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SITUATION UPDATE 18 May, 2021 Back

Situation Update - India’s second wave of COVID-19 healthcare crisis

Leanne Self

India's Covid-19 Situation overwhelms healthcare system

Summary

  • India has faced a significant surge in COVID-19 cases since mid-March, with the country's total case tally now surpassing 25 million.
  • Data from several Indian states shows a slow but steady decline in cases, suggesting that the peak has already been reached. However, researchers say this is an "illusion" as the figures are likely to be vastly underrepresenting the true situation.
  • Prime Minister Narendra Modi and his Bharatiya Janata Party (BJP) have attracted widespread criticism for their alleged mishandling of the second wave.
  • The government has taken steps to curb the spread of the virus, which include banning vaccine exports, imposing local lockdown restrictions and requesting aid from allies.
  • Modi remains reluctant to impose a second national lockdown after a strict lockdown during the country's first wave resulted in a significant rise in poverty.
  • India's ban on vaccine exports to COVAX is significantly impacting the global vaccination effort, especially to low- and middle-income countries.

Situation

Since mid-March, India has faced a significant surge in COVID-19 cases in what Prime Minister Narendra Modi has described as a coronavirus “storm” that is overwhelming the county’s healthcare system. Between mid-March and early May, India repeatedly set new global records for the highest number of cases recorded in one day as well as new domestic records for the highest number of COVID-related deaths in one day. However, daily cases have been in general decline since reaching a peak of 414,188 on Thursday, 6 May. On Monday, 17 May, the daily cases number dropped to below 300,000 for the first time since 21 April and on Tuesday, 18 May, India registered 263,533 cases in the previous 24 hours, which has led to speculation that the peak has been reached. Despite this, the daily death toll set a new record of 4,329 on 18 May, bringing the total death toll to 278,719.

New Delhi, which has been one of the worst hit by the pandemic, has seen a steady decline in daily infections in the past week, while other highly impacted states such as Maharashtra, Uttar Pradesh and Chhattisgarh are also witnessing a slow but steady fall in cases. While the health ministry has said that the second wave in the country is "stabilising", Professor Vincent Rajkumar of the US’ Mayo Clinic warned that “this drop in confirmed COVID cases in India is an illusion". Due to backlogs of test results and poor access to testing, as well as overwhelmed crematoriums and burial grounds, the total tally of registered infections and associated fatalities are likely to be a significant underestimate of the true case numbers. Instead, actual infections and deaths could be five to 10 times higher.

Although data shows a potential decline in cases in some states, the epidemiological situation remains critical as the country continues to face perilous oxygen shortages and a high demand for hospital beds. World Health Organization (WHO) Chief Scientist Soumya Swaminathan has warned that “there are still many parts of the country which have not yet experienced the peak, they are still going up", including rural areas and states such as West Bengal, Tamil Nadu and Uttarakhand.

The vaccine rollout in the country has been slow despite having one of the world’s largest vaccine producers, the Serum Institute of India (SII). So far, India has vaccinated 40.5 million people, which equates to only 3% of its vast population. After initially failing to secure enough vaccine doses for its own population, India at the end of March banned all vaccine exports in a bid to ramp up its domestic vaccination drive. However, the current vaccine capacity of the SII does not compare to the number of Indian’s eligible for vaccination. Due to a lack of funding and resources, India’s shortage in vaccination supply is projected to last until at least July. Furthermore, although Modi remains reluctant to impose a national lockdown citing concerns of an economic crisis, in recent months, 35 of India’s 36 states and union territories have imposed their own restrictions to varying degrees based on the states’ epidemiological situation.

While India’s government attempts to curb the virus with increased vaccination drives and restrictions, the country’s COVID-19 crisis has attracted widespread international concern with some 40 countries pledging to help. In recent weeks, vital medical supplies, including ventilators, oxygen concentrators and face masks, have started to reach hospitals across the country. The WHO, the UK, Germany, Australia, Ireland, France and Russia are among those who have shipped vital medical supplies to India.

Analysis

At the beginning of the year, India was witnessing a steady and stable decline in COVID-19 cases and by mid-February the country was registering an average of 11,000 cases per day, while the seven-day rolling average of daily deaths from the disease had fallen to below 100. With relatively low infections and deaths being registered, the ruling Bharatiya Janata Party's (BJP) national executive committee passed a resolution in February which stated, “The party unequivocally hails its leadership for introducing India to the world as a proud and victorious nation in the fight against Covid.” However, the BJP’s premature victory declaration has since been widely criticised.

The coming of the second wave in India was not for lack of warning. Despite evidence of a rise in COVID-19 cases in early March and previous warnings from health officials against complacency, Modi’s government removed COVID-19 restrictions and lifted associated lockdowns which saw life in India return to a sense of “normal” for most residents. Not only had restrictions been lifted but Modi’s government also encouraged the public to gather at religious festivals and political rallies, most notably for the Holi festival at the end of March, election rallies in West Bengal, Kerala, Tamil Nadu, Puducherry and Assam between March and April, and religious congregations in Haridwar in March and April to celebrate the Kumbh Mela Hindu festival. While customary guidance on COVID-19 was issued for these events, there was an evident lack of social distancing and the use of face masks was widely absent among the attendees. Although it could be argued that India’s second wave was unavoidable, its severity has most likely been driven by these numerous events which have been termed “super-spreader events”.

In addition to this, the complacency that emerged from the illusion that the pandemic had ended likely led to a state of under-preparedness in terms of stockpiling medical supplies and health system readiness. Former health secretary of Maharashtra state Mahesh Zagade criticised the government, saying it “should have taken an inventory of oxygen and [the drug] Remdesivir and then ramped up manufacturing capacity". Additionally, Gautam Menon, a professor at Ashoka University, said that India should have begun careful genomic surveillance in January to detect variants, as these could be fuelling the surge of cases. There is speculation that the B.1.617 variant, which was first detected in India in December 2020, is partly responsible for India’s second wave; however, without genomic surveillance the impact of the variant or potential presence of other variants is unclear.

Furthermore, with infections declining at the beginning of the year, fewer citizens were being vaccinated and the government had begun exporting a large percentage of its vaccine supply to COVAX, a global initiative aimed at equitable access to COVID-19 vaccines for 92 low- and middle-income countries, as part of its “vaccine diplomacy”. These factors slowed down the country’s domestic vaccination campaign considerably, which aimed to inoculate 250 million people by the end of July. In addition, COVID-19 testing has become more difficult to arrange and results have been taking longer than expected, increasing the risk of infected people not self-isolating when necessary. According to doctors in New Delhi and Mumbai, booking slots and turn-around times for PCR tests are taking between three and eight days.

It took the BJP and other politicians weeks and months after these decisions were made before realising the seriousness of the disaster. In an attempt to curb the further spread of the second wave and relieve the overwhelmed healthcare system, Modi sped up emergency approval for foreign vaccines, requested aid from allies, banned vaccine exports at the end of March and expanded the eligibility for vaccinations to all adults aged 18 and over from 1 May. However, Modi remains reluctant to impose a national lockdown, arguing that it should only be a “last resort”. India’s struggling economy makes it much harder for the government to impose a second national lockdown. In March 2020, when the country experienced its first COVID-19 wave, Modi imposed a sweeping national lockdown with very little notice, which saw state borders close, inter-state travel banned and business operations halted. The national lockdown was imposed for approximately four months which saw much of the country’s population slide into poverty, most of whom are still recovering. Ajnesh Prasad, a professor and Canada Research Chair in the School of Business at Royal Roads University, argued that lockdown measures such as staying indoors, remote learning and social distancing are “luxuries” that simply are not available to the vast majority of Indians who live in densely populated areas. Prasad added that "without a government establishing a robust system of social support through public policy, which would appear in the form of social assistance programs like stipend or subsidies, a lockdown isn't feasible". Instead, the government has decided to focus on “micro-containment zones” which has seen lockdowns and restrictions imposed on cities, districts and states based on their epidemiological situation.

Strong criticism of Modi and his BJP party’s alleged mishandling of the country’s second wave of COVID-19 has likely affected his popularity among the public which in turn may have had an impact on this year’s state elections. Despite weeks of heavy campaigning in West Bengal, the results of the state’s eight phase polls saw Modi’s BJP fail to gain the key state from the incumbent Mamata Banerjee of the Trinamool Congress party (TMC). While retaining power in the state of Assam and winning in Puducherry union territory, the BJP was also defeated in the southern states of Kerala and Tamil Nadu. The question now is whether disillusionment with Modi's handling of the COVID-19 crisis will deepen, gradually weakening his popularity.

Implications

Without mitigation, experts estimate that India could reach more than one million COVID-19 cases per day with over one million cumulative COVID-19 deaths by 1 August 2021. While the imposition of a national lockdown is not likely at this stage, local administrations have decided to impose lockdowns and restrictions in their cities, districts and states based on their epidemiological situation. Until 24 May, lockdown measures are expected to remain in place in New Delhi, as well as the states of Goa, Sikkim, Mizoram, Tamil Nadu and Puducherry union territory. Meanwhile, in West Bengal, lockdown measures will be imposed until 30 May, and measures in Manipur State will run until at least 28 May. Lockdown measures and restrictions vary between cities and states but can include a night-time curfew, movement restrictions, non-essential business closures and restrictions on social gatherings, among others. Although not as severe as a national lockdown, locally imposed restrictions such as closures of non-essential businesses could still have a lasting economic impact on business owners and workers alike.

The fact remains that the high circulation of the virus in any population further creates continued opportunities for new variants to emerge and spread across the world. Already some seventeen countries have reported cases of the Indian B.1.617 variant, highlighting that the pandemic is an ongoing global affair and that no country will have controlled the spread until every country in the world has done so. Therefore, numerous countries across the world have had little choice but to implement travel bans and restrictions on passengers travelling to and from India in an effort to prevent the spread of COVID-19, especially the Indian B.1.617 variant. At least 35 countries including Australia, Bangladesh, Canada, France, Nepal, Pakistan, the UK and the US have imposed such restrictions on those wishing to travel to and from India. If travel to India is undertaken and a traveller requires a negative PCR COVID-19 test to return to their point of origin, it should be noted that difficulties obtaining a test appointment and delays receiving results may cause disruption to travel.

As India ramps up its domestic vaccination campaign, it should be noted that at this time it is not possible to procure COVID-19 vaccines via private commercial means. In India, vaccinations are only available through government public health schemes. This is an appropriate global strategy to achieve vaccination of the most vulnerable people as quickly as possible. India’s outbreak is not only having an impact on vaccinations domestically, but it is also significantly impacting the global vaccination effort following the government’s vaccine export ban to COVAX at the end of March. COVAX has not made a vaccine shipment from India since the ban which has significantly impacted vaccination programmes in other counties that are solely relying on India’s pharmaceutical industry, especially low- and middle-income countries in Africa and Asia where vaccine rollouts are already slow. It is understood that COVAX is in talks with India's government to potentially resume exports; however, even if successful, there is little clarity on when large-scale shipments will resume.
India is also one of the world’s largest producers of generic medications, antiretrovirals and tuberculosis medications; therefore, the global supply chain for these medications is also likely to be disrupted by the COVID-19 crisis in India. Initial findings indicate that disruption is occurring through Indian ports during the current second wave of COVID-19 in the country. Although there are no restrictions directly affecting import/export operations both through air and seaports, secondary factors are affecting operational capabilities.

Meanwhile, local doctors have seen a significant increase in cases of Mucormycosis, a fungal infection that can cause loss of eyesight and removal of the nose and jawbone. According to the doctors, Mucormycosis is fatal for people who have weak immune systems, meaning that hospitals in India overwhelmed with COVID-19 patients are a favourable environment for Mucormycosis to spread rapidly. Some hospitals are recording more than 500 cases of Mucormycosis. Research into the correlation between COVID-19 infection and Mucormycosis is limited at this time; however, the further spread of the latter could pose a further complication for patients recovering from COVID-19.