‘Back to July-Aug 2020’: Experts Explain Maharashtra’s COVID Surge
‘No magic vaccine, we just need more public discipline to stop another lockdown,” say experts.
Maharashtra registered its highest number of new COVID cases ever (including during its peak) on Thursday, 18 March, 2021, at 25,833. Simultaneously, the fatalities in the Mumbai Metropolitan Region have surpassed the 20,000 mark with 14 deaths in the past 24 hours - making it the worst-hit in the country. These developments came a day after Maharashtra total deaths zoomed past the 53,000 mark, exactly a year since the first COVID-19 fatality was recorded on 17 March, 2020.
The sudden spike in numbers is worrying to say the least. What’s going on in Maharashtra?
“The rate of increasing cases is disturbing. And it’s not just Maharashtra that needs to worry, we are looking at a situation that will impact the whole country since India does not have tight borders.”Dr Swapneil Parikh, Internal medicine specialist
FIT talks to Dr SP Kalantri, Medical Superintendent of Kasturba Hospital and MGIMS, Wardha, Maharashtra and Dr Swapneil Parikh, an internal medicine specialist in Mumbai and author of ‘The Coronavirus: What You Need to Know About the Global Pandemic’, to find out more.
‘There is a Definite Second Wave’
Dr Kalantri says his hospital “naively celebrated in mid-January 2021,” when there was a dip in COVID cases and there was hope the pandemic was on its last legs. “But we are hit hard right now. At our peak in 2020 we had 190 hospitalizations, and now we are at 154.”
“We still need more data to determine why the sudden spike but it is very challenging for us right now. Our ICUs are full, our ventilators are full. We are again at that point where we are forced to turn patients away.”Dr SP Kalantri, Medical Superintendent of Kasturba Hospital and MGIMS, Wardha, Maharashtra.
The sustained uncertainty is taking its toll and Dr Kalantri explains how this time around, the rushed panic of the first wave has been replaced by fatigue and resignation at his hospital in Wardha. “Our health workers have been working hard for almost 1 year. This has taken a mental, emotional toll. Many have gotten infected, many have gone back to their homes. It is hard to manage.”
COVID has overstretched our healthcare infrastructure and just when we thought India was getting to a better place, the sudden spike has demoralised frontliners who will bear the brunt of the rising cases.
Why The Sudden Spike & What Does This Mean?
The data needs to talk, say experts. “Till then, we have just assumptions and speculations,” says Dr Kalantri. “There are theories that winters have come hard in North-East Vidharbha but this is a weak theory. Other theories are that wedding season and the unlock have meant a lot of mixing, lack of social distancing, travelling and no regard for protocols.”
Dr Parikh says the problem is brewing.
“Maharashtra has one of the most transparent data reporting systems, but I have no doubt that this is not just a one-state problem. With porous borders and increased travelling, cases will explode in other parts of India too.”Dr Parikh
Pune, Mumbai, Nagpur are seeing a “disturbing” increase says Dr Parikh, explaining that Nagpur’s data is particularly alarming as sero studies indicated that parts of the city had high seropositivity between 50-75 per cent. “This means a huge population have antibodies and were already infected.”
“Nagpur has a population of around 25 lakh, and we are seeing about 2500-3000 new cases per day with very high test positivity. We have reached the limit of testing capacity. I would estimate that if we are seeing 2500 cases a day, there are at least 25,000 new infections per day as the lower limit.”
“In a city of 25 lakh, there are at least 25,000 new infections per day. This means 1 in 100 people. It’s extremely alarming. We haven’t seen this kind of growth in India even in the last peak. And in the context that a large number of people are already exposed.”Dr Parikh
Could These be Re-infections?
“We don’t know,” says Dr Parikh. "Either the seroprevalence data is wrong, which is worrying, or these are re-infections. And one would hope that most of these re-infections are mild. But my colleagues are saying that they are seeing severe disease in younger age groups now.”
This means that there are more hospitalizations and evidence of pulmonary compromise in younger people. “They are seeing very high viral loads in young people, prolonged duration of the disease.”
However, Dr Kalantri says that in Wardha, which is about 76 kms south of Nagpur, the virus is showing two worrying signs: “One, older people are getting infected more and two, it is much more transmissible than last time. Now entire families and neighbourhoods are getting infected.”
Dr Kalantri says that perhaps their testing has improved this time around so they are picking up more cases. “Wardha also had a seropositivity of 29 per cent. 1 in 3 people developed antibodies but still the numbers are high.”
For every 1 infected person, he says, 30 are not picked up. This is a scary figure as even if the other 30 are asymptomatic they are carriers. “For every one seriously ill COVID patient, dozens are missed and with high transmissibility, this is scary.”
“The situation is like last August or July. Yes we have more centres and are better prepared but there is increasing fatigue in the healthcare workers and in the general public who are not as disciplined about preventive measures anymore.”Dr S P Kalantri
Dr Parikh says more than the jump in cases, he is extremely concerned that this jump is occurring in an area with high seroprevalence, “where many thought there was the lower bound of herd immunity with non-pharmaceutical intervention. But we are seeing that’s not the case.”
Could This Be a New Variant?
Again, the data is just not there yet. “We don’t have enough or good quality genomic surveillance testing. We have a bit of a blind spot in genomic sequencing but I do think this is a variant related issue and we need to be very careful of what’s happening in Maharashtra and specifically in Nagpur right now,” says Dr Parikh.
On Wednesday, scientific institutes under the National Centre for Disease Control (NCDC) alerted the Centre of a variant with a double mutation in Maharashtra but there was no evidence yet that this is linked to the surge.
“We don’t know, we have been doing paltry sequencing so we have no idea of what’s going on. The target is 5 per cent of all positive samples but we aren't even doing 1 per cent,” adds Dr Parikh.
Sources say that so far 7,000 virus samples have been sequenced, of which 200 were lifted from parts of Maharashtra, reported The New Indian Express. 20 per cent of these 200 have two mutations they found.
“We are too focused on finding a mutation but look at what’s happening worldwide with the virus. There is this phenomenon called convergent evolution where the virus is evolving in a similar way to reach a similar outcome. There needs to be some prioritising of sequencing infections in individuals who are immuno-compromised or have persistent infections,” explains Dr Parikh. This is because there is evidence that when people get infected for a prolonged period, especially those who have some immuno-deficiency, then the virus undergoes a period of evolution within the same host. This means it mutates and transmits to the next person like that.
Still, it doesn't have to be a mutation as Dr Parikh explains there are different kinds of spreads. “Initially spread in clusters may look like low-grade linear growth but it may suddenly start to show exponential growth; it can take time so see exponential growth after restrictions are lifted.”
The New Case & Hospitalisation Time Lag
One of the silver linings of this jump is that case deaths and hospitalizations have not jumped rapidly. A source in Mumbai’s Bhabha hospital said that their hospital has not yet started admitting COVID patients.
“There’s something called a time lag,” says Dr Parikh.
“Today’s infections are tomorrow’s cases which are day after’s hospitalizations which are day after’s deaths”Dr Parikh
Besides, like Dr Kalantri said, his hospital is already bursting at the seams so we can assume hospitalizations will follow in other parts too.
As India’s vaccination program gears up, hopefully, we won’t see as many deaths.
Vaccines to the Rescue? ‘Only Partly’
"Hopefully, the elderly will be protected from deaths,” says Dr Parikh.
But Dr Kalantri isn't as hopeful.
“People believed that as the vaccine comes a magic medicine has arrived. A panacea. They lowered their guard. But I want to say this to everyone: the vaccine is only partly preventative.”Dr Kalantri
“I wish there were signs outside each vaccination centre that said clearly: YOU WILL BE PARTLY PROTECTED WITH THE VACCINE. PLEASE STILL WEAR YOUR MASK!” adds Dr Kalantri.
He tells me that people are also losing confidence in the vaccine, as he knows of doctors who have become infected post both their shots too. Does this mean people will go back to safety measures like masking and distancing?
“There’s a lot of fatigue. People have resigned themselves to their fate, and there’s a huge fall in discipline. I understand the fatigue but primary preventative measures need to come back.”Dr Kalantri
How to Stop Another Lockdown
We know this. Masking, social distancing, hand washing.
“Another lockdown will be devastating,” says Dr Kalantri. On the new measures by the Maharashtra government on 50 per cent capacity in restaurants and theatres, Dr Kalantri says these will not be enough as they won’t work. “Come on, will a husband and wife sit 6 feet apart in a theatre? You go to have fun, you can't enforce these rules so they make no sense.”
“I want everyone to know there is no magic cure. We just have to continue with small, simple measures: masking properly, wear fitted masks, be distanced.”Dr Kalantri.
An increase in public health communication that is not so reliant on vaccines as the cure will help as well.
“We need to monitor our indoor air quality, ensure air filtration too,” adds Dr Parikh.
The bottom line? We already know what needs to be done to help curb transmission, the real question is: will we step up?
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