As the second wave of Covid-19 subsides, several states in India have begun to prepare for a third wave, with a special focus on protecting children.

For instance, the Uttar Pradesh government plans to identify and vaccinate parents of children below 10 years. Since June 15, the state government started distribute free medicine kits consisting of cough syrup and chewable tablets among children through its network of Accredited Social Health Activists or ASHA and other frontline workers.

Jharkhand has prepared a manual detailing its treatment plans and management of children during the third wave, and has estimated that it would require over 6,000 beds for them. It states that at least 14 lakh children in the state would be at risk of Covid-19 in the third wave, even though those below 14 years comprised only 5% of the total cases between March and April this year.

In Karnataka, the government has set up a task force to create additional pediatric wards and Covid care centres for children across districts.

But what is the scientific evidence that these initiatives are based on? What do we know about the third wave and which demographic it will affect the most?

Not enough, said scientists and doctors who spoke to “By now it is very clear there is no scientific or epidemiological evidence that the third wave would affect children disproportionately,” said epidemiologist Chandrakant Lahariya.

A report prepared by The Lancets Covid-19 Commission India Task Force also comes to the same conclusion. So far, most children infected with Covid-19 have remained asymptomatic while mild infections were predominant among those with symptoms, the report stated.

Without any evidence, states were reacting in a “knee-jerk” manner, scientists said. “It is lucrative for states to set up these things,” said Lahariya. “States are procedural and want to give an impression that they are following the process.”

Third wave and children

How exactly did the theory of the third wave impacting children come about?

Scientists did not have an answer but pointed to an editorial that appeared in The Times of India on May 12. It was authored by Dr Devi Shetty, a cardiac surgeon and the head of Karnataka’s Covid-19 task force to prepare for the third wave.

Since vaccines are only permitted for those above 18 years, Shetty, in the editorial, urged authorities to vaccinate parents quickly and claimed that the third wave was “likely to attack children predominantly”.

“During the first wave, Covid attacked mainly the elderly and spared youngsters,” he wrote. “The second wave is attacking a large number of young breadwinners. The third wave is likely to attack children, since most adults are already infected or immunised.”

He argued that treating children and babies in ICU units was different from treating adults. “Even if we assume that just 20% of them get infected and 5% of the infected need critical care, we need 1.65 lakh paediatric ICU beds,” he claimed.

Shetty did not respond to’s queries sent over email regarding the scientific basis for his claims. But weeks after his editorial, the Indian Academy of Paediatrics issued a statement on May 22 that it was highly unlikely the third wave would exclusively affect children. “A very small percentage of infected children may develop moderate-severe disease. If there is a massive increase in the overall numbers of infected individuals, a large number of children with moderate-severe disease may be seen,” it stated.

On the other hand, when asked about the scientific evidence determining its decisions, health officials in Jharkhand said the state had made the manual only to prepare for the unforeseen.

“Our state is the only state that has made comprehensive measures,” said Dr Shantanu Agrahari, the chairperson of the state’s empowered committee to prepare for the third wave. “We have prepared this manual in case there is a third wave. If there is no third wave then we will not implement this manual.”

In Uttar Pradesh, the state started off by distributing 18 lakh medical kits to children, and plans to distribute a total of 50 lakh kits, said Dr DS Negi, the director general in the state government’s medical health and family welfare department. The kits were divided according to various age groups for children below 18 years, and would include paracetamol tablets, cough syrup, multivitamin chewables and drops, oral rehydration solution tablets and Ivermectin, he said.

Negi did not reveal the expenses incurred by the state for this initiative. “We order all these medicines in bulk so we cannot calculate how much went in for the kits,” he said.

Scientists however, said the distribution of these kits had no preventative value. “In a sense, it is no different from Baba Ramdev’s Coronil being distributed,” said Vineeta Bal, an immunologist and professor at Indian Institute of Scientific Education and Research, Pune.

“The only useful thing to do is mask and distancing, as well as vaccination [for adults],” she said. “Cough syrup and stuff are just superficial efforts to show that they are doing something.”

A health worker in New Delhi plays a board game with children tested positive for the Covid-19 infection. Photo: AFP

‘Trying to predict the unpredictable’

There remains very little information on what India’s third wave of Covid-19 could be like.

“In a way we are trying to predict the unpredictable because we have barely understood the virus,” said Dr SP Kalantri, professor of medicine and medical superintendent at the Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra.

“The virus does not believe in these mathematical steps,” said Kalantri, dismissing the assumption that children would be the only vulnerable group left if the third wave strikes. “The virus is like someone who is deeply drunk, he does not know where his next step is, and we are trying to predict this next step.”

While there is no indication of when the third wave will occur, scientists said the theory that it could mainly affect children, depended on multiple variables. “How many people are available to get infected is the primary determinant,” said Vineeta Bal.

A lot of it also depends on how much population immunity exists, that is the number of vaccinated adults who could protect children, said Jacob John, professor of community medicine at Christian Medical College, Vellore.

“There is no reason to believe that children are more likely to get affected,” he said. “The only other thing I can think of is that adults will get vaccinated and as they get vaccinated there will be fewer adults who will get infected.”

But Kalantri was sceptical of this possibility because of the pace of vaccination in the country, considering that as of June 13, only 25.3 crore doses have been administered in the country of a billion plus people, with only 4.8 crore being second doses.

“I am not sure if this theory will really hold because we do not have enough resources to immunise our population,” Kalantri said. “It might take at least a year or so before we are able to cover even 80% of the population,” he said. “It all depends on how aggressively we vaccinate. It is a challenging task, even for the government.”

Multiple variables and ‘no data’

Other scientists said that the assumption of children getting affected at a higher rate depended on the timing of the third wave. Bal hypothesised that if the third wave came in the next three months, then it would be children as well as other unvaccinated adults who would be affected, given the current vaccination rate.

“If it happens later and later then it is likely that only children will be affected if most adults are vaccinated,” Bal said.

Adding another caveat, she said if the third wave was delayed to June or July next year, and assuming the vaccine related immunity does not last for longer than a year, then that would make more adults susceptible to the virus next year.

“So there is no one single answer about only children getting affected,” she said. “But if we had data on serology from all over the country, then we would know how much of Indian population was infected and protected. But we don’t have data.”

Even if children were to be affected, there was evidence to show that their mortality rate was far lesser, according to a study published in The Lancet in March. The study analysed the child mortality rates in seven countries including the USA, UK, Italy, Germany and South Korea.

“Overall, there was no clear evidence of a trend of increasing mortality throughout the period up to February, 2021, but additional deaths have clearly occurred in children and young people during periods of high community transmission,” it states.