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Major infectious diseases – England and Scotland update, week 15

This will be a quick update only as I am officially on holiday. The weather on the North Coast of Scotland has been fabulous this week – sunshine, blue sky, warm for April except for a nippy cold wind, and no midges. Wish I could stay here longer.

All disease indicators seem to be going down except Rhinovirus positivity. UKHSA has not released the Pillar 1 data in their spreadsheets, but the most recent data show some decline, albeit at a possibly slower rate – 15-19 and 85+ might actually be going up again!

Scotland follows a similar pattern, with sharp declines in most age classes, except for 85+. Their wave seems to be following the English one by about 3 weeks.

English Flu and RSV are also (slightly) down, following the seasonal pattern.

Scarlet Fever levels have again massively dropped and I hope this is a real drop, not due to reporting.

Finally, there is a slight uptick in the Rhinovirus positivity, although the number of positive samples going slightly down. I expect the numbers to be stable before rising up again in summer.

India update

There is a bit of evidence of slowing down in India, where the Arcturus strain continues to grow. After a “usual” few days’ drop, the numbers are picking up again.

India’s Covid resurgence

As you might have seen from my earlier posts on this blog, I am very fond of India. It is a fantastic country, with a wonderful landscape and even more wonderful people. I have had the privilege of visiting India every year since 2019 (except for the lockdown in 2021), and I really enjoyed every minute I spent there.

India’s Covid history

India has had a rough time over the Covid pandemic. Its attempt at Zero Covid in early 2020 went spectacularly wrong (note that on the 0-100 scale of the Stringency Index, India reached 100 and the UK only 80 during the 2020 lockdowns). I still remember videos of Indian police beating those escaping the lockdowns with bamboo sticks.

Relaxation of the rules in mid-2020 coincided with the late 2020 and mid-2021 outbreaks and the rise of the Delta variant (which originated in India before spreading throughout the world). The Omicron wave in the winter of 2021-22 was similarly devastating, although, by that time, vaccination helped reduce the death toll.

Although the primary vaccination cover is remarkable for a country of this size and with social and economic conditions, 67% were vaccinated compared to 75% in the UK. The booster programme was not as successful – only 16% compared with nearly 60% in the UK.

Reporting

But the biggest problem with the official statistic has been its massive underestimation of cases and deaths. It is particularly visible for the Omicron wave in 2021/22 and casts doubts on the current records.

Compare the official notifications and the estimations of excess deaths below. Excess mortality is a difficult thing to calculate, but it is a fairly reliable measure of Covid impact. The official death toll, in turn, relies on reporting which is often unreliable.

Firstly, the estimates of excess deaths in India are way larger than the actual records. In fact, most Indian deaths which can reasonably be attributed to Covid (deaths in excess compared to pre-pandemic years) are not recorded at all.

This is in contrast with the US, where the two lines follow each other pretty accurately. There might be some argument that some excess deaths in the US are attributable to non-Covid causes (e.g. lack of medical care during lockdowns) or long-term effects of lockdowns, but most of them are clearly attributable to Covid.

Secondly, there is a big difference between how the second (Delta) wave and the third (Omicron) wave look for recorded Covid deaths and for excess deaths. In official records (see the first graph in this post), the number of deaths in the Omicron wave is much lower than for Delta.

But, for the excess deaths – which arguably better capture the impact of Covid – the difference is much smaller. This suggests that the deaths in the Omicron wave were even more severely under-reported than in the Delta one.

Thirdly, there is a massive uncertainty in the estimation of excess deaths in India throughout the pandemic. Contrast this with the US, where the excess deaths are well known, except for the last few time points. India simply does not keep a good record of births and deaths.

Return of Covid

When I was in India in February, there were no signs of an ongoing pandemic. People mixed freely and there were only a few masks seen around. In fact, I have repeatedly heard people talking about the pandemic as something from the past. A nightmare dream that it is now gone.

And indeed, at that time, the number of cases and deaths was very low. From December to about mid-February, India was reporting only about 100 cases per day, more than 100 times fewer than the UK – despite being 25 times larger. Even accounting for under-reporting, Covid seemed to have almost disappeared.

But, this period has not lasted long, and the Indian government was aware of the change already in March. The rise of a new variant – XBB.1.16 – has been creating a new wave.

Indeed, the increase in the virus prevalence is now seen both in official records:

and in wastewater measurements:

We are still far from the previous waves, but the current growth is indeed something to be concerned about, particularly due to a very low booster vaccination cover.

What is the future?

Is India likely to be a source of another global variant similar to the Delta outbreak in 2021? It is definitely possible, but there is hope that we are globally in a different position now than we were two years ago.

Globally, we are in a much better position now than even a year ago. The combined “immunity wall” of both vaccine- and infection-induced protection probably still holds. Yes, we are likely to see repeated outbreaks, but they are likely to be limited in size and duration.

Unless, another Covid variant appears that manages to break the wall…

Major infectious diseases – England and Scotland update, week 14

TL&DR: All indicators are down this week, Covid cases, hospitalisation and deaths are sharply down, as are Scarlet fever cases. Time will tell whether this is a lasting drop or it is a result of inefficient reporting. Flu and RSV are also down, although already at low numbers.

Covid

While the cases are slowly going down, hospital admissions and Pillar 1 positivity experienced a sharp decline. I was originally sceptical about associating this with changes in reporting, but this is now an increasingly likely reason for such a rapid change.

To be clear, I believe that there is a decline, but I suspect there are other factors driving the reported numbers down.

Cases are clearly down in both England and in Scotland. How much of it is driven by the Easter school and work break, will be seen in the next few weeks, but there is no doubt we are over the wave crest.

Flu and RSV

Both flu and RSV continue following their seasonal pre-pandemic pattern, with numbers low and slowly declining.

Scarlet fever

Something rather strange happened to Scarlet fever notifications this week, with a huge drop in reported cases. While such declines are not completely unusual and indeed happened in pre-pandemic years (see 2017-18 season data), but I will believe it when I see the notifications next week.

I would not be surprised if this week’s numbers were revised upwards, but still expect the general trend to be a decline.

Rhinovirus

Apologies for still “poaching” the graph from the UKHSA report. The numbers are also down and it appears we are now in a “sweet spot” – a seasonal break before the summer months (from week 20) when the numbers will be picking up again.