In the first week of May 2021, the Principal Scientific Adviser to the Government of India made a statement that a third wave of Covid-19 was inevitable. The perspective and intention seemed to be prepared for response. However, soon another discourse emerged, that children would be disproportionately affected in the third wave. No one really knows the origin of this unsubstantiated claim but understandably, it created panic amongst parents. A few events around that time gave further credence to this theory. As an example, in a hearing, a bench of the Supreme Court of India asked about the government’s plan to protect children from the third wave.
The state of Maharashtra set up a separate state taskforce for Covid-19 in children. The Karnataka State Commission for Protection of Child Rights recommended the setting up of paediatric Covid taskforces in every district. A celebrated medical doctor made a statement that children would be affected excessively (though that was not evidence-based) and demanded that paediatric Covid Intensive Care Units (ICU), to cater to up to five per cent of the child population in India should be set up. A news report came from Singapore that with the emergence of new strains and new cases, the country had temporarily closed schools (the reason was very different). All of these developments in quick succession were interpreted by many as confirmation that the third wave would mainly affect the children.
No evidence
The fact is that there is no scientific evidence and epidemiological data - from any country or part of the world - that children were, or would be more commonly affected in second, third or any subsequent wave of Covid-19. By the end of May 2021, every serious Indian expert on Covid and disease epidemiology has spoken and confirmed that children are not at any additional risk in subsequent waves of Covid-19. On what basis could this be argued?
A number of countries have already experienced three or four waves of the pandemic and even a few Indian states, such as Delhi have already seen four waves, and the children have not been affected disproportionately. We know through the successive sero-surveys in Indian cities, states and even national surveys that children have always been infected at the similar rate similar to all other age groups. It is just that children don’t develop moderate or severe disease, as the ACE-2 receptors in the lungs on which SARS CoV-2 binds are under-developed in children and the virus fails to find its way to the lungs of the children. Therefore, while children have been infected in all the waves of Covid-19, they do not develop severe disease.
Pre-existing condition
Yet, a small proportion of children (far smaller than adults) do get moderately infected. It has been observed that only those children who have pre-existing disease or on treatment for some other condition develop severe Covid infection. The NITI Aayog and the ICMR have reported that in the second wave, of the total admitted patients, 5.8 per cent were 0-19 years old, from 4.2 per cent in the first wave.
The age group constitutes nearly 43 per cent of India’s population. Clearly, Covid-19 infections in children remain low. A few sick children may develop Multisystem Inflammatory Syndrome of Children (MIS-C); however, those numbers remain small. Clearly, there is no evidence that children have been at higher risk of developing disease. There is another reason to be assured that while new strains of virus have been reported from India, there is no evidence that even these new strains have increased pathogenicity to younger age groups or children.
Proportional rise in cases
Then, what may have resulted in the origin of the idea that children would be more commonly affected? It is likely that doctors attending Covid-infected children have seen more cases than in the first wave; however, the overall cases in the country also increased by four to six-fold and sustained for a few weeks. Therefore, the rise was proportional to the overall increase in cases. Second, the misinformation has been a constant companion of Covid-19 virus. The unverified and unsubstantiated claim that children would be excessively affected in the third wave circulated on social media. Thankfully, a coordinated expert discourse has dispelled the rumour and the fear of parents allayed.
Though children are not at higher risk of disease in the third wave, to ensure effective pandemic response, the government, at both the national and state levels, should prepare for all possible scenarios to respond to the third wave. There is merit in ensuring that Covid testing and treatment services are strengthened, including easy access for testing of children. The genomic sequencing and clinical studies regularly examine transmissibility or pathogenicity of circulating strains in all age groups.
Though the setting up a separate taskforce for Covid may be an attractive idea, it carries the risk of fragmented response. It would be better if a single task force at the state-level, with the participation of child health experts, looks into strategies and plans holistically. Consideration on the opening of the schools and a plan for the vaccination of children should be part of the overall national and state level plans for pandemic response. The health experts speaking about Covid-19 need to support their assumptions, not merely on their clinical experience but in the broader epidemiological context, to avoid any possible panic. As of now, there is no reason to believe that children would be at higher risk of developing Covid in third or any subsequent waves; however, preparation without causing an unnecessary alarm and panic has to be the approach to follow.
The writer is a medical doctor and India’s leading public policy and health systems expert. He is the co-author of Till We Win: India’s Fight Against The COVID-19 Pandemic. He would be happy to answer questions from readers at: c.lahariya@gmail.com
