With nearly 2.4 million coronavirus cases and 47,000 deaths, India is the world’s third-most affected country, behind the United States and Brazil. It reported a record daily increase of 66,999 cases on Thursday, and added 942 fatalities, overtaking Britain to have the world’s fourth-highest death toll, after the US, Brazil and Mexico. With infection rates rapidly rising, there are fears among health experts and the public that the worst is yet to come for the country of 1.3 billion people. So far for August, India has had the highest share of the global caseload, reporting between 23 and 29 per cent of new daily infections. And the South Asian nation’s second million cases came within 21 days, faster than both the US and Brazil, which reached the grim milestone in 43 days and 27 days respectively. This is despite the fact that India ’s testing rate – about 18,300 per million – is significantly lower than other badly hit countries. There are also concerns that the extent of the situation is not being fully reported as the health care system is limited in its ability to map the trend. Where does India stand? Since India reported its first Covid-19 case in January, most fatalities have been in a handful of states – Maharastra, Tamil Nadu, New Delhi, Gujarat, and Karnataka – which together account for over half the country’s death toll. “It is hard to say based on reported case counts whether the true peak is yet to come. Looking at the state level data I feel there will be surges and peaks across various states in August,” said Bhramar Mukherjee, a professor of epidemiology and head of the biostatistics department at the University of Michigan. “India will hit 3 million reported cases within the next 7-10 days,” she said. The only positive for the central government is the low case fatality rate (CFR) – the ratio between positive cases and deaths – which dipped to under 2 per cent this week against the global average of 3.7 per cent. But there are concerns that coronavirus-related deaths are being undercounted. How is the Narendra Modi government handling the situation? Unlike in the early stages of the virus outbreak, the government has gradually decentralised its response and empowered state administrations to take greater control in issues like allocating health care resources and implementing lockdown measures. “India is not a monolithic entity,” said Dr Srinath Reddy, president of the Public Health Foundation of India. A variety of factors such as geography, rate of infections in a particular region, urban set-ups and demography should also be taken into account to determine the trend in managing the crisis, he explained. “The epidemic entered, in terms of the virus entry, through relatively economically better-developed parts of the country like western India, National Capital Region [New Delhi], southern India. Then it spread to the adjoining districts,” said Reddy, adding that authorities should now focus on limiting the spread to India’s hinterlands. India has not yet peaked in most settings – deaths continue to go up. Epidemiologist Prabhat Jha This week, Prime Minister Narendra Modi held a virtual meeting with 10 chief ministers who head the states collectively responsible for 80 per cent of India’s caseload, urging them to increase testing, contact tracing and surveillance. Meanwhile, five government ministers, including Home Affairs minister Amit Shah , Modi’s right-hand man, have tested positive for the virus, while former president Pranab Mukherjee and a number of other high-profile figures, including Bollywood stars Amitabh Bachchan , his son Abishek and daughter-in-law Aishwarya Rai have also been infected. Some of them have recovered. India’s Amit Shah has Covid-19 – and little sympathy from social media How much worse will it get? “India is likely to have the virus and its consequences well into the fall,” said Prabhat Jha, professor and chair in global health and epidemiology at the University of Toronto. While the government bodies are reluctant to forecast worst-case scenarios, independent experts warn the country should brace for a fresh wave of infections in the foreseeable future and a long battle ahead. “India has not yet peaked in most settings – deaths continue to go up, with perhaps a levelling in Delhi. The Indian overall death rates [which are more reliable in urban areas but less reliable in rural areas] show slower growth rates, but still upward trajectories,” cautioned Jha. Some India slums ‘may have reached herd immunity’, study finds In terms of different modelling methods, public health experts predict the overall number of cases in India could run into hundreds of millions, but point out this should be seen in relation to the country’s population of 1.3 billion. Professor Mukherjee said the reported case numbers are only the “tip of the iceberg” if one considers the serosurveys in New Delhi and Mumbai which study antibodies and suggest disease prevalence vastly outnumbered the actual cases. “We need to have large-scale population-based seroprevalence surveys to understand the true extent of transmission nationwide,” she concluded. What is the public mood? Indians are caught in a difficult situation as the four-month lockdown measures are progressively relaxed while the outbreak looks set to worsen. Throughout the country, public transport remains largely crippled, interstate movement is limited, and mass gatherings are restricted. Yet people are desperate to resurrect their livelihoods, which have been decimated by the crisis. “First, I hauled my small savings. Then I sold my belongings. Then I borrowed some money for my family’s survival, and now my small business is on the verge of collapse. I badly hope this recovers soon,” said Manjunath Prasad, a small-scale gold merchant in Bangalore. The negative effects of the prolonged lockdown are also showing in some parts of the country, with people increasingly disregarding social distancing guidelines and safety measures such as wearing masks, despite continuous warnings from health experts and governments. What about India’s vaccine? Against the backdrop of Russia claiming a successful vaccine and prompting warnings from the scientific community over incomplete trials, three major candidates are in different phases of human clinical trials in India. Two are home-grown. Despite the government’s initial ambitious aim to dole out an indigenous vaccine for public use by Independence Day, August 15, it was forced to draw back as the unreasonable deadline risked endangering lives and discrediting scientific research. Nevertheless, an expert panel comprising members from various arms of the government met for the first time on August 12 to discuss the strategy for procurement, inventory management, funding and delivery of vaccination programmes once a successful vaccine emerges. The government hopes to have an edge in vaccine distribution, considering India is home to the world’s leading manufactures and suppliers.