COVID-19: Second waves emerge in many countries. Is India ready?

Easing lockdown restrictions will need to be implemented with great caution

By Swagata Dey
Published: Monday 04 May 2020

The Union government has divided the country into red, orange and green zones to ease the nationwide lockdown — in place to curb the spread of the novel coronavirus disease (COVID-19) — from May 4, 2020.

Of India's over 730 districts, 130 fall in the red category while 284 and 319 districts fall in the orange and green categories, respectively. The intensity of measures will continue to be severe in the red zones, with substantial leeway given in orange and green zones.

Limited public transport and e-commerce of non-essential items, for instance, will now be allowed in green zones.

The easing of lockdown restrictions — though great on paper — will need to be implemented with strict caution. The slightest complacency will lead to a re-surge of infections for which we are woefully underprepared at present.

The extended five-week nationwide lockdown may have helped plateau the number of infections. A re-surge in the number of cases in the coming months, however, is inevitable.

Easing of the restrictions, change in weather patterns, the inherent nature of pandemics and a combination of these factors may lead to a new phase of infections.

The 1918 Spanish flu — for instance — came to affect people in three distinct waves before finally subsiding in the summer of 1919.

The death toll from each wave was higher than the previous ones. The United States experienced the first wave of cases of the swine flu — caused by the H1N1 influenza virus — in the spring of 2009, followed by a second wave in autumn.

The virus (SARS-CoV-2) — similar to the earlier severe acute respiratory syndrome (SARS) viruses — might potentially behave in the same manner.

While epidemiological models can predict the trajectory of such pandemics at a global scale, local outcomes are dependent on national policies, social distancing efforts and the general immunity of the people.

The theory of the virus mutating in different regions has been floated. There is, however, not a lot of concrete scientific evidence to support this.

Globally, several countries are already dealing with a second surge of infections. Singapore — armed with the experience of a SARS outbreak in 2003 — had incorporated ‘pandemic best practices’ and was witness to fewer infections.

The number of cases since then, however, rose steadily since April 15 and by April 20, about 5,900 cases were reported.

All the new patients did not have links with one another, raising fears of a deadlier community transmission phase. Hong Kong too managed to contain the initial infections, like Singapore, at the onset of the pandemic in mid-March. A sense of complacency, however, seemed to have set in and a second surge since late March has overburdened the healthcare systems in the city.

Japan too seemed to have done well and did not implement harsh measures: A move that has come back to haunt the country. Over 14,000 cases were reported in the island nation by April end, with Tokyo emerging as a new Asian hotspot.

Hokkaido — the northernmost prefecture in Japan — acted independently to enforce social distancing and carried out aggressive testing.

The number of infections was as low as two a day in mid-March and restrictions were, hence, lifted. After an eight-day gap, 135 new cases were reported and within a month, a lockdown had to re-imposed in the region.

Wuhan in China — from where the virus reportedly originated — imposed a harsh lockdown and brought down the number of cases. A few weeks later, a new lockdown had to be imposed in China’s central Henan province, which was also witness to several cases of re-infection.

While aggressive testing in South Korea has been a model worldwide to contain the spread of the virus, the country reported about 120 re-infections until mid-April. It has now begun preparing for a fresh surge of cases, likely to emerge in September in conjunction with the annual flu season.

This is another cause of concern as COVID-19 — unlike scarlet fever or chicken pox — does not lead to passive immunity. Patients, therefore, once infected and cured are not immune to re-infection. Even worse is the possibility of such people being asymptomatic: While they continue to lead normal lives, they may be infecting others around them.

While India is still in phase one of COVID-19 — and the five-week lockdown has surely helped to contain the spread — we cannot afford to be complacent.

A study using city scale simulations — jointly conducted by the Indian Institute of Science in Bengaluru and Tata Institute of Fundamental Research in Mumbai — predicts how the disease may evolve after restrictions are slowly lifted.

Each of the simulations incorporates city-wise population demographics, local interactions and community crowding along with multiple transmission co-efficients used in epidemiological studies. The infection is likely to come back in a second wave in Mumbai and Bengaluru, with a health threat to the public likely to remain.

The only thing we can control is the timing of the new peak and how well we apply the lessons we ought to have learnt in phase one of COVID-19 in India. This should include addressing all our failures in phase one as controlling any pandemic depends on the strength of the weakest links in our healthcare systems.

This lockdown period and the coming months of May and June will provide a valuable window to carry out resource mobilisation for the next peak, likely in August or after. While only a vaccine or treatment prosocial is the ultimate goal, both are still a long way ahead.

Meanwhile, steps such as replenishing personal protective equipment and revamping production of medical grade masks along with expanding capacity of hospital beds, will help.

The rate of testing must be revamped, with pool testing and rapid testing added to the fray.

A protocol must be devised for patients with milder symptoms that will help them self-quarantine at home and recuperate without infecting others. Finally, personal hygiene and social distancing will have to continue for the foreseeable future.

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