The second ‘national wave’ of COVID-19 pandemic in India is over, speaking strictly in terms of epidemiology. The weekly rolling average of new COVID-19 cases has stabilised around 35,000 and the test positivity rate (TPR) is hovering around 2 per cent. The effective reproduction number, popularly referred to as the R-factor, has remained below 1 for many weeks, except for a few blips here and there. The sero-prevalence in the fourth nationwide sero-survey (which had a midpoint of 25 June) indicated that two-third Indian population had antibodies and is thus protected.
It has been three months since the survey—some more natural COVID-19 infections although at far lower rate have been reported and vaccine coverage has improved and two-third adult population has received at least one shot of COVID-19 vaccine—and it is very likely that 80 per cent or above Indian population has protection against the virus, either through natural infection or vaccination.
The key point to remember is that with all these aspects, the ‘national wave’ can be considered to be over; however, the COVID-19 pandemic is not over in India yet.
If the second wave is over, what do the daily new cases indicate? These daily new cases indicate ongoing sustained transmission, a new baseline and reflect the local—at state and district level—COVID-19 waves. There are nearly 70 odd districts across India, which have reported a TPR of 5 per cent or higher and sustained transmission. Kerala, Maharashtra and a few Northeastern states such as Manipur are still witnessing these local waves.
The recent trends should nudge our policymakers and health experts to look at pandemic preparedness and response in India from a fresh perspective. It is time to think about subsequent COVID-19 waves from a sub-national perspective. India may or may not have a pan-India wave of COVID-19, but sub-national or localised waves cannot be ruled out.
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Next Three Months are Crucial
In this context, the next three months, October to December, marked by the festive and holiday season in India and the behaviour of people during this period (shopping& participating in get-togethers) would determine the course of the pandemic. World over, any kind of gathering, be it large or small, has resulted in a spike in COVID-19 cases in the following period. Therefore, even if daily new cases come down in the immediate setting, people must adhere to COVID-appropriate behaviour (CAB). Everyone, especially those not fully vaccinated, needs to avoid gatherings.
With high levels of sero-prevalence, a new variant with higher transmissibility alone may not be enough to fuel the next wave. In fact, unless there is a new variant which has immune escape ability, it is unlikely India would have a major third national wave. However, in some states and districts with relatively low vaccination coverage, combined with low adherence to CAB and mass gatherings, especially in rallies and election campaigns, a fresh surge is a possibility.
If COVID-19 cases in major cities and a few districts go up without a major spike in other states, it could still result in an overall increase at the national level. However, the high vaccine coverage with at least one dose gives us an assurance that the third wave, as and when it arrives, would be like a hill and not a mountain. It is time we shed our fear of the virus but continue to stay cautious and follow COVID-appropriate behaviour.
Shed Fear, Send Kids to School
Soon after the second wave, the discourse in media that third or subsequent COVID-19 waves would affect children was not based upon scientific and epidemiological evidence and can be best described as misinformation. Scientific evidence states that children are not at additional risk of COVID-19 in any subsequent wave and the delta variant does not behave any differently for children than the other and previous variants. Epidemiological data from many countries have pointed out that fully vaccinated adults have far greater risk of moderate to severe disease than even unvaccinated children. COVID-19 has turned out to be a disease with bad outcomes in adults. Fortunately, children are protected.
However, what we do need to know is that children get infected at the same rate as adults. They, however, do not develop severe disease. At this stage of the pandemic, infection alone is not a concern but its outcome is. Scientists and researchers have gained some insights into why children are protected from COVID-19.
First, for COVID-19 to develop into a severe disease the virus needs to enter the lungs and multiply; it does so by attaching itself to the ACE-2 receptors. These ACE-2 receptors are under-developed in children, thereby offering children some protection against severe disease. Second, children have a higher level of active neutrophils, which start eating viral particles before they have a chance to replicate. The epithelial cells in the nose of the children are believed to coordinate this quick response. Third, children mount a better innate immune response than adults. Soon after an infection, the innate immune system of children starts producing high levels of signalling proteins, such as interferon-gamma and interleukin-17, which alert and activate the immune system very quickly. This response is slow in adults, which mainly depends on adaptive immune response through antibody formation.
Fourth, children have a very high expression of a particular gene encoding MDA5 receptor, which recognises viruses and immediately triggers production of interferons. In adults, this response takes two days to get activated while in children it starts on day zero. This quick response is considered a reason why children are better protected. These factors have led scientists and experts to conclude that children are safe from COVID-19.
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Reopen Schools for All Age Groups
It is time Indian states use this science and consider re-opening schools for all classes, with top priority to children in primary schools. The available global data on age distribution of COVID-19 indicates that all children are naturally at lower risk from COVID-19. The age distribution for moderate to severe illness and mortality follows a ‘J-shaped curve’, where 10-year-olds are at lowest risk among all age groups. Thereafter, the risk increases every passing year, in both directions—from nine to one as well as 11 upwards, till let’s say 85 years of age. Children around the base of “J”, 6-year-olds to 14-year-olds, or the age group in primary and upper primary schools, are at lowest risk of COVID-19. In fact, it is among other reasons why primary schools must be the first to resume classroom teaching.
A leading association of 6,000 medical doctors and epidemiologists has categorically recommended that it is safe to open all schools, including pre-schools, with required safety measures. They have reviewed data and concluded that the fears are unfounded and school opening does not increase the risk of SARS-CoV-2 transmission in the community, and that COVID-19 vaccination is not a requirement to re-start schools (this author is a signatory to the recommendations).
Many parents are waiting to get their children vaccinated. Vaccines for kids could be available in the next few months but it will be an add-on and beneficial for only a select group of high-risk children with pre-existing health issues. It is likely to be available for some 12-17-year-old children. In fact, dengue or malaria is proving to be more fatal in children than SARS-CoV-2. We do not close schools during a dengue or malaria outbreak. We should not keep schools closed when COVID-19 is not a risk to children.
While the second national wave is over, not reopening schools is doing immense damage to children’s learning curve and nutritional status in the formative years. In fact, if restrictions must be placed on any age group, they should be for adults. Children are protected and must return to schools.
In the weeks and months ahead, India should prepare for localised waves. People must continue to follow COVID-appropriate behaviour even as kids go back to school. Together, we can do it.
Dr Chandrakant Lahariya (MBBS, MD), Physician-Epidemiologist, is India’s leading expert on COVID-19 disease and vaccines. The views expressed in this article are those of the author and do not represent the stand of this publication.
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