We seem to take it for granted that the COVID-19 infections are on decline in most parts of the world. However, the time for complacency and full easing of restrictions hasn't come yet. There are several factors that may make things worse for us: rise of immunity-evading variants, pockets of unvaccinated people, waning immunity in fully vaccinated people, booster doses and children's vaccines etc. as well as standard SOPs (masking, sanitisation and distancing).
The delta variant and the new subvariant (Delta plus/AY.4.2) is still prevalent in several parts of the world, including India. Large parts of the world, especially Africa, have very low vaccination rates. What's worrisome is that even in highly vaccinated regions e.g. Eastern Europe and now Western Europe, we now see a huge surge in Covid cases. Low vaccination rate, waning immunity, violation of SOPs such as masking, lack of booster doses and kids' vaccines and possibly new variants may drive a surge in COVID infections across the globe including India (and Manipur).
A fresh Covid-19 wave is currently sweeping across Europe (NPR, Nov. 12, 2021). There has been an alarming spike in cases in Germany, the Netherlands and Austria. In Germany, the number of infections has crossed the 50,000-mark for the first time since the beginning of the pandemic (Business Standard, Nov. 13, 2021). Europe is now back at the epicentre of the pandemic. Russia now leads the world in total COVID deaths for the first time since the start of the pandemic. The Netherlands has announced that it would impose a partial lockdown starting from Saturday, November 13, 2021. Vaccine hesitancy, waning immunity among the vaccinated, relaxed restrictions and winter crowding in poorly ventilated indoor spaces may be among the factors driving the surge. We must all be beware that all these factors apply to large chunks of India, including Manipur.
In Manipur, we're still just about 30 per cent fully vaccinated, and waning immunity may be significant in those who got inoculated early e.g. healthcare workers. In addition, low vaccination rates in several hill districts, no booster shots, no vaccines for children, winter crowding and near-complete easing of restrictions may trigger a fresh wave of infections in our state too. We can only pray that god forbid that Manipur may escape a third wave, if it indeed comes along!
Will a Third Wave hit india?
It's not yet clear if a new wave of COVID-19 will emerge or not. In India, many experts opine that COVID-19 has already become an endemic and no new wave of pandemic will occur in the country. However, there is a complex interplay of new variants, vaccination rate, waning immunity and booster doses, provision of children's vaccines and easing/enforcement of restrictions and winter crowding etc. that will determine the trajectory of COVID-19 infections. We cannot afford to be complacent yet!
The need for booster doses to priority group as vaccine-induced immunity declines
It's now quite clear that vaccine-induced immunity declines significantly 6 months after receiving the second dose. It would be quite desirable to give booster shots for at least certain categories of people. The priority groups include healthcare workers, the elderly and the vulnerable people (those with comorbidities) etc.
The Government of India will soon release a document on administering a booster (third) vaccine dose (TOI, Nov. 12, 2021). The government will take its decision based on recommendations given by ICMR and expert teams. It seems that GOI plans to fully vaccinate the eligible population before going ahead with plans for giving booster shots.
However, the necessity for administering booster doses to the elderly, those aged 65 and above, healthcare workers who got vaccinated (first dose) in January, and those with underlying conditions (heart diseases, transplant & cancer patients etc.) remains quite urgent. If booster shots are not administered to at least certain priority groups, surge in infections among the unvaccinated will be compounded by breakthrough infections among the fully vaccinated, and possible transmission among children and adults in crowded locations with easing of restrictions such as masking. We can only hope that the relevant authorities come out soon with a booster policy for priority sections of the population.
Why is the government delaying rollout of COVID Vaccines for children?
India has already approved two vaccines for kids: ZyCoV-D and Covaxin, but they haven't been rolled out yet. The Union Health Minister has said that the government doesn't want to rush and will only go ahead with vaccinations for children only after further studies (TOI, Nov. 12, 2021). It (GOI) thinks that we need to be very cautious about administering vaccines to our children.
However, the full opening of our schools will not be easy without rolling out vaccines for school-going children; at least, we need to expedite vaccine rollout for kids of age 12 to 18.
Three things remain a priority: vaccinating kids, administering booster shots, and reducing the gap between CoviShield doses. The Kerala government has urged the centre to address these urgent needs (News18, Nov. 13, 2021). It has highlighted the necessity for giving booster doses to people with co-morbidities, reducing the gap between the first and second dose of CoviShield, and administering vaccines to India's children.
New COVID Drugs to blunt the sting of Coronavirus | How effective is molnupiravir (lagevrio) and paxlovid.
We've been eagerly waiting for a medicine to blunt the sting of the coronavirus. Earlier, we had tried remdesivir, HCQ, ritonavir and lopinavir etc. But these were not drugs meant specifically for COVID-19. Now, two new medicines specific for SARS-CoV-2 have appeared on the scene: molnupiravir (lagevrio) and paxlovid. These are medicines made by Merck and Pfizer companies (The Conversation, Nov. 12, 2021). On Nov. 11, UK has approved molnupiravir for mild-to-moderate cases (IE, Nov. 9, 2021). If given early, soon after testing positive or within 5 days of symptom onset, this drug promises to significantly reduce hospitalizations and deaths. In the US, evaluation by the FDA is underway for possible approval of molnupiravir, whereas in India trials for this drug are currently underway. The other drug, paxlovid, manufactured by Pfizer also reduces hospitalizations and deaths but it remains to be approved. These new drugs may lead to more effective management of severe COVID patients. However, the medicines may not be effectives for people who are already hospitalized with serious infections. Both these drugs are oral pills, unlike remdesivir which is usually given as injections.
Molnupiravir was originally developed for influenza but has now been 'repurposed' for COVID-19. The UK regulatory body has found the drug to be quite safe and effective. Merch plans to produce about 10 million doses by the end of 2021. However, according to a report by Nature journal, the biggest obstacle to wide use of the medicine may be its cost, approximately $700 for a 5-day course (equals about 50,000 Indian Rupees).
Molnupiravir inhibits replication of SARS-CoV-2 whereas paxlovid is a protease inhibitor, which inhibits proteolysis and prevents maturation of viral proteins required for assembly of SARS-CoV-2 viral particles inside the human cells.
Possible Measures for Manipur
While we need to assume that there may be a third wave in Manipur too, we must initiate measures to squarely face a possible third wave in our state. These may include:
Preparations for administering vaccines to kids in Manipur & booster shots to priority group or high-risk people (elderly, healthcare workers and people with weak immune systems).
Conducting immediate seroprevalence studies to understand what per cent of population in Manipur and in its different districts are still susceptible to the coronavirus.
Speeding up vaccinations in a big way; aggressive vaccinations with monthly targets to cover all eligible populations with first doses in the next few weeks (4-6 weeks); and targeted vaccinations of all adult populations with second doses in the next 2-3 months.
Regular & repeated COVID testing of symtomatic people in hotspots.
Enhancing the ratio of RT-PCT to Rapid Antigen Testing (RAT).
Weekly "awareness messaging" about the pandemic to the public by a designated healthcare official.
Genomic sequencing of a subset of positive cases and surveillance of the variants including the delta variant: which COVID strains are there in Manipur, where are they, and where are they moving towards; and whether any new variants are emerging.
Contact tracing and government-monitored isolation of positive cases, wherever feasible.
Boosting healthcare provisions such as medical oxygen plants, tankers and cylinders; steroids, antifungal drugs, oxygen concentrators, ventilators, oximeters, masks, PPEs, sanitizers etc.
Strengthening of healthcare infrastructure such as construction of new COVID hospitals.
Provision of more COVID care centres (CCCs), more Covid beds and ICUs in existing hospitals
Constitution of a special taskforce for the third wave; a separate taskforce for pediatric COVID is also highly recommended.
Special provisions for kids such as pediatric hospitals, wards, and ICUs, pediatric oximeters, concentrators, and ventilators and strengthening of staff such as pediatricians and pediatric nurses and paramedical workers etc.