Reduced media coverage, opening up of the economy and poor COVID-19 etiquette from the public are the reasons behind the rise in COVID-19 cases in India, say experts.
After reporting less than 10,000 cases in February, India has witnessed a steady rise in COVID-19 cases in March with the seven-day average on March 20 at 31,651 cases. Maharashtra has been reporting the highest number of cases due to steep rise in cases.
According to Dr Ishwar Gilada, Consultant, HIV & Infectious Diseases, Unison Medicare & Research Centre, lockdown fatigue coupled with the wedding season has contributed to the increase in cases. With five states going to polls, the number will only rise.
"When you see the spurt now, you go back at least 1-1.5 months. Lots of weddings happening, lots of social gatherings happening, it was a lockdown fatigue," Dr Gilada said.
"What we will see in the next couple of months or so, five states which are election states, there is no social distancing or masking; right from the leaders at the top to those at the bottom. So, we are going to see (cases rise). There is also Kumbh Mela going on in Haridwar where social distancing is not possible and where you cannot use a mask when you are taking a dip in the Ganga," Dr Gilada added.
The spurt in cases coupled with a possible rise in fatality rate will be mentally draining on healthcare workers despite having experience combatting the disease according to Dr Gunjan Chanchalani, Consultant Intensivist, St Elizabeth Hospitals.
"Till September-October, everyone was overworked and now the doctors and the nurses have had some amount of relaxation period. Though they are not mentally prepared for a second wave, treating the patients for them is not a real challenge now. They are kind of prepared for what is to be done, how it is to be taken care of and that could be the reason.
"But as the number of cases increase, and the hospitals get overwhelmed and the people get overworked, I am sure that the probably the fatality rate may go much higher than the first wave," Dr Chanchalani said.
Edited excerpts from the interview follow
Govindraj Ethiraj: Let me begin with you Dr Chanchalani. What have you been seeing? I spoke to you over 7-8 months ago and at that time we were pretty much close to the peak. There was a lot of concern and panic around. That panic may not be there today. But the number of cases that we just spoke about is much higher.
Dr Gunjan Chanchalani: Yes, the cases definitely have been increasing over the last couple of weeks and they are actually rising, skyrocketing as you have said and probably, we are not at the peak. Cases may go up a little more—the reason being there is no lockdown now and people have actually taken the whole thing quite in a relaxed manner. Maybe because the media hype is not much, there is no lockdown, there is no message from the PM. So, the fear in the people is less; plus, everybody has incurred some or the other loss in the last one year. So, for them earning and making up for those losses and giving their family priority from a monetary side is more important. So, they have been kind of neglecting the disease and even if you go out, even if it is important to go out and work, they are not even following the basic public health precautions that needed to be taken here.
Even wearing a mask, even if the bus is crowded, not more than 50% of the people will be found wearing a mask. Even on the roads, in a crowded place many do not wear a mask and even though they stand close to each other. So, that is the worst thing. Cases may increase more rapidly and though we are wiser from the previous wave—we know what works, we know when to catch the patient, when to refer to the hospital, we know when to do a CT scan—though we may get wiser, but still we may not have enough health capacity and the death rate may actually go higher than what we got in the first phase. So that is the main worry right now.
GE: Tell us about the patients that you are now seeing. I am talking about the fresh COVID cases compared to what you were seeing in the March-April to September phase 2020. Any difference in the nature of symptoms and of course the time at which they are coming in?
GC: The time that they are coming in is comparatively a little later now, I would say that. As I said many are neglecting the symptoms. The main symptoms that majority of them get is probably a little fever and malaise. Initially there was panic. So, the first episode of fever and people would contact the doctor, start taking precautions, stop going out, be away from the family and isolate them in a room if possible and everything. But now as the panic has reduced all this is not happening.
They are coming to the hospital a little later, but not really that late as it would because every doctor in the community is now educated about what to do when COVID happens. But one thing I am seeing is that the lung involvement in this wave is probably a little earlier than what it was. Earlier when we would do CT scans on the 3rd or the 4th day of the illness, we would many times not find any lung involvement and that would probably be seen at the end of the first week or the early second week.
But here now, when they come to us with a CT scan done on Day3 or Day 2 there is already a lung involvement that is there. So, this probably shows that in this wave, the virus variant that is there is probably involving the lung a little faster than what it was in the first wave.
GE: Dr Gilada you have been tracking many infectious diseases including HIV in the past. What have you seen in the way this has progressed between March of last year and now, even as we finish a year now?
Dr Ishwar Gilada: What we clearly understand is the human behaviour and the virus behaviour. They are both unpredictable. Actually, after all this kind of pandemic, the whole year is gone, a lot of economic impact, people should have understood. As Gunjan said people are not behaving properly, COVID behaviour is not there(sic). Today morning I did one survey at the Worli Seaface, which is almost six months after I have done that. I find the same thing! Actually, worse than what it was six months ago when it was the peak of the pandemic. So, 40% people are wearing the mask; 20% people are not wearing it properly, so in reality 80% of the people are not wearing the mask. That too in an area such as Worli Seaface -- where the wealthy strata of society, health-conscious people, middle-aged group people and they are not wearing masks. So, if that is the behaviour, there is going to be a problem and that we are starting to see.
And the only saving grace as Gunjan said is that our health preparedness is proper, much better than earlier, our oxygen bed, our ICU bed, ventilators are available, medicines are in plenty, doctors' understanding is much better than earlier--they know what to use and what not to use. And most importantly, this current strain of the virus is super spreader but not a killer. So, our case fatality rate has come down to 0.7(zero point seven) which used to be 3.5 ( three point five) earlier in Mumbai, it came down to 2 - 2.5 or so, then 1.5 and now currency at 0.7. So, this is the situation.
GE: In your understanding why is this happening now? People, I guess, started becoming careless since December or January. Yet we saw or seeing this sudden spurt from about 300 cases in the city of Mumbai for instance to almost 2500 plus cases—all in the matter of weeks. What could have triggered this sudden change or spurt?
IG: Actually, those who have been observing for the last one month or so, it is not sudden, it is happening slowly. See, what happens is: if one becomes 2, the increase is only one. But when 2 becomes 4, it is 2 increase. So likewise, it is increasing more. So, when you see the spurt now, you go back at least 1-1.5 months. Lots of marriages happening, lots of social gatherings happening, it was a lockdown fatigue. People want to meet their relatives, even my family members want to come and visit me which they have not done so far for over a year.
Then the vaccine has come. Yes, vaccine has come, but vaccine has not come in the arm, vaccine has come on paper does mean that there is vaccination. And that way the speed of vaccination is also not as good as it should have been. When particularly India is a world producer of vaccines, plenty of vaccines are available, plenty of vaccine doses are available but they are not utilised. I think we need to look at several issues and they are multifactorial. What we will see in the next couple of months or so, five states which are election states, there is no social distancing or masking; right from the leaders at the top to those at the bottom. So, we are going to see (more case). There is also Kumbh Mela going on in Haridwar where social distancing is not possible and where you cannot use a mask when you are taking a dip in the Ganga.
GE: But the cases at this point, at least going by the data we have, seem to be spiking only in some parts of the country, more so in Maharashtra, and may be a few other states. Maharashtra seems to have led the race, so to speak. If there is a behaviour change all over the country, and if there are polls happening in other parts of the country, so why is that the cases are spurting here?
IG: As I said in the beginning the virus behaviour is unpredictable. What we are seeing, the so called BIMARU states, Bihar, Madhya Pradesh, Rajasthan and UP, if you single out two states, Bihar and UP you find that their rate is so low and all along it is low. So there is something in the poorer states, where the health parameters are very poor, there all along death rate is low, in Bihar the death rate is 0.6% (zero point six percent) all along. Either we have to prove that the data they are giving is wrong or follow them. Every time Maharashtra cannot be the leader for the whole country. There are sometime where even UP and Bihar can be leaders.
I would like to suggest that there should be some serious studies to be done. Both by administrators and the scientific community to see what is good in those two states where the [numbers] are not escalating. Despite the exodus of people who went from here, migrant labourers who went back...despite that they have curtailed. Maybe they have taken early lockdown, administrative machinery, whatever they have done they have done well.
GE: Some of the epidemiologists that I have been talking to are saying that because they are more rural and there may be more dispersion of population, that could be one reason why it has not spread much. Dr Chanchalani, you talked about an early lung infection or impact on the lung. Could you tell us a little more about what that means, how it is playing out?
GC: See, the phases of COVID, the first phase is more like a viral illness. It is more like a flu. Then it comes to the second phase, i.e., the immunogenic phase. The virus creates an immunogenic reaction in the body that affects the lungs. So, this the patho-physiology that we have been reading all this while. And when it says that by the end of the first week and the beginning of the second week when the lung gets involved, the immunogenic phase starts and the oxygen level starts dipping. So earlier when we used to do the scans in the first week, most of the times the first week scans would be normal. The 3rd-4th day scans that we would have.
But now when we are doing the scans—people have probably realised that a CT scan is a faster way to detect a COVID infection which involves the lungs. So now people are coming to us with the scans. Earlier, people would come to us probably a little later also and we would scan them in the second week and most of the time not find an infection in the first week, even if we did it. Now people are coming up with the scan where on the 3rd or 4th day itself there is lung involvement though their oxygenation is maintained. And probably many of them may not have an oxygen dip and they may recover with that itself. Even in a mild disease we are now seeing a lung involvement, which I would not have scanned in the first wave at all.
Now, since the community has realised that scans are important, they are doing more scans and probably that is one of the reasons why. But as I can say with my experience that I saw in the first wave is in the first week also when we would scan somebody, we would not find any lung involvement but now we find the lung involvement. I do not understand. Maybe it is the new variant but then I am not the right person for this. There should be a good genetic study to find out whether the new variant is causing it or the human body's reaction that is causing it.
GE: What is this leading to? Again, in your experience, the patients that you have seen, or you have treated yourself or have seen been treated around you what happens after this?
GC: When the lung gets affected, the more and more percentage the lung gets involved, the oxygenation will dip. So that is why the lung involvement is very important. That is why most of the deaths are due to the oxygenation dip. Lung involvement is probably a sign that tells us that probably I need to be more cautious about this patient, observing more carefully, and if the patient continues to spike beyond the 4th, 5th or the 6th day I will want to probably treat him with steroids or do a repeat scan to see if the spread is increasing and probably treat him with antiviral like Remdesivir or something.
But as Sir said, the fatality we are seeing in the second wave is lesser, we are now more prepared, and probably till about a week or ten days back we had empty beds in every hospital. So, when there were empty beds, and people had come out of the burn out that had gone through. Till September end, October everyone was overworked and now the doctors and the nurses have had some amount of relaxation period; though they are not mentally prepared for a second wave, but still treating the patients for them is not a real challenge now. They are kind of prepared for what is to be done, how it is to be taken care of and that could be the reason. But as the number of cases increase, and the hospitals get overwhelmed and the people get overworked, I am sure that the probably the fatality rate may go much higher than the first wave.
Because this time, this virus, as Dr Ishwar mentioned, is spreading more faster than what it was. It could be human behaviour related or it could be the genes of the virus itself. Again, we do not know. We need to study this further to know that.
GE: Dr Gilada, this has been pointed out by many people that, some of the newer variants, the South African, the UK ...they spread faster. Can you explain what that means--especially when they say more infectious but not necessarily more impactful
IG: Basically, the virus has two qualities. One is the spreading factor and one is the lethal factor. Currently what we see is spreading faster. And sparing people from death, sparing people from critical illness. And if that is the case. then we should be looking at our own variants what we have seen, what our studies have done...South African, Brazilan, or UK strains are not found in much number. And as a habit, we have a habit of blaming others rather than looking at our own strengths.
There are some different strains found in Amravati, Nagpur, Jalgaon and Akola, I think we should study that. Secondly, what we need to do is...do not count Maharashtra...because Maharashtra's population is high. It is only comparable to Bihar but a lot of other states are low. So, we should talk about per million population what are the infections. And in that per million population currently Maharashtra is actually at number 7 (seven). Smaller states such as Goa, or Union Territory like Ladakh, Delhi, Kerala, Puducherry, Chandigarh and then Maharashtra. When you look district-wise, per million districts, in that also Mumbai is 24. There are lots of districts ahead of us. So therefore, I think we should not look at only real numbers. We should look at real new infections, per million infections, and per million deaths.
Most important thing is what the honourable Prime Minister said almost a month back—if we are able to bring down the death rate to less than one, we have won half the war. And I think we have brought that to 0.7% …. there are a lot of states where death rate is 0.5%. We do not need a lockdown or panic about them.
GE: To be fair when we are saying that we are getting worried and say for the city of Mumbai it is almost 2800 cases, we are only comparing with Mumbai city last year. I know you are right about the per capita, but we are only comparing with the same city at a different time.
IG: You see, last year there were no locals. Now locals are opened up. What we suggested is that you cannot stop locals but you ask people, those who want to travel on locals, to also use a shield. Apart from face masks, if there is a face shield there is double protection. And that has been proved scientifically. So, when you are opening up, you must put some conditions that people are willing to follow. They want to earn their livelihood; they are willing to follow those kinds of conditions. But currently there is nothing followed there.
GE: Dr Chanchalani as we look ahead, who are the kinds of people who are more at risk? Any changes in that ...who should be more careful? And secondly, how strong or secure are we in terms of medical response in terms of the medicines we are offering? But in terms of medical response and who is more susceptible...your sense?
GC: In India we do not have any such study to show who is more susceptible in the second wave per say. But in the first wave, yes elderly were more susceptible, people who are obese, people who had diabetes, hypertension, these were more susceptible.
But if you see studies from abroad that were there, these have shown that in other countries, children were more affected. Though the mortality was not very significant even in the first wave also, in the second wave and also, they found that the pregnant people were also at risk, as compared to... they found more pregnant with COVID rather than in the previous wave. So, in India I think that the risk factors will remain the same—elderly or the young people, or the pregnant people who have compromised immunity. Specially obese and diabetes we saw a very bad response, severe disease in the obese and diabetic in the first wave, I think that continues to be there.
Any comorbidity whether it is hypertension, diabetes, or heart disease or the kidney disease, all these people are more susceptible to get a severe disease and they need to continue to be more cautious about their health and avoid crowded places and use maybe double protection like Dr Ishwar said—use a mask as well as a face shield, a sit gives almost near complete protection if you are using that. I think the main reason a face shield gives protection is that it prevents you also from touching your face repeatedly, from adjusting your mask and everything. Because the virus also tends to spread through fomites, so it may be there in your hand and you might touch your face or your eyes, and it spreads through that. So, if you are wearing a face shield it protects your itself from touching your face repeatedly and prevents you from getting infected and that could be one of the reasons that could be there. So, they need to continue that.
About the medical response, as I said, currently yes, we are prepared. We are out of the burnout and we are kind of fresh to work again. Plus, we have enough stock of medication for now. But as I said, as the cases will increase, severe cases will increase, maybe we will not be prepared and maybe we will see a worse outcome than what we saw in the previous wave.
Probably the Indian Government needs to stock up--last time we even had the shortage of steroids for a very small phase--so all these medications need to be stocked up by the Indian government so that we do not have a shortage of antiviral drugs and steroids and everything.
GE: Are you saying that we are headed to a shortage right now?
GC: We may, we may, I do not know. Because this virus tends to spread very fast and faster. As you say, even if a young person is going out for work, he may not get a severe disease but he may come home to give his parents or somebody who is more immunocompromised to give the disease. And once it is in the house everybody in the family is affected as such. Not just for work, they are even going out on outings--birthday parties, small get-togethers. So that is going to spread faster. So, we need to be prepared for the worser kind of wave, worser peak than what we saw last time.
GE: Dr Gilada, we are also obviously rolling out a vaccine. The vaccine is right now for sixty plus or those with comorbidities with 45-60. It is a bit of a slow start, a lot of people we all know are not taking the vaccine despite being eligible for it. How do you see this evolving now? As more people take the vaccine will we be able to create some level of herd immunity, of some level, not the absolute number? Or will the virus as potentially things are going move much faster and therefore render this whole vaccine effort somewhat ineffective at least for now?
IG: There are two things. One is in principle, who should be getting the vaccine. On one hand we are blaming the 20-40 age group that they are culprits; they are bringing infection home and they are people spreading in the society. Now, on one hand if we blame them actually our policy should be youth-centric. Why were we successful in HIV? Because rather than blaming the young people, we put them in the programme, they were made part of the programme and it was a youth centric policy.
Now also if they are the breadwinners, they are the people who are going to get infection from here to there or there to here, they should be prioritised. We have no shortage of vaccine production. We have been able to supply to the rest of the world, why should we not give them?
And secondly at that time death rate was more in the comorbid people and old people. Now if the death rate has settled to 0.7% from 3.5% then we should be looking at spreading less and if spreading less has to be there, then young people have to be targeted.
Now, looking at the pace of vaccination, we have started very slowly and there are very few centres, they work for only six or seven hours a day, Saturday and Sunday they do not work, they want to reconcile their effort. Actually, we are training those people who are not trained to give injection, and we are telling them how to fill up the syringe, etc. There is a lot of vaccine wastage—Prime Minister also said.
We should have, there are 12 lakh 50 thousand MBBS doctors. I am not even counting non-MBBS doctors. There are 3 lakh 70 thousand postgraduate doctors. Even out of this 16 thousand, 20% of them are used, there are 3 lakh doctors available for vaccination. 100 vaccines per day, it would count 3 crore per day. So, all priority populations can be finished in just 10 days. So why not open up vaccination in primary health centres and sub centres There are 23,000 PHCs and 1 lakh 47 thousand sub centres. So many vaccination centres can start and it can reach the villages.
Currently it is there only in the city and taluka places. So, we need to look at those issues. We need to incentivise that if you are taking a vaccine, after two weeks you can travel, there should be a travel certificate. There should not be an RT PCR requirement. If you are paying for vaccination, income tax rebates will be there, CSR and so on. So, there are multiple ways of increasing vaccination and opening up...everybody is not asking for a free vaccine. They do not want to spend three to four hours in the vaccine queue. They want to get it from their own doctors in just 10 minutes. Now we know that there is no need to wait for 30 minutes, there is no need to do a lot of things that are currently done, and we can do it.