How India’s second wave became the worst COVID-19 surge in the world

New Delhi — During the past few weeks, Indian social media has been inundated with SOS messages: hospitals tweeting about dwindling oxygen supplies and physicians watching helplessly as patients perish from preventable deaths. A journalist pleading for but denied a hospital bed took to Twitter to log his deteriorating condition till he died. Overwhelmed crematoria are working round-the-clock to keep up with the pace of bodies; furnaces have melted down from overuse and additional funeral platforms are being built outside. Such are the heartbreaking messages and haunting images that highlight the formidable second wave of the coronavirus pandemic raging through the country.

India broke the world record for the most new coronavirus cases this week, surpassing 330,000 new cases on Friday, as deaths in the past 24 hours jumped to a record 2,263, the health ministry said. The United States held the previous one-day record with 300,669 new cases recorded on January 8, 2021.

"We completely let down our guard and assumed in January that the pandemic was over—and COVID surveillance and control took a back seat,” says K. Srinath Reddy, president of the Public Health Foundation of India. But “there were still a fairly large proportion of people in the big cities, but also in smaller cities and villages, who were not exposed to the virus last year, who were susceptible.”

As cases declined from September 2020 to mid-February 2021, the Indian government, led by Prime Minister Narendra Modi, ignored warnings of a second wave, despite the fact that new variants were identified as far back as in January, according to media reports.

“We kept warning that the pandemic was not over but no one was listening,” says Rakesh Mishra, senior principal scientist and director of the Hyderabad-based Center for Cellular and Molecular Biology, who is currently investigating whether a new homegrown variant—B.1.617—is behind India’s second surge.

After the first wave, Mishra says, the healthcare system moved on to tackle other medical emergencies that were neglected during the first wave, and dedicated COVID-19 facilities were converted back to their previous functions.

In March, a few weeks before the new surge, Indian health minister and physician Harsh Vardhan asserted that India was in the “endgame” of the COVID-19 pandemic, justifying his government’s decision to export medical resources to other countries. India had increased its oxygen exports to other countries by a whopping 734 percent in January 2021. It also exported around 193 million doses of vaccines. But the picture changed drastically when India began recording a dramatic increase in new cases from April 15 onward, with more than 200,000 cases daily; now hospitals are running out of oxygen. On April 23, the Indian media reported that 25 critically ill COVID patients died due to oxygen shortages in a government hospital in Delhi.  

“The surge took us by surprise and the system is now totally overwhelmed,” says Mishra. Indians are being turned away from vaccination centers because supplies have run out. 

From calm to chaos in a New Delhi suburb

Early on the morning of April 22 at Kailash Hospital in Noida’s sector 71, a quiet, tree-lined residential area, at least ten people affected by the SARS-COV 2 virus were waiting for high-resolution compounded tomography—a sophisticated lung scan that is used to determine inflammation in COVID-19 patients. Their ages varied from mid-thirties to late sixties, and all were waiting to discover possible damage from the coronavirus. By 1 p.m., the numbers had swelled to over 50 people.

This leafy suburb of the Indian capital that lies in the neighboring state of Uttar Pradesh has a population of around 637,000—most of whom live in skyscrapers that dot the city skyline—and over 3,700 active cases. On April 18, it recorded 700 new cases, the highest one-day case spike in the state since the pandemic began last year. 

In what is a stark contrast to last year, apartment authorities are delivering daily case updates within the building complexes. Chat groups are filled with pleas for food delivery, home sanitation, and requests for medicines and other COVID-related supplies, as hospitals continue to turn away seriously ill patients and pharmacies struggle to supply basic medicines such as paracetamols or Fabipiravir, an anti-viral tablet approved for treating mild to moderate COVID-19 symptoms.   

“We are turning away 10-15 patients every day,” says Monu (who goes by just his first name), one of the Kailash Hospital’s attendants. “There are no beds.” 

On April 22, the Delhi High Court had convened for a special hearing at 8 pm —responding to an urgent plea filed by one of Delhi’s top hospitals, Max Patparganj. The hospital had informed the court that it had only three hours of oxygen left—placing the lives of 400 of its patients, including 262 who were COVID positive, under duress. 

Is the homegrown double mutant B.1.617 responsible for the surge?

This second wave in India has been widely attributed to the B.1.1.7 variant—first identified in the U.K.—which had ramped up cases in the state of Punjab. Another possible culprit is a homegrown variant, called B.1.617, with two worrying mutations, that originated in Maharashtra, the worst affected state. 

This variant, B.1.617, is also believed to be triggering new surges in Bangladesh and Pakistan and led many countries, including the U.S., Canada, and the U.K., to advise citizens against traveling to the region. 

The University of Washington’s IHME says seroprevalence surveys, which measure the percentage of people in a population who have antibodies against the SARS-CoV 2 virus, and their own modeling strongly suggests that the new surge is linked to “escape variants”— which can override immunity afforded by previous infection. Vaccines, too, are less effective against these variants. However, experiments completed at Mishra’s institute on April 22 found that the B.1.617 was not resistant to the protection offered by Covishield (also known as the AstraZeneca vaccine), one of the vaccines in India's inoculation program.

“A bigger second wave is a global, historical trend of this infection,” says epidemiologist Rajib Dasgupta, chairperson of the Centre of Social Medicine & Community Health at Jawaharlal Nehru University in New Delhi. Once a new variant is identified, he adds, its epidemiology must be investigated and key resources moved to affected areas to strengthen capabilities.

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In India the surge is specific to particular districts within a state. This is “unlike in the U.K., for example, where the U.K. variant was found to be responsible for 70-80 percent of the cases,” Dasgupta says. “India is so large and heterogenous that multiple variants can be anticipated to emerge, and will need to be identified and tracked.”  

Wherever a new variant emerges, he says, it will most likely lead to a faster spread, particularly if it is an escape variant. Identifying those variants and customizing the response can help contain surges more effectively, he adds. “One epidemic is actually multiple epidemics in a country like India, and you need to have multiple strategies to address them,” says Dasgupta.

Mishra’s institute also found that the double mutant is only responsible for around 10 percent of the cases countrywide. In Maharashtra, where this variant was dominant, it accounted for only 30 percent of the cases. “I would blame this surge on human behavior,” says Mishra. 

Premature euphoria over herd immunity 

Second surges have typically been blamed on human behavior worldwide. During the second wave in the U.S. that lasted 45 days, Lisa Maragakis, an infectious disease specialist at Johns Hopkins University School of Medicine, wrote in an article that noted “after many months of canceled activities, economic challenges and stress, people are frustrated and tired of taking coronavirus precautions” and these factors were “driving surges and spikes in COVID-19 cases.” 

In India, too, a year of COVID-fatigue gave way to an ill-advised euphoria over herd immunity as cases began to dip in January. But as Reddy says “in this very mobile age, unless the whole world acquires substantial immunity, [herd immunity] cannot [happen].”

But warnings such as these, Reddy says, were shouted down by the people as “negative sentiments.” Mishra was accused by many of his acquaintances of creating false alarm over a second wave. On April 1, the Kumbh Mela, an annual religious event, was also allowed to begin with full fanfare. As 3.5 million Indian devotees gathered in the state of Uttarakhand to take an annual holy dip in the Ganges, it was unsurprising that it turned into a superspreader event—although its full effect won’t be known for a few weeks. In the short term it pushed up the number of daily cases in Uttarakhand from 30 to 60 cases in February to 2,000-2,500 this month. 

Cinemas, schools, malls, bars, and restaurants were allowed to open in October last year, guest restrictions in wedding ceremonies were relaxed, and politicians freely crisscrossed the country for election rallies as four Indian states went to the polls for regional elections. 

In West Bengal, a state currently electing a new government, voting extends from March 27 till April 29 with the state continuing to host extensive rallies and crowded electioneering even as daily cases surge. On April 1, the state had recorded 6,519 cases. In the last 24 hours it recorded 12,000 new cases—and the count is expected to go up to 20,000 by the end of the week. 

A separate, more infectious variant, named the Bengal strain—a triple mutant—has also been identified as the cause of many of the infections in the state. Prime Minister Modi called off election rallies in West Bengal on April 23 in light of the surge. 

‘A race against time’

Could the second wave have been prevented? Experts say no. But it could have been substantially contained. “Typically in all countries the second wave is always much bigger than the first wave, and the reason is that in the second wave a lot of younger adults are affected,” says Dasgupta. 

A briefing by the Institute for Health Metrics and Evaluation (IHME), an independent global health research center at the University of Washington, says India’s daily COVID-19 cases are now double the number in the previous peak in September 2020. The institute predicts the COVID-19 death toll in India will likely double to 665,000 by August 1, 2021. 

“Without drastic measures to decrease social mixing and increase effective face mask use, the situation currently looks quite grim in India,” the briefing said.  

The IHME predicts daily deaths will peak at 5,600, on May 10. The institute says that if India is able to achieve universal mask coverage in the next week, it could prevent 70,000 deaths. 

Come May 1, every Indian above the age of 18 will be eligible for vaccination. If that happens on schedule, the IHME predicts another 85,600 lives could be saved by August 1.

The coming three to four weeks, Reddy says, will be crucial to contain the surge: “It’s a race against time.”