Political Races, Religious Congregations, and Inefficacious Measures Amid the Second Wave of COVID-19 in India

India is currently dealing with the period after the peak of the disastrous second wave of the COVID-19 pandemic. Daily reported cases are ebbing after reaching a peak of 0.4 million cases on May 7, 2021, with a positive test rate of approximately 22%.¹ Multiple reasons have been hypothesized for the second wave, the most common being the rapid transmission of the Delta variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), early relaxation of control measures, and ignorance of COVID-19–appropriate behavior.² The Union Health Ministry began reporting the unusual surge of cases in states such as Maharashtra, Punjab, and Kerala by the end of February 2021. The states were advised to “Test, Track, and Treat” by relying on RT-PCR (reverse transcription–polymerase chain reaction) rather than rapid antigen-based tests, accelerating vaccination, sending public health teams to affected areas for analysis, and promoting COVID-19–appropriate behavior. The state of Maharashtra, which reported the highest surge in cases, instituted multiple restrictive measures in early April that were equivalent to a complete lockdown, and the other states followed suit.³

CONGREGATING EVENTS AT START OF SECOND WAVE

During the months of March and April 2021, the states of Assam, Kerala, Tamil Nadu, and West Bengal and the union territory of Puducherry conducted elections whose candidates held political rallies consisting of large gatherings where COVID-19–appropriate behavior was defied; as a result, the states faced an unprecedented surge of new cases.^1,4 Of particular note are the massive political rallies in West Bengal, which imminent political leaders from the country’s ruling party attended.⁴ These events are linked to a massive surge of cases in West Bengal. There were 198 new cases on March 1, 2020, and a peak of 20 846 new cases on May 14, 2021, with a positivity rate of 29.75%.¹

The Kumbh Mela (celebrated every 12 years) was held in early 2021 at Haridwar in Uttarakhand and contributed to the rising cases. The Union Health Ministry projected an attendance of 1 million people on regular days and about 5 million people on certain days for the holy bath at the banks of the Ganges River. Hosting the Kumbh Mela amid a pandemic was partly a calculated political and economic decision.⁵ Even though the Health Ministry and the state government provided guidelines for the event—which included mandatory wearing of masks, maintaining social distance, obtaining medical certification, and mandatory RT-PCR reports for devotees—a blatant violation of norms was observed at the event, whose overall participants included 9.1 million devotees and a congregation of 6 million during April.⁵ These events are linked to a rise in the number of new cases in Uttarakhand: from 69 cases on March 11, the day of the first holy bath, to a peak of 7749 new cases on May 12. A positivity rate of approximately 23% occurred in the last 15 days of the event.¹

REPERCUSSIONS OF INDIA’S SECOND WAVE

As the upsurge of cases instigated the drastic second wave of COVID-19 in India, the health care system’s inadequacies and lack of preparedness began to be exposed.⁶ Many areas across the country faced shortages of hospital beds, ventilators, and oxygen supply owing to overloaded health care facilities.⁶ A surge in oxygen demand peaked at 9000 metric tons as compared with 3095 metric tons during the first wave.⁷ About 629 deaths have been linked to oxygen shortages across the country between April 6 and May 19, 2021—although the Union Health Ministry has reported no such deaths.^7,8 Prompt action and coordination between the state and the union government ensured that the states’ oxygen demands were met by facilitating equitable distribution based primarily on the active case load.⁷

The availability of drugs such as Remdesivir was limited because of the increased demand, indiscriminate use, hoarding, and selling the drug at exorbitant prices.⁹ Subsequently, the government banned exporting Remdesivir and implemented stricter regulations to ensure its proper use.⁹

The excess number of deaths attributable to COVID-19 during India’s second wave remains enigmatic and has been estimated to be much higher than the official COVID-19 mortality data.¹⁰ The five states of Andhra Pradesh, Bihar, Kerala, Madhya Pradesh, and Tamil Nadu cumulatively had more than 0.46 million excess deaths in the first five months of 2021, but the official COVID-19 death data accounted for only approximately 6% of these excess deaths.¹⁰ Additionally, from March to July 2020, there were 989 deaths attributable to the strict lockdown during the first wave, of which 23% are owing to financial distress and starvation.¹¹

Since the start of 2021, the government has focused on its nationwide vaccination drive. Currently in phase 3, the drive has resulted in the complete vaccination of approximately 147.50 million eligible citizens, which corresponds to roughly 15.69% of the total eligible population older than 18 years.¹² The accessibility and utility of AarogyaSetu—the contact-tracing application that the government developed—pose concerns: there have been approximately 202 million application downloads, suggesting it is currently inaccessible to 85% of the population.

CHALLENGES AHEAD FOR INDIA

Even though we could cite a multitude of reasons for India’s second COVID-19 wave, it is necessary to undertake measures to prevent further damage and the emergence of an additional wave. First, the monitoring and sharing of genomic variations in SARS-CoV-2 need to be significantly increased to study the various strains in the community and their characteristics.⁶ As of August 16, 2021, the Indian SARS-CoV-2 Genomics Consortium has sequenced only 0.23% of the reported COVID-19 cases as compared with the United Kingdom and Australia, which have sequenced and shared 11.1% and 49.9% of their COVID-19 cases, respectively.^13,14 The Delta variant continues to be the main variant of concern and is still responsible for a very high proportion of the vaccine breakthrough cases in India.¹⁴ The emergence of Delta sublineages in India is currently being monitored, and there is no functional evidence of increased transmissibility.¹⁴

Second, key pandemic surveillance indicators data need to be made publicly available, which includes disaggregated data on new COVID-19 cases; deaths by age, sex, comorbidities, and vaccination status; transmission categories of cases; the number of hospitalized COVID-19 patients; COVID-19 clusters; influenza-like illnesses and severe acute respiratory illnesses; and COVID-19 among health care workers. These data will aid researchers and public health experts as they analyze the situation and tailor the response.¹⁵

Third, restrictions on movement similar to the lockdown of the first wave need to be evaluated with a focus on the burden placed on the population; prompt quantification of the morbidity and mortality that such measures cause is key to this evaluation.¹¹ The discussion on policy actions for COVID-19 control measures should be based in equity and should prioritize protecting lives and valuing the interests of vulnerable and the marginalized populations; efforts need to be made to reduce inequalities and disparities.¹⁶

Fourth, the COVID-19 pandemic’s indirect consequences owing to disruptions in the delivery and utilization of routine services, including essential health and nutrition services, need to be addressed.¹⁷ The government must ensure that the population-level health indicators are not affected drastically by the disruption of India’s health care services. Modeling studies have already estimated a 15% and 18% increase in child and maternal mortality, respectively, in 2020 compared with 2019.¹⁷ Also, prepandemic data show that the infant mortality decline has been stagnant and even reversed in some states in 2017 and 2018. Child nutrition indicators have not improved between 2015–2016 and 2019–2020; in some states, the proportion of underweight children and stunting has increased.^18,19 Early restoration of health care services is pivotal and requires triaging to identify priorities, succinct communication to the community, and increasing the health care workforce.²⁰

Finally, the COVID-19 vaccination program’s efforts need to be expanded. India has administered approximately 640 million vaccine doses, the highest number of doses administered worldwide but has completely vaccinated only 32.42% of the population older than 60 years; the United States, by comparison, has administered 369 million vaccines and has vaccinated 81.7% of the population older than 65 years.¹² Also, vaccination of the population older than 60 years declined in India after the beginning of phase 3 and has been down by nearly 50%.¹² The government must ensure equitable distribution of vaccines to the priority groups in both urban and rural areas, especially in areas where public health services are deficient, by employing the vast network of local and community health care workers to further improve vaccination coverage.⁶

CONCLUSIONS

As India recovers from the second wave and its repercussions, its causes must be promptly analyzed, and measures to prevent further damage and ensure preparedness must be instituted before there is a potential third wave of COVID-19.