Why India’s second wave has been deadlier, explained in five charts

A more virulent strain that led to greater hospitalizations and overwhelmed health capacity, complacency among senior functionaries who ignored warnings, delayed mobility and crowd restrictions, and limited vaccine coverage in most parts of the country created a fatal mix that allowed the virus to claim many more lives than before, epidemiologists and medical experts said.

“When the uptick (in cases) was visible in February, one needed to intensify the preventive measures and scale up COVID-care infrastructure and accelerate vaccination, pressing feet to the floor," said Bhramar Mukherjee, a professor of epidemiology at the University of Michigan. “We still continued with life, with little or no use of masks. The virus was getting ready for the second wave to come back harder, we were not."

The Indian SARS-CoV-2 Genetics Consortium, or INSACOG had warned top central officials about the virulent nature of the new strain and its capacity to wreak havoc in early March. That warning was ignored and even till a month later, large gatherings and election rallies went unhindered. Another warning from a parliamentary panel that flagged the lack of medical oxygen and oxygenated beds in the country in November last year was also ignored.

Under-reported Deaths

An unprepared health system crumbled under the weight of rising case-loads, and patients who could have survived with timely medical advice or oxygen, succumbed in large numbers during this wave.

Even India’s official count suggests that the total deaths in April were 30% higher than in September, when the first wave peaked. The true difference could be higher. Deaths were likely to have been under-reported by a factor of 2-3 times in the first wave, said Gautam Menon, a professor of physics and biology at Ashoka University. It is too early to come up with a figure for this wave, he said.

Regional differences in reporting standards makes such estimation difficult. Even in the ongoing wave, the extent of under-reporting seems to vary widely across cities.

In other parts of the world, health statisticians have used all-cause mortality numbers to estimate the impact of covid on mortality figures. Given low death registration in India, that method can’t be easily replicated. Where more reliable data on deaths exist, such as in Mumbai and Kerala, the trends they presented last year were divergent.

Four Drivers

Given that the chances of under-reporting are higher in regions where the health capacity is stretched, and this is likely to reflect in the detection of both cases and deaths, a useful metric to track is the case-adjusted fatality rates. Given that both the numerator and the denominator in this ratio are under-counts, the ratio itself provides a more accurate picture of the state of the health crisis than either cases or deaths.

An analysis of the case-adjusted fatality rates show that four major hotspots - Uttar Pradesh, Delhi, Gujarat, and Chhattisgarh - were mainly responsible for the spike in all-India fatality rates in April. The case-adjusted fatality rates reported here compare the deaths on a given day compared to the cases a fortnight ago (to account for the time-lag between cases turning severe).

The silver lining is that the fatality rates seem to have peaked in all four of these states but other states such as in the eastern parts of the country are emerging as areas of concern now.

Testing Matters

One big difference between high-fatality states such as Uttar Pradesh and Delhi and those with relatively low fatalities such as Kerala and Maharashtra lies in testing. Despite increasing positivity rates, Delhi and Uttar Pradesh were quite slow to ramp up testing. In contrast, Kerala and Maharashtra were looking for the virus even when other states had scaled down testing in February, and were already reporting high caseloads by early March, giving them greater time to plan containment measures. But these states were the exceptions.

Globally, countries such as the UK or South Africa, which scaled up testing and containment measures after detecting new mutants, were able to bring down fatalities quickly. But countries such as India and Brazil, which did not respond fast, saw a rising tide of fatalities.

If only India had followed in the footsteps of UK and South Africa, we wouldn’t have lost as many of our near and dear ones as we did over the past few weeks.