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Accelerate vaccinations to curb Covid spread and variants: Health experts

To prevent any upcoming ‘waves’ of the virus, the government needs to vaccinate more people in a shorter period and allow private hospitals to play a bigger role, suggest top healthcare experts and doctors.

Shalini Bhardwaj

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NEW DELHI: The threat of the spread of mutant variants, its implications and the ‘second wave’ of Covid-19—which The Sunday Guardian’s ‘Medically Speaking’ section was among the first to report—is looming large in the country today. The Sunday Guardian discussed the matter with prominent medical experts Dr Harsh Mahajan, founder of Mahajan Imaging and chief radiologist, Dr Dhiren Gupta, Chairman-elect of the Indian Academy of Paediatrics (Intensive Care Chapter) and doctor at the Sir Ganga Ram Hospital, Dr Avinash Bhondve, former president of IMA Maharashtra, Dr Neeraj Nischal, Associate Professor of Medicine at the All India Institute of Medical Sciences and Dr J.A. Jayalal, National President, Indian Medical Association, to find out how the situation can be managed better.

Dr Neeraj NischalDr Harsh MahajanDr Dhiren GuptaDr Avinash Bhondve

Q: Are we seeing the second wave of Covid-19 or moving towards it?

Dr Nischal: This concept of a wave has been described by epidemiologists. Based on the experience of previous pandemics, it is certain that there will be multiple waves. The moment we lower down our guards, as long as we have vulnerable populations and do not vaccinate most of the population, these waves are going to come. That’s why we have to ensure that we follow the Covid-appropriate behaviours we have been talking about for the last one year. But it is easier said than done. Everyone is saturated and we all want to go out and enjoy the way we did in the past. But the pandemic has not gone away. We will be in big trouble if we lower our guards and that is why, second wave or not, things depend on us. If we allow it to propagate, we will definitely have the second wave, and if we control it right away, we might be safe from the situation which most European countries and the US faced recently.

Q: Maharashtra is going through a bad phase. There was a time when the number of cases was declining but if we see the latest data, the maximum cases have been reported from Maharashtra. What can be the reason behind it? Are people taking it for granted?

Dr Bhondve: Let us talk of some practical and theoretical things. First of all, as Dr Neeraj rightly said, the waves will keep on coming. In early February, new cases were around 2,000 a day, which have gone up to more than 23,000. Before that, in the month of December and January, the number of cases and daily cases and all other parameters came down, but never touched the zero line or went back to the base line. So, this is the rise in the number of cases. There are many reasons. We always blame the common people for not using masks or not observing social distancing, but these things were there even in December and January. The main reason behind the rise in new cases since early February is the government of Maharashtra giving instructions to district officers to increase testing and contact tracing. It was clearly advised that for every patient 280 contacts should be traced. When this number started increasing, it was quite obvious that 90% of the cases, which were asymptomatic or mildly symptomatic, were diagnosed.

Also, the rate at which patients are increasing is very fast. The patients are mostly in the age group of 20 to 45 years, and they are mostly asymptomatic or mildly symptomatic. There was a similar scenario in Britain, where they investigated this and did long sequencing on most of these patients. Like it was a variant in Britain, it could be a variant which has evolved in Maharashtra. These types of sequencing should be done on the patients from Maharashtra like it was done for the patients who came from Britain, South Africa and Brazil.

I think the sum total of all these things is the reason behind the rising cases in Maharashtra.

Q: So, how is Covid-19 striking back?

Dr Mahajan: We know this RNA virus tends to mutate very rapidly. If we see, there are over 100,000 mutations, and over 7,000 have happened in India itself. Out of that, the variants that concern the most have been the three—the UK, South Africa and Brazil variants—as Dr Bhondve also said. In India, about 7,000 patient samples have been genome sequenced, out of which about 200 are from Maharashtra. Out of these 200, in 20% of them they have found two mutations. This is at present. However, as time passes and we do more sequencing, we will know whether it is really the one causing this rapid surge because it is already known that it can be more contagious. The government has now said that 5% of all positive samples across the country will be sequenced. In December, the government also formed institutes for genomic surveillance. So, it’s only when we do more genomic sequencing, that we will know the kind of mutations happening, how they are spreading across the country, if they are similar to the strains found in other parts of the world, and if this is a new Maharashtra strain. But the important point is that if we protect ourselves and we follow Covid-appropriate behaviour, especially the use of masks and practising hygiene and social distancing, we can overcome any mutations and variants. However, we have seen of late, not only in Maharashtra or Punjab, where most of the new cases are happening, but also in Delhi and other parts of the country, that people have reached a level of fatigue. There is a release now, markets are full and weddings are happening, even indoors with hundreds of people. If we continue this, irrespective of what the variant may be, we will get more cases.

But Maharashtra does appear to be at the start of a second wave, as has been said. This may also be due to enhanced testing and very stringent contact tracing where we are picking up more of the asymptomatic variety. This is also the time when the vaccination drive in these pockets needs to be accelerated and the Central Government has to give permission to states to vaccinate those between 20 and 45 years as they are the ones who are getting maximally infected.

Q: What would you like to say about people forgetting to follow Covid-appropriate behaviour?

Dr Gupta: We know this is going to come, which means we cannot stop it. These viruses are going to be here with us. What we need to find out is how we can prevent infections and reduce the number of patients getting infected. Dr Harsh has beautifully defined it. I would like to define it on the levels of the individual, the government and the virus. On the virus level, we know it has marked each and every community. This virus knows much more than what the medical sciences know about this virus.

On the government and individual levels, what I have found is that people are scared of the side effects of the vaccine. So, as Dr Mahajan said, all the population should be vaccinated very quickly. This way we can prevent this virus from circulating quickly, prevent its mutations and suppress such waves, which are otherwise bound to happen. Secondly, there is the problem of ignoring Covid-related behaviours. The kisan andolan is still in full swing, cricket matches have begun, and even politicians are moving here and there without masks. With this type of attitude, whatever we do and whatever programs we start at whatever level, the public is going to behave like this. But what we can do is enhance our vaccination program. There is a lack not only on the government level; it is also the public that is responsible. They are so scared of the vaccine’s side-effects that they forget how bad this virus is. I have worked in the Covid ward and seen people who got infected. Young people think that they cannot get infected or if they do, it would be mild, but they forget that they are the people who are going to spread this virus to the elderly.

But these things are not very simple. I have seen many doctors getting fed up with masks and we have seen that continuously wearing them for 12 hours induces some hypoxia. So, it’s easier to preach. But at the individual level, Covid-appropriate behaviour is very important. We should get vaccinated and, as Dr Mahajan said, open up vaccinations for 20-40-year-olds too and also allow all sorts of vaccines available in the market. We have inoculated more than 2 crore people and no major side effects have happened. We have also got our indigenous vaccine, i.e. Covaxin. This should be promoted as well. We should ask other companies, which have been approved in the US, like Pfizer or Moderna, to export to India. It should be like a flea market: whosoever wants to get it and can pay should get whatever they think is medically suitable. Everyone has to pitch in, including the government, because this is going to rise. I look at the Covid wards, we get a daily warning from our medical director about them being full. So, this is the only way to stop it or slow it down.

Q: The IMA has already urged people and the government to not drop their guard against Covid-19.

Dr Jayalal: Yes, it is quite painful to know that even after very sustainable efforts by the government and healthcare professionals to control the virus, there has been a sudden spike in cases across the country. It is painful to note we have crossed even 36,000 cases in a day, which only denotes we are reaching the second wave. But it is nothing new and it is not in our hands because with any pandemic, multiple waves are inevitable. So, at this moment, we don’t need to panic. We need to sensitize our people. One of the most important things for hospitals and other places where people are accumulated is proper ventilation. Schools have opened and children are coming in, but in many school buildings, the infrastructure and ventilation systems are not adequate. The government should spend much more effort on this because this is not on the children, it is on administrators and management. When we were starting with the pandemic, one of the greatest tasks the Indian Medical Association undertook was to equip hospitals with Covid-appropriate infrastructure with one-way traffic to patients, restrictions on the number of people entering, masking and proper cleaning of the place, etc.

Also, with the elections now, we have seen videos where for every nomination, though there is a control measure, for example, only five to ten persons should go, thousands of people are crowding. The Election Commission has taken a very important step by making sure all officers at the election booths are vaccinated. Now we have also requested the government to make it mandatory for agents coming to the political booths to show vaccination certification. Moreover, as Dr Harsh Mahajan and others said, vaccination should be made more available. There is no point restricting vaccinations when India is able to export more than 5.8 crore vaccines. Vaccination should be provided at the doorstep level. We need to be on a war footing.

Common sense has to prevail among the public too. People believe that Covid is not going to do anything to them and that kind of mindset has settled in because political leaders are not leading by example. That should be punished. We would like to express on behalf of the IMA that in all the countries, the second wave has been more disastrous than the first. Though we have scientific knowledge and know the effects of disasters, we must aggressively fight it. Be assured that the Government of India and the medical fraternity will be on the front lines and we will control and treat people as much as possible. The only thing we want is that the government and our colleagues come together and follow Covid protocol.

Q: Do you think speeding up vaccinations can reduce Covid-19 cases in Maharashtra?

Dr Bhondve: Yes, definitely. As Dr Jayalal rightly said, vaccinations can be increased. I would like to inform all of you that when the two vaccines were allowed to be used on an emergency basis, it was only the IMA under Dr Jayalal that declared that the vaccines are safe. At the same time, neither the Government of India nor any state governments have come out with a statement saying the vaccines are safe and everybody has to take it. With previous vaccines like for polio and other things like the Swacchta Abhiyaan, there were a lot of advertisements. Celebrities were asked to talk about it on TV. But nothing has been done for the Covid vaccinations. This has had a very bad impact on the common people. Right now, even in the first phase, only 40%-50% of doctors and healthcare workers were vaccinated. In the stage where all people over 60 years are being vaccinated, if you observe the statistics, there are people who are not even aware that there is vaccination available and they should get vaccinated. As Dhiren sir rightly said, we have to educate such people. Then there are divyaang people or the handicapped. They are supposed to take the vaccination but none of them are getting it. Meanwhile, for people who are between 45 and 59 years of age, the numbers are not sufficient. 

Secondly, the Government of India said that all vaccination centres should run 24×7. But this is not being seen. All hospitals should be allowed to do vaccinations and take care of any side effects. In Pune, we have around 600 hospitals. So, if we allow even 500 hospitals, at a rate of 100 people, we can vaccinate 50,000 people more. So, the timing and number of hospitals should be increased. And as Dr Dhiren rightly said, more than 3 crore people have been vaccinated and there are no serious side effects. So why not open up the market and vaccines be given by hospitals without all these registrations? During the Covid situation, when the beds in government hospitals were full or restricted, the government allowed beds in all private hospitals, even ones with 5 and 10 beds. So, for accelerating the vaccination drive, all private hospitals should be given a freer hand. Even the VCI head has said this. But it is not being implemented practically. We hope this gets implemented and the vaccine campaign is accelerated so we can control it in 6-8 weeks.

RNA virus tends to mutate very rapidly. If we see, there are over 100,000 mutations, and over 7,000 have happened in India itself. Out of that, the variants that concern the most have been the three—the UK, South Africa and Brazil variants.

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Medically Speaking

COVID-19 VACCINE COULD SOON BE DELIVERED VIA MOUTH, NOSE AND SKIN

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Currently, there are 9 approved vaccines against SARS-CoV-2 virus that are used to prevent transmission, and prevent hospitalisation and deaths. However, all vaccines are given intramuscularly and appear to induce systemic protective immunity and not sterile immunity, and carry minor side effects. Current vaccines predominantly induce IgG antibody response and very little IgA responses. IgA is a predominant protective antibody in the nose and pharynx.

In natural Covid-19 infection, both IgG and IgA responses are induced. This is one of the reasons why after full vaccination some individuals, though rare, are still susceptible to SARS-CoV-2 infection. Taking into consideration current status of repeated surges and mutations in SARS-CoV-2, it is likely that this virus would be with us for some time. We also do not know how long vaccine-induced immunity would last.  Therefore, we may require booster vaccines and modified vaccines to overcome mutant strains.

Furthermore, there is a hesitation in getting injectable vaccines, and then there are problems with storage and shelf life of vaccines. Thus, there is a need to develop vaccines that are not only directed against spike protein where most mutations occur, but directed against other viral proteins that are not susceptible to mutations, for example nucleocapsid and membrane proteins. In addition, there is a need to develop vaccines that may be administered by alternative routes including orally, inhalation, and under the skin. A number of such vaccines are in Phase I trial to determine safety. If proven safe, these vaccines will undergo phase II and phase III clinical trials to determine effectiveness of the vaccine. UB-612 multitope peptide-based vaccine (COVAXX; developed by United Biomedical, Inc) is composed of SARS-CoV-2 amino acid sequences of the receptor binding domain.

Further formulated with designer Th and CTL epitope peptides derived from the S2 subunit, membrane, and nucleoprotein regions of SARS-CoV-2 structural proteins for induction of memory recall, T-cell activation, and effector functions against SARS-CoV-2. In Taiwan, phase 2 trial, and phase 2/3 trial in Brazil have started. Altimmune, Inc has developed intranasal COVID-19 vaccine (AdCOVID). It is a single-dose vaccine. Preclinical results showed stimulation of antigen-specific CD4+ and CD8+ T-cells in mildly affected lungs as early as 10th day. Phase 1 safety and immunogenicity study has begun in Q4 2020. University of Oxford, UK has developed ChAdOx1 nCov-19 inhaled vaccine. 

Dose-ranging trial for orally inhaled vaccine phase 1 trials in 30 volunteers has started. Self-amplified (saRNA) synthetic inhaled vaccine is developed at Imperial College of London. VXA-CoV2-1 is an oral vaccine (Vaxart). Recombinant adenovirus vector type 5 (Ad5) expressing coronavirus antigen and a toll-like receptor 3 (TLR3) agonist as an adjuvant is used. Preliminary phase 1 trial in a large number of subjects, vaccine induced CD8 T-cell responses to the viral spike protein. Neutralising antibodies not detected in most subjects. Company is evaluating an optimal dosing schedule in order to assess efficacy in phase 2 trials. The PittCoVacc Covid-19 vaccine has been developed by two scientists at University of Pittsburgh School of Medicine, Pittsburg, PA. Vaccine candidate using transdermal micro-needle for Covid-19. In mice, vaccines produced antibodies over a 2-wk period; micro-needles are made of sugar, making it easy to mass-produce and store without refrigeration.

In near future, we can expect many more vaccines targeted against multiple components of SARS-CoV-2 to be delivered by convenient oral and inhaled routes that would be effective against expanding mutant strains.

The writer is Professor of Medicine, University of California, Irvine, California, USA.

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Medically Speaking

USE OXYGEN JUDICIOUSLY, FOLLOW DOCTORS’ ADVICE: CORONA TIPS FROM TOP EXPERTS

Shalini Bhardwaj

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Seeing India hit record highs in Covid-19 cases every day has left a lot of people panicking and looking for advice on what to do if someone shows symptoms of the infection. Three of India’s best doctors—Dr Randeep Guleria, Dr Naresh Trehan and Dr Devi Shetty—provide answers to common queries and highlight the most important points that people must keep in mind amid the ongoing surge.

DR RANDEEP GULERIA, DIRECTOR, AIIMS-DELHI

More than 85% of Covid patients will recover without any specific treatment. Most will have symptoms like common cold, sore throat, etc. Over 5-7 days, they’ll recover with symptomatic treatment. Only 15% may advance to a moderate form of the disease.

Oxygen is a treatment, like a drug. Taking oxygen intermittently is an absolute waste of oxygen. There is no data that shows that this will be of any help to you and therefore you shouldn’t do it.

In healthy individuals with oxygen saturation of 93-94, there’s no need to take high flow oxygen just to maintain saturation at 98-99. It’s not going to be of any benefit. If it is less than 94, you need close monitoring, but you still may not need oxygen.

Do not consider Remdesivir to be a magic bullet. Most of us who are in home isolation or in the hospital don’t actually need any specific treatment. Only a small percentage requires Remdesivir.

In terms of the number of people who need oxygen and oxygen supply, we are well balanced. As a country, if we work together and use oxygen and Remdesivir judiciously, there will be no shortages anywhere.

The vaccine prevents you from getting the disease in the form of a severe illness. It may not prevent you from getting the infection. It is important to understand that even after taking the vaccine, we may get a positive report. That is why it is important to wear a mask even after the vaccine.

Cross-ventilation reduces the risk of infection in closed places. Don’t be in groups, whether any of you are positive or not.

DR NARESH TREHAN, CHAIRMAN AND MD, MEDANTA

Today we have enough oxygen, if we try to use it judiciously. I want to tell the public that if you don’t need oxygen, then don’t use it as a security blanket. Wasting oxygen will only lead to depriving someone who needs it.

We now have a protocol that Remdesivir is not to be given to everyone who tests positive. Only after doctors look at test results, symptoms and comorbidities of a patient, it can be given. Remdesivir isn’t a ‘Ram baan’; it only decreases the viral load in people who need it.

A lesser percentage of people require hospitalisation. Hospital beds should be utilised judiciously and responsibly. This responsibility rests on all of us.

DR DEVI SHETTY, CHAIRMAN, NARAYANA HEALTH

If you have any symptoms like body ache, cold, cough, indigestion and vomiting, I have one important message: get yourself tested for Covid-19. It is the most important thing.

In case you are positive, see a doctor and get his opinion. Do not panic; Covid-19 is common now. It is a problem that can be solved, provided you get medical help at an early stage and follow the doctor’s instructions.

There is a possibility that you may be asymptomatic. Doctors will tell you to stay at home, isolate yourself, wear a mask and check your oxygen saturation every six hours.

If your O2 saturation is above 94%, there is no problem. But if it is falling after exercise, you need to call a doctor. It’s important you get the right treatment at the right time.

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Medically Speaking

This isn’t a second wave, but a tsunami: Experts on Covid surge

Planning in advance and ensuring stocks of oxygen, Remdesivir could have prevented such a rise in the number of new cases, say doctors.

Shalini Bhardwaj

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The daily spikes in Covid-19 cases have left many wondering where India went wrong. Did people stop following Covid-appropriate behavior, or did the government make a mistake by not planning for a second wave, which had been observed in the West and was likely to hit India next? Eminent doctors Dr Nita Radhakrishnan, HoD, Pediatric Hematology-Oncology, SSPHPGTI, Noida, Dr Shuchin Bajaj, founder and director of Ujala Cygnus hospitals, Dr Avinash Bhondve, former president, IMA Maharashtra, and Dr Prachi Jain, ENT specialist, Alchemist Hospital, speak to The Sunday Guardian about their views on what is causing the deadly second wave of Covid-19 in India.

Q: What exactly went wrong that has left India so vulnerable to a second wave of Covid-19 with multiple mutations?

Dr Shuchin Bajaj: Till around February, we were all congratulating ourselves and patting our backs for being the only one among the top five affected countries that had not seen a second wave. We were attributing it to our natural immunity and other factors. The WHO, in fact, wrote a paper saying it was due to the mass behaviour of Indians and the government enforcing monetary penalties for not wearing masks. But it was not the correct way to think. We work in the hinterland, in rural areas and semi-rural areas and we saw that nobody was wearing masks there, whether at election rallies or celebrations or at the farmers’ movement. So I think it is the virus’ behaviour, as has been seen repeatedly in various countries, where it goes away and comes back viciously as a second wave. This is exactly what happened a century ago with the Spanish flu as well. The second wave was much deadlier and wider in scope. Unfortunately, although we knew about this behaviour, that this was happening in Western countries and we were about three or four months behind them, we did not take it seriously enough. We did not realise that it would affect us as well. We went about merrily, attending weddings and parties, and now it has come back with a vengeance. It is like a tsunami now, it is no longer a wave. The numbers are shooting up rapidly and we are seeing so many mutant variants of concern that I think there are a few tough months ahead of us.

Q: What do we blame for India’s latest Covid crisis?

Dr Avinash Bhondve: As Dr Bajaj rightly said, in the month of December and January, all the people, including the Government of India, thought that this corona wave has come down and is almost gone. But we had been expecting a second wave in November and December. Fortunately, the numbers came down that time. However, in the great return, it was found that there was a new strain and there were a lot of patients who were affected rather rapidly—30 times faster than the previous virus. They did immediate genome sequencing and found out that there is a new mutant. We asked the government to take great precautions. Flights from Great Britain were stopped but genome sequencing of all those who came, which had been advised, was not done in full capacity. A few hundred were examined but there was more than that. At the same time, we got strains from Brazil and South Africa and even after that very few samples were tested. Then it was declared that a new strain was found in Amravati. Towards the end of January, the numbers were coming down but it never touched the baseline, so it was clear that the second wave was bound to come in a few days and it happened in February when the numbers started rising again. It was absurdly speedy and the government should have informed all the people that this is the speed at which the numbers are increasing. The government is saying that it happened because of people not following Covid-appropriate behaviour but they did not do that even in the months of September October or January or even today. So that was not the main reason, also since the numbers were increasing more in Maharashtra and Kerala. It was quite clear that there was some Covid strain or mutant which had been ignored. The early preventive measures which had been advised came out on 25 March, when the previous year’s highest point was crossed and it was announced that there are at least two mutants.  By the double mutant, it was said that 18% to 20% people in Maharashtra were affected then, but today, as per the latest report, around 61% are affected. So, for all these things precautions should have been taken in February, especially contact tracing, which was advised but not done. Many who were asymptomatic or mildly symptomatic were not diagnosed so they spread the infection as carriers. They were people travelling for business, in local trains and buses, and all this became the main reason for the spread of the new mutants.

Secondly, when the vaccinations began in January, it was so slow that at some places there was only one centre open or only open for four days a week. So many people, even doctors and health workers, avoided taking it because of their work. The government never came out with an open statement saying the vaccines are safe. It was never announced officially. It was also expected that new vaccines would come, which would be better. These were things which the government never planned. Even planning ahead for hospital beds. In Maharashtra, all those Covid centres or jumbo Covid centres where 500 to 1000 people used to be accommodated were closed. The doctors were sent back as they had been taken on a contract basis. There was no planning or expectations about future events. Then, when the numbers started increasing, they never accepted it as the second wave, and were then taken aback with its speed.

Right now, the healthcare system in Maharashtra has totally collapsed. There is absolutely no place, even for simple isolation beds. Oxygen beds and ventilators and the ICU are really out of the question. Even Remdesivir is not available. Around 5% of the infected people may require Remdesivir. So if there are 50,000 patients per day, you require that amount. But it was not planned which is why Remdesivir is falling short now. It is the same for oxygen. Even worse is the state at crematoriums where people are waiting for hours to perform the last rites of their relatives. It is happening for not listening to experts or those who have been studying pandemics.

Q: How are children getting affected by Covid-19? Especially children who already have diseases like cancer and have low immunity levels.

Dr Nita Radhakrishnan: Globally, there has been big concern from the beginning about how this infection is going to affect immune-compromised patients. In many situations, it was found that cancer patients were more susceptible and died of the infection more. Then later on, we saw that the overall mortality was much higher in adult cancer patients than in children. For children with cancer, mortality is definitely higher than among the normal population, but it is not very high either. There are a couple of reasons. One, cancer patients are kept isolated anyway. Their families know the importance of hand hygiene and protection and not going out to crowded places. These things have been there even before the pandemic started. So, in a way, these children were protected. But I agree with the previous speakers on the statement that we have been very lax as a community. The government issuing a challan for not wearing a mask will never be a solution. It has to come from all of us. We have to decide as a group that we will wear masks till our immunity is at a level which is good enough to tackle the infection. Till the time that doesn’t happen, these children, including cancer patients, are going to be highly susceptible to the disease.

Q: How is Sputnik V different from Covishield? What is its composition?

Dr Prachi Jain: All these vaccines are basically aimed at different components of the virus. Some vaccines use mRNA, some use the whole protein, some use the spike protein. In the case of Sputnik V, which is roughly 91.6% efficient, it is a little different from Covishield. In this, different components have been used but the efficacy has been around 90%.

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Medically Speaking

AGE DISTRIBUTION SAME IN SECOND WAVE, OXYGEN DEMAND HIGH, SAYS ICMR DIRECTOR GENERAL

Shalini Bhardwaj

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In a virtual press conference, three senior members of the national Covid-19 task force, Niti Aayog member V.K. Paul, ICMR Director General Balram Bhargava and AIIMS Delhi director Randeep Guleria, presented data pertinent to the ongoing Covid wave.

Dr Bhargava said there is no difference between the first wave and the second wave and the data showed that over 70% of patients in hospitals in both waves of the infection are above 40 years of age, indicating that seniors are still at higher risk. “Older population continues to be more vulnerable to be admitted in the hospital in the current wave,” Bhargava said while sharing the data.

There is no difference in the percentage of deaths between the first wave and second wave from the data we have,” the ICMR DG added, as per ANI reports.

The statistics presented also outlined that there is a higher need for supplemental oxygen — over 54% in hospitalised patients during the second wave. However, it also showed a decrease in the demand for ventilators, which has come down during the second wave, with only 27.8% of those admitted in hospitals needing it, as compared to over 37% who required it during the first wave.

He also said that more cases of breathlessness are being reported during this wave, while in the last wave, symptoms like dry cough, joint pain, headaches were more prevalent.

The ICMR DG also listed three main reasons for the higher transmissibility of Covid-19: laxity, Covid-inappropriate behaviour and various unidentified mutations. “We have had a tremendous amount of laxity, Covid-19-inappropriate behaviour and various unidentified mutations. Of them, some are of concern — the UK, Brazilian and South African variants, which have been demonstrated to have higher transmissibility,” he said. He also added that a double mutant has been found in India but its higher transmissibility has not been established.

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Medically Speaking

A COCKTAIL OF DRUGS CAN BE MORE HARMFUL FOR COVID: AIIMS DIRECTOR

Shalini Bhardwaj

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In an interview on Monday, AIIMS Director Dr Randeep Guleria briefed the public on the importance of drug management during the ongoing pandemic, which has sparked concerns about shortages of medicines like Remdesivir.

“As far as drug management is concerned, there are two aspects – one is drugs and the other is the timing of drugs,” he said, warning that, “Giving a cocktail of drugs can also be more harmful.”

He also spoke about treating Covid-19 through drugs, steroids and CT scans. However, he advised against the use of Remdesivir for people recovering at home. “Studies have shown that Remdesivir is not a magic bullet and it is not reducing mortality. We may use it as we don’t have an antiviral drug. It’s of no use if given early to asymptomatic individuals/ones with mild symptoms. Also of no use, if given late,” he said.

“The majority of patients will improve with just symptomatic treatment. It’s only when you have moderate patients who are admitted that we need to look at steroids and other antiviral drugs (like Remedesivir) by following protocols and rationally give treatment,” he added.

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Medically Speaking

Variants, inappropriate behaviour, Covid fatigue have led to a surge: Top doctors

The ongoing coronavirus surge is not really a sudden, one-off incident. About 100 years ago, there was a similar pandemic, healthcare experts tell The Sunday Guardian in an exclusive interview.

Shalini Bhardwaj

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Top doctors and healthcare experts Dr Rakesh Mishra, director of CSIR-CCMB, Dr Padma Srivastava, senior neurologist from All Indian Institute of Medical Sciences, and Dr S.K. Sarin, director of ILBS, told this paper why they think India is witnessing a massive surge in Covid-19 cases now and how this surge can be controlled. Excerpts:

Q. What explains the sudden surge in Covid-19?

Dr Rakesh Mishra: The most logical reason for the surge in Covid cases is that 2-3 months ago, things were in control, but gradually we started to become careless and common people thought that coronavirus is now gone and normal life can be resumed. We are seeing the consequence of that carelessness. When the number of cases rise, it picks up like a chain reaction. Political activities, farmers’ protests, marriage parties, local trains, schools reopening, restaurant opening, bars opening, malls opening and all such things mean lots of exposure to people in public and these things led to the sudden increase in cases. Also, over a period of time, more variants have emerged and this has affected a large number of people.

Q: In Punjab, we are seeing a lot of people been infected by the UK variant?

Dr Rakesh Mishra: You can actually link that very nicely if you see the data of the UK variant. It means that these are the travellers who initially came from the UK and then participated in some activity where a large number of people came together and then they went to smaller cities and villages and started to spread the virus. But the reason for spreading is only one which is when people are not careful. When people are in close proximity without protection to an infected person, who is also not protected, this is bound to happen. It doesn’t matter which variant it is.

Q. What would you like to say about the sudden surge?

Dr Padma Srivastava: Again, as Dr Mishra said, it is not really sudden. About 100 years ago, there was a very similar pandemic. There was also a second wave which was steeper and worse and then a third wave and then probably, it just vanished. So, what we are seeing today is not an unexpected development. What has happened now, as professor Mishra said, is the presence of variants. To add to it is Covid-inappropriate behavior, which may be due to Covid fatigue as well as overconfidence following the arrival of Covid vaccines. So, people threw caution to the wind at a time when mutants were present and active. Historically, we are going to hit waves and waves again. And for safety, vaccination and Covid-appropriate behaviour are the best bet.

Q: The situation in India is worsening, what are the steps we should all take now?

Dr S.K. Sarin: First, we have to accept that we have a difficult situation and we are actually having more infections now than we anticipated. This is likely to probably overshoot last year’s numbers; so first, we have to accept that we are down in the dumps, we are in trouble and, therefore, if we accept that, then certainly, we have to manage at least this wave of severe and rapidly spreading infection and then, the second step would be to think about how we can prevent a subsequent wave and not let these waves keep on coming and disturbing our economy and lives.

As Dr Mishra and Dr Padma have already said, in my opinion, this was anticipated even in January when things opened up very rapidly. We had the first mutant coming and the UK variant had come or at least was detected at that time and from then on, everyone knew that like in UK, in three months, it would lead to a major proportion of people getting infected. We are not doing as many sequencing as we should for the virus types, but it is anticipated that in a few weeks, this may become a major problem of viral variants infecting Indians. Of course, other variants are there; the virus has a life cycle of about 12-16 weeks until the time it has a major mutation.

So while they are occurring, we should be aware of mutants coming and infecting the population in different cities where it was not there. What is worrying is that we had opened up almost all our transport systems and our offices back in January thinking that the virus has gone away; also, we thought that now that the vaccine has arrived, all of us will be vaccinated soon. These two things have probably help the spread of the virus now. The worry now is the number of deaths piling up in the next 2 to 4 weeks’ time when the infection becomes deeper and more and more people get infected. I think the situation is difficult, but all of us have a collective responsibility.

Q: How can we check such waves?

Dr Rakesh Mishra: Genome sequencing let you explore the aspects of the virus–what kind of changes it is acquiring and if there is any particular area where a particular variant is increasing in number. We have to keep in mind that we are only generating the mutants by allowing the virus groups to spread across a large number of people and mutations are a natural process of any life form. Genome sequencing provides valuable information which gives us some hints about what might be happening, but to control the spread of the virus, we all have to be extremely careful and behave in a Covid-appropriate manner.

Q: Do you think lockdown is one of the useful options?

Dr S.K. Sarin: Once you finish two to four weeks of lockdown, people tend to think that the virus has gone and they start doing multiple times the level of activities they did earlier; so lockdown sometimes is not a very positive way of managing such things.

As Dr Padma said we have to get things like hospitals, ICU beds, drugs, protocols and healthcare workers in order; however, testing and tracing has to be as strict as possible. Lockdown has to be self imposed–you have to see that you actually lock yourself down compared to others to stop the transmission of the virus. The virus is like a villain, it will go away and then show up again and again.

We need to vaccinate our population faster; we have just done 7% vaccination of our population which is much less, especially with respect to areas where the virus is spreading fast like in Maharashtra or maybe Karnataka and Delhi. I think the age bar should be removed and mass vaccination is required as fast as possible. In the history of medicine, there has never been an occasion when the whole world has to be vaccinated and that too fast. So, there are challenges, challenges of making vaccines available, challenges of side effects, challenges of getting people to vaccinate and most importantly, getting people to accept a vaccine. Having said that, through the media, it is very important for us to communicate that there are two types of vaccines available: one is your mask and the second is the available vaccine and we have to employ both of them. Get your shot, do not be hesitant because there are advantages of getting a vaccine. Some people say he got two shots of vaccines, still he got infection, so what is the use of getting vaccination? But it is important to understand that if someone got vaccine shots and even then that person got infected, the infection will be milder. The severity of the disease is reduced as also the severity or possibility of transmitting the virus to others.

The other advantage of vaccines is that you will have antibodies which will at least last for six months to a year; but that should not make you abandon all the Covid-appropriate behavior. Also, once you have a vaccine, you can become and work like a frontline worker. No doctor, nurse, or healthcare worker should work if they have not received both doses of the vaccine. In fact, if there is a possibility, there is a support, we should test the immunization because vaccination is not equal to immunization; immunization means we have a high level of protective antibodies; we have not come to that stage yet. If you are over cautious that a certain vaccine may have side effects, we will lose more lives. Take whichever vaccine is available; they’re safe as millions have taken them.

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