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What explains the rapid spike and then sharp decline of cases of the April-to-June wave?

India emerged in June and July of 2021 from a particularly savage second wave of COVID-19, with total confirmed . But this could be a dramatic under-counting.  have put  in the range of 3.4 million to 4.9 million.

This wave was driven by multiple coronavirus variants, , first identified in India and now the main source of infections in many countries. Because the emerging threat was ,  starting in early April, with the  becoming a major problem.

Both the alpha and delta variants are highly contagious, with delta being nearly  as the original strain of SARS-CoV-2. The rapid rise in cases in India is attributed to the high viral load – the amount of virus infecting a person – of delta, which is  than other strains. This resulted in widespread infections among household members with rates as as high as 80% to 100%.

The decline of cases in India has been surprisingly rapid given that there were  in the first week of May and the  in some districts was . Similar  were observed more recently in the U.K., Netherlands and Israel – perhaps a result of a combination of high vaccination rates and high infection levels. Daily cases in India are .

What’s the progress with vaccination?

With the vaccination campaign substantially picking up in India, about . A record  were administered on Aug. 17, 2021 in a bid to achieve the 250 million target for August, although .

Supply situations continue to be challenging. Production of the Covaxin vaccine, developed by Indian company Bharat Biotech, , at least in part due to quality issues of some batches.  haven’t worked out and Johnson & Johnson  in August. Production of the Russia-developed Sputnik V by an Indian partner  and . Covishield from AstraZeneca continues to be the workhorse, accounting for  to date.

An estimated 9 million doses will need to be administered daily through the next five months . For comparison, average daily vaccinations in the U.S. at its peak in April was . An added challenge for the Indian campaign will be the vaccination of children. Vaccination of an estimated 400 million in the 2-18 years age group is likely to begin  though emergency authorization is .

How many of India’s 1.3 billion people have been infected?

In the aftermath of the second wave from roughly April to June, the Indian Council of Medical Research  in June and July 2021 to test for antibodies in blood samples from residents across 70 districts of 21 states. The overall sero-prevalence was 67.6%, a huge increase from 24.1% recorded in the third round from December, 2020 to January, 2021. The presence of antibodies indicates that a person has either been exposed to the coronavirus or has been vaccinated.

Sero-positivity among children was 57.2% in those aged 6-9 years and 61.6% among those who are 10-17 years old. Experts believe that there is not much scientific evidence that  in a third wave. The government, however, anticipates the possibility of intermittent surges in the number of cases and prepared  for children and adolescents in preparation for a third wave. Seroprevalence among those above 45 years was 77.6% and 66.7% among younger adults, indicating the effect of vaccination .

The coronavirus had spread through the entire country; seroprevalence among the rural population (66.5%) was only slightly lower than in urban counterparts. A  have emerged, from a low of 44.4% in Kerala to 79% in Madhya Pradesh.

The extent of undercount – the difference between estimated cases (based on seroprevalence) and actual cases detected by RT-PCR and rapid antigen tests – is particularly worrying. Nationally, the system  cases for every one detected.

What are the prospects for the weeks and months ahead?

With about  each day as of mid August, a new uptick is likely in the cards. The Indian states experiencing most of these new cases are those with , ranging between 50% and 70%. The 400 million sero-negative pool – that is people who have not been infected or had the vaccine – .

Forecasting by modelers  and peaking at 100,000 to 150,000 infections a day by October. An alternative projection expects the peak in cases going . States currently reporting higher daily cases are also testing at . The case fatality rate in these states is also  and health service capacities are not yet stretched. For its part, the federal government announced the second phase of its emergency response policy with targets that go until .

Has the economy opened back up?

COVID-19 vaccination in India has been marked by both  and ; negotiating both will be crucial in the weeks ahead.

The  have included rural and remote locations and a lack of access to the internet; a gender divide has emerged too with more men being vaccinated than women. As vaccination progresses with underlying inequities, the phenomenon of “” emerges – pockets that are highly vaccinated and adjacent to places or communities with low coverage. The communities with low coverage are vulnerable to hyperlocal outbreaks.

Most economic activities have resumed, and the  and  are opening up too. A  on June 6, 2021, issued by the public health associations in India urged that district-level sero-surveys be undertaken by the state or federal health services to enable a more granular understanding of the epidemiologic context to enable planning. While this was , such systematic surveys .

The World Health Organization advises that public health and social measures in the context of COVID-19 . Planning at the district level in India shall be crucial in the journey ahead.