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Reports from India describe a dire situation for COVID-19, with a record daily number of cases, low oxygen for fans and a transmission speed that points to things getting worse before they get better.
Could such a scenario develop in the United States in the future?
Experts generally agree that the US is in a better position with recent gains in vaccination against COVID-19. However, there are several unknowns: will the slow pace of vaccinations take effect? What about variants? Will the relaxation of public health measures play a role in some states?
One thing is for sure: India reported its sixth consecutive day with more than 300,000 new cases of COVID-19 on April 27th. In addition, the official death toll of 198,000 is probably a lower number, based on a test positivity rate that averages 20% nationwide.
Humanitarian crisis
New case reports coming out of India are likely to be a “brutally underestimation,” said Ashish Jha, MD, MPH, dean of Brown University School of Public Health in Providence, Rhode Island, during a session informative of April 27th.
Similarly, the total figures of nearly 200,000 people are “clearly an understatement,” Jha said. “The best estimates are ten times more.”
“The virus is engulfing the people of our city like a monster,” says Mamtesh Sharma, a Bhopal city official, who is widely quoted in the media.
“There is no doubt that a humanitarian emergency is unfolding in India right now,” said Michael Head, a senior doctor in global health research at the University of Southampton in the UK. “Stories of a collapsed health system are numerous, with reports of oxygen shortages for hospitalized patients and bodies burning at street pyres.”
The mortality rate in India does not keep pace with the sharp rise in new cases, a bright and lonely point of the figures. The mortality rate often lags behind infections for several weeks, so the situation may change.
The United States initially undertook to ship raw materials for vaccines to India and subsequently added will be sent 60 million doses of the AstraZeneca vaccine to help the catastrophe unfold. India reports 14 million cumulative cases, second only to the 32 million reported so far in the United States.
“The second wave of COVID-19 in India, which started on February 11, 2021, presents a dire situation as the number of cases crossed 0.2 million a day on April 14, 2021, ” writes Rajesh Ranjan, MD, and colleagues in a prepress published online April 21, 2021 a MedRxiv.
The daily rate of 0.2 million is more than double what the country experienced during the first peak. “The data suggest that the virus is currently much more infectious than the first wave, but the number of daily deaths from infection is lower,” they write.
In the US there are more likely to be limited outbreaks
When asked if this rise could take place in the United States, said Kartik Cherabuddi, MD Medscape Medical News“We’ve experienced this recently in Michigan and Ontario, so we don’t have to lower our guard.”
Vaccinations are the most effective strategy to prevent future growth, added Cherabuddi, an associate professor of medicine in the Division of Infectious Diseases and Global Medicine at the University of Florida College of Medicine, Gainesville. “So far we have had a great response, but there are signs of a slowdown in demand. We need to advocate the removal of all barriers to vaccination.”
The slowdown in vaccination in the United States is not surprising, Jha said. “I think the seven-day moving average above 3 million is gone. That number will continue to decline.”
He stressed that the slowdown in vaccinations is not a failure. “It’s exactly what we expected: vaccine-hungry people are over. Vaccination of everyone else is slower.”
Cherabuddi predicted that the U.S. is more likely to see smaller regional outbreaks compared to another nationwide increase.
“The availability of vaccines in the United States is certainly an advantage. However, although more than a quarter of the population is fully vaccinated, it is possible that if we fail to combat vaccine misinformation, much of the population remains unvaccinated This could limit our ability to control the pandemic and lead to ongoing clusters, ”said Tom Frieden, MD, MPH, former CDC director and president and CEO of Resolve to Save Lives. Medscape Medical News.
“The contrast with the United States is almost discordant,” Jha said. The United States is at the end of a “mini fourth wave.” For the first time in a month, new cases are less than 60,000 a day. He hopes that this general decline will continue in the new cases, and if the United States cannot reach zero cases, at least 10,000 per day would be welcome nationwide.
Jha agreed that nationwide climbs are unlikely. Still, “I’m worried about pockets in the US.” For example, he is particularly concerned about five states with low vaccination rates that could see the summer rise when people move to air conditioning: Alabama, Georgia, Arkansas, Mississippi and Louisiana.
Views on variants
Ranjan and colleagues point to variant B.1.617 of SARS-CoV-2, a “highly infectious mutant double variation” of SARS-CoV-2, “negligent behavior” of the population, and relaxation of interventions in India. They point out that more research is needed to determine if the infections associated with B.1.1617 are more or less severe than the wild-type virus.
Jha said variant B.1.1.7 first identified in the UK plays a more important role in India at this time than other worrying variants.
“The situation in India demonstrates the need to keep variants with masks in line, to distance themselves and close strategically, and also to increase vaccine manufacturing globally,” Frieden said.
India has a “huge capacity” in vaccine manufacturing and could become the South Asian vaccine supplier by creating a mRNA vaccine manufacturing center, he added. The creation of regional vaccine manufacturing centers “will take longer than we want, so we need to start right now.”
A desktop perspective
“The second wave in India seems much more precarious than the first wave and the situation could get out of control quickly if strict measures are not taken,” Ranjan and colleagues wrote. Vaccinations are essential, they add, but “given the large population of India and the current spread of virus mutants to remote locations in India, these strategies may not be sufficient to slow the spread of the virus.” .
“It is in our individual and collective interest to expand vaccination worldwide as quickly as possible, with dissemination to hesitant and at-risk communities, and to reduce dissemination as effectively as possible with masking and distancing, especially inside, ”Frieden said. dit.
“He can’t blind us to the light at the end of the tunnel in the United States,” he added. “Rising India reminds us that the virus learns about us and adapts faster than we learn and adapt to it, and that COVID-19 is a continuing and growing risk.”
Interestingly, although India is the world’s largest producer of vaccines, “it has not had the largest implementation of vaccination, meaning that so far only 9% of people are protected,” said Martin Hibberd. professor of emerging infectious diseases. at the London School of Hygiene & Tropical Medicine, he told the Science Media Center in the UK.
In their study, Ranjan and colleagues calculated the probability that each infected person would transmit the virus to another, known as the reproduction number (Rt). When the Rt is greater than 1, each person is likely to spread the virus to another person, for example. The current Rt in India is about 1.37, compared to 1.09 in September 2020.
Another measure, the mortality rate (CFR), has tended to fall from 3.5% during the first peak in India in April 2020 to 1.2% a year later. “The decrease in the CFR curve suggests a silver coating of a relatively less fatal mutant,” Ranjan and colleagues write. “However, given an exponential increase in cases at a very high rate, it is expected that soon sanitary facilities will be completely restricted, which will lead to the unavailability of hospital beds and ventilators for people in need This could lead to an increase in CFR. “
India “Does not leave the forest”
Based on this model, researchers predict that the peak of the current second wave will occur in mid-May, when new cases are estimated to reach 0.36 million.
“While there is a lot of attention right now, in the right way, in cities and large towns, we need to act immediately to prevent accelerated spread to smaller towns and villages where the majority of the population lives,” he said. Cherabuddi, who is also affiliated with India COVID SOS, a volunteer group of scientists, clinicians, engineers, policymakers and epidemiologists from around the world who support the fight against COVID-19 in India.
“The next 4 to 6 weeks will be very difficult for India,” Jha said. “By no means is India close to the forest.”
“It’s really important for us to remember that this is a global pandemic,” he added. “Even though the virus is running anywhere, we are at risk.”
A likely scenario over the next year or so is that “we will see the United States, Europe and a few other countries in good shape – putting out fires here and there due to outbreaks – and much of the world on fire at high rates. of infection, ”Jha said. “This is not a future that any of us want.”
Ranjan, Jha, Frieden, Hibberd and Head have no relevant financial relationships to reveal. The pre-printing of the study was supported in part by a SERB MATRICS project. MedRxiv included a warning indicating that prepress is not peer-reviewed and should not be used to guide clinical practice.
MedRxiv. Published online April 21, 2020.
Damian McNamara is a staff Miami-based journalist. It covers a wide range of medical specialties, including infectious diseases, gastroenterology and neurology. Follow Damian on Twitter: @MedReporter.
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