Planning needs to start now for third Covid-19 wave, says expert, warns of child infections

Eminent virologist Dr V Ravi says there is strong evidence to suggest that the hardest hit will be children

As the pace of vaccinations slows down even as Covid-19 makes a resurgence, there is growing concern that a third wave of infections will hit India between October and December of this year. The eminent virologist, Dr V Ravi, said that there is strong evidence to suggest that the hardest hit will be children - which could result in egregious scenes unless the country and Karnataka can scale up its paediatric healthcare infrastructure.

Q. You have mentioned that children will bear the brunt of the third wave. But is there certainty that the third wave will materialise?

Europe is undergoing its third wave of infections right now, while the United States is in its fourth wave. Japan, Singapore and a few other Asian countries are also experiencing their third waves. Waves are inevitable in an outbreak. Containment depends on how quickly you can vaccinate people. In a country of our size, only a fraction of adults have been vaccinated. As per calculations, the process of vaccination will take another three to six months to finish. By that stage, only about 50% of the population will have been vaccinated - None of them will be children because vaccines for them are not yet ready.

Also read: Forget third wave, child Covid cases already increasing in second wave

Q. What can we expect to see in the next few months?

The second wave will potentially become manageable only by the end of June. There will be a quiet period of two to three months. Then the third wave will begin. All adults who have not been immunised will be at risk, but children will comprise a significant chunk of infections.

Q. But we have seen child infections before. What could be the potential new scale of infection?

We are talking about a high number of susceptible children. In the first wave, about 4% of infections were children. In the second wave, this share has increased to between 10 and 20%. In addition, according to the sero-survey results, about 25% of children in India have already been exposed to Covid-19 during the past 17 months. This leaves 60% of our children still susceptible to infection. In numerical terms, this is roughly 18 crore children in India. Let’s say 20% get infected in the third wave - that is 3.6 cr children. Most child cases will be mild but if we assume that even 1% of children develop serious complications from the disease, that is 3.6 lakh children who would need to be hospitalised.

Also read: Karnataka reports 38,603 new Covid cases, 476 deaths

Q. Do we have adequate paediatric intensive care facilities to tackle these cases?

No, we do not. This is why we must start our preparation right now. We should also start having conversations around the opening of schools. Whether schools should be reopened? whether remote learning should take greater precedence over regular schooling?. We also have to scale up our paediatric inpatient infrastructure.

Q. How should the government view proposals to scale up health resources? What is the long-term picture it should be seeing?

We have to start thinking about whatever has happened so far as being a war against an invisible enemy. We allocate nearly 40% of our GDP to the armed forces, but our allocation for healthcare is under 2%. Is it too much to ask for better healthcare services? Medical resources and the numbers of trained personnel have to be increased.This century has been dubbed as the “virus century.” In the last 20 years, we have had three viral outbreaks: MERS, Sars-CoV-1 and now Sars-CoV-2. Of course, Sars-CoV-2 has taken the cake and should prompt changes. To be frank, the medical infrastructure scaled up now will be useful in the future. We will continue to see new kinds of viral outbreaks.

Also read: Four southern states and Maharashtra driving India's Covid-19 epidemic

Q. There is disappointment that the vaccines have not been able to prevent infections. How would you address this?

We all know people who have had various Covid-19 vaccines but have nevertheless become infected. But when it comes to all vaccines, the data is very clear: it reduces the mortality and severity of infection. People are expecting too much from the vaccines under the impression that it can stop infections. Even in the Polio vaccine, infections happen but the disease is prevented. The same is true for the measles vaccine as well.

Q. With the Sars-CoV-2 virus mutating as it is, would we require new vaccinations in the coming year to keep up protection?

It is too early to dismiss those concerns. All of the vaccines approved for use so far are effective against the existing variants of the virus. But if a significant mutant arises in the future, we may have to take a booster shot. This is why genomic sequencing is so important - It will help us keep a track of mutants.

Q. Will we see a potential new Variant of Concern (VOC) in the months to come?

That is the million-dollar question. It is very difficult to determine when a potential new VOC will rear up. People have to understand that in one infected person alone, millions of viral particles are being born and only the fittest survive. These, in turn, spread and eventually lead to new mutants.

Q. A case in point is the new variant B.1.617 which has rapidly taken over in Karnataka?

Precisely. This variant has absolutely taken over from all other previous variants. One way of determining if a variant is genuinely more infectious, is to see under what conditions it spread and if it created a large number of infections through super-spreader events. From January to March, the dominant variant in Karnataka was B.1.36 which dominated all other variants. But it was not necessarily more infectious and was instead being transmitted through super-spreader events such as marriages, political gatherings, religious events and other public congregations. But from April onwards, after restrictions were brought in, B.1.617 has started to surge and has now taken over. This alone should tell us that it is more infectious than other variants.

Also read: Discussions under way on extending lockdown in Karnataka, no decision yet, says CM

Q. But is it more virulent? What are its clinical manifestations?

There is no data on clinical effects yet. There is no evidence to say that it is more virulent.

Q. The issue of reinfections if often not considered. Won’t this increase the size of the susceptible population?

In the first wave, the incidence of reinfection was about 1%. Now, it is between 5 to 10%. Reinfections are happening and my bet is that those who experienced reinfection came down with a mutant. If a new variant of concern develops in the new few months, we will see more infections in the third wave.

Q. What is the limit of protection from natural antibodies for a person recently recovered from Covid-19?

Initially, it was thought that a person had up to six months of protection, but based on what we are seeing now, it appears to be between three to six months. Six months is the optimal outer limit of natural antibodies. However, the amount of antigen we are pumping in through vaccines is much more than the natural infection and consequently it induces prolonged immunity in a person.

Q. There has been frustration that India has not been able to scale up its genome sequencing? What are some of the challenges in genomic sequencing?

Sequencing is a very laborious process that takes a minimum of 10 days to complete. It can also be expensive. In India, there are about 50 centres that have sequencing facilities but there is an acute shortage of trained personnel. In Karnataka, in consultations with the Health Minister, Dr K Sudhakar, it has been agreed to set up four new genomic centres in four corners of Karnataka. They will be set up in medical colleges, which already have a research infrastructure.

Q. Why did the second wave blow up as it has? Why have there been so many deaths this time around?

In the first wave, we stressed on lives over livelihoods. That came at the cost of livelihoods. In the second wave, we stressed the economy over lives. We need to balance both lives and livelihoods. But how are Kumbh Mela and elections responsible for economic revival? Someone should enlighten me. I feel very disturbed when I see the situation. We seem to be making the same mistakes that we made before.

Q. Is the ongoing lockdown useful at all?

The biggest impact of the lockdown which cannot be quantified is that it restricts movement and contact amongst people. In addition people become scared and they begin taking precautions. It is when there are no stringent restrictions that people go back to normal and their covid appropriate behaviors come down.