From June 26 this year, the daily reported COVID-19 cases in India started falling below 50,000. In July and August, the daily cases hovered between 30,000 and 40,000. In early September, the daily cases consistently fell below 40,000, and by September 24 they were below 30,000. Over the past week, the daily cases have remained below 20,000. There have been no upswing trends and this has consistently remained so for the past 16 consecutive weeks since June 26. What does this trend say about the COVID-19 pandemic in India?
Well, according to two senior experts — virologist Dr T Jacob John and epidemiologist Dr Jayaprakash Muliyil — the COVID-19 epidemic is over as far as India is concerned. On June 26, 2021, India entered the endemic phase, with remote chances of a third wave. Epidemic refers to the sudden increase in an infectious disease, more than expected, over a larger geographical area, for a given period of time. Endemic, on the other hand, is when the disease is prevalent or regularly reported within a particular community or smaller area. Dengue, for example, is endemic to India.
“Pandemic is a multi-country epidemic. For India, it is an epidemic. COVID-19 started in different countries at different times, and it will end at different times in each of these countries in a staggered manner. On June 26 this year, India entered the endemic phase,” said Dr Jacob, a former professor at the Christian Medical College, Vellore.
He explained why. “When the weekly cases start being fairly stable with no major upswing, barring a jump in cases for three to four days, that’s when the endemic begins, and India started showing the trend on June 27,” said Dr Jacob, who is also the former director of the Indian Council of Medical Research’s (ICMR) Centre of Advanced Research in Virology. “That said, it is not a certificate that we did everything right,” he added.
“The best way to explain an endemic to a layman is, ‘yes, the virus could be around with us, whether you like it or not.’ But, there is no need for containment or isolation, and a vaccine will protect you," said Dr Jayaprakash Muliyil, Chairman of the Scientific Advisory Committee of the ICMR’s National Institute of Epidemiology (ICMR-NIE).
In an interview with TNM, the two prominent healthcare scientists explain why a third wave is unlikely, the possible triggers in future, the endemic strategies that India should adopt and the role of children in the whole endemic management equation.
Dr Jayaprakash: As a country, we are highly protected against any waves, which means, the possibility of a third wave is extremely remote. A large percentage of the population got their immunity by natural infection, which produces strong and lasting immunity against future COVID-19 infections or death. We call it a robust, lasting immunity. However, natural immunity works only if you survive the infection. Vaccination will protect people from severe infections and deaths.
The Delta variant of the coronavirus was the nasty variant that increased the transmissibility of the virus. But, when that variant came around, it did not infect people who were infected with the original virus. Dharavi in Mumbai, for example, did not see any fresh cases as they were visited by the old virus. This means, so far, every variant has obeyed the basic rules of mutation. There could be a new mutant that will not adhere to the basic rules and ignore our already acquired immunity, although that possibility is also rare. Besides, coronavirus is supposed to be less mutagenic (capable of inducing genetic mutation) than the influenza virus, and the flu (pandemic) happens about every 40 years. Besides, the viruses need a susceptible population to sustain a wave.
There will be scattered cases in future, for the simple reason that the vaccination will not reduce the transmission because the chances of breakthrough infections are higher than reinfections following the previous infection. But that will also dwindle.
Watch: What's COVID-19 vaccine breakthrough infections
Dr Jacob: When we have come 16 weeks with a slow and steady downfall of COVID-19 cases, or the endemic state, the likelihood of a third wave is extremely low, at least in the immediate, foreseeable future. If a third wave happens, that will probably be confined to children. However, that situation is something we can prevent or do something about now.
Today, children are the reservoirs of the virus, feeding into adults. Instead of fast-tracking adult vaccination in the middle of an endemic stage, why are we not fast-tracking the children's vaccination? Scientific data informs us that children carry the same volume of viruses as adults. Everybody knows that children don’t die from these diseases or are not severely affected, but that is no excuse to not vaccinate them. We must intervene by breaking the reservoir and vaccinating the children on an urgent basis.
Another factor is that if a variant is far more infectious than the Delta variant and has a tendency to escape the immunity induced by existing vaccines, then a third wave is possible, which will include children and adults.
Dr Jacob: We have been attacking the epidemic till now. However, the rules of the game are different now. Let us attack the endemic COVID-19 by reducing its impact.
Our goal should be to reduce the onslaught of infections even lower, just like we vaccinate against influenza to bring it down even lower. During the epidemic COVID-19, the priority was vaccinating the susceptible and adult population, and doing more COVID-19 tests. The time for that is over now. It is more important to vaccinate the children, and there is no need to ramp up the RT-PCR tests anymore.
Dr Jayaprakash: Natural infection due to H1N1 (a subtype of influenza A virus), for example, causes a sharp rise in numbers and then a sharp fall. Then everything is quiet for a year or so. That is the epidemic pattern. Subsequently, influenza has become an endemic disease.
Similarly, we can't get rid of the coronavirus. The virus, after a natural infection, could cause re-infections due to one’s immunity makeup, although fewer. However, after vaccination, there can be a higher rate of breakthrough infections. As a result, it keeps spreading around. So, even if children are vaccinated, they could still bring home the disease. But, what I am hoping is, that too simmers down.
What the government should focus on now is to ensure surveillance over the occurrence of new virus strains. If there are any, there should be special areas of study to see if there is any difference in the way they mutate. If they are following the general rule, no need to worry because we have hundreds of variations.
Also, the administrative officials can now step back and hand over the disease management to the health department and hospitals. There is no need to interfere. There is no need to increase the testing. It is time to change our strategies. Get yourself vaccinated and wear a mask. Otherwise, you are fine. Life should go on.