Preparing for the next COVID-19 wave

Vaccinating the vulnerable, constant surveillance and reliable data will help India tackle the third wave

Updated - December 04, 2021 10:30 pm IST

Published - June 09, 2021 12:15 am IST

A healthcare worker gives a dose of Covishield to a shepherd during a vaccination drive at a forest area in J&K’s Pulwama district on June 7, 2021.

A healthcare worker gives a dose of Covishield to a shepherd during a vaccination drive at a forest area in J&K’s Pulwama district on June 7, 2021.

Using the data in Karnataka, Aniruddha Adiga et al. show in a paper in medRxiv that a third COVID-19 wave is imminent in the State even if the strongest non-pharmaceutical interventions (NPIs) are implemented and 1,67,000 persons are vaccinated each day. This is corroborated by evidence from other countries. It took nearly eight weeks in the U.K. to go from a second to a third wave, 17 weeks in Italy, and 23 weeks in the U.S. Some people are still debating whether there will be a third wave. It is not a question of ‘if’ but ‘when’. In all likelihood, the next wave might be in late November or December in India. Despite the quantum of cases in the next wave, it is important to plan and prepare for it. These are several actions that India needs to take to prepare for and tackle the next wave.


Data from several States indicate that the average age of mortality is reducing in several States and stabilising at 30-45 years. This suggests that vaccination might have already offered survival advantage to those aged 45 years and above. This was the main objective of providing vaccination: preventing deaths and limiting serious morbidity requiring ventilation or oxygenated beds.


Given the undoubted benefits of vaccination, extraordinary efforts will have to be made to secure vaccines for vulnerable people. The vaccine supply constraints are likely to be resolved by the end of July. Till then, people with co-morbidities, irrespective of age, should be prioritised for vaccination. Micro planning for vaccination should be strengthened. For this, health workers and volunteers need to go house to house and prepare lists of all the eligible beneficiaries. Next, efforts should be made to help in registering and vaccinating the vulnerable. We estimate that the country should vaccinate at least 10 million people each day to cover the vulnerable population in the next three months. To reach this pace, it is important to develop a strong mobilisation strategy, address the concerns of the vulnerable, and improve access to vaccination sites. A strong focus on bottom-up micro planning, similar to what was adopted during the measles-rubella elimination programme and polio programme, can be helpful.

The periods between waves

We only wake up to disease threats when there is a large outbreak. We have selective amnesia to health-related issues in the intervening periods and quickly get back to ‘normal’ activities. But it is these intervening periods between waves/outbreaks that are actually important. It is during these periods that surveillance needs to be meticulous. One of the critical aspects of surveillance is to sustain aggressive testing, especially in symptomatic individuals, and keep a close watch on the seven-day moving average of the test positivity rate (TPR). A TPR of less than 5% indicates that the disease is under control. Another important facet of surveillance is genomic sequencing to keep a watch on the emergence of new variants of SARS-CoV-2.

The surveillance programme in the country needs strengthening, and strict review should guide the early identification of clusters. Timely investigation and early containment of outbreaks should be the mainstay of preventing the onslaught of cases and deaths. Combining the syndromic approach with enhanced testing levels is necessary for all the areas. Preparing for the next wave involves developing a standardised definition for minimum cases to be detected in each part of the country. Based on the available data, States can aim to detect and review, say, 1,000-1,300 cases per million each month provided adequate testing is done. This will help them identify areas where there is poor reporting and strengthen the overall response in these areas. In order to detect these cases, nearly 20,000-25,000 tests per million will have to be done each month.


Use data-driven interventions

As stated by historian John Barry, the most important lesson from the 1918 influenza is to “tell the truth”. Whenever true figures are suppressed during a pandemic, the data get skewed. As a result, modellers make unreliable projections, and wrong policies and programmes are formulated. Hence, data should be made freely available to experts. Systematic collection, compilation and analysis of clinical, epidemiological and laboratory data is paramount to decision-making. A core expert group comprising clinicians, epidemiologists and laboratory personnel should be constituted at every level (district, State and national) and entrusted with the responsibility of suggesting appropriate interventions to the concerned authorities. Data alone should drive interventions.

The COVID-19 pandemic has been associated with a high attack rate among household contacts. Therefore, non-pharmacological interventions represent the cornerstone to halting transmission. These include avoiding mass gatherings, closing schools, isolating those with infection, contact tracing, and implementing infection prevention strategies in health care settings. These are critical to achieving at least a 50% reduction in transmission, which correlates with a basic reproductive number lower or equal to one (R0 ≤ 1). A critical determinant that ensures the success of any intervention, whether vaccination or NPIs, is appropriate communication. Therefore, a robust communication strategy must be developed that is directed at behavioural change for subverting the third wave.

The available data indicate that every age group was affected in the second COVID-19 wave. The susceptible persons comprise those not protected by vaccination or those who are not infected yet. The proportion of susceptible people is higher in the younger age groups, including children. A higher risk of infection is not the same as a higher risk of serious illness, especially for children. However, even if there is a small proportion of complications and deaths, absolute numbers can strain the health system resulting in a shortage of beds. Higher mortality is not so specific to the virulence of the virus, or age group, but mostly arises from the shortage of beds during a sudden surge in cases.

To reduce the number of deaths, we should immediately create adequate capacity to handle the surge. More paediatricICUs and specialist care are needed to handle a complex disorder, namely Multisystem Inflammatory Syndrome. Enhancing paediatric specialised beds and ICUs can help in managing meningitis and other diseases in the community. Many patients who have recovered from active COVID-19 infection are experiencing long-term residual effects of the disease both physically and mentally. It is necessary to address these issues in all hospitals through counselling at the time of discharge and by establishing post-COVID-19 care clinics and services. We need to make a realistic assessment of needs. Every effort should be made to strengthen the human resources and infrastructure in the rural, vulnerable and remote areas.

Giridhara R. Babu is a Professor of Epidemiology at the IIPH-Bengaluru, Public Health Foundation of India and V. Ravi is a Neurovirologist and nodal officer for genomic confirmation of SARS-CoV-2,Government of Karnataka

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