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lies ahead?
• CHANDRAKANT LAHARIYA
India’s successful vaccination drive along with relevant revisions in its strategy
have proved useful in the third wave
Getty
• COVID-19
• DELTA
• DIGITAL HEALTH
• OMICRON
• SARS COV2
• TELEMEDICINE
• THIRD WAVE
• VACCINATION
In the third week of November 2021, India was reporting around 7,000 to 9,000 daily
new COVID-19 cases. The COVID-19 vaccination was getting accelerated and
there was more supply of vaccines than demand. There was a glimmer of hope
that by early 2022, life would return to normal. Then, in the last week of
November, the emergence of Omicron (B.1.1.529)—the fifth and the latest
variant of concern (VOC) of SARS CoV2—changed almost everything.
India now is in the middle of the third COVID-19 wave. The new cases have
increased exponentially and on 19 January 2022, India reported around 317,000 new
COVID-19 cases. Nearly all states of India are showing an upward trend with a rise
in test positivity rate (TPR). The active COVID-19 cases have reached a seven-
month high, in spite of change in the case definition, where a confirmed COVID-
19 case is taken off the list of the active cases after seven days, against the earlier
approach of being considered an active case for 14 days.
Based upon genome sequenced data, the share of Omicron in all states are
seeing a rise. We also know that Delta was the reason behind an
unforgettable second wave in India and that the same variant is unlikely to
cause a fresh wave.
Alongside, the officially confirmed/reported Omicron cases in India, till 20
January 2022, stood at 9,200 only. The number of confirmed Omicron cases is
based upon the genomic sequencing, which happens only on a very small subset
of confirmed COVID-19 cases. However, in recent weeks, of all the samples
genetically sequenced, the majority have been found to be Omicron with an
upward trend. In Delhi, up to 90 percent of total samples sequenced were
Omicron, and in Mumbai, this proportion was upward of 60 percent. Based upon
genome sequenced data, the share of Omicron in all states are seeing a rise. We
also know that Delta was the reason behind an unforgettable second wave in
India and that the same variant is unlikely to cause a fresh wave. Therefore, the
third wave is being considered to be driven by Omicron.
In the ongoing wave, there are a few silver linings as well. A majority of new
infections—upto 80 percent to 90 percent confirmed cases—are asymptomatic
or mild symptomatic. The occupancy of hospital beds, oxygen beds, and ICU beds
has remained low (being termed as ‘de-coupling’ of SARS CoV2 infection from
moderate to severe disease). People who are fully vaccinated are unlikely to
develop symptomatic disease. There are other health systems factors that give
some assurance. There are COVID-19 cases admitted in hospitals; however, the
majority of COVID-19 dedicated beds are free. Then, there is the situation where
a proportion of people who are admitted to occupy COVID-19 beds are
‘incidentally’ detected, when they were admitted for some other health
conditions. They did not come to the hospital for COVID-19 symptoms but for
other health conditions. Nearly all COVID-19 patients in the ICU are those who
are either unvaccinated or have pre-existing health conditions.
The data indicates that COVID-19 vaccines are very effective in modifying
the outcome of infections and continue to prevent an individual from
suffering severe disease, hospitalisation, and death.
In the ongoing wave—with a few exceptions—the response of both the Union
and State governments in India has been more balanced, evidence-informed, and
driven by the principles of public health. The Union government has revised and
updated some of the key policies related to COVID-19 testing, isolation, contact
tracing, treatment guidelines, and hospital discharge. There is less emphasis on
contact tracing. The isolation period has been revised to seven days of being
tested for COVID-19, provided that they do not have fever for the last three days.
India’s latest COVID-19 testing policy, inter alia, does not recommend testing of
asymptomatic individuals in community settings or that of the contacts of
confirmed COVID-19 cases in home settings. The revised testing strategy, a first
in the last 16 months, has reduced the burden on testing facilities, ensuring
targeted and timely testing for those who are likely to develop adverse outcomes.
In a period of 10 days, the revised testing policy has reduced the panic (amongst
the public), has opened the door for easing out restrictions and re-opening of the
schools, without any impact on the pandemic response and management.
With a revised contact tracing approach and testing policy, and the decoupling of
infection from hospitalisation, there is a need for a fresh look at the COVID-19
indicators to be used to decide response strategies. Till the end of 2021, the most
commonly used indicator was new COVID-19 cases, which in light of revised
policies, is not a useful parameter anymore. Therefore, relevant COVID-19 policy
decisions and strategies need to be determined by more pertinent indicators
such as hospitalisation rate as well as ICU admission rate and less by the test
positivity rate.
India’s latest COVID-19 testing policy, inter alia, does not recommend
testing of asymptomatic individuals in community settings or that of the
contacts of confirmed COVID-19 cases in home settings.
There is a lot of interest amongst people whether the COVID-19 peak (of the third
wave) in a particular city is over or not. With testing strategy revised (rightfully
so), and asymptomatic not being identified, the peak has limited meaning. In fact,
with widespread transmission, it does not matter much if and when the peak
would happen. What we need to remember is that as long as SARS CoV2 cases are
being reported from any setting, we should be adhering to COVID appropriate
behavior.
Considering that the majority of the cases are asymptomatic and SARS
CoV-2 transmission is widespread, the role of other restrictions is also very
limited.
This epidemiological understanding essentially means that the states and
districts need to be prepared to respond to the emergence of Omicron cases in
their settings. While a few strategies have already been revised, there are a few
other older strategies which need to be reconsidered. As an example, there is no
evidence that night curfews and weekend curfews work to control the spread of
the virus. Considering that the majority of the cases are asymptomatic and SARS
CoV-2 transmission is widespread, the role of other restrictions is also very
limited. These are areas where more science and epidemiology need to be used
to develop policy interventions. A societal approach to the pandemic response
should be a priority, with ensuring that the poor and marginalised and economic
activities are not disproportionately impacted.
Once the COVID-19 pandemic is over, infection will not be a major risk for most
people. However, those at high risk of disease will still need to follow some
additional preventive measures and possibly receive regular booster doses of
vaccines. That stage—where new COVID-19 cases would reach a low rate and
with countries effectively being able to handle the need for hospitalisation of
those at high risk—would be termed endemic. Thereafter, there could be an
occasional increase in COVID-19 cases in different settings—localised or a
slightly wider area, similar to what happens with dengue or chikungunya viruses
where there are cases at regular intervals.
The future of epidemics in the world depends on the participation and solidarity
of all countries. If select countries of the world are busy giving their population
the third and fourth doses of the vaccine and people in Africa do not even get the
first two doses, then new variants can emerge and the epidemic can be
prolonged. It can only be hoped that rich countries will share vaccines by
learning from the emergence of Omicron. Alongside, it is likely that countries
would define endemic stage differently, depending upon their context and health
system capacity.
If select countries of the world are busy giving their population the third
and fourth doses of the vaccine and people in Africa do not even get the first
two doses, then new variants can emerge and the epidemic can be
prolonged.
Going by the current epidemiological trends, it is possible that the third wave
could be over in India by mid or late March 2022. Therefore, while each of the
Indian states prepare to respond to the ongoing third wave, it is also the time to
prepare for the endemicity.
2022 is the 75th year of India’s independence. Our health system has been tested
by the COVID-19 pandemic. It is time that every Indian state declares 2022 as the
year for strengthening government health facilities. It is time that governments
recommit to strengthening primary health services in every state of the country.
For this, one of the first steps has to be that the state governments immediately
increase the allocation of government funds for health. India’s National Health
Policy mentions that states should spend 8 percent of their budget on health
services, but in reality it is only 5 percent. This needs immediate attention. Now
is the time to make health the priority of every state government.
There are some other hopes from the year 2022 as well. It is possible that new
measures and initiatives in the field of health such as digital health and
telemedicine will take health services far and wide to the last mile access. It is
possible that health could become an issue in the state elections, in which voters
will determine the performance of parties in power on the basis of what they did
for the health sector in the previous five years.
At the individual and family level, it is a hope that learning from the pandemic,
people will, from now onwards, not hesitate to avail mental health services. It is
possible and necessary that people should give more attention to preventive
medicine and health and wellness.
India’s National Health Policy mentions that states should spend 8 percent
of their budget on health services, but in reality it is only 5 percent.
While we are keen on ending the pandemic, the more immediate concern is that
in settings where cases are declining, urgent attention needs to paid to ensure
that non-COVID essential health services revert to normal. Any decision on the
pandemic should keep the poorest and marginalised populations in mind and
livelihoods should not be impacted. Most importantly, schools need to be opened
urgently. Children remain at low risk of facing severe illness due to COVID-19.
However, with schools closed for nearly two years, they have arguably been the
worst impacted by the pandemic in India.
The Indian states seem to be doing well in responding to the ongoing wave. All
that is needed now is to weed out a few more unscientific approaches, pitch in
more science-based processes, and put public health at the front of the pandemic
response, and ensure that people follow COVID-appropriate behavior for some
more weeks. And keeping in mind the post-pandemic phase, we should start
preparing for the endemicity of COVID-19 and for living with COVID-19. With
most of the high-income countries struggling to find a way out of the pandemic,
it is an opportunity for India to lead the way.