Third Wave of the COVID-19 Pandemic in India: What Lies Ahead?

BY CHANDRAKANT LAHARIYA

India’s successful vaccination drive along with relevant revisions in its strategy have proved useful in the third wave.

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.

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.

Comparison between waves

Epidemiologically speaking, the pattern of cases and hospitalisation in the COVID-19 third wave in India is different from the previous two waves. Why so? The answer lies in a  combination of factors, including natural infections in the last two years, vaccination of the adult population (nearly 90 percent of the adult population has received at least one shot and 70 percent both shots and, the country has administered a total of 1.57 billion COVID-19 vaccine doses in one year), and high transmissibility but less virulence of the Omicron variant. 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. The ongoing wave is a testimony to the effectiveness of COVID-19 vaccines.

It is also worthwhile to note that the role of COVID-19 vaccines—at least those being used in India—in reducing transmission is limited. Therefore, in spite of vaccination, a person can get infected. To prevent infection and reduce transmission, even a vaccinated individual needs to continue to keep wearing a mask in public places. In fact, the three to four-folds higher transmissibility of Omicron in comparison to the Delta variant demands that people wear masks  more carefully and diligently than before. It is a reminder that people need to choose the right mask and wear it at all times when meeting people other than family members, both indoors and the outdoors.

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.

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.

How is the third wave likely to unfold in India?

Let’s understand the epidemiology of waves and what to expect in the current wave in India. It is near consensus that the Omicron wave is more like a ‘flash flood’. The cases will rise exponentially in two to three weeks and decline equally within two to three weeks. This was experienced in South Africa and in many other countries and seems to be the pattern in Delhi and Mumbai in India as well. Going by this, in the ongoing wave in India, there would not be a sharp and clear peak. The daily new COVID-19 cases are already high and hovering at that level. It is likely that after major cities (where cases are already on a downward trend), the cases will start to rise in urban areas in most districts of India. Likewise, it is possible that by the time urban settings would start to see a decline, the cases might start to rise in rural India. This would be a situation of three different waves in quick succession, merged into one and keeping the daily new COVID-19 cases sustained at a high level. Against this backdrop, the traditional bell-shaped curve with a clear peak is an unlikely scenario. It is possible that the daily COVID-19 cases would stay at a slightly higher level for a few weeks, before the weekly average would rise and fall in a narrow yet high range, before cases would start tapering off. In this wave, the epidemic curve is more likely to be inverse ‘U’-shaped. The modeling and epidemiological data indicates that the ongoing wave of COVID-19 in India may peter out by late February or early March 2022. The base of U might be seen during mid-January to mid-February 2022.

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.

Is the end in sight?

While all of us are keen for the ongoing wave to end, everyone has one pressing question: When would the COVID-19 pandemic be over? The recent developments, especially with the Omicron wave resulting in antibody levels—in those vaccinated in the past—to be at levels to be able to protect from future Delta infections, gives hope that the pandemic could be over soon. Then, going by the evolution process of viruses in general, natural infection by SARS CoV2 in the last two years, COVID-19 vaccination in the last one year as well by key features of Omicron, it is hoped that COVID-19 pandemic should end by mid or end 2022. However, there are two crucial caveats. One, this would be possible if there is no new variant, which is more transmissible or has a heavy ability to escape the immune system, and two, if the rich countries share COVID-19 vaccines with all the other countries and address vaccine inequity urgently.

Then, we need to remember that even when the pandemic is over, new COVID-19 cases will continue to be reported. The “zero-COVID” policy is not a strategy for any setting, unless the country is an island that remains disconnected from every other country or a few vaccines with ‘sterilising immunity’ are developed.

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.

When will the world expect to reach endemicity for COVID-19?

To answer this question, we need to remember that in epidemiology, the context matters a lot. In the ongoing pandemic, every country is different—by level of natural infection, vaccination coverage and exposure to Omicron variant. Therefore, it is likely that every country would reach COVID-19 endemicity at different points of time. For example, the wave of COVID-19 has not spread so fast in the continent of Africa. Only a smaller proportion of the population has been fully vaccinated in Africa, so the risk of the COVID-19 epidemic can remain for a long time.

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.

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.

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.

Disclaimer: The opinions expressed in this article are the personal opinions of the authors.