Mumbai: With 294,115 new cases reported on April 20, India now has 21,50,119 active COVID-19 cases, with the second highest number of reported cases, cumulatively, in the world. The number is expected to rise and stabilise at a level much higher than the peak in 2020. There is panic and fear as more and more people are getting admitted to hospitals either for lack of oxygen or because their condition is deteriorating faster than they expected. This, coupled with all the visuals we see, what we read, creates a situation that is undesirable and based on insufficient understanding of what is going on from a medical point of view.
We want to answer three questions for our readers. One, what should you do if you suspect that you have COVID-19, whether or not you test positive, and what should you not do? Two, what is the medical response or treatment protocol for COVID-19 and how is it decided? Third, what is the progression of COVID-19 in this second wave and is it different from the first?
We speak to Tushar Parmar, head of critical care at Apollo Hospitals in Navi Mumbai, and Richa Sareen, consultant for pulmonology and critical care medicine at Fortis Hospital, Vasant Kunj, Delhi.
Edited excerpts from an interview with Govindraj Ethiraj:
Richa Sareen: There are a few differences we are seeing in this current wave. One definitely is that the infectiousness is very, very high. If one person of the family is turning positive, almost the entire family is turning positive. The last time around, it was not that much. The second is that the majority of patients that we are getting now are between 30 and 50 years, and they are sick enough to get admitted. Their oxygen levels are going down, they are getting pneumonia on CT scans. Last time, the younger population was not having a serious illness. In fact, The Times of India has compared the percentage of people in the first wave and the second, along with their symptoms. The percentage of young people testing positive is almost the same but the severity is much more now—many more people are hypoxic [low on oxygen] and require oxygen, and many more people have CT findings [CT scans are being used to diagnose COVID-19, particularly in patients who have tested negative in RT-PCR tests but have symptoms; they are not foolproof tests for COVID-19, as they can only show whether there is viral infection in the respiratory cavity, but not which kind of a viral infection].
The third thing is that pediatricians are seeing younger children becoming symptomatic. Last time, if someone had COVID-19 and their family were tested, the children could turn out to be positive but absolutely asymptomatic. But this time around children are getting symptoms. They are getting high-grade fevers, cough, cold, flu-like symptoms, loose motions...
Tushar Parmar: The basic difference between 2020 and 2021 is the age group—more younger people have serious illness and are coming to the ICU. There are two-fold distinctions: one, the number [of patients] gets almost doubled everyday; second, the infectivity rises so that entire families are [infected]. More people need hospitalisation or ICU beds.
This wave is taking quite a toll on every aspect of life. Most of the intensive care beds are occupied at this point of time. The average length of stay in ICU ranges from seven days to... a month. So, the inflow is too much, outgoing is a little lesser in number. So why are we seeing this amount of surge? Because a patient does not get better very soon, even if they get each and every treatment that has been documented, and they don't go out of ICUs so we cannot accommodate each and every patient in the same environment, in the same hospital or same kind of setup. That is the primary problem that I feel is taking things out of hand.
The second part involves the kind of symptoms coming into the picture and the presentation—whether [the doctor is] presented with a normal viral fever or whether there is some amount of organ involvement. When I say organ involvement, there would be a couple of differences—whether the heart is also involved, whether the brain is also involved, whether the lung is also involved. This time each and every patient coming to hospital with a heart attack is also found to be Covid-positive. They come with a brain stroke at a younger age, they are found to be Covid-positive. They have a huge clot in the lung, they are Covid-positive. So different organ involvement is worrisome in the younger population this time.
Govindraj Ethiraj: The number of younger people getting infected may be roughly similar to 2020 but clearly, the impact this infection has had on them is much higher. Can you walk us through what is happening more specifically, with cases you have seen and with younger people?
RS: This time more and more people are coming with pneumonia, people are going into lung failure, respiratory failure, thus requiring oxygen in the first week itself. Earlier, what we used to see was that deterioration was happening in the second week of illness. Now people are presenting with high-grade fevers on one or two days and on the third or fourth day, their oxygen levels are going down and that needs hospitalisation. If they do not get hospitalised in a day or two, their situation reaches a point where they require an ICU.
This time the patients are not really responding to the treatment we have been giving through the past year and the ICU exit rate is low. People are staying in the ICU for longer durations of time, people are staying in general in hospitals for a longer duration of time. Fevers are not getting controlled very early on, unlike the case with moderate patients last year—you'd start remdesivir, or intravenous steroids, and within a couple of days you'd see some response. Now, it is taking longer for the fever to go away, and that is why the hospitals are full and the infection has spread at such an unprecedented rate. The occupancy of each bed is longer and is making the situation very bad this time.
GE: How are you responding to patients, what is the kind of treatment you are giving them and how is that affecting the perception of the medicines people require and the panic we are seeing outside?
TP: The crux of treatment remains very clear: you treat the viral load, you treat the inflammation and you treat the thrombotic complication if there are blood clots. The rest of the medication is experimental therapy.
If you present within seven to nine days of illnesses, the chances are an antiviral may help. Beyond seven to nine days of your primary symptom, the antiviral may not help you at all. Second, in the inflammatory phase, you give some amount of steroids. If there are complications resulting from steroids, like a rise in blood sugar, they have a prosperity to increase the infection. Then we come to the third part, when we need to give some blood thinner.
We are giving these three basic treatments to almost all the patients, from probably last June or July, because remdesivir was available from that point of time in India. About remdesivir: the data suggest remdesivir definitely shortens hospital stay in mild to moderate cases, but it cannot prevent death. If I am going to have a bad lung [condition] and am going to need a ventilator, remdesivir might not be able to prevent death. Steroids, though, have been associated with a certain amount of mortality benefits.
And the rest of the [experimental] therapies, depending on the situation, we use tocilizumab, bamlanivimab, thymosin alpha-1. Their impact is not clear yet—a lot of literature says it will increase infection, a lot of literature says it is beneficial to the patient but still not unusual. We give them basic therapy within the right time frame, but if they don't improve, we ask the family if they want to go ahead with experimental therapies, and which ones. According to that, we choose our next plan of action.
GE: Dr Sareen, do you concur… are these the three basic categories of concern?
RS: Yes, absolutely. The major problem we are facing in COVID is the inflammatory phase, in which the virus triggers an inflammatory response in the body that causes all the problems and is different for different people. Some people will go into an inflammatory phase, some will not; some will go faster, some will go later. It is the inflammation that we have to target, which we do through anti-inflammatory therapies. Steroids are the only thing proven to be of value as far as mortality is concerned, and every day some or the other newer anti-inflammatory medicines are coming up. Randomised trials are needed to know what is working, what is not working, but right now anti-inflammatory medicines are the main line of treatment for someone who has severe COVID-19 illness.
GE: What does remdesivir do and how important is it from your experience? Should we be panicking and buying remdesivir the way we are currently?
TP: The guidelines say if you are within seven to nine days of the bracket of illness, you can utilise remdesivir and that may benefit you—again, not in terms of mortality but of a shorter stay [in hospital], and in moderate to mild cases, not in severe cases.
Purchasing large amounts of remdesivir would not be so helpful if you have already crossed a certain number of days of your illness. Most people stay at home for six-seven days. They start with the usual medication, when they reach hospital they are crossing seven-eight days of their illness, and whether remdesivir is going to benefit you or not is very questionable at that stage because it is clear that viral replication stops after seven to nine days of illness.
RS: Basically, what people need to understand rather than just loading up on remdesivir and other medicines is that they have to report [at a doctor's] early. For the first few days, people are just sitting with their eyes shut and they are saying it is seasonal change and not COVID-19, let me see for another few days. So they go like this for four-five days and they don't get tested. Then, they get tested and take some medications at home. They call somebody and follow some alternative medicine. And then, they reach us once their oxygen level starts to dip.
This denial of symptoms, we have seen in 2020 and in 2021. Patients will take some ayurvedic medication—some certain brands of ayurveda which are claiming that their medications are healing people. Then what happens is that the patient starts going into the inflammatory phase, oxygen saturation in the blood starts to dip, specifically among people who have co-morbidities, people who are obese, as obesity and hypertension are two risk factors for severe COVID-19 infection. And then they come to us at a stage where their oxygen levels are already at 70% or 80%, they require ICU admissions. Once the viral replication phase is over, we do offer remdesivir but what role it has at that stage is yet to be clear.
Any antiviral therapy that you have to initiate, you have to initiate it in the first five to seven days. It is then that you can control the viral replication, which happens exponentially and high viral loads have an impact on the amount of inflammation that happens later.
GE: What should you be doing and not doing? If you try and get a test, in big cities results are getting delayed, in small towns, people are not being tested.
TP: It is essential to know what are the symptoms of COVID-19 that you can have—loss of sense of smell and taste are the primary ones. Fever and body ache are the symptoms that you need to worry about in the beginning and start consultation with a physician or doctor. There are a few different kinds of symptoms such as persistent headache, being in a confused state, that are new symptoms coming with COVID-19. There is one atypical sign, a left-sided redness of the eye, conjunctivitis, this is also one of the new signs.
If you suspect anything, you must keep on monitoring your temperature and your oxygen saturation. If you have a fever spike and low saturation, seek medical help at the earliest. In this situation, you must start medicines as per guidance.
If no hospital beds are available, but you have some amount of coughing or oxygen saturation on the lower side, we suggest you keep changing the position of your body and lying in different positions so that your oxygen saturation is maintained and you start treating yourself by expanding the lungs in a better way. Start this at home, so you are in a better position when you reach hospital. Online consultation could guide you on what should be done for COVID-19 at this time.
RS: Do not go out unless it is very, very urgent and if you are going out, please wear a mask and practice social distancing. Lockdown in Delhi and other cities will go away in a few days but COVID-19 appropriate behaviour is something that has to go a long way in overcoming the pandemic. Secondly, if you get any symptoms, not everybody is getting fever on the first day, I have seen many patients who only have loose motions, only vomiting, these are the symptoms where people don't even suspect COVID-19. Or even a little bit of malaise. I recently spoke to a patient who, sometime back, was not checking the temperature of her child. She thought it seemed normal to the touch.
If you have any infectious symptoms now, and if more than one family member is having symptoms, then you have to suspect COVID-19. The first thing you have to do is, please isolate yourself at home so that you can protect your other family members. This is one thing people don't do in our society, which we face day in and day out. One person gets COVID-19 and after three or four days the entire family gets it.
Teleconsult is easy; it will not only make you less anxious, you will be able to speak to a doctor one-on-one and you'll be able to tell your symptoms and the other person will be able to tell you what to do, what not to do. And in the meantime, till the time you get your reports—it is generally taking 48-72 hours and that can't be helped because the burden on labs is too much—but till you get a report, please remain isolated and please follow the advice of your physician. Keep on taking a good diet, keep on having lots of fluids and if your oxygen is coming between 93 and 94, awake proning is something we recommend for everybody, specifically people who have generally lower oxygen levels, people who are obese, people who are smokers, people who have weakened lungs. You just need to lie on your tummy and it actually helps a lot. And please, do not be anxious and be calm and face the situation rather than being panicky.
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