Re-emergence of COVID-19 and preparedness

Introduction

The COVID-19 pandemic irrevocably altered the global public health landscape. After a prolonged calm, an uptick in test positivity and sentinel-site wastewater signals since April 2025 has revived concerns of a “re-emergence” phase. While caseloads are nowhere near the catastrophic Delta wave of 2021, the appearance of highly transmissible JN.1-descended lineages (e.g., NB.1.8.1, LF.7.1.2) warrants renewed vigilance. This editorial discusses the latest epidemiological data (cutoff: June 6, 2025), evaluates India’s multilayered surveillance and response capacity, and reviews regulatory progress on updated vaccines.

Current Global and Regional Status of COVID-19

Globally, the World Health Organization (WHO) received 206,279 new laboratory-confirmed cases during the latest 28-day reporting window (April 28, 2025–May 25, 2025), an eight-fold rise (≈661%) over the 27,134 cases reported in the previous 28-day period.[1] In South-East Asia, India notified more than 5000 infections (June 6, 2025).[2] Hospital admission rates remain <1/100,000 population, but respiratory-intensive care unit bed utilization has inched upward in high-burden states such as Kerala and Delhi [Table 1].

Table 1.

Active COVID-19 cases and populationnormalized rates in key Indian states (June 6, 2025)

State	Active cases	Population (million)	Active cases per 100,000
Kerala	1679	34.6	4.85
Delhi	562	19.0	2.96
Gujarat	508	69.0	0.74
Maharashtra	526	124.0	0.42

Source: Ministry of Health and Family Welfare dashboard (https://www.mohfw.gov.in) accessed June 6, 2025. Rates calculated with the latest Census projections

Genomic and Variant Surveillance

As of the cutoff date, the Indian SARS-CoV-2 Genomics Consortium (INSACOG) has uploaded 12,472 sequences for 2025 to the Global Initiative on Sharing All Influenza Data; 33% belong to the JN.1 lineage and 18% to its NB.1.8.1 descendant.[3] Preliminary antigenic cartography indicates ≥1.7-fold reduction in neutralization titers for sera taken 6 months postbivalent booster.[4] Although these figures do not automatically translate to vaccine failure, they support deploying updated monovalent formulations.

Surveillance Systems: Strengths and Challenges

India operates a three-tier surveillance architecture: (i) Syndromic screening of influenza-like illness (ILI) and severe acute respiratory infection across 73 Integrated Disease Surveillance Programme (IDSP) sentinel hospitals;[3] (ii) quantitative Reverse transcription polymerase chain reaction (RT-PCR) monitoring of SARS-CoV-2 N1/N2 gene copies in wastewater at 47 urban treatment plants;[5] and (iii) real-time whole-genome sequencing through the 61-laboratory INSACOG network. Funding unpredictability and lag times in public reporting remain major bottlenecks. The median interval from sample collection to genomic upload is currently 12 days, twice the WHO target. Routine public dashboards for wastewater findings are absent, curtailing community risk perception.

Updated Vaccines and Regulatory Landscape

On May 15, 2025, the WHO Technical Advisory Group on COVID-19 Vaccine Composition recommended a monovalent JN.1 spike antigen for all updated formulations.[6] The US FDA and UK Medicines and Healthcare products Regulatory Agency subsequently approved JN.1-mRNA boosters from Moderna and Pfizer-BioNTech. India’s Subject Expert Committee granted restricted emergency use authorisation on May 6, 2025, to Corbevax-JN.1 (50 µg recombinant receptor-binding domain) for adults ≥18 years as a single booster dose, contingent on postmarketing surveillance.[7] Pediatric dossiers and heterologous-booster trials are under review [Table 2].

Table 2.

Regulatory status of JN.1updated COVID19 vaccines (June 14, 2025)

Agency	Product(s)	Status
US FDA	mRNA1273.9 (moderna); BNT162b2JN.1 (PfizerBioNTech)	Approved May 29, 2025
MHRA (UK)	Same as above	Approved May 30, 2025
EMA	Spikevax XBB.1.5 May 30, 202	Under rolling review
CDSCO (India)	Corbevax-JN.1 (biological E) (SARS-CoV-2-RBD219 N1C1 variant)[8]	EUA approved earlier; under phase III trials for JN.1-specific formulation
CDSCO (India)	CorbevaxXBB.1.5 (biological E) (SARS-CoV-2-RBD203-N1_XBB.1.5 variant)[8]	Approved under EUA for 5+ age group, 2-dose schedule (day 0 and day 28)
CDSCO (India)	COVOVAX JN.1 (Serum Institute of India/Novavax)[8]	Approved for precautionary dose in ≥18 years, part of CIC trials

Source: Public statements of respective regulators (FDA, MHRA, EMA, CDSCO) and company press releases; compiled June 14, 2025. EUA=Emergency use authorization, MHRA=Medicines and healthcare products regulatory agency, EMA=European Medicines Agency, CDSCO=Central Drugs Standard Control Organization, CIC=COVID-influenza combination vaccine

Pharmacovigilance Imperatives

The Pharmacovigilance Programme of India (PvPI) reports that, between January 2025 and May 2025, 1327 adverse events following immunization (AEFI) were logged for all COVID-19 vaccines, an incidence of 7.6/million doses, with zero new safety signals. PvPI and IDSP are currently piloting a linked lot-traceability module using two-dimensional barcodes, designed to shorten detection-to-signal time below 30 days.[9] Practicing pharmacologists can enhance postmarketing safety by reporting AEFI promptly, participating in causality-assessment committees, and collaborating on real-world effectiveness studies against emerging variants.[10]

Co-circulating Respiratory Viruses

Co-circulation of other respiratory viruses complicates differential diagnosis and preparedness planning. Sentinel surveillance shows that respiratory syncytial virus positivity among children <5 years rose to 14% in May 2025[11] while Nipah virus re-emerged in Kerala with a single confirmed case on May 10, 2025.[12] Seasonal influenza A (H1N1) accounted for 9% of ILI samples nationally in week 22 of 2025.[13] These data underscore the need for multiplex RT-PCR panels at district hospitals and flexible surge-capacity plans [Table 3].

Table 3.

Trends in major respiratory pathogens, India, May–June 2025

Virus	Surveillance method	Trend	Regions most affected
SARSCoV2	ILI/SARI, wastewater, WGS	Gradual rise; elderly disproportionately affected	Kerala, Delhi, Maharashtra
Influenza A (H1N1)	ICMR ILI/SARI network	Seasonal surge	PanIndia
RSV	Paediatric SARI	High positivity in <5 years and ≥60 years	Maharashtra, Delhi
Nipah	RTPCR and contacttracing	Isolated case/cluster	Kozhikode and Malappuram (Kerala)

Sources: INSACOG weekly bulletin; ICMRVRDL network; NIV field reports; MoHFW press releases (accessed June 14, 2025). RSV=Respiratory syncytial virus, ICMR=Indian council of medical research, ILI=Influenzalike illness, WGS=Wholegenome sequencing, SARI=Severe acute respiratory infection, RT-PCR=Reverse transcription-polymerase chain reaction, INSACOG=Indian SARSCoV2 Genomics Consortium

Policy Recommendations for the Elderly

Given that persons ≥60 years accounted for 63% of COVID-19 deaths logged in 2024, targeted interventions are essential:

• Offer on-site JN.1 booster clinics at geriatric outpatient departments and long-term care facilities

• Reinstate free quarterly rapid antigen test distribution for high-risk households

• Expand pneumococcal vaccination uptake to ≥80% to mitigate bacterial co-infections accompanying viral illness

• Encourage tele-health triage lines to reduce unnecessary hospital visits during surge weeks.

Conclusion

While the current resurgence of COVID-19 in India remains modest, a history cautions against complacency. Sustained surveillance, rapid vaccine updates, and a robust pharmacovigilance ecosystem constitute the tripod of preparedness. If implemented with transparency and community engagement, these measures can avert future high-intensity waves and protect the most vulnerable.