Preparing for the third COVID-19 wave

Even as the second wave of the pandemic reaches its peak in India, people are already anticipating a third wave. Pandemics and epidemics generally progress in waves before they ebb. There is also speculation, particularly in the media, that the third wave will put children at greater risk. The first wave mostly involved the elderly and those with co-morbidities. In the second wave, many people in their 30s and 40s suffered severe symptoms and fatalities. The logical conclusion drawn from this is that the next wave will put children at greater risk. This seems plausible as children and teenagers are yet to be vaccinated for COVID-19.

However, this does not account for the fact that many children, including new-borns, are already being infected by SARS-CoV-2 at present. In fact, whenever we test a child who has been in contact with an adult patient, they not only come positive but also have a higher viral load than adults. However, they exhibit milder symptoms or are asymptomatic though some children have developed moderate to severe symptoms including ones who developed Multisystem Inflammatory Syndrome in Children or MIS-C. However, these remain rare manifestations of the disease in children. That said, more infections are now being reported for children compared to earlier. In fact, the number of children infected rose to 15% in the second wave compared to 4% earlier. A recent study by AIIMS, New Delhi and WHO found high sero-positivity amongst children, which means they have been equally susceptible to COVID-19 as adults.

Children seem to have innate or acquired immunity. Innate immunity is immunity a child has at birth through antibodies transferred during the third trimester as well as antibodies found in the mother’s milk that offers protection from various infections in the first year of life. It may also be an acquired immunity, which is something a child develops in response to infections. For instance, children in day-care centres and schools are exposed to many respiratory infections, which may result in them having a higher baseline of antibodies for respiratory viruses. This might provide some protection from SARS-CoV-2.

We see respiratory infections as a disease of children. In fact, many children suffer at least one episode of cough and cold each year and, unlike adults, they develop high fever and severe symptoms. Crèches and schools are ideal breeding grounds for such viral infections, and many children get infected at the same time. Through such incidents, children develop immunity that lasts for a long time. This immune response possibly provides cross immunity for SARS-CoV-2. However, it is worrisome that schools are currently closed and there is less community transfer among children. Thus, the immunity may wane over time and children may start developing symptomatic infections including COVID-19.

Also, adults suffer a more severe impact from COVID-19 due to an overreaction to the virus (cytokine storm) by their robust immune system. The young and naïve immune system of a child will give a normal response rather than an aggressive immune response when they get the virus. The intense immune reaction is what causes damage—often irreversible—to the lungs and other organs in adults.

Vaccination is the only plausible explanation for the shift in the age group of people severely infected by COVID-19 in India’s second wave. Vaccination and precautions are protecting the elderly. This might imply that a proportionally higher number of children will be infected in the third wave if they are not vaccinated even if they suffer fewer symptoms. It is also possible that early communication on COVID-19 focussed primarily on risks faced by the elderly. Younger people may have been a little careless and faced greater exposure to the virus. We were unprepared for the second wave. We are now anticipating the third wave. There is an urgent need to increase the vaccination process in India and include the paediatric population, especially those over 12 years of age. At the same time, we must create and upgrade infrastructure to treat children across the country. We must learn from our own failures and the experience of countries where a number of children died from COVID-19.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

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