Is India heading towards a possible fourth wave of COVID?

As far as the pandemic goes, the number of fresh cases of COVID-19 in the country continues to rise with Delhi and Maharashtra, considered among the most vulnerable states in the country. Is this a sign of another COVID-19 wave in India, and what precautions people and health systems have to take to avoid the massive devastation as seen during the second wave. In a conversation moderated by Ramya Kannan, J RadhakrishnanAnd Prabhdeep Kauri, discuss possible scenarios. Edited excerpt:

Is the rising case and test positivity rate, which we are seeing in Delhi and Maharashtra, a sign of a possible fourth wave of COVID-19 in India?

J Radhakrishnan: This is a tricky question; Whether or not the next wave will come depends on what kind of version will come. Secondly, it will also depend on the level of immunity in the population – both due to recovery from a natural infection, and also on the rapidly increasing vaccination. Of course, we must remember that vaccination has been around for a long time, and it is practical to expect different levels of immunity from it. So our best position is that we need to be on guard, we just can’t be overconfident that there can’t be any more waves, because the last time I remember was January-February of 2021, people clearly Was overconfident. On the other hand, I personally think that unless there is a major delta-like version, it may not be as bad as it was in May last year.

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But having said that, what we need to look at is really testing it all in all settings. Now, what has happened is that there has been a sharp decline in people subjecting themselves to testing. We also need to pay special attention to the places where doubling is taking place. For example, the way cases have increased in Delhi. If, over a continuous period of time, a district or group of districts starts showing such signs, it is a sure warning. We also have to do genomic sequencing on a regular basis.

Prabhdeep Kaur: I agree, first of all, with Radhakrishnan on the fact that we should continue to look for any changes in the existing pattern. I think that’s the most important thing in epidemiology – whether we’re finding a new group, in a population where we don’t expect it. Also, if we see a steady increase in cases in a particular district or several districts, then we need to worry about it, as we have seen in the previous waves. You are right that Delhi and Maharashtra usually show the first trend and other states follow it. With that said, I believe it is likely that we may see some jump in cases as well.

However, to what extent we need to worry about this is an entirely different issue. This could mean that we need to improve our surveillance – that is, most importantly, both epidemiological surveillance and genomic surveillance. But whether we need to restrict any activity or do we need to worry about increasing hospitalizations, it is too early to see any of this at this point in time.

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Do we expect this wave, if it does indeed come, to dominate the XE version?

Prabhdeep Kaur: As we know, in all the genomic surveillance data that has been released by various certifying institutions, BA.1 was predominant. And now it has been shifted to BA.2. Currently, with the entire INSACOG network of laboratories, I think we are in a very good position to know when changes occur in our population. In line with international trends, as you have seen in other countries such as China, Thailand and the UK, we know that the version has changed, with the new version replacing BA.1 and BA. 2. The same is likely to happen in India, and we just need to keep a close eye on it.

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But as far as our limited understanding is concerned, since we’ve only been studying it for a very short period of time, it’s clear that this new version is kind of major. We also know that it has very fast growth and high transmission efficiency. So this is something that we should keep in mind. We know that these patterns are global as far as COVID is concerned. So, what we get to see in one part of the world, over time, happens in other parts of the world. According to this, yes, I do believe that the XE could be the next variant, which could replace the old variant in the times to come.

J Radhakrishnan: In the latest data we analyzed in Tamil Nadu between January and March, the Omicron version was 94.7% and the delta was still around 2.7%. All other variants were about 2.6%. Of course, we have BA.1 and BA.2.

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Ultimately, we have to be concerned about whether there are clinical changes in the new forms, and how we treat them. Delta rapidly affected the lungs, rapidly becoming extinct. Till date, we have, in the state, only 232 active patients, hardly 10 in hospital and none in ICU. This is a good sign.

But the same thing happened in January 2021 as well. Before we knew it, Delta came in and it spread very quickly. Therefore, we are taking samples as per the advice of the NIE and not only when there is a family group. We are taking samples and keeping an eye on those returning from abroad. Till now, we have not taken any XE version in Tamil Nadu.

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The main concern at the implementation stage is the abandonment by the public of both the pillars that helped us in the previous waves – masking and social distancing. Another source of concern is the loss of interest in vaccinating oneself.

Isn’t a period of three months long enough to study a variant, since XE was first described in January? We have three months to study it, why are we still saying we have limited understanding of the recombinant version?

Prabhdeep Kaur: As far as COVID is concerned, when we plan a response – either public health or clinical care – we need to analyze whether there is anything more that needs to be done than what we are currently doing and on a wider scale. are. So we need to keep in mind that there are certain characteristics of diversity that determine whether we do or don’t do certain things. What happened is that this version didn’t show any features that changed the course of the interventions we were running. Whatever solutions we started with for Omicron seem to be suitable for this version as well. We continue to see if the variants are further mutating, or causing case death or more hospitalization. Since none of this has been observed or documented, the focus remains on the same measures that were already initiated, which are promoting boosters, ensuring that masking continues and the very best. be monitored. As an epidemiologist I will stress again that surveillance is really important. I think we’re a little lax with that, but if we keep looking, the patterns will really tell us if there’s something different going on around us besides, of course, genomic monitoring.

Since compulsory masking has been officially removed, will it be difficult to ensure masking as a public health measure now?

J Radhakrishnan: There should be public health preventive measures, we cannot leave them. This is an important protective mechanism, since now that crowds have resumed, it is always safe to wear a mask. It gives us some level of protection, even if others around us are not masked yet. People increasingly forget the importance and relevance of non-medical measures which are very important. They have to be reinforced from time to time. Caution is far better than overconfidence.

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Prabhdeep Kaur: We at NIE are monitoring the use of masks in Chennai city. We saw the use of masks decreased in the second half of 2020, and then, after the delta wave around March-April, it increased. Thereafter, again, in the later part of the year, around the festive season, there was a further decline. So what we understand from this is that people are responding to what they are hearing from the media and from various sources.

Also vaccination is very important. We must use this time, when cases are still not high, to aggressively educate the public to take their first and second doses, and use boosters if they are eligible for it. Masking and vaccination are the best tools we have today.

In the case of a possible third or fourth wave, is there a way to recommend that states implement some sort of shutdown, or once again implement restrictions in phases?

Prabhdeep Kaur: I think now we have a pretty good idea of ​​when to impose sanctions and what restrictions are needed, which is what we’ve learned over the past two years. And we are continuously monitoring the situation. So every week, we analyze the data that is in the public domain, which is released by the state governments, and we look at some key indicators like the number of cases, test positivity and what is the change in bed occupancy.

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What we’ve seen over time isn’t that all of a sudden you need to shut everything down. It takes time to convert all these indicators. This, in fact, gives us enough time to respond as to what measures we need to take in advance. So as of now, I think we are doing well and there is no need for any restrictions. But we must continue to monitor these indicators very carefully.

We’ve also learned that extreme measures are really the last option, and we may not need them. But if there is any concern, and these indicators suggest that there is a very rapid transmission, then we need to think about measures like enforcing masking compliance, reducing crowding and perhaps limiting the size of gatherings.

Given that the economy is still recovering from the brutal lockdown, will it be easy to reimpose restrictions?

J Radhakrishnan: As Kaur said we now have a huge amount of learning compared to what we knew in the beginning. And as implementers of policy, we have been consistently guided by public health expertise at both the national and international levels.

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The latest instructions are that you need to look at test positivity, hospital bed stay and the rate of spread. We are also constantly practicing militarily – use of beds, use of oxygen, ventilators, if every service required is adequately prepared.

With this information, at present, I personally feel that we are not at the level where we need to look at the extremes. But we definitely need to understand that common sense precautions, like wearing a mask in crowded areas, getting tested if you have a fever or someone near you is sick. I still think we should take it week by week, look at the weekly trends and prepare ourselves. This is not the stage where we need to panic.