COVID-19 Endgame? Maybe for the U.S., but Not the Planet

We’ve gotten used to a “shrinking world” in the last several decades: shrinking because of advances in transportation, communication, and interconnected economies, among other things. Keep that in mind, because even as the United States is vaccinating more citizens and its COVID-19 transmission rate declines, the situation in many other nations remains precarious. The Infectious Diseases Society of America (IDSA) held a press briefing to discuss the state of affairs in India and Africa, as well as the reasons behind the surge and what the global community can do to help.

The loudest alarm bells are ringing in India, with news outlets describing residents desperate for oxygen and hospital beds and cremating bodies on funeral pyres that burn at all hours.

“The India situation is really an unprecedented public health emergency,” asserted Krutika Kuppalli, MD, FIDSA, an IDSA Fellow and vice chair of its Global Health Committee as well as assistant professor in the Division of Infectious Diseases at the Medical University of South Carolina in Charleston. “As of today, it’s estimated that there are 23.3 million cases related to COVID, and over 250,000 deaths, and it’s likely that these are underestimated given problems with testing, given problems with keeping accurate counts of fatalities in the country.” Kuppalli said current projections predict more than 1.5 million deaths in India by September 1 unless drastic measures are taken.

One reason for the fast spread of the virus in India is the variant B.1.617, which displays increased transmissibility, Kuppalli said, outcompeting the B.1.1.7 variant that has been prevalent in Britain. The B.1.617 variant has appeared in 49 other countries as well.

Laurie Saloman, MS

Another cause of the virus’ wildfire spread is the demographics of India itself. “India struggles with complex population density issues, given that it is a country of over a billion people, complex socioeconomic issues, and—now that they overcame the first wave of infections—there was this false narrative that maybe India had overcome COVID” Kuppalli said. “And with that narrative there was a relaxing of public health measures. So when you have the relaxing of public health measures with the population density and socioeconomic issues, it really was ripe for the development of the spread of these infections.”

The COVID-19 horror stories unfolding in India and other nations should give pause as the U.S. celebrates the relaxing of mask mandates and as vaccinations here keep surging (even starting to include children as young as 12 years old), while infections, hospitalizations, and deaths decline. Over 700 epidemiologists surveyed by the New York Times say that “the true end of the pandemic—when it becomes safer to return to most activities without precautions—will arrive once at least 70% of Americans of all ages are vaccinated…. Adolescents just began receiving vaccines … and those for children younger than 12 are not yet approved.”

David Celentano, the chair of epidemiology at Johns Hopkins University and one of the 723 epidemiologists who participated in the survey, tells the newspaper that “children are key to ending the pandemic.”

The epidemiologists surveyed are confident that the pandemic will end in the U.S. (but perhaps not as quickly as some assume) and in about 5 years COVID-19 “will be more like the flu, circulating at a lower rate and with some deaths every year—but no longer a public health crisis necessitating lockdowns,” according to the Times.

Meanwhile, the situation in India remains frought. The virus is beginning to migrate from India’s urban centers to rural locales, which Kuppalli said will be especially challenging given the lower level of COVID-19 understanding in more outlying villages.

Working with other medical and scientific professionals, Kuppalli has been instrumental in raising awareness of the disease in India. She and her team created an infographic on how people can care for themselves when they have COVID-19 and when to call for medical help. The infographic went viral on social media and was translated into 20 Indian languages, plus Nepal and Sri Lankan tongues. She also helped found the nonprofit INDIA COVID SOS, which aims to share relevant info about COVID-19 and provide help to the suffering population.

Because Indian hospitals are at capacity, the international community can help by providing resources such as oxygen, along with tackling the logistics of transporting oxygen in India. Also needed is help with setting up field hospitals, providing telemedicine support, and expanding the use of rapid testing. “If we can leverage capacities that are already there and develop public or private partnerships to increase genomic sequencing, that would be helpful,” Kuppalli added.

Kuppalli noted that the Serum Institute of India is responsible for delivering close to 200 million doses of vaccine to the COVID-19 Vaccines Global Access (COVAX), which helps distribute vaccines in resource-limited countries. Due to the public health emergency in India, those doses will be delayed at least until July. High-income countries that have a surplus of vaccines can make a real difference by donating those doses to India and other countries having difficulty battling the virus, she said.

The rest of Southeast Asia is also a potential tinderbox, Kuppalli said. Nepal is already beginning to see a surge, and experts are concerned about highly populated, high-density nations such as Pakistan, Afghanistan, and Bangladesh “If COVID starts wreaking havoc in these areas, it could make Southeast Asia destabilized and cause huge repercussions throughout the globe,” Kuppalli said, stressing that it’s in everyone’s interest to support India now and stave off long-term global health and economic repercussions.

Another locale where COVID-19 may be poised to run wild is Africa. Although the current caseload there is somewhat lower than what was reported over the winter, that is a function of limited testing and incomplete data, said Dawd Siraj, MD, FIDSA, an IDSA Fellow and vice chair of its Global Health Committee as well as professor of medicine, Division of Infectious Diseases at the University of Wisconsin-Madison.

Nigeria, for instance, has reported only 165,000 COVID-19 cases--yet it is the most populous country in Africa. “We really have to translate and interpret those numbers very cautiously,” Siraj said. Roughly 45 million tests have been administered in Africa compared with 300 million in India. The U.S. has tested almost 40 times more than Africa. With a test positivity rate of 10.4%, well above the 5% threshold at which the pandemic can be considered under control, Africa likely has many more positive cases than it is catching. The case fatality rate of 2.7% also is higher in Africa than elsewhere, Siraj pointed out: Globally, the virus has a death rate of about 2%, with the U.S. death rate at 1.76%.

With the high transmission rate among a young population that has not yet experienced a devastating surge, new variants making the rounds, the absence of real-time data, and a relative sliver of the population vaccinated, Siraj is apprehensive about the situation: “The pandemic has yet to unfold on the continent of Africa. My fear is that the worst is yet to come.” The continent must double down on basic public health measures, he insisted, as well as scale up treatments such as oxygen and ventilators.

The original version of this article first appeared in Contagion®.