‘Mumbai Needs Home Care For Asymptomatics, More Testing As Cases Set To Surge’
Mumbai has crossed 10,000 cases of COVID-19 on May 6, 2020, according to the Brihanmumbai Municipal Corporation (BMC) and the Ministry of Health and Family Welfare. This is 68% of all cases in Maharashtra, and 21% of all cases across the country.
IndiaSpend spoke to Farah Ingale, a senior consultant of internal medicine at Hiranandani and Fortis Hospitals in Mumbai and Behram Pardiwala, an internal medicine expert at Wockhardt Hospital, on whether patients now are presenting different symptoms than those in the first 40 days of the pandemic, the experience of pregnant women and children who have contracted COVID-19, the medical capacity to handle the increasing number of patients, and the need for home care for asymptomatic COVID-19 patients.
Edited excerpts from the interview.
What are the kinds of cases that you are seeing today of coronavirus patients and how has that changed in the last 35-40 days?
Ingale: Since the last one month we have admissions only of COVID patients, that is from mild to moderate cases. Of course, we have made arrangements for the serious patients as well, but so far they have not required any ventilator or other management like a serious patient does. Previously we used to hear COVID does not affect children that much, but as of today, there are about five-six paediatric patients, and more coming in. The trend in symptoms and signs are as usual, they come in with fever, they come with cough, with breathlessness.
More than 50% of the patients also have abdominal symptoms, gastro-intestinal symptoms like abdominal pain, diarrhoea. Apart from that there are non-specific symptoms, some of them have conjunctivitis also. They have typical X-Ray findings, we did CT scans for them, one patient had hematemesis [vomiting of blood], typical CT scan findings of pneumonitis [inflammation of lung tissue]. Of course the lab parameters, that's typical lymphopenia [low lymphocyte count]... creatinine, LDH, CRP [markers of kidney and heart function, and inflammation] are high and so on.
We are getting paediatric patients as well these days. We have pregnant ladies also. But I didn't find any different symptoms in pregnant ladies, they are all the same like any other patient. And the course of illness is also the same in them.
Please walk us through what you have been seeing.
Pardiwala: We have roughly about 70 patients with COVID admitted in the hospital, both in the Intensive Care Unit and in the ward. You must understand one thing is that, it is now in the community, there is no question about it. I don't think that the curve is going to go down, it is going to go up. But most of these patients, I am glad to say, are stable. Out of the 75-80 patients we have at present in the hospital, almost 70 of them are stable, five of them require really serious intensive care treatment.
Yes, in our country we do seem to be getting a lot of diarrhoea, a lot of abdominal symptoms. I think that not only is it particular to our country but I believe that there was a report that they have found the COVID virus even in the sewage system in Stockholm. So this is something we need to keep in mind and that is one of the ways in which COVID could be spreading.
The other thing is, I don't like to differentiate but the poor patients come in with classical symptoms--cough, cold, fever, breathlessness, low saturation, backaches, etc. The better-off patients don't come in like that--they come with mental confusion, especially the ones with the comorbid conditions. Just this morning I had an admission, elderly man, diabetic, loose motions, his GP [general physician] was treating him for fever since seven days. I insisted on a COVID test, and lo and behold, it came positive. And there was no way you could suspect it in him.
Yesterday, a woman staying in a chawl with lots of people, a Muslim lady, coughing. She said: doctor give me treatment. I said no treatment, get your COVID [test] done. It is so difficult to get your COVID test done. So we had to cook up a story; listen to this, [we had] to cook up a story she had diarrhoea, she had this, she had that, and that is how we did the COVID test. We couldn't get the COVID test yesterday, but fortunately St George accepted her, we admitted her, this morning it came positive, this afternoon she died. So these are the presentations we get. This is something, I don't know why, but we seem to be losing a lot of patients who fall through the cracks. Because if these patients could have been picked up a little earlier, we [could save them].
Did she not come to you because of stigma?
Pardiwala: Patients may not come because of stigma. But if I convince the patient, forget the stigma, the labs don't do the test! What do you do? I am sure Dr Ingale must be facing the same problem. I mean in my mind, I am convinced that this is COVID, but the lab says we will not do it, what do you do? A lot of general practitioners talk to me, and two of them have told me that the Municipal Medical Officer told them if you send (someone) for a COVID test and it comes out negative, we will prosecute you. I mean look at that!
Any further insight into why the woman died? Apart from the fact that it was a delayed admission?
Pardiwala: Yes, she came in from a very congested locality. She was symptomatic since about seven-eight days, she was going to her family physician who was treating her for a routine cough and cold. I think it is high time that the general physicians realise that they need to have a very high index of suspicion, as far as COVID-19 is concerned. Any unusual presentation, anything which is even slightly variable, you should always get it checked, but you can't get it checked. So that is the catch-22 situation. It is, believe me, in reality, a horrendous situation.
One is the fact there were so many more gastro-intestinal cases. Now are these cases to the exclusion of respiratory symptoms or or do you see both of them?
Ingale: We see both of them also. But some of them come with exclusive gastro-intestinal symptoms. Like Dr Pardiwala has rightly said, those patients who are admitted in single wards [those who are wealthier], in those patients we don't see as much respiratory complaints as such. But in general wards, people from all four sides are coughing. It is really scary for us, though we are in PPE, but you don't know. So it [the symptoms] is variable. But it is already reported in the literature, and that is what we are seeing in our general practice also, that 50% of patients have gastro-intestinal symptoms and cough and fever is a very common presentation. Breathlessness, yes some of them have. X-ray shows the picture and the scans show the picture.
What is the proportion of children and are the symptoms presenting differently in children?
Ingale: The very good thing about children is that most of them are asymptomatic and if at all they suffer, they have mild symptoms. Uptil now what we have seen is only mild fever, mild cough and not many symptoms. They recover also faster compared to adults and to those with comorbidities, like diabetic patients and cardiac patients, who deteriorate fast. But in children, maybe because there are no comorbidities, they recover faster and they have mild symptoms, they are usually not that serious. Some of them may become, there are reported cases, but normally they are mostly asymptomatic, mostly mild and recover better.
What are you seeing in pregnant women?
Ingale: We have about three pregnant ladies admitted with us, one is totally asymptomatic, just because she is positive and she is pregnant she is admitted, there are no symptoms at all. The other two have fever and a mild cough, that is all. Otherwise, they are pretty stable. Pregnancy is not known to adversely affect COVID and the outcome is also not different. So they are all stable at the moment, most patients are stable at the moment.
Does that mean you are not administering any strong medicine, which could also affect the baby?
Ingale: We are giving medicines, but we have to see, if a pregnant lady is there, those medicines which cannot be given in pregnancy, are not given. But the medicines we are using normally can be given to pregnant ladies as well. So those who are positive we are giving them medicines which are safe for pregnancy as such, and they are tolerating it properly.
What about the medical ability and the infrastructure that we have today? The hospitals are now filling up. How are you going to respond to the next round of cases, which you yourself said are going to be more than before?
Pardiwala: Absolutely...75% of our patients do not require hospitalisation. They can easily stay at home. That means that out of 75, I can discharge 55 patients, right? As I said that in intensive care, there is only one patient on a ventilator, others are all on high-flow oxygen, just about five-six of them. That's it. Nobody else is really that bad. Because the municipality [BMC] says that you should admit a COVID patient, we are admitting these patients. I think it is high time that we now relax the rules a little. That, if the patient is asymptomatic, if the patient is young, if the patient has no comorbid conditions, if the patient is able to self-quarantine, in a single room, by themself and has caregivers, they should be given that option.
My understanding was that in some cases, that was already happening, at least in Mumbai.
Pardiwala: There’s many a slip between the cup and the lip. What happens is, different people have different interpretations. Some people may accept, some people may not accept it. I’ll give you the classic example of somebody I know very personally, who was admitted in a hospital, he came positive, on discharge he was still positive, he went home, but the municipality is ringing him up morning and night [saying he needs] to be hospitalised, and they are still chasing him up. So you know what people say is different from what people do.
Ingale: In Navi Mumbai, it is a little different. What the corporation has done [create two] CCCs--Community Care Centres. They have made two sections--one for COVID, one for non-COVID. So those patients who are asymptomatic, or have mild symptoms, those who don't require so much medical attention, they can be kept at the COVID CCC, where there is medical supervision. In the non-COVID ones, there is no medical supervision, the patients have to take care of themselves and report to the authorities in case they develop any symptoms. If the positive ones under medical supervision develop some symptoms and require hospitalisation, they are shifted to hospital. Ours is a DCHC [Dedicated Covid Health Centre], [for those with] mild to moderate cases, and then we have the COVID hospitals.
The number of patients are on the rise, and as of today, we don't have beds available in our hospitals. There are three hospitals allocated for COVID positive, the private ones I am talking of, and most of them are nearly full. That is why there are now these alternative arrangements, and even they said that if the patient is asymptomatic, but COVID positive, they can stay at home, but somebody has to look after them at home, they have to be in a separate room, temperature has to be monitored, morning and evening, the caregiver has to watch them very closely, and if they develop some symptoms then they can be admitted.
When we are repeating, some tests are coming positive after seven-eight days, upto 10 days also. First test is negative, the second is positive again, but the patient is asymptomatic. So we can’t hold them on for such a long time in the hospital. But we need to supervise them also. So we can shift them to CCCs, or if they are asymptomatic, at home in a separate room and somebody monitors them. That is what we have started doing here in Navi Mumbai at least.
If you were to look ahead, do you feel if we were to send home people who are obviously not serious, and really focus on the 15% who need medical attention, then we will not have the kind of load that the hospitals are now beginning to start bearing?
Pardiwala: Yes. I would tend to agree with that statement. I think that a lot of patients are cluttering up the hospitals just now. The other thing is that the requirement that they should be tested for another swab, after five days and mandatorily they have to be kept in the hospital until the five-day period is over, that also clutters up the hospitals. In my ward, at the moment I have got about five patients, two of whose reports should come in today, two whose reports will be done tomorrow, and one day after tomorrow. They all are asymptomatic, they are lying down there and waiting for reports, you can’t do anything about it. So we have to think a little out of the box, and once you streamline it, I am sure that you will get a lot of beds which are available, at least in Mumbai.
Looking ahead, next couple of weeks, how are you bracing yourself? What are you expecting? And how are you preparing yourself?
Pardiwala: I am expecting a lot of COVID patients to come in. I am also expecting a lot of serious COVID patients to come in, because it is in the community now. You still have the lockdown, just wait until the lockdown opens up a little, and you will find a huge surge of patients. You have a huge number of patients in all your slums, just now. By just keeping them locked down there, it doesn't make any sense. Again remember, it is because of fear that people don't get tested. If you test, you will get many, many more patients. What I am fearful about is that a lot of these patients will require intensive care. So we are bracing ourselves for that, in terms of manpower, equipment and everything. Let us hope for the best.
Ingale: Post lockdown, the scenario is going to get worse, and we are getting prepared for the same. Because we are not able to do that many tests--one is we are short of kits, everyone cannot afford them, reports also do not come and again because of fear patients also don't come forward--that is why I don’t know how many we are missing out on. And most of them are asymptomatic, so naturally we don't test those patients. So we may be missing out many patients, and they are the ones who actually spread the infection. Post-lockdown, the scenario is going to get bad, and we are expecting a huge surge, and we are prepared for it. As of now, we will take it as it comes.
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