CME INDIA Presentation by Dr. S. K. Gupta, MD (Med), FICP, CFM (France) Clinical Asst. Professor GS Medical College, CCSU, Uttar Pradesh, India. Visiting Consultant, Max Super Specialty Hospital, New Delhi.

Third Wave? Third Booster?

A meeting was held on the Aegis of East Delhi Physicians Association on 10th July 2021. Padam Shree Prof. Raman Gangakhedkar from ICMR enlightened the audience with his original ideas, Dr. Moorjhani, Infectious Diseases Specialist New York, USA, also shared his experiences. Meeting was chaired by Dr. SK Gupta, Dr. Pankaj Chaudhary Dr. Anupam Kr Singh and Moderated by Dr. Ruby.

Cape of Good Hope

The Critical Issue

Key issues

Dr S K Gupta:

• Should HCW especially Doctors opt for 3rd dose Booster of Covid Vaccine as it is already six months since they received last dose, as antibody levels might have waned significantly? 

Dr Gangakhedkar:

• No need of third Dose (Booster) even to Health Care Workers in current scenario because:
  1. Data is showing that current covid vaccines (including Covaxin and Covishield) provide at least a year long good protection.
  2. Sensitisation of memory T cells is likely to give longer protection even if antibody titres wane off.
  3. In India vaccination started on Jan 16 so it just bit too early to talk about Booster vaccination even for HCW. Though antibody levels continue to decrease in absence of fresh challenges by the antigen (it is also possible that HCW keep getting some exposure to virus by nature of their job), But T cells seen by Gamma Interferon Ellispot assay have been shown to provide protection against disease.
  4. Covid appropriate behaviour Mask Hand Sanitizer and Social Distancing can protect up to 85% of covid infections.
  5. Currently there are no variants of Public health concern in sight which could be totally evading the vaccine driven immunity. Available vaccines have shown to provide significant immunity against variants of concern.
  6. In case immune escape variant takes over in near future
     • HCW will be the first to be offered the vaccine
     • Vaccines can be tweaked to newer variants.
  7. Though some breakthrough infection have occurred in HCW despite two doses of vaccine. Most of such cases have been mild.

Dr Moorjhani:

• Lately mortality among cases of breakthrough infection has been 0.1% in New York.

Dr Gangakhedkar:

• Mortality after breakthrough infection is mainly has occurred  in very old age  people having comorbidities, so such HCW who are old infirm and have serious co-morbidities can be considered by Booster dose.

Dr Moorjhani:

• In USA third Booster dose is being planned for following patients:
  • Dialysis patients.
  • Transplant recipients.
  • Immunocompromised.

Dr S K Gupta:

• UAE (Dubai) is offering a third dose of Vaccine to its Citizens as the graph of cases continues to remain high despite very high vaccination coverage of population. In UAE more than 50% people received China’s Sinopharm Vaccine.

Dr Gangakhedkar:

• Sinopharm vaccine from China had shown varied efficacy of ~51% to 80% in different countries which remains unexplained. There could be doubts about transparency of data (regarding vaccine) from China. Such a question does not arise for vaccines used in India.

Dr Ruby:

What about the revaccination of those with poor antibody titres on antibody testing?

Dr Gangakhedkar:

• Antibody testing is not recommended for such a purpose.
  • Different vaccines produce different antibodies like anti-Spike, Anti Nucleocapsid IgG Etc.
  • Various antibody kits would measure the differently.
  • Protection cut off levels of antibody have not been defined.
  • T cell responses can’t be measured in routine and are not likely to be commercially available in near future.
  • Antibody levels may vary with time interval of vaccination.
• If a properly timed antibody test is conducted using a standardised kit and results show poor response then Revaccination using a vaccine from different platform (√Vector, √mRNA, √inactivated etc.) should be considered in old, immunocompromised and people with comorbidities.

What concerns now?

• Because of variants the Covid Reproductive number R0 has increased since the middle of April, bringing apprehension- of an impending surge in cases.
• New case surges a global worry but India must still aim to prevent a third wave -WHO’s Dr Swaminathan
• Govt Continues to take strict action: recently busy Gaffar market of Delhi was closed by authorities because people & shopkeepers were not able to obey Covid appropriate behaviour.
• More than 38 crore vaccine doses have been administered in the country so far under the nationwide vaccination drive. But our aim is Inoculation of 95 Crore population.

Motivate yourself, family, and staff to get vaccinated

• Over 1.44 crore unutilised COVID-19 vaccine doses available with states, private hospitals: Centre as on 11 July 21.
• Second wave continues:
• India reported 41,506 fresh Covid-19 cases as of July 11, Sunday, and 895 related deaths.
• Daily new cases at the beginning of second wave were ~8200.
• The daily positivity rate is at 2.25%, less than 3% for 20 consecutive days.
• India continues to conduct high number of tests ~18.5 lakh per day despite dropping new cases.
• Goa, Himachal Pradesh, Kerala, Maharashtra, Rajasthan, Tamil Nadu, Uttarakhand, and West Bengal can be the hotspot of the new Covid surge.
• North Eastern states need to take extra care in wake high load of vulnerable population.
• Kerala continues with high number of cases because state Govt was successfully able to flatten the curve initially.

Final Point

“Ensure strict adherence to the protocols prescribed in respect of wearing of masks, social distancing and other safe behaviour.”

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