Mumbai: The city of Mumbai continues to lead the national tally with nearly 20,000 confirmed COVID-19 cases. On the other hand, the guidelines for lockdown-four, starting May 18, 2020, allow for easing of restrictions, and that might also result in a surge of cases.
Even as we talk about that, we speak to two doctors from the city to understand where we stand today on the frontlines, in hospitals. A new worry is paediatrics--are children also likely to face some version of the coronavirus as we are seeing some early trends in cities like New York? To answer these questions, I am joined by Tanu Singhal, consultant, paediatrics and infectious disease, Kokilaben Dhirubhai Ambani Hospital, and Vaishali Lokhande, consultant, internal medicine, at Apollo Hospital, Navi Mumbai.
What are the broad trends and the progression that you have seen particularly in the last few weeks?
TS: We have definitely seen more people getting infected now. As a percentage of tests, we are getting many more positives (we have been testing for COVID-19 for the past two months now). Many of these are patients who have come with COVID-like symptoms, and there are many [others] who have been admitted to the hospital for some other reason, and are screened and found to be positive. We are also seeing many more healthcare workers getting infected.
You are saying that people who were not likely to be the first round of suspects are testing positive. This means there are far more people carrying this disease than we think there are.
TS: We must also understand that, right now, we are doing a test which picks up the viral RNA in the throat. [Read our explainer of the RT-PCR test here]. So we do not know if people who test positive have COVID and are now recovering, or if they are going to get symptoms over the next few days--because we also know that once somebody has caught COVID, the swab can remain positive for a long time. That is the other dilemma that we have.
The main reason for testing them is for infection control--so that they are isolated from other people in the hospital, and are moved into the COVID unit. But then, [patients] who have come in for, let’s say, a fracture or a myocardial infarction or some other disease, are testing positive. It means that there are a lot many more people [who are infected]. Is there anything else, besides rising numbers, that is changing in your assessment of these patients or in their diagnosis?
TS: We are not seeing too many severely ill patients. We always had 2-3 people getting admitted to our unit every week with severe illness, and that is the rate which we are seeing even now. Now, whether this is because our unit is full, and we cannot take more sick people, [I am not sure]. I would like Dr Vaishali to comment on this about her thoughts.
VL: I am working in a non-COVID centre, we run a flu OPD [outpatient department] on a regular basis, manned by physicians and chest physicians. We are seeing a lot of cases [of people] who come with symptoms, which are not really typical COVID--except for the fever--and they turn out to be positive; people who claim to have no travel or contact history and come out positive; people who have not stepped out of their houses and come positive. So, either they are not able to recall the history... and the numbers are really going up. A lot of patients come in for other reasons--a cancer patient comes for chemotherapy, and the test is done before admission, and [they] turn out to be positive. The whole unit--the doctors seeing the patient--gets quarantined. So, I am seeing people with very vague symptoms testing positive. Since we are not a typical COVID centre, when we admit a patient for fever, the moment the test comes positive, we are supposed to transfer them. Rarely has there been a case of severe acute respiratory illness, who would fulfill the criteria for typical, severely ill COVID. We are not really dealing with those.
What are these vague or different symptoms you are seeing?
VL: The other day, I had a staff [member] getting his mother in for some vague symptom, and because we have a dedicated flu area, the patient is kind of triaged into the particular flu OPD area. She came with a vague fever and some discomfort in the throat a few days back. The fever was also low-grade. We did a throat test and it came positive. These are people who are not really expected to be positive, because their exposure--as we are talking about community spread--to a [person] suspected [to have] COVID or a confirmed COVID [patient] is less possible. So, it is just surprising. There are patients who come with just plain fever, and no respiratory symptoms like sore throat, cough, cold--purely fever and myalgia, and they come out positive. So, the spectrum of the disease is not the one learnt in the literature.
Therefore, it also means that a much larger percentage of people are walking around with it in Mumbai, and perhaps in other places too.
VL: Actually, that is a worry. Now the dictum would be that everybody is COVID [positive] until proved otherwise if they walk into the hospital for whatever reason. It is not just [about] the person getting affected, he might not suffer; but the vulnerable population in the community around him, his family members may have a bad time. They might end up [needing a] ventilator and in the ICU, and may not make it. So, it is not just people who are symptomatic; the asymptomatic spreaders are a major worry, I feel.
Dr Singhal, are there any cases in children that you are seeing that have caused you worry?
TS: Not yet. We have now [had] an experience of about four months all over the world. It has been said that children generally do not fall sick--that is the only silver lining to this epidemic. Even if they get infected, they usually have mild symptoms or are asymptomatic.
The only thing is that, like what was said earlier, we had a girl who came with diabetic ketoacidosis--which is a medical emergency in a child who is 14 years old. As per the protocol, we tested her for COVID as she was going to be in the ICU, and she was COVID-positive. Her disease is not explained by COVID; she is just carrying it in her throat. Luckily, she did well. That is the other thing, we do not know how much COVID is contributing to the illnesses of people who come with these kinds of symptoms. We also know that if, a week back, a person had a little bit of fever and sore throat and recovered, and now you do a test for that person, it may still be positive for a long time to come.
Could you dwell a little on this particular patient? In your assessment, what could have been the problem beyond the core assessment that you have done?
TS: It could just be that she must have been exposed to somebody who had COVID, and she got infected. But her disease was not due to COVID, because she behaved like a diabetic ketoacidosis, we gave her insulin etc., and she recovered. If COVID was causing a problem, then she would have a much more stormy course with other problems, which did not happen. So, if you start testing people left, right and centre, you will pick up many more people who are infected asymptomatically.
There is some discussion around newer kinds of symptoms, particularly in children. Are you looking out for that? Is that an area of concern?
TS: Yes, recently from Europe (especially London) and the USA, there have been reports of this multisystem inflammatory syndrome, when children come with high fever, low blood pressure, and their heart is not functioning well--mimicking Kawasaki disease, which is a disease we commonly see in children for which we do not know the cause. So, these kinds of cases--and they have bad outcomes--are being reported. But from India, as of now, I know that there are two patients seen with a similar presentation—one each in Tamil Nadu and Kerala. One of them has already recovered. It is not that it is happening left, right and centre.
As the lockdown lifts, how do we stay better prepared, and what is your task going to be like? How will you be better prepared to handle the surge?
TS: First of all, we are already seeing a surge, despite the lockdown [being] in place, and one of the reasons is [that] this is not a complete shutdown. The other problem, which I think is different in Mumbai, is [that] people stay in very small houses. That is what we have been seeing too--a lot of infections happening in people who are staying close together. So, even if there is one person who is going out to buy groceries and comes back home, there is a very good chance that the person is transmitting [the] infection to family members, and that may be one of the reasons why, despite a lockdown, you have so many more cases in Mumbai, or a densely congested metropolis.
I think the numbers are just going to go on increasing as time goes by, till a substantial amount of the population is infected and the cases start falling. However, it is also possible that weather may have a role to play. Everything about this epidemic is unpredictable, nobody even knows what is going to happen in the next week. All predictions go way off course. So, we really do not know, but obviously the numbers will go up. But, as far as we are not seeing very many severe cases, that is a good thing. Because you would say that we are having a 3% case fatality rate across India, which is similar to what is being reported in other countries. But I feel that the denominator is less. There are many more people who are infected, which we are not picking up. So, if your denominator goes up, then your case fatality rate goes down. The government has given a new discharge policy, wherein patients can go out of hospitals faster; you do not need to do the nasal swabs to document negativity. I think now, the focus should be on building bed capacity, so that sick people are taken care of well.
We should also pay attention to non-COVID patients, because there is a lot of collateral damage happening now because of COVID. People sick with other illnesses come to hospitals and they cannot get admitted because there is fear everywhere, and many nursing homes are closed. And suppose some of these patients come with illnesses that are non-COVID but are sampled, and found positive in the throat, their surgeries get postponed, their chemotherapy gets postponed, dialysis is difficult. So somewhere, people have to balance COVID and also pay attention to the non-COVID illnesses.
VL: I am expecting things to get worse from now. Once the lockdown is lifted, community mingling will happen. Despite these lockdown measures, we have already touched 70,000 cases in India. [The interview was conducted on May 13, 2020.] So, it is going to get worse, I feel, especially in crowded cities like Mumbai. I do not think there is much we can do, because we cannot just function like this forever. The rules will change, but I am dreading July and August because Navi Mumbai is a hotbed for dengue also. We will see a lot of [patients with] dengue, malaria, respiratory illnesses (non-COVID ones), and pneumonia. The hospitals will be really overwhelming, work will be really overwhelming.
As Dr Singhal said, I think the mild cases could be managed at home, but the person who is advised to stay at home should be sensible enough to follow the advice and not move out in the community. I do not think that is happening. People have been tested and they are moving out into the community, and probably by the time their reports come positive, they have already mingled with 15-20 other people, it is difficult to even trace their contacts, I am sure that is what the authorities are facing. As the resources are going to be short, we are creating 2,000, 5,000-bedded units, in BKC and Worli Dome-NSCI. They might get really full in some time, I feel. So, my view is that the mild ones should be kept at home.
Any specific advice to patients or citizens on what they should be doing in the post lockdown phase?
TS: So, my first advice would be to not go out of the house unless it is really essential. The elderly should definitely stay at home. The ones who have comorbidities should continue to stay at home. The people who have to go out have to wear masks, use hand hygiene, and try and see how they can do their work effectively, and once they come home they have to follow social distancing, try and be away. The moment they get these symptoms, they need to separate themselves--and that is easier said than done. As I said, most people in Mumbai live in very small houses. That is also the problem that we are facing about mild symptoms being treated at home--because the person says, “I stay in a one room home with five other people. If I am going to stay at home then what will happen to the other people?” We also have to take care of that. As far as children are concerned, I would say that if your vaccines are pending upto the age of nine months, they should be taken. They should not be postponed. But all other non-essential things, [people should] try and avoid taking children out. I definitely do not think this is the time for schools to open--because online [teaching] can be done, and even if children go to school three to four months late, it is ok. But as Dr Lokhande said, we do not know what will happen in the monsoon because it is not that the other illnesses will stop; then we will have to deal with the other surge of dengue, malaria, leptospira and flu as well.
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