Covid-19 cases spiral out of control as India’s health system cracks under the pressure

Dr. Krishna Reddy, Regional Director of South Asia at ACCESS Health International has written an analysis of the devastating Covid-19 surge in India, discussing the vulnerabilities of India’s health systems and what reforms are needed to contain the pandemic. More of Dr. Reddy’s insights can be viewed at the InOrder website.

The Covid-19 pandemic is spreading through the country like a wild forest fire. The pace of transmission has left scientists, medical community, and governments flummoxed and constantly looking for answers. The World Health Organization stated last week that one in every three new Covid-19 cases globally is now being reported in India.1The week ending May 3 marked themost fatal week of the Covid-19 pandemicin India so far, with a recorded 26.46 lakh new cases and over 24,000 deaths.2Even as the daily infection numbers registered a slight drop after hitting a high of over 4 lakh on April 30, India’s second wave of Covid-19 infections is showing no promising signs of slowing down.

The total tally of Covid-19 cases in India currently stands at over 20 million cases of which17 percent are currently active, 82 percent are recoveries and 1.10 percent have resulted in death.3Nearly seven million cases were reported in April, a big share of the total cases India has recorded since the start of the pandemic last year.3 With the sudden exponential surge in cases, the country’s overwhelmed healthcare system is faced with supply shortages for hospital beds, oxygen, medicines, vaccines and healthcare workers.

Cases in the second wave started rising in February, when India was reporting an average of about 10,000 infections a day. But the situation progressively worsened in April, ending the month by repeatedly setting new national and global records for daily cases. Even though the death rate is comparatively low in India, an underreporting and undercounting of deaths is not entirelyunlikely. This can be construed fromseveral media reports that highlight the overcrowding at crematoriums and burial grounds with bodies of Covid-19 deceased.

The research community is now trying to understand the reasons behind the extraordinary surge. Many experts believe that the second wave is a result of a combination of several factors, including the rise and spread of infectious variants, mass gatherings for political rallies and religious events, increased unrestricted social interactions, a lax attitude among people, non-adherence to Covid appropriate behaviour, and the low vaccination coverage. Unravelling the causes has the potential to guide governments across the world facing similar rise in infection rates.

There has also been data showing a direct positive correlation between population density and the number of Covid-19-affected persons. For example, in recent times, no big festivals or political events took place in Mumbai, Bengaluru, and Delhi. Yet, in terms of Covid-19 caseload, as of April 26, 2021, these three cities contributed the most. The second wave is also seeing infection rates rising in smaller cities and towns. According to The Lancet, preliminary analysis indicates that the second wave has spread with a deeper penetration into tier 2 and tier 3 cities.5This indicates that even as political and religious gatherings are partly driving the surge, a lack of awareness and people’s indifference towards complying with Covid-19 safety and hygiene norms are contributing to the rising number of cases.

The last couple of months have been marked by the emergence of at least two important dominant variants, one is a U.K. variant, one is an Indian variant. The Indian government reportedly said last month that 80 percent of cases in Punjab were due to the highly contagious U.K. variant, which is known as B.1.1.7. Meanwhile, the Indian variant is known as B.1.617 and has multiple sub-lineages with slightly different characteristic mutations. This has become dominant in the state of Maharashtra which is recording the highest number of cases among all states. The WHO classified it as a variant of interest in its epidemiological update on the pandemic last month.  Both these variants are linked to increased transmissibility and an ability to evade immune protection in the population.

Shortage of oxygen, beds, and other medical supplies

As Covid-19 positive cases started to spiral out of control, health infrastructure in several parts of the country, especially cities, cracked under the sudden pressure. State governments have been struggling to set up new infrastructure to meet this exponential demand.  Several announcements are now being made about the construction of new health facilities and oxygen plants.

The most acute crisis in the country currently is a shortage of oxygen in hospitals. Inadequate oxygen-supported beds, ICU beds, ventilators and medical oxygen has severely affected hospitals in many cities in their fight to save patients. Indian social media is flooded with desperate requests from people all over the country, seeking help to get  oxygen cylinders or hospital beds with oxygen or ventilators for their dear ones. In the recent weeks,many hospitals across the country have reported deaths owing to depletion of oxygen and unavailability of timely replenishment. 7

According to the World Health Organization, around 15 percent of Covid-19 patients suffer from breathlessness. However, at present, the daily supply of oxygen is proving to be inadequate for India. India’s daily production capacity for oxygen is 7127 metric tonnes and consumption is 3842 metric tonnes, according to Indian Government data released in early April. However a few days later, Max Hospital, a private hospital, approached a Delhi court to inform them about an oxygen shortage at their facility. During the hearing, the government is reported to have told the court that India’s oxygen consumption was over 8000 metric tonnes per day by April 21.5 A lot of the current demand is being met by the private sector including volunteer groups and unfortunately even the black market. The latter is selling oxygen to needy patients at up to ten times it original price.

India ramped up its health infrastructure during the first wave last year. The reason why India is facing an acute shortage today despite this is that as cases started decreasing after the September peak last year, the pace at which health infrastructure was being augmented, also slowed down considerably. An analysis of government data reveals that the number of oxygen-supported beds, ICU beds and ventilators saw a drastic decrease between September last year (when India saw the peak of the first Covid-19 wave) and January end this year (just before the second wave started, around mid-February) 6

Experts have called this a failure of governance.7 India was not able tochannelize oxygen distribution over the past year which ultimately led to a demand supply mismatch in several parts of the country.

Recently, India ordered its armed forces to help tackle the surge. Countries including Britain, Germany and the United States have pledged to send urgent medical aid. Nearly 1500 Pressure Swing Adsorption (PSA) medical oxygen generation plants are being developed under the aegis of the Ministry of Health and Family Welfare. To increase availability of oxygen the ministry is also working on converting nitrogen plants into oxygen plants.

The country has also been facing a dearth of medicines. A number of drugs and injections of which there is no evidence in the treatment of Covid are being prescribed irrationally leading to supplies running out and helpless citizens falling prey to black market operatives.

Vaccination Challenges:

From being a major global exporter and grantor of Covid-19 vaccines earlier this year, India has had to cut back on its exports significantly and even look at imports to meet the unprecedented domestic demand. Moreover, the earlier vaccine hesitancy has given way to vaccine urgency, requiring the country to ramp up its vaccine manufacturing capacity to increase the pace of vaccination in the country. The recent opening up of vaccination for all above the age of 18 means that India will need to speed up its vaccine manufacturing significantly to cover the close to 600 million Indians falling in the age group of 18-44 years. Across the country, many instances of vaccination centres being temporarily dysfunctional because of the unavailability of jabs at their facility are being reported. 

As of May 2, only two percent of India’s 1.3 billion people have been fully vaccinated with both doses. Nearly ten percent of the population has received at least one dose.8 Between January and April, India exported and donated 66 million doses of vaccines to over 70 countries as a part of its vaccine diplomacy programme.8 Now, however, the Serum Institute of India, which produces the Oxford-AstraZeneca vaccine, has been asked by the Indian government to stop all its exports.

The sudden stop on export of vaccines from India is likely to affect the global vaccine supply. The COVAX vaccine-sharing facility, run by the GAVI vaccine alliance and the WHO, has provided more than 45 million doses of Covid-19 vaccine to 120 economies, of which a majority so far are the AstraZeneca shot made by the Serum Institute of India. It had expected 90 million doses for March and April for the 60 lowest income countries and those have not been made available because of India’s domestic demand.9

New Vaccination Policy

Under its new Covid vaccination strategy, called the Liberalised Pricing and Accelerated National Covid-19 Vaccination Strategy that came into effect on May 1, the MoHFW has ‘liberalised’ the vaccination drive to allow states, private hospitals and industrial establishments to procure the doses directly from manufacturers. Under the third phase of the vaccination drive which started from May 1, vaccine manufacturers would supply 50 per cent of their monthly Central Drugs Laboratory (CDL) released doses to the central government and would be free to supply the remaining 50 per cent doses to state governments and in the open market.

Moreover, manufacturers will be expected to make an advance declaration of the price for 50 percent supply that would be available to state government in the other channel other than that of the Government of India channel. Based on this price, States, private hospitals, industrial establishments through their hospitals may procure vaccine doses from the manufacturers. Private hospitals would have to procure their supplies of Covid-19 vaccine exclusively from the 50 percent supply earmarked for other than Govt. of India channel. The price charged for vaccination by private hospitals would be monitored.

Meanwhile, the government last month has fast-tracked emergency approvals for importing vaccines from Pfizer-BioNTech, Johnson & Johnson, Novavax, Moderna and Russia’s Sputnik V. The latest guidelines for import of foreign vaccines by the private sector and state governments were released by the Central Drugs Standards Control Organisation (CDSCO). The guidelines stated that for vaccines not yet approved or licensed in India, the importer of the foreign manufacturers will need to obtain key permissions or licenses from CDSCO. All imports will take place based on the guidelines on the of the liberalized policy. Dr Reddy’s Laboratories, the custodian of the Sputnik V vaccine in India, will import 250 million doses from Russia. Pfizer is currently negotiating an expedited approval pathway for the use of its vaccine in the country. 

How well are the current vaccines doing?

In what is being seen as a glimmer of hope to the current crisis, Covishield and Covaxin, the two Covid-19 vaccines currently in use in India, have shown efficacy against the Indian double mutant strain and show milder illness in case of infection post vaccination. The study was conducted by the Institute of Genomics and Integrative Biology (IGIB), on the effectiveness of the available vaccines on the B.1.617 variant.

Another study has found that people who have been vaccinated with Covaxin have protection against the double mutant (B.1.617) variant first found in India. 10 This study was carried out by the Indian Council of Medical Research and Bharat Biotech researchers. So far, 21 countries have detected the B.1.617 variant. Of those, the majority of cases has been reported from India. An earlier study had found that Covaxinalso neutralises the B.1.1.7 variant that was first found in the U.K. Another study conducted by the Indian Council of Medical Research in association with the National Institute of Virology showed that Covaxin demonstrated potential effectiveness against the Brazil variant too. 11

Last month,data released by the ICMR showed that nearly 0.04 per cent of people who have taken the second dose of Covaxin have tested positive for Covid-19. The percentage of those who tested positive after taking the second dose of Covishield is 0.03 per cent.12

This data refers to people who were infected with Covid-19 after several days of taking the first or second dose of a vaccine. As per the data, onlytwo to four people per 10,000 population are being infected with Covid-19 post vaccination.

The data shared by the government shows that Covaxin had been administered to 1.1 crore people in India as on April 21. Of these, about 93 lakh people have received their first dose and around 17 lakh have received the second dose.Among the 93 lakh who have received the first dose, 4,208 people tested positive after taking the shot.Among the 17 lakh who have taken the second shot, only 695 tested positive for Covid-19.

In the case of Covishield, the data shows that nearly 10 crore people have received its first dose as on April 21.Of these, 17,145 tested positive for Covid-19 after taking the shot. More than 1.5 crore people have also received their second dose of Covishield, of which 5,014 people tested positive.Covishield has an efficacy of around 70 per cent while Covaxin reportedly has shown an interim efficacy of around 81 per cent in its Phase 3 trials.

Where do we go from here?

Like during the initial months of the first wave last years, lockdowns and curfews have become the norm once again in several parts of the country.  People will need to learn to adapt to short, local lockdowns in the event of continued future spike in infection rates. Most epidemiologists predict more waves, given that India is evidently still far away from reaching herd immunity and its vaccination rate remains slow.

To control the unprecedented second wave surge, the Lancet India Task Force has suggested a number of measures to reduce infection rates across the country.13  The report titled ‘Country-wide Containment Strategies for Reducing COVID-19 Cases in India’ published on April 30, 2021, states that a series of actions are needed to flatten the graph.14 Some of these require closures, some require targeted containment, whereas, others need effective public messaging to influence individual behavior.The Task Force said the country needs a coordinated response across all states in a systematic, synchronized manner.

Covid-19 has exposed the integral fault lines in our healthcare system. It has shown that the crux of our problem is systemic, perpetuated by the gross under-investment in public health in the country. India continues to have one of the lowest public healthcare budgets across the world. This pandemic has brought to the fore the major afflictions that have been shackling India’s healthcare since decades.