Dr. Rohit Bhayana
Independent International Healthcare Management Expert
MBBS – Pt BDS Postgraduate Institute, Rohtak
D.Ortho, DNB (Ortho)
MRCS – Royal College of Surgeons of Edinburgh
MBA – International Healthcare Management from Frankfurt, Germany
( 9 Mins. Read)
The first wave of COVID-19 saw those with significant co-morbidities, medically vulnerable, and mostly past-middle-age adults hospitalized and losing their battle with the virus. 2020 showed us which almost none of us had seen in our lifetimes before.
Then came the progress in vaccines. Come 2021 and we thought its all over now – the numbers were down, the vaccines were being made and peoples and governments showed signs of “victory-belief”.
Then, Europe and US got infected in January and February 2021. Then came the second wave in India. April and May 2021 saw the worst we have ever seen in our lifetime so far – hospitalizations and bodies all around us, funeral pyres and burials became the only sight on media and streaming sites. The world looked in horror as India burned.
What was unique in this wave was the speed with which it spread and attained peaks, and the rate of hospitalizations and mortality. What was also unique was the demographic strata involved. We saw healthy, young adults, hospitalized and dying. Sub-45 mortality which was rare in the first wave, was a common theme now. Despite vaccinations, people were dying.
We blamed the double mutation – the world called it Indian variant.
Will there be a Third Wave?
Experience of virus behavior from western countries and recent modelling by a number of experts has clearly shown that there will be a third wave in India – in near future, perhaps within the next 6 months, and possibly as early as October 2021. And there could be more mutations.
With the population affected growing younger with each wave, it’s only a matter of time when kids start falling to this monster. The second wave affected the children in a bigger and harsher way than the first. There is a strong possibility that the third wave can go even farther with children and younger population. The main reasons postulated are – vaccination progress in older population; and, mutations. Till now the mortality rates in children has remained a small fraction of total mortality. However whether that can change in the third wave is not easy to predict. Different people believe in different ways.
One view is that children have growing immune systems and as a part of national immunization programmes , they get vaccinated for a variety of diseases, so there can be some cross-immunity granting them broad-based protection.
The other view is that in the absence of vaccination, children are not only a gaping hole in the building of herd immunity of the population, but also are themselves at a higher risk of hospitalization and mortality in further waves, when vaccination progresses in adult populations the virus will find them more vulnerable than vaccinated adults.
It is the second view which is gaining more popularity in Western countries now.
Vaccine trials in children
The US has approved Pfizer mRNA vaccine for over-12 years children. So has Canada. The UK was trialing Astra Zeneca vaccine for 5-18 years of children which has been put on hold due to risk of clots.
Moderna announced their trial in children aged 6 months to 12 years in March.
Novavax vaccine is undergoing trials in adolescents aged 12-17 years. A number of other vaccine candidates have also put forward plans for trials in children.
On May 11, 2021, the Drugs Controller General of India cleared Covaxin for its trials on children aged 2 years to 12 years in India.
ZyCoV-D, currently undergoing phase three trials in India, is also being tested in adolescents aged 12 and above.
However it is not as simple as it sounds.
As mentioned above, immune response in children is stronger than adults and also variable due to other vaccinations already ongoing or received. This could present problems in measuring immune markers which is a modality currently being utilized in vaccine effectiveness studies.
Secondly, the children have, till now, shown reasonable resilience towards serious disease, hospitalizations and deaths, though second wave has shown worse. The test positivity rates in children is also lower than adults. To establish vaccine effectiveness in low positivity rates would require long-term studies with large sample size preferably at multiple centres simultaneously.
Doing so without a global vaccine alliance would be tedious as companies would be competing with each other rather than collaborating.
The Way Forward
India and the World must be prepared for subsequent waves.
Particularly in India, there was an apparent response-lag while handling the second wave, which, according to many, led to increased hospitalizations and deaths. We need to learn from our mistakes.
The following steps should be taken up by Government of India in conjunction with state governments:
- Capacity retention and augmentation: The second wave has seen temporary infrastructures coming up as make-shift hospitals with Oxygen beds. Recent out cry by public and media and intervention by courts has resulted in governments acting to increase ICU and ventilator capacities, improving infrastructure and handling of oxygen generation and distribution, home oxygen concentrator supplies and capacities, and streamlining essential medication supplies and distribution, including acknowledgment and checks on black-marketing and hoarding. Foreign aids – both state sponsored and non-governmental – whether organised or sporadic has poured in to provide equipment, medications and infrastructure. These added provisions/ capacities and infrastructures should not be dismantled or rolled back once the numbers climb down, which is expected by mid-to-end July. Rather capacity building and streamlining should continue to ensure swifter response for subsequent waves. Checks on black-marketing should be strengthened.
- Vaccination trials should happen on children.
- Early lockdown should be planned and implemented. The lockdown should be national rather than regional. This is important for two reasons –
- Decreasing contact between individuals, movement between regions, and halting of contagion travelling to those areas otherwise showing less inherent infections. The North Eastern states and Indian villages are classical examples we saw in second wave. Had we locked down nationally in end of March when new cases were climbing above 50-60K per day, or even in the beginning of April when we crossed 1 Lakh new cases per day, a lot of spread could have been prevented. States went into regional lockdowns only when the new cases started approaching near 3 lakh per day, and by then it was already too late. We must remember, the effects of lockdown will not be visible before three weeks, so it must be planned abundantly in advance. The regional lockdown started showing results by mid-May. So there’s a strong evidence-based case for a national lockdown early in the wave to halt its progression in tracks.
- Preventing overwhelming of healthcare infrastructure. India has lesser healthcare beds, personnel, equipment and medications per 100,000 population as compared to the western countries. Its impact on mortality rates in second wave cannot be overemphasized. Lockdown keeps the flow of new cases on a slower pace than otherwise, which in turn helps in getting the beds freed from discharge of already admitted cases, and arrangement of treatment facilities like oxygen and essential medications more feasible. Rather what we saw was an explosion of cases needing hospitalization all at once resulting in serious shortage of already scarce and stretched healthcare resources.
- Federalization of corona management
- Vaccination planning: Current vaccination status as on 20 May 2021 shows India has vaccinated about 10.7% of her population by at least one dose and around 3% of population by two doses. However this is on danger of getting derailed as a number of states have highlighted vaccine shortages in the last few weeks. Large pauses between vaccination drives due to shortages of vaccines only is bound to slow down the efforts towards fighting the virus. Constantly increasing gaps between doses (from 4-6 weeks in January to 8-10 weeks and now 12-16 weeks has the propensity of eroding public confidence and creating vaccine panic in masses. and again symbolizes vaccine shortages due to poor planning. Proper vaccine plan is intended to provide an optimum level of immunity against the virus. Therefore staggered gaps should be only premised on pure scientific evidence and administrative incapacity should not be allowed to harp upon the immunological effects. To this effect a better strategy would have been phased rolling out in brackets of 3-5 years age-steps rather than 18-45 all at once.
There has been a notable increase in transmissibility and virulence as seen during second wave due to the mutant strain B1.617, which has three subsets, at least one of which (B1.617.2) has now been recognized as a “Variant of Concern”, it is also known as the Indian variant.
The data released by Public Health England last week has shown that two doses of Astra Zeneca vaccine may be up to 60% effective again severe disease from this variant of concern first detected in India. This variant is being largely blamed for the catastrophic second wave in India in April and May 2021.
There is a realistic danger that poor vaccination planning could actually facilitate development of further mutants. Protection from vaccine is achieved after three weeks of first dose and 7-14 days of second dose and exposure during these vulnerable periods could increase chances of getting infected.
- Shielding of vulnerable: vulnerable population includes children who are an important subset from multiple aspects. Routine hygiene measures and COVID appropriate behavior – washing hands, wearing masks, and keeping 6-8 feet distance must be adhered to. Double masking has been shown to be more effective in the second wave than single mask. Home schooling and distance examinations should continue at least till the end of 2021. Malnutrition should be specifically addressed in children. The parents need to protect themselves in order to be able to protect their children.
The recent report of 341 children getting affected by the virus in Dausa, Rajasthan and similar cases reported from Rudraprayag in Uttarakhand shows the trend virus is heading to. This should not be taken as an isolated incident but as a warning sign of things to come.
If we continue to see children falling to infections, the virus gets another 30-40% of population within its reach. And the more population the virus can access, the stronger are the chances of new mutations arising, leading to possibility of further waves, besides increasing hospitalizations and deaths in current wave, and possibility of vaccine-evasive and immunity-evasive strains. Therefore quick and properly planned vaccination with potent vaccines gains further importance.
The recent step by Singapore government to shut down its schools (which they had opened after gaining control over infections previously) shows the importance of “shielding”.
This information is for general guidance and reflects the opinions and experience of the author. It is not intended to replace specialist consultation or provide treatment advice for specific cases.