In January 2021, there was a self-congratulatory mood in India, as the steady fall in case and death counts after September 2020 appeared to signal “final” victory over COVID-19. Politicians and public health experts gushed about herd immunity having been acquired, even as other regions of the world were battling second or third waves. International experts, too, opined that the virus appeared to be blocked by a “human wall” of persons who had gained the protective armour of immunity even before the vaccines started rolling out. The international media, which previously attributed India’s low case and death counts (per million population) to undercounting, suddenly started enquiring as to how India had pulled off a miracle.
There were some voices of caution which questioned the breezy assumption that the magic cloak of herd immunity had descended on India. Their pleas for continued discipline in observing public health measures to curtail viral transmission had few takers. Technical experts in the government too pointed out that much of the population was still susceptible. However, the fatigue of pandemic restrictions and the urge to return to normal life made politicians, public figures, traders, travellers, sportspersons, shoppers, religious groups and revellers want to believe that all of India was liberated.
The wily virus had other plans. Not only did it strike back but it brought in a brood of mutant progeny to run around with great speed as kids do. The relaxation of international travel restrictions made it easy for mutants first reported in the UK, USA, Brazil and South Africa to enter. Variants have emerged from within India too. A “double mutant” has been reported from some states, combining mutations observed earlier in California with those previously noted in India and some other countries. These spike protein mutations appear to confer the virus with extra ability to prise open entry into human cells. Whether they enhance or reduce its virulent trait for causing severe disease remains to be seen.
Alarm bells are presently sounding off as daily case counts, test positivity rates and hospital admission rates are rising. Death rates are not rising as fast, suggesting that either the virus is less virulent now or case management methods are more efficient. It is also possible that more young persons are being infected now, with less severe manifestations than among the elderly who may have accounted for a higher proportion of patients during the first wave. Only age and gender disaggregated data on diagnosed cases, hospital admissions and deaths will provide us better insights. The rate of geographic spread is faster than in the first wave, both because of the variants and less rigour in the containment methods.
Our response has to be informed by the lessons we have learnt over the 14 months since the virus first landed in India in end-January 2020, and shaped by the current context. Broadly, we need to frame and effectively implement our strategy across four areas: Containment of transmission, care of the infected, immunisation of the population and protection of the essential functions of society. These have to proceed in tandem. This resistance has to be sustained over the next six months without premature proclamations of victory and vacation of space for the virus to occupy.
For effective containment, we need to prevent new infections and quickly detect infections that do arise. Public health mandates on masks, physical distancing, avoidance of crowded events and mass gatherings must be enforced with political will and administrative skill. Elections can be conducted with local canvassing instead of mega rallies, along with intelligent use of mass and social media. If work from home is possible, prayer from home too can be a pious personal offering of devotion. People must be mobilised and motivated to protect themselves, their families and others too, through messaging via both mass media and closer to home community networks. The role of civil society organisations, largely ignored in the past response, must be greatly enhanced.
Detection of cases cannot depend only on viral detection tests, which we now know have many false negatives (especially in the rapid antigen tests) and some false positives (attributed to nucleic acid residues from “dead viruses”). Symptoms suggestive of COVID-19 should also be used for early case detection by primary healthcare teams visiting homes and also for promoting citizen awareness to stimulate voluntary isolation and self-referral for testing. Clinically suspected cases must isolate and use masks at home, even if they test negative. Repeat tests, during the course of the illness, reduce the false negative rate. Genomic analysis of a sizeable fraction of all positive test samples will help to identify and track the spread of variants. However, the mainstay of defence against any strain of virus remains the combination of masks, physical distancing and avoiding crowds. Testing alone will not help, if we do not adopt contact tracing and other public health measures.
Clinical care of infected persons is now better informed by research which has shown the benefits of home care to many and of prone positioning, oxygen, steroids and anti-coagulants for hospitalised patients. The need to mobilise both public and private hospitals and upgrade district hospitals was recognised during the first wave. That knowledge should reduce response time lag in the current surge.
We must aim to vaccinate all persons above 35 years of age and others with associated disease conditions, by August 15 this year. Even as more vaccines get regulatory approval, we must train and engage more vaccinators and get the private sector to offer stronger support to the public sector. Vaccine confidence must be promoted at the community level, by building trust in public health advisories and clearing misconceptions through local networks.
The test of our nation this time around will not only come in meeting the challenge of the virus through a smart, strong and sustained strategic public health response but also in ensuring that the vulnerabilities of our economic and social structures are not exposed or exacerbated. Both economic livelihoods and educational opportunities have to be protected. Lockdowns and laxity cannot become a perpetual seesaw of our society. We have to display determination and discipline to commit ourselves to a long haul fight this time and not view every skirmish won as the end of the battle. That is the variant we need to bring into our strategy if we have to overcome the variants that the virus hurls at us.
This article first appeared in the print edition on April 2, 2021 under the title ‘Our second Covid test’. K Srinath Reddy, a cardiologist and epidemiologist, is President, Public Health Foundation of India (PHFI). Views are personal.
Testing for COVID-19 at Sector 16 in Panchkula. (Express Photo: Jaipal Singh) 
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