Second Wave - A Wake-Up Call

Patterns exist in our seemingly patternless lives, and the most common pattern is the circle.

- Dean Koontz

Speaking of patterns, I remember someone saying that the patterns we perceive are determined by the stories we want to believe. The stories might relate to fashion, your favourite stock, or it can be the stories of Corona.

However, if the patterns are broken, a new world begins to emerge. This is why I decided to blog on the second wave of Corona when people have started creating their own stories based on all the charts, patterns, and gossip.

Over the last few months, the country eased out completely from previous restrictions, with all sectors encouraging borders to reopen. However, the sudden surge in the number of new daily cases has been exponential, and there is no doubt that the second wave will be more severe than it was last year, at least if the steep rise is any indication. In fact, since 15th February, the number of cases has increased to more than 10-fold.

Some experts have said that the current wave is propelled by emerging mutant variants – notwithstanding the Government's denial. Natural evolutionary changes in the virus have rendered it more transmissible than previous strains.

The second wave of coronavirus is said to have brought new symptoms of the infection. While the usual symptoms of COVID-19 include fever, body ache, loss of smell and taste, chills, breathlessness, several studies suggest that red eyes, gastronomical conditions, and hearing impairment are becoming new symptoms.

If you were to believe irresistible mathematical models from different groups, India would witness unprecedented growth in cases, much more than what it saw in the first wave.

Even with a conservative estimate of 100,000 cases each day in the entire country, we will require 5,000-10,000 beds every day for critical care and the corresponding oxygen supply (assuming 5-10% would require hospitalization). At this rate, cases will accumulate faster and will cause the health system to collapse way before anybody could imagine.

What history tells about the second wave

If there is anything in history that resembles what is now happening to the country, then it would be the Spanish Flu pandemic that had devastated India during the 1918-1920 period. This flu had estimated to have killed between 50 to 100 million people worldwide, of which 17 – 18 million belonged to Indian Soil. This is the highest and fastest death rate ever for any epidemic in India's history. It far exceeds the 10 million deaths from the 1896 Plague, which ran over two decades.

The outbreak most severely affected younger people in 20–40, with women suffering disproportionately. The disease's spread got exacerbated by a failed monsoon and the resultant famine-like conditions that had left people underfed and weak and forced them to move into densely populated cities.

In his memoirs, the Hindi poet, Suryakant Tripathi, wrote, "Ganga was swollen with dead bodies." The sanitary commissioner's report for 1918 also noted that all rivers across India were clogged up with bodies because of a shortage of firewood for cremation.

The mysterious flu was marked in its First Wave by relatively low mortality among the very young and old. This did not guarantee any immunity to the deadly second wave, though. India's first wave began its spread fast as Indian soldiers who were asymptomatic carriers returned by train to their home towns and villages from World War 1.

However, the death rates were not high enough to create alarm, given that the war and other illnesses were taking a greater toll. It was when the virus underwent a sudden mutation in its antigenic nature that the pandemic left its mark on global and Indian demographics – this time among the most productive age group of 20–40-year-olds.

In India, the mortality among young women in the reproductive age group was exceptionally high, resulting in a 30% drop in the birth rate for 1919.

The similarities between instructions issued during the Influenza of 1918 regarding protective protocols and how to make a face mask and those issued today are startlingly similar…100 years later!

This is particularly relevant in today's Covid-19 pandemic, as a vaccine created for a first wave virus may be ineffective against its mutated version. This is a historical warning that countries should not lower their guard even with a vaccine present.

Even so, it has almost been wiped out from public memory. Perhaps part of the reason is that pandemics, even if as deadly, do not capture the public imagination in the way wars tend to. Another big reason could be that there has not been nearly enough writing on, and therefore, awareness of the extent of damage in India.

Differences in Spanish Flu and Covid

Unlike Covid-19, the Spanish Flu virus was of the H1N1 strain with avian origin genes, but, like Covid-19, it was transmitted via respiratory droplets. As with Covid-19, older adults were most at risk of developing severe symptoms. However, in stark contrast to Covid-19, the Spanish flu also impacted children under five and adults aged 20-40. In fact, a 25-year-old was more likely to die from the Spanish flu than a 74-year-old was. This is unusual for flu.

Covid-19, however, generally affects children in relatively minor ways, and adults aged 20-40 are significantly less likely to develop severe symptoms than older adults.

As with swine flu, it may be that older adults at the time of the Spanish flu had pre-existing immunity to a similar pathogen. Perhaps the 1889–1890 flu pandemic, or the Russian flu, afforded some protection to those who survived it.

Some scientists believe that younger people's vigorous immune responses might have led to more severe lung symptoms due to "exuberant pulmonary exudation." In other words, young people's strong immune responses may produce excess fluid in the lungs, making breathing even more difficult.

At the time, there were no vaccines to prevent the disease and no antibiotics to treat the bacterial infections that sometimes developed alongside it. The virulent nature of this particular H1N1 strain and the lack of medication available made this the most severe pandemic in recent history.

During this period, India experienced two distinct epidemic waves: A mild one in the spring or summer of 1918 and a second and much more lethal one in the autumn or winter.

The Covid mutants

A mutation is a change in a genetic sequence. Mutations occur in nucleotides, the primary substances that make up the prominent RNA and DNA molecules. The sequence of these nucleotides in the RNA or DNA determines the amino-acid sequence, the building blocks of proteins.

Most mutations are inconsequential and don't alter the virus's behaviour. But some mutations trigger changes in the spike protein and other key areas, resulting in changed viral attributes like the virus's infectiousness, transmissibility, severity and immunity-evading potential.

If enough mutations happen in a viral family tree or a lineage, the virus can begin to function differently, and the lineage can become a so-called 'variant of concern.'

Mutations in the spike gene can make the virus inherently "better" at infecting people or help the virus escape neutralizing antibodies infecting those who have already been infected by the virus earlier. However, Scientists say that India's new double variant is not likely to be more deadly or more inherently transmissible, but more data is needed to be sure.

Vaccination

I shall restrict the discussion on vaccinations to Covid shield and Covaxin as they alone are being utilized in India.

Covishield

The Oxford-AstraZeneca vaccine is being manufactured locally by the Serum Institute of India, the world's largest vaccine manufacturer. It says it is producing more than 50 million doses a month.

The vaccine is made from a weakened version of a common cold virus (known as an adenovirus) from chimpanzees. It has been modified to look more like coronavirus - although it can't cause illness.

Covaxin

Bharat Biotech, a 24-year-old vaccine maker, has a portfolio of 16 vaccines produces Covaxin.

Covaxin is an inactivated vaccine which means that it is made up of killed coronaviruses, making it safe to be injected into the body. It is an inactivated vaccine developed by chemically treating novel coronavirus samples to make them incapable of reproduction.

Bharat Biotech used a sample of the coronavirus, isolated by India's National Institute of Virology.

When administered, immune cells can still recognize the dead virus, prompting the immune system to make antibodies against the pandemic virus.

Covishield had the advantage of large-scale clinical trials being conducted elsewhere that generated efficacy data quickly, requiring small scale studies in India. But it also has a disadvantage — the initial messy data about doses, intervals and age groups and miscommunication by AstraZeneca have led to confused messaging about how to use the vaccine.

Covaxin has the advantage of tremendous support from India's Government, but the disadvantage of needing to do large-scale clinical trials in India, never an easy task, given the lack of clinical research experience at many sites.

Immunity and Vaccination

One's immune system doesn't respond just to all foreign things. It responds to foreign things that it perceives to be dangerous.

Vaccines work by introducing a safe version of a pathogen to a patient's immune system. Your immune system remembers its past encounters and responds more efficiently if it sees the same pathogen again. However, it generates memory only if the vaccine packs enough danger signals to kick off a solid immune response.

As a result, your immune system's need to sense danger before responding is at once extremely important and highly problematic. The requirement for danger means that your immune system is programmed not to respond unless a clear threat is identified. It also means that if I'm developing a vaccine, I have to convince your immune system that the vaccine itself is a threat worth taking seriously.

What's Next?

So there is not much time available to plan to save lives as the dramatic ascent continues. We should not delay any further in responding to the second wave.

We should have had a plan by now for a graded distribution of beds for critical care, when needed, ready to be deployed in a short time. Deploy battle-ready infrastructure and human resources in each state to take on the virus while it attacks the country's vast population.

The real threat is to overestimate our ability and underestimate the virus. Unfortunately, the current approach appears to be 'business as usual' with no strict compliance to COVID-19-appropriate behaviour. Changing this strategy could be pivotal in reducing the adverse impact (the number of cases).

Research needs to proceed parallelly at an equal pace. We need to know more about the people who are getting infected. Where are they from? Age? Gender? Vaccinated? Previously infected? Disease severity? If we have this information and can tie it together, we can achieve more tailored strategies for control instead of strategies that have an uncertain effect.

We need to ramp up our genetic-sequencing programme urgently. A sincere attempt should be made to assess the efficacy of existing, approved vaccines against the new variants.

It is also essential to understand the mechanisms involved in the infectiousness and virulence of the newer variants. For this, lab models are needed to mimic spread and virulence mechanisms efficiently.

Swift and rapid vaccine coverage are not only necessary but essential for ensuring any modest levels of success in tackling this pandemic.

Is another Lockdown necessary?

When our Prime Minister announced the first lockdown on 24th March 2020, the country's number of positive corona cases was around 500 nos. The lockdown made everyone an expert to comment on its implementation, which was equally fuelled by the media for their TRP's.

After all is said and done, India was still looked high for how it managed the first wave and how it curtailed the virus's spread, and the eventual deaths compare to all the developed nations in the world.

Today, the daily cases are touching around 1.5 lakh cases, yet lockdown seems to be a worry and not the surging deaths. The phrase more people will die of hunger than the virus sounds good, and it is meant to sound good, just like all the exciting lies.

Stock markets may crash, but the traders won't die. The banking system may fail, but the bankers won't break. Jobs may be gone, and yet people shall continue to survive. The economy may fall, but it won't disappear. And yes, when it comes to the daily wage earners and those living in poverty, the Government can step in to feed their hunger. I am sure it will cost just a fraction of its GST collections.

A Lockdown may pause the economy; however, it will be at the cost of buying some time for its limited medical resources. It is OK to stop a while as long as you are going in the right direction. There is no point running fast when the direction is wrong, leading one to a wrong destination.

The Future Ahead

During the Spanish flu that affected India, it did not strike everyone equally. Most British people in India lived in spacious houses with gardens and yards, compared to the lower classes of city-dwelling Indians, who lived in densely populated areas.

Many British also employed household staff to care for them – in times of health and sickness – so they were only lightly touched by the pandemic and were largely unconcerned by the chaos sweeping through the country.

While the pandemic was of little consequence to India's British residents, the perception was wildly different among the Indian people, who spoke of universal devastation. A letter published in a periodical lamented, "India perhaps never saw such hard times before. There is wailing on all sides.There is neither village nor town throughout the length and breadth of the country which has not paid a heavy toll."

Elsewhere, the Sanitary Commissioner of Punjab noted, "the streets and lanes of cities were littered with dead and dying people … nearly every household was lamenting a death, and everywhere terror and confusion reigned."

Geography wasn't the only dividing factor, however. In Mumbai, almost seven-and-a-half times as many lower-caste Indians died compared to their British counterparts - 61.6 per thousand versus 8.3 per thousand.

Normalcy, however, did not quite return to India. The spring of 1919 would see the British atrocities at Amritsar and, shortly thereafter, Gandhi's Non-Cooperation Movement's launch. Influenza became one more example of British injustice that spurred Indian people on in their fight for independence.

A nationalist periodical stated, "In no other civilized country could a government have left things so much undone as did the Government of India did during the prevalence of such a terrible and catastrophic epidemic."

The virus also infected Mahatma Gandhi. The pandemic had a significant influence on the freedom movement in the country. The healthcare system in the country was unable to meet the sudden increase in demands for medical attention. The pandemic's consequent toll of death and misery and economic fallout led to the rise in emotion against colonial rule.

The long, slow death of the British Empire had begun.

The British are long gone now. We can't divert our anger on our own people. It's time to work together to come out alive. Let's get safe; let's help our people and get ready for the war ahead together as one.