By Prathiba Raju and Abhishek Bhatia
New Delhi: As India is witnessing a rise in COVID-19 cases, the Union Ministry of Health and Family Welfare (MoHFW) has revised guidelines for the public to effectively tackle and manage the disease. The country had crossed over 1,000 positive SARS-CoV-2 cases on Sunday after almost four and a half months.
The last time that peak occurred was when the Omicron BF.7 variant was detected in December 2022. According to the Indian SARS-CoV-2 Genomic Consortia (INSACOG), the XBB.1.16 variant and highly transmissible sub-lineages formed from a combination of the Omicron sub-variants BA2.75 and BA2 are the most prevalent strains in central India. Union Minister of State for Health and Family Welfare (MoHFW) Dr Bharati Prawin Pawar, recently informed Rajya Sabha, that Omicron and its sublineages still dominate the SARS-CoV-2 spread across the country.
ETHealthworld spoke exclusively with the top scientific minds in the country to understand the factors contributing to the ongoing rise in COVID-19 cases across the country, especially in states such as Maharashtra, Kerala, Gujarat, Tamil Nadu, Telangana, and Karnataka. Experts opined on a series of issues focusing on the current scenario, including the much-talked-about XBB. 1.16 has the potential to invite another COVID wave, and whether influenza can act as a catalyst will give birth to uncertainty among the states already warned by the Center over the proliferation of positive cases.
For the last few days, Max Hospital has started seeing some COVID positive cases. As per Dr Sandeep Budhiraja, Group Medical Director, Max Healthcare, and Senior Director, Institute of Internal Medicine, most of these patients are in outpatient clinics and have symptoms no different from the seasonal flu. Dr Budhiraja explained that the patients are essentially complaining of fever, headache, body aches, cough and cold, and some abdominal discomfort, and most of these symptoms are attributed to the seasonal flu.
ETHealthworld spoke to Dr Raman Gangakhedkar, former Head Scientist of Epidemiology and Communicable Diseases, Indian Council of Medical Research (ICMR). Explaining the situation in clear terms, Dr Gangakhedkar said due to persistent fever and the resemblance of influenza symptoms with COVID-19, people are coming forward to get themselves tested, which earlier wasn’t the case due to hesitancy and self-testing. With this, the numbers are likely to increase because the governments earlier weren’t able to capture the endemic infection.
Could XBB 1.16 invite another wave?
Scientists believe that a fast-spreading XBB.1 descendant, XBB.1.16, could be behind the recent surge in COVID cases in India. Dr Rajib Dasgupta, Head, Centre for Social Medicine and Community Health, JNU, affirmed that, as is now reasonably well known, the COVID XBB 1.16 variant seems to be fueling the surge.
XBB 1.16 has so far not caused any mortality in India. XBB.1.5 had earlier been declared a variant of interest (VOI) by the World Health Organisation (WHO). Gujarat is the state that has seen the sharpest rise in COVID-19 infection cases. The Gujarat Biotechnology Research Centre (GBRC) sequenced the genomes of the most recent 50 confirmed COVID cases, and they found that 37, or 74 per cent, of these samples, belonged to the XBB.1 branch.
“Like COVID-19, influenza (H3N2 currently) also causes complications and potential mortality among the elderly and those with severe comorbidities and immunodeficient states. It is somewhat early to speculate on how fast XBB 1.16 will spread or whether it will cause excess complications and mortality. Most of the XBB-related mortality in the UK has been among the elderly so far, many in care home settings,” Dr Dasgupta continued.
Dr Gangakhedkar said there is no reason to believe that there is data that says XBB 1.16 is a variant of concern. People’s health-seeking behavior plays a major role in the increment in reported numbers of a particular variant, and therefore, the concern should be focused more on surveillance. “We have to look at COVID-19, but we have also got to remember that this infection is now endemic. Unless we find a variant that is cause for concern, which is far away when it comes to comparison with the Omicron variants, we may not worry. Variants are anyway going to come because the virus keeps on mutating.”
“The situation demands that we be very careful and cautious,” said Dr Budhiraja adding that the government, at its level, needs to ramp up the testing of people, including genomic surveillance that is important to identify the variant.
COVID cases: Are we heading back to square one?
Dr Ambarish Joshi, Sr Consultant, Pulmonary and Sleep Medicine, Primus Super Speciality Hospital, agreed that the rising COVID-19 cases regularly are a cause for concern. Usually, it starts like this and can have devastating consequences. The pulmonary expert added that we are on the edge, where ignorance can lead to another pandemic.
“After receiving the vaccination doses, people are not following basic safety norms to maintain hygiene and wear masks in crowds. Also, many of them have not taken the booster dose, which has made it more difficult to suppress the remaining effects of the virus. It is not over yet, and we should get back to maintaining social distance as well as safety measures,” said Dr Joshi.
H3N2 is in the news, and people who have symptoms are getting their tests done, and nowadays many of these panels have tests for these respiratory viruses and COVID, so they are getting detected as COVID-positive as well. Many people are relying on home antigen tests; Dr Budhiraja indicated that, in addition, most of these cases are mild and can be managed at home with just a simple symptomatic treatment.
Highlighting that we do have some cases coming to the hospital with lower respiratory infections, and these come with mixed infections, more so with H3N2, and very few COVID admissions, Dr Budhiraja said, “These are generally people with multiple medical co-morbidities, elderly patients, diabetic patients, patients with heart disease, asthma, lung problems, or they come to the hospital for some other reason and get detected positive because they are running a fever, so these patients do need some specific treatment.”
Experts suggest that the changing season, rise in other respiratory illnesses, and low immunity could be possible reasons behind the current spike in infection cases. Adding to it, Dr Aditya S Chowti, Senior Consultant – Internal Medicine, Fortis Hospital, Cunningham Road, Bangalore, said, “The resemblance of symptoms between COVID-19 and seasonal influenza makes it arduous to distinguish one from the other without diagnostic testing. The swift transmission of both diseases can trigger a surge in hospitalisations, ultimately straining healthcare systems.”
Refusing to call the recent rise in cases a worrisome situation, Dr Gangakhedkar spoke about relying more on the value of statistical significance than an absolute number. He added that it is difficult to distinguish which kind of virus has affected the patient at this early stage. Doctors are testing patients for both H3N2 and COVID-19 viruses, and that could be a major factor behind the increase in coronavirus cases.
“Now that things have changed, it all depends on health-seeking or treatment-seeking behavior. So, the numbers are increasing, but there is no cause for panic. But we need to be vigilant. The surveillance has to pick up if any new mutant is spreading rapidly in clusters, and then only one has to start worrying about it,” said Dr Gangakhedkar.
Prevention is key to controlling the spike in flu and respiratory illnesses
According to medical practitioners, respiratory illnesses are going to be present, but at the same time, these are easily preventable if all of us learn how to protect not only ourselves but also others if we become infected. Like COVID-19, the Influenza A subtype of H3N2 also can cause complications and potential mortality among the elderly and those with severe comorbidities or immune deficient states.
Cautioning that one needs to be watchful for COVID-19 given a seasonal influenza outbreak, Dr Joshi said, “Seasonal influenza is a year-round disease burden. It causes respiratory issues, and the symptoms are very similar to COVID-19.” He added by mentioning that COVID-19 at times can be tricky, and many times it can be asymptomatic as well. Therefore, getting in touch with a healthcare professional as soon as changes are felt in the body is essential.
Flu occurs due to the seasonal cold wave and is an annually recurring period. However, doctors recommend that taking the right measures can save a lot of trouble. Experts we spoke to categorically highlighted the need for community awareness of the need to wear masks, follow hand hygiene, and take annual flu shots.
However, experts point out that the number of influenza cases in India is currently increasing exponentially. The most recent information on IDSP-IHIP (Integrated Health Information Platform) indicates that a total of 397,814 cases of influenza-like illness (ILI) were reported for January 2023. In February 2023, the figure increased to 436,523 instances, and in the first nine days of March 2023, it was 133,412 cases.
Does the solution lie in the booster shots?
Many nations use the third and, reportedly, fourth booster doses as preventative doses against COVID-19. The penetration of booster dosage is very poor in India. As of March 1, 2023, around 22,85,81,945 booster doses of precaution had been given to the Indian population, making up roughly 10.35 per cent of all vaccines.
Speaking about the vulnerable population that must go for booster doses, Dr Gangakhedkar said, “Booster doses are a must for people aged 60 and over, especially for those who have chronic morbidities. We at least know vaccines work very well. It protects you so much against hospitalization and death. So those who have not taken COVID-19 boosters should try to get the booster shot as soon as possible.”
Booster dosage is recommended by the WHO as well as the Indian government. Notably, the doctors we spoke to said that the Indian population is skeptical and apprehensive about taking booster doses.
“There is no need to start taking additional doses of the COVID vaccine right now. Also, those who have not yet completed their three doses of the COVID vaccine should take it. It is important to remember that precautions will go a long way toward preventing this disease. And if at all you come down with symptoms, simply self-isolate, rest, hydrate yourself well, take paracetamol, get in touch with your doctor if your symptoms are not resolving, and most importantly, do not panic,” said Dr Budhiraja.
To find mutations early, experts urged a stronger focus on genetic surveillance. Government must increase its testing of citizens and educate the public about the advantages of getting an annual flu shot. Apart from immunization, people must resume adhering to the standard safety precautions, such as masking up, maintaining hand cleanliness, isolating oneself if symptoms appear, maintaining social distance, and avoiding crowded areas for those at risk. By taking these safeguards and safety measures, we can prevent the spread of COVID-19 and seasonal influenza and safeguard our communities and ourselves.
To prevent individuals from resorting to antibiotics, the Indian Council of Medical Research (ICMR) announced updated COVID-19 guidelines. The recommendation does not indicate the use of HCQ, Ivermectin, Molnupiravir, Favipiravir, Azithromycin, and Doxycycline.