Updated: April 15, 2021 8:57:59 am
There was never any doubt that India will face a second wave of the COVID-19 pandemic. What was not known was when, and how big it would be. Now we know that the second wave is here. It is “faster and higher” — all that we hoped it would not be. The possibility that this is a surveillance bias, as we are now counting people with the disease better due to ramped-up testing facilities as compared to the early stage of the first wave cannot be entirely discounted. Even adjusting for that fact, this wave appears to be bigger than the first one. So, what explains it? The size of any epidemic is a function of three things — the size of the pool of the susceptible population, the pattern of contact between the members of the population (frequency, mix, closeness and duration) and probability of spread during that contact (infectiousness of the agent). Let us have a look at each of these in the current context.
The newer variants of the virus have the potential to change the infectiousness both ways, and there is some early indication that the infectiousness has increased in the second wave. But this is unlikely to be an important reason for the large second wave. However, this is an area where constant vigilance is required.
As many people have already been infected in the first wave, the pool of susceptibles should be smaller. Serosurveys also support this as they found that about 25 per cent of people had already been infected nationally. However, this is an average and hides significant variations by state, age and place of residence. Populations with lower seroprevalence become the potential pool for the second wave. For example, while the first wave in Mumbai was driven by slum dwellers, this time around, it could be the residents of apartments. Given India’s large population base, the actual number of people are sufficiently large to enable multiple waves till we achieve a more even spread of protected people. The persistence of protectiveness of antibodies of those already infected and their cross-protectiveness to newer strains is not well established, though the lack of it is unlikely to be a major contributor to the second wave. It should also be emphasised that vaccination would reduce the pool of susceptibles. However, the current level of vaccination coverage is not sufficient to make a significant difference to this wave, given the fact that we are already riding it. It is a good strategy to prevent the next wave, if we can achieve substantial coverage with it. We also know that it prevents severe disease, and hence reduces the death toll.
With the removal of most restrictions, the probability of contact between individuals has risen sharply. We can all see crowded marketplaces, malls and restaurants; public transport is functional. When I visited a park last month, I was surprised that it was fully crowded with hundreds of families and elders, with little use of masks and no social distancing being followed. While a return to normality is needed, and with it some increase in cases is inevitable, what can and should be avoided are super-spreader events like a crowded park, the Kumbh mela, election rallies, etc.
While the government may justify them on social, economic, religious and political grounds, it makes little sense to the public when crowding in public places is allowed, but curbs are imposed on individual freedom with curfews or weekend lockdowns. On top of this, there is a renewed emphasis on penalising individuals for their behavior, including not wearing a mask in their own car. The message to the public is that the onus of controlling this pandemic is now on individuals and not the government. This is not prudent. Even if the opening of society was to be done for various reasons, the public should have been prepared for such a change. It is inappropriate to blame individual community members, when there is no effective communication which explains the rationale behind the decisions taken. A much stronger community engagement with a robust communication strategy and lesser emphasis on “criminalising” inappropriate behaviour is required. There is already anecdotal evidence of intentional disregard to the government directives. Let us not wait for it to worsen.
A nuanced communication campaign is the need of the hour and is conspicuous by its complete absence. It is just not enough to keep reiterating the same message. Press briefings by health ministry officials or ministers or messages by the Prime Minister or chief ministers seem to be the core of the current communication campaign. Any communication expert would tell you that this only leads to fatigue. What is urgently needed is a robust evidence-based communication campaign. Rather than being driven by politicians, this must be designed and executed by communication professionals in tandem with public health professionals. Such a campaign would involve proactive serial assessment of the community perceptions and concerns, testing and refining messages through an evolving campaign, using multiple media channels based on their audience size and type to reinforce the key messages. Such serial surveys also help provide a policy feedback loop for the government to revise their strategy. Communication should not only cover issues related to COVID-appropriate behaviour, but also address issues related to vaccination, such as its need, concerns related to adverse effects and effectiveness. India has no shortage of creative people and we are capable of designing effective media campaigns.
Such a campaign supported by a strategy based on tested and sound public health principles will work. A district-specific strategy of “test, trace, treat” along with containment measures (isolation and quarantine) is still the best way to deal with the situation. To implement them with the same rigour as before, we would need to strengthen and incentivise the beleaguered health staff. We also need to put a stop to political bickering; it erodes public trust and confidence. While strategic mistakes during the first wave can be accepted and condoned, we cannot afford an encore.
This column first appeared in the print edition on April 15, 2021 under the title ‘Bending the second wave’. The writer is professor of community medicine, AIIMS, New Delhi. Views are personal
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