The lurking fear of a third wave weighs heavy on the minds of a large section of Indians scarred by the devastation on display during the second wave a few months ago. Eminent pulmonologist and the director of the All India Institute of Medical Sciences (AIIMS) in Delhi, Dr Randeep Guleria, attempted to assuage some of these concerns in an interview with CNN-News18, while accentuating the importance of masking, social distancing and vaccination, as also the possible impact of the third wave on children and the appropriate process to reopen schools.
We have seen what the sero survey numbers are telling us. Two-thirds of this country already has antibodies. What does this mean, Dr Guleria? Does it mean that two-thirds of India is now protected against the virus, and that we have little to worry about?
I don’t think that we can say that. One-third is still susceptible. And when we start looking at the sero survey, we need to really look at it in a critical and proper manner. The sero survey tells us how many people have antibodies. Now there are two things that we need to keep in mind, that is at a given point in time…and we don’t know that where is the cut-off at which you can say that if you have an ‘X’ amount of antibodies then you are protected from re-infection sufficiently enough or you are not. So we don’t really know that. Secondly, we know that antibodies will wane with time. So for those people who have antibodies but have had the infection, let’s say last year, and now it has been many months, their antibody count will gradually fall if they are not vaccinated. And they may be prone to re-infection. And with the vaccination going on, we start looking at R-E: the effective reproduction number, where we look at the population which has been vaccinated and the population which has also got the infection and then see how the rate of transmission be looked at. So, the news is good because it suggests that a significant number of Indians have antibodies and therefore it shows that it is less likely for subsequent waves to be as bad as previous ones. Because as compared to the previous sero surveys where it was only around 20-21 per cent and now we have crossed 50 per cent and even 60 per cent: meaning that many people have had the infection, are protected and vaccines are also now increasingly being given and, therefore, I think it is a good sign that in the future, at least severe disease will not be there. We may have mild disease and, thus, we may not have a very bad third wave.
You are saying that given that the sero prevalence has found that two-thirds of India has antibodies, so the third wave will not be as bad or as severe as the second wave. But does it also impact the timing of the third wave? Of course, no one is still sure when the third wave is coming. You have the SBI saying something, you have other experts saying something. But do these numbers impact when the third wave will come?
So that is a difficult question because the timing of the third wave may have a lot of variables. Also, when we say two-thirds of India, we must remember that this is looking at it in a generic term. We still will have pockets where you may have a large susceptible population; so you may have areas where people have had the infection because that is where the infection spread among contacts, and you may have areas where the vaccine uptake is high and these are the areas where the bulk of the two-thirds may come from. But you have other areas as well in the country, where a large number of people have vaccine hesitancy, they haven’t got themselves vaccinated and also have not had the infection. And that becomes a susceptible pocket. So, we cannot generalise that this two-thirds means that the whole of India is like this. There are areas where it may be more than two-thirds and there are areas where it may be much less than two-thirds and that is why, if in these areas there occurs an event that causes infection to spread, then they may see a surge in the number of cases and we may have a new wave. It is difficult to say when it will happen. It can be in a few weeks and months from now, but that is a difficult question to answer.
The SBI is saying that it could come in August and peak in September. Is that an estimation that you would go with as well?
I think that September or October seems likely because if we look at how things have behaved. We have the restrictions being lifted up and at the same time, we are seeing that a lot of travel is happening, Covid-appropriate behaviour is not being followed as it should be and although we have seen that the cases have come down— we are now at 30,000 cases a day from 4 lakh a day— but if you look at it from the first wave, the numbers are still high and we haven’t really come down significantly to say that the second wave is over. And with a lot of opening up and travelling happening, let us say one-third of the population…there is a chance that in the next few weeks, that is by September or so, we may see a surge in the number of cases.
Doctor, now to a section of our population that everyone is very concerned about, children. We’ll come to the discussion on whether it’s time to open up the schools or not, but before that, the sero survey shows that more than 50 per cent of India’s children have antibodies. Does it mean that the theory which said that the third wave will have a huge impact on children, is not likely to happen? Is that what it means?
Correct. I would like to add two or three things to that. One, the argument for the third wave impacting children was the children are still susceptible because we have protected them and they don’t have vaccination; therefore, they will be the ones who have not had an infection and, therefore, whenever there is a surge in the number of cases, children will get impacted more than adults who have either had the infection or have been vaccinated. The sero survey shows that is not true. Children also got the infection to a large extent but they had a milder infection and they recovered from it. And, it was shown by two other studies as well, one that we did where we looked at antibodies in smaller pockets and children had up to 60% antibodies in our study. And, also when we started enrolling children for vaccine trials: more than 50 per cent of the children who came and volunteered for getting themselves vaccinated, when we tested them for antibodies, they already had antibodies. There is a lot of data emerging, which shows that children have already been infected and had mild infections. In the first and second wave, we found that very few children got admitted with severe Covid; most of them had mild illness and they recovered. Therefore, I don’t think the theory that the children will have a severe infection in the coming wave or will be the ones most affected, is true. Now there is more evidence based on the sero survey to support that.
So, Dr Guleria, the question that all parents want to ask is, is it now safe enough to send our children to school? Is it safe enough for schools to reopen?
This is a tough question because this will vary from area to area. I’ll add a few things first. If we start looking at a risk-benefit analysis with the sero survey showing that more than 50 per cent children have antibodies, we also know they had mild illness. But at the same time we also know that children have suffered a lot for more than 18 months because they had online classes, especially the children who are marginalised who don’t have access to the internet or to computers or to smartphones; they have literally dropped out of school. School is not just about giving education through online classes: it’s also about character-building and social interactions, it’s about building friends and a lot of other things as well. Therefore, if we look at all of this, then we can look at a graded way of opening schools only in those areas where the positivity rate is low. For example, in an area where the positivity rate is less than 5 per cent and there are very few cases, you can open a school in close surveillance to see if there is any increase in the number of cases there. You could have alternate days in which one half of schools come on one day and the remaining half comes on another day to avoid crowding, and each area will have to be innovative. If the weather is good, then we can have more outdoor activities and classes where the chances of infection are very less and spread is very low. A lot of innovations have to be locally developed. I think if we do this then we can look at opening schools to some extent. Hopefully, by September we should have vaccines available for children and that will also be a big boost. So, in a graded manner, we can start looking at opening up the schools.
You are saying that in areas where the positivity rate is low, given the fact that by September the vaccines will come, India can look at opening schools. Do we need to wait for children to get vaccinated? Say, for example, Zydus comes by September…do we need for all kids to be vaccinated who are going to school before schools reopen or can it happen before that as well?
Both Zydus and Bharat Biotech should be available…we are hoping that. I think we should look at a few things. One is the chance that severe infection is less among children and more than 50 per cent of children, according to the sero survey, have had a mild infection and have had antibodies. In a graded manner, we could open schools before that with close observation and in areas where the infection rate is very low. At the same time, I think we need to balance several things out and a practical way of doing it in several areas, and if it is practical then we should try and move in that direction.
If a school is thinking of reopening, what do they need to keep in mind? Kids need to be in masks, social distancing also, but what else? We have been talking about models in Sweden and Nordic countries; they’ve kept their schools open through the pandemic, but India is not Sweden or Finland or Norway.
Correct. Our schools are large and the number of students is bigger and social distancing is going to be very, very difficult, but masking may still be possible. That is why we have to develop new strategies. you may have to do screening, you have to make sure that children, even if they have mild symptoms, stay at home and don’t come to school; some sort of strategy has to be developed. Rather than whole schools coming over, half can study online and the other half can come physically to the school and alternate that so that physical distancing is maintained and develop other strategies. Also, keep a close watch on what is happening in the community because infections happening in children goes hand in hand with the infections happening in the community. If you find the positivity rate going up in the community, then you should consider closing down the school. At the same time, it’s also important for the teachers in schools to get themselves vaccinated. When the schools are opening up, then the authorities should also ensure that teachers must come forward and get themselves vaccinated, so they are also protected and they don’t catch the virus.
The ICMR is saying you can open schools, but when you do that, primary schools need to open up first and then secondary schools. What is the logic behind that?
The data that is there, suggests that the infection is much lesser in younger children as compared to the older children because their immune system is able to tackle the infection better. The virus attaches itself to what is called ace receptors and in the nasal and throat areas of the children these receptors are less, and therefore the virus is not able to attach itself in large amounts in the nose and throat of the children, and thereby they get a milder infection. And this is much more in younger children as compared to the older children. The logic behind starting the primary section first is because the safety signals there are much stronger as compared to middle and higher schools, where you still have a little bit more infection. One could look at it for all schools rather than just primary schools.
So you are saying that it’s not necessary to open primary schools first and we can look at opening entire schools?
Yes, but in a manner, that physical distancing is properly maintained and crowds are avoided. And if one is very much concerned, then they can start from primary-level schools and observe for two-three weeks, and if things are all right, then gradually start opening up the senior classes in a graded manner.
You’ve said vaccines for children should be available in September. Are you talking about one vaccine or two vaccines, and when can India start inoculating its children? If it’s approved in September then it will likely take some time for the inoculation to start.
We already have vaccine centres and vaccines are already being given. Trials are going on and the follow-up is going on only for the Bharat Biotech vaccine. The Zydus vaccine has already completed the trial in children, so this data should be out. Once the regulatory approval happens, hopefully, it should happen in September, then it will just be about adding this group to the CoWIN portal, so they can get vaccinated quickly once this is done. So, I don’t think it will take as long as it has taken in the past to get the vaccination in children because it’s an ongoing process and as we decrease the age from 45 to 18 we can bring it down to a lesser age group and that could also be included in the vaccination programme.