What Explains India’s Ongoing COVID Surge?

New Delhi: India’s COVID-19 daily test positivity rate (TPR) breached the 7% mark after a long period of time on August 14. According to the government’s daily bulletin for the day, it stood at 7.52%; a rate above 5% is what the World Health Organisation (WHO) sees as a potential cause of concern.

The total number of people who tested positive on August 15 in the country was 14,917. On June 28, the total number of positive cases had gone beyond 15,000 for the first time in recent months. This was in sharp contrast to the scenario just 30 days ago. On May 23, India reported a mere 1,627 cases.

For the entire month of June, July and August up until now, the total number of daily cases have remained in five digits.

COVID-19 scenario in numbers

National snapshot

However, these numbers have to be read with a very important caveat. Many people are now using rapid antigen test (RAT) kits to do self-testing at homes. And those returning positive through RAT kits are not reporting their cases for the national tally. So the above numbers, in all probability, do not reflect the true scenario of testing itself. Add to this the factor of cases being missed, which is always a possibility with any big outbreak.

The national capital, New Delhi, is also on the radar for consistently reporting a high positivity rate – mostly above 12%-15% in the last seven days, at least. The number of new cases being registered in the last one week have averaged around 2000. It was on June 14 that the national capital breached the 1,000 mark of daily cases.

COVID-19 scenario in numbers

Delhi snapshot

Maharashtra, on the other hand, had registered more than 6,000 cases on June 26. Only 26 days before that, the state had logged a little more than 1,000 cases. However, now the cases have declined there. For the last one week the state has been averaging around 1,600-1,700 cases on a daily basis – meaning the small surge that the state witnessed is ebbing now.

The caveats – of cases getting self-tested at home and not becoming part of the daily tally and cases getting missed – apply to Delhi and Maharashtra as to the rest of India.

As many as 159 districts across India are reporting more than 5% positivity rate, according to the Ministry of Health and Family Welfare report updated till August 11. Another 144 districts are reporting more than 10% positivity rate. Thus, half of India’s total districts have a positivity rate of more than 5%.

What’s behind this rise?

What has been causing the graph to move upwards? Is there a new sub-variant, because any surge is invariably linked with that? We don’t know.

This is simply because India’s genome sequencing consortium, which functions under the Union government’s Department of Biotechnology, has stopped issuing its ‘weekly bulletin’. The bulletin is supposed to inform citizens about dominant sub-variants of the virus at any given time.

The last ‘weekly bulletin‘ was issued nearly a month ago, on July 11. A week is enough time for the situation to change on the front of genomics; a month is definitely much more than enough.

Though India’s genomics consortium hasn’t put out any consolidated information, there are other secondary sources that can be traced to understand the scenario of variants. GISAID is a platform where sequences from all across the world are submitted. Outbreak.info, an open-source database that tracks variants among other things, sources information from GISAID. According to Outbreak.info, BA.5 sub-variant of omicron has been the most dominant one in the last 30 days in India.

Source: Outbreak.info

BA.5 is one of the descendant lineages of the BA.2 sub-variant of the omicron variant of the novel coronavirus. The other notable descendant lineages of BA.2 are BA.4 and BA.2.75.

According to Outbreak.info, the second most dominant lineage found in genomes in India was BA.2.75. Thus, it’s BA.2.75 and BA.5 lineages which seem to be driving the current trajectory of COVID-19 cases in India.

While talking to The Wire, Maharashtra’s genome sequencing coordinator Rajesh Karyakarte said both of them may up the transmission, and hence, increase the overall numbers. However,  the public health system will not be stretched in the way it was during the second wave. Karyakarte is the head of the microbiology department at BJ Medical College and Sassoon General Hospital, Pune. He claimed that his team was first to report BA.2.75 to the global scientific community when it was found in a few samples in Maharashtra. His team has also conducted studies on BA.2.75 and BA.5.

“We had three key findings. They escape immunity provided by vaccines and will cause a breakthrough infection. But they don’t result in a spike in hospitalisation numbers [thus indicating a mild disease]. The patients’ demand for supplemental oxygen hasn’t gone up,” he said, and added that the findings have been sent for publication.

He said BA.2.75 was responsible for the small uptick in Maharashtra in June-July. About Delhi, he didn’t have the information. However, Delhi’s Lok Nayak Jai Prakash Narayan Hospital also found this lineage to be the most prevalent in the samples that were sequenced there.

preprint posted by a group of scientists from various Japanese institutes on bioRxiv on August 8 sheds some more light on its significance. The paper said the R-value, that is number of people that will get infected from one positive case, was slightly higher for BA.2.75 as compared to its sibling lineage, BA.5, The paper said both of them were simultaneously spreading in India.

BA.5 spreads in the south part including Tamil Nadu and Telangana states, while BA.2.75 spreads the other parts including Himachal Pradesh, Odisha, Haryana, Rajasthan and Maharashtra, it said. And then in some of these states, both were spreading.

The paper also said that BA.2.75 wound outcompete all sub-variants and lineages of omicron in India, including BA.5.

About the disease profile, the paper said the same thing what Karyakarte told The Wire.

‘Current surges are little ripples’

While the numbers and new forms of coronavirus may sound worrying, virologist Shahid Jameel says there was no need to panic. “These are just little ripples,” he said, describing the recent surge.

“This is how [causing alternating small surges] virus will behave in the next few months; or probably years. People will react differently to the virus depending on their immunity and age, genetic profile and vaccination status,” he added with an oft-repeated disclaimer: We still don’t understand this virus fully.

But he sounded worried with one thing – that India’s genomics consortium has not put out a weekly bulletin in the last one month. “Any let up on genome sequencing may keep us blind about new forms of the virus,” he said.

Both Karyakarate and Jameel said it is but natural that the virus will keep producing newer forms, because that is the only way it can sustain against the vaccines and immunity due to prior infections.

‘Don’t overuse medicines’

Mumbai-based pulmonologist  Lancelot Pinto said he also didn’t find serious disease when Mumbai recently witnessed an uptick in cases. “Rarely someone needed oxygen support and even those who needed it had other morbidities like heart or kidney ailments,” he said.

“There were no signature symptoms. Extreme sore throat was what people mostly came up with,” he added.

While Pinto was relieved that the disease profile had changed for the better as compared to the horrific delta wave, his complaints regarding overuse of medicines had hardly changed. Take the case of steroids. Though rarely, they are still being prescribed, he found when patients came to him for a second opinion. There is a plethora of scientific evidence that only a minuscule proportion of patients need them in a special set of circumstances.

In addition, patients self-medicate for COVID-19 now. “Dolo and Azithromycin [which is an antibiotic and has no role in COVID-19 treatment] have become like tap water,” he said.

Besides, all the experts that The Wire spoke to made a point to repeat what has almost disappeared from practice but finds all support in scientific evidence: “Mask up.”