The Mystery Of India's Plummeting COVID-19 Cases

Last September, India was confirming nearly 100,000 new coronavirus cases a day. It was on track to overtake the United States to become the country with the highest reported COVID-19 caseload in the world. Hospitals were full. The Indian economy nosedived into an unprecedented recession.

But four months later, India's coronavirus numbers have plummeted. Late last month, on Jan. 26, the country's Health Ministry confirmed a record low of about 9,100 new daily cases — in a country of nearly 1.4 billion people. It was India's lowest daily tally in eight months. On Monday, India confirmed about 11,000 cases.

"It's not that India is testing less or things are going underreported," says Jishnu Das, a health economist at Georgetown University. "It's been rising, rising — and now suddenly, it's vanished! I mean, hospital ICU utilization has gone down. Every indicator says the numbers are down."

Scientists say it's a mystery. They're probing why India's coronavirus numbers have declined so dramatically — and so suddenly, in September and October, months before any vaccinations began.

They're trying to figure out what Indians may be doing right and how to mimic that in other countries that are still suffering.

"It's the million-dollar question. Obviously, the classic public health measures are working: Testing has increased, people are going to hospitals earlier and deaths have dropped," says Genevie Fernandes, a public health researcher with the Global Health Governance Programme at the University of Edinburgh. "But it's really still a mystery. It's very easy to get complacent, especially because many parts of the world are going through second and third waves. We need to be on our guard."

Scholars are examining India's mask mandates and public compliance, as well as its climate, its demographics and patterns of diseases that typically circulate in the country.

India is one of several countries — mostly in Asia, Africa and South America — that have mandated masks in public spaces. Prime Minister Narendra Modi appeared on TV wearing a mask very early in the coronavirus pandemic. The messaging was clear.

In many Indian municipalities, including the megacity Mumbai, police hand out tickets — fines of 200 rupees ($2.75) — to violators. Mumbai's mask mandate even applies outdoors, to joggers on the beach and passengers in open-air rickshaws.

"Every time they fine a person 200 rupees, they also give them a mask to wear," explains Fernandes, a Mumbai native. "Very stereotypically, we [Indians] are known to break rules! You see traffic rules being broken all the time," she says, laughing.

But in the pandemic, when it comes to masks, "the police, the monitoring, enforcement — all that was ramped up," she says.

Authorities reportedly collected the equivalent of $37,000 in mask fines in Mumbai on New Year's Eve alone.

But the fines and mandates appear to have worked: In a survey published in July, 95% of respondents said they wore a mask the last time they went out. The survey was conducted by phone in June by the National Council of Applied Economic Research, India's biggest independent economic policy group.

Awareness is widespread. Whenever you make a phone call in India — on landlines and mobiles — instead of a ring tone, you hear government-sponsored messages warning you to wash your hands and wear a mask. One message was recorded by Bollywood legend Amitabh Bachchan, 78, who battled and recovered from COVID-19 last summer.

The mask and hand-washing messages have now been replaced with new ones urging people to get vaccinated; India began vaccinations on Jan. 16.

Aside from mask compliance, there's also India's climate: Most of the country is hot and humid. That too has deepened the mystery. There's some evidence that India's climate may help reduce the spread of respiratory viruses. But there's also some evidence to the contrary.

A review of hundreds of scientific articles, published in September in the journal PLOS One, found that warm and wet climates seem to reduce the spread of COVID-19. Heat and humidity combine to render coronaviruses less active — though the certainty of that conclusion, the review says, is low. Previous research has also found that droplets of the virus may stay afloat longer in air that's cold and dry.

"When the air is humid and warm, [the droplets] fall to the ground more quickly, and it makes transmission harder," Elizabeth McGraw, director of the Center for Infectious Disease Dynamics at Pennsylvania State University, told NPR last year. (However, the science of transmission is still evolving.)

In a survey of COVID-19 cases in India's Punjab state, Das, the health economist at Georgetown, found that 76% of patients there did not infect a single other person — though it's unclear why. He and his colleagues examined data collected from contact tracing and found that most patients who did infect others infected only a few other people, while a few patients infected many. Overall, 10% of cases accounted for 80% of infections. One implication, which Das says he's investigating further, is the possibility of making contact tracing more efficient by first testing a patient's immediate family members. If no one at all is infected, the process can end there.

"The temperature, of course, is in our favor. We do not have too cold of a climate," says Dr. Daksha Shah, an epidemiologist and deputy executive health officer for the city of Mumbai. "So many viruses are known to multiply more in colder regions."

But there's also some scientific evidence to the contrary, that India might actually be more conducive to the coronavirus: Research published in December in the journal GeoHealth says that urban India's severe air pollution might exacerbate COVID-19. Not only does pollution weaken the body's immune system, but when air is thick with pollutants, those particles may help buoy the virus, allowing it to stay airborne longer.

A paper published in July in The Lancet says extreme heat may also force people indoors, into air-conditioned spaces — and thus might contribute to the virus's spread. The Natural Resources Defense Council has warned that extreme heat can lead to a spike in other illnesses — dehydration, diarrhea — that might lead to overcrowding in hospitals and clinics already struggling to treat victims of COVID-19.

Another point to consider about India is how many other diseases are already rampant: malaria, dengue fever, typhoid, hepatitis, cholera. Millions of Indians also lack access to clean drinking water, sanitation and hygienic food. Some experts speculate that people with robust immune systems may be more likely to survive in India in the first place.

"All of us have pretty good immunity! Look at the average Indian: He or she has probably had malaria at some point in his life or typhoid or dengue," says Sayli Udas-Mankikar, an urban policy expert at the Observer Research Foundation in Mumbai. "You end up with basic immunity toward grave diseases."

Two new scientific papers support that thesis, though they have yet to be peer-reviewed: One study by Indian scientists from Chennai and Pune, published in October, found that low- and lower-middle-income countries with less access to health care facilities, hygiene and sanitation actually have lower numbers of COVID-19 deaths per capita. Another study by scientists at India's Dr. Rajendra Prasad Government Medical College, published in August, found that COVID-19 deaths per capita are lower in countries where people are exposed to a diverse range of microbes and bacteria.

But experts warn that these two studies are preliminary and should serve only as a springboard for more investigation.

"They're not based on any biological data. So they're good for generating a hypothesis, but now we really need to do the studies that will result in explanations," says Dr. Gagandeep Kang, an infectious diseases researcher at the Christian Medical College in Vellore. "I hope scientists work more on this soon. We need deeper dives into India's immune responses."

According to Health Ministry figures, the coronavirus has killed 154,392 people in India as of Feb. 1. That's a mortality rate of 1.44% — much lower than that of the United States or many European countries. (But Brazil's death rate is higher than India's, and Brazil and India are both lower-middle-income countries.)

A study of nearly 85,000 coronavirus cases in India, published in November in the journal Science, found that the COVID-19 mortality rate actually decreases there after age 65 — possibly because Indians who live past that age are such outliers. There are so few of them.

"Those Indians who do live that long tend to be more healthy than average or more wealthy — or both," says health economist Das.

Serological surveys — random testing for antibodies — show that a majority of people in certain areas of India may have already been exposed to the coronavirus, without developing symptoms. Last week, preliminary findings from a fifth serological study of 28,000 people in India's capital showed that 56% of residents already have antibodies, though a final report has not yet been published. The figures were higher in more crowded areas. Last summer, another survey by Mumbai's health department and a government think tank found that 57% of Mumbai slum-dwellers and 16% of people living in other areas had antibodies suggesting prior exposure to the coronavirus.

But many experts caution that herd immunity — a controversial term, they say — would only begin to be achieved if at least 60% to 80% of the population had antibodies. It's also unclear whether antibodies convey lasting immunity and, if so, for how long. More serological surveys are needed, they say.

India's climate and demographics have not changed during the pandemic. And the drop in India's COVID-19 caseload has been recent. It hit a peak in September and has declined inexplicably since then.

In fact, India's numbers went down exactly when experts predicted they would spike: in October, when millions of people gathered for the Hindu festivals of Diwali and Durga Puja. It's when air pollution is also worst, and experts feared that would exacerbate the pandemic too.

Cases have also declined despite what many thought would be a superspreader event: tens of thousands of Indian farmers camping out on the capital's outskirts for months.

Shah, the epidemiologist, wonders if, just like more infectious variants of the coronavirus have been discovered in the U.K. and elsewhere, perhaps a milder variant may have started mutating in India.

"Some processes must have happened. This is an evolution of the virus itself. In some places there are mutations happening," she says. "We need some more deeper evidence and deeper studies."

"Three options: One is that it's gone because of the way people behaved, so we need to continue that behavior. Or it's gone because it's gone and it's never going to come back — great!" says Das, from Georgetown. "Or it's gone, but we don't know why it's gone — and it may come back."

That last option is what keeps scientists and public health experts up at night.

So for now, Indians are kind of holding their breath — just doing what they're doing — until they get vaccinated.

Thanks for posting this.

There's some evidence that India's climate may help reduce the spread of respiratory viruses.

Another study by scientists at India's Dr. Rajendra Prasad Government Medical College, published in August, found that COVID-19 deaths per capita are lower in countries where people are exposed to a diverse range of microbes and bacteria.

So warm climate, which facilitates the spread of many contagious diseases, itself hinders CV-19 transmission, while the high rate of contagious disease infection helps combat the CV-19 itself. All in all more testimony against "stay-sheltered." And masks.

Related: The quarantine of children may negatively affect their development of immune systems. Research by two professors found that keeping children masked, however necessary, could undermine their bodies’ ability to learn how to fight pathogens. During the Covid-19 pandemic, the world is unwittingly conducting what amounts to the largest immunological experiment in history on our own children... Memory T cells begin to form during the first years of life and accumulate during childhood. However, for memory T cells to become functionally mature, multiple exposures may be necessary, particularly for cells residing in tissues such as the lung and intestines, where we encounter numerous pathogens. These exposures typically and naturally occur during the everyday experiences of childhood — such as interactions with friends, teachers, trips to the playground, sports — all of which have been curtailed or shut down entirely during efforts to mitigate viral spread. As a result, we are altering the frequency, breadth and degree of exposures that are crucial for immune memory development.[https://www.nytimes.com/2020/11/25/opinion/sunday/covid-quarantine-children-immune-systems.html]

"I don’t believe that the authors are sincere"

Indeed. Even worse, the entire US medical establishment isn't sincere. They are largely ignoring the efficacious prophylactic treatments available. Read what Dr. George Fareed has to say about this: Dr. George Fareed and Dr. Brian Tyson share early treatment protocol. Their protocol combines Ivermectin and HCQ in addition to the usual other vitamins, minerals, and supplements. You can actually set up a telehealth discussion with Dr. Fareed.

Corona-type viruses were circulating before Covid came along. Perhaps they were common in India

Living here in Southern India, you are on to something. Firstly, before COVID, there would be something going around every 3-4 weeks. You got used to drinking boiled water, Vick's, and whatever the replacement for aspirin here is, to get over it. The Indians have well practiced immune systems. Also after a very few months the authorities simply reopened the economy. The government could not afford to keep it closed and replace everyone's income. The locals now emphasize Vitamin C, D, and good nutrition.

The Indian shops in my region have been open since December. The streets are very busy with traffic jams just like before. The Indian States have opened up travel to each other, but there are restrictions in some cases. Grocery stores are also busy. Inside the stores, people are careful to wear masks. Outside, most wear masks but a small percentage do not. In India, the streets are jammed and business is vigorous. Even the street beggars are now out in force trying to make up for lost earnings.

I would go further and speculate that a coronavirus almost identical to COVID-19 in its spike protein has gone through much of the population of India and Africa as recently as late fall of 2019. Perhaps it is a virus that got modified into COVID-19 in a Chinese lab or it mutated naturally before it got to the lab, but no one ever really noticed the original as a threat because it was at that point not causing much serious disease.

We know the “D614G” strain took over rapidly from the prior COVID-19 strain (”D614”, IIRC.) Maybe D614 had an ancestor that was close enough to confer good immunity in many, and it was only partially through India and Africa when the new, more dangerous variants took off.

I’d also note that some of us were discussing on another thread that COVID-19 likely spread through India’s cities, esp. the slums, very quickly, and slowed in rural areas, which latter actually make up over 1/2 the population. Plus, testing there could be missing an order of magnitude fewer cases out of the total actual cases than it finds in the US. Perhaps the cities already have herd immunity through a combination of these factors, and far fewer obese people, the much younger demographic, and treatments (zinc) held fatalities down.

I would think most people in India do not live / work in air conditioning, so, the warm climate in many areas (it’s not ALL hot) should help also.

In any event, my “bet” would be on a combination of at least 3, and maybe more factors, at play. And, hopefully immunities will snub the more infectious variants from causing another round of serious illnesses.

Thoughts?

Long article lists many possible explanations, except Ivermectin. Gee NPR, wonder why?

That would suggest that someone got it right. The liberal media’s aversion to Modi is only second, if that, to Trump. Giving credit to the government would be against their chosen narrative. Add to that, the news that Trump might not have been wrong on HCQ etc means that those unpalatable facts are quickly buried.

Herd immunity in a country of 1.3 billion is a joke of an idea, especially if it’s a sudden drop from 100000 a day to about 10000 a day but that’s better than having to praise Modi and maybe Trump for the “Liberal “ media.

Your comments are interesting. If something close to today's COVID was going around India in late 2019, we would generally will have had herd immunity by the time the "Big Guy" came to town. Also in southern India there are two seasons - hot and then extremely hot. The fields are green all year and farmers have just prepared and planted new crops. They must get two or three harvest per year in this part of the world.

My guess is that if it was carefully studied, for a variety of reasons, masks and social distancing will in the long run be found to reduce serious or worse COVID-19 case rates 80% or more, but mild cases by 50% or less. After 2 years or so, for total cases that 2nd % will be quite a bit lower. (The 1st will be much aided by the vaccines.) This will be true of other very contagious respiratory diseases, also.

I am keeping in mind that a great many more tests on symptomatic people with symptoms turn out to be negative / “something-not-COVID” than turn out to be COVID-19-positive, so, there are still a lot of other pathogens out there making people (including kids) ill. Flu, however, being less contagious, has been greatly lowered by the COVID-19 mitigations. Whether this will affect future flus is hard to say, as flu mutates frequently anyway...

A last thought: India’s life expectancy is quite low, despite low obesity in the population. This is due to many factors, including infant mortality, but every source I looked at cited these widespread illnesses we are talking about as a significant factor. They may be a heavy price to pay for better COVID-19 immunity. And maybe survivors are just “tougher” individuals in the 1st place.

Ivermectin cocktail for $2.

The whole country has it.

Precisely. That, and HCQ, early on.

And, other countries....including the US have proven that strict mask mandates don’t prevent infection rates.

Or... In my scenario maybe India was just closer to herd immunity than, say, the Western World, and COVID-19 was more contagious than the earlier virus, so COVID burned out the remaining pool of vulnerable people in India’s cities quickly, then slowed greatly.

It is very hard to say: I see India as a very large, very complex puzzle, and that’s not just with regard to COVID-19.

Being fit and in good health by the grace of God, versus 70% Americans overweight, 42% obese; 100 million w/ high blood pressure; 23 mil w/ type 2 diabetes will in the long run be found to reduce serious or worse COVID-19 case rates 80% or more without masks, while these and other restrictions will end up costing more lives over time.

I certainly would not like the government to try to force people to lose weight. It would be impossible, any way. On the other hand, it might have been helpful during the early months of this pandemic if there would have been some focus on encouraging people to build up their own immunity and try to lessen the impact of their comorbidities, where possible.

Many people were, and are, almost in a panic over catching this virus and so might have been very motivated to do things to decrease their chance of a bad outcome if they did get Covid-19. Instead they wear a mask even while walking alone outdoors and voted for Biden, who will “keep us safe.”

No argument about the good health part of it, but, if you think the government(s) have overstepped now, just wait until they go full on tyrannical to force people to lose weight.

I actually doubt that the liberal government would ever do that (except indirectly via impoverishment) for consistent with their "progressive" perversion of everything God had ordained, by precept or principle, by design or decree, then rather than self discipline being exercised in abstaining from immoral conduct (incldng. gluttony) and speech, then self discipline means refraining from engaging in any actions (from wearing fur to playing chess to hiring persons based upon qualifications versus race) or speech (from referring to "brown bag" lunches to male and female wires and slave drives). In contrast, such actions and speech as fornication and profanity are never to be censored.

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