The Ongoing COVID-19 Crisis In India: Updates

India continues to face the world’s most devastating wave of the coronavirus pandemic, an onslaught of infections and deaths that has overwhelmed the nation’s health-care system and prompted lockdowns across the country. Each day now brings a world record in new cases per day, with the nation reporting more than 400,000 on Saturday — the tenth straight day more than 300,000 cases have been confirmed. Though international aid continues to arrive, including from the U.S., well over 3,000 people are dying every day as well, and both that and the number of new infections are via the government’s official count — which is definitely much lower than the actual numbers of sick and dying, according to local journalists. Below is an ongoing look at the staggering crisis, including new developments and the likely consequences.

Adar Poonawalla, the CEO of Serum of Institute of India, the largest vaccine manufacturer in the world, including the AstraZeneca COVID vaccine in India, moved to the U.K. with his family just before the country restricted travel from India a week ago. In an interview with the Times of London, Poonawalla said the decision was in part due to the harassment he was receiving:

The calls come from some of the most powerful men in India. They come from the chief ministers of Indian states, heads of business conglomerates and others demanding instant supplies of Covishield, as the AstraZeneca vaccine is known in India. “ ‘Threats’ is an understatement,” Poonawalla says. “The level of expectation and aggression is really unprecedented. It’s overwhelming. Everyone feels they should get the vaccine. They can’t understand why anyone else should get it before them.”

The calls begin cordially, but when Poonawalla explains that he cannot possibly meet the callers’ demands “the conversations go in a very different direction”, he says. “They are saying if you don’t give us the vaccine it’s not going to be good … It’s not foul language. It’s the tone. It’s the implication of what they might do if I don’t comply. It’s taking control. It’s coming over and basically surrounding the place and not letting us do anything unless we give in to their demands.”

“Everything falls on my shoulders but I can’t do it alone,” he continued. “I don’t want to be in a situation where you are just trying to do your job, and just because you can’t supply the needs of X, Y or Z you really don’t want to guess what they are going to do.”

The World Health Organization recently citied a “perfect storm” combination of three factors for the horrifying surge of new COVID cases in India: low vaccination rates, mass gatherings, and more contagious COVID variants. Put even more simply, India — and in particular Prime Minister Narendra Modi and the country’s central government, which is controlled by Modi’s BJP party — tried to get back to normal prematurely, and the country is now paying an enormous price for turning its back on the coronavirus.

It all started, according to Indian health care journalist Vikas Dandekar, when India’s impressive-looking quick turnaround from the first wave “raised false hopes that the virus had run out of steam in India and the country would be spared a second wave”:

Virologists, modeling experts, and prominent epidemiologists appeared on TV shows to suggest that herd immunity may have kicked in, with testing in some cities showing the existence of anti-Covid antibodies in up to half of communities. Some professed that Indians have stronger-than-average immune systems, or they may be spared from COVID-19 by cross protection from other infectious diseases. A few invoked evolutionary biology and said the virus will not kill all its hosts and endanger its own existence.

Then India’s hyper-nationalism took over. Prime Minister Narendra Modi and senior leaders from his Bharatiya Janata Party, who thrive on overwhelming popularity, took no time to claim victory in the fight against the virus. Election rallies attracted soaring crowds. As Modi and Amit Shah, the two top leaders, brazenly took off their masks during their incessant campaigns, those in the crowds followed and dropped theirs.

Further fueling new cases was Kumbh Mela, a gargantuan confluence of Hindu pilgrims who gathered for a holy dip in the Ganges River. As many as 2.5 million people took part, with scant attention to COVID-19 safety protocols. By the time an avalanche of criticism cut short the festival, the virus had infected thousands of pilgrims, who took it home to their neighborhoods and villages.

Efforts to crank up a badly hobbled economy also added to the spread. Business and manufacturing activities began reopening in May 2020 as ministers projected a V-shaped economic recovery while scientific messaging to keep wearing masks and follow social distancing took a beating. Masks, which had become part of public life in India for most part of 2020, gradually disappeared from faces.

Meanwhile, the country has had a sluggish vaccine rollout — with only 1 percent of the population now fully vaccinated — leaving India extremely vulnerable to community transmission, particularly with more transmissible coronavirus variants like B.1.1.7 spreading.

In mid-February, the country was reporting less than 10,000 COVID cases and 100 deaths a day. An exponential explosion has followed. India reported more than 400,000 new COVID-19 infections in a 24-hour period on Saturday, and is still setting a new world record in daily cases every day.

The number of people who have been killed by COVID-19 in India is now over 211,000. At least 30 percent of those deaths have come in the last two months, and the country is now recording over 3,300 new deaths every day. India now accounts for more than a third of the world’s current cases, and nearly 40 percent of new cases reportedly globally of the last few months.

And all of those numbers and calculations are based on the government’s official data, which experts agree is a severe undercount.

Thus far, India’s mass-vaccination efforts have not gone well — which is one of the primary reasons it was left vulnerable for the current wave of cases. Two vaccines are currently available in the country, AstraZeneca’s and one developed by India’s own Bharat Biotech. Both are two-dose vaccines, and manufactured in India. Nearly 11 percent of the country’s almost 1.4 billion residents have gotten at least one dose of a COVID vaccine — which offers some protection against infection — but just over 2 percent of the population has received a second dose. The country opened up eligibility for the vaccine to all adults on May 1, but that may simply worsen another problem:

There isn’t enough vaccine supply
That’s despite India being the world’s largest supplier of vaccines, as the Atlantic’s Yasmeen Serhan recently explained:

India’s role as a major pharmaceutical producer has been spotlighted during the pandemic; it has provided 20 percent of the world’s generic drugs as well as more than 60 percent of the world’s vaccines, despite having inoculated just 1 percent of its own population against COVID-19.* The country has the capacity to manufacture 70 million doses a month, but even with all of those doses directed toward its domestic needs, they’re not enough to meet the overwhelming demand. At present, India is administering some 3 million doses a day. To protect its population of 1.4 billion, [University of Michigan biostatician and epidemiologist Bhramar] Mukherjee said that rate would need to increase threefold.

Multiple states in India reportedly ran out of vaccine ahead of the weekend, forcing the temporary closure of many vaccination sites.

The U.S. and other foreign governments have begun — too late, according to may critics — trying to help bolster India’s vaccine supply and vaccine-production efforts, but it’s not clear how quickly that will result in actual vaccinations.

The shortage isn’t the only problem
On top of everything else, the Indian Express reported earlier this week that India’s efforts to actually get shots in arms has been plagued with issues at the state and local level:

As India tries to accelerate its massive vaccination programme in the middle of a devastating second Covid-19 wave, ground reports from states indicate a complex set of problems ranging from shortage of doses to glitches on the registration portal to panic and fear of the vaccines running out. If the initial weeks of vaccination saw a general reluctance among the public, the severity of the pandemic’s second wave has forced them to flock to vaccination centres, flouting the very rules meant to keep them safe. And to top it off, the [government] will open vaccination to everyone above the age of 18 from May 1, even as [hundreds of thousands] of people in the 45-60 and above 60 high-priority age groups still await the jab.

As one example, a combination of limited vaccine supply and mass-scheduling error prompted chaos at one of the main vaccination centers in the southern Indian city of Thiruvananthapuram last Monday, per the Express:

[A]t the Jimmy George Indoor Stadium[,] COVID-19 protocols were blatantly violated as hundreds of people, many of them above 60 years of age with comorbidities, flocked to the centre from 7 am to get a shot. The bizarre reason for the crowd was that a majority of them had been provided the same time-slot online. With no access to drinking water or seating, at least three persons fainted in the queue and had to be admitted to hospitals.

On Wednesday, after registration for people aged 18-44 to schedule vaccinations was opened up, the central government web portal and a major app used for booking appointments both briefly crashed under the demand.

Another issue: almost half of the population of India doesn’t have internet access.

India’s government played politics with its vaccines — and lost
At the Financial Times, Gideon Rachman recently argued that vaccine nationalism appears to have blown up in India and Modi’s face: the government failed to place timely orders with Indian vaccine manufacturers; it dragged its feet on authorizing foreign vaccines while promoting one designed in India; and vaccine diplomacy concerns, both as a point of national pride and competition with rival power China, led the government to export vaccines it clearly should have been keeping more of that supply and distributing it to its own citizens instead.

There has also been backlash over the central government allowing India’s pharmaceutical companies to charge state governments and private hospitals for vaccines administered to people under the age of 45, and set their own prices, which led to a partial walk-back from one of the companies on Monday.

As is the case in every major new COVID outbreak around the world, there has been a lot of attention on how coronavirus variants might be fueling the skyrocketing number of cases in India — and in particular, the B.1.617 variant which originated in the country. The other variant being detected in genetic surveillance of India cases is the better known B.1.1.7 variant which originated in the U.K., is believed to be more transmissible, and has been taking hold in the U.S. and many other countries. Both are spreading in India, albeit not universally, according to available data — and the variants are likely making it easier for the coronavirus to spread there. How much, and why, is not yet fully clear.

B.1.617 has been referred to as a “double mutant,” since the variant (or rather, one of the three versions of the variant which have been detected) has two worrying mutations which could be making it more dangerous. One mutation likely makes B.1.617 more transmissible, similar to B.1.1.7. The other is the same mutation found in the B.1.351 South Africa variant which scientists believe has a minor impact on vaccine efficacy.

First of all, every variant could be called a multiple mutant, since numerous mutations are normal. So the “double mutant” description for B.1.617, which sounds sort of scary, is a bit of a misnomer. Second, and more importantly, there just isn’t enough evidence to support the conclusion that B.1.617 is fueling the outbreak in India, or, as some have been worrying, better able to break through the protection provided the COVID vaccines which have been administered in the country, or better able to reinfect people who have antibodies from a previous coronavirus infection. Thus far, the available data on so-called “breakthrough infections” in India — real-world COVID cases among fully vaccinated people — indicates that only a fraction of a percent (.02 to .04 percent) of fully vaccinated people there have caught COVID.

Unfortunately, for a variety of not-great reasons, there isn’t enough genomic sequencing currently being done of cases in India to get a more complete picture of how prevalent the variants have become, as the New York Times emphasized on Tuesday:

So far the evidence is inconclusive, and researchers caution that other factors could explain the viciousness of the outbreak[.] … Still, the presence of the variant could complicate the taming of India’s Covid-19 disaster. “The current wave of Covid has a different clinical behavior,” said Dr. Sujay Shad, a senior cardiac surgeon at Sir Ganga Ram Hospital, where two of the doctors needed supplemental oxygen to recover. “It’s affecting young adults. It’s affecting families. It’s a new thing altogether. Two-month-old babies are getting infected.” …

“While it’s almost certainly true B.1.617 is playing a role, it’s unclear how much it’s contributing directly to the surge and how that compares to other circulating variants, especially B.1.1.7,” said Kristian Andersen, a virologist at the Scripps Research Institute in San Diego.

The U.S. will begin restricting travel from India next week in an effort to prevent the spread of the coronavirus, the White House announced Friday. The restrictions, which will go into place Tuesday, May 4, will ban entry to the U.S. for people who have been in India over the previous 14 days, CNN reports — though not everyone:

The policy will not apply to American citizens, lawful permanent residents or other people with exemptions. As with all international travelers, individuals who fit that criteria traveling from India must still test negative prior to leaving the country, quarantine if they have not been vaccinated and test negative again upon reentering the US from India. The restrictions also do not apply to humanitarian workers.

That policy is similar to the restrictions currently in place for travelers who have been in the E.U. and Brazil. Numerous other countries have already restricted travel from India, including the U.K. and Canada.

The city’s municipal government announced the closure of 94 vaccination centers on Friday, citing the lack of vaccine supply, and said the closures would only last through Sunday. Only 26.7 million people — about 2 percent of India’s population of nearly 1.4 billion — have been fully vaccinated as of the end of the week — though 152 million doses have been administered nationwide. Residents of New Delhi have also been asked not to show up for vaccinations on Saturday due to the lack of supply there. Reuters reports that several states in India have run out of vaccine doses.

This post has been updated.