The third wave of COVID 19 is imminent in India. In an article published in Nature in September 2020, it was mentioned that a typical SARS-CoV-2 virus accumulates only two single-letter mutations per month in its genome — a rate of change about half that of influenza and one-quarter that of HIV. Despite the virus’s sluggish mutation rate, researchers have catalogued more than 12,000 mutations in SARS-CoV-2 genomes.
Scientists can spot mutations faster than they can make sense of them. Many mutations will have no consequence for the virus’s ability to spread or cause disease, because they do not alter the shape of a protein. Scientists said that as population-wide immunity rises, whether through infection or vaccination, a steady trickle of immune-evading mutations could help SARS-CoV-2 to establish itself permanently. Our immune responses to coronavirus infections, including to SARS-CoV-2, aren’t strong or long-lived enough to generate selection pressure that leads to significantly altered virus strains.
Manaus, a Brazilian city of more than two million, has stood out as one of the world’s leading COVID hotspots. Brazil’s president Jair Bolsonaro has promoted the idea of letting the pathogen move throughout the population until most people have been infected, to get close to herd immunity. Manaus was the first city in the world to reach herd immunity—the point at which enough people are immune to a virus that the spread of new infections is hindered. Preliminary preprint study of researchers at the University of São Paulo estimated that 66 percent of the population had been infected with SARS-CoV-2 (they later revised their figure to 76 percent as of October).
In December 2020 a second wave
did hit. And by January the city’s health system, had collapsed. ICUs were full
to bursting, and oxygen supplies became exhausted. Some patients were airlifted
to other regions of Brazil. But many died of asphyxiation on makeshift beds in
hospital corridors or their home.
More severe than the first one, the new wave took Manaus by surprise. Wearing masks and practicing social distancing had been discarded in the belief the city had reached herd immunity. Caseloads surged out of control, and bleak milestones from last year were surpassed. In January alone more than 3,200 excess deaths were logged,
The Manaus variant, or more formally P.1, caused reinfections in people, who had earlier bouts or could have sped the rate of transmission among the still uninfected. William Hanage, an epidemiologist at the Harvard T. H. Chan School of Public Heath said that Herd immunity through infection, instead of a vaccine, only comes with an enormous amount of illness and death.
Resistance to new measures
persisted for months in Brazilian towns. Social distancing and mask wearing
lagged. The Manaus experience holds a cautionary message for the rest of the
world, including the U.S., about maintaining basic public health strictures
even as vaccination campaigns progress. And it underlines why only a global
approach to immunizations will work. Manaus got hit really hard because they
dropped all of their mitigations, and they didn’t have an adequate state of
herd immunity, as was assumed. Latin American countries—where vaccination
numbers are behind the global North and infection rates are high—are fertile
ground for breeding new variants. The more the virus spreads, the more it is
able to find vulnerable groups in which mutations can arise.
The P.1 mutation is believed to have emerged in Manaus in early November 2020, but by January it made up three quarters of all variants detected in the city and had spread to Japan. It has since been detected in at least 34 other countries and regions, including the U.S. and the U.K. Like other variants first detected in the U.K. and South Africa, P.1’s 17 mutations occurred unusually quickly, and many of them are in the spike protein, which is used to penetrate the cells of an infected person. Fiocruz researchers found that the level of SARS-CoV-2, or viral load, in patients infected with the variant was 10 times higher. CADDE study estimated that P.1 dodges 25 to 61 percent of protective immunity gained from infection with earlier variants.
Immunity gained through
vaccination appears to be more robust than immunity achieved from infection. Johnson
& Johnson’s jab proved 85 percent effective against severe disease in
trials in Brazil—no less than it did in the U.S. Experts say that the situation
is worrying—not just for the people of Brazil but for the rest of the world as
well because of the virus’s track record of acquiring mutations in areas where
it abounds.
The above mentioned facts derived from a number of studies done internationally bring home three facts in Indian context–
1. The probability of a third wave would be higher if the virus cannot be controlled quickly in the second wave as it will get more opportunity to mutate.
2. Immunity gained through vaccination will provide a better security against a mutating virus but vaccinating a large population is difficult.
3. Public Health measures like masks, social distancing and lockdowns seem to control the spread of the virus, and indirectly control the processes of development of viral variants in the future, which are more infectious and fatal.
International understanding on vaccination is required. Accelerating the vaccine campaign throughout the world will be helpful in controlling the pandemic. If COVID is somewhere, it has the potential to be everywhere. Thus, vaccination of the entire population in the world is required, simultaneously. I will not discuss the details of politico-economic dimensions of vaccination in this post.
I want to focus my attention on
the other aspect – Public Health.
The success of Public Health depends entirely on data. Restricting viral spreads to limited geographies would be much easier if data related to disease is provided to researchers, epidemiologists and statisticians.
I will take a simple example. Data related to patients, who have been hospitalised and those who have died, disaggregated on the basis of those who have or have not received vaccine, doses of vaccine, co morbidities, age, gender, rural-urban, residence, on a real time basis and flashed on a dashboard would be so helpful in developing targeted vaccination drives, testing for affected populations, taking public health measures and creating awareness.
If it is found that hospitalisation of patients is increasing in Jaipur from nearby areas, care could be taken close to them by establishing make-shift COVID centres or care units. If there is vaccine hesitancy or casual attitude towards social distancing measures, targeted awareness campaigns could be launched.
In a country which has robust IT infrastructure it is not difficult to create dashboards with easily accessible databases. If data can save lives, doctors and data scientists should work together.
While the Indian Council of Medical Research has granular data on all residents who’ve been tested so far, it restricts access to this database. 300 scientists have asked PM Modi to give access to data for charting Covid-19 spread. Their petition says - “The ICMR database is inaccessible to anyone outside of the government and perhaps also to many within the government,” they wrote. “While new pandemics can have unpredictable features, our inability to adequately manage the spread of infections has, to a large extent, resulted from epidemiological data not being systematically collected and released in a timely manner to the scientific community.”
State Governments should heed a request for data on an urgent basis. We request for recording of data at the hospitals and vaccination centers too and transferring it to a centralized database. Digitizing patient data at the hospitals would not take much time with a lot of technological tools like scanners and spreadsheets available.
Vaccine Hesitancy is probably not found in the cities where COVID second wave spread has happened. But it is still prevalent in the smaller towns and villages. I have personal information about the early stage of vaccination, in a city like Jaipur, where vaccines were wasted because people did not show up in adequate numbers for vaccination. A data check on foot-falls at vaccination centers would eliminate the wastage of vaccines, which is almost criminal in the present scenario. Only with vaccination will we be able to control the pandemic and stop the emergence of new viral variants.
For a densely populated country like India, a third, fourth or fifth wave may occur. In the second wave virus has moved to small towns and villages. Tracking is imminent and essential.
I can give numerous examples where systemic data management and analytics can help make hospital supply chain robust, predict demand for resources, medicines, beds in the wake of new wave and can help in controlling the pandemic better. If only I have an access to data.
Will the government respond to the call?
There is a possibility that the virus weakens itself during mutations. In spite of the anguish, pain and agony that is prevalent around us, a human being wants to be optimistic. Yet data collected during the current pandemic will go a long way in managing the future bursts.
