Mumbai: While the number of coronavirus cases continues to rise across the country, people are taking some comfort in government data that show only 2.55% of COVID-19 patients are in intensive care units (ICU) and fewer than 5% are in critical care. The number of patients on ventilators, which was at one time seen as a critical indicator of the state of patients or the progression of the pandemic, is very low--actually in single digits--across the country.
However, the number of patients on ventilators and in ICUs in the city of Mumbai, which has more cases than any other Indian city or state, is high. For instance, the Municipal Corporation of Greater Mumbai has put out figures showing that 72% of ventilators and 99% of ICUs are currently occupied.
We spoke with two specialists and senior doctors at the frontlines--Farah Ingale, senior consultant, internal medicine at Fortis Network and Hiranandani, and Bharat G. Jagiasi, head, critical care at Reliance Hospital, both based in Navi Mumbai--to understand why this is the case.
Dr Ingale, what are your takeaways from what you have been seeing in the last couple of weeks about the progression of the disease?
FI: Mumbai is a metropolitan city; the population density is very high. All major metropolitan cities, all over the world, have a large number of cases.
Take Dharavi, for instance. It is Asia’s largest and the world’s most densely populated slum. It is spread over 2.4 sq km, but the population is around 700,000-900,000. So, imagine how they must be accommodating themselves: In a room of 10x10 or 10x12 ft, there are about 10-12 people staying. So, social distance has gone for a toss. And they do not have attached toilets or washrooms, so they use the common ones. This virus gets excreted in the stools also, and it can remain alive for 4-6 weeks. Once an infected patient uses the washroom or toilet, they should flush it out properly and the others should not ideally use it for 1-2 hours, which is not possible.
So, I think that is the reason—no social distancing, not much personal hygiene, and then the residents are into trade: They have leather, textile and pottery; people from good socio-economic status [potential carriers] go and visit their shops, and that is how I think it must have gotten transmitted.
That explains the high number of cases. What explains the high number of cases going into intensive care?
FI: As you said, 75-80% of cases are asymptomatic or mild; 15% of cases actually are serious and only 5% are critical. And then, [there could be] different strains of the virus also, which we are not yet clear about. Initially, there were a high number of serious cases, but now the figure has come down. It is at par with any other major city across the world.
Dr Jagiasi, do these numbers from the BMC match what you are seeing in your hospital?
BJ: We have had around 250-300 cases admitted under my care; around 50-60 have passed through the ICUs and there are a certain number on ventilator. Around 170-180 have been discharged and 80-85 are left under my care.
I think there is confusion on the figures: Intensive care and critical care are the same thing. You cannot have different figures for intensive care and critical care. So, what they must be thinking is, there is a certain set of patients who require just oxygen--using hyponasal cannula or non-invasive ventilation--and they recover. Those are still severe, but they [the authorities] must have said that those are moderately severe. And there are certain cases that require full-blown ventilators. We have those cases also. Percentage-wise, as Dr Ingale rightly said, around 10-15% cases need intensive care. But severe are the ones that, I would grade, require a ventilator. Those are around 3% or 2.5% of the cases. That is at my institute. I do not know what is happening at other institutes.
The problem here is, the average ventilation time is pretty long. [When] one of my patients goes on the ventilator, the minimum days on ventilation is 14, and it could extend to 25-30 days, which [occupies] my ventilator for a long period of time. This is not true in other diseases, where the patient is ventilator-free in five to seven days. Here, my ventilator is occupied for a longer time, and this is where the acute shortage of ventilators comes into play.
You are also saying that most of these patients have been on ventilator for more than 14 days or at least 14 days.
BJ: That is the average/median time, [and] that is across the globe. The recovery is very slow among these patients; so the average ventilation time, if someone recovers obviously, is around 10-14 days.
Dr Ingale, what is the number of COVID-19 patients who are on ventilators vs the number of patients who are in the general ward--in your hospital or others that you know of?
FI: As Dr Bharat has rightly said, the number of patients on ventilators is at par with any statistics, anywhere else. It is not that we have too many… and it varies from person to person as to how many days they are on ventilator. But usually, it takes two to three weeks once they are on a ventilator.
Now, our hospital is a DCHC [dedicated COVID health centre], so we mostly have mild to moderate patients. But you never know; patients just deteriorate fast, even in a day. And for our in-house patients who require ventilators, we put them on ventilators. We do not accept serious patients from outside, because ours is not a COVID hospital. So, like Dr Bharat said, it [percentage of patients on ventilators] is around 2-3%, and that figure matches the figure anywhere else. And it is not like [in] Mumbai, patients are more on ventilators, or [in] Mumbai, the patients are not recovering. Many of them are recovering; we are following the standard protocol and they are responding as they are doing everywhere else.
What is the percentage of patients in intensive care? FI & BJ: About 5%.
When COVID-19 patients go into an intensive care unit, how long are they usually there, in your experience?
BJ: As we said, recovery takes pretty long. The average stay in ICU is around 10-12 days. And if a patient gets ventilated, then the stay is prolonged.
The percentage of [patients on] ventilators--though ours is matching with what the society has--[differs]; obviously, there are different demographics. If I have more diabetics, more [patients who are] 65 years and above--those are the risk factors associated with the patients going on the ventilators. We have very few patients who are young and on the ventilator. But, it all depends on the demographics.
There are institutes where there are more patients on ventilators; but the reason is [that] they have more older patients, diabetic patients, heart patients.
Dr Jagiasi, in your hospital, suppose there are 10 beds in the intensive care unit. How many are being occupied by COVID patients, and how many are being occupied by non-COVID patients, who may have been there much earlier?
BJ: We are a COVID unit, so we have certain assigned ventilator beds, certain assigned beds for the COVID patients; so all those beds are occupied by the COVID patients.
We have [a] few beds for non-COVID patients as well, but the occupancy there is low--because I think in this era, people are not willing to come to the hospital for other complaints. That is the reason those beds are lying vacant. But whatever number [of beds] has been allotted for the COVID patients, all those are almost occupied.
Dr Ingale, let me put the same question to you. The reason I am asking this is that in normal times, hospitals are full in this country, and people are in intensive care, people are getting ventilated for all kinds of problems. What is the load that you are seeing at this point, particularly in critical care units, apart from COVID?
FI: As Dr Bharat has rightly said, in this period of lockdown, people are not supposed to move out of their house unnecessarily, except for urgent work. What I have seen is, because we are staying indoors, the incidence of most communicable diseases has come down. Of course, there are patients, but nor many. Maybe because of fear, they are not coming out. And we are not doing elective surgeries. In [most] surgical ICUs, we have post-op patients. We are not doing elective surgeries this season; more concentration is on COVID.
That does not mean that we are not accepting non-COVID patients, or [that] we are neglecting them. But the overall reporting from non-COVID patients is comparatively less. It is only the emergencies that we are taking. So, we have both the COVID patients, and we have started non-COVID work also, but everywhere else as well, the non-COVID work is much less; it is only the emergencies that are coming [in].
And maybe because of this lockdown, because of social distancing, because we are using masks, the incidence of infectious diseases, I feel, has come down dramatically. That is why maybe those patients are not coming out that much, and they are not reporting to us, because incidence itself has come down.
Can you give us an illustration of an infectious disease people may not be getting now, but may have been getting earlier, because they are adopting all these precautions?
FI: All sorts of communicable diseases, basically, which are transmitted through droplets--that is, respiratory illnesses. The other, because people are not going out, they are eating at home, so maybe the gastrointestinal problems--[that arise] because of eating in restaurants, hotels, and outside food--are also less. So gastroenteritis cases, respiratory problems, cough, cold, coryza and influenza-like illnesses... all these have come down.
We are talking about critical care; we are not just talking about patients coming into your hospital?
FI: Yes, that is true. But then those patients also sometimes get critical; because of the infection. If the infection spreads everywhere, they land in sepsis, multi-organ problems and so on. Not all of them.
But now, even the diabetics are taking extra care of themselves. Those patients who become serious usually are the elderly patients, diabetics, those who have cardiovascular problems, hypertensives. Now they are also taking good care of themselves, not exposing themselves, taking medicines on time, consulting with their doctor... they are keeping the problems under control, maybe because of extra fear they have. So they are not getting that serious.
That is a good thing to hear. I am assuming that the other kinds of cases you are not getting much are accidents.
FI: Accidents also, because nobody is there on the roads to drive that much. Not many vehicles are on the roads. That is true.
Is that your experience also, Dr Jagiasi?
BJ: I agree. Maybe because of the lockdown, everyone is sitting at home. So, you have enough time to look after yourselves. Everyone is taking medications on time. They are not missing doses, which would routinely happen when we are busy with the work. And going out is gone, outside food is gone, so incidences of food poisoning have really gone down.
I would just like to add one more thing—the air is more purified now outside; because the pollution level has really come down. The patients who were coming to the intensive care were [those with] acute exacerbation of asthma or chronic obstructive pulmonary disease; they were the ones who were taking a major bite of the ventilators. So, all those numbers have come down because the air is more purified, there is no more exacerbation, neither because of the polluted air, nor because of the infections.
Are you seeing a dramatic difference in these cases between January-February-March and April-May?
BJ: It is a very big difference. What we are seeing is the number of non-COVID patients has come down significantly… whatever issues you consider--pulmonary disease, cardiovascular disease, abdominal disease--everything has come down.
This is not because people are trying to get admission into hospitals but are not able to? You are saying, fundamentally, the disease profile--at least for now--has changed?
BJ: No, for the normal non-COVID area, I think there are enough beds available everywhere, because though the hospital has been assigned just 20% of the beds in the non-COVID area as per the new regulations of the government, even [among those] 20%, [some] beds are lying vacant. I do not think occupying [or finding a bed among] that 20% is a problem, anywhere in India at least.
I was speaking to Dr Srinath Reddy of the Public Health Foundation of India, and he said the only data point that matters is the deaths per million, or essentially how many people are dying. What is your current experience on that score, Dr Ingale? Are we doing well?
FI: We are doing really fine, I can say, because the number of deaths has come down now. Initially, the mortality was very high in Mumbai... it was about 7.2%. It has now come down to 2.9-3%. So, we are doing well, we are at par.
Now, people have got used to [the treatment protocols]. I think there is a sort of... I cannot exactly say herd immunity, but maybe many of them are already infected, maybe they are asymptomatic [and therefore] they do not come to us. And those people actually are not very infectious to the society, but they may be helping indirectly in developing the immunity in the society.
And the people are responding, so we are at par as far as mortality is concerned. But, I do not think the problem is going to go away that easily. I think it will stay. It may be like with HIV patients, the measles patients, the chicken pox and other viral illnesses, which comes in crops, maybe seasonal; it may stay. And a vaccine is not seen in the near future. It may take 1-1.5 years. So the problem is going to stay.
But then, over a period of months, we have experiences from all over the world and we have learnt which medicines are working better. So, we have come to, in a way, better treat the patients now, with experiences from all over the world and we are getting better results. So, the mortality definitely has come down.
Dr Jagiasi, what is your sense on mortality? How are we doing? Also, in the deaths that we are seeing, are there any more insights about where the incidence is higher, or among which demographics?
BJ: No, the mortality has come down. But my explanation of mortality coming down is different from what Dr Ingale says. I would say that we are lucky we were not the initial ones to have the disease. We had the experience of China, Italy, the NHS [the public healthcare system of the UK] and we are talking to our colleagues across the globe. So, the understanding of the disease is better among the critical care specialists.
Initially, we thought it was more of a pneumonia, but now everyone agrees that it is more of a thrombosis, or hypercoagulative state. So, the treatment is now different from what it was initially. Now we have learnt to manage the disease in a different way. And the mortality has significantly come down, even the survival from the ventilator is better than the global numbers initially.
Dr Jagiasi, you are also the joint secretary of the Indian Society of Critical Care Medicine. So, what are the kind of notes that you and your colleagues are exchanging right now?
BJ: There are regular webinars happening, and we have involved all our friends from the US, Italy, the UK. So, understanding of the disease is better. Initially, maybe two months back, we used to ask them what exactly is happening around, and they had those post-mortem reports. So, the treatment has varied: What they were doing initially and what we are doing now is really different; we have a different approach altogether towards the patient and that is what is helping us. So, the discussions go on. It is a dynamic field, because it is a new thing. So, everyday something new comes up and it helps us a lot.
In the deaths that we have seen, are there any new trends or common factors, besides the data on the age profile?
BJ: Obesity is the number one risk factor; it is more of a risk factor than diabetes and hypertension. Obesity is one of the highest risk factors; this is what we are getting the information from across the globe.
Correction: An earlier version had misspelled Farah Ingale's last name. We regret the error.
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