The BMJ: The third wave of COVID-19 pandemic will break out in India?

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The BMJ: The third wave of COVID-19 pandemic will break out in India?

The second wave of the epidemic has not yet subsided, and India has been warned that “or a third wave of COVID-19 epidemic will break out”?

The second wave of violent COVID-19 epidemic caused 100,000 deaths in India in May; as of June 8, the cumulative number of COVID-19 infections in India has exceeded 2.88 million, and nearly 346,000 people have died.

However, the Indian Medical Association, which is composed of top medical experts, stated that in view of the global conditions and epidemic history, the third wave of epidemics in India has been “inevitable and imminent” and is expected to be between August and October.

On September 24, researchers reported on the “The BMJ” how the COVID-19 virus affects children in India, and how the authorities formulate plans to improve medical services in response to the third wave.

Delta variants are cunning, and most cases are asymptomatic; some parents don’t even believe in vaccines and viruses; currently only 15.4% of adults in India have been fully vaccinated, let alone children; health infrastructure is very tight, leading to deaths Increase. Is India ready to deal with the third wave of COVID-19?

After the first wave of the epidemic, people relaxed their vigilance. Political elections and religious festivals have led to large-scale crowd gatherings (such as the Dahu Festival, where more than 4 million people gathered in the same place), people no longer wear masks, and most India seems to have returned to “normal”. The sudden increase in the second wave of epidemics is likely to be caused by these potential super-spreading events and India’s overwhelmed health infrastructure.

As the impact of the second wave of the epidemic in India has gradually subsided, several states have gradually unblocked them, allowing tourism and religious gatherings to take place. At present, social media is flooded with videos and photos of Indian tourists who do not wear masks when traveling and do not maintain social distancing. The threat of the third wave of the epidemic is increasingly present in the country.

In September 2020, a 15-year-old healthy boy, Marbaniang, was taken to a hospital in Hilon, India due to fever, cough and difficulty breathing. He immediately received non-invasive ventilation and intravenous fluids, but five and a half hours after admission, he passed away. He was the first child in Meghalaya to die from the COVID-19 virus.

This state in northeastern India had the highest case fatality rate (8.3%) during the first wave of the spread of the new coronavirus. During the second wave, the region had the highest rate of positive test results (7-8%, compared to the national average of 2.5%). As of August, about 22% of infections occurred under the age of 18.

On September 24, researchers published an article “Children, covid-19, and India’s looming third wave” in “The BMJ“, reporting how the COVID-19 virus affects children in India, and what is expected to happen in India In the third wave of the pandemic, how the authorities made plans to improve medical services.

BMJ: The third wave of COVID-19 pandemic will break out in India? doi:https://doi.org/10.1136/bmj.n2328

The COVID-19 virus has worsened India’s imperfect health system, causing more than 430,000 deaths , including 1,500 children.

Children infected with the new coronavirus usually do not experience the most severe effects. However, with the emergence of a new wave of SARS-CoV-2 mutations on a global scale, especially in countries where the promotion of vaccination is slow, the proportion of children infected with the new coronavirus and severely ill has increased this year.

According to data from the Indonesian Ministry of Health, 13% of people infected with the new coronavirus in August (534,182 out of 4,109,039 cases) were under 18, and the case fatality rate was 1%.

According to data from the Infectious Diseases Committee of the American Academy of Pediatrics, the infection rate in the United States is much higher than that in Indonesia. As of August 26, children accounted for 14.6% of the cumulative cases. Between July 31 and August 6, although the case fatality rate was about 0.24%, 216 children were hospitalized with COVID-19 pneumonia every day.

In India, there is a lack of data on hospitalizations and deaths of infected children, and it is not clear whether official figures are lower than reality. Only a few states, including Karnataka, Tamil Nadu, and Kerala, publish age-based infection and death numbers, and the Federal Ministry of Health and Family Welfare does not have a public central database.

According to data shared by the medical authorities of Jaipur, the capital of Rajasthan, 10.7% of the local cases were patients under the age of 20 from January to July 2021, with peaks in April and May. Chief Medical and Health Officer Narottam Sharma told The BMJ that only 2% of the cases had symptoms.

Jenny Swett, a pediatrician at the Ganesh Das Maternity and Child Health Research Institute in Hilon, said that this year she has seen more cases of moderate to severe child infections with the new coronavirus, most of which suffer from respiratory symptoms and acute gastroenteritis.

The increase in deaths (2.7% in August) may be the result of delayed hospitalization of children (up to 7 days), mainly because parents and caregivers are skeptical of the new coronavirus and vaccines. Swett also told that some parents refused treatment even when their children tested positive.

They think that the new coronavirus does not exist; it is a fiction. In some cases, parents disregarded our advice and discharged their children from the hospital.

Most published data indicate that children with the new coronavirus are usually asymptomatic or mildly symptomatic, and the mortality rate of multiple system inflammatory syndrome (MIS-C) (related to new coronavirus infection) is very low.

In a report published in June, the Indian Task Force of the Lancet New Coronavirus Committee found that the death rate of 2,600 children under the age of 10 who were hospitalized with the new coronavirus was 2.4%.

Among the children who died, most had comorbidities (asthma, gastrointestinal disease, diabetes, or neurological dysfunction).

Studies in India and elsewhere have not found any evidence that children are more susceptible to Delta mutation. A survey conducted by the All India Institute of Medical Sciences (AIIMS) found that there were 55.7% of the virus in the blood samples of children aged 2-17, compared with 63.5% for adults.

The National Disaster Management Institute of the Government of India formed a team to assess the possible impact of the third wave of new coronavirus infections on children, especially since children under 18 have not yet been vaccinated. The team includes pediatricians from some of the most respected medical institutions in India.

They stated that the pediatric facilities in India are “not enough to treat children on a large scale”. For example, the health infrastructure in Meghalaya State is so tight that 877 newborns and 61 pregnant women will die in 2020, and the state’s medical resources have been reused to manage the new coronavirus.

According to the health minister of Meghalaya State, in May, 13 of the 17 children diagnosed with the COVID-19 virus died.

Although Ganesh Das is the largest maternity and child hospital in Meghalaya, Ganesh Das did not have a children’s intensive care unit until the state government announced in June that it planned to establish an intensive care unit (ICU) in three district hospitals. Jenny Swett said: “Just a few weeks ago, a child needed to be admitted to the ICU, but we didn’t have our own bed. For a while we tried to find a bed in another hospital.”

India has acted: “We already felt the power of Delta during the second wave of epidemics.” In response to the third wave of epidemics, the federal government allocated funds to hospitals in July and instructed them to increase intensive care beds by 20,000. 20% of these beds are designated for children, and pediatric wards have been established in all 736 district hospitals.

Swett told The BMJ: “Our medical infrastructure is not ready for serious cases. Until recently, only one government hospital had a pediatric ICU, which is a tertiary care center.”

The city of Jaipur has established 25 oxygen centers. Sharma told “The BMJ”: “We have reserved 75 ICU beds for children at JK Lone Hospital and added 300 beds. The affiliated hospital will help us if needed.

The government also ensures that the community health center can accommodate children. Equip the center with 15 ventilators and train staff how to use them. “Several Indian states are preparing to reopen schools that have been closed for most of the time since the outbreak.

At the time of writing this report, only 15.4% of adults in India have been fully vaccinated, and vaccination activities for children have not yet started. Doctors told The BMJ that the current school may be “too early”.

India’s credit rating agency CRISIL once issued a report saying that with the decline in the number of cases, what is needed now is to vaccinate the people quickly and achieve a broad-based economic recovery.

It is estimated that in order to reach the goal of vaccinating the entire adult population by December this year, India’s vaccination rate must be tripled.

Chetan Ginigeri, a pediatrician in Bangalore, said: “Unless nearly 50-70% of the adult population is fully vaccinated, and we vaccinate young people in the next 3-4 months, and then vaccinate children, the logistical problems of opening a school will be very serious. (COVID-19 virus cases may increase).” K Sujatha Rao, former health minister and education minister of Andhra Pradesh, pointed out that children may also be infected in temples, markets and open shopping malls.

Swett said that the parents who brought their children to the Hilon Government Children’s Hospital came from all areas of Meghalaya and most of them were not vaccinated.

This is because of distrust of the government and vaccines, and sometimes for religious reasons.

Meghalaya State is one of the countries with the lowest vaccination rate in the country, 400,000 people out of a population of 3.3 million are fully vaccinated (slightly more than 1 million people received one dose).

Family members in Meghalaya state are unwilling to accept the COVID-19 virus as the cause of their death and doubt whether the virus exists. Marbaniang’s mother, Irinda, said: “Our local legislators are running around, but none of them has tested positive. I think the new coronavirus is a money-making conspiracy, and no one in my family wants to be vaccinated.”

This is a gesture Swett sees every day. She said: “When the school is closed and the children are not taken to crowded places, the children are being infected by adults at home. If their parents are hesitant to vaccinate, they are also unlikely to follow the COVID-19 virus (protection). )protocol.”

Reference materials:

1.https://www.bmj.com/content/374/bmj.n2328

BMJ: The third wave of COVID-19 pandemic will break out in India?

(source:internet, reference only)

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