Abstract
Public health experts have warned that India is going to face the third wave of COVID-19 soon. However, experts differ in their prediction on when it will hit the country and how severe it would be. Different experts have predicted a different timeline for the impending third wave ranging from mid-July to October 2021. The epidemic curve of the second wave of COVID-19 in India is declining since it recorded the highest numbers of laboratory confirmed COVID-19 cases on 6 May 2021. A close look at the pattern of reported cases in India over the last couple of weeks reveals that the second wave of COVID-19 has not yet reached its base. The country has been registering around 40 to 50 thousand new cases (range of weekly average) since 1 July 2021, which is 0.12% to 0.15% of the cumulative total cases. This indicates that the epidemic is still in the control phase and has not reached the containment stage. On 7 September 2021, the country reported 43,401 new COVID-19 cases, of which five states contributed 88.5%. The states of Kerala (30,196), Tamil Nadu (1,587), Andhra Pradesh (1,361), Karnataka (1,102), Maharashtra (4,174), J&K, and a few states of the North-East are largely contributing to this tally of daily new COVID cases. The number of districts reporting more than 100 new COVID cases has declined from 108 districts in June, 58 in July, to 38 in September 2021. Hence, it is evident that the COVID-19 epidemic in India has a varying pattern in states. The weekly positivity rate is also declining and has stabilised below 3%. However, 35 districts—mainly in Kerala and some in Himachal Pradesh and the North-East—are still reporting over 10% positivity. Besides, 30 districts have positivity rates ranging between 5% and 10%. The states of Kerala and Maharashtra have recorded a rise in R0, which has crossed the threshold of 1. These disturbing findings indicate that the disease might go out of control in these states if appropriate interventions are not implemented soon. Data on surveillance of COVID variants in the states reporting a proportionately higher burden of COVID-19 indicate that a newer variant of COVID-19 has been identified, that is, Delta-plus. Although the number of cases reported with the Delta-plus variant is few, it is unknown if it would be more transmissible and severe than the Delta variant. Still, these findings support the possibilities of an impending third wave of COVID-19.
ICMR conducted the fourth round of sero-surveillance in 70 districts of 21 states and union territories during 14 June to 6 July 2021, revealed seropositivity amongst 67.6% of the sampled population above the age of six years and 85.2% among healthcare workers against the SARS-CoV-2. The findings of the fourth round of sero-surveillance indicate that during the second wave of COVID-19 (March 2021 onwards), a large proportion of India’s population has acquired COVID infection and, as a result, have developed antibodies against COVID-19.
India launched vaccination against COVID-19 on 15 January 2021, with two indigenous vaccines—Covisheild and Covaxin. As of 7 September 2021, India has administered more than 700 million doses of vaccine. One hundred sixty-four million persons (12% of the eligible population) have received two doses, while five hundred thirty-six million people have received one dose of COVID vaccine. Vaccination coverage varies widely between states. Although, the proportion of fully vaccinated persons in India is just 12% compared to the world’s average (29.4%) to date. With the rate at which India is vaccinating its population, it is expected that all eligible people will be vaccinated by December 2021.
The new Corona variant—COVID Delta-plus—was first identified in Maharashtra’s Ratnagiri and Jalgaon districts. The Delta-plus variant is also reported from Madhya Pradesh, Tamil Nadu, Kerala, Karnataka and J&K. Commonly used vaccines in India (Covisheild and Covaxin) are effective against the Delta variant of COVID. The efficacy of these vaccines against the Delta-plus variant is not known yet.
With the declining number of COVID-19 cases during the latter part of July 2021, the Ministry of Home Affairs (MHA) Government of India issued revised guidelines for COVID management on 14 July 2021. With low numbers of daily COVID-19 cases, several states have decided to carefully permit commercial, social and political activities. The states also decided to open offices, schools and public transport. The MHA further changed the COVID guidelines because of the overall stable COVID pandemic situation on 28 August 2021, and advised the states to take pro-active containment measures to effectively arrest the spike in cases and contain the spread of transmission. These guidelines reiterated that it is essential to identify warning signs of potential surges early on and take appropriate measures to curb the spread. This would require a localised approach, as mentioned in Ministry of Health and Family Welfare (MoHFW) advisories dated 25.04.2021 and 28.06.2021.
Whether the third wave of COVID-19 will occur as predicted or it may not happen at all given the rapid vaccination in all states remains to be seen. Six states out of twenty-nine states of India are still reporting more than 1,000 COVID cases per day. The new variant of COVID—the Delta-plus is also reported in these states. The other concern is that if COVID-19 start rising in states and districts hitherto reporting low numbers, how severe will it be? Will it surpass the cases reported during the second wave, or will it remain truncated? If the third wave strikes as predicted by public health experts, will children suffer in higher numbers?
Considering the fact that more than two-third population is naturally infected, 700 million persons have been vaccinated with one dose of COVID vaccine, the number of districts reporting more than 100 new cases are declining steadily, and no new variant of the COVID has emerged, it could be construed that likelihood of the third wave is feeble. The possibility of age shift and a focal outbreak of the disease in population groups not yet infected and vaccinated will remain. Still, we must keep our fingers crossed and carefully watch the emergence of newer variants of the virus capable of fooling natural and vaccine-induced immunity.
Also, how the COVID-19 epidemic will behave in India will solely depend upon how the states manage the declining second wave through effective public health measures of testing, tracing, quarantine, isolation and enforcement of COVID appropriate behaviours. It will depend upon how rapidly vaccination of all eligible populations with two doses is achieved. It will be contingent on the respective state governments’ decision to open commercial, social, political and religious activities on the status of implementation of control measures taken in the state and effective public health interventions undertaken to check on the emergence of newer variants of the disease agent. The other important determinants of the future trend of COVID-19 in different states and the country would depend upon the occurrence of natural immunity through inapparent and apparent COVID infection and active vaccination of the eligible population.
The global trends of COVID-19 pandemic have shown third and fourth waves of pandemic. Taking cues from these trends, the possibilities of the third wave is high and imminent in India. The second wave was severe and sharp, and it is tailing off now at seemingly new normal. But it is the time when the third wave may trigger off. Let us be future-ready with preparedness of health systems to fight the potential third wave, including hospitals. Strong and uninterrupted logistic and supply chain and continuous disease surveillance shall be the key interventions to confront the third wave.
The government should revisit its COVID prevention and control strategies as the disease is still majorly confined only to a few states and districts of India. It is high time to devise a district-based strategy depending upon the caseload and transmission levels. District with few cases should emphasise micro-containment coupled with intensified early detection, contact tracing, quarantine and isolation. The population movement from other districts should be regulated to ensure a curb on imported cases. At the same time, the strategy of testing, contact tracing, quarantine, isolation should be intensified in districts with a higher caseload. All districts should aim at vaccinating the entire eligible population at the earliest, including children will significantly contribute to thwarting the third wave of COVID epidemic.