What explains the death of relatively young Indians to Covid-19 ?

One of the most dreadful impressions during the second wave of this pandemic is that this time around the virus is mostly attacking younger people. Fuel to fire is fed by vivid descriptions of young patients succumbing to the infection, or more disturbingly, narration of serious complications in children. So much so, the medical consensus seems to predict that the third wave will hit the paediatric age group. This impression gains ground by inputs from well-meaning clinicians working round the clock. Media reports fuel the panic in the population.

The fascinating discipline of epidemiology can be compared to chess. The epidemiologist sees the whole board. As doctors, we all start with clinical medicine and the majority continue in this stream. Few choose epidemiology and public health, the less glamorous, somewhat abstract discipline. Even during pandemics eminent clinicians are sought for their views being well known public figures.

The transformation from clinical medicine to epidemiology is akin to a chess player evolving to masters’ level. In pandemics, clinicians and epidemiologists will have different perspectives. Clinicians have contributed immensely in the present crises, some even with their lives. As a result, treatment regimes have been refined, and case fatality rates have come down considerably. However, they are not ideally positioned to see the dynamics of the pandemic in the population.

There is no marked difference in the age profiles of people affected with Covid-19 in the current wave compared to last year. This was stated in an official briefing around end of April 2021, by Dr V.K. Paul, a paediatrician, member of NITI Aayog and Dr Balram Bhargava, Director General of Indian Council of Medical Research (ICMR).

They elaborated that this year 32% of the cases were below 30 years, as compared to 31% last year. The average age of patients this year is 49 years compared to 50 last year. Last year there was 4.2% of patients between 0-19 years, this year it is 5.8%; while the 20-40 years bracket comprises 25% of the case load this year compared to 23% last year.

Why the panic then, including an amateurish editorial in Lancet? The speed, spike and bounce of the second wave took everyone by surprise. During this middle game crisis, let us analyse our strengths and weakness, which will help us predict how we are going to fare in the coming months.

Like most Asian and African countries, we do have a demographic advantage. We have a broad base of young adults and children to cushion the full impact of the pandemic. Sweden, which did not close schools during the pandemic, supports this proposition. In spite of schools being open throughout, there was no excess morbidity or mortality among the Swedish school children or their school staff.

Comparison of overweight prevalence based on Body Mass Index (BMI) show that countries in the West, all have overweight prevalence around 60% compared to around 20% in the Asian and African Countries. Age and obesity drive mortality rates from coronavirus 10 to 20 times higher in the developed world compared to developing countries.

Two outlier countries provide another clue to this question and present interesting contrasts.

Japan has the highest age profile, but their obesity profile is one-third of the West. Their mortality from Covid-19 is almost 15 times less than the Western countries. The strongest factor in Japan appears to be overall good health as evidenced by low BMI of the population.

The other outlier country is Brazil, which holds important lessons for India. It has lower age profile but obesity profile is similar to the West. Like India it is a rapidly developing economy with change in lifestyle, physical activity and diet. The mortality from Covid-19 in Brazil is exceeding that in many Western countries. Obesity is a greater driver of lethality than age.

Will the third wave impact the young? While overall we have a lean population, there is a tendency for the recently affluent population to adopt sedentary lifestyles, fast food, alcohol and smoking. Moreover, due to genetic handicap, Indians are more prone to diabetes and diseases of coronary heart disease a decade or two earlier than their Caucasian counterpart.

What is the way forward? We have to beef up the public health infrastructure equitably, and address the lifestyle changes among the newly affluent. A number of studies in our field practice areas brought out these incipient trends among the youth and young adults.

We found the younger generation four times more likely to be deficient in Vitamin D compared to the older generation. Diabetes was fairly prevalent in our rural and urban population, and more than half younger diabetics in the 35 to 45 years age group were not aware of their diabetes status. Risk factors of non-communicable diseases were prevalent both among urban and rural youth and young people.

Childhood malnutrition remains quite high as brought out in studies by our postgraduates and faculty.

We lose about 2000 under five children every day due to preventable diseases against a background of child malnutrition. Loss of livelihoods and interruption of child community nutrition programs at the community level will increase child malnutrition and child deaths. While Covid-19 may be mild on the child with normal nutrition, severe malnutrition in children may make them vulnerable to Covid-19.

If we do not address these concerns, we may face the third wave in which young people and children will bear the brunt, not due to lack of vaccination, as the present amateurish consensus seem to suggest, but as a result of not addressing the modifiable risk factors.

If like an amateur strategist we look only at the major piece the new queen, the vaccine, we may be left holding the queen but losing the game.

(The writer is Professor and Head, Department of Community Health and Clinical Epidemeologist, DY Patil Medical College, Pune)