How India can tackle future COVID-19 waves

India is in the grip of the second wave of the novel coronavirus disease (COVID-19) pandemic. The daily infections and fatalities have reduced after weeks of lockdowns. But we need to be very cautious as restrictions ease amid the ongoing wave.

Experts have predicted a dire third wave in the near future and warned it will be more concerning than the previous surges. We, meanwhile, have to deal with ‘wave 2.5’ now with the second wave waning and the upcoming third wave.

It has to be borne in mind that mobility of the people and the economy are dependent on the healthcare facilities and healthcare workers. It is imperative that we, the hospitals and healthcare workers, are not stressed. 

Measures during wave 2.5           

Circuit-breaker lockdowns must be imposed locally whenever there is strain on hospitals in an area, as COVID-19 cases rise. 

The virus spreads via aerosols and direct contact. There is no direct measure of aerosol concentration but carbon dioxide (CO2) is said to be a proxy for aerosols. An increase in CO2 density reveals the concentration of aerosols which may contain the virus. 

CO2 levels should be displayed prominently at offices, malls, buses, metro trains, railway stations, schools, colleges and other public spaces. Cross ventilation should be improved and crowd control measures should be taken immediately if the CO2 concentration is above 1,000 parts per million. 

The heating, ventilation and air conditioning systems should be configured to preferably 12 air changes per hour and high-efficiency particulate air filters and air purifiers should be used. Mass crowds and gatherings, especially indoors, have to be dispersed until the metrics reduce.           

Luxury buses, metro railways and trains should be encouraged to open windows to improve cross-ventilation.           

Vaccination should be taken up as a people's movement. Vaccine appointments should be made easy for people who do not have smartphones or are technologically challenged. Door-to-door volunteers have to be sent to help them. Transportation must be arranged for the physically challenged, immune-compromised and elderly patients, or they have to be jabbed at the doorstep.           

Special hours at banks, supermarkets and farmers’ markets should be dedicated for senior citizens, pregnant women and physically challenged to shield them from crowds.           

Black fungus (mucormycosis) cases need special attention. Black fungus is a part of a series of aggressive fungal diseases that attack COVID-19 patients. This includes the deadly yeast called Candida auris and Aspergillus fungi.

Black fungus is part of a new disease complex called COVID-19-associated pulmonary aspergillosis. Recently recovered patients, especially those with diabetes, need to be monitored regularly and taken for treatment to nodal hospitals immediately if they show symptoms.

Long COVID-19 is another area that needs focus. Special hospital wards have to be set up for the treatment of recovered patients to follow up on their health conditions. A panel consisting of nutritional and medical experts should be appointed to go over the recommendations of nutritional and post-recovery medical conditions and treatment.

A longitudinal study on the lines of the Framingham Heart study, the first long-term study of its kind, should be constituted to investigate the long COVID-19 patients encompassing various geographic areas, ages and medical conditions.

Preparing for third wave           

Sewage water testing should be pioneered. Testing should be done in the current wave in hospitals where there are known cases, in order to cross-check and tweak the testing process as required.

Research has to be initiated into how to develop low-cost oxygen plants to function as captive units in hospitals in urban and, especially, rural areas to avoid pitfalls in oxygen supply, as we have witnessed during the second wave.

Cheaper pressure-swing absorption, zeolite technology, sodium chlorate, iron powder technology currently being used in submarines should be explored. The units should be easily scalable and be able to be readily assembled and transported as needed.       

Research into development of low-cost negative pressure and isolation rooms should be started too. These rooms would be of use even after the pandemic in treatment of tuberculosis and other communicable diseases. Ventilation in hospitals should be studied and measures taken to prevent the aerosol spread of pathogens.

The third wave has the potential to impact children and immune-compromised patients. So, we need to proactively take measures to protect this segment. Children with conditions such as asthma or juvenile diabetes or other immunodeficiencies are at a very high risk.

Children have to be screened for any such conditions during routine doctor visits. Such children should be registered. Vaccination dose and treatment regimen established for children. Health cards be issued for easy identification.

There can be a severe dearth of paediatric facilities and personnel. Doctors should be trained comprehensively in paediatric treatment, with established protocols and new facilities created.

Disposing biohazard

Disposal protocols of vaccines, medical and hospital waste must be studied in detail to prevent health issues and environmental degradation. Biowaste from the hospitals, especially makeshift facilities, and homes of COVID-19 patients, have the potential to cause bacterial and fungal outbreaks if not disposed properly.

Plastics from personal protective equipment, vaccines, masks and medicine packaging pose a massive challenge if left out without proper disposal. Similarly, medical needles pose a danger.

Newer protocols are needed when dealing with a scale of pandemic proportions.The recommended home isolation of patients pose a big problem because their biowaste land up in public dustbins and can be hazardous to garbage collectors.

Ramping up sequencing, rural infra

Genome sequencing of the virus must be done on a war footing in India. It is reported that we only sequence only 0.1 per cent of the cases. We aggressively need to adapt a “know your virus” strategy to understand the variants and their potential to escalate as variants of interest and concern.

We need to pursue a genomic forensic analysis to understand the epidemiology and virus variants. This will help in better planning containment strategies.     

We have seen the rural population getting affected in the second wave and scrambling for hospitals. Most Indian patients have no access to modern treatment and are confined to home isolation with no medication.

Most of the people are unable to pay the hospital admission fees and several get discharged mid-course and are unable to continue the treatment because of the costs. Even most middle-class people cannot afford full treatment as no insurance, including government insurance, is being honoured. Patients are burdened with unnecessary medication, asking the relative to procure rare medications, giving industrial oxygen instead of medical oxygen.

Most doctors are mute spectators to the hospital management’s aggressive methods to charge the patients. The attitude of several doctors is quite contrary to the “Hippocratic oath”.

Life sciences as a subject in university curricula and as a research in universities/institutes is not given the importance it deserves. Emphasis, especially in private universities, is engineering and software oriented.

We hardly have a few central government research institutes that focus on molecular level DNA, RNA, proteins, hormones, antibodies, receptor-ligand interactions, drugs verses enzymes proteins. DNA or RNA sequencing analysis. This area is still in a nascent stage. It is imperative on the part of the government to prioritise the understanding of virology, immunology and epidemiology.

Views expressed by the authors do not necessarily reflect that of Down To Earth.

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