Why third wave of Covid-19 will occur? Who are at Risk ? Why it will affect Children, What are symptoms and clinical features How to diagnose and treat children? How to prevent? What are Preventive measures ?

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2. :: INTRODUCTION ::
• Many countries have restarted their normal
routine after covid-19 pandemic.
• While, some countries including India
struggling with third wave of covid-19.
• Third wave is out of understanding for
laymen, and may do not accept this
possibilities.
• But, this third wave is predicted on scientific
bases by scientific pannels, Medical experts
and Global leaders.

3. :: Pattern of Pandemic in population ::
• Pandemics tend to occur in waves, and each
wave causes a large number of cases.
• Eventually, most of the population may get
immune by Asymptomatic or Symptomatic
infections (herd immunity).
• Over a time disease may die out OR may
become endemic in the community with low
transmission rates.

4. • Covid is caused by SARS CoV2 RNA Virus.
This virus spreads from person to person.
• As soon as it enters in human body, it starts
process of its growth, and produce more numbers
of similar viruses.
• For that it contains RNA, on the basis of RNA it
replicates many copies of it.
:: What are waves in Pandemic?
ORIGINAL VIRUS COPY-1 COPY-2 COPY-3
[1]

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• But, in some cases it could not produce same
copy of RNA, and it produce another type of
virus.
• This new virus is little different than the
Original virus in characteristics. Because , its
protein, spikes etc are changed.
• Such new type of virus is called VARIANT.
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:: What are waves in Pandemic?
ORIGINAL VIRUS COPY-1 VARIANT-1 VARIANT-2
[2]

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• The whole procedure is called mutation in
scientific terms.
• So many variants can be produce from one
original virus.
• Many types or variants are produced from
Original (SARS CoV 2 -Wuhan) virus in the
world.
• Some variants are powerful, others are weak.
Weak variants could not sustain for long time.
• Variants which are more powerful for disease
are known as variants of concern by WHO.

7. • There are so many vaiants of concern
identified so far; Alpha, Beta, gamma, delta
etc.
• Now a days Delta variant is in talk.
• Delta variant found in India, during second
wave, more damage caused by delta variant.
• Now delta variant is found more than 98
countries in world.
• The scientific name of delta variant is B
1.617.2

8. According to WHO :
• India has UK variant (Spreading in many states)
• South Africa and Brazil variants (in some states)
• Double mutant “B.1.618 ” in West Maharastra
• Triple mutant “B.1.618” in west Bangal
• There will be more due to huge turn over
In fact the second wave is due to many variants and
not due to the single variant of first wave.
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Many variants are in India

9. • Recently, scientist have found changes in Delta.
The new variant of delta is K417N or Delta plus.
• So, Detla plus, may have many differnt
characteristics than Delta.
• More than 40 cases are found in India, with new
Delta plus variant.
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Wave-2 by Delta . . Wave - 3 by ??
DELTA DELTA + DELTA +
Caused Second
WAVE
May Cause Third
WAVE ???

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• Comparison for : Prediction for 3rd -Wave :
• 1st Delta was found in Octo 2020. It is
responsible for deadly second wave in India.
• 1st case of Delta plus found on 5th April 2021.
This variant may be cause for third wave in
India.
• The predictions of third wave are made by
following Five factors.
Comparision : Delta and Delta plus

11. • These five points will help to predict about third wave
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Delta and Delta plus variant :
Transmissibility
Virulence :
1
2
Test Compliant :
3
4 Drug Compliant :
Vaccine Efficacy :
5
Delta+ is less transmissible
than delta
Ability to kill, Delta+ is less
fatal than Delta
Both identifiable with rapid
and RTPCR
Supportive drugs will work
on both; Delta and Delta +
effective on Delta, but
Delta+ reduce rate up to 30%

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• Mutants emerge if they have transmission
advantage over predecessors.
1. A million a month vs a week tells us that all
new variants are spreading 3-4 times faster
than D614G varinat.
2. People and Government facilitated rapid
dissemination of mutant variants by giving up
on masks and physical distancing.
3. Eg. Kumbh mela (Jan -1 to April-20) and
election rallies (February through April 1st
week).
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Why did infection spread so fast ?

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• Epidemiology : Foundation Science of Public
Health
• In India, Epidemiology is used much in
Research
• Taught in Medical colleges and in schools of
public health
• Not used in health management, because there
is no Public Health Infrastructure.
• Destiny says : India Needs Public Health
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Epidemiology : Who wants it ?

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:: Ministry of Health ::
1 2 3 4
Dept of
Health
Services
Dept of
Family
Welfare
Dep of
Health
Research
Missing
Dept of
Public
Health
India’s Ministry of Health has a Missing
Elephant !!!!!

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• A wave requires suffcient population
• Left – over from 1st wave (700 million) plus
65,000 births per day : so . . . . .
• 10 weeks . . . . . . Just 5 million children
• Variants with greater RO emerged, Unnoticed
• Failed to vaccinate at least 20-30 % of
population to provide immune.
• Encouraged crowding, avoid safety measures
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Why did the Second wave emerged ? - 1

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• 50% population was vulnerable after 1st wave
• Left with D614G, There would not have been
second wave, but new variants emerged.
• The group of 10 labs (INSACOG) assigned for
monitoring 5% of viruses for variant did not so
• Entry of UK, south Africa and Brazil variants
were unnoticed until 2nd wave emerged.
• Indian Mutants (B.1.617 and 618) sperad fast
in Maharastra and West Bengal
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Why did the Second wave emerged ? - 2

17. Attrributes of first wave :
• Started : 06.03.2020; Peacked : 16.09.2020 (191
days)
• Pre – Peak Cases : 5,115,893,(26,785/day)
• Post-Peak Cases : 5,108,904 (49,124 / day)
• End : 28.12.2020 (104 days)
• Whole wave : 295 days (>42 weeks, ~ 10 months)
• Cases : 10,224,791 (34,660 / day)
• One Million Cases per month
Rather symmetrical of bell-shaped . .

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• Started : 09.03.2021
• Peaked : 06.05.2021 (58 days; ˃ 8 weeks)
• Cases till peak : 10,240,661 (176563 / day)
• Surge volume 176,563 / 26,785 = 6.6 times
• Surge speed in days 191 / 58 = 3.3 times
• One Million per 6 days
• Time to reach million 30 / 6 = 5 times faster
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:: Second Wave – Pre-peak Profile ::

19. Around 23 African countries experienced third wave of
COVID-19 as of July 13, 2021, according to CDC.
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21. • First wave : severe disease occurred - primarily
- elderly and individuals with co-morbidities.
• Second wave : Severe disease - younger group
(30-45 years), also without co-morbidities.
• If Third wave : likely to infect remaining non-
immune individuals - include children also.
• Latest sero-survey : infected children of 10-17
years was around 25%, the same as adults.
• Children are as susceptible as adults and olders
to develop infection but not severe disease.
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Risk : Children and third Wave

22. • 1st and 2nd wave make
some population
immune (herd
immunity)
• Some population
immune by vaccines
• Remaining part is
unprotected : Children
• No Vaccine > 18 yrs
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WHY ? CHILDREN are at RISK ?
• Census :
• 41 % consist of < 18 years,
it is large number
• First wave : 1-2 %
Children affected
• Second wave : 10 %
• Third wave : ??????

23. • Coronaviruses can spread in
Children by :
• Parents and Elders are Major
Source (Schools closed,
children are at home only)
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• After Second wave, sudden carelessnes by
parents, children attended all functions with
parents, gatherings etc.
• Parents do not follow themselves or force
Children for safety and precautions
TRANSMISSION:

24. • There are four stages for disease transmission:
• Stage 1: Imported cases:
• Disease is just introduced by traveled people .
• Stage 2: Local transmission
• Travelers spread infection : family, neighbors and friends.
• Stage 3: Community transmission
• Infection spreads in community in large areas.
• Stage 4: Widespread outbreak or Epidemic stage
• Fourth and Final stage of transmission, a widespread
outbreak - an epidemic - as the number of cases and
deaths begin rapidly multiplying, with no end in sight.
STAGES OF TRANSMISSION:

25. • Infection enters in body via following :
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Portals of Entry :
NOSE : EYES :
1 2
MOUTH :
3

26. • Incubation Period is
varied from person to
person.
• But average incubation
period found is 2 to 15
days in recent cases.
INCUBATION PERIOD :

27. REPLICATION OF CORONA VIRUS ::

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Corona Virus Enters LUNGS
Alveoli
(2 types of cells in alveoli)
Pneuomocyte
type-1
Pneumocyte
type-2
Helps for Gas
exchange
Produce
surfactant
Surfactant prevent
lung from collapse
Adhere Pneumocyte-2
( S-Protein- ACE-2
Receptor )
PATHOGENESIS OF COVID -19 :: 1

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Entry in Cells and
replication
APC(Antigen presenting
Cell)- MHC
Cytokine Storm
Release of IL-1, IL-6 ,
TNF alpha
Vasodilatation & Increased
vascular Permeability
PATHOGENESIS OF COVID -19 :: 2

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Alveolar edema-Surfactant Dysregulation-
Collapse of alveoli
Hypoxia- Increased
Work of Breathing
MSOF –Multi system organ failure
SIRS – Systemic
Inflammatory Response
Syndrome
PATHOGENESIS OF COVID -19 :: 3

31. Fever
Dry cough
Fatigue
Running nose
Body ache
Headache
Vomiting
Anosmia : In ability to smell
Ageusia : Inability to taste
Abdominal related complaints
Commom Clinical Features :

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MILD CASES : 98%
MODERATE
CASES : 1 - 2 %
SEVERE
CASES :
0.5 - 1 %
Spectrum : Disease severity in Children :

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• Fever, Sore throat, rhinorrhoea, Cough,
Diarrhoea, vomiting, Pain in abdomen,
• Mild : Saturation > 94,
• No tachypnoea,
• No dehydration
• Mild can be treated at home.
• Home isolation
Asymptomatic or Mild disease :
[1]

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• Fast Breathing (age based) :
1. < 2 months : > 60 / min
2. 2-12 months : > 50/min
3. 1-5 years : > 40/min
4. > 5 years : > 30/min
• SPO2 : 90-94 %
• No signs of severe illness (systemic
involvement)
• Moderate or severe dehydration
Moderate disease (Pneumonia) :
[2]

35. • Pneumonia with any of the following :
1. Increased respiratory efforts (grunting, severe
retractions)
2. (if speaking) Inability to complete full
sentences
3. Cyanosis, SPO2 : less than 90 %
4. Letharty, somnolence, seizures, oliguria,
• Keywords : Mild will never convert
immediate severe, It will take time, identify it.
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Severe illness, Severe pneumonia :
[3]

36. 1. ARDS : (Acute Respiratory Distress
Syndrome),
2. Sepsis, Septic Shock,
3. MODS : (Multiple Organ dysfunction
Syndrome), Thrombosis,
4. MIS-C : (Multi system inflammatory
syndrome in Children)
• Hospitalization : PICU, HDU(High
Dependency Unit)
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CRITICAL CONDITION :

37. • COVID Suspect case:
• Patient with ARI & or history of travel to a location of
Community Transmission in last 14 days.
• Pt with ARI & close contact with COVID pt in last 14 days
• Or a pt with severe ARI in absence of alternative diagnosis
• Probable case:
• A suspected case with Test result inconclusive
• or test could not be done yet, having some symptoms.
• Confirmed case:
• A Pt with positive COVID-19 test, even he do not have
clinical signs and symptoms present.
CLINICAL APPROACH :

38. 1. RTPCR : If positive, do not confirm by CT
Scan
2. RTPCR : CT value (cycle threshold) : less
then 35 is significant : value, more than 35 is
not covid positive :
3. Mild symptoms, Mild covid no other
investigations required
4. CRP, D-dimer, HRCT etc should be decided
by pediatrician
DIAGNOSIS ::

39. 1. Fever : PCM 10-15 mg/kg, repeat every 4-6
hours
2. Avoid NSAIDS (Ibuprofen, Mefenamic acid)
3. Cough suppressant : No role
4. Throat Soothing : Warm saline garlgles :
only older children, adolescents
5. Antibiotics : not indicated
6. Adequet hydration, supportive care
:: TREATMENT :: MILD DISEASE
:: TREATMENT ::

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1. Hospitalization : NO ICU needed
2. Monitor Progress
3. Feeding, fluid to avoid dehydration, over hydration
4. Antipyretics
5. Suspicion of bacterial infection : Amoxycillin
6. SPO2 < 94 % give O2
7. Rapid progression : steroids (by pediatrician)
8. Rare cases : Remdesivir (by pediatrician)
:: TREATME MODERATE DISEASE
TREATMENT

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1. Intensive Care, PICU
2. ARDS, Sepsis, Septic shock, MIS-C
3. Investigations, Evaluate thrombosis, HLH organ failure,
4. Steroids, Remdesivir
5. Empiric Antimicrobials
6. Oxygen therapy
7. Restricted fluid therapy
8. Ventilation
:: TREATME SEVERE DISEASE
TREATMENT

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• Following Children will required special care.
Children : Requires Special Care :
Congenital Heart Disease
Kidney Diseases
1
2
Genetic diseases
3
4 Imminity Disorders
Metabolic disorders
5

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:: TREATME VACCINATION :
PREVENTION
• Develope Herd Immunity before 3rd wave.
• Immune by disease or by Vaccination. First
option is uncertain and may be fatal.
Vaccination is safe and under our control.
• Before third wave : atleast 40 % population
must be vaccinated.
• But unfortunately . . . . . .
• In India 7.9 % people are fully vaccinated,
• while 20.8 % are vaccinated for first dose.

44. • This rate is much lower than other countries.
1. USA : 50.4 %
2. UK : 58.1 %
3. Israel : 59.5 %
4. Spain : 59.3 %
5. Canada : 60.7 %
6. India : 7.9 %
• Source : http://www.mygov.in/information/covid-19
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Vaccination : Worlwide :: (Fully )

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:: TREATME GENERAL MEASURES
PREVENTION
1. Above 2 years, Mask with three layers.
2. Less exposure to children, shopping, market,
functions etc.
3. frequent Hand washing habit, personal
sanitizer for them.
4. Adult, specially mothers should vaccinted,
because children needs mother.
5. Identify symptoms in Children, Consult and
follow Pediatrician.

46. • Managing Children is More difficult :
• Adult patient cooperate, follow instruction
etc, can left alone with oxygen mask, etc
• Children can not left alone, remove oxygen
mask, needs care taker :
• Limited Nurses, even can not sedate them
• Only parents can manage : 24 hours
• Parents sitting with them must Vaccinated !!!
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Children : Hospitalization a Challange

47. • less then 6 months; Breast feeding is
must for nurishment.
• Good News : Covid +ve mothers can
breastfeed if they wish to do so.
• Practice respiratory hygiene, cover
mouth –nose, Wash hands; Routinely
clean, disinfect surfaces.
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Breast Feeding : Covid +ve Mother :
• If Lactating mother is on Flabiflu, she should stop
Breast feeding and restart after 7 days of complete
flabiflu.

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3. Doctors and Nurses to meet possible requirements
(beds do not treat patients)
4. Equipments, Medicines to meet more numbers;
PREPAREDNESS : THIRD WAVE
• Learnt from previous waves . .
• FOUR things are must :
1. Vaccination : safe surrounding to children
2. Medical Staff : Trained for covid care

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