I've been avoiding writing about this because it feels too close to the bone at the moment. But important to discuss- so here goes. What's unfolding in India is absolutely tragic & horrific (and was preventable). Unfortunately, it's likely to get worse before it gets better.

We've been seeing rapid growth in the pandemic, which hit some parts of India (e.g. Maharashtra, W. Bengal, Delhi) earlier than others - but cases are now growing exponentially in every part of India. India has had >300K *reported* cases and >2000 *reported* deaths in 24 hrs.

Deaths & cases are being substantially underreported. The positivity rate in Delhi is 36% and testing isn't available for many. It's estimated that deaths are being underreported by ~10x, with level of underreporting varying from place to place. https://twitter.com/DrEricDing/status/1384789570957500416?s=20

What's worse is that growth hasn't stopped- cases haven't plateaued off yet. The stage of growth is different in different regions depending on restrictions, but cases are still growing across most of India. Ineffective, or short lockdowns have been instituted in some places.

In Maharastra the govt tried 'curbs' for sometime without a full lockdown & only instituted a lockdown recently. Delhi instituted a *6 day* lockdown recently & W. Bengal continued election rallies while cases were surging and 3 election candidates died during this period.

Why?

I know that this is probably linked to a new variant, that may be more transmissible, and more likely to escape immune responses, but it doesn't change the fact that we've been seeing exponential rises in many parts of India for 6 weeks. So why didn't the government act?

I honestly don't understand this. We know how exponential growth occurs- we've seen it time and time again. The government cannot possibly claim that this has taken them by surprise, given this is how exponential growth works unless we take action to curb it. And they didn't.

I'm not going to link to pictures or videos, but the situation in India is utterly horrific- people are dying without healthcare, waiting outside hospitals because of shortages of bed and oxygen. Including young people. And we know that we're not even seeing the full picture.

But what does the future hold?
Cases in Delhi, W. Bengal, and most other states still growing. Early signs perhaps of growth slowing in Maharashtra but hard to say, given positivity rates of 16% suggesting massive underreporting.

We know there is a ~3 wk lag between infections & deaths. The current steep death curve we're seeing (which we know are hugely underestimated) represents infections from about 3 wks or so ago. This means that the impact of the rapid rise over the past 3 wks is yet to be felt.

What can we expect?
If we assume case numbers are completely accurate & not underestimated (so very conservative estimates), the no. of cases today can be expected to result in 6600 deaths a day in 3 wks time, assuming a case fatality rate of 2% (possibly conservative).

If we assume cases are underestimated by 5x (many scientists in India think current rates are underestimated by ~10x), we can expect ~33,000 deaths in *a day* in 3 wks time. I know this sounds crazy, and I'm struggling to believe these figures myself, but this is plausible.

And of course case fatality rates are very dependent on health resources available- including hospital beds, ICU beds, oxygen, and basic healthcare, which we know there are acute shortages of at this point in time. What's the situation going to be over the next 3 weeks?

Higher fatality rates (or a higher level of underestimation of cases) could mean an even higher death toll - of course it's very likely much of this toll will not be reported, as is happening now. E.g. current deaths could already be at ~20,000 per day, based on cremation data

The government needs to act now- almost every single state is showing rapid exponential growth. Waiting every single minute costs lives. There needs to be immediate lockdowns with emergency support nationally for healthcare services that are completely overwhelmed.

The worst part is that this wave has occurred following a period the pandemic was widely reported to be under control in India. Places like Delhi were thought to have had high levels of exposure - between 50-60% based on sero-prevalence studies, before the current wave began.

I know some will disagree with me, and suggest this is 'alarmism', but I do think that the current wave is cause for alarm, and potentially linked to the new variant of concern - given the temporal & geographical associations of observed growth rate with variant growth.

Also concerning are data from Maharashtra & more recently travel data from India recorded by PHE, that shows the frequency of B.1.617 rising even against a background of B.1.1.7- need to interpret with caution given low sample sizes & possibly samples may not be representative.

But more than sufficient reason to be concerned. New variants can shift the shape of a pandemic and cause devastation, but we do that doesn't abdicate the govt of responsibility and its complete failure to prevent the humanitarian disaster currently unfolding.

Given the govt inaction in the face of a pandemic trajectory that has been clear for weeks, one can only describe this as negligent manslaughter. Action even a few weeks ago would have saved tens of thousands of lives at the very least.

A request to the global scientific community- I know many want to feel this is something that couldn't happen where they live & perhaps the Indian context isn't relevant, and want to reassure by minimising what's happening in India, with some suggesting concerns are 'alarmist'

I'm also seeing a lot of reports being shared based on very limited, or non-transparent data. I think we all want re-assurance and positivity right now (I definitely do), but it's important to convey uncertainty, where things aren't clear at the moment & avoid false reassurance.

It's important everyone (vaccinated or not) continues to take precautions to protect themselves. Trying to prevent getting infected is the best way to protect health- in a system where health systems are overwhelmed. Please take the vaccine as and when it's offered & do so safely

I also want to highlight that the Indian community in the UK is reeling from this. I think many will have family in India who are being affected by this, and it's frankly awful to be sitting here helplessly watching this tragedy and not being able to do anything.

The international community also needs to come together here, and support- this is a humanitarian disaster that impacts everyone. The international community must support India with provision of PPE, drugs, life-saving oxygen supplies and vaccines.