After nearly five months of being able to travel freely at all hours, residents in Delhi now have to make peace with a new night curfew. The national capital reported 331 new Covid cases on December 27, the highest single-day rise since June 9. The figure was nearly 10 times higher than the number of fresh cases reported on December 1. Keeping the surge in mind, the Delhi government joined neighbouring Haryana and Uttar Pradesh in imposing a night curfew. Even though Delhi’s test positivity rate is only 0.68 per cent, well below the WHO (World Health Organization) recommendation of 5 per cent or lower, officials are erring on the side of caution as the new highly infectious Covid variant, Omicron, has already been detected in at least 165 cases in the state, as on December 28.
India had logged 653 Omicron cases across 21 states and Union territories till December 28, of which 186 patients had recovered or migrated, according to the ministry of health and family welfare (MoHFW). Maharashtra recorded the maximum cases (167), followed by Delhi (165), Kerala (57), Telangana (55), Gujarat (49) and Rajasthan (46). As seen with the second wave caused by the Delta variant earlier this year, any sustained rise in Covid cases is a warning of an oncoming surge. “We shouldn’t wait for things to get as bad as they are abroad, particularly in the UK. Omicron has caused major surges globally and we must be prepared to stop a similar situation in India,” says Dr Randeep Guleria, director, AIIMS, New Delhi.
Omicron, or the B.1.1.529 variant, which was first reported in late November in South Africa, is fast replacing Delta globally. As on December 28, it had spread to 108 countries and caused 151,000 infections and 26 deaths. The variant, which has eight more mutations in its receptor binding domain (the part the virus uses to enter human cells) than Delta, has a doubling time of 1.5-3 days. Household and contact studies in the UK confirm it to be the most infectious Covid strain to date. “The next few weeks will give us a clear picture of Omicron’s spread in India,” says Dr Sandeep Budhiraja, group medical director, Max Healthcare. “It has replaced the older strains in several countries and will behave no differently in India.”
On a national scale, there are no indicators of a rapid spread yet. As on December 27, India’s R-value (the number of people a Covid patient can infect) was below 1, indicating slow transmission, while the national test positivity rate was 0.98 per cent. About 20 districts, though, had a weekly positivity rate of over 5 per cent. These were in Kerala, Mizoram, Sikkim, Manipur and West Bengal. The R-value in some metros is also a cause for concern. As on December 15, Delhi had the highest R-value of 1.12, followed by Mumbai (1.10), Bengaluru (1.07), Kolkata (1.05) and Chennai (1.04).
Halting a potential wave
Some studies suggest the virus has already spread enough to trigger a third national wave. An IIT Kanpur study, uses a statistical tool called the Gaussian Mixture model, predicts early February to be the peak of the third wave. There are also predictions based on global examples about how bad the wave can get. France, despite 81 per cent vaccination coverage, clocked 100,000 new cases on December 28. “A similar outbreak in India, given our population, could see nearly 1.3 million cases a day,” warns Dr V.K. Paul, member, NITI Aayog. “We need to watch the situation closely. It is important to focus on preventing a third wave.” Other experts are hopeful a wave may not come at all. “Let us wait two more weeks and see if the numbers continue to increase. At the same time, we must double down on Covid precautions and get our hospitals ready,” says Dr Rahul Pandit, director of critical care medicine and ICU at Fortis Mulund, Mumbai.
A lockdown should be the last option, experts say. “You don’t need extensive lockdowns to live with Covid. The ‘test-trace-treat-vaccinate’ strategy is far more advanced today than a year ago. We should use these tools to our advantage,” says noted virologist Dr Gagandeep Kang. Indeed, current guidelines ask states to impose lockdowns only when the test positivity rate is higher than 10 per cent or hospital bed occupancy crosses 40 per cent. Strategic measures should be implemented wherever there is indication of a spread. For instance, Mumbai’s R-value is already over 1. While the city is not in lockdown, steps have been taken to reduce public contact, such as compulsory wearing of masks in schools and limited hours. Maharashtra also has a night curfew and malls and cinemas have been closed.
Prime Minister Narendra Modi, on December 25, too stressed on Covid-appropriate behaviour, particularly the wearing of masks. “One needs to wear a three-ply or an N95 mask. Single-layer cotton or cloth masks are not going to help,” says Dr Ankita Baidya, a Delhi-based infectious diseases specialist.
Vaccine is the weapon
Experts are hopeful that vaccines will help reduce both the spread and severity of Covid disease this time. Eight Covid-19 vaccines have got emergency use authorisation from India’s drug regulator —Covishield, Covaxin, ZyCoV-D, Sputnik V, Moderna, Johnson & Johnson, Corbevax and Covovax. Around 89 per cent of individuals above the age of 18 in the country have received a single dose of vaccine and 61 per cent have been fully vaccinated.
However, there are signs that two dose vaccines won’t be enough to stop Omicron. Over 90 per cent of the Omicron cases in India were fully vaccinated, 3 per cent had taken booster shots abroad and another 2 per cent were partially vaccinated. A study by London’s Imperial College says protection against severe disease caused by Omicron was a paltry 20 per cent after two doses of Covishield (taken by roughly 88 per cent of Indians vaccinated so far), and protection against death only 30 per cent. A booster shot improved protection against severe disease to 80 per cent and against death to 88 per cent. “A booster shot may provide 70-75 per cent protection against symptomatic infection,” notes Dr Kang.
The Indian government has announced booster shots from January 10 for fully vaccinated healthcare and frontline workers as well as people above the age of 60 with co-morbidities. For the latter, the shot will be given on doctor’s advice and can be taken only nine months after the second dose. Children in the age group of 15 to 18 will be eligible for a Covaxin jab from January 3. “Vaccinating children will ensure they do not pass on the illness to family members and would act as an added protection against Omicron,” says Dr Naresh Trehan, chairman & MD, Medanta Hospital, Gurugram.
It is unclear, though, which vaccine can be taken as a booster. The Com-COV2 study in the UK found people had a better immune response when they received a first dose of AstraZeneca or Pfizer-BioNTech shots followed by Moderna nine weeks later. Deliberations are on within the MoHFW that the recently approved Covovax vaccine, to be produced by the Serum Institute of India, could be a contender for the third dose for those who have taken Covishield. And that Covishield itself could become a booster for those who took Covaxin. A decision is pending. “We are awaiting more data on the best practices for a third shot. We need a vaccine that can be scaled up for a booster shot,” says an MoHFW official, requesting anonymity.
In the best case scenario, Omicron itself could end up providing natural immunity to many. “Data suggests Omicron is like a live weakened virus. If it only causes mild illness then it will be a booster for the vaccination and a vaccine dose for others,” says Dr Budhiraja.
Treatment preparations for a surge are underway even as containment steps are being taken. India has an estimated 1,810,083 isolation beds, 494,314 oxygen beds, 139,300 ICU beds and 18,836 MT per day of oxygen. The government has also cleared anti-viral drug Molnupiravir for use. In a clinical trial of high-risk people during the early course of illness, the drug was shown to reduce hospitalisation and deaths by around 30 per cent. It will be manufactured by 13 companies in India.
Delhi’s Sarojini Nagar market on Dec. 28; (ANI)
Data on Omicron cases in India showed only 30 per cent to be symptomatic—mostly similar to that of common cold. “People are likely to confuse Omicron infection with common cold. The disease caused by Omicron is quite different from Delta. So far, it is milder,” says Rakesh Mishra, director, Tata Institute for Genetics and Society, Bengaluru, and former chief of the Centre for Cellular and Molecular Biology at the Council of Scientific and Industrial Research (CSIR).
India’s daily testing has fallen since September, and ranged between 886,263 and 1.25 million in the first week of December, as per ICMR (Indian Council of Medical Research). Kerala, with a positivity rate of 7.7 per cent—the highest in the country—had conducted only 42,149 tests on December 26. “Covid treatment and prevention depends heavily on timely diagnosis. Many of the medicines have to be given in the first few days after symptoms set in. It is difficult to ascertain the full spread and pin down upon emerging hotspots if people do not come forward for testing,” says Dr Pandit.
A major challenge on the horizon is the assembly elections scheduled in early 2022 in UP, Punjab, Uttarakhand, Goa and Manipur. On December 23, health secretary Rajesh Bhushan asked all poll-bound states to ramp up vaccination. The MoHFW has sent multidisciplinary teams to UP and Punjab over these states reporting vaccinations below the national average. In UP, 83 per cent of the eligible population has received the first dose and 46 per cent are fully vaccinated. Punjab has administered 26 million doses; 77 per cent of the eligible population has received the first dose and 41 per cent are fully vaccinated. “We have seen how breaking Covid protection rules can lead to sudden surges. Those mistakes shouldn’t be repeated,” says public health expert K. Srinath Reddy. While vaccines, new treatment options and ramped up Covid infrastructure have placed us in a stronger position against Omicron than during the Delta wave, complacency can prove costly.
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