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COVID-19 Crisis in India: Lessons for the World

May 1, 2021 | Article No. 78

COVID-19 Crisis in India: Lessons for the World

May 1, 2021 | Article No. 78

Contributors

Ayesha Siddiqua MSc, PhD

Mohit Bhandari MD, PhD

Insights


  • India is currently facing the biggest crisis of the COVID-19 pandemic.

  • As of late April, the daily number of cases and deaths have risen well above 300,000 and 2000, respectively – although these figures are thought to be significantly underestimated.

  • The new surge in cases have put tremendous strain on the health care system, notably leading to fatal shortages of medical oxygen supply in high need areas for patients in critical condition.

  • Scientists and physicians alike have concluded that relaxing social distancing measures too early are, in part, responsible for this new wave.

  • The presence of the new “double mutation” variant further complicates the new surge in cases. 

  • Mass vaccination and committing to strict social distancing measures again can reduce the toll of the pandemic in India in the months to come. 


“The stories, pictures and videos coming out of India are devastating. Scenes of people lying on the ground on the street with oxygen masks connected to empty tanks, dying outside of hospitals that did not have capacity to take them in, health care systems collapsing. There are make-shift outdoor hospitals, mass cremations sites, and reports of families having to keep dead bodies of relatives at home for two days because there was no wood left to build a funeral pyre. Hospital with mere hours left of oxygen supply.”
 

Vohra-Miller (2021) (1)

“India’s coronavirus infections rate is growing at the fastest pace in the world… The 350,179 new cases (as of April 26, 2021) pushed India’s total past 17 million, behind only the United States. Deaths rose by 2,812 in the past 24 hours, bringing total fatalities to 195,123, the health ministry said, though the number is believed to be vastly undercounted.”

Al Jazeera (2021) (2)

“Interviews from cremation grounds across the country, where the fires never stop, portray an extensive pattern of deaths far exceeding the official figures. Nervous politicians and hospital administrators may be undercounting or overlooking large numbers of dead, analysts say. And grieving families may be hiding Covid connections as well, out of shame, adding to the confusion in this enormous nation of 1.4 billion.”

Gettleman et al (2021) (3)

“It’s a complete massacre of data…from all the modeling we’ve done, we believe the true number of deaths is two to five times what is being reported.”

Dr. Bhramar Mukherjee

Professor of Epidemiology, University of Michigan (3)

The COVID-19 pandemic has, in many countries, exacerbated many preexisting precarious circumstances, including severe poverty, gender inequality, and domestic violence. Public health measures such as lockdowns which are imperative for reducing the spread of SARS-CoV-2 do not always seem practical in developing countries for extended periods of time, as it is a surefire formula for decimating the economic wellbeing of working-class people and driving them straight to hunger. Furthermore, in regions with high population density, it is challenging to effectively maintain social distancing which also facilitates the spread of SARS-CoV-2. It is precisely the challenges with dense populations and lack of effective lockdown and social distancing measures that have led India to be one of the countries with the highest number of daily cases and deaths throughout this pandemic. In mid-September 2020, the number of 7-day average cases rose close to 100,000. Encouragingly, while this number kept declining up to March 2021, there was a dramatic increase in cases soon after – with over 300,000 cases and 2000 deaths per day observed from mid-April 2021. These staggering numbers would overwhelm any healthcare system in the world, let alone one that is already under-resourced. Scientists have predicted that the current situation in India will get worse before it will get better. This makes us question – what specific circumstances have led to India’s new wave—and are there lessons for the world? Despite the many challenges they experience to enforce preventative measures, they were still doing relatively well to control the spread of SARS-CoV-2 just a few months ago. A critical analysis of factors that landed India in one of the worst public health crises the country has ever seen will not only help them plan a sound mitigation strategy, but it will also serve as an important lesson for other countries to prevent a similar crisis from happening in the months to come. 


“More than 70 percent patients in both waves are more than 40 years old, only marginally higher proportion of younger patients.”

Times of India (2021) (4)

“As per the government data, 5.8% hospitalized patients were between 0-19 age in the second wave in comparison to 4.2% from the same age group in the first covid-19 wave.”

Sharma (2021) (5)

“The oxygen shortage has become so dire that a Sikh house of worship in capital New Delhi began offering free breathing sessions with shared tanks to COVID-19 patients waiting for a hospital bed.”

Al Jazeera (2021) (2)

A Look at the Two Waves of COVID-19 in India

Looking at the trajectory of COVID-19 cases in India from February 2020 to April 2021, two distinct waves are observed (Exhibit 1). The first peak was observed in September 2020, with the highest number of new cases (n=97,894) recorded on September 16 (6). The second peak is being observed right now, with 360,927 new cases recorded as of April 27, 2021. While these numbers are astounding as they are, it has been repeatedly concluded that both cases and deaths are likely severely undercounted – and represent a fraction of the real spread of the virus that has thrown India in a complete state of emergency (3,7). 


Exhibit 1: The Number of New Cases of COVID-19 in India on the First Day of Each Month, followed by the Surge in April (6)


It is important to note that in the months before and after the first peak in September 2020, the number of daily cases in India have been high, with thousands of daily new cases observed since May 2020 (6). In order to reduce the number of cases, the Indian government has issued several lockdowns earlier last year (Exhibit 2). However, even after the first wave in 2020 with thousands of daily new cases emerging in the months following September, there were no lockdowns to attempt to control the spread of SARS-CoV-2. 


Exhibit 2: Timeline of Lockdowns in India during the COVID-19 Pandemic


Phase 1 March 25 to April 14, 2020
Phase 2 April 15 to May 3, 2020
Phase 3 May 4 to May 17, 2020
Phase 4 May 18 to May 31, 2020

 

A recent analysis by the Indian Council of Medical Research compared the similarities and differences between the two waves (Exhibit 3). Overall, older individuals have been most susceptible during both the waves, whereas proportion of patients showing symptoms of breathlessness and requiring oxygen has been much higher during the second wave.  


Exhibit 3: Key Characteristics of the First and Second Wave of COVID-19 in India (4,5)


Scroll Horizontally >

  First Wave Second Wave
Age groups of cases Older patients are more vulnerable  Older patients are more vulnerable 
Symptoms Higher proportion of patients showed sore throat and dry cough 

Higher proportion of asymptomatic individuals got admitted to hospitals

Higher proportion of admitted patients showed breathlessness

Medical support requirement Mechanical ventilator requirement is higher Oxygen requirement is higher

 

“The situation in India is grave and complex. India saw a sharp decline in cases earlier this year, with around 10,000 cases on average per day in February. This unfortunately led to a sense of complacency, with some experts claiming preemptively that the country had achieved herd immunity. Subsequently, life returned to a form of “normalcy,” with weddings, religious festivals and political rallies being commonplace. Even Kumbh Mela, which is one of the largest gatherings in the world that sees upwards of 110 million people over the duration of the festival and up to 30 million people per day, went ahead as planned.”

Vohra-Miller (2021) (1)

“We completely let down our guard and assumed in January that the pandemic was over—and COVID surveillance and control took a back seat…but there were still a fairly large proportion of people in the big cities, but also in smaller cities and villages, who were not exposed to the virus last year, who were susceptible.”

Dr. K. Srinath Reddy, President

Public Health Foundation of India (8)

Calling an Early Victory

The spike in cases during the second wave of COVID-19 has been viewed as a consequence of the premature re-opening of India’s economy. Indian officials had declared victory over the pandemic in January 2021, when the daily number of cases in the country was still close to 20,000 early in the month and never below 10,000 later in the month (6). Even under these circumstances, very large social gatherings were allowed to proceed, including weddings, election rallies, and religious festivals that were attended by millions of people (1). These gatherings raised two important concerns: 1. facilitate the spread of the virus and 2. increase the chances for the virus to mutate by giving it more opportunities to circulate in the population. Indeed, a new SARS-CoV-2 variant, initially detected in India (known as the B.1.617 “double mutation” variant with two mutations: E484Q and L452R), is thought to play a role in the sudden surge of cases (9). While there is limited data on the B.1.617 variant due to lack of widespread sample testing in India, it was reported in March 2020 that this new variant accounted for 15-20% of samples sequenced in Maharashtra, a hard-hit state where more than 60% of all active cases were found (10). To be noted, however, scientists indicated that it is too early to know how debilitating the new variant is and caution must be exercised before drawing definite conclusions regarding the impact of this new variant (3).  



Experts conclude now that policies should have maintained rigorous strategies to prevent the spread of SARS-CoV-2, including physical distancing, wearing masks, and avoiding large crowds (7). Research and medical professionals have suggested that the government should have used 2020 to acquire resources and develop systems to battle the likelihood of a new surge of the virus (7). Notably, while the shortages of medical oxygen supply have been rampant in hard hit regions in Northern and Western India, there is indeed surplus supply in Eastern India – yet, logistical barriers have impeded the transport of this critical resource to areas of need thus far. The overall lack of surveillance data collection in a timely manner to prepare for future waves, failure of centralized administrative bureaucracy, and poor execution of key decisions regarding the acquisition and dissemination of crucial resources have been identified as some key determinants for the current raging wave of COVID-19 in India


“India’s Covid vaccine campaign is struggling: Less than 10 percent of Indians have gotten even one dose, despite India being the world’s leading vaccine manufacturer.”

Gettleman et al (2021) (3)

“Earlier this year, the US placed a temporary ban on exporting raw materials critical for vaccine production. This controversial decision meant vaccine makers around the world, including the Serum Institute of India (SII), faced a shortage of materials to make Covid-19 vaccines and were forced to look elsewhere.”

Yeung (2021) (11)

“With the global supply of vaccines unlikely to pick up until the end of this year, what is required now is international leadership and a recognition that, despite the best intentions of the World Health Organization and the vaccine-sharing Covax initiative to fairly distribute jabs, the pandemic may require a period of more focused firefighting where difficult and sometimes unpopular decisions need to be made.”

“That will require countries to look beyond their own health crises to see that the pandemic could still get much worse without intervention. Experts have repeatedly warned that allowing the virus to circulate unchecked increases the risk that dangerous new strains will emerge and prolong the pandemic.”

The Guardian (2021) (12)

Vaccine Nationalism Will Not End the Pandemic

Notwithstanding the limited data availability, current evidence suggests that the two mutations from the B.1.617 variant are associated with a poorer antibody response (10). This means that antibodies which are developed as a result of getting a vaccine or a previous SARS-CoV-2 infection are less effective at neutralizing the new version of the disease (10). Nonetheless, even though the vaccines may not stop individuals from getting the infection, they will still prevent severe disease and death from the disease – which are compelling reasons to ramp up the vaccination campaign in India (10). 



Higher income countries have jumped to the opportunity to pre-purchase a significant portion of doses of many vaccines, leaving a very small portion of doses available for lower- and middle-income countries (13). This raises important ethical and practical questions, both of which have implications for how quickly the pandemic will be over. On a practical ground, vaccinated countries will invariably see the introduction of new variants of the virus unless there is a global action to distribute vaccines equitably.  



India has been dubbed as the “world’s pharmacy” during this pandemic and is one of the largest suppliers to COVAX, the COVID-19 Vaccine Global Access program established to ensure an equitable global vaccine allocation mechanism. While pledging its support to COVAX, India distributed most of its manufactured vaccines globally, accounting for 60% of the global vaccine supply for this program, but only managed to vaccinate 10% of its own population with just one dose and 1% with both doses (1). This highlights the importance of taking a global approach to disseminate vaccines to not disproportionately disadvantage any country with overwhelming responsibility. The existing shortage of vaccines in India was further compounded by the temporary ban from the US on exporting raw materials critical for vaccine production, which significantly hindered manufacturing efforts in India. 



Even though the US has now offered to make raw material available to urgently manufacture Covishield, the Oxford-AstraZeneca vaccine made by Serum Institute of India, this is help coming a little too late (7). Vaccines simply will not be manufactured and administered to the civilians of India fast enough at this point to develop the herd immunity needed to prevent cases from rising. The biggest damage has been already done and it is now an uphill battle for India – where the world has a moral responsibility to put aside any nationalistic sentiments that they exhibited throughout the pandemic to only protect their own people, and step up to help the people of India who are experiencing the biggest tyranny of this pandemic.  


“What is different in India – a country with a fragile health system and even weaker surveillance – is the huge possibility for harm locally and globally, perhaps on a scale not yet seen in the pandemic.”

The Guardian (2021) (12)

“This ‘me first’ strategy (of hoarding vaccines or material to manufacture vaccines) is not only inequitable, it is unwise because we know how the pandemic unfolds in one country will eventually happen in another.”

Vohra-Miller (2021) (1)

India’s Lessons for the World

It is with heavy hearts we watch the crisis in India unfold and count on our world leaders to make swift decisions to provide this country with much needed support and relief. We would like to highlight that without careful planning, the crisis in India will not be an exception in this pandemic but rather the norm in other countries as we navigate through the next few months. The plight of COVID-19 in India shows why it is far too early to grow complacent of public health measures to prevent the spread of the virus, when the daily case load has reached thousands in many countries as they proceed through their own successive waves, while simultaneously battling new variants of the virus. Continuous social distancing coupled with a rigorous vaccination campaign is our only hope for keeping case counts, and associated hospitalizations and deaths down. Needless to say, this of course needs to occur in tandem with rapid testing of suspected cases and offering the most vulnerable individuals with enough support so they can afford to stay at home when they are sick. Even in higher income countries such as Canada, the past year has demonstrated these are topics of highly politicized debate – which has delayed many crucial decisions to curb the toll of COVID-19 in this country. Yet, if the case of India has taught us anything, it is time for leaders to put all political agendas aside and work together to bring an end to this pandemic – as it really is the only way to see an end to this tragedy. 


References

1.    Vohra-Miller S (2021). India is in a COVID-19 crisis. South Asian-Canadians are weeping from afar, but also seeing devastating parallels for our people in Ontario. Retrieved from https://www.thestar.com/opinion/contributors/2021/04/24/india-is-in-a-covid-19-crisis-south-asian-canadians-are-weeping-from-afar-but-also-seeing-devastating-parallels-for-our-people-in-ontario.html

2.    Al Jazeera (2021). COVID patients, families beg for oxygen at India’s hospitals. Retrieved from https://www.aljazeera.com/gallery/2021/4/26/oxygen-demand-outstrips-supply-in-indias-covid-hotspots

3.    Gettleman J et al (2021). As Covid-19 devastates India, deaths go undercounted. Retrieved from https://www.nytimes.com/2021/04/24/world/asia/india-coronavirus-deaths.html

4.    Times of India (2021). First vs second wave of Covid-19 in India: Things you need to know. Retrieved from https://timesofindia.indiatimes.com/india/first-vs-second-wave-of-covid-19-in-india-things-you-need-to-know/articleshow/82143427.cms

5.    Sharma NC (2021). Covid-19 first vs second wave: Oxygen demand higher, marginal rise in younger person hospitlised, shows data. Retrieved from https://www.livemint.com/news/india/first-vs-second-wave-oxygen-demand-higher-marginal-rise-in-younger-person-hospitlised-shows-gov-data-11618855777997.html

6.    The New York Times (2021). India Coronavirus Map and Case Count. Retrieved from https://www.nytimes.com/interactive/2020/world/asia/india-coronavirus-cases.html

7.    Saaliq S & Hussain A (2021). Coronavirus 'swallowing' people in India; crematoriums overwhelmed. Retrieved from https://www.ctvnews.ca/world/coronavirus-swallowing-people-in-india-crematoriums-overwhelmed-1.5401433

8.    Bhowmick N (2021). How India’s second wave became the worst COVID-19 surge in the world. Retrieved from https://www.nationalgeographic.com/science/article/how-indias-second-wave-became-the-worst-covid-19-surge-in-the-world

9.    LiveMint (2021). India's 'double mutation' covid virus variant is worrying the world. Retrieved from https://www.livemint.com/news/india/indias-double-mutation-covid-virus-variant-is-worrying-the-world-11618789603145.html

10.    CBC News (2021). What we know about the coronavirus variant contributing to India's surging caseload. Retrieved from https://www.cbc.ca/news/health/india-b1617-variant-explainer-1.5998121

11.    Yeung J (2021). As India breaks another global Covid-19 record and hospitals run out of oxygen, countries pledge assistance and aid. Retrieved from https://www.cnn.com/2021/04/26/india/india-covid-international-aid-intl-hnk/index.html

12.    The Guardian (2021). Why India’s worsening Covid crisis is a dire problem for the world. Retrieved from https://www.theguardian.com/world/2021/apr/25/the. -world-must-act-indias-covid-crisis-is-a-dire-problem-for-us-all

13.    Wouters OJ et al (2021). Challenges in ensuring global access to COVID-19 vaccines: Production, affordability, allocation, and deployment. The Lancet 397: 1023–1034. DOI: 10.1016/S0140-6736(21)00306-8. 


Contributors

Ayesha Siddiqua MSc, PhD

Ayesha Siddiqua completed her graduate training from the Health Research Methodology Program in the Department of Health Research Methods, Evidence, and Impact at McMaster University. She is a Data Scientist at OrthoEvidence.

Mohit Bhandari MD, PhD

Dr. Mohit Bhandari is a Professor of Surgery and University Scholar at McMaster University, Canada. He holds a Canada Research Chair in Evidence-Based Orthopaedic Surgery and serves as the Editor-in-Chief of OrthoEvidence.

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