CME INDIA Presentation by Prof Dr. S. Arulrhaj, Past National President, IMA, Past National President, API Past Commonwealth President, CMA, UK, Commonwealth Medical Association Trust, UK, Founder Chairman CHPA, UK, Founder, Commonwealth Medical Evarsity. Dr. B. C. Roy National Awardee. www.healthy-india.net.

What is going on?

• An unprecedented upsurge of COVID-19-positive cases and deaths is currently being witnessed across India. According to WHO, India reported an average of 3.9 lakhs.
• of new cases during the first week of May 2021 which equals 47% of new cases reported globally and 276 daily cases per million population.
• The positive cases and death cases of COVID-19 in India were all time high in midst of a catastrophizing second wave.
• The states of India are interconnected so there are very high chances of the virus spreading from one person to another person when social distance goes down. This is why states such as Delhi, Haryana, Karnataka, Tamil Nadu, Kerala, and Maharashtra are mostly affected by the second wave. Leading to more penetration even in Rural India a phenomenon hitherto not seen.

What is the meaning of a wave?

• Devoid of a precise technical definition, the term ‘wave’ is used to signify the rising and falling trends of a disease over a long period of time when drawn over a graph. The term is also used to describe the seasonality of a disease or infection over successive periods of time.
• In India, there were two distinct waves of Covid-19 infections over the last one year with the first wave reaching its peak in September last year and the second wave beginning from March-April reaching peak on 22 April 21.

What is 3rd wave?

• The third wave currently under discussion refers to a possible surge in cases at the National level. The National curve seems to have entered a declining phase now, after having peaked on May 6. In the last two weeks, the daily case count has dropped. If current trends continue, it is expected that by July, India would reach the same level of case counts as in February. If there is a fresh surge after that, and continues for a few weeks or months, it would get classified as the third wave.

Will wave THREE come?

Health authorities have been warning of a possible third wave of Covid -19 infections as in other Nations (1)

Model based Predictions of Third Wave

• SIR model Predictions.
• The Susceptible–Infected–Recovered (SIR) model is formulated for epidemiology. As per SIR Model analysis the third wave will start in the first week of August 2021 and will end during October 2021. As per the result , the third wave will take a peak during the first week of September 2021 in India. Like the second wave, the predicted epidemic rate of the third wave by fractal model shows some peaks after October. The third wave may be controlled by preventive arrangements, if so then these peaks will not occur. (2)

Will third wave only affect Children?

• No. Both waves till now saw virus affecting all age groups and mortality was predominantly high in old age people (22%) and the least among children(0.3%). Similar trends in other Nations too.So clear indication that all age groups were affected in both waves and to large extent in similar way. But as Second wave had 4 times the positivity of first wave it involved much larger population causing bigger havoc. 

1st wave learnings & 2nd wave learnings

Table below shows age demographic and death rate in two waves (data up to peak of second wave 22nd April)

Above Table indicates that age Pattern remained same despite vaccination of older age population; On similar pattern should be the infectivity of Third wave though likely to be on much smaller scale.

• Kids usually have mild illness and improve fast. Incidence of serious multi inflammatory Syndrome MIS -C is less than 1: 1000 cases. Also ACE 2 receptors which provide binding site to Virus for entry into cell are poorly developed in Children making them less vulnerable to Covid19.  This data may provide a sigh of relief to all mothers (3).

Herd Immunity – Hope to contain Covid

• Herd immunity’, also known as ‘population immunity’, is the indirect protection from an infectious disease that happens when a population is immune either through vaccination or immunity developed through previous infection. Herd immunity against COVID-19 should be achieved by protecting people through vaccination, not by exposing them to the pathogen that causes the disease. 
• Vaccines train our immune systems to create proteins that fight disease, known as ‘antibodies’, just as would happen when we are exposed to a disease but – crucially – vaccines work without making us sick. Vaccinated people are protected from getting the disease in question and passing on the pathogen, breaking any chains of transmission.(4)

Herd Immunity: Present Scenario

• Herd Immunity occurs when 75 % of the Population are immunized either by Infection or vaccine.

135cr Population 75% = 100 crore around.

• For one positive patient 10 more patients are Positive but not detected. Rough Estimate:

Up to now cases. 3 Crore Test Positive Report TPR

Active 3 X 10 = 30 Crore

Vaccinated = 23 Crore (9.2cr 1st dose. 4.7cr both doses) Total 53 Crore

Suggestive if the fact that large population is still vulnerable to Infection (5)

• So, we need at least 60 crore population to be immunized by vaccination of Two Doses to reach to Herd Immunity & walk without Mask.  Herculian task but has to be done.

Further Viral Mutations – Threat looms large

• The recent emergence of more transmissible COVID-19 variants with higher case fatality poses a serious threat to efforts to control the pandemic. Those variants already identified render anti-viral treatments ineffective, evade immunity from natural infection and, with emerging evidence that some variants reduce efficacy of the first-generation vaccines. It is inevitable that further variants will emerge that pose a more significant threat to vaccine efficacy.

Is coronavirus 3rd wave 100% inevitable?

• Ever since Principal Scientific Advisor K Vijay Raghavan warned of an impending third wave of Coronavirus in the country in early May, authorities and health experts have warned people of the third wave of Covid-19 several times. Even though the exact timing of the third wave remains uncertain, Vijay Raghavan few days later said that if strong measures are taken then the country could altogether avert the third wave (6).

Will the 3rd wave be more lethal?

• Usually as the number of people who have been infected with the disease increases, the successive waves of infection are milder in comparison to the initial waves. However, in case of India, Coronavirus defied this logic as contrary to estimates only a miniscule population of the country had got infected with Coronavirus in the first wave and an overwhelming majority of people were still vulnerable to Coronavirus.
• Witnessing a large number of cases and an increase in number of deaths during the second wave, many are predicting that the third Covid-19 wave will be even more lethal in the country.

A. Covid-19 Third wave in India could be as severe as second(6)

A third wave of Covid-19 could be just as severe as the second wave and can last up to 98 days, an SBI report said on Tuesday. Citing international experience, the SBI Ecowrap report estimated that the intensity of the third wave won’t be much different than the second wave. However, it said that deaths can be minimised with better preparedness.

B. Covid Third Wave: What Epidemiologists say? (7,8)

• Both alpha & delta variants were the main drivers of the second wave in India. Will India experience a third wave and worryingly more waves in the future?
• The case count will decrease beneath 50,000 around June 13 – Dr.Giridgara Babu
• If we had acted in mid-March thousands of lives could have been saved. We need to stay prepared for any number of waves& variants – Dr. Bhramar Mukherjee
• There is no doubt that there will be another wave around November December. – GB
• The government is projecting 10 million vaccinations per day by mid July. Over 28 million have been already infected naturally though the actual numbers will be many times more. – GB
• We need to keep India’s age pyramid in mind. 40% of the Indian population is in 0-18 years for whom we do not have any vaccines. If we can get Pfizer vaccine for those aged 12-18 years & pregnant women & Covaxin gets approved for kids that will be a big help to the immunisation strategy. – BM
• The 1.3 billion plus people in India constitute the source population at risk of infection, we have a long way to go, Ideally, more than 70 % of people should be protected with the vaccine in order to have lower peaks of the waves. – GB
• Every eligible person should get at least one dose by December, – GB

C. What Dr Ravi, Neurovirologist, says? (9):

• It took nearly 8 weeks in UK to go from second wave to third wave, 17 weeks in Italy, 23 weeks in USA. The next wave in India is supposed to be in November or December 2021.
• USE DATA DRIVEN INTERVENTION: tell the exact data of the death, as fake data can allow the modellers to make unreliable projections, and wrong policies and programmes are formulated.
• A core expert group comprising clinician, epidemiologist, and laboratory personnels should be constituted at every level (Districts, State, National).

D. SBI Study (10)

How to Gear up for third wave?

Govt and hospitals to focus on:

1. Ramping up their ICU beds and facilities especially for children.

2. Improve the infrastructure in the ICU, pediatric and neonatal ICU.

3. Prepare rooms with two portions in room keeping in mind that an attendant will have to be kept with their Covid-positive child.

4. Procuring oxygen masks, high-flow nasal cannulas, pediatric oximeter probes, special ventilators and BIPAP machines & Drugs, adults & children.

5. Training of health personnel for pediatric interventions, neonatologists and paediatric intensivists which could be a serious limiting factor.

6. Installing Oxygen Generators in Hospitals.

7. Universal Vaccination

• Above 18 years are getting vaccines.
• Increase vaccination numbers.
• Promote vaccination in Rural areas.
• High risk groups to be vaccinated 1st.
• After lockdown vaccination to be initiated in big industries, as vaccination camp
• Vaccine to reach doorsteps as done in many states.
• Start vaccine between 2 to 18 years soon.
• Make Vaccines effective against Mutants too.

8. Vaccine for Mutants

• Most first-generation vaccines and treatments target a single virus protein, the spike protein, and are very vulnerable to mutations and emergence of new strains. Given that we are currently only finding variants where we have the capability to sequence, and not necessarily where they are occurring, this could already be the case.
• It is not coincidence that the three new variants have been picked up in the last quarter of 2020, we can expect a more rapid evolution of the virus in 2021 and more new variants as it adapts to humans (biological adaptation) and is now under increasing immunological pressure from infection and vaccination (immunological adaptation).
• Vaccine for children below 18 yrs.
• 12 year onwards Started in US UK. On May 10, the Food and Drug Administration (FDA) expanded the emergency use authorization for the Pfizer-BioNTech COVID-19 vaccine to include adolescents as young as 12 years old. Other COVID-19 vaccines may be approved for younger adolescents over the next few months.
• Moderna announced in an early analysis of phase 2 and 3 results that its clinical trial showed that the vaccine had an efficacy of 96 percent against symptomatic coronavirus infection in 12- to 17-year-olds. Trial for above 2 yrs started Pfizer’s ongoing pediatric vaccine trial includes children 6 months to 2 years old. Moderna is also recruiting younger children for its pediatric vaccine trial.

9. Clinical Challenges 3rd wave

• Youth & children
• Clinical features
  • Early Breathlessness
  • Early cytokine storm
• Diagnosis
  • Atypical Presentations
  • Mutant Identification
• Complications
  • systemic inflammation
  • Skin & vascular lesions

10. New Normals 3rd Wave

Treatments

• Doxy Azithro HCQS Ivermectin gone.
• Antivirals – Guidelines. Remdesivir gone; New arrivals?
• Monoclonal Antibodies.
• Steroids (SUPER HEROS).
• Heparin & Antiplatelets (SUPER HEROS).
• Oxygen (SUPER HEROS).
• Oxygen Administration.
• Nasal catheter, Mask, Rebreathig bag, NIV- CPAP.
• Invasive Ventilation– Adult, Paediatric, Neonatal.

11. Public responsibilities

• People should reduce hospital visit for simple issues.
• Avoid 3 Cs: Crowded places, Close contact with others, Confined places with poor ventilation.  Wash hands frequently. Wear mask properly.
• Parents must not forget their bit to Educate Children and adolescents about Covid Appropriate behaviour, Disease treatment and Self-management in Isolation.

12. Professional Associations & IMA

• Sensitise Family Physicians – First Responders.
• Education & Training HCP.
• Promote Fever clinics.
• Develop Management Protocols.
• Support Government with Bed, care, O2 & Vaccination etc.

13. Government of India

• Pandemic Preparedness.
• UNIVERSAL VACCINATION.
• Invest on Health Infra.
• More Testing Tracking Contacts & Isolation.
• Travel Checking – Airports.
• Vaccination policy for Domestic & International Airports.
• Digital Travel Data & Tracking.

Conclusion

• Covid third wave is inevitable in late 2021, as per factual analytics.
• More youth & children will be affected, Mumbai example.
• Sever lung Inflammatory disease will be seen.
• Mortality may be more.
• More Admission Beds & ICU care will be needed.

Way forward – SURGICAL STRIKE ON COVID

• Universal Vaccination.
• Preventive Measures continuing-SMS.
• More testing, Tracking & Isolation.

We can avert or lighten the numbers, severity, Death & Children infection. Together we can; will achieve.

(Edited by Dr S K Gupta, MBBS MD (Med), FICP CFM (France), Senior Consultant Physician and Internist, Visiting MAX Super Speciality Hospital, Clinical Asst. Professor GS Medical College Uttar Pradesh).

References:

1. Clipped from The Indian Express – May 20,2021
2. Eur. Phys. J. Plus (2021) 136:596, https://doi.org/10.1140/epjp/s13360-021-01586-7
3. Covid update 182 www.who.int/covid19
4. American Journal of Life Sciences 2021; 9(2): 19-24 http://www.sciencepublishinggroup.com/j/ajls doi: 10.11648/j.ajls.20210902.11ISSN: 2328-5702 (Print); ISSN: 2328-5737 (Online)
5. Finance Minister The Hindu 10th June 2021)
6. Financial Express Online | May 20, 2021 1:52 PM
7. Jun 02, 2021, 04:54PM IST Source: TOI.in
8. The Hindu – 6th June 2020
9. The Hindu – June 9th 2020
10. Economic Times Online Last Updated: Jun 02, 2021, 05:56 PM IST

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