Why Did India Have A Massive Spike in COVID-19 Cases?

I have written several articles on the coronavirus and on masks and healthcare issues. A series of links have been provided at the bottom of this article for your convenience. This article will, however address a different aspect of the virus or on healthcare issues in general.

When the pandemic started, India defied expectations by having a milder outbreak than had been predicted. Now, it is seeing a deadly second wave that is bringing the country’s health system to its knees – so what is behind this, and how much is the new India variant responsible?

This time last year, theories about India’s astonishingly low rates of COVID-19 infection included hot weather, natural immunity and the country’s high proportion of young people; some also attributed it to the country’s harsh lockdown. India was doing so well that in megacities like Mumbai and Delhi, officials had begun dismantling temporary COVID-19 facilities. Fast-forward to now, April 2021, and cases and deaths are soaring, leaving hospitals running out of oxygen. The shortage of beds and space is so acute that people are dying in car parks waiting to be admitted. The virus is spreading faster than ever before in India despite previous high infection rates in megacities, which should have conferred some protection.

The pandemic is sweeping through India at a pace that has staggered scientists. Daily case numbers have exploded since early March: the government reported 273,810 new infections nationally on 18 April. High numbers in India have also helped drive global cases to a daily high of 854,855 in the past week, almost breaking a record set in January.

Just months earlier, antibody data had suggested that many people in cities such as Delhi and Chennai had already been infected, leading some researchers to conclude that the worst of the pandemic was over in the country.

Researchers in India are now trying to pinpoint what is behind the unprecedented surge, which could be due to an unfortunate confluence of factors, including the emergence of particularly infectious variants, a rise in unrestricted social interactions, and low vaccine coverage. Untangling the causes could be helpful to governments trying to suppress or prevent similar surges around the world.

European countries such as France and Germany are also currently experiencing large outbreaks relative to their size, and nations including Brazil and the United States are reporting high infection rates at around 70,000 a day. But India’s daily totals are now some of the highest ever recorded for any country, and are not far off a peak of 300,000 cases seen in the United States on 2 January.

‘Ripple in a bathtub’

COVID-19 case numbers started to drop in India last September, after a high of around 100,000 daily infections. But they began to rise again in March and the current peak is more than double the previous one (see ‘Surging cases of COVID-19’).

“The second wave has made the last one look like a ripple in a bathtub,” says Zarir Udwadia, a clinician-researcher in pulmonary medicine at P D Hinduja Hospital & Medical Research Centre in Mumbai, who spoke to Nature during a break from working in the intensive-care unit. He describes a “nightmarish” situation at hospitals, where beds and treatments are in extremely short supply.

Shahid Jameel, a virologist at Ashoka University in Sonipat, agrees that the intensity of the current wave is startling. “I was expecting fresh waves of infection, but I would not have dreamt that it would be this strong,” he says.India’s COVID-vaccine woes — by the numbers

Studies that tested for SARS-CoV-2 antibodies — an indicator of past infection — in December and January estimated that more than 50% of the population in some areas of India’s large cities had already been exposed to the virus, which should have conferred some immunity, says Manoj Murhekar, an epidemiologist at the National Institute of Epidemiology in Chennai, who led the work. The studies also suggested that, nationally, some 271 million people had been infected1 — about one-fifth of India’s population of 1.4 billion.

These figures made some researchers optimistic that the next stage of the pandemic would be less severe, says Ramanan Laxminarayan, an epidemiologist in Princeton University, New Jersey, who is based in New Delhi. But the latest eruption of COVID-19 is forcing them to rethink.

One explanation might be that the first wave primarily hit the urban poor. Antibody studies might not have been representative of the entire population and potentially overestimated exposure in other groups, he says.

The antibody data did not reflect the uneven spread of the virus, agrees Gagandeep Kang, a virologist at the Christian Medical College in Vellore, India. “The virus may be getting into populations that were previously able to protect themselves,” she says. That could include wealthier urban communities, in which people isolated during the first wave but had started mingling by the second.

SURGING CASES. New daily cases in India have been rapidly on the rise. The latest peak has reached 249,000 cases.
Source: Our World in Data

The extraordinary surge in cases had been unexpected given that, by some estimates, as much as 20% of the population were thought to have antibodies to COVID-19, with this figure rising to 50% in large cities (although the researchers acknowledge this could have been an over-estimate). In addition, India started its vaccination drive on 16 January and by the start of April had declared that it had given more than 100 million vaccines in a record 85 days, compared to 89 days for the USA. But this number is a drop in the ocean for a population of 1.4 billion people, and there is a long road ahead.

So, what happened? Several factors seem to have come together in a perfect storm to create one of the worse COVID-19 outbreaks the world has seen so far.

Fast-moving variants?

But some researchers say that the speed and scale of the current outbreak suggest a new ingredient: emerging variants of the virus.

Udwadia has anecdotally observed that entire households are now getting infected — unlike in the first wave of COVID-19, when single individuals would test positive. He attributes this to the presence of more-infectious variants. “If one person in the family has it, I can guarantee that everyone in the family has it,” he says.

Genomic surveillance data show that the variant B.1.1.7, which was first identified in the United Kingdom, has become the dominant form of the virus in the Indian state of Punjab. Although scientists are still investigating whether or not the variant is more deadly, it does contain the L452R mutation that affects the virus’ spike protein. This protein is key to the way the virus hooks on to our cells. Early research suggests that this mutation makes the virus more infectious. This doesn’t necessarily mean that the variant will be any more deadly, but it means that more people are at risk.

And a new and potentially concerning variant first identified in India late last year, known as B.1.617, has become dominant in the state of Maharashtra. B.1.617 has drawn attention because it contains two mutations that have been linked to increased transmissibility and an ability to evade immune protection. It has now been detected in 20 other countries. Laboratories in India are trying to culture it to test how fast it replicates, and whether blood from vaccinated individuals can block infection, says Jameel.

More worrying is the way that the mutation could change the shape of the spike protein. As most COVID-19 vaccines target this protein, with antibodies being produced to recognise and attack it, any change to the shape could make vaccines less effective.

B1617 carries a second mutation called E484Q, and this also changes the spike protein. Laboratory research suggests that similar mutations are less vulnerable to antibodies, which could again reduce the potency of vaccines. 

Some Indian scientists are now attributing a new anecdotal observation that a single case is leading to entire households becoming infected due to this increased infectiousness.

The situation in India looks similar to that late last year in Brazil, he adds, where a resurgence of COVID-19 in the city of Manaus coincided with the spread of a highly transmissible variant known as P.1, which might have been able to evade immunity conferred by infections with earlier strains.

But others say that the existing sequencing data are not sufficient to make such claims. “As the numbers of sequences available are low, relative to the number of cases in India, we do need to be cautious,” says David Robertson, a virologist at the University of Glasgow, UK.

Mixing, moving and travelling

Some say that emerging variants account for only a small part of India’s surge in infections. In many regions that are experiencing outbreaks, they don’t make up the majority of genomes sequenced, says Anurag Agrawal, director of the CSIR Institute of Genomics and Integrative Biology in New Delhi.

Srinath Reddy, an epidemiologist and head of the Public Health Foundation of India in New Delhi, argues that people letting their guards down is a bigger driver. “The pandemic resurfaced in a fully open society where people were mixing and moving and travelling,” he says.India will supply coronavirus vaccines to the world — will its people benefit?

With cases declining after last September’s peak, “there was a public narrative that India had conquered COVID-19”, says Laxminarayan. In recent months, large crowds have gathered indoors and outdoors for political rallies, religious celebrations and weddings.

The nationwide vaccination campaign, which kicked off in January, might even have contributed to an uptick in cases, if it caused people to ease public-health measures. “The arrival of the vaccine put everyone into a relaxed mood,” says Laxminarayan.

More than 120 million doses have been administered, mostly of an Indian-produced version of the Oxford–AstraZeneca vaccine called Covishield. But that’s less than 10% of India’s population, so there is still a long way to go. In particular, India needs to ramp up vaccinations in the hardest-hit regions, says Kang.

Some people might have become infected while getting vaccines, says Udwadia, because crowds often share clinic waiting areas with ill people who are waiting to be seen.

See how rural India has been overrun by the pandemic’s second wave

Sparse healthcare. Social stigma. Undercounted deaths. The consequences for the country’s rural populations will likely play out for years to come.


There were no funeral pyres on June 10 at the Tavarekere mass crematorium, roughly 19 miles outside the South Indian city of Bengaluru; for the first time since April, the site had received no bodies. In large cities throughout India, daily COVID-19 cases are decreasing, the supply of medical oxygen is becoming consistent, and a system of triage at hospitals has been established. There is a sense that the COVID-19 pandemic’s deadly second wave has passed.

But outside India’s dense urban centers, COVID-19 is still battering the rural regions where two-thirds of the country’s population lives. Despite sparse or nonexistent COVID-19 testing outside cities, the data team at The Hindu newspaper has estimated that 65 percent of new cases through the beginning of June 2021 are in rural and semi-rural areas.

Lack of access to essential healthcare, misdiagnosis, pandemic denial, and social stigma are all fueling the spread of the virus in the countryside. In India’s poorer northern states, some villagers have dumped the bodies of relatives who have died of COVID-19 in the sacred river Ganges; others have fled to cattle sheds and farms, the only spaces where they can socially distance.

The body of a man who died from COVID-19 lies cocooned in plastic wrap.
The body of an 18-year-old man cocooned in plastic wrap lies in the bed of a pickup truck at the MAHAN Trust hospital to be transported home. Married for only six months, he died of COVID-19 complications minutes after being brought to the intensive care unit. He was lat…Read More
A family of five is monitored for COVID-19 symptoms.
Shyamkali Baiga and her four children, who have all tested positive for COVID-19, have their temperatures checked by community health worker Savni Baiga in Bahaud in Mungeli, Chhattisgarh. They are all under home quarantine. Half of this village of 400 refuse…Read More
Doctors attend to a baby suffering from COVID-19.
Doctors perform a procedure on a COVID-19-positive two-month-old to drain the pus forming in his knees at Jan Sawasthya Sahyog’s hospital.
Son plays music for hospitalized father suffering from COVID-19.
Ashik Parvez, 28, plays an Islamic prayer on his mobile phone for his father Nabi Khan, 50, who was critically ill in the intensive care unit at the Government Medical College Hospital.

A core part of the crisis is the fact that migrant workers and religious pilgrims had to leave larger cities as lockdowns were imposed during the surge. According to a report released by the city government on May 21, more than 800,000 migrant workers left Delhi. Other Indian cities saw a similar exodus. Estimates suggest anywhere from 22 million to 50 million migrant workers returned to their home states and villages during the 2020 COVID-19 lockdowns, but it’s not yet clear how many traveled home this year.

COVID in rural India

In large cities throughout India, daily

COVID-19 cases are decreasing. But

outside India’s dense urban centers

the second wave is still battering the

rural regions where two thirds of the

country’s population live.

“The story of rural India is actually a double whammy,” says Rama V. Baru, a healthcare policy expert at the Center for Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, and a member of the Indian Council of Medical Research that is spearheading India’s pandemic response.

“There is the visible crisis of not getting care, and the invisible story of the migrant crisis, where migrant workers who were forced to return to their villages have acted as carriers of the infection,” Baru says. “The migrant crisis and the rural spread are not separate, they are very much connected.”

What’s more, undercounting the deaths of India’s rural citizens is making their loss invisible. As of June 18, India officially has 794,493 active COVID-19 cases and 16,546 deaths in the last seven days—most in rural regions. But these figures are likely a gross underestimate, which some experts calculate might be six times higher. (Here’s why it is so difficult to gauge the pandemic’s death toll.)

A losing battle

Upendra Avula, 24, was relieved in early May when his 45-year-old diabetic father was finally on the path to recovery after a particularly severe bout of COVID-19. A first-generation graduate and civil engineer, Avula and his family live in Nagarkurnool, which is among the most underdeveloped regions in the southern Indian state of Telangana. He had been able to provide timely care for his father based on telemedicine consultations, via smartphone, with Vishnu Mummadi, a 32-year-old physician at Asram Medical College in Eluru, about 250 miles away from Avula’s village.

But on May 6 his father’s condition began to deteriorate rapidly, so Avula reconnected with Mummadi. While on-call in his own hospital, Mummadi is also teleconsulting and offering advice to families of COVID-19 patients across rural Andhra Pradesh and Telangana. He told Avula to move his father to a government hospital. But apart from a bed, the hospital had little to offer. There was no medical infrastructure or staff who could help. So Mummadi told Avula which medicines and simple diagnostic tools to purchase and how to monitor his father and act as his nurse.

When his father stopped responding to the medicine and his blood oxygen level dropped below 90 at around 10 p.m., Mummadi advised him to seek out a hospital with respiratory support in the nearby Mahbubnagar district. By the time they managed to get a bed, his father’s oxygen levels had dropped to 50. He improved a little after receiving oxygen, but then continued to get sicker. At 7.30 a.m. on May 7, his father passed away. Avula then began taking care of his mother, who had also caught the virus. She has since recovered.

A COVID-19 testing camp in rural India.
A COVID-19 testing camp at Primary Health Centre in Khudiya in Mungeli, Chhattisgarh, India. On this day, 12 of 19 samples taken tested positive in a Rapid Antigen Test. The more reliable and accurate RT PCR test is only available at a bigger hospital about 12 miles away.
Man receives a chest X-Ray.
A technician takes a chest x-ray of a 47-year-old man in the COVID-19 ward at Jan Swasthya Sahyog’s hospital in Ganiyari, Chhattisgarh, India.

Avula’s story is emblematic of how the rural spread of the virus has been amplified by sparse access to healthcare in much of the country. According to a 2015 report from by insurance group Swiss Re and the Harvard T.H. Chan School of Public Health, only 25 percent of Indians have access to healthcare services. In addition, 60 percent of the country’s estimated two million health workers cater to urban India, according to a 2016 report from the World Health Organization.

Overall, the country has just 80 doctors practicing of all types of medicine—allopathic, Ayurvedic, and homeopathic—and 61 nurses per 100,000 people. Of the physicians in rural India, only 19 percent had a medical degree, compared with 58 percent of those in urban zones.

Mummadi says that while most doctors are trying everything they can to save every life they can, “we are witnessing and hearing about really bizarre situations.”

For instance, many doctors in rural India are misdiagnosing COVID 19 as typhoid. India is among the worst afflicted countries when it comes to this disease; according to the latest Global Burden of Disease report, published by the medical journal the Lancet, the country had 5.8 million cases, and 58,552 people died due to typhoid in 2017. Doctors use the Widal test to detect typhoid, but this test is old and unreliable and can also produce a false positive result when a patient has COVID-19. When a sick patient tests positive, instead of following up with a COVID-19 test or even assessing the patients’ blood oxygen level, rural medical practitioners give the patients antibiotics.

“A patient who might be suffering from COVID-19 is not only misdiagnosed but is also given the wrong medication,” says Mummadi. Because antibiotics kill bacteria and not viruses, the patients’ condition only worsens. “By the time they come to the regional hospital, there is a long delay from the first onset of symptoms. This makes it harder to treat them and ensure they recover.”

Medical staff attend to woman who fainted.
Medical staff tend to a woman who fainted as she watched a sample being taken from her husband’s nose to test for black fungus (mucormycosis), in the ICU of the Government Medical College Hospital in Ambikapur in Surguja, Chhattisgarh, India.

In impoverished states such as Uttar Pradesh and Bihar, proper diagnostics and technological interventions were not set up, so rural people there are also turning to harmful medications that fail to treat the virus, says Amir Ullah Khan, a health economist at the Centre for Development Policy and Practice based in Hyderabad. These treatments range from using an iron rod to brand the patient in the parts of their body where they complain of pain, to diet plans that claim to cure COVID-19. (This is how the Indian government has been pushing unproven Ayurvedic treatments to treat COVID-19.)

Prayers offered to sacrificial goat in India.
Manohar Patil, 50, holds a sacrificial goat as his daughter and son-in-law offer prayers to it at an ashram run by Bhanlal Jawarkar, 70, right, in Dadida in the Melghat region of Amaravati in Maharashtra. The Mores claimed Jawarkar cured Jamuna More of oral cancer two y…Read More
Drying smoking stick leaves in India.
Tendu leaves, used as a wrapper for a local smoking stick, are left to dry on the grounds of a school in Mendrapara in Bilaspur, Chhattisgarh. Foraged from central Indian forests in the summers, the leaves are a major source of income for families, who head into the fo…Read More

And with only 35 percent of Indians having any kind of health insurance, the majority spend money out of pocket to pay healthcare service providers directly at the time of service. This means that many citizens are left to fend for themselves during a health crisis.

“During the last wave and the lockdowns of last year, even those who were reasonably better off completely ran out of cash,” says Khan. “When the second wave hit, there was no cash to fall back upon.”

Indigenous communities suffer the most

The second surge in India has even reached into more remote communities that fared better during the first wave. The village of Bamhani sits deep within the central Indian forests of the Achanakmar wildlife sanctuary and tiger reserve, in the Indian state of Chhattisgarh. It’s home to the Adivasi—indigenous communities of Gond, Baiga, and Oraon—who are among the most disempowered in India.

According to fourth National Family Health Survey, conducted in 2015-16 on behalf of the Indian government, the Adivasis of India already fare the worst according to various health indicators such as child mortality, child malnutrition, and chronic malnutrition.

“As our analysis of the NFHS-4 data shows, the Adivasis really are at the bottom of not only health but all development indicators,” says Venkat Ramanujam, a scholar at the Ashoka Trust for Research in Ecology and the Environment, Bengaluru, who studies changing Adivasi livelihoods in central India.

This region in central India escaped much of the pandemic in 2020, but during the second wave it wasn’t as lucky. When the first wave peaked in October 2020, the district of Mungeli, where Bamhani is located, had a total of 2,755 cases. Last month, even as the second wave was just beginning to spread to India’s rural regions, Mungeli had a total of 21,332 cases, of which 5,217 were active.

To seek medical attention, villagers must visit one of three affiliate centers set up by Jan Swasthya Sahyog (People’s Health Support Group), or ask for help from health workers who make daily visits and provide basic medicines as well as advice. When they need more advanced care, the patient’s family is advised to take them to the Jan Swasthya Sahyog hospital, more than 40 miles away.

Health worker walks door-to-door in rural India.
Health worker Kalabai Maravi walks door-to-door monitoring and tracking rural villagers for COVID-19 symptoms in Bamhani, deep inside the core zone of the Achanakmar Tiger Reserve in Mungeli, Chhattisgarh, India. Frontline health workers like Maravi are critical in prov…Read More
A doctor attends to a COVID-19 patient
Ashish Satav, left, checks on his 60-year-old patient, who tested positive for COVID-19 at MAHAN Trust’s hospital. The plastic sheets are pulled over when Dr. Satav attends his patients to help prevent the only senior doctor handling COVID-19 cases from catching an infection.

Apart from resources, social stigma associated with testing positive for COVID-19, mistrust of the government, and disease denial are also major issues here, says Pranav Dhamdhere, a 29-year-old physician at Jan Swsathya Sahyog. Even though villagers know that COVID-19 can be lethal, most are still reluctant to come to the hospital.

“Many times, by the time they come in, the patient is at quite an advanced stage of hypoxia. What we are trying to do here is to use the resources we have in the most optimal way, to do the best we can.”

Related issues like lockdowns are also having an adverse impact here. “Over this year and the last, I have lost patients who were suffering from various types of cancer and even tuberculosis who could have been operated on or medicated back to health pre-pandemic,” Dhamdhere says.

T. Jacob John, a retired professor of clinical virology at Christian Medical College in Vellore and former head of the Indian Council for Medical Research’s Center for Advanced Research in Virology, fears the situation is much worse than what we know so far.

“The rural wave will be outside the radar of the media,” John says. “The way dead bodies are floating in rivers tells you that rural people are not able to cope. It is a horrible nightmare that is going on for most of India’s rural citizens.”



RELAXING RESTRICTIONS AMID SLOW VACCINE UPTAKE

India isn’t the only country seeing rising cases, with several countries in Europe now seeing spikes in numbers, but these are related largely to the easing of restrictions and increased mobility.

India went from a strict lockdown, that was imposed so suddenly that people from villages were left stranded in cities, to increasingly large crowds gathering for political rallies, religious celebrations, weddings and funerals.

COVID-19 vaccines have been rolled out in India for months now, but initial uptake was sluggish. This seemed in part to be due to hesitancy and the perception that vaccine development was rushed. But it may also relate to a feeling of complacency stemming from the belief that the pandemic was waning in India.

We now need to watch carefully for the India variant to emerge elsewhere. While some countries have banned travel to India, largely because of the B1617 variant, travelers may have already unknowingly carried the new variant on flights out of India. People infected with COVID-19 were found on all 27 outbound flights between India and Canada between 4 and 14 April. While most planes are now grounded in India, it may already be too late to contain a highly transmissible new variant.

What has the government done about it?

India is making coronavirus vaccines available to anyone over age 18 starting May 1. It is also curbing the number of coronavirus vaccines that it exports and focusing on distributing those doses to citizens.

Some cities and states have announced new lockdown restrictions, including curfews and bans on travel and nonessential activities. Modi, meanwhile, has said that lockdowns should be a last resort and declined to institute one nationwide. Modi’s administration is sending oxygen tankers on “Oxygen Express” trains to parts of the country that are facing urgent shortages, and freeing up military stockpiles of medical equipment. Armed forces have been deployed to hospitals. But the government has also ordered social media platforms to take down critical posts that call attention to the catastrophic state of affairs in India, which many see as a case of misplaced priorities.

Why are there oxygen shortages?

Typically, India’s hospitals and medical clinics use only about 15 percent of the liquid oxygen produced in the country. Recently, however, nearly 90 percent of the country’s total supply has been diverted to health-care facilities, Rajesh Bhushan, a senior health official, told the BBC.

Since some Indian states do not have plants where they can produce their own liquid oxygen, they have to wait for supplies to be trucked in from other parts of the country. Filling up an oxygen tanker takes two hours, according to the BBC, which has led to lengthy lines outside oxygen plants. Once full, the tankers can only drive at 25 mph and travel during daylight hours.

As demand soars in crowded hospitals, some critics say that the government should have been better prepared. In October, India’s health ministry announced a plan to build more oxygen plants, but so far only 33 out 162 have been constructed. Modi announced plans for another 551 oxygen plants — one for each district — on Sunday. The prime minister has ordered that those “be made functional as soon as possible,” a news release from his office stated, but it may already be too late for many of the patients who are dying due to oxygen shortages at hospitals across India right now.

“We have been telling authorities that we are willing to increase our capacity, but we need financial aid for that,” Rajabhau Shinde, who runs a small oxygen plant in Maharashtra, told the BBC. “This should not have happened. As the saying goes, dig the well before you’re thirsty. But we didn’t do that.”

How has the world responded?

Countries across the world have stepped up to help.

Singapore, Germany and the United Kingdom dispatched oxygen-related materials to India over the weekend. France, Russia and Australia will send medical aid, and China and Pakistan have offered help.

The European Union is coordinating with member states to provide oxygen and medicine, and World Health Organization Director General Tedros Adhanom Ghebreyesus said Monday that the WHO would send additional staff and supplies to India.

As other countries offered aid, pressure mounted over the weekend for the United States to do more.

Recently the Biden administration said it would send raw vaccine materials, ventilators, personal protective equipment, oxygen-related supplies and therapeutic medicines to India. It is also mobilizing an American “strike team” of health experts, as well as funding for “a substantial expansion” of Indian vaccine manufacturing capability. In a phone call with Modi, Biden pledged to support India’s efforts to beat back the virus surge. The White House also announced Monday that the United States will share up to 60 million doses of the Oxford-AstraZeneca coronavirus vaccine with other countries after they undergo a safety check — a process that could take weeks or months. It is unclear how many of those doses will go to India.

Resources

nature.com, “India’s massive COVID surge puzzles scientists,” By Smriti Mallapaty;” gavi.org, “Why is India’s COVID-19 pandemic skyrocketing?, By Priya Joi; washingtonpost, “How did the covid-19 outbreak in India get so bad?, By Antonia Noori Farzan and Claire Parker; nationalgeographic.com, “See how rural India has been overrun by the pandemic’s second wave: Sparse healthcare. Social stigma. Undercounted deaths. The consequences for the country’s rural populations will likely play out for years to come,” By SIBI ARASU;

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