New Delhi: With the festivals of Holi and the Mahakumbh in Haridwar just round the corner, and five states in the midst of a hectic election season, India's 'second wave' is firmly upon us, data indicate.

"A second wave of COVID-19 in India is very clear from the data now," said Rijo John, a health economist and adjunct professor at Rajagiri College of Social Sciences, Kerala.

This rise comes along with the presence of new variants of the SARS-CoV-2 virus, and scientists are still trying to figure out how these variants behave. Is another lockdown the answer, or is it somehow getting individuals, communities, businesses and administrators to behave with COVID-19 precautions?

Experts point out that lockdowns will once again destroy livelihoods and squeeze the economy. Instead, they say, India must double down on genomic sequencing to spot new variants, the pace of vaccination must pick up, and COVID-19 precautions must continue apace.

The numbers

"When COVID-19 cases began to fall in early 2021, people began to feel like the pandemic was behind us," said Srinath Reddy, president of the Public Health Foundation of India. "With greater mobility and mingling, we gave the SARS-CoV-2 virus an additional chance to surge through."

India's confirmed cases of COVID-19 had reached its peak on September 16, 2020, at 97,860 cases confirmed in a single day. From this high point, India's COVID-19 numbers came down to a low of just 8,579 cases confirmed on February 1, 2021.

Thus, in the early months of 2021, India's curve of the pandemic had begun to flatten, making it appear like the pandemic was being beaten down.

In this same period, testing too reached its high point in September, and similarly fell in February: from 1.49 million tests done on a single day on September 24, 2020, to a low point of just 486,122 tests on February 14, 2021.

But cases have been on a rise since then, and on March 21, 2021, the central government reported about 47,000 cases. In other words, India's confirmed cases had risen 4.5 times since the low point of February 1, 2021.

At the same time, vaccination has not been happening at the pace needed in order for India to achieve its target, we reported in March 2021. Two months into the programme, India has met 7% of its target to administer 500 million doses by July 2021. It must administer 3.65 million shots per day to achieve this target.

"From my regular analysis of COVID-19 data, it shows that daily new cases on a seven-day average has risen by 167% (from its seven-day average low point in February), deaths have increased 71% in the same period, but daily testing has increased only by 31% in this same period," said John. "There is an evident surge ongoing in 10 states and union territories currently."

Why are cases rising?

"We urgently need deeper dives into the data on COVID-19 cases, hospitalisations, deaths, and genome sequencing data, to understand why there's a spike in cases in India," said Gagandeep Kang, professor at the Christian Medical College in Vellore.

Sero-survey data can provide some insight. "For example, are cases rising in places that may have achieved a high level of sero-positivity already? If yes, then one can find out if they are new cases, or are occurring among people who have moved into these areas, or if they are re-infections, or if there is a new variant of the virus, and so on," she said.

The 'epidemiological triad' of factors--the agent, the host and the environment--must all be studied, said Giridhar Babu, an epidemiologist with the Public Health Foundation of India. "The agent is the virus which is definitely changing and scientists are still figuring out things about the variants by genome sequencing," he said, "As hosts, whether all of us have been practicing COVID-19 precautions, and getting vaccinated, will explain why there's a rise in numbers. And as for the environment, it is everything happening around us, such as whether the government is allowing cinemas, public transport and events that can allow the spread of the virus."

Lockdown or no lockdown?

"The solution to the rising numbers will not be an easy or quick one. There are two schools of thought, one that thinks a lockdown may be useful because it can protect lives, and another that thinks that a lockdown would destroy livelihoods and thus lives," said Reddy.

Numerous cities and states have announced various curbs once again, and some elected leaders have warned of new lockdowns. However, after the first central government-imposed lockdown in March 2020 and its harsh fallouts, including its impact on the economy and stress on people's finances, another lockdown may not be the way forward, analysts told IndiaSpend.

"A lockdown was necessary to help India develop its healthcare infrastructure to deal with the COVID-19 crisis. Now that is already in place along with treatment protocols, so there is no need for another lockdown," said Babu.

How to balance economic activities and the public health crisis will be key, said Reddy. "So for example, how can we best manage closed work-spaces? As much as possible, people should work from home but where unavoidable, offices should stagger work-days and work timings," he said. "Public transport should also be staggered, in the sense of limiting the number of people who can crowd on a bus or train, while increasing the number of public transport options available. Ventilation is key, and people should not drop their masks." Religious gatherings, political events and other similar mass gatherings should also be regulated, he said.

We also need to track chains of transmission, Kang said, and Babu added that each factor in the epidemiological triad needs a different solution. In dealing with the virus, extensive genomic sequencing and contact-tracing is essential. In dealing with people, getting them vaccinated quickly and ensuring they take precautions will help bring down cases. And in order to deal with the environment, instead of a lockdown, a more practicable solution is to ensure that people do not congregate, especially in closed spaces, and ensuring that offices and events follow health norms.

Above all, vaccination must be sped up, Babu said, because it is the surest clinical way to protect people from COVID-19, "especially because changing people's daily behaviour is quite hard and COVID-19 appropriate behaviour is not really being practised".

COVID-19 variants: What do we know?

As on March 18, 2021, 400 cases of the UK, South Africa and Brazil variants of SARS-CoV-2 had been detected in India, according to a text-based media alert from the Union health ministry. This seems like a small and non-threatening number, said Reddy, but this is because this has come out of a very small fraction of all positive cases which are being sent for genomic sequencing.

India had planned to do the genome sequencing of 5% of positive COVID-19 samples from every state, the Centre told parliament on March 19. The purpose of this was to identify "potential outbreaks and related strains as part of continuous surveillance."

By March 10, various states and union territories had sent 19,092 RT-PCR positive samples of COVID-19 to the government for genome sequencing to check for strains of COVID-19. Of these, 4,869 samples had been processed. Among the processed samples, 284 samples have been detected to be positive for the 'UK strain' and 11 samples positive for the 'South African strain' and 1 sample positive for the 'Brazil strain'.

"With new variants of COVID-19 in the country, we still don't know to what extent they are playing a role in the surge in cases, unless we do more extensive genomic testing," said Reddy. And until this can take off at a substantial pace, we will have to keep up with social distancing and mask-wearing, he said.

The new COVID-19 variants may be more infectious but not necessarily clinically more severe, said Rakesh Mishra, director of Centre for Cellular and Molecular Biology, in an interview with IndiaSpend in December 2020. While not being clinically more severe, more people catching the infection could mean that more people would crowd hospitals, Reddy told IndiaSpend in December 2020.

But the pace of this sequencing has been slow, according to a paper published by Indian government scientists: "India has so far not been sequencing SARS-CoV-2 isolates to full capacity, having deposited only about 6,400 genomes of the over 10.4 million recorded cases (0.06%)."

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