India looked like it had beaten Covid, but cases are now skyrocketing. What changed?

n elderly woman gasped for air at the main 1,000-bed Covid hospital in Mumbai, India, even as a ventilator pumped oxygen into her lungs. She collapsed after hours of struggling for each breath, but came round again after doctors performed CPR to stimulate her heart back to life.

Dr Sharad Achwar knew she would not survive. The infection had ravaged her lungs. Her daughter was called from the hospital and told: “Your mother has a few hours.”

The daughter was furious at first, replying: “Do not say this doctor, all I have is her.” But like hundreds of thousands of other Indians in this pandemic, she had no choice but to accept the toll taken by Covid-19 on her family.

India was hit hard by coronavirus last year, recording one the highest caseloads in the world alongside the US and Brazil. But numbers started declining rapidly after last summer and by January this year, as vaccines started to roll out, the health minister proclaimed the country had reached the end of the pandemic.

But after months with few restrictions, and just as life was starting to look normal again, cases have suddenly exploded, with a tsunami of infections sweeping the country and putting ICUs into what doctors have called a “war-like” situation.

With many other nations making rapid progress on vaccinations, the country is now the global epicentre for the disease, while concerns are mounting about the new variants involved.

Doctors in the Indian states facing the worst pressure paint a grim picture, describing a chaotic and overwhelming intake of desperately sick patients.

Loved ones wailing outside hospitals, ambulances queued up with patients, crematoria and graveyards drowning in dead bodies, failed resuscitations and families scrambling for beds, plasma, and even basic medical supplies such as oxygen, stretchers and ventilators: these are common scenes witnessed across India.

“What we are dealing with here is a catastrophe. I have to look after 75 beds of an ICU daily and the input of patients is way more than the output. We are at full capacity,” Dr Achwar says.

“Patients are dying suddenly of hypoxia. There are more patients here than the doctors could attend and all the monitoring equipment has been exhausted. We are suffering,” a resident doctor from Mumbai’s state-run Sion hospital tells The Independent, on condition of anonymity.

Maharashtra, the state where Mumbai is located, has for several weeks been painted as an outlier in terms of the new outbreak, but the situation is now no better in the capital Delhi, where Dr Atul Gogoi of Sir Ganga Ram Hospital says ICU beds and even general wards are out of capacity. He says the situation is becoming increasingly difficult with each passing day.

Having to remain “aloof” during this “war-like” fight against the disease is taking its toll, he says. “We are worn out physically as the workload is constantly increasing, [but also] mentally as we regularly deal with emotional breakdowns of elderly people.”

India’s outbreak is worse now than it was at any point last year, with the country registering a series of grim milestones in the past few weeks. As well as overtaking Brazil in total caseload, the country has recorded daily spikes of more than 200,000 new infections over a 48-hour period in the last week.

While there remains insufficient data to attribute the new wave to any one cause, scientists say an indigenous variant of the virus called B.1.617 is likely to be fuelling the flames, coupled with a fatigue with safety precautions that has seen a return to crowding and a reluctance to wear masks across the country.

It may be that multiple more infectious variants are at play here. Testing has shown the presence of the UK’s B.1.1.7, South Africa’s B.1.351 and Brazil’s P1 spreading among the population. These variants have been found in Maharashtra, Punjab, Kerala, Delhi, and Karnataka states, which between them contribute a high proportion of new cases.

However, the greatest concerns swirl around India’s B.1.617, which has been dubbed the “double mutant” variant in media reports, although it actually has 15 mutations from the original virus. This is because it carries two specific and concerning mutations in its spike protein that have cropped up elsewhere during the pandemic – known as E484Q and L452R. It is the first time that these genetic changes have evolved together in a single variant.

In the UK, 77 cases of this new variant have now been discovered.

“Based on experience from other countries about E484Q and L425R strain we expect it to spread faster and to evade antibody responses in people who had infections or vaccination,” says virologist Shahid Jameel, who is part of India’s Covid genomics consortium (Insacog), an association of 10 national laboratories formed in January by the government to conduct genomic sequencing of variants.

India is restricted by the fact it is currently sequencing less than 1 per cent of Covid-19 samples. Experts believe both B.1.617 and the UK variant are likely to be far more widespread than the figures suggest, but it’s impossible to know just how prevalent they have become.

“I wouldn’t be surprised if one component of the increase is this variant,” says Professor Deenan Pillay, a virologist at University College London echoing opinions of several other experts.

This biologically distinct double mutation “could make things even worse overall,” says Aris Katzourakis, a professor of evolution and genomics at Oxford University, and raises the possibility that B.1.617 is very well-adapted to reinfecting those individuals who have acquired immunity through infection or injection.

However, Prof Pillay explains that the variant’s defining characteristics will be the result of a whole “constellation of mutations” that it has acquired in the so-called spike protein – the part of the virus responsible for gaining entry to human cells.

If this “three dimensional structure” changes significantly through evolution, he says, the virus can better penetrate our cells or evade the neutralising effects of antibodies, which are designed to latch on to the spike proteins and prevent the binding process.

In worst-hit Maharashtra, which has 50 per cent of the current national caseload, laboratory testing has shown that B.1.617 accounted for 61 per cent of sampled infections between January and March. To the north, in Punjab, some 80 per cent of cases have been caused by the highly transmissible UK variant instead.

But Prof Jameel’s hunch is that the virus has spread across “several states,” including West Bengal, where election rallies continued unabated, and the northern state of Uttrakhand, where millions gathered to take a dip in the Ganges during the Kumbh Mela festival – the largest human pilgrimage anywhere in the world, and which was allowed to go ahead in spite of the pandemic.

The attendees of the festival, who numbered in their millions on some days, might have now carried the virus to the length and breadth of India.

The prevalence of the Indian variant in Maharashtra is “certainly evidence that the B.1.617 variant is more infectious than the older strain” as it has replaced it so rapidly, says Prof Gautam Menon from Ashoka University in Delhi.

“Anecdotally, compared to the first wave there seems to be a larger proportion of asymptomatic infections as well as patients with non-standard symptoms. The overall age of those with the disease seems to be younger than earlier,” Prof Menon says.

India has been slow to study the B.1.617 variant, says Dr Gagandeep Kang, microbiology professor at the Christian Medical College in Vellore, a lapse that is leaving officials in the dark about what level of interventions will have to be put in place. She said “we know nothing” about the variant as government officials “are not putting together data to draw conclusions”.

“What we did is we sequenced a bit initially and then we took a holiday and then after variants came back we started sequencing again. Even now we have not ramped up to a level we should,” she says. “Doing patchy on-again-off-again surveillance, reporting randomly, is not how a surveillance system is conducted.”

As to how B.1.617 first emerged, Professor Julian Tang, a virologist at Leicester University, speculates that it could be the product of what is known as a “recombination event”. This involves the “sporadic co-infection of two different variants in the same person,” he says.

Under these circumstances, the different viruses can swap chunks of their genetic coding relevant to the spike protein to produce a “progeny” that carries a “combination of the different mutation patterns”. Regardless of how it came into being, B.1.617 is “potentially a worrying variant to keep an eye on,” adds Prof Tang.

Even so, scientists are hopeful that the current generation of vaccines will remain effective against the variant, and others like it, even if they have developed the power to evade parts of the body’s immune response.

Vaccines becoming a bit less effective over time is a phenomenon seen with many diseases and “some protection is always better than no protection,” says Prof Pillay. And that protection is what could make the difference between a person who doesn’t develop symptoms at all, and one who ends up becoming hospitalised and dying.

However, with the clock ticking in the face of this latest surge, the real challenge is rolling out India’s vaccine supplies as quickly as possible. “The pace of vaccination is relatively better than in most countries but not at the desired level,” says Giridhara Babu, a professor of epidemiology at the Public Health Foundation of India.

“India needs to cover at least 10 million doses per day to protect the vulnerable in the next few months. The expansion and faster coverage of vaccines can be more helpful in reducing mortality.”