COVID-19 – New variants lead surges, brewing a humanitarian crisis in India and Brazil
As the advanced economies of the world ramp up vaccinations, with a subsequent fall in mortality rates and a positive outlook, the pandemic has taken a turn for the worse in two of the major emerging markets. April 2021 marked the highest daily COVID death tolls in India and Brazil. Left with the unfathomable choice between the risk of starvation and risk of infection, the grim reality on the ground has forced millions of people to engage in social interactions to sustain their families. Driven primarily by the emergence of newer, insidious, more transmissible variants, likely contributors to these unprecedented surges include a combination of delayed government responses, a breakdown of public health measures and slower vaccination rates.
Until a few weeks ago, it was assumed that India had seen the worst of the pandemic and had emerged with a relatively light toll. In April 2021, things took a sudden and dramatic turn as India reported the highest number of new COVID-19 cases anywhere in the world. With an average of over 386,000 cases detected daily and a shortage of vaccines across multiple states, the situation appears to be increasingly grave 1. As India's official death count surpassed 200,000, there are mounting concerns that the true death toll is substantially higher. Analysis from the Financial Times, based on reports from crematoriums, indicate that the staggering mortality figures could be 8 times as higher than currently recorded 2.
As a second wave of COVID-19 passes through the country, in many cities a greater proportion of its victims appear to be in the 20-40 age group. Comparatively, the first wave last year mainly claimed the lives of the elderly and the clinically vulnerable 3. Despite the high case load, the lower death rate in the first wave (compared to countries in Europe and North America) can perhaps be partly attributed to the large proportion of young people in the population, who are more resilient to severe COVID-19 reactions 4. Seroprevalence studies from December 2020 estimated that more than 50% of the population in the largest cities may have been previously infected, which would have conferred some immunity 5, 6. At present, the duration of immunity acquired from infection is unknown. It is plausible that those who had a more severe reaction to COVID-19 the first time may have mounted a stronger immune response in contrast to those who were asymptomatic or had milder presentations.
These latest developments could be spurred on by variants including the newer, more transmissible Indian ‘double mutant’, B.1.617- which indicates that despite previous mild exposure to the virus, individuals may remain vulnerable to reinfection 7. Troublingly, there are indications that the Indian variant can exhibit higher infectivity and lethality in the younger populations.
With hospital beds at capacity and critical shortages in oxygen supply, the government is now reliant on importing medical oxygen to meet the rising demand. With medical facilities overwhelmed and supplies low, the mortality rate may further spike, as public health systems collapse under the pressure, unable to deliver the care required to save those who may have otherwise recovered.
Brazil, too, continues to be ravaged by the pandemic, powered on by the highly transmissible P.1 variant. First detected in Japan in January 2021 amongst individuals with a recent travel history to Brazil, the variant is thought to be 1.7 to 2.4-times more contagious than the original SARS-CoV-2 strain. Of greater concern is the finding that this variant is more likely to evade immune protection achieved through previous infection 8. There is, at present, limited information on the efficacy of vaccines against this variant.
Brazil is perhaps contending with the worst phase of the pandemic yet (Fig. 1). With increased reporting of COVID-19 cases, intensive care units filled with younger patients, the country is on the cusp of turning into the global epicentre of the pandemic.
Delayed enforcement of social distancing and other public health measures resulted in Brazil reporting the worst COVID-19 mortality figures in South America 9. Brazil currently has the second highest COVID-19 death toll worldwide. Representatives from the Brazilian health ministry have gone as far as to urge women to delay pregnancy as this variant appears to elicit a more aggressive response in those expecting 10.
Médecins Sans Frontieres noted that the lack of a centralised response to the COVID crisis has driven Brazil to the brink of a humanitarian catastrophe. Stemming from a shortage of oxygen and intensive-care beds, medical professionals are forced to improvise to manage the inevitable overflow 11. The Brazilian variant is now seeding new waves in neighbouring countries. The P.1 variant is prolific across South America, estimated in 40% of cases in Lima, Peru and 30% in Uruguay, along with Colombia, Argentina, Venezuela and Chile 12.
Fig 1: Daily new confirmed cases of COVID-19, per million. Our World In Data
Younger lives on the line
After a year of shielding the old and vulnerable, the record surge of cases has forced us to broaden our focus. For the first time in the life cycle of the pandemic, there is concern that the virus impacts younger people. Data from two metropolitan cities in India indicates that 48% of COVID-19 patients in Mumbai were under the age of 40, and, worryingly, 65% of hospitalised patients in Delhi were below the age of 45 13.
Further reports claim that the B.1.617 Indian variant is spreading rapidly amongst children between 8 months and 14 years of age 14. In the first wave, where children seemed to be mostly asymptomatic, this time around the variant appears to have a wider spectrum of non-respiratory symptoms such as gastrointestinal complaints 15.
The Brazilian P.1 variant also appears to be affecting younger ages to a greater degree than the initial strains. A study comparing the fatality rate in 20-39 year olds in the hospitalised population in the state of Amazonas (where the variant is thought to have emerged) observed that deaths were 2.7 times higher in the second wave in January 2021 compared to the first wave in April-May 2020 16. Furthermore, in the state of Parana the same age group saw a tripling in case fatality rates within a month, rising from 0.04% in January to 0.13% in February 2021 17. A doubling of case fatality was noted during the same time period for 30-39, 40-49 and 50-59 year olds.
Due to the diverse set of symptoms associated with the P.1 variant in the younger population, healthcare professionals may have dismissed initial concerns of COVID. It is possible that these early mild symptoms may have resulted in younger patients presenting to hospitals at the later stages of an acute, severe illness and succumbing to it soon after 18.
A cause for global concern
Without appropriate and timely measures to control the rapid spread in these populous nations, COVID-19 will remain a serious threat to life and could seed new strains globally before vaccination programs have the chance to be effective.
Over the course of the last year and as a direct consequence of the pandemic, reports have highlighted the global financial impact demonstrated by the contracting of economies and the percentage decrease in GDP (Fig. 2). As perhaps expected, the world's poorest nations are being hit the hardest. The COVID-19 vaccine race has brought to the fore the inequalities in global distribution. Delays in vaccinating densely populated regions and thus allowing the virus to ‘run amok’ increases the likelihood of community transmission and of newer mutations emerging which may elude previously established immune responses.
Fig 2: GDP % change in 2020 across BRICS nations compared to the World, The Economist
It is evident that high rates of vaccination alone are insufficient. With an increasing number of infectious variants, premature easing of social distancing measures may do more harm than good. We need to strike a balance between strict restrictions (such as the closing of businesses), which have widespread negative economic impact but significant public health benefits, with smaller targeted measures, such as mask wearing.
While more developed, wealthier nations have armed themselves with vaccines in this viral war, it is clear that without approaching this in a humanitarian manner and aiding the vaccinations efforts of struggling countries, the pandemic threatens to go on for an extended period. A true 'return to normal' will see all countries curbing the spread, as without this, open borders could see the gains made by vaccinations impeded by circulating variants. Insurance companies should be closely monitoring the situation as it continues to evolve. The rise in variants which evade vaccine responses could lead to additional waves, as parts of the world reopen for business and travel. Insurers will need to have a forward-looking view on the potential threats that arise.
- The Guardian. India Covid crisis: first US relief supplies arrive as cases hit new record 2021 [Available from: https://www.theguardian.com/world/2021/apr/30/india-covid-crisis-first-us-relief-supplies-arrive-as-country-hits-new-record-cases.
- Financial Times. India’s devastating second wave: ‘It is much worse this time’ 2021 [Available from: https://www.ft.com/content/683914a3-134f-40b6-989b-21e0ba1dc403.
- The Guardian. ‘A tsunami of cases’: desperation as Covid second wave batters India 2021 [Available from: https://www.theguardian.com/world/2021/apr/14/a-tsunami-of-cases-desperation-as-covid-second-wave-batters-india.
- TIME. Officially, India Has the World’s Second-Worst COVID-19 Outbreak. Unofficially, It’s Almost Certainly the Worst 2021 [Available from: https://time.com/5954416/india-covid-second-wave/.
- Nature. India’s massive COVID surge puzzles scientists 2021 [Available from: https://www.nature.com/articles/d41586-021-01059-y.
- Velumani A; et al. SARS-CoV-2 Seroprevalence in 12 Cities of India from July-December 2020. medRxiv. 2021.
- The New York Times. India’s New Covid Mystery 2021 [Available from: https://www.nytimes.com/2021/04/26/briefing/Nomadland-Europe-travel-Covid-19.html.
- Faria N, al. e. Genomics and epidemiology of the P.1 SARS-CoV-2 lineage in Manaus, Brazil. Science. 2021;eabh2644.
- The New York Times. Coronavirus in Brazil: What You Need to Know 2021 [Available from: https://www.nytimes.com/article/brazil-coronavirus-cases.html.
- The Guardian. Brazil warns women to delay pregnancy amid Covid-19 surge 2021 [Available from: https://www.theguardian.com/world/2021/apr/16/brazil-warns-women-to-delay-pregnancy-amid-covid-19-surge.
- Médecins Sans Frontières. Failed COVID-19 response drives Brazil to humanitarian catastrophe 2021 [Available from: https://www.msf.org/failed-coronavirus-response-drives-brazil-humanitarian-catastrophe.
- The Washington Post. Brazil has become South America’s superspreader event 2021 [Available from: https://www.washingtonpost.com/world/2021/04/05/brazil-variant-coronavirus-south-america/.
- The Telegraph. Mystery shrouds growth in Covid cases in young people 2021 [Available from: https://www.telegraph.co.uk/global-health/science-and-disease/mystery-shrouds-growth-covid-cases-young-people/.
- Times of India. Coronavirus Symptoms In Kids: New COVID-19 Variant Infects Kids Easily, Here Are Signs And Symptoms To Look Out For 2021 [Available from: https://timesofindia.indiatimes.com/life-style/health-fitness/health-news/coronavirus-symptoms-in-kids-new-covid-19-variant-infects-kids-easily-here-are-signs-and-symptoms-to-look-out-for/photostory/82131178.cms.
- India Today. How second wave of Covid-19 is different from first in symptoms, spread 2021 [Available from: https://www.indiatoday.in/coronavirus-outbreak/story/coronavirus-india-second-wave-1791677-2021-04-16.
- Ribas Freitas; et al. The emergence of novel SARS-CoV-2 variant P.1 in Amazonas (Brazil) was temporally associated with a change in the age and gender profile of COVID-19 mortality. SciElo preprints. 2021.
- Santos de Oliveira; et al. Sudden rise in COVID-19 case fatality among young and middle-aged adults in the south of Brazil after identification of the novel B.126.96.36.199 (P.1) SARS-CoV-2 strain: analysis of data from the state of Parana. medRxiv.
- The Guardian. Spreading faster, hitting harder – why young Brazilians are dying of Covid 2021 [Available from: https://www.theguardian.com/world/2021/apr/16/spreading-faster-hitting-harder-why-young-brazilians-are-dying-of-covid.