Mumbai: As the second wave of Covid-19 in India is subsiding, the question is what is going to happen in the third wave. Across most countries, Covid-19 has not impacted children disproportionately, other than in Brazil, where 2,200 children under the age of 10 years are reported to have died of Covid-19. This is still a small proportion of all deaths--482,019--reported in Brazil. But it is much higher than, say for instance, the US, where 620 children between the ages of 0-4 years reportedly died because of Covid-19 and 383 children between 5 and 14 years of 823,063 deaths in all.

This could be driven by variants of the Covid-19 virus, such as the gamma variant in Brazil. What do we know about the delta variant in India and what could it mean for the third wave, particularly in the context of children and paediatric care?

To answer this question, we spoke to Amit Gupta, director of newborn services at Oxford University Hospitals in the UK. He is an MBBS and MD from Surat, and was appointed as a consultant in neonatal medicine at the John Radcliffe Hospital at Oxford University in 2009. He continues to work remotely in India and Sri Lanka, particularly in training people.

We also spoke to Tanu Singhal, a consultant in paediatrics and infectious diseases at the Kokilaben Dhirubhai Ambani Hospital in Mumbai. She studied paediatrics at the All India Institute of Medical Sciences (AIIMS), and infectious diseases and international health at the London School of Hygiene and Tropical Medicine.

Edited excerpts from the interview:

Dr Singhal, how are you seeing the progression from wave two to wave three, particularly as the number of overall cases recede in most of India, including in cities like Mumbai.

TS: First of all, I would like to say that this prophecy that children are going to be affected more in the third wave does not really have a lot of scientific evidence behind it. It is mainly speculation, and I will tell you why that is. In the first wave, we saw elderly people getting affected. Then in the second wave, we saw a lot of young adults getting affected. So, we think that as that third wave comes in the children will get more affected. Also, during the second wave we saw a little bit more severe disease in children as compared to the first wave. However, at the same time, 99% of those children recovered.

The second reason is that adults and elderly people will be well vaccinated by then. And children will not have received their vaccines and that is where they are going to be more affected. The third thing is that, as the second wave recedes, we will have schools opening up, and children who have not been infected till now will go out and will get infected, and have a disease in the third wave.

Those are the reasons why we think that children may be more affected. At the same time, I want to draw your attention to a sero-survey done in January, in which they compared the sero-prevalence of Covid-19 in adults and in children between the ages of 10 to 17 years. It was the same in both--about 24.7%. It means that children did get infected in the first wave, but it is just that they did not have so many symptoms. Generally speaking, Covid-19 is a mild disease in children because of various biological reasons. So, I feel that children--as a proportion of those who get infected--may constitute a larger proportion [in the third wave], but overall, the disease should not be very severe, unless we have a dramatically different variant coming into the picture.

Dr Gupta, is there a sense that different variants could behave completely differently?

AG: All I can say is, from the variants that we have had so far, none of them have extraordinarily attacked children. We have not had any of the variants which have gone and attacked children in preference to adults. The illness in children tends to be really mild and it continues to be mild. There is a very small proportion of children who can get exceptionally unwell because of an immune sort of reaction to Covid-19. And, it is called MISC [Multi-System Inflammatory Syndrome in Children]. I think, in the US all over, they have seen 800 cases of MISC. In that case, the child can get very unwell and there can be cardiac manifestations and gastrointestinal manifestations. The recognition of that illness is very important.

Let us come to what we have seen in India. The data from India would support that during wave two, when the virus was at its peak, when the infection rate was quite high, no matter how much shielding you would do, kids in the family would have got infected as the secondary infection rate of Covid-19 is very high. But we have not seen an upsurge, or an overloading of our paediatric hospitals, during wave two in India. And that is also supported by the data that we have got from the All India Institute [of Medical Sciences], which confirms that.

Now, let us just take one step forward and go to wave three. By wave three, what you mean is: either you have got a new mutant, which is causing a wave three or, this current mutant, once you relaxed restrictions, it then starts infecting more and more people. On one hand that will happen. [On] the other hand, your vaccination numbers will go up. If the mutant does not change, if there is no new mutant, the expectation is in wave three, the total number of cases will be lower. Because if vaccination rates get picked up a little bit then it is not expected that you will have a repeat of the second wave. It can happen, but it is unlikely. So my premise is this: if we were not overloaded in the second wave, why should we fear that our paediatric hospitals will suddenly get overburdened in wave three, which is likely to be lighter than wave two by all indications. Unless, of course, suddenly out of the blue, you get a mutant, which then infects children in preference to adults.

Is there anything that we can take away, Dr Gupta, from the UK or Europe? The UK is at a very advanced pace of vaccination and has covered a very large proportion of its adult population. But if you were to go back a few months, how were things then, particularly as you moved from the second to the third wave?

AG: The third wave has not happened. It has been talked about and at some point it might come. But the vaccination strategy for kids relies heavily upon vaccinating a population of children so that when they are in school, they do not circulate the virus and then come home and infect the adult population. So the primary motive here is not to protect children as much as prevent the circulating virus. And I think that is a very important point to get across. It is not that suddenly people discovered that children in the UK were filling up wards and we needed to have a vaccine strategy to protect their health. The primary driver there is to reduce the circulating virus. I will give you an example of Israel. What happened in Israel? They did not have to vaccinate the young children because the adults have such high levels of vaccination that the children were immune anyway, so they do not have infection in kids.

Dr Singhal, The point about children not being infected in preference to adults. What is your experience on the ground here, particularly through the second wave. And are you able to project ahead?

TS: What we have usually seen in the second wave is that children have been infected from adults and not the other way around. So usually those children who have been infected have had a family member who was infected. It is not like the child is the one who is infected and the child then spreads the infection to the parents. The other thing we have seen in the second wave is that the case reproduction rate is so high that children have--all the family members have--got infected. Whereas in the first wave, you would see that upto 40% of the family would get infected. But this [variant] is so highly transmissible that all children got infected. And that is why if one would conduct seroprevalence studies now, you would find that you would have similar rates of infection amongst adults as well as children--unless, of course, they are very small children.

AG: I completely agree with you, doctor. We have not measured that secondary infection in kids. But I will bet you that if you did a seroprevalence study, you would find a comparable rate in kids. The whole issue of getting very excited about the third wave and kids, needs to be toned down a little bit. I think it is getting ahead of us. It is making a lot of people anxious, and I think we have to go with what we know from not only from abroad, but also from India. Some of it [the anxiety] comes from the sense of fear and the sheer helplessness that we had in the second wave--that we must not be caught unaware. We should not be caught unprepared. I think that is driving this fear.

Parents are anxious to get children back to school. Children in many cases also want to, I'm sure, get out of the house, if not back into the school. So that creates a new consideration for the spread of infection and disease. How are you looking at that? And particularly since this could start playing out in the coming months.

TS: So, one thing which we have learned till now is that when the rates of infection go down, at that time much of transmission does not happen in school. So, we have a time between the second and the third wave. I think this time should be utilised for some partial opening of schools, where children can go in batches because they need that kind of social contact. And then it is possible that when the third wave hits, we again close schools down. We will have some time between the second and third wave where we can afford to open schools and get children there. Because otherwise if you do not open them now, and then you say we will do everything once it finally goes away, we do not know when that time will come. So, we will have to learn to live with the virus. If you remember the last meeting we had, I had said that the precautions went down in October-November, and, the surge came somewhere in February and March. So it was not the opening up or the lack of precautions which drove the second wave. It was actually a new virus which came into the picture. I think there is some time before a new virus would come. And therefore, I think this is the time when children should be allowed to go to school in batches, for maybe two hours or so, with proper precautions.

AG: Schools are much more organised. It is not like you are [in the] open bazaar. Having kids learn about social distancing, wearing masks… it is a lot easier to police, a lot easier to train and learn [in school]. So I think in that respect, schools are less chaotic. And I think we should encourage this reopening of schools for the time period now, between the second and third waves. The fear of the virus circulating and getting out of control is not as much in schools as in the general community. I mean, you see the pictures from Delhi or my hometown and people are thronging the markets. That is far more uncontrolled than a school environment where there is a lot of oversight.

The other thing I would want to highlight also is in the UK, of course, the vaccination strategy is focusing on adults at the moment, but we have got the vaccine approved--the Pfizer vaccine, which is approved for kids. The idea is to vaccinate kids as well. But the idea behind that I reiterate is not because we are particularly worried about children's health. We are more concerned that the kids are also playing a part in the transmission of the virus. So it is dampening down that part. It comes back to the original question: how much should we fear illness in kids? I think that is comprehensively answered in the sense that we should not be fearful. It is not that we should be complacent, because there is a small number [of children] who will get very unwell. But it then links to resources and if you have got a limited pool of resources, would you want to spend that in opening up a lot of paediatric intensive care units? It is a political question. But from our perspective, we would say that for value for money, in relation to Covid-19, national resources are better spent where you get the most bang for your buck.

Dr Singhal, a parent would perhaps say that yes maybe transmission possibility is relatively less in a school, but the fear is that if the virus does jump from one child to the other, nothing may happen to the children, but that they may bring the virus back home. Despite the fact that we are vaccinated, and also given that many of us in the country are not going to be fully vaccinated for many months going forward, where does this equation leave us?

TS: The first and second waves happened without the children going to school, did it not? I mean, the children had no part to play in that. It means that there are various other places from where adults and the elderly catch infections. If you have adults and the elderly vaccinated--which is happening at a very, very fast pace--and we know that the disease is less severe in vaccinated people--especially two weeks after receiving two doses--then I think, we need to give the children a chance as well. You know, to go out and learn, because otherwise we would see a mental health epidemic in front of us--which is already happening. Also, you have to see, if you are opening the markets, we are opening everything else, then why are we not opening schools? As Dr Amit said, it is easier to police schools. I think we cannot stay in a state of lockdown forever, and we do not know how long this will last. So at some point, we have to cross the bridge.

AG: I think it is important to say the end game of this whole business is vaccination and getting the numbers up. So, it is between us and the virus. Some countries are doing it better than the others, but what is happening in India is that we are on an accelerated path of vaccination. And, it is that judgment that we are constantly making: how much to lock down? How much to open up? And, this will be, as they say in Hindi aankh micholi [a game of hide and seek], and will continue till a few months. Till you get enough vaccinated people on board. What we should hope and pray is that there is no new mutant. I think that is where the problem may happen--if a new mountain comes along and disrupts the pathway, that would be the most disruptive risk.

Ideally school should not be opened up until everybody is vaccinated, but you know, we are talking about one bad option versus one less bad option. We have to choose the lesser of the two evils. And the lesser of the two evils is if you are opening up everywhere else, and you have got a system where children have been sitting at home for over a year, and you can monitor them [at school], well, you might as well open schools now and still continue the vaccination in adults. That would be the balance that you might strike between achieving reasonable mental health and managing risks.

Right now we are not vaccinating children in this country, but obviously there's a lot of discussion around that. What would you advocate?

TS: Unfortunately we do not have any vaccine approved for kids so far in India. Covaxin trials have started, but it will be sometime before that data becomes available. And we do not know whether Pfizer and Moderna will come and when they are going to come. But, if the vaccines were to be available, then they should be first given to children who have comorbidities because those are the group of children who are likely to get severe Covid-19 disease. Second, I think adolescents [should get priority], because even amongst people who are healthy and get severe Covid-19, adolescents are an important population. So I would suggest that we first give it to children with co-morbidities and then to adolescents. As data about the safety and efficacy accumulates, then we move down to the lower age groups. And I think that is what is happening all over the world, because even in Canada and in the US, they are right now vaccinating children between the ages of 12 and 15.

AG: There is a very good ethical argument to make, where countries like the UK, which have got most of the adults vaccinated, are getting kids vaccinated, which is, in terms of public health policy, still a luxury. Because you are not trying to protect disease in those cases as much as you are trying to dampen the virus. So, I would say there is a very strong case for many of the Western countries to be giving the Pfizer vaccine doses, if it is approved, to actually vaccinate the adult population [in other countries]. I have some sympathy for the idea that instead of many of the Western countries racing to vaccinate their children, it is much better that those vaccines are donated to countries like India, where you are struggling to get the vaccination rates up.

TS: I would like to disagree a little bit, because India still has access to vaccines. I think right now the limitation is not so much as the number of vaccines as the capacity to vaccinate. I mean, we are vaccinating between two to three million people every day in the country. I think there are many other countries which do not even have the access that India has. We may argue ethically, but when you are the head of a country, and if you do not vaccinate the children and send your vaccines outside, you are not going to be very popular because people need to look at their home before outside. So unfortunately, it is an unequal world.

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