Through 2020 and the first few months of 2021, India experienced a relatively low COVID-19 caseload. However, on April 30th, India broke the world record for the most COVID-19 cases in one day, reaching over 400,000 . India is the second country to surpass 20 million COVID-19 cases, after the United States .
A “double mutant” variant called B.1.617 is one of the main factors driving India’s second wave. This variant has two unusual mutations, E484Q and L425R; E484Q is present in the variants detected in South Africa and Brazil, and L425R is present in the strain dominant in California . Initial evidence suggests that the two major mutations in B.1.617 increase its infectiousness and ability to evade the immune system . Because of this, it is possible vaccinated individuals with compromised immune systems are still prone to severe infection . Additionally, evidence points to the possibility of reinfection with B.1.617. Even with limited social distancing, India maintained a low caseload throughout 2020 and early 2021, perhaps due to the small number of susceptible persons; now, fading immunity and evasion are driving this surge through reinfections .
Apart from this rapidly spreading variant, factors contributing to this surge include social gatherings, slow vaccine rollout, and unprepared healthcare systems. In early April, millions of people gathered along the Ganga River for a Hindu religious festival; this gathering caused over 2,000 cases, but this number likely is underestimated . Additionally, Indian Prime Minister Narendra Modi gathered hundreds of thousands of people for election rallies throughout March . Additionally, studies conducted in January showed that most people living in large cities in India had COVID-19 antibodies, so perhaps their perceived risk of COVID-19 infection was low, and therefore continued to gather in large groups .
India’s national vaccine program began three months ago, but only 9% of the population has been immunized thus far . Surveys suggest that many residents did not feel the need to get vaccinated immediately or were skeptical about its efficacy . Furthermore, when cases began to spike, healthcare workers shifted their focus from vaccination to caring for the sick .
Due to the low caseload in early 2021, healthcare systems did not expect an abrupt influx of COVID-19 infections. That said, India is currently facing a testing shortage and lacking resources, such as beds and medications, to treat infected patients . This resource shortage is preventing India from quantifying the true number of infected persons. If the cases and deaths are underreported, public health officials and healthcare providers cannot estimate the number of people who will seek healthcare . Thus, hospitals are struggling to provide oxygen and medications as resources are limited .
The Institute for Health Metrics and Evaluation at the University of Washington developed a model to project the number of COVID-19 cases and deaths in India. This model estimates 1 million COVID-19-related deaths by the end of July . However, this model also estimates 674 million people will be vaccinated by August 1st, which can save over 91,000 lives . This model suggests that with increased vaccination efforts and lockdowns, India can significantly reduce the caseload and death rate of COVID-19.