Exponential growth of healthcare and preparedness for 3rd wave in India

Dr. M. Mukhyaprana Prabhu, Professor and Unit Chief Medicine of Clinical Lipidologist, Department of Medicine, Kasturba Medical College, Manipal, MAHE about third wave of COVID & possible challenges

The COVID-19 pandemic caused by SARS Cov2 (novel corona virus) is a highly contagious disease-causing pneumonia along with multisystem involvement in varying degrees, and has caused havoc in health care system all over the world.

Is the third wave inevitable?

History of previous pandemics have shown that all pandemics occur in waves. A wave with respect to pandemic is a curve of any outbreak which reflects the rise and fall of the number of cases over a defined period. Various mathematical models have predicted a third wave, one of which is based on data of Susceptible(S)-Vaccinated (V)-Exposed (E)-Infectious (I)-Recovered(R)-Dead (D) model. With infectivity R0 being 2.044, second wave peaked in May as expected and started decreasing by June and end by October. But the third wave is expected by November 2021.  It is almost certain the we will have the third wave before year end. As per predictions, more number of children and adolescents may be affected. Whether it will be more severe in terms of spread and hospitalisation it is not yet certain. In children, Covid infection is usually mild and doesn’t require hospitalisation. One year of experience suggests that small percentage of children may develop Multisystem inflammatory syndrome (MISI-C) which may needs special attention. As first wave mainly affected Metro cities, and capitals and second wave affected smaller towns and villages, third wave is also expected in villages and rural areas where less number of people are exposed to virus.

Challenges and preparedness for third wave

COVID pandemic has exposed the lacunae of our public health system and also has provided opportunity to improve health care system. Some strategies for combating third wave and further waves is universal vaccination, improved health care delivery in peripheries, facilitating telemedicine for chronic non communicable diseases, increasing health care personnel and use of digital technology like tele ICU with monitoring by critical care specialist.

Vaccine: It is the most potent tool that we have against COVID-19 infections. Though we do not have concrete data on the level of protection offered by the various vaccines against the mutant strains, most of the experts agree that some degree of protection against severe infections do exist. Present evidence says Covaxin and Covishield available in India at present are effective against mutants. The third vaccine, Sputnik V has recently been introduced and there is no data suggesting efficacy against mutants.  The m RNA based vaccines (Pfizer & Moderna) which will be available by 2022 are the only vaccines approved in children at present and are probably less effective against epsilon and delta variants.   The combined production capacity of Covishield and Covaxin is only around 60-70 million doses/month and at this rate it may take more than two years to fully vaccinate India’s population. So, we explore options like scaling up capacity and procuring ready-made vaccines from abroad. Massive vaccination drive and boosting production to vaccinate maximum population is the best strategy in combating third wave. Presently only Pfizer vaccine is approved for children between 12- 18 years. Covaxin has started clinical trials in children and results may be available in a few months. Single dose nasal vaccine by Bharuch biotech is in advanced stage of clinical trial, and if approved may be more suitable for children. Vaccine safety in children is a big concern.

Health care infrastructure: As next wave is expected to be in children increasing paediatric ICU facilities, ICU training for paediatricians and pediatric critical care personnel is the need of the hour. Improving basic health care facilities in PHCs, district hospitals and small nursing homes is also a necessary step. In villages, testing and monitoring can be done by interns, medical students and Ayush doctors. Along with vaccination drive, testing capacity too has to be considerably increased in rural places. Only rapid identification of cases and strict isolation can help to flatten the curve till the vaccine rollout is adequate. As pandemic is driven by viral mutation, new mutants may appear which has to be identified and controlled. India needs to establish Virology centres with genomic facilities. During second wave, the medical crisis was due to unprecedented oxygen demand exceeding capacities. Hence each medical college should have oxygen generating plants, and industrial production of oxygen concentrators and ventilators should be further rammed up. ICU and ventilators need trained manpower, special training for paediatricians, and increase in residents (MD/DNB) in clinical specialties’ (Medicine, emergency medicine, paediatrics, pulmonary medicine, anaesthesia, critical care & ENT) is urgently needed.  In COVID second wave we saw significant increase in secondary fungal infections. (Mucormycosis, candida & Gram negative sepsis). Third wave may have similar problems, and hence strategies for rational use of steroids, anti-viral drugs, antibiotics, infection control measures and availability of life saving antibiotics have to planned well in advance.

In spite of exponential growth in health sector, COVID pandemic has brought glaring weakness in health sector due to unprecedented crisis. India needs greater public investment into the healthcare sector and increase budget allocation for sectors which shape determinants of health such as water, sanitation, nutrition etc. The public expenditure on healthcare is just above 1 percent of the Gross Domestic Product (GDP) and need to raise it to at least 2.5 percent in the near term. Most   developed countries already spend more than 10 percent of its GDP as public health expenditure.

This pandemic has shown the deficiencies in our healthcare system and laid bare the systemic under-investment in public health over the last half a century. Building a fair and equitable healthcare system, which incorporates all strata of population may be the only solution to prevent (or rather limit the impact of) future pandemics. Serious thought on digital platforms for individual health data, systematic referral system and dedicated teams for health surveillance for pattern recognition of early / evolving epidemic needs to be given.

Apart from this, we need to institutionalise the processes to ensure adherence to COVID appropriate behavioural changes like social distancing, hygiene measures and appropriate use of masks. This can be done through a mix of behaviour change communication, regulatory efforts and community mobilisation. All of this has to be continued till we achieve a vaccination coverage of more than 80 percent when herd immunity can set in and end pandemic.