COVID-19 4th wave may not be deadly, but here’s what India needs to watch out for

India has been recording an increase in daily COVID-19 cases for over a couple of weeks now, raising concerns about the fourth wave of infections.
A health worker inoculates a woman with a booster dose against COVID-19
A health worker inoculates a woman with a booster dose against COVID-19
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India has been seeing a steady uptick in daily COVID-19 cases for a couple of weeks now. On April 24, 2,593 people had tested positive for the novel coronavirus in the country, with cities like Delhi, Mumbai, and Bengaluru also noting a rise. A week ago, COVID-19 infections had jumped by 90% in India (crossing the 2,000-mark in a day). However, this was found to be due to a spurt in cases in Delhi and Haryana, and Kerala reporting its COVID-19 number after four days. These, along with the dominance of the BA.2 variant of Omicron in India, have led to concerns about the fourth wave of COVID-19 infections in the country.

While there are indicators that India does need to look out for, experts say it is unlikely that the current scenario will lead to a wave as deadly as the one caused by the Delta variant during the months from April to June last year. They also say that the recent rise in cases is the result of factors including waning vaccine immunity and the lifting of COVID-19 restrictions in most parts of the country.

Will there be a fourth wave?

Dr Shahid Jameel, research fellow, Green Templeton College, University of Oxford, says that it is unlikely we will see a new COVID-19 “wave” comparable to Delta, because “the viruses that are causing the infections now are not fundamentally different from Omicron, which has already caused a lot of infections in the country.” Even the XE variant is not more severe than Omicron, experts have said.

“The BA.2 variant is 2-20% more infectious than Omicron. Schools have reopened and children are not vaccinated. Most states have removed pandemic-related mandates. All of these factors have led to an increase in infections. We will record sporadic increases in different places at different times, depending on local dynamics,” Dr Shahid explains. Pandemics are not just biological and medical, but economic and political, he says. “After two years of restrictions and now vaccinations, people on the street have declared for themselves that the pandemic is over. That is also a major driving force.”

Gautam Menon, professor of physics and biology at Ashoka University, points out that every major wave has been associated with a certain variant. “The original Alpha variant, the Delta, and then the Omicron variants caused a sharp increase. Omicron is also extremely transmissible. Besides, most people (who are eligible for vaccination) have a hybrid immunity at this point – either they are partially or fully vaccinated and/or have contracted the infection. So, for them, especially if they do not have comorbidities, the symptoms are likely to be similar to that of the common flu. While it is always a good idea to be cautious and avoid the infection altogether, the consequences of getting infected have reduced substantially,” he says.

The experts say that while an increase may be recorded, unless India starts seeing a substantial increase in hospitalisation and serious disease, things are likely to remain under control. That being said, Gautam also cautions: “We don’t know what new variants will emerge in the future, and we also know that immunity wanes. But I don’t really trust any projections for a new wave right now. It isn't that I believe that there will not be a fourth wave. It's just that it is impossible to predict.”

What India should watch out for

While what is being called a potential fourth wave may not cause as much concern as the previous waves, experts state that India must continue to track certain indicators of the pandemic in order to avoid health emergencies.

“There is already a reservoir of immunity in the population. However, India should look out for anomalous increases in cases,” Gautam says. He also suggests public health surveillance testing, which the Centres for Disease Control define as “ongoing, systematic collection, analysis, and interpretation of health-related data essential to the planning, implementation, and evaluation of public health practice.” Gautam says that the country should be doing random surveillance testing (5-10 people from random districts with influenza-like symptoms), syndromic surveillance (clusters of cases), and wastewater surveillance, which will be a “good indication of when cases might increase in the future.”

Beyond the increase in daily cases logged, India must be mindful of any clusters or incidences of hospitalisation and ICU admission which could indicate serious disease, and therefore, the possibility of a mutation in the virus. Dr Shahid and Gautam both emphasise the need to continue genomic sequencing to keep tabs on variants too. “A fourth wave will not come from an Omicron variant that undergoes an incremental change. It can come from a completely different variant that emerges on its own. The Delta didn’t emerge from the Alpha variant; Omicron didn’t emerge from Delta. If a new variant emerges that evades immunity better, the only way to keep an eye out is to keep testing and continue genomic sequencing. Or we will not see it on time,” Dr Shahid warns.

He adds that while the popular media discourse seems to be focusing on rising numbers of COVID-19 cases, we are not talking enough about preparing our health facilities for long COVID. “It is far more severe in people with underlying morbidities like diabetes and cardiovascular diseases, the incidence of both of which is high in India. A major issue in long COVID is fatigue, which affects everyday lives and the productivity of people too,” Dr Shahid says.

Vaccination and therapeutics

Apart from continuing mask mandates (especially indoors), ensuring ventilation in closed spaces, and avoiding crowding, global health experts have been reiterating the importance of vaccine equity to comprehensively deal with the pandemic, and prevent mutations that evade immunity of existing vaccines. While India has vaccinated over 97% of its eligible population (over 18 years) with the first dose of the COVID-19 vaccine, global vaccine equity is still a challenge, thanks to intellectual property regimes and pharma companies being unwilling to share trade secrets and technological know-how to ramp up production.

“Vaccines do not protect people from infections, especially after a few months. But they do reduce the severity of the disease. Due to the latter, it also means you are infectious for a lesser period of time, which reduces the opportunity for the virus to spread. However, the lesser the vaccine coverage, the more opportunity the virus has to mutate, and the higher the chances for a new variant with properties like immune escape. From a global perspective, places that have poor vaccine coverage should rectify the same and ramp up coverage,” Dr Shahid says.

Apart from ensuring that globally everyone has at least one dose of the vaccine, the focus should also be on administering boosters to those with comorbidities, and now that a majority of the adult population and vulnerable population has a threshold vaccine coverage, to vaccinate children. “In March 2021, I would have said the public health gains from vaccinating children are much lesser compared to vaccinating people at higher risk. Children aged below 12 are at very little risk. India is on the right track – vaccinating adults before slowly opening up vaccination for 15 to 17-year-olds, and now 12 to 14-year-olds, especially now that schools have reopened,” he says.

Both Dr Shahid and Gautam also stress on the need for ramping up therapeutics to treat COVID-19. “There are now two drugs that are known to treat COVID-19 – Pfizer’s Paxlovit and molnupiravir – the former being safer, while the latter has some complications. India is a powerhouse of generic drugs and should work towards enhancing therapeutics. That would help bring the disease to a truly endemic and manageable state,” Dr Shahid says. “It is very likely that this virus will stay with us and keep changing slightly as all viruses do. We have to learn to live with it. We need to have immunisation programmes. We should be able to figure out better therapeutics as well,” Gautam concurs.

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