One out of every six human beings lives in India.
The progress of the pandemic in India has an outsize influence on the global fight against the virus. The current wave of COVID-19 in India affects each and every one of us no matter where we live.
The country is now reporting > 300,000 cases a day: the worst at any point in the pandemic. How did India get to this point?
1) Politics: Many states in India have scheduled elections in March/April 2021. Several political leaders have held large rallies with little social distancing/face masking in evidence. Rallies went ahead despite community transmission for political reasons. The situation is similar to Trump's election rallies in 2020 setting off a large outbreak in the US [ref 1] .
2) Complacent governance: Using sharp/strict lockdowns and a strong grass roots public health drive, India had managed to avoid the worst exigencies of the pandemic in 2020. The government boasted a victory against COVID-19 and many (including key figures in power) felt that the worst was over. The world's largest vaccination drive was also underway, further driving unfounded optimism. Although 140 million doses of COVID-19 vaccines have been administered, this is only 10% of the billion-strong population. After the previous wave, more than 70% of the population remains susceptible to COVID-19. The country is still far from herd immunity.
3) Pandemic fatigue: Lockdowns in 2020 frequently pitted lives against livelihoods and a good part of the population was sick of it. The gradual relaxation of mask usage and social distancing culminated in large religious gatherings during the Kumbh Mela (one of the largest gatherings on the planet). Mass movements of pilgrims have probably spread the virus far and wide in the Indian hinterland.
4) Chronic medical conditions: although the population is relatively young, hypertension, diabetes, and obesity are widely prevalent in India. These are all risk factors for severe COVID-19. This explains the surge in patients requiring hospitalization exhausting oxygen supplies and ICU beds rapidly.
5) Variants?: This is the last on the list and there is actually no convincing evidence that variants are driving transmission in India over and above the human behavioural factors noted above. A particular variant called B.1.617 is increasingly detected in some, but not all parts of the country [ref 2] . This has been called a 'double mutant' in the media, but this is a ridiculous name as all variants of concern carry several mutations (not just two). B.1.617 lacks the N501Y mutation (associated with increasing transmissibility). However, one of its mutations L452R may increase infectivity of the virus modestly [ref 3] . Luckily, preliminary data suggests that B.1.617 may not be able to escape vaccine-induced immunity too much [ref 4] . At this stage, the B.1.351 and P.1 variants are more of a concern than B.1.617.
India is in for a very difficult summer. The size of this wave is certainly amplified by uneven healthcare capacity, questionable policymaking, and population density. However, this is a clear warning that the conditions leading to a COVID-19 tsunami can (and do) arise anywhere in the world without herd immunity. Even regions with low levels of community transmission can suddenly experience super-spreader events leading to exponential rises in cases.
Therefore, if you have the unique privilege/ opportunity/ gift to get a COVID-19 vaccine, PLEASE GET VACCINATED! Vaccination is a civic responsibility. Your decision on this doesn't just affect your body, but those of the people around you.
References:
1. The Effects of Large Group Meetings on the Spread of COVID-19: The Case of Trump Rallies, (SSRN, 18 Dec 2020)
2. B.1.617... Lineage Report (outbreak.info)
3. Transmission, infectivity, and antibody neutralization of an emerging SARS-CoV-2 variant in California carrying a L452R spike protein mutation (medrxiv.org)
4. Neutralization of variant under investigation B.1.617 with sera of BBV152 vaccinees
