India Covid-19 update - Vaccines, CFR and new variants
I wrote several articles on Covid-19 pandemic in India last year. This article is about more update on the present situation of pandemic in India. In February & early march, i read several reports in news media, including in western media about mystery regarding flattening of curve in India and low Covid-19 death rates compared to rest of the world. These reports missed several critical elements which i will explain in this article. I will also give a brief report on situation of vaccines we are using in India right now and also an international perspective on how vaccines remain unavailable to developing nations despite the world in unprecedented crisis of this pandemic. Finally, i will look into the mysterious second Covid-19 wave in India and some interesting things which needs attention of the scientific community.
India's low case counts and low death rates - How and why we missed Covid deaths? - Is it really possible to miss hundreds of thousands of deaths? - Putting statistics into perspective - This analysis is also applicable in understanding low death rates of other poor backward nations
From the very beginning, India lagged far behind developed nations in Covid-19 testing and clinical diagnosis of cases. The reasons for this are obvious, that is the poor & almost non existent healthcare infrastructure in much of the country. I have mentioned all about this in earlier reports about lack of healthcare facilities & hospitals in much of rural India. In the first wave of pandemic, developing countries like India had no resources to do large scale testing. Testing kits, medical supplies and chemicals needed to manufacture testing kits came from China, South Korea and other nations. Most of these supply line was cornered by America and European nations. India got little resources for testing. While the scarcity of testing kits was a big problem, there was another problem with substandard testing kits which was major problem in poor states like Bihar. Since poor states do not have a robust medical system of laboratories, the government relied heavily on Rapid Antigen tests which can give instant result in 20 minutes without any need of lab processing. But these kits gave too many false negatives and skewed the data in a big way (read 1, 2, 3 & 4). States like Bihar did as much as 90% of their testing with Antigen tests as against the ICMR guideline which prescribed RT-PCR testing as the gold standard. If you conduct antigen tests on 10,000 positive samples which gives false negatives in 10% of cases, that means you are missing as much as 1000 real Covid cases in your testing. While 10% of false negatives can skew the overall data in a big way, the testing kits had worse accuracy sometimes even less than 50%.
India daily tests per 1000 people. Comparison with other countries.
India total cumulative tests per 1000 people. Comparison with other countries. Data (1 & 2)
Regarding low death rates, many healthcare reporters have done reports on how Covid-19 deaths remain grossly under reported in India (read 1, 2, 3 & 4). The logic is simple. Firstly, to have an accurate data on Covid deaths, you need to register deaths. As per WHO, as much as 90% of deaths aren't medically registered in India. Millions of Indians die every year and we don't know their cause of death. As much as 26% of deaths aren't even registered at all. So millions of Indians die every year and don't even get registered in any way whatsoever. For a reported Covid-19 death, the person's death has to be medically certified by Doctor. If there are no healthcare facilities and Doctor in the area (as is the case in many parts of India), a Covid death will go unreported. Even if, sick Covid patient with a preexisting conditions gets admitted and dies in hospital, its a fair possibility that the patient's death is attributed to preexisting condition rather than Covid. Since Covid-19 deaths overwhelmingly occur in old age population and people with preexisting conditions, these deaths do not get captured in broken backward healthcare system of India. The deaths in old age brackets will be recorded mostly as deaths from natural causes or from preexisting diseases. In many cases, deaths won't be registered at all.
To get real idea about case fatality rate and under-reporting of Covid deaths in India, we need accurate data. Reliable data ideally comes from good healthcare system with extensive testing, clinical diagnosis and proper system of medical certification of Covid deaths. But all that remains elusive in India. But here is a simple model to analyze Covid fatality rate in India. We know that rural India (comprising of around 70%) of population have very poor healthcare infrastructure. Healthcare system in top tier urban cities is also bad but is far better than rest of India. Here we see very interesting trend of disparity between total Covid deaths in top cities (Mumbai, Delhi etc) compared to rural backward states like Bihar. And this underscores my point, the cities having better healthcare system are able to detect and capture Covid deaths much better than in backward states where there is poor or non existent healthcare system.
Map showing cities Delhi, Mumbai, Bangaluru, Kolkata and Bihar State. India States and District wise Covid-19 data available here.
Four major top tier cities (Delhi, Mumbai, Bengaluru & Kolkata) with combined population of 67 million have a total 1.7 Million Covid cases and 31,000 deaths (i am rounding off the figures). Compare this to population, Covid cases and deaths in a State like Bihar. Bihar with population of 130 million (more than UK & Italy combined) has officially recorded only 260,000 Covid cases and 1500 deaths. The disparity is huge. Why Bihar has such a low number of cases and deaths? There is no real explanation for this except if we assume the scenario that Covid did not spread in Bihar. But that's not true. The Covid has spread in Bihar just like Delhi & Mumbai. Bihar at one time had 13% positivity rate which implied full blown epidemic. And consider the super spreader events of huge election rallies without any social distancing (read 1 & 2). This was followed by multi phase Bihar state elections which also were super spreader events. Only explanation for low number of cases and deaths is obviously that real number of deaths are higher but we have not recorded them. Such trend can be seen in many states. Odisha with population of 47 Million (same as Spain) has officially recorded only 2000 deaths. State of Uttar Pradesh with Population of 230 Million (almost half of population of EU) has officially recorded only 9000 deaths.
We don't need to compare Covid deaths of Delhi and Bihar which is far away state. Lets compare Covid deaths of Delhi and its adjacent NCR cities (Gautam Budh Nagar, Ghaziabad, Gurgaon and Faridabad). These NCR cities are adjacent to Delhi and businesses, infrastructure and social life of these cities are very much integrated. Only difference between these cities is territorial jurisdiction of state governments. Gautam Budh Nagar & Ghaziabad are districts of Uttar Pradesh while Faridabad and Gurgaon belong to Haryana. Healthcare system and Governance of Delhi is much better compared to regions of Uttar Pradesh and Haryana (Uttar Pradesh actually has among the worst healthcare system & governance in India). Here again we see the same trend of disparity between Covid deaths in Delhi and combined Covid deaths in these NCR cities. Delhi with population of 20 million has around 680,000 Covid cases and 11,000 Covid deaths (i am rounding off the figures). Four adjacent NCR cities have combined population of 11.4 million but has officially recorded only 170,000 cases and around 1000 total deaths. The disparity in data of deaths is huge.
With such a huge disparity of Covid deaths in backward state like Bihar when compared with top tier Indian cities, another point that is raised by some people is that how can we miss hundreds of thousands of deaths? On a national scale, if we assume that Covid-19 is causing deaths at such a large scale (like in many developed nations, around 0.1% - 0.2% of population has died of Covid), that would mean more than a million deaths in India. Is that a too far fetched scenario? Actually its not if we consider that 90% of deaths are not medically registered and 26% of deaths are not registered at all in Govt records. This is where we need to put statistics into perspective. In articles that i read on Washington Post, i did not find mention of several critical points. These articles do not mention the great disparity in India's Covid deaths between developed urban parts of country and poor backward rural parts of country. News media ignores an important point how Deaths are simply not captured because of failed health system. But there is a broader point in addition to that. News media makes viewers to think that Death count in India is low because hundreds of thousands of deaths cannot just go unnoticeable. But then, news media doesn't mention some critical statistics of India that are very relevant to give some context. Millions of deaths occur from malnutrition, starvation, diseases like Tuberculosis, Malaria and simple diseases like Diarrhea and many are not registered in any records.
According to official data, Tuberculosis cause 79,000 deaths annually in India (real figures may be much more). More than 200,000 Indians die annually with Diarrhea, and mostly children (read 1 & 2). As much as 600,000 children under 5 years of age die because of malnutrition annually in India (read 1 & 2). More than 200,000 Indians die because of lack of clean drinking water. Lets do a comparison with a developed nations like America. Only 542 people died of TB and 300 children die from Diarrhea in America annually. In India, as much as 4000 children die every day from hunger and simple preventable diseases. This is more than the daily peak of Covid death in America.
So Millions of deaths occur in India due to poverty & hunger, and simple preventable diseases. All this is well documented, yet no one really cares about these statistics. Now put Covid death figures in perspective. Do you think a million more deaths due to Covid is really a big deal? I mean millions of Indians die from poverty and hunger every year, and it doesn't matter to our government and specially the present government (read 1 & 2). Our media and experts don't discuss about it. The reality of poverty and social backwardness is always there in back of our mind but we never fully articulate it. Millions of deaths due to poverty and hunger was a normal affair in India before the pandemic. We know that pandemic was a seismic event that imploded the whole Indian economy and this was aggravated by Austerity drive of Govt in wake of an economic depression. How many more millions died because of poverty & hunger due to pandemic induced depression? This brings us to the point that while the Covid deaths may have been under-reported and overlooked, the bigger problem may well be the deaths induced by economic depression caused by Covid. Interestingly our media experts and analysts don't pay much attention to it.
Vaccines in India - Western vaccine technology remain out of reach of India and developing nations - Chinese and Russian Vaccines also not available in India - Covishield (Astrazeneca) and Covaxin are two approved vaccines in use right now - Concerns on safety and efficacy - Global problem with vaccines due to IPs patents
India is using two vaccines right now. Covishield is the British Astrazeneca-Oxford vaccine manufactured in joint venture with Indian Vaccine maker SII (Serum institute of India) which is the largest vaccine maker of the world, also importing vaccines to many other countries. There have been few deaths in people administered with Covishield but its a tiny fraction compared to overall people who have been safely vaccinated. Astrazeneca vaccine, as of now remains unapproved in US and several other developed nations. Astrazeneca vaccine is also subject to various restrictions in Europe due to some newly discovered complications (read 1 & 2). Astrazeneca vaccine is also discontinued in South Africa due to doubts on its efficacy against South African variant of virus.
Covaxin is developed by private Indian company Bharat Biotech in some sort of collaboration with ICMR. ICMR is central government institution for medical research and has been currently tasked for formulating policies for Covid response in India. Covaxin has undergone phase 2 and phase 3 clinical trails, however, only phase 2 trial data has been published by the vaccine developers. Full data on Phase 3 Clinical trials is yet to be published and peer reviewed. The company as well as Government, however, claim that Covaxin is safe and has 81% efficacy according to interim phase 3 results. Indian Govt approved Covaxin even before any phase 3 trials were conducted similar to Russia's approval of Sputnik V. Ruling Modi Govt wanted to launch vaccine even before conducting any clinical trials, wanting to announce the vaccine on 15 August, India's independence day. Fortunately, there were Doctors like AIIMS director Dr Randeep Guleria (member of India's Coronavirus task force, he's India's equivalent of Dr Fauci), who resisted political pressures and expressed their disapproval for launching vaccine without ascertaining its efficacy & safety (read 1 & 2). Covaxin was approved for clinical use in Jan 2021 by the Govt after conducting phase 2 trials and is widely used by healthcare workers as well as ordinary citizens.
I do not know the real reasons on why Govt pushed for fast approval of Covaxin without a thorough study on its safety and efficacy. Whether the efficacy is 80% or 60% or 50%, i don't really know. But my apprehension is that our Government and scientists in Coronavirus task force were convinced that Covaxin triggers antibody response and is safe for use. The degree of efficacy remains unknown but vaccine will be successful in preventing serious cases of Covid and hospitalizations. So even if vaccine has low efficacy, but if it prevents serious and moderate effects of Covid that results in hospitalizations, the vaccine still serves a very important purpose. The vaccine is ultimately a life saver. Of course, these are not proper protocols for use of vaccines but this is the pragmatic approach many countries are taking in this pandemic specially due to lack of resources. This is similar to use of China's Sinovac vaccine in Brazil which is among the worst affected countries in this pandemic. While Sinovac has a low efficacy in Brazil, its said to be 100% effective in preventing hospitalizations and hence ultimately preventing deaths (read 1).
Covishield and Covaxin are launched in phases according to priority groups and availability. Healthcare workers were placed on top priority, followed by senior citizens & people with preexisting conditions, and then according to age brackets with younger population at the bottom of the priority scale. Vaccine is given free at government hospitals and at a nominal regulated price at Private Hospitals (costs around $8 for two doses). Vaccines are scarce considering the huge population of country and also challenges in outreach to rural parts of country. There are also other critical reasons.
Western vaccines like Moderna & Pfizer are not available in India. These vaccines are manufactured by western Pharmaceutical companies on 'for profit' basis. These companies wanted to market their vaccines in India in joint venture with Indian pharma companies but there is no partnership yet to launch these vaccines in India. I think most obvious reason is pricing as the Covid vaccines prices are tightly regulated by the Govt in India, there are no prospects for these vaccines to be profitable in India as in North America and Europe. Also, Indian Government want these Pfizer to conduct more local trials for their vaccines in India but this is a non starter because there is no point in conducting more trials without any scope of actual commercial profitability in India. Pfizer wants assurance from Indian Govt on freedom of pricing & export restrictions to safeguard its commercial interests. With surge in Covid cases, Indian Govt has restricted exports of vaccines to focus on domestic vaccination programs. Western Pharma companies do not want to be subjected these kind of restrictions. It appears that western Phama companies are interested in tapping into manufacturing capacity of India's local Pharma industry for building export hub rather than marketing its vaccines in India itself as there is not much scope for profitability due to strict price controls on vaccines in Indian markets.
In the beginning of pandemic, it was expected that since pandemic is a global threat, there will be joint effort by all countries specially the developed nations in research and development of drugs and vaccines. US under Trump withdrew from WHO and blocked all its technology access to the world. Western Pharma companies developed their vaccines on 'for profit' basis to be marketed in North American and European markets. The cost of these vaccines are not a problem for these developed nations and Governments are footing the bill of their national vaccination program. However, the 'for profit' model of vaccines is a problem for poor countries like India with a population of nearly 1.4 Billion (more than North America & Europe combined) which doesn't fit the business viability model of western companies. Fortunately, companies like Astrazeneca took a different approach by considering the business viability in huge size of the markets. Pricing their vaccines lower, even if company only makes profit of some cents on a single dose of vaccine, there is a demand for hundreds of millions of doses in developing countries which would ultimately be profitable for companies.
After departure of Trump, new Biden Administration in America rejoined the WHO and committed in Covax program which is funding for vaccines specially for poor countries. Covax program itself is flawed by design because it doesn't actually solve the real constraints in vaccine outreach to developing countries. What are these constraints? These are Intellectual Property patents which blocks the technology transfers and make the technology as exclusive property of companies. American economist, Dean Baker, has written extensively on these issues and the economic and social impact of IP monopolies of companies. These IP monopolies are great deterrent to industrial and scientific progress, and also contribute greatly to social inequality. The impact of these IP monopolies on public health specially in wake of pandemic is very clear. Baker has also written extensively on alternate ideas of funding scientific research and development which will be beneficial to both private sector and public good, will result in open source free flow of technology and ultimately lead to fast paced scientific progress nationally and globally . These ideas may take time to implement considering that some of the reforms will require partnership with China which US doesn't see favorably right now. But, Baker explains that at the very minimum, what we need is TRIPS waiver of Covid vaccine patents at WTO. India and dozens of developing countries have applied at WTO for TRIPS waiver of vaccine patents but America, Europe, Japan and Australia (basically the free democratic world) is not in favor of this.
Indian Govt pointed out that temporary waiver of patents will unlock additional manufacturing capacity to produce these vaccines. After all, the scarcity of vaccines is completely artificial. Right now, vaccine production is only in hands of companies (and their joint venture partners) who own the patents of these vaccines. If these patents are open source, any Pharmaceutical company with production capability can manufacture the vaccines and these will be priced at minimal nominal costs. Also if Research and Development of vaccines is open source, the trials of vaccines can be carried out extensively across countries which will ascertain safety and efficacy of vaccines early and timely. This data can be shared among countries without any restrictions and thus will bring more transparency and credibility in vaccine development process.
Russian and Chinese vaccines also remain unavailable in India. Due to geopolitical reasons, i don't think Chinese vaccines will be available in India. After Chinese PLA aggression that killed Indian troops in Ladakh last year, the foreign relations between India and China remain strained. China also launched cyber attacks against India's financial system and electricity grid infrastructure. India in retaliation has banned several types of trade and commerce with China, though import of medical supplies remain exempted as of now. But given all the tensions with China, i don't think Indian Govt will allow Chinese vaccines in India. I don't know why Russia's Sputnik V remains unavailable in India. Sputnik V is based on similar adenovirus vector technology like Astrazeneca and now has been shown to have good efficacy and safety.
India's second Covid-19 wave - New variants in various states - Mysterious rise of cases in states which had very high seroprevalance in first wave of pandemic - Slow vaccination program
India is undergoing new wave of Covid infections. New wave started sometime last month. Before the big spike in Covid cases, there were warning signs about the upcoming problems. AIIMS director Dr Guleria said that new variants have emerged in India that can cause reinfections. India had very little Genomic analysis of virus samples but it was discovered earlier last month that as much as 81% of infections in state of Punjab are the UK variants of virus which in known to be more fatal and infectious relative to other virus mutations.
Maharashtra State which was the worst affected in first wave of pandemic is again the most affected in the new wave with record rise in cases in last two weeks. Interesting thing is rapid rise of infections in cities like Mumbai which were hit hardest in the first wave. Seroprevalence data showed that as much as 60%-75% of Mumbai slum population was infected in first wave. Note that 50% of entire Mumbai population lives in slums which practically do not have any social distancing, hygiene & sanitation and other virus control measures. Overall, i believe that majority of Mumbai population, was infected by end of 2020 and attained a degree of herd immunity as new Covid cases in urban slums fell to 0 (read 1 & 2). Now, interestingly, Mumbai Covid cases are rising at unprecedented scale even bypassing the records of first wave (read 1 & 2).
Urban slums were swept away with virus in first wave. Sero surveys showed that overwhelming majority of slum population had presence of antibodies, meaning they got infected sometime in first wave. Its known that antibodies may only last for few months, but as per my knowledge, people still retain cellular immunity of virus. Basically, body can regenerate antibodies in case virus attacks the body again. What could be the reason for such a rapid rise of infections in Mumbai as well as other parts of India? We know that new variants have emerged in India. Are these new variants (read 1 & 2) causing reinfection? These are the things we don't know yet. But its concerning to see that population which had a degree natural immunity (after getting infected) in first wave is again hit hard in the second wave. This throws into doubt about immunity & its longevity.
Another factor for rise of Covid is complacency of Government in vaccination program. While the lack of vaccines is bad enough, Govt did not take aggressive vaccination initiative as was needed. Indian exported 64 Million vaccine doses (mostly Astrazeneca) to foreign countries. Remember that America has taken the 'America first' approach by using the Defense production act and banning vaccine exports and this has also lead to shortage of biomedical supplies needed to manufacture vaccines in other countries. Europe has also restricted vaccine exports and focusing on vaccination of citizens in European union. But Modi Govt was exporting millions of doses of vaccines while seconds wave was brewing.
We need to take long term view of dealing with this pandemic and cooperation between developed and developing countries is essential in ending this pandemic. Assuming the problems of new emerging virus variants and possible reinfections, i don't think developing country's medical system have the capability to deal with the problem. Also 'for profit' patent system of vaccines will only prolong the pandemic as sharing and transfer of scientific research & vaccine technology will be greatly hindered. The economic impact of pandemic on nations worldwide is huge. While pandemic caused economic depression throughout the world, the most serious economic damage was caused in developing countries. Developed nations had luxury of going into lockdown because their economic and industrial strength, and competent political leadership (ok there were exceptions like Trump). Citizens of developed nations had economic relief measures, Govt support programs and flexible work from home alternatives which mitigated the impact of economic impact on their personal lives. But poor countries bore the worst burden. I explained how pandemic swept through India and Government had no control over it. Most of the labor force in poor nations work on daily wages, hand to mouth to survive every day. How will people survive if national economy go into lockdown? And don't expect anything from corrupt political leadership of the 3rd world countries. Forget about any paychecks from the government, the government even stopped paying salaries to government employees in the pandemic.
In early phase of pandemic, WHO said pandemic will be one big wave that will last for some time. The wave was supposed to last until we have herd immunity either from vaccinations or from natural infections. But now we see many waves and many variants of virus. US has had at least three waves while Europe has just been struck with its third wave. In India we are having massive second wave, even in areas which were supposedly hit hard in first wave. There is no real coordinated global response to the pandemic. In simple terms, there is no strategy to end this pandemic. I don't expect much from my government, but i hope there are smart leaderships in other countries that have the sense and understanding to deal with this pandemic. And critical part of strategy to end this pandemic is global cooperation. Even if not on permanent basis, at least on temporary basis for the duration of this pandemic.
Edit - Vaccine exports by India as of present date is 64 Million according of India's foreign ministry (MEA) data.
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