Waiting for the Third Wave

Epidemiologists and medical experts give scores of reasons why India can’t avoid a truly lethal third wave after the current spike in cases dies down. These include new, mutated virus variants, a suboptimal vaccination strategy, vaccine breakthroughs via immune evasion and the natural expiry of vaccine protection and finally, the natural tendency of the virus to find new and unprotected hosts

Waiting for the Third Wave

On 17th May, Union Health Minister Dr Harsh Vardhan said in a press conference in New Delhi that India’s new caseload numbers for COVID-19 had dipped below the three lakh/day mark for the first time, well below the peak of four lakh/day just two weeks earlier. Vardhan’s statement also conveyed the sense that the second wave was on an inexorable decline.

However, the government’s failure to acknowledge that the decline had come at the cost of an almost complete lockdown merely served as a troubling reminder of its confidence just two months earlier, when it had declared victory over COVID-19 in India.

It was this confidence that underlay the sense of complacency among the general public and the government machinery that ultimately helped make India’s second COVID-19 wave more lethal than it needed to be.

Contrary to the government’s optimism, India seems set to see new waves of COVID 19 every time it relaxes the restrictive measures put in place to curb viral transmission. The reason for this is simple — the virus is still actively transmitting within the population, and generating more and more mutations and variants as it does so.

As for the immediate future, epidemiologists and medical experts cite several reasons why India can’t avoid a truly lethal next wave, mostly likely this winter. These reasons include newly mutated virus variants, a suboptimal vaccination strategy, vaccine breakthroughs via immune evasion and the natural expiry of vaccine protection and finally, the natural tendency of the virus to find new and unprotected hosts.

Out of these, the biggest risks are the potential emergence of virus variants that can override vaccines, and a large, vaccine-naive host-base, i.e., those below 18 years of age.

US Centers for Disease Control and Prevention have warned recently that many of these variants can override vaccines and unleash severe disease. “They are fast movers. Some of the new variants, including the D614G mutant, can spread more rapidly than the original coronavirus by infecting human respiratory epithelial cells. Death is common after infection. Moreover, the mutant can resist monoclonal antibodies effectively,” the CDC cautioned.

According to medical experts, booster shots of the vaccines will be required to protect against emerging strains. However, such protocols are not yet in place in many countries, including India.

Meanwhile, Institute for Health Metrics and Evaluation (IHME), an independent global health research centre at University of Washington, predicts that daily deaths in India will peak at 5,600 soon. It has also projected 665,000 COVID deaths by August 1, 2021.

“Without drastic measures to decrease social mixing and increase effective face-mask use, the situation currently looks quite grim in India,” the Institute warned. It estimates that universal mask coverage could prevent 70,000 deaths and that if the vaccination target for every Indian above 18 is met on schedule, another 85,600 lives would be saved by August 1.

Critical Winter

Based on the history of the COVID-pandemic elsewhere, the third wave is most likely to take place during the winter season in India, ie., towards the end of November or early December 2021. This is also going to be the festive season in the country. According to a review published in International Journal of Environmental Research and Public Health, 5 August 2020, it is very unlikely that the present pace of vaccination can cover the entire vulnerable population of India within this short window of time before the festive season.

Even though the inoculation with the current vaccines provides the much needed protection at least from disease severity as incidence of reinfection has now become pretty common in India, the challenging part is how to cover the significantly large still unprotected population across the country within this short period.

According to a recent media report citing the views of M Vidyasagar, senior professor at IIT, Hyderabad, and a mathematical modeling expert under the government of Karnataka, even if the government could vaccinate the entire population, the possibility of a ‘Third Wave’ of COVID-19 can’t be avoided. This is because the vaccines currently form part of the National COVID-19 Vaccination Programme will lose their immunity within 6 months. So, even those people who are vaccinated will begin to lose immunity towards the festive period.

What can make things even worse, according to Dr. Giridhar Babu, Epidemiologist and Professor at Indian Institute of Public Health in Bengaluru, is the fact that children are likely to be the most affected and vulnerable in the new wave. This is due to two reasons: First, the vaccine naive children can easily become hosts to the virus, which is looking for unprotected hosts, and secondly, the vaccination of children is still a question mark, given that the clinical trials for child immunisation with existing vaccines have just started and will take another six to eight months to generate their primary data. Moreover, manufacturing the required doses too will take time.

Experts are also of the opinion that even if the government could vaccinate the entire population, the possibility of a third wave can’t be ruled out as those who get vaccinated now are likely to lose much of that immunity over the next six months.

Rapid transmission

In a series of papers published in the Journal of the American Medical Association entitled; Temperature, Humidity, and Latitude Analysis to Estimate Potential Spread and Seasonality of Coronavirus Disease-2019, authors Mohammad M Sajadi and others have observed certain links to the peak of infection and the climatic variations.

They base their conclusions on insights gleaned from the experience with the COVID-19 pandemic so far. The impact of the weather on the progression of the pandemic was highlighted through a comparison of the experience of the southern and northern hemispheres of the earth. The authors point out that the COVID-19 situation in the southern hemisphere was different from that of the north. While the southern hemisphere was moving out of the winter at the peak of infections, the southern hemisphere was moving into winter.

They point out that in the case of novel viruses, the prevailing climate has a crucial role to play because they have enough time to get established in the new environment. If there is a suitable climatic slot for the virus to flourish, there is a chance for a ‘third or fourth wave’, when the same season returns.

Another study entitled—Severe Acute Respiratory Syndrome (SARS): A Year in Review, published in Annual Review of Medicine, observed that SARS and MERS are reported to be more related to climatological factors than secondary circulation dynamics. This makes novel viruses much less predictable than established viruses with respect to their persistence and re-emergence in the following years or seasons. Sometimes they can be more virulent in their later outbreaks.

The CIDRAP Viewpoint Working Group on COVID-19 at the University of Minnesota have presented their conclusions in Part I of their report: “The Future of the COVID-19 Pandemic: Lessons Learned from Pandemic Influenza”. This study observes that until a novel virus becomes endemic and recycles from its existing form to other mutated forms, its seasonal prevalence would be difficult to predict. At the same time, they confirm an extended period of persistence for the current SARS-CoV-2 pandemic.

Among the various climatic factors, humidity seems to occupy a prominent role, as it is related to the amount of water vapour held by the air. It must be noted that atmospheric pressure and temperature also can modulate the humidity of the air. A relatively small amount of water vapour is able to saturate cold air, whereas more water vapour is required to bring warm air to saturation. Moreover, the viability of pathogens in exhaled aerosol droplets is crucial as a potential driver of COVID-19 transmission, according to the paper published by Tellier, R. in the Journal of Royal Society Interface, 2009: (Aerosol transmission of influenza virus: A review of new studies). So, winter season is considered as the most ideal time for the third resurge of COVID-19 in India.

Double and triple mutants

Epidemiologists theorise that the current resurgence of COVID-19 in India is caused to a large extent by the double mutant variant, B.1.617, first discovered in the country. The B.1.617 variant was detected in Maharashtra in October 2020. It was found to carry two key mutations — E484Q and L452R — and hence referred to as the ‘Double Mutant’. But now, more key mutations have entered the scene. A new virus variant containing three key mutations — E154K, P681R and Q1071H — has also been found and is often referred to as the ‘triple mutant’. According to some sources, the vaccines currently in use in India can fight this variant and reduce the severity of the disease, though they cannot block it from proliferating in the body completely. So some experts believe that B.1.617 can remain dominant in India’s third wave of COVID-19.

The three mutations found in the ‘triple mutant’ can make the virus more infectious in nature with a high rate of mortality.

These mutations, initially observed separately in other ‘Variants of Concern’ from the UK, South Africa and Brazil, comprise: (i) Deletion and two changes in the spike protein (ii) Deletion of H146 and Y145, and (iii) Mutation in E484K and D614G in the spike protein.

According to Dr. Vinod Scaria, chief scientist at the Institute of Genomic and Integrative Biology (CSIR-IGIB), New Delhi, the variant B.1.618 makes 12% of all the SARS-Co-2 found in India whereas B.1.617, with three key mutations, constitutes about 28%.

Besides the above two Indian variants, other variants of concern circulating in India include the UK variant (B.1.1.7), the South African variant (B.1.351) and the Brazilian variant (P.1).

Regarding the potential of these variants to cause a ‘third wave’ of COVID-19, Dr. Vinod opines that nothing can be said conclusively at this stage, as more research is needed to connect these variants with the surge of infections. However, since some of the mutant variants are feared to be able to escape RT-PCR based detection tests, there is a chance that they can increase the chance of transmission of the disease even more.

— with inputs from N S Arunkumar and Agencies

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What can be done?

There should be a surveillance system for immediate detection of deadly variants of SARS-Co-V2. All state and central government owned research institutions must be linked to a single online platform. Similar to what WHO is now beginning to set up in Berlin, a ‘Pandemic Surveillance Hub’ must be established, giving timely feedback to the government so that timely actions can be taken.

The following basic facilities must be ensured to address the upcoming situation:

Oxygen

Rather than attempting to transport and distribute medical oxygen based on demand, Oxygen Plants can be established in all government hospitals. There should be a real-time monitoring mechanism for the countrywide production, storage and distribution of medical oxygen. The equipment developed by DRDO for the army can be supplied to hospitals.

Drugs

All essential drugs used for the clinical management of COVID-19 and associated ailments like Mucormycosis must be made ready to be supplied to all states. Accessibility to these drugs must be ensured through efficient procurement mechanisms. Indian companies can be given licences to make generic versions of the drugs like dexamethasone, remdesivir and amphotericin-B.

Vaccination

The rate and speed of vaccination should be increased so that it covers people based on two factors instead of age alone: (1) Those who are the most exposed to the disease, like courier agents, food vendors, etc. & (2) those who are most vulnerable due to their predisposed health conditions or whose immunity is impaired. Vaccines for children must be brought in urgently.

Ventilators and Beds

The government should ensure maximum hospital beds at its disposal and they must be used for the treatment of COVID-19 patients. The supply of the required numbers of ventilators and beds should be ensured, with some reserved to manage emergency situations. The availability of beds, ventilators and other facilities must be documented and updated.

Healthcare Workforce

Healthcare staff who have recently retired should be returned to practice. Those from academic or scientific facilities can also be shifted to frontline healthcare duties. All healthcare personnel must be given training for their own personal protection and for the diagnosis and management of COVID-19 patients. There must be a window for registration of all the working health staff.

Hospital Hygiene

Ensure proper hygiene and sterile practices in every clinical procedure in hospitals as well as the hospital environment. Eliminate possibilities of secondary infection to patients while in the hospital. Implement strong quality audits at hospitals and provision to punish hospital management/authorities if found fluting quality standards. 

Global Scale Telemedicine

Telemedicine consultation should be available to COVID-19 patients also, following the model successfully followed by the State Government of Kerala. This can help patients to get immediate medical help and guidance. This can be scaled up to a global level through linking with other networks such as British Association of Physicians of Indian Origin.

Patient Mobility Services

Transportation facilities must be ensured for quick and safe transportation of COVID-19 infected patients to hospitals. As the patients would require oxygen during transit, the vehicles must be provided with such facilities. Apart from ambulances, other types of rented vehicles also can be equipped for this purpose to address emergency situations.

 

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