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What We Know So Far About India's Third Wave – and Why it's a Mistake to Dismiss it as 'Mild'

The number of districts reporting a test positivity rate greater than 5% has jumped by an order of magnitude in less than a week.

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For more such coverage of the COVID-19 pandemic, read and follow The Wire Science.

New Delhi: Of 748 districts in India, as many as 200 are reporting a COVID-19 test positivity rate (TPR) greater than 5%. According to new data analysed by the Union health ministry, until January 8, these districts were scattered across India, with no apparent clustering.

On January 5, a ministry official had said at a press conference in New Delhi that the number of districts reporting a TPR of more than 5% was 71. In the last five days or so, the number of such districts jumped by 127.

A TPR greater than 5% is considered a matter of concern because it indicates that the testing capacity available in a region is missing out on a large number of cases of SARS-CoV-2 infection and that the epidemic curve is growing.

Of these 200 districts, half are reporting a TPR of more than 10% – up from only 28 on January 5. The district with the highest TPR is Lahaul and Spiti (61.11%), followed by Kolkata (57.98%) and its neighbour Howrah (46.4%).

The states with the most districts whose TPR has crossed 10% are West Bengal (15 districts), Delhi (10), Maharashtra and Mizoram (nine each), Punjab (six), Arunachal Pradesh, Jharkhand, Himachal Pradesh, Haryana and Chhattisgarh (five each). The rest have fewer, while seven – including Kerala, Gujarat, Bihar and Assam – have one each.

Then there’s the other 100 reporting a TPR of 5-10% – whose number was 43 on January 5.

Other than indicating that the novel coronavirus is rampaging through the country, the scatter of high-TPR districts also tells us that the third wave is no longer limited to metropolitan centres or even tier I cities. It has made clear inroads into small towns as well, many of which are connected to rural areas.

There’s another number, like the TPR, that can give us a sense of how the virus is spreading – and the implication of its value echo that of the TPR as well. This is the basic reproductive number, or R – the number of people to whom the virus is spreading, on average, from one person who has tested positive for the infection.

According to Sitabhra Sinha, a senior faculty member at the Institute of Mathematical Sciences, Chennai, the R of India as a whole stood at 3.14 for the week ending January 7.

So if there are 100 cases to begin with, the virus will spread from them to 314 others, and from these 314 to 986 people, and so forth.

Also read: As COVID Changes Our Relationship With the Outside, Psychologists See Rise of ‘Cave Syndrome’

Sinha told The Wire Science that he hasn’t seen such a high R number for the country in toto during the entire pandemic. And as with the high-TRP districts, R’s value has jumped as well: until January 2, according to Sinha’s calculations, it was 1.96.

He also found that the virus is practically running amok in states with impending elections. The R numbers of Uttar Pradesh and Punjab were 4.36 and 3.43 for the week ending January 2. A value of 4.36 is already very high, but the R numbers of Bihar and Jharkhand are even higher – 6 and 5.38, respectively.

Of course elections alone aren’t responsible: Bihar, Jharkhand and Uttar Pradesh are also predominantly rural and lack good health infrastructure.

The current wave will subside only when the R number drops below 1. This day may be some way off: every state in India with at least 500 active cases had R numbers greater than 1 until January 2, according to Sinha.

While these numbers are hard to ignore on the one hand, officials of the Indian government have refused to call the third wave by its name, at least in public. Indian Council of Medical Research director-general Balram Bhargava was asked twice at the January 5 presser if we’re in the throes of another wave. He only said: “It is clear that there is exponential growth in cases.”

The omicron variant

While Bhargava also said that the omicron variant is the “predominant” strain, there is no data in the public domain about the number of samples in which genome-sequencing facilities are finding this variant.

The Indian SARS-CoV-2 Genomics Consortium (INSACOG) used to issue a weekly bulletin describing the landscape of variants in India; it stopped after December 20, 2021. And the December 20 bulletin had no information about the prevalence of the omicron variant in the samples it had received to sequence until then.

It just said: “Appropriate public health measures and investigations are being conducted for surveillance of omicron.”

Another dashboard, entitled ‘Indian COVID-19 Genome Surveillance’, also doesn’t speak of the fraction of samples in which scientists have found the omicron variant.

As a result the only source of information we have about omicron is the Union health ministry, and its data on January 9 said there were 3,623 such cases in the country. This number is likely to be higher, since not all samples with the variant are likely to have been sequenced.

Almost no country on the planet is able to sequence all samples collected from its population, but regular and sufficient sequencing is important to get a good sense of the variant’s spread.

There’s another problem: the omicron variant has also been spreading to the accompaniment of a message that its infection will but be mild. Bereft of the nuances, this message – which initially came from political leaders – has become an albatross around India’s neck, with many people throwing caution to the wind even as the numbers are surging.

Delhi registered 22,700 cases on January 9 and 1,618 (7% of new cases) were hospitalised. Of the latter, 27.19% required oxygen support, 19% required ICU beds, 2.7% required ventilator support and 17 died.

Just a week earlier, on January 2, the city reported 3,194 new cases, 238 required hospitalisation (7%). And of those hospitalised, 1.68% required ventilator support and 39% required supplemental oxygen. There were no deaths.

Commuters walk on a crowded railway platform amid a nationwide surge in coronavirus virus cases, during the third wave of COVID-19 in Kolkata, Monday, Jan.10, 2022. Photo: PTI/Swapan Mahapatra

Similarly, on January 9, Mumbai registered 19,474 new cases, while 21.3% of COVID-19 beds were occupied. As many as 82% of cases were asymptomatic, and the city had a case-doubling time of 41 days.

A week earlier, Mumbai registered 8,063 new cases, some 89% of whom were asymptomatic. But the COVID-19 bed occupancy rate was a much lower 10%.  There were no deaths, and the case-doubling time was 183 days.

These jumps in India’s two most populous cities are an indication of the complacency. In her latest warning, of sorts, the WHO technical lead for COVID-19, Maria Van Kerkhove, said on January 8, “We have heard some people suggest that omicron is just mild. That’s not the case. There is evidence that omicron is causing less severe disease, but it doesn’t mean that omicron is mild … omicron is not the common cold.”

She also said the sheer case load – even the people with non-severe COVID-19 – could, and has been, burdening healthcare workers. In fact, there may be reason to believe more healthcare workers are falling ill with the virus during this wave than before. In Delhi alone, more than 700 healthcare workers in six big government hospitals have tested positive.

Kerkhove said this has an impact on patient care – both COVID and non-COVID. India’s biggest government healthcare facility, the All India Institute of Medical Sciences (AIIMS), New Delhi, issued a circular on January 7 saying all speciality clinics are to be shut in the wake of “continuing increase in COVID-19 patients requiring hospitalisation”.

The institute has also suspended all routine hospital admissions and non-essential surgeries.

In Maharashtra, 300 doctors tested positive in four days. In Bihar’s Nalanda Medical College and Hospital, which is the state’s nodal COVID-19 centre, 159 doctors did so in two days. There have been similar reports from West Bengal and Tamil Nadu. All these facilities are well-equipped, so if they are reeling, it wouldn’t be a stretch to imagine that less well-equipped centres are faring worse.

Watch: ‘Omicron Intrinsically Less Virulent but Next Variant Likely To Be More Severe’

As if frustrated with the blanket statement that “omicron is mild”, NITI Aayog member (health) Vinod K. Paul said on January 5: “Don’t take [omicron variant] for granted. Hospitals will get overwhelmed. Even if the disease is mild, you will have to take leave and sit at home. Life will come to a halt.”

Biostatistician Bhramar Mukherjee narrated to The Wire Science on January 2 the US experience, where the omicron variant is believed to have caused over a million new infections – an international record – on January 4.

“Essential workers have fallen sick… no teachers to teach. What if that happens in India?” Mukherjee wondered.

When the virus surges – no matter which strain – the entire healthcare system is threatened. To echo virologist Shahid Jameel, a fraction of a large number is also a large number: even if the omicron variant causes a smaller fraction of people to fall ill with severe disease, that number is still big.

Complacency also allows the delta variant to spread.

In addition, doctors falling sick – even mildly – takes them out of service for some time, and both COVID and non-COVID patients suffer.

Also, the longer the virus – again, no matter which strain – circulates in the population, the more opportunities it will have to accrue mutations and potentially develop into a more debilitating strain.

What’s coming for India?

Almost all experts have said that the faster the number of cases rises, the faster it will fall – but they haven’t been able to say when exactly this will happen.

Both Mukherjee and Gautam Menon, a professor of physics and biology at Ashoka University, Sonepat, told The Wire Science that cases in India, as a whole, could start dropping in the second half of January. Individual states, however, are likely to have their peaks at different times.

But their projections come with lots of caveats – especially in terms of hospitalisation and lack of access to this and other important data. Without any countrywide numbers on these indicators being in the public domain, modellers have said it is extremely difficult to say when the peak or what the fatality rate might be.

Even after two years of the COVID-19 pandemic, India doesn’t have a centralised database on COVID-19 hospitalisation, reinfections and other important indicators.

Another issue, and which has divided experts, is testing. One group of experts believes that since the omicron variant is highly transmissible and will eventually infect many people without them even knowing, random testing is useless. Even the Government of India’s latest guidelines say the asymptomatic contacts of a person who has tested positive needn’t be tested. But another group says that if we don’t test, the virus could spread from an untested and asymptomatic individual to others.

“It depends” on where you are, Jameel told The Wire Science. “In countries like the UK and the US, one can get easy access to tests that can be conducted at home, and by oneself. If that is the case in India, do random testing,” he said.

“But if not, don’t panic if you are not getting a test and have no symptoms plus no comorbidities,”  he added.

As for the risk of passing the infection onto an elderly or vulnerable person – Jameel said it would be prudent to default to being very careful. “They need to be protected from everything. If you are in their company, you need to be tested. Otherwise, if you have a cold, assume it to be COVID and just isolate.”

On the other hand, Giridhar R. Babu, a professor of life course epidemiology at the Public Health Foundation of India, Bengaluru, said we shouldn’t limit people from being tested but that we should modify the definition of a COVID-19 case.

“If one is positive (for virus) and is not hospitalised, then s/he is shouldn’t be counted as a case, now, but only as somebody infected. A case should be somebody who is hospitalised,” he told The Wire Science.

All the experts to whom The Wire Science spoke also said the booster doses – which the Indian government has been calling ‘precaution doses’ – won’t have an impact on the ongoing ‘omicron wave’ in India because of the timelines.

“In any case, it is late now,” Jameel said.

“But what if there is going to be another Greek letter after omicron! So boosted protection for the elderly [and the immunocompromised] is always good.”

Finally, of course, there’s the fatigue we all confront. “There is a sense of defeat in people and I completely understand that sentiment,” Mukherjee said. “Two jabs done, and have already restricted themselves for two years. And when they were hoping for normalcy, omicron appeared.”

“But brace yourself for a sandstorm [of cases], where you basically put your head down,” she said. “You just hunker down until it passes through. Then you lift up your head again.”