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April 27, 2021

India's Covid-19 surge (and the 'double mutant' variant), explained

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    Spurred by a "double whammy" of relaxed pandemic precautions and the emergence of more contagious variants, India is reporting more than a quarter-million new Covid-19 cases per day, breaking global records and overwhelming the nation's hospitals and crematoriums.

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    'Spreading like wildfire'

    According to the Wall Street Journal, India on Sunday reported nearly 350,000 new coronavirus cases, marking the fourth consecutive day the nation has broken the global record for a single-day increase in infections. In comparison, just three months ago, the nation was reporting a daily case rate of fewer than 15,000.

    As of Friday, the nation's Covid-19 death toll hit 2,263, bringing the total of confirmed deaths to 186,920—which many experts consider to be an undercount.

    The latest surge differs not only in the number of people infected, but also the different demographics of affected patients, according to Lalit Kant, an infectious-disease epidemiologist and former head of the Division of Epidemiology and Communicable Diseases at the Indian Council of Medical Research. Younger patients are being hit harder in this latest surge, with people between the ages of 26 and 44 accounting for about 40% of total cases and nearly 10% of deaths, Kant said. In comparison, during India's previous wave of Covid-19 infections, people aged 60 and older accounted for nearly all deaths.

    And faced with record-breaking numbers of infected patients seeking care, hospitals are overwhelmed, the New York Times reports. Hospitals are running out of oxygen to supply patients, as well as protective gear for their own staff, and people are "dying in line waiting to see doctors," according to the Times. According to the Journal, crematoriums are running out of room for the dead.

    "[T]he infection is spreading like wildfire," said Suranjit Chatterjee, an internal-medicine specialist and coordinator of the Covid-19 wards at Delhi's Indraprastha Apollo Hospital. According to Chatterjee, because the hospitals are so crowded, patients who can gain admittance are often far sicker than they were in the first wave, with the average temperature reading between 2 or 3 degrees higher than those recorded last year, as well as lower oxygen levels.

    What's behind the surge?

    According to public health experts, the latest wave of infections in India appears to be driven by many of the same factors that have enabled surges elsewhere—namely, a relaxation of pandemic control measures like masking and social distancing, as well as the emergence of highly contagious variants.

    "India had a double whammy," said T. Jacob John, a retired professor of virology at the Christian Medical College in India. "We let our guard down when the variants were spreading. It was the worst time to do so."

    Earlier in the pandemic, India had expected severe waves of Covid-19 illness, but many early cases in the country were mild. In response, the nation's government leaders have eased many pandemic restrictions, allowing weddings, political rallies, and large religious gatherings to occur unchecked—events that, when coupled with the spread of more contagious variants, seem to have acted as superspreader events, the Times reports.

    For instance, the nation's Health Ministry has said that both B.1.1.7, the variant first identified in Britain, and P.1, the variant first identified in Brazil, are now circulating in India, with the B.1.1.7 variant accounting for about half of the cases in New Delhi during the last week of March. There's also a new variant, called B.1.617, that seems to be more contagious due to several mutations, including two well-known ones—L452R and E484Q—that appear to make the virus more infectious, better at evading antibodies, and potentially better at sidestepping the body's immune system. The variant, colloquially referred to as the "double mutant" variant, is now the dominant strain in the Indian state of Maharashtra, the Journal reports.

    In response to the surge, several local governments in the nation, including Delhi and Mumbai, have since reinstituted several pandemic restrictions on travel, weddings, shopping, and other activities. However, the nation is still struggling to vaccinate its population, with just 10% of people having received at least one dose—meaning there are more than a billion people still to vaccinate fully, the Times reports.

    To help meet that demand, India—the world's leading producer of vaccines—has reduced the number of vaccines it is exporting and has called on other nations, including the United States, for assistance, according to the Times.

    What does this mean for other nations?

    According to the Journal, the situation in India, if unchecked, could create a breeding ground for new, potentially more dangerous variants.

    "It is a major point of concern that more troublesome variants can emerge if left unchecked," Rakesh Mishra, director of the Centre for Cellular and Molecular Biology. "I don't even want to imagine a more nasty variant."

    Already, experts say that although the currently available vaccines should work against B.1.617, they could be slightly less effective. "Likely vaccines will protect against severe illness and death but not against infection in those (people) with poorer immune systems," Cambridge University's Ravi Gupta tweeted, adding that evidence suggests people who've been previously infected with Covid-19 may be vulnerable to reinfection with this variant—which may be driving India's current surge.

    In addition, the variant has already spread to at least 21 other nations, including the United States, Germany, Turkey, and Nigeria. In the United Kingdom, genome sequencers found that the variant occurred among people who had not recently traveled, suggesting the variant has spread within the community.

    In the United States specifically, Benjamin Pinsky, director of the Clinical Virology Laboratory at Stanford University, said researchers have identified at least 20 confirmed or suspected cases of the double mutant variant since late March. According to Pinsky, samples collected for those individuals are being used to test how the virus reacts to monoclonal antibodies and plasmas from people who've either been previously infected or been vaccinated—information that could inform future vaccination development.

    America to send help

    On Sunday, the Biden administration announced that in addition to sending India therapeutics, rapid diagnostic test kits, ventilators, and PPE, it also had partially lifted a ban on exporting the raw materials for vaccines so as to help the nation boost its vaccine supplies.

    "Just as India sent assistance to the United States as our hospitals were strained early in the pandemic, the United States is determined to help India in its time of need," Emily Horne, a spokesperson for the National Security Council, said. She added that the United States had "identified sources of specific raw material urgently required for Indian manufacture of the Covishield vaccine," which is the Indian-produced version of the AstraZeneca vaccine.

    In addition to supplies and the raw vaccine materials, Horne said the United States is "pursuing options to provide oxygen generation" and will send a team of CDC public health advisors to work with health officials in India and the U.S. Embassy.

    Further, the Biden administration on Monday pledged to make up to 60 million doses of the AstraZeneca vaccine—which has not yet been authorized for use in the United States—available to other countries, including India, so long as federal regulators determine the doses are safe, the Times reports. The doses require review because they were manufactured at a Baltimore plant where production had been suspended over contamination concerns.

    According to the Times, the announcement marks a shift in the Biden administration's approach toward addressing the pandemic. As recently as Thursday, when asked why the United States had not yet lifted its ban on exporting raw vaccine materials, Ned Price, a spokesperson for the State Department, said "the United States first and foremost is engaged in an ambitious and effective and, so far, successful effort to vaccinate the American people" (Agarwal et. al, Wall Street Journal, 4/25; Leary/Siddiqui, Wall Street Journal, 4/25; Li/Agarwal, Wall Street Journal, 4/23; Doucleff, "Goats and Soda," NPR, 4/24; Lonsdorf, NPR, 4/25; Leonhart, New York Times, 4/26; Rogers/Stolberg, New York Times, 4/25; Stolberg, New York Times, 4/26).

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