Karnataka, particularly Bengaluru, is on edge after the confirmation that the second wave of the Covid 19 pandemic is underway. A second wave had been in the making for the past three months. Nearly four months ago, at a webinar hosted by Karnataka Janaarogya Chaluvali (KJC) titled, ‘Second Wave and Covid19 vaccines: Possibilities, preparedness and implications for the community- based preventive work’, the speaker Dr. Himanshu had rightly predicted that one needs to gear up for the second wave. He had warned that the government should not slacken the pace of its test-trace- treat strategy and people should not get complacent about following preventive measures such as wearing masks, handing washing and physical distancing. The onset of the second wave in Karnataka and few other states seem to indicate that we have faltered on both counts.
Cases across the country began steadily climbing from early march 2021. Unlike the first wave, the numbers quickly swelled. For example, during the first wave, it took 32 days to increase from 18000 to 50000. But now in the second wave, it took a mere 17 days for the cases to rise from 18,377 on March 11 to 50518 on 27 this year. In just a week, the rate of new infections have increased by 66% which was the largest week-on-week case growth witnessed in the country since May 10, 2020. As in the first wave, it is states like Maharashtra, Karnataka, Kerala and Punjab that are contributing to nearly 75% of the cases (See figure below). Other numbers in states like Gujarat, Tamil Nadu and Andhra Pradesh are also climbing up. It is expected that these states with higher levels of urbanization, industrialization, large cities and greater levels of intra -state, inter- state and international movements will get affected first. So one can expect other states such as UP, West Bengal, Orissa to experience the second wave somewhat later.
What explains the sudden advent of the second wave and its faster spread?
Several experts point out that the second wave is not ‘sudden’. It was to be expected because such has been the nature of various viral pandemics in the past. The word ‘wave’ means a pattern of peaks and valleys and implies that one can expect a rise even when there is trough. it has been observed that each wave is associated with certain factors such as seasons, climate, human activity patterns etc. and each wave differs in various ways such as its severity, who it affects and so on. Based on such studies, SARSCoV2 had been predicted to follow the past pandemic pattern of waves. For instance in early December, when large parts of Europe experienced the second wave it was found to be more severe than the first.
It has been pointed out that in India the political class became complacent when sero- prevalence rates reached 30 to 40% believing that we were close to reaching ‘herd immunity’. We now know that predictions about ‘herd immunity’ have been wrong. For example, initially it was predicted that at least 60% of the population has to be infected with the virus to attain herd immunity. But in Brazil the pandemic continues its unrelenting course even though sero- surveillance rate is around 73%.
This kind of misplaced preoccupation with herd immunity soon translated into laxity. Religious gatherings, rallies and election campaigns were permitted unhindered with a simultaneous dip in testing, tracking and surveillance activities. For instance, in a shocking case of gross neglect, the Karnataka government claimed that 570 international travelers of the total 2406 who arrived between 1st and 21st December 2020 had gone missing! So it is no surprise if we have several new strains of viruses from different countries entering and freely circulating in the country.
The other cause that experts are looking at is fatigue among people at having to keep up with the same level of precautions. For instance, BBMP has collected a whopping Rs 10 crore in fines over the last year indicating that people have failed to use masks consistently. It is understandable that people do get tired at having to constantly be on alert. But one must remember that as of now wearing masks, frequent hand washing and physical distancing are the only guaranteed ways in which one can keep oneself safe from the virus. All other interventions, be it treatment or vaccinations, continue to be work- progress. Only over time will we gain enough understanding about their effectiveness.
What about ‘mutant variants’ and different strains of the virus?
The genetic material of SARS-CoV-2 is the ribonucleic acid (RNA). A complete set of an organism’s RNA or DNA is called a genome. During the process of replication errors often occur which results in viruses that are similar but not exact copies of the original virus. These errors in the viral RNA are called mutations, and viruses with these mutations are called variants. Variants could differ by a single or many mutations. For example, an analysis of the samples collected from Maharashtra showed an increase in variants with two mutations (named E484Q and L452R mutations) as compared to the samples in December. Presence of mutations need not cause any change in infectiousness or virulence or in other words, the virus’ behavior. But when the mutation causes a change in behavior of the virus then it is called a strain. For example a study by the Imperial College London found the new strain in the UK to have an ‘R’ value of 1.45, while it was around 0.92 for the previous strain indicating that it is far more infectious than the earlier strain.
Presently, the biggest concern regarding the second wave is the prevalence of different mutant variants of the virus here and the different strains from the UK, South Africa and Brazil that could be circulating. To understand the extent to which these might be contributing or not to higher infectiousness and whether they will cause more severe disease one needs to undertake a laboratory procedure called genome sequencing. This procedure is used to determine the entire genetic makeup of a specific organism and to find changes in areas of the genome. For example, NIMHANS tested 86 samples of UK returnees and found 25 were positive for the UK strain. But none had Brazilian or the South African strain. Similarly, the National Centre for Disease Control (NCDC) tested 401 samples from Punjab and found that 81 percent of them tested positive for the UK strain. And we find that Punjab, as on March 24, had the third highest number of active cases in the country and the highest case fatality rate (CFR), the proportion of deaths among total individuals infected.
But these samples are far too small to arrive at any conclusion about whether or not these strains are fuelling the spread or virulence of the disease or whether any other strain has been formed. Experts say that if we have to understand the second wave and put in early preventive measures then we have to expand the genome sequencing procedure. India started genome sequencing in early January through the 10 labs that are part of the Indian SARS-CoV-2 Genomic Consortium (INSACOG). But funds constraints have stalled the expansion of genome sequencing as of end march 2021.
What about health system preparedness?
Karnataka government is confident about the facilities it has put in place in terms of HDU and ICU facilities. But what is of serious concern is the exhaustion among frontline workers, the ASHAs who have been the driving force behind the state’s preventive efforts. They have not been paid any incentives for the risk they face during the tracing and testing process. Their morale is low and many of them wonder whether it is worth putting their life on the line when their efforts are neither recognized nor rewarded. BBMP has declared that it has increased the number of ASHA workers, 1 ASHA worker for every 500 population. But merely increasing the number of workers while continuing its exploitative tactics is unethical and shameful. The government should substantially increase the salaries of ASHA workers and initiate action to make them permanent. This would be the least it could do to increase frontline staff’s motivation and thereby strengthening its preventive strategies.
Does vaccination lead to a decrease in transmission?
While the government’s vaccination efforts are slowly increasing, it continues to be a small fraction of the total population that needs to be covered. It is also far too early to expect that the vaccination to take effect such that it contributes to a decrease in transmission. Further, It will depend on the strains of viruses circulating in the population and whether or not the vaccine will be effective on them. At the same time it is important to increase the pace of vaccination. The recent move by the government to cover all those above the age of 45 years irrespective of their co- morbidity status is an important step in that direction.
In conclusion it is important to step up trace- test- treat strategy on the ground while bringing in measures to prevent mass gatherings of all kinds, reduce footfalls in malls, theaters and other such places and stringently enforce use of masks in all public places.
At the individual level, it is important for people to remember that herd immunity is elusive and may not happen at all, we are not yet clear about the effectiveness of the vaccine and Covid 19 disease causes not only acute symptoms but also long lasting sequel such as lung damage. Therefore individuals have to be responsible and continue to wear masks and wear them correctly, frequently wash hands and ensure physical distance in public, avoid indoor gatherings of any kind for some more time.
Finally ensuring adequate funds for surveillance and expanding genome sequencing to 5% of tested samples is crucial to make appropriate decisions for containing the second wave.
The author is a convener of Karnataka Janarogya Chaluvali ( Campaign for healthcare Karnataka) and a Health Activist. She also holds a Ph.D. in Public Health from NIMHANS. The article was First published in Nyayapatha a Kannada Weekly of Gauri Media.