In DepthCOVID-19

India speeds up vaccinations as cases soar again

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Science  02 Apr 2021:
Vol. 372, Issue 6537, pp. 12-13
DOI: 10.1126/science.372.6537.12

Science's COVID-19 reporting is supported by the Heising-Simons Foundation

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Senior citizens wait in line at a COVID-19 vaccination center in Mumbai, India.


Just over 1 month ago, many Indians believed the pandemic was winding down. Cases of COVID-19 had declined continuously and dramatically for five straight months, travel restrictions had been lifted, and wedding season was in full swing.

But now a second wave is hitting. Nationwide, cases have soared from just over 11,000 daily in mid-February to more than 60,000 per day as Science went to press, more than half of them in Maharashtra state, of which Mumbai is the capital. The remainder are concentrated in seven other states, but scientists worry the disease may soon surge across the country again. India is fighting the rise with new restrictions and efforts to step up vaccination. But although the country produces two authorized COVID-19 vaccines, its immunization campaign has yet to gather steam.

Coming after India's first giant wave of cases, which peaked in September 2020, the spectacular decline defied dire predictions. Antibody surveys, which suggested densely populated areas in cities such as New Delhi and Mumbai were near herd immunity, raised hopes that transmission was burning out. But the optimism may have been unfounded; a more recent survey across 700 districts found only about 22% of Indians had been exposed overall. Meanwhile, control measures such as wearing masks were loosened, travel and social gatherings increased, and testing and contact tracing stumbled. “We let our guard down too quickly,” says virologist Shahid Jameel of Ashoka University.


Mutations may also be reigniting the pandemic. Just over 800 of more than 11,000 samples sequenced in recent months tested positive for B.1.1.7, a variant first discovered in the United Kingdom that is known to be more infectious. In Punjab, it was detected in 81% of 400 sequenced samples. Scientists are also investigating a variant with two mutations, E484Q and L452R, found in certain districts that are seeing an exceptional surge in cases. The two mutations are associated with “immune escape,” or an ability to elude antibodies, and increased infectivity, health ministry officials said last week, although there is no evidence yet that this variant is causing the surge.

Climate could play a role as well. In Europe and the United States, the winter drives people indoors, where the virus spreads easily. In India, the increasing heat of spring may lead people to retreat to the fans and air conditioners of their homes, says epidemiologist Prabhat Jha, director of the Centre for Global Health Research, which has offices in India and Canada.

Meanwhile, less than 5% of India's 1.3 billion people have received at least one dose of vaccine. The government is striving to accelerate the pace, now about 2 million to 3 million shots per day; on 23 March it announced that everyone over age 45 can get a shot starting 1 April. The AstraZeneca vaccine, manufactured by the Serum Institute of India, accounts for most of the shots delivered so far. The other locally produced vaccine, Covaxin, was developed by Bharat Biotech in collaboration with the Indian Council of Medical Research.

India has reportedly put on hold exports of the AstraZeneca vaccine to help meet domestic demand. Since January, India had exported 60 million doses to some 80 countries, through bilateral aid, commercial contracts, and the COVID-19 Vaccines Global Access Facility, a global scheme to increase access to the vaccine.

Vaccine coverage among the country's poor is lowest, because of low awareness and day workers' inability to take time off, social workers say. In Mumbai, authorities have begun to set up vaccination centers in slums. Also needed, says Arun Kumar, head of Apnalaya, a nonprofit that works in the city's slums, are “massive community-based programs to clear vaccine fears.”

Some of those fears stem from Covaxin's hasty approval in early January, before data from phase 3 trials were available. “It created a doubt,” says former federal health secretary K. Sujatha Rao. “Once trust is broken, it's not easily regained.” (On 3 March, Bharat Biotech announced the vaccine had 81% efficacy, based on an as-yet-unpublished initial analysis of 43 cases.)

Reports of violations of informed consent in trials and inadequate transparency around adverse events may have also shaken confidence. On 16 March, a group of 29 doctors and researchers wrote a letter about reported deaths, about 100 so far, of vaccinees. Although the vaccines may not be responsible, the petitioners say, the government should investigate them and disclose its findings. Unlike at least 20 European countries, India has not paused use of the AstraZeneca vaccine after reports of serious clotting disorders (see p. 14); officials say they are reviewing the data.

In an attempt to slow the second wave, several states and cities have reintroduced curbs on social gatherings, imposed temporary lockdowns, and stepped up testing and tracing. In Mumbai, once again a hot spot of the pandemic, the city banned public celebrations of the spring festival of Holi. “We were lucky compared to what might have been,” says epidemiologist Giridhar Babu of the Public Health Foundation of India. “But the story is not over. The virus keeps surprising us.”

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