COVID-19 pandemic in India: Challenges and a glimpse of hope 
 
Since April, India has been in the second wave of COVID-19, with the brutal consequences of skyrocketing infections, increasing deaths, and medical supply shortage. 
 
Amid the chaos, Dr Gagandeep Kang, an Indian microbiologist and virologist at the Department of Gastrointestinal Sciences, the Christian Medical College in India's Vellore city, has tracked the national and state governments' progress in fighting against the pandemic.
 
Spoke at an online webinar on India's lesson learned in the COVID-19 pandemic, held by the Health Intervention and Technology Assessment Program (HITAP) on October 14, Dr Gang told the several challenges faced by her country.
 
Those include testing inaccessibility, limited manufacturing and regulatory capacity in the medical field, misinformation, and political fracture that influence the country's ability to manage the pandemic effectively. 
 
But she also found hope in some Indian states that increase people's immunity and vaccination despite all the challenges and overwhelming healthcare system.
 
Limitation on testing 
Over 34 million cumulative COVID-19 cases and around 450,000 deaths were reported in mid-October. The country is ranked second and third for countries with the highest cumulative infections and death, respectively. 
 
However, the actual numbers of deaths are unknown, said Dr Kang, also a fellow of the Royal Society. Estimates suggest that there were up to 10 times more COVID-19 relevant deaths than were officially recorded. 
 
That's because mild and asymptomatic cases are less likely to be detected, or infectious people can't reach out to testing in the government's surveillance systems. 
 
Since May last year, the Indian Council of Medical Research (ICMR) has conducted nationwide serosurveys, which examines the percentage of the population exposed to the virus.
 
Its first serosurvey, conducted between May and June last year when the country was under the stringent lockdown, found that 0.73% of adults aged over 18 years from 21 states had COVID-19 antibodies---meaning the majority of the Indian population were at risk of exposing to the virus. Those living in urban slums were one of the most risks. 
 
"It was a mess last year when it came to testing. There was a lot of fraud. One of the first things to do with infectious disease is to increase the ability to diagnose. Instead, we had a command and control structure in which we had to get permission to perform testing, and we wouldn't be allowed to test in many situations," said Dr Kang. 
 
"The reason for that was the government wanted to control how many cases were reported. India refused to admit that the disease was prevalent in the population." 
 
Boosting immunization
However, the fourth serosurvey, conducted in 70 districts between June and July this year, offered a glimpse of hope as the percentage increased to 67.6% after the Indian government started a mass vaccination program in January. 
 
It also showed that at least 400 million people, or nearly a third of India's 1.4 billion population, were still unprotected against the infection. 
 
"On top of more than 67% seropositivity, we also have to recognize that India has been giving out almost a billion doses of vaccines. Our experience in the last four months with boosting immunization and vaccination will push the 67% to a higher percentage," said Dr Kang.
 
"I don't think we will have a widespread transmission and increase in cases as we saw during the second wave."
 
What will likely happen is the transmission within families or population groups that are continually susceptible to infection. If there are new highly contagious variants, she said, the arrival of the third wave is possible. 
 
India has also strengthened its genomic surveillance since the pandemic broke out. 
 
In December last year, The Ministry of Health and Family Welfare, Department of Biotechnology, ICMR, and the Council for Scientific and Industrial Research jointly established the "Indian SARS-CoV-2 Genomics Consortium (INSACOG)."
 
It is a network of multi-laboratory and agency forming up to monitor COVID-19 genomic variations. It aims to understand how the virus spreads and evolves and provides information to aid public health response. 
 
Quality remains an issue
Challenges arose along the way of fighting against the pandemic, including the manufacturing quality in the medical field.
 
"India has had a huge focus on essentially self-reliance on making its own diagnosis tests, ventilators, and PPE [Personal Protective Equipment.] Because of the shortage of supplies due to the lockdown and international supply chain disruption," said Dr Kang. 
 
"While manufacturers have been ramping up for diagnosis, the quality remains an issue. The standard for validation remains an issue too. In addition to strengthening manufacturing capacity, India also has to strengthen regulatory capacity and process that policymakers frequently are not willing to apply."
 
Quality is also an issue for hospitals, each of which has different levels of equipment and staff availability. Public health responses among state governments are also varied depending on their policies and available resources, creating geographically unequal access to testing and treatment among Indian people. 
 
At an early stage of the pandemic, information on COVID-19 infection and vaccination did not penetrate throughout the population, leaving spaces for inaccurate information to circulate.
 
India worked with UNICEF to prepare a guideline for communication strategy. Though it is generally effective, the lack of transparency in policy-making hampers the level of its effectiveness.  
 
"The government has tried very hard to communicate with people but the basis of some policy decisions has been unclear. We discussed some of the issues around how you make the decision on who [provides] the test and why you test, what kind of drugs are used, and when vaccines should be given to people," said Dr Kang.
 
"If there were transparency in policy-making, overall communication around COVID-19 would have been stronger with more cooperation from the communities."  
  
Political fracture
In India, public health response is managed by the state governments while the national policy comes from the central government -- the political system that can cause misunderstanding and mistrust between central decision-makers and local administrations in the context of lagging transparency.  
 
Some state governments reported high infection and fatality rates and were targeted by the government for doing a bad job in controlling the spread of the virus. But the reality is otherwise, said Dr Kang. The high rates reflect their good surveillance and reporting system. 
 
Kerala, a state on India's tropical Malabar Coast, has reported between 50% and 60% of cases in India since July. 
 
But the serosurveys found the state had increased the immunization rate from 0.33% of the population in May last year to over 42% in a year later, resulting in the state's consistent effort to vaccinate people. By mid-October, more than 70% of the Kerala population were vaccinated, higher than the national vaccination rate at 50% of population.  
 
"There is at least one state that does a good job in flattering the curb. It's possible to do a good thing even within the [political] fractured structure," she said.
 
"Overall, because we had a bad time in India during the second wave, we actually are in a not too bad position today. We still need to be watchful. We still have a lot to do."
 
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