About two-thirds of people in India have antibodies from exposure to the coronavirus. (Reuters: Rupak De Chowdhuri)
This article was first published in ABC News online. Read the full article here.
The number of new COVID-19 cases and deaths in India has dropped dramatically since a second wave of the virus peaked in May.
First the Alpha and then the Delta variant - which was first detected in India and is now causing strife elsewhere in the world - ravaged the country.
But the seven-day average of daily reported cases this week is just a tenth of the 400,000 recorded during the peak.
Reported deaths are down, too, with an average of fewer than 500 per day, down from more than 4,000 per day.
Image: COVID-19 cases in India. Source: ABC News
According to health authorities, more than 439,000 people in India have now died with the virus.
The relatively stable numbers, which lasted throughout August, prompted the World Health Organization's chief scientist to suggest India may have reached a state of "endemicity".
That is, it may be endemic or constantly present in a particular place.
So how did they get there and is the worst of the pandemic over for India?
What is it like in India at the moment?
While the usual caveats apply about numbers being underestimated due to inadequate testing and reporting, it's clear that things have improved India-wide.
In May, Delhi's health system was completely overwhelmed, with medical oxygen supplies exhausted, leading to distressing images of makeshift outdoor crematoriums.
This week, less than 2 per cent of Delhi's COVID-19 beds were occupied.
Business has picked back up and schools are reopening in some states.
Soumyadeep Bhaumik, from the George Institute India in New Delhi, said the health system was now "functioning normally" and focusing on vaccination.
However, he said, life was not back to a pre-COVID normal.
Cases were low across most of India but there had been a surge in Kerala in the past few days, he said.
"There is no 'lockdown' now but movement restrictions appropriate to the transmission are now being implemented in different states in India," he told the ABC.
"Kerala has more restrictions now because cases are increasing, but other states, which have low cases, have fewer."
How did India get out of the Delta wave?
While India's federal government did not implement a nationwide lockdown during the second wave, by mid-May almost all of India's 36 states and territories had instituted full or partial lockdowns.
Other countries such as the UK, the Netherlands and Israel saw sharp declines in cases as a consequence of high vaccination rates and high infection levels.
Image: India is one of the world's major vaccine producers but was forced to halt exports during the second wave. Source: Reuters - Adnan Abidi
In India, only about 10 per cent of the population are fully vaccinated, while about 36 per cent of people have had at least one shot.
However, a serology survey conducted in June and July indicated two out of three people in India had COVID-19 antibodies.
"The massive community spread in COVID-19 in the second wave earlier this year meant a lot of people were exposed - symptomatic or otherwise," Dr Bhaumik said.
"It also created awareness about the need to wear masks, avoiding crowds et cetera."
University of Cambridge researcher Ankur Mutreja told the ABC the combination of the state lockdowns and the increase in natural immunity combined to flatten the curve.
"While lockdowns hammer the curve directly, natural exposure during leaky lockdowns facilitates that hammering," Dr Mutreja said.
He said the high rate of antibodies from exposure was helping to keep a lid on the situation for the moment.
"Vaccination rates have also increased massively in India since the second wave, with more than 10 million doses being administered each day for the last few days," he said.
Conspiracy theories about ivermectin and hydroxychloroquine
A conspiracy theory going around at the moment is that India began treating people en masse with hydroxychloroquine or ivermectin and that was responsible for the fall in cases and deaths.
AAP fact checked the claim and found it was baseless.
"There is no evidence that new guidance on the use of ivermectin and hydroxychloroquine led to a reduction in COVID-19 cases in India," they found.
"In fact, hydroxychloroquine was reported to be in widespread use well prior to the country's second-wave outbreak."
Experts - including ivermectin's manufacturers - have repeatedly said there was no evidence the drugs were effective in treating COVID-19.
'We may be entering some stage of endemicity'
WHO chief scientist Soumya Swaminathan late last month told The Wire that while India would probably experience a third wave, it would likely not be as severe as the second.
"We may be entering some kind of stage of endemicity, where there is low-level transmission or moderate-level transmission going on but we are not seeing the kinds of exponential growth and peaks that we saw a few months ago," Dr Swaminathan said.
India would continue to have "ups and downs in different parts of the country" in areas that were less affected in the first and second waves or with lower levels of vaccine coverage, she said.
That's why Kerala, which was less affected during the second wave, was experiencing a surge now, she said.
David Anderson, from the Burnet Institute in Melbourne, said "endemic" normally just meant that a disease was always present in a population.
"That means that if you have a susceptible population, whether they're unvaccinated or they haven't been infected previously, it can find them and infect them," he said.
He said whether an endemic virus could be managed well enough to prevent an unacceptable loss of life was another question.
He said he didn't believe having two-thirds of the population vaccinated or with antibodies from COVID-19 infections was enough to prevent exponential growth.
Either more people had been exposed to the virus than the serology surveys indicated or the impact of the virus now was being under-reported, or both, he said.
"I can't help but think that in India, they must still be having quite high rates of infection, but people are just not seeking care to the same degree," he said.
What does the future hold?
Since May India's state and federal governments have put more resources into public education on social distancing, tightened the borders, hired more health workers, set up new medical oxygen plants, stockpiled medicines for infections such as mucormycosis and beefed up the country's virus tracking system.
The experts contacted by the ABC agreed that India's relative respite from COVID-19 was probably only temporary and a third wave was on its way.
When it will arrive and how severe it will be is up for debate.
Dr Mutreja said vaccination rates had "increased massively" since the second wave, with more than 10 million doses being administered each day for the last few days, but another wave was "imminent".
He said how big it would be depended on how quickly the Delta variant evolved into a "more capable escape variant", the speed of India's vaccination campaign and how effective the vaccines were against the next variant.
Rajib Dasgupta, chair of Jawaharlal Nehru University's Centre of Social Medicine and Community Health, agreed that the combination of increasing vaccination coverage and high levels of immunity acquired through infections was protecting much of the population.
But the emergence or importation of any new variant could potentially lead to new surges, he said.
"Forecasting by modellers indicates a third wave beginning in August and peaking at 100,000 to 150,000 infections a day by October," Dr Dasgupta wrote in an article for The Conversation.
"An alternative projection expects the peak in cases going until November."
Dr Bhaumik said the idea was always to flatten the surges and ensure they were smaller and less deadly each time - and try make the time between the surges as long as possible.
He said it was now "abundantly clear" that COVID-19 was here to stay globally for at least the near future.
"Strategies which hinge on vaccine coverage-related removal of 'lockdown' is not really helpful as variants will keep on rising globally and eventually spread," he said.
"No country can remain an island closed to international travel for years altogether in a global world.
"Graded public health response is the way forward and we have to learn to be pragmatic in living with COVID-19."
