Is India heading towards a possible fourth wave of COVID-19?

Masking and vaccination, the best tools available today, are the need of the hour

Updated - April 22, 2022 11:51 am IST

Published - April 22, 2022 12:25 am IST

A health worker collects swab samples from a man for a COVID-19 test in New Delhi on April 20, 2022.

A health worker collects swab samples from a man for a COVID-19 test in New Delhi on April 20, 2022. | Photo Credit: R.V. MOORTHY

The number of fresh cases of COVID-19 in the country has been going up steadily in Delhi and Maharashtra, considered bellwether States in the country, as far as the pandemic goes. Is this an indication of a further COVID-19 wave in India, and what are the precautions that people and health systems have to take in order to avoid devastation on a scale as was seen during the second wave. In a conversation moderated by Ramya Kannan, J. Radhakrishnan, and Prabhdeep Kaur, discuss the possible scenarios. Edited excerpts:

Are the rising case numbers, and test positivity rate, that we are seeing in Delhi and Maharashtra indicative of a possible fourth wave of COVID-19 in India?

J. Radhakrishnan: This is a difficult question; whether the next wave will come or not depends on the type of variant that will come through. Secondly, it will also depend on the level of immunity in the population — both on account of recovery from a natural infection, and also on rapidly increasing vaccinations. Of course, we must remember that vaccination has happened over a period of a long time, and it is practical to expect varying levels of immunity from that. So our best position is that we need to be guarded, we just cannot be overconfident that there can be no more waves, because last time I remember in January-February of 2021, people were clearly overconfident. On the other hand, I personally feel that unless there is a dominant Delta-like variant at play, it may not be as bad as it was in May last year.

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But having said that, what we need to look at is really testing everybody in all settings. Now, what has happened is there is a rapid decline in people subjecting themselves to tests. We also need to specifically look out for locations where there is doubling. For instance, in Delhi, the way the cases have gone up. If, consistently over a period of time, one district or a group of districts start showing such a sign, then it is a sure warning. We also have to do genomic sequencing on a regular basis.

Prabhdeep Kaur: I would agree, first of all, with Radhakrishnan, on the fact that we need to keep looking for any changes in the existing pattern. I think that's the most important thing in epidemiology — whether we are finding any new clusters, in populations where we do not expect it. Also, if we look at persistent increase in cases in any particular district or a number of districts, then we need to worry about it, simply going by the pattern we have noticed in the past waves. You are right that Delhi and Maharashtra usually show up the trends first and the other States follow. Going by that, I do believe that it's likely that we may also see some upsurge in cases.

However, to what extent we need to worry about it, is a totally different issue. It could mean that we need to improve our surveillance — this is the most important thing, both epidemiological surveillance, as well as genomic surveillance. But whether we need to restrict any activities or whether we need to worry about increasing hospitalisation, at this juncture, it's very premature to see any of that.

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Do we expect this wave, if it indeed does come, to be dominated by the XE variant?

Prabhdeep Kaur: We know, from whatever genomic surveillance data has been released by various certified institutions, that BA.1 was predominant. And now it's moved to BA.2. Currently, with the entire INSACOG network of labs in place, I think we are in a very good position to know when the variant changes in our population. Going by the international trends, as you have seen in other countries like China, Thailand, and U.K., we do know that there is a change in variant, the new variant is replacing BA.1 and BA. 2. The same is likely to happen in India as well, and we just need to keep a close watch.

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But as far as whatever limited understanding we have, since we've been studying this for a very short period of time only, it is clear that this new variant is sort of becoming predominant. What we also know is that it has a very rapid growth and high transmissibility. So that is something we need to keep in mind. We know that these patterns, as far as COVID is concerned, are global. So, whatever we get to see in one part of the world, over a period of time, it happens in other parts of the world. Going by that, yes, I do believe that XE may be the next variant, which may replace older variants in times to come.

J. Radhakrishnan: In the latest data which we analysed in Tamil Nadu, between January and March, the Omicron variant was 94.7% and Delta still was around 2.7%. All other variants were about 2.6%. Of course, we do have BA.1 and BA.2.

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Ultimately, we have to be worried about whether clinical changes are there in the new variants, and how we treat them. Delta rapidly affected the lungs, there was rapid desaturation. As on date, we have, in the State, only 232 active patients, hardly 10 are in hospital and nobody is in the ICU. That's a good sign.

But the same thing happened in January 2021. Before we knew it, Delta crept in, and it was a very rapid spread. So, we are taking, as advised by the NIE, samples not only when there is a family cluster. We are taking samples and keeping a watch on those returning from abroad. So far, we have picked up no XE variant in Tamil Nadu.

Also read | As COVID-19 cases surge, DDMA makes masks mandatory; ₹500 penalty for violation

The main concern at the implementation level is the public’s abandonment of both the pillars which helped us in the past waves — adherence to masking and social distancing. Another source of worry is the falling interest in vaccinating oneself.

Is a three-month period not sufficient to study a variant, since XE was first described in January? We have had three months to study it, why are we still saying we have a limited understanding of the recombinant variant?

Prabhdeep Kaur: As far as COVID is concerned, when we plan a response — either public health or clinical care — we have to analyse if something more needs to be done than what we are doing currently, and at a broader level. So what we need to keep in mind is that there are certain characteristics of the variant which determine whether we do certain things or we don’t do them. What has happened is that this variant did not show any such characteristics, that is, those that changed the course of interventions we had ongoing. Whatever measures we had initiated for Omicron seem appropriate for this variant as well. We keep watching whether variants are changing further, or causing increasing case fatality or excess hospitalisations. Since none of that has been observed or documented, the focus has remained on the same measures which were already initiated, which is promoting boosters, ensuring that masking continues and doing very good surveillance. I will again emphasise, as an epidemiologist, that surveillance is really the key. I feel that we have become a little bit lax with that, but if we keep looking, the patterns will really tell us if anything different is happening around us, in addition to, of course, genomic surveillance.

Since mandatory masking has been dropped officially, will it be difficult now to go back to ensuring masking as a public health measure? 

J. Radhakrishnan: The public health preventive measures have to be in place, we just cannot abandon them. It’s an important protective mechanism, since crowds have resumed now, it is safe to always have a mask on. It affords us some level of protection even if others around us are not masked now. People tend to rapidly forget the importance and relevance of the non-medical measures which are very important. They have to be reinforced periodically. Caution is far better than overconfidence.

Also read | Mask compliance on the wane

Prabhdeep Kaur: We at NIE have been monitoring mask use in Chennai city. We observed that mask use declined in the latter half of 2020, and thereafter, after the Delta wave around March-April, it went up. Subsequently, again, in the later part of the year, around the festive season, it had further declined. So what we understand from this is that people seem to be responding to whatever they are hearing from the media and various sources.

Also, vaccination is very important. We should use this time, when cases are still not high, to aggressively educate the public to take their first and second doses, and the booster if they are eligible for it. Masking and vaccination are the best tools we have today.

In case of a possible third or a fourth wave, is the way to go is to recommend that States implement a closure of some sort, or introduce restrictions in stages once again?

Prabhdeep Kaur: I think now we have a very good idea when to enforce restrictions and what restrictions are required, from what we have learned over the last two years. And we are continuously monitoring the situation. So every week, we analyse the data which is there in the public domain, which is released by State governments, and we look at certain key indicators such as what is the change in the number of cases, test positivity and bed occupancy.

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What we have seen over time is that, it's not that all of a sudden you just need to close down everything. It does take time for all these indicators to change. This, in fact, gives us sufficient time to respond in terms of what measures we need to put in place in advance. So as of now, I think we are doing fine and there is no need for any restriction. But we must keep monitoring these indicators very carefully.

We have also learnt that the extreme measures are really the last option, and we may not need them. But if there is a concern, and these indicators suggest that there is very rapid transmission, we need to think of measures such as enforcing masking compliance, reducing crowding, and maybe restricting the size of gatherings

Given that the economy is still recovering from brutal lockdowns, will it be easy to implement restrictions again?

J. Radhakrishnan: As Kaur said there is a large amount of learning that we have now, compared to what we knew in the beginning. And as implementers of policy, we have been constantly guided by public health expertise — both at the national and international levels.

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The latest instructions are that you need to look at the test positivity, the hospital bed occupancy and the rate of spread. We are also constantly conducting drills in a military fashion — bed usage, oxygen usage, ventilators, if every service that may be required is adequately prepared.

With this information, at present, I personally feel that we are not at a stage where we need to look at the extremes. But we definitely need to understand that common sense precautions, such as masking in a crowded area, getting tested if you have a fever or someone around you is ill, should be taken. I still feel we need to take it by the week, look at the weekly trends, and keep ourselves ready. This is not the stage where we need to panic.

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