Despite a lockdown of two weeks, J&K continues to see a constant rise in the number of cases. The barrage of patients requiring admission is a looming crisis for the region’s healthcare system. Amidst this scenario, the peak and the decline of the ‘Second Wave’ is the most deliberated question. We spoke at length to various experts regarding the expected trend. A précis of the conversations:
Dr Rouf Hussain Rather, a Community Medicine Specialist, working in Kashmir’s Divisional level COVID19 control room said Kashmir has 2 to 4 weeks more to go till it reaches peak, till which time, he said, the cases would continue to rise. “Our peak is expected at the cusp of May and June,” he said. Adding that during the first part of June, daily cases would be constant with no major fluctuations. The month of July, he said, Kashmir will see a significant respite in the number of cases and a downward curve, he believes.
In addition, “differential exposure and differential effect between districts” also needs to be accounted for. “The districts other than Srinagar follow a lag pattern. Cases rise first in Srinagar and the other districts follow, the trend being two weeks lag. When the Srinagar wave will reach top, other districts will continue to have a rise,” he said. “When Srinagar wave will start coming down, other districts will reach their peak. It is due to this difference that our peak will remain for 3-4 weeks and not come down immediately.” Similarly deaths also follow a lag pattern of 2 to 4 weeks with case diagnosis & daily deaths increase or decrease a few weeks later than new cases.
Dr Rather had predicted and posted in February that the Second Wave will hit Kashmir in the first week of April, the numbers to constantly increase till the end of May. He has a word of caution though – the calculations depend on a number of factors that contribute in increasing or decreasing cases and delaying or hastening the peak. “The number of cases would directly depend on the number of tests carried out. No model can calculate the exact number of cases, it is just an estimate based on certain variables – tests, public health measures and community behavior,” he said. He stressed upon preventive measures like face mask usage, maintaining social distance, avoiding gatherings and following other COVID19 related SOPs. “The only long-term & dependable measure is vaccination and people should participate in it,” Dr Rouf said.
Dr Rather gave a point wise description of the variables affecting the rise and the peak of COVID19 cases.
1. Testing: If we decrease the tests by half, the cases would definitely reduce significantly and similarly, if we double the tests, the cases would also increase. It also depends on who we are testing. If we are testing people who have very little public interaction and dealing, the number of positives is going to fall. If we test people with high public dealing, those who have close contact with positive cases, or are symptomatic, the number of positives is expected to be higher. The timing of the test also plays a role: If we test a contact person on the first or second day of contact, the probability of the positive result drops, but if we test around 4th, 5th or 6thday of contact, there would be more positives.
The cases also depend on what kind of tests are being used. If we are using more Rapid Antigen Tests (RAT), the positives would be lesser. Using RT-PCR, the cases automatically rise as the detection rate is higher in RT-PCR as compared to RAT.
2. Lockdown: If there is a lockdown, and people have reduced mixing, the cases would drop in a few weeks. If there are no such measures and public gatherings take place, the cases will be more. Epidemiologically, the number of cases depend on how the virus behaves in a body and in a community. All these factors play part in the number of cases. It is not a summative calculation.
3. Sero-prevalence: Last year, in the first wave, around 80,000 cases were reported from Kashmir. The fact is only 80,000 were diagnosed. The sero-prevalence studies showed that nearly 40 percent of people in Kashmir were infected and had recovered and that’s when the numbers started declining. The number could have been more given the fact that a significant proportion of people do not develop antibodies post infection with SARS-CoV2.
The peak calculation is basically the estimate of the time when a certain sero-prevalence level is reached. It’s volume and time depends on the rate of spread of infections. Once sero-prevalence has reached a certain level where there is less number of susceptible people, the cases start coming down. That is the end of the peak.
Prof Parvaiz A Koul is an expert on viral influenza pandemics, a pulmonologist and a physician. He retired last month from SKIMS Soura as head of the Internal Medicine department. Prof Koul said the past experience showed that Kashmir’s peak lagged a few weeks from the rest of India. He however said this time around, it was a different scenario given the sudden spike in infections. “The new variants are constantly changing the dynamics of the pandemic,” he said. He said lockdown and lockdown specific behavior are both factors affecting the case load. “I estimate we have around three more weeks to go to reach where India is right now – peak,” he said.
Prof Koul said pandemics followed a cycle and pattern – from the infection to death, different stages of the disease reflect differently in numbers. “When the wave hits, the cases rise but deaths don’t rise immediately. We saw this in our case in April – cases increased without any significant increase in deaths. And in May, we have the deaths hitting us hard,” he said
Prof Koul said when the case load starts decreasing in June, deaths will continue increasing among those that are infected and not yet recovered. “We need to understand these factors and not create false alarms,” he said.
Prof S Saleem Khan, head department of social and preventive medicine at GMC Srinagar said the current lockdown would have a significant impact on the expected peak value and time of the pandemic in J&K. “Lockdowns spread the cases over a period of time,” he said. He said J&K’s cases were on rise and restrictions would prolong the wave. “It was very important to have this lockdown to prevent the healthcare system from overburdening. This is the time we get to salvage our resources and utilize them better,” he said.
Prof Khan said there was a difference between first and the current wave of COVID19. This virus has higher infectivity, so the chances of spread are very high now as compared to last year. “The cases, naturally, are going to be very high,” he said. Secondly, complete lockdown and suspension of travel played an important role last year – the spread was slower. “This year, much of that is missing.”
Prof Khan said his fingers were crossed regarding the estimate of mortality in SARS-CoV2 Second Wave. “Third, the fatality of this wave is uncertain at this point. The actual figure of the infected is not known. We have more cases over a short period of time and the actual rate of death will be evident from some time later,” he said.
Prof Koul however argues that the world was “a little better equipped” to reduce deaths. “We know, to a large extent, what does not work in this infection. So, hopefully, we will put to use interventions that we still hope are working – oxygen, steroids, to some extent some medications,” he said. Furthermore, he said, the subsequent waves will largely depend on what proportion of population has developed immunity against the virus, either naturally or with a vaccine. “Vaccination coverage and vaccine efficacy against the emerging strains of the virus is a significant variable,” he said.