami of cases’: desperation as Covid second wave batters India, appeared in ‘The Guardian’ on April 14, 2021, captures this desperate struggle of the nation. Another recent report depicted with grim pictures, how India is grappling with the second wave of Covid-19, terming it as ‘a nation in distress.’ There are enough indications that India’s fragile health infrastructure has already collapsed in some places.

According to another news item on April 14, 2021, more than 111 million people has been vaccinated in India, by that time. Notably, this number was achieved after fears of AstraZeneca’s Covishield vaccine shortages, which subsequently prompted the Indian Government to temporarily halt its exports by the Pune-based vaccine manufacturer – Serum Institute of India (SII).

Going by another estimate, if the current momentum continues, India would be able to vaccinate 40% of its population by December 2021, and 60% of the population by May 2022. The report cautions that ‘the non-availability of vaccines may scuttle the pace.’ As per the W.H.O release, three in five Indians need to be vaccinated, to reach herd immunity. For which, the country needs 145 crore doses of vaccine by May 2022. India currently has the capacity to manufacture 100 crore-130 crore doses per year, as per a Rajya Sabha committee report. Another report of April 10, 2021 also highlights, ‘at least 10 states in India have reported a vaccine shortage and many vaccine centers have been reported shut.’

My wife and I also experienced the Covishield vaccine shortage in Mumbai. Our scheduled online appointment for vaccination through Co-Win website of the Government at Sir HN Reliance Hospital,Girgaon, Mumbai, for April 17, 2021, was cancelled. At past 10 pm on April 16, 2021, the hospital rang us up to inform that they have closed their Covid vaccination center till fresh vaccine stocks reach them.

To combat the Covid pandemic – ‘Pharmacy of the World’ goes local:

Yes, to combat the Covid pandemic, the ‘Pharmacy of the World’ goes local for some critical Covid drugs and vaccines, several times in the past. This happened earlier with drugs, like Hydroxychloroquine, when India banned its export to cater to the domestic need for Covid treatment. It happened again now, as ‘Remdesivir, API and formulation were placed under Export ban on 11.04.2021.’

Similarly, India has now, reportedly, put a temporary hold on all major exports of the AstraZeneca’sCoronavirus vaccine (Covishield in India), made by the SII, amid an increase in domestic demand due to a surge in infection. As the news item highlights: ‘It will also affect supplies to Gavi, the W.H.O backed vaccine alliance, through which more than 190 participating economies – 98 higher-income and 92 low and middle-income, are expected to get vaccine doses.’ Such temporary measures are now necessary for India to effectively respond to India’s Covid fight – especially the vaccine crunch.

India’s current vaccine imbroglio, as Covid second wave strikes hard:

Besides the SII, a second Indian company — Hyderabad-based Bharat Biotech, was given permission in January for emergency use of its Covaxin, developed in collaboration with the ICMR. Although, Bharat Biotech can make 12.5 million doses each month, these will be a small proportion of the doses administered in the country, so far.

To effectively respond to the prevailing vaccine crunch, Indian Government already approved the ‘emergency use’ of Sputnik V vaccine, which will be imported till its domestic production commences. Further, the country’s health authorities have now decided to consider the grant of ‘emergency use’ approval of several other internationally developed vaccines, such as, Pfizer – BioNTech double-dose vaccine and Johnson & Johnson’s single-shot vaccine. At least, till then, India’s vaccine imbroglio to vaccinate all adult population in the country, irrespective of age – particularly when Covid second wave is not sparing the young adults, is expected to continue.

Conclusion:

The jaw-dropping pandemic situation, and the pathway to deal with this crisis, especially in India, is getting increasingly complicated in every passing day. As reported on April 16, 2021, Covid-19 is now fooling RT-PCR tests – the most reliable type of Covid test as on date. It is so alarming because: ‘A false negative report is bad for the patient as they might delay consulting a doctor. It’s also bad for others, as the patient might not isolate, and spread the virus around,’ as the report underscores. It has started happening because: ‘Multiple mutations in the coronavirus over 15 months are making parts of it unrecognizable to lab tests.’

Experts are trying to fathom, whether or not more people are dying in India’s Covid second wave, as compared to the equivalent time period of the first wave. This causes an added cause of great concern because, in the six months before the start of the second wave (from September 2020 to January 2021), India’s overall case fatality rate (CFR) was only around 1.1%. This means only 1.1% of cases resulted in deaths. Currently, at the very beginning of the second wave, CFR has already increased to 1.3% and remains below peak levels seen in the first wave – as of date.

Above all, many people – virtually from all social, political, religious and economic strata, are openly flouting the basic norms of Covid appropriate behavior, as daily seen on different TV news channels. Ironically, these are happening at a time, when Indian health care infrastructure is creaking against the enormous and devastating power of the second wave Covid pandemic.

‘Pharmacy of the world’ has also gone local for some critical Covid-19 drugs and vaccines, to save lives and livelihoods of the Indian population, having no other better alternative in sight, at this hour. Isn’t this a sign of ‘A Nation in Distress’ that makes a fervent appeal to all of us, at least, to behave properly – by religiously following the lifesaving Covid guidelines?

By: Tapan J. Ray    

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

 

Covid 19: Some Unanswered Questions in India

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Ending all speculations, the national lockdown 2.0 with all previous stringent provisions and more, expecting to bring the deadly microbe under a tight leash in India, commenced on April 15, 2020. This is expected to continue till May 03, 2020, keeping a window of opportunity open, for a case by case review, after April 20, which is today. This is now a known fact. But what is still not known to many are the answers to some critical question, such as, the following three, for example:

  • Will the standalone plan for strict compliance of prescribed social distancing norms for over 40 days and possibly much beyond, a comprehensive strategy to end the Covid 19 warfare in India?
  • As this game plan to save lives also involves livelihood of a large population, will it lead to hunger, involving many families?
  • When will the Covid19 nightmare end in India and how?

In this article, let me deal with these three questions, with illustrations.

Is social distancing’ alone a comprehensive strategy?

Experts believe that ‘social distancing’ is undoubtedly one of the key strategic components in the war against the invisible enemy Covid 19, especially to contain the spread of the virus. However, it’s not considered a standalone or a comprehensive strategy to win Covid19 warfare, for good, as it doesn’t help identify asymptomatic individuals – potential candidates for the continued spread of Coronavirus.

What scientific studies reveal?

Covid19 testing strategy in India is mainly focused on foreign returned and symptomatic individuals, alongside contact tracing. Interestingly, the study on the Covid19 outbreak in China, published by Nature Medicine on April 15, 2020, concluded – 44 per cent of those who tested positive, contracted the disease from an asymptomatic person. This happens, as the viral shedding, that can infect another individual, takes place, at least, 2-3 days before symptoms manifest.

Thus, along with containing the spread, it is equally important to trace the asymptomatic individuals at an early stage, then isolate and quarantine them at appropriate facilities, as necessary. Accordingly, many countries follow intensive testing guidelines from an early stage of disease spread. South Korea, for example, has been successful in this area, during the first wave. The same is being followed in the subsequent waves of outbreaks, till an effective antidote, like a vaccine is available to end the war. Hence, this is considered as a comprehensive strategy in the interim period. It was also well discussed and captured by the Indian media.

Lockdowns delay the peaks by about three months:

Experts indicated, ‘lockdowns merely delay the outbreak’s peak by about three months.’ They have also cautioned: ‘Asian countries risk new waves of Coronavirus infections when they lift lockdowns. The same could happen in the rest of the world.’ The world is now witnessing the second wave of outbreak in many countries.

Two seemingly contradictory messages surface:

Going by the ICMR data, according to media reports, India has conducted around 160,000 tests as on April 8, 2020 with the country’s tally of positive cases stands at 6,237 (at 6 pm on April 9). This indicates, 3.8 percent of the tests yielded positive results for Coronavirus. In comparison, the US with a much lesser population than India, has conducted 2.2 million tests. This is the highest among all countries, and a fifth of all those tests throwing up positive results.

An analysis by Worldometer  Get the data  Created with Datawrapper, of Covid-19 tests per capita of the top ten countries, by the number of tests conducted along with India, reveals something interesting. With a population of around 1.3 billion, India’s Covid-19 tests per 10,000 population has been merely 0.04. This is perhaps one of the lowest, especially considering India’s vast population with high density, poor living conditions of a large number of people, besides other risk factors.

Curiously, even the ICMR acknowledged on April 15 that it is critical to increase testing for Covid-19, as the number of cases in India is “rising exponentially.” However, on April 16, 2020, the Government again defended its testing strategy, as Coronavirus cases in India crossed the 13,000 mark on that day.

Didn’t India get a space to ‘buy time’ in 21-day lockdown period?

It was widely expected that the 21-day national lockdown was announced to buy precious time to prepare the country to roll out a comprehensive strategy. This was expected to include, identification of the asymptomatic individuals or persons with very mild symptoms, through intensive testing. Isolation and quarantine these individuals are of immense importance, thereafter, as the situation will demand.

But, why this hasn’t happened that way, as yet, by garnering requisite wherewithal, from – before, during the 21-day national lockdown period, to date, remains an unanswered question.

Will lockdown 2.0 lead to hunger in many poor families?

Dr. Amartya Sen, the Nobel Laureate and the Harvard University professor  explained the situation in an article, published on April 08, 2020. He wrote: “If a sudden lockdown prevents millions of laborers from earning an income, starvation in some scale cannot be far off.” Even the US, which is considered a quintessential free enterprise economy, has instituted income subsidies through massive federal spending for the unemployed and the poor, Professor Sen wrote.

The current situation was anticipated by global experts, well before it surfaced:

Even before it surfaced so strikingly, Professor Sen cautioned, the more affluent may be concerned only about not getting the disease, while others have to worry also about earning an income, which may be threatened by the disease or by an anti-disease policy, such as a lockdown. For those away from home, such as migrant workers, finding the means of getting back home, could also be a huge emotional concern that needs to be addressed with empathy. The emerging situation in this regard, also increases the risk of disease spread in various different ways.

Another renowned economist, Professor Ricardo Hausmann at Harvard University has, reportedly, said, further lockdowns could have dire consequences. Strict social-distancing measures mean that people must stay at home, so many cannot work, particularly those on a daily wage. Developing nations, such as India, do not have much financial flexibility to pay, for these migrants to stay at home for long, he added. Let me hasten to add, India has already announced a financial package for this purpose. But…

Would the announced stimulus package mitigate the economic and social needs?

1.7 trillion rupees (US$ 22.6 billion) stimulus package that India has announced for the poor, is termed modest by the economists, considering the population of the country. India has to weigh the numbers of deaths that will be caused by the loss of livelihoods against those caused by the disease. “For those who have to stay at home, they starve to death,” Professor Hausmann said.

Thus, the question of charting a clear pathway – striking a right balance between life and livelihood, in the face of Coronavirus pandemic in India, also remains an unanswered question.

When will Covid19 nightmare end and how?

It is virtually impossible to win the war against Coronavirus, decisively, only through social distancing as a standalone strategy. Even ‘The Lancet (Infectious Diseases)’ study of March 23, 2020, concluded: “In the absence of any pharmaceutical intervention, the only strategy against COVID-19 is to reduce mixing of susceptible and infectious people through early ascertainment of cases or reduction of contact.”

‘Early assessment of cases or reduction of contact’ will call for a comprehensive strategy-mix of social distancing – intensive testing of asymptomatic individuals – isolation and quarantining those who will test positive. The paper also underscored: “The effectiveness and societal impact of quarantine and social distancing will depend on the credibility of public health authorities, political leaders, and institutions. It is important that policy makers maintain the public’s trust through use of evidence-based interventions and fully transparent, fact-based communication.”

‘If’ and ‘but’ exist:

Interestingly, in the ‘The Lancet’ study, the authors estimated that 7·5 percent of infections are clinically asymptomatic. Whereas, the study published in Nature Medicine on April 15, 2020, concluded that 44 per cent of those who tested positive contracted the disease from an asymptomatic person.  Moreover, The Lancet paper acknowledged that higher asymptomatic proportions will influence the effectiveness of social-distancing interventions. But, the question remains, when will Covid19 nightmare end and how?

Primary ways to end the war:

This issue has been deliberated with scientific reasons in many articles. One such is titled, ‘Herd immunity is the only way the Coronavirus pandemic will end — and it would require a vaccine. Here’s how it works.’ This was published in the ‘Business Insider,’ on April 14, 2020. Like other papers, it also reiterated that individuals could gain immunity to the new Coronavirus, if they develop antibodies. This can happen, primarily in two ways:

  • Herd immunity or after people get infected and recover
  • Vaccination

According to Gavi, herd immunity is the indirect protection from a contagious infectious disease that happens when a population is immune either through vaccination or immunity developed through previous infection. Even people who aren’t vaccinated, or in whom the vaccine doesn’t trigger immunity, are protected because people around them who are immune can act as buffers between them and an infected person. Once herd immunity has been established for a while, and the ability of the disease to spread is hindered, the disease can eventually be eliminated, e.g., eradication of smallpox.

However, many scientific papers indicate that pursuing herd immunity through infection by allowing the virus to spread, rather than through a vaccine, would lead to hundreds of thousands more deaths. Moreover, some evidence indicates that a recovered person’s immunity may not be permanent. Hence, developing immunity through vaccination will always be a prudent choice.

Although, how fast an effective vaccine will be available for mass vaccination remains a key question,the good news is, a British scientist who is developing a Coronavirus vaccine, expects it to be ready by September, 2020. Meanwhile, I reckon, a disease specific antiviral drugs will be available to treat the infected persons and prevent death.

Conclusion:

Many of us in India, at various times, behave in a difficult to understand or even a mutually contradictory way. For example, at the call of crisis leadership in the country, in the midst of a Janata Curfew on March 22, 2020, people clapped or got engaged in beating pots and pans from their respective balconies, together at 5 pm. This happened with a huge participation, ‘as a mark of respect for the frontline health workers and medical professionals who were working day and night to contain the COVID-19 pandemic and selflessly treating patients who are affected by it.’ Later on, the same health care professionals and workers were assaulted, abused and even stigmatized, as they try hard to fight the virus. Intriguingly, many of the same people earlier participated in beating pots and pans to show respect for them.

Similarly, ‘citizens across the country lit Diya, Candles and flashed their mobile and torch lights on Sunday following our Prime Minister’s appeal, for a 9-minute blackout to dispel the “darkness” spread by Coronavirus.’ Ironically, in later days, many of these people – from the super rich to poor, acted in contrary to this purpose, for totally different reasons. This happened. But, understanding why it happened in India – right from the call – to its immaculate execution and the contradiction that followed on the ground, is a complex task for many. Perhaps, as complex to understand as, why containing the Coronavirus disease spread, through social distancing alone, is being considered as the only way to win the war against Covid19.

All countries in the world, as the experts say, will reach and pass the peak of the first wave of Coronavirus outbreak at some time. This will possibly not mean the end of the Covid19 war, before a vaccine is available. Thus, long term protection of people against Covid19, in the shortest possible time, is the name of the game. In the midst of these, life moves on – with some critical questions still remaining unanswered. Nonetheless, the resolve to fight and win this war, against an invisible enemy, be it only through social distancing, or with a more comprehensive and scientifically explainable strategy and ultimately a vaccine, continues to linger.

By: Tapan J. Ray   

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.