India needs to prepare well for a competent and concerted response that can anticipate, avert or attenuate future public health emergencies
Several States in India have started to open up, with their respective lists of permitted and restricted activities. While there is concern about the undercounting of cases and deaths in some States, the overall trend of a receding second wave is not being disputed. The frenetic rush and public anguish, which marked the frequently futile search for hospital beds that became the painful images of the second wave are no longer the dominant themes of Indian or international media reports. That, in itself, provides assurance that the second wave is ebbing.
However, it would be unwise to assume that the turbulent waters of the second wave have stilled and the boat is set on a safe course ahead. We still need to see whether there will be a rebound when the lockdown eases. There are already reports of people rushing to tourist spots and holiday resorts. Malls and restaurants are crowded. These represent the more affluent sections, but the signals they send can misguide the rest of the population. Desire to live life to the full is understandable after lockdowns but wisdom must caution against abandonment of safeguards against a virus which still poses an active threat. Common sense tells us that if some careless revellers start prancing around when the boat has just left the rough sea, it can still capsize, putting everybody in danger.
Even as we steady the boat, when it sails out of choppy waters, we must watch the charts and study the signals to see when it might be rocked again by a third wave. Considerable speculation has already commenced in the media about the timing and contours of such a wave. Predictions have been made, by mathematical modellers and some epidemiologists, that we may be rocked by the third wave in November this year. While the accuracy of such predictions is uncertain, since they are based on several assumptions, we do need to be well prepared to meet such a threat whenever it arises.
Several elements will determine the severity of a third wave: the nature of variants in circulation; the number of persons who have acquired immunity from vaccination or recent infection; the number of susceptible people who are available for the virus to infect and cause symptomatic illness; adherence of people to public health advisories on wearing masks and avoiding crowds; ability of public authorities to prevent super-spreader events and the preparedness of our health systems to ensure timely case detection, supportive home care or assured hospitalisation with competent service provision.
Our surveillance systems must be sharpened, to detect the levels of circulating variants and emergence of new forms. Case detection will need to be based on both testing and clinical features gathered by healthcare teams visiting homes. False negative results from tests can be compensated by adding clinical criteria (syndromic surveillance, as used for other infectious disease outbreaks). Genomic analysis of 5-10 per cent of all positive test samples would be needed, with higher levels of scrutiny for virus samples recovered from international travellers. Since testing would pose more challenges in rural areas, symptom-based surveillance and contact-based quarantine would have to be followed, along with the use of rapid antigen tests for spot diagnosis and mobile laboratories to carry samples for RT-PCR testing to authorised laboratories.
Home care would be appropriate and adequate for 80-85 per cent of all symptomatically infected cases. Primary health care teams must be trained in providing supportive care and monitoring. Symptoms, pulse oximetry readings, temperature should be part of daily monitoring of such home-managed persons. If the person is a diabetic, blood sugar too should be monitored with a glucometer. Telemedicine facilities should be scaled up and standardised, to support home management. Prior planning should be done to ensure timely transfer of a person under home care to an intermediate or advanced care facility when the need arises.
Sub-district, district and medical college hospitals should be equipped to handle a possible surge of the third wave. It is difficult to predict how severe it would be, as it depends on the behaviour of the virus and its different variants, as well as the behaviour of people in adhering to public health advisories on masks, ventilation and avoidance of crowding. However, strengthening of the healthcare infrastructure and health workforce at various levels of care is long overdue.This is an opportunity to reduce the existing disparities of healthcare provisions between states and districts as well as between urban and rural areas.
There is speculation in the media that children will be more affected in a third wave. It is possible that more children will be exposed in an open society than during the first wave when they were mostly sheltered or even during the second wave when they were still partly guarded. Numbers of susceptible adults may also decrease by that time as several of them would have been vaccinated or infected by then. Nevertheless, adults will still be far more likely to have severe infection than children where the vast majority will have asymptomatic or mild infections. Even so, expanding hospital services for children, including intensive care capacity, will still serve a useful purpose by strengthening paediatric care for many serious illnesses.
Vaccination must be speeded up, with accelerated domestic production and international procurement. The number of vaccination centres must be increased. Vaccination in rural areas will require careful planning of logistics, sensitive communication for confidence building, support for overcoming technology barriers to registration and availability of close-to-home vaccination centres. The Delta variant poses challenges with high infectivity and capacity for vaccine evasion, at higher levels than the wild virus or the Alpha variant. However, there is reassuring evidence that the variant responds well to two doses of all available vaccines. So, we need to provide both doses of vaccines to vulnerable persons, identified by age and co-morbidities. Even pregnant women now need to be regarded as candidates for priority vaccination.
The period of relative calm will also give us time to build partnerships between and among government services, local bodies, non-governmental organisations, school personnel, trade unions, industry representatives, community groups and citizen volunteers. Capacity-building for concerted action among these groups will give us the collective strength to respond more effectively to the third wave. Whether to promote Covid-appropriate behaviour or to reduce vaccine hesitancy, local networks in the community are vital. Community based surveillance systems can also give early alerts of rising cases.
We should also utilise this opportunity to enhance health and nutrition literacy to increase immunity. Healthy diets and physical activity are vital for both innate and adaptive immunity to fight the virus and also for prevention and control of non-communicable diseases which are the predominant co-morbidities that predict poor outcomes in Covid infection. Promotion of healthy living habits using the Covid platform, will help foster future health and well-being.
We need to prepare well for a competent and concerted response that can anticipate, avert or attenuate future public health emergencies. By being forewarned and forearmed, we can restrict the third wave to a ripple rather than a tidal wave.
The writer, a cardiologist and epidemiologist, is president, Public Health Foundation of India. The views expressed are personal.