India must have a covid plan to meet the eventuality of a new variant
PremiumWe should track variant-wise data closely and adapt our vaccination programme to the mutation paths taken by the virus
With India’s second covid wave having ebbed, all eyes are on a possible third wave. Who will be affected, when might it come, and how can India prepare for it?
While the rest of the world is focused on the Delta variant, India should be focused on an unknown future variant, which we shall call ‘Epsilon’. The next wave is unlikely to be caused by Delta. Gene sequencing suggests Delta drove the second wave and likely infected as many people as it could. While India did impose local lockdowns, they were relaxed before the wave finished. So Delta is held at bay not by such restrictions, but by population immunity, which will likely endure.
The Indian Council of Medical Research’s (ICMR) serological survey from June/July 2021 suggests that 67% of the population has antibodies to covid. Antibody tests cannot tell whether these are for a pre-Delta or Delta variant. However, a serological survey from Tamil Nadu just before the second wave showed seroprevalence close to one-third level after exposure to the original variant. It is possible that some people caught a pre-Delta variant and then were reinfected with Delta in the second wave. This suggests that one-third or less of population only has immunity to pre-Delta variants and the rest have immunity to at least the Delta variant.
Even 67% immunity could be an underestimate by the next wave. The government’s vaccination campaign has been inoculating 4-5 million people per day to the original variant.
If two-thirds or more are protected from prevailing variants, how much should we fear an Epsilon variant? We don’t fully know. India’s two primary vaccines, Covishield and Covaxin, may be formulated for the original variant, but they do provide reasonable protection against Delta. If covid follows the evolutionary pattern of seasonal influenza and evolves in one direction, those infected with Delta will likely have greater protection against Epsilon than those infected or vaccinated with pre-Delta strains. But that protection may be better for avoiding harm from infection than from catching the infection itself. Recent evidence on breakthrough infections suggests that Delta is transmissible among the vaccinated, but much less than among the unvaccinated. Since evolution selects for replication, the next strain could be even more transmissible. But one saving grace may be that evolution does not directly select for greater harm from infection. Greater harm kills the host more quickly, potentially slowing replication.
When will a future Epsilon variant arrive? While the Delta variant was spotted first in India and is now ravaging other countries, the next variant of concern could originate anywhere, in India or abroad. There are no good models to predict when or where it could emerge. There are not enough variants to generate the data required to determine how frequently new ones will emerge. But we do know that other coronaviruses evolve and escape immunity, so we cannot ignore the risk.
We need more data to predict when Epsilon may arrive. India must gather a fixed number of positive samples around the country each week, sequence them, and share the data with its population and other countries. Other countries should do the same. This would track the rate at which new mutations are moving away from existing strains.
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We may be able to mitigate the harm from a future Epsilon strain with additional vaccination. First, we must complete the country’s existing vaccination plan quickly. If we lack supply, we should prioritize those without any antibodies and try fractional dosing. In the short run, vaccination even against the original strain likely helps reduce viral evolution because it reduces infections, which generate mutations. India should also resume its mission to vaccinate the rest of the world, since new strains could start anywhere and come to India.
Second, India must support the development of reformulated vaccines that contain Delta and newer strains. It should not worry about vaccine prices and provide quick regulatory approval. Drug manufacturers should not have to worry that they will be vilified or lose money on investments. The Prime Minister’s Office must implement its own ‘Operation Warp Speed’ to get modified these vaccines approved. India must act like it is fighting a war, not negotiating a procurement contract. Foreign suppliers should not be scared away. ‘Made in India’ must not be an obstacle to ‘Alive in India’.
Third, India must build the infrastructure that makes its covid vaccination drive permanent. India has a durable childhood vaccination network. But with covid, it has conducted adult immunization for the first time in decades. No one knows if the third wave will be the last, or covid will become endemic. India should treat covid vaccination campaigns like elections, a national mission that is planned and repeated every few years.
If India is able to finish its current vaccine sprint and turn it into an annual campaign, it may be able to reduce the dangers of another covid wave and adapt to possibly endemic covid. Vaccines will not be perfect, but will hopefully make covid more like the flu—possibly common, but not that harmful. This, together with better surveillance, will allow us to know how often people will need to be vaccinated and what strains should be targeted by future vaccines. India can do it. And India must.
Anup Malani & Stuti Sachdeva are, respectively, the Lee and Brena Freeman professor at the University of Chicago Law School and a professor at the University’s Pritzker School of Medicine; and a member of the COVIN Working Group
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