How to prepare for a COVID-19 third wave, and future health emergencies

Building a fair and equitable healthcare system, which works for all the people, may be the only solution to prevent -- or rather limit the impact of -- future pandemics

(RAJIV SINGH). As the number of COVID-19 cases and test positivity rates are showing signs of plateauing in major urban centres across India, we see desperate scenes in small towns and villages. We read about people dying in their homes unable to access medical care. We see pictures of people waiting for their turn to cremate their loved ones in funeral grounds. COVID-19 is a humanitarian disaster where no state is spared, poor or rich.

Now there is a talk of a COVID-19 third wave, if we are not able to vaccinate the population fast enough or if citizens do not follow the ‘social vaccines’ (hand washing, use of masks and physical distancing). Let’s examine the truth about the possibility of a third wave.

No respiratory viral infection has been as deadly as the 1918 Spanish Flu. Data from the United Kingdom show us that the disease followed three waves. The second wave was more deadly and long-lasting than the first or third ones.

In the graph below, the area under the curve of the second wave was almost twice that of first and third waves combined. Agreed that the healthcare delivery landscape and the age pyramid may have been vastly different a century ago in the UK, but this historical data shows how an outbreak behaves in a population.

The Waves

The first wave usually affects the most vulnerable sections of the population: the old, sick and the immuno-compromised. The second wave starts when the epidemic spreads into the general population, which may not have got the infection during the first wave and who do not have protective antibodies against the pathogen. The second and third waves of the infection is usually due to mutant strains, which may partially escape the immunity offered by previous infections.

In the case of Spanish Flu, the destruction caused by World War I and lack of laboratory surveillance capacity may have played a part in augmenting the spread and increasing mortality; but the learnings from that outbreak is definitely applicable in the case of COVID-19.

We have seen a lot of parallels between the Spanish Flu virus and the one causing COVID-19, though they are very different phylogenetically. Therefore, it is only reasonable to anticipate a third wave of virus infections and prepare for it.

Vaccine 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. Therefore, relying on vaccines is the most rational way to prevent a third wave.

Short Term

But at present, we do not have the capacity to produce vaccines fast enough to vaccinate our entire population in the next few months. 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 vaccinate India’s population. So we have to look at other options, like scaling up capacity and ready-made vaccines from abroad.

The scaling up of capacity promised by the Serum Institute of India (SII) and Bharat Biotech, which manufactures the vaccines currently used in India, is going to take time and we cannot rely on that process to rapidly increase the rate of vaccination.

In the short term, pre-prepared vaccines from abroad seem to be the only viable option if we want to vaccinate the most vulnerable groups and economically-productive sections of the population rapidly. The decision to allow the import and use of Russian-made Sputnik V is a welcome step in this regard. We need more such vaccines, including China’s Sinopharm which was recently approved for emergency use by World Health Organization.

Medium Term

In the medium-term, our existing vaccine manufacturing capacity should be repurposed to make COVID-19 vaccines. India supplies a major proportion of the vaccine requirements of Gavi-the vaccine alliance and has access to most of the technology platforms for vaccine production. When the United States has supported lifting the patent protection available to COVID-19 vaccines, India should be able to leverage its production capabilities and rapidly augment capacity.

Besides vaccination, in the short and medium term, we should also aim to increase the testing capacity. Only rapid identification of cases and strict isolation can help to flatten the curve till the vaccine rollout is adequate. Apart from this, we need to institutionalise the processes to ensure adherence to social vaccines. 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.

Long Term

In the long term, however, we should be expecting similar pandemics to hit us. Be it antimicrobial resistance or newer viruses, there are a number of health threats which can manifest in several catastrophic ways. The only way out is to strengthen our health system and ensure a basic bouquet of healthcare services to our entire population.

The United Nations High Level Political Declaration on Universal Health Coverage calls for accessible and equitable healthcare services to every single person; and advocates greater emphasis on primary healthcare. India should be able to strengthen our three tier healthcare system by pouring more resources into the primary healthcare centres. It is estimated that almost 90 percent of the medical treatment demand can be satisfied at the primary health level and very few patients need to be referred to higher rungs of the healthcare ladder.

For this, we need greater public investment into the healthcare sector and increase budgetary 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 we need to raise it to at least 2.5 percent in the near term. We need to remember that several developed countries already spend more than 10 percent of its GDP as public health expenditure.

This pandemic has shown us 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 works for all the people, may be the only solution to prevent (or rather limit the impact of) future pandemics.

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