India has long suffered from tuberculosis and attempts have continued to contain its spread. Prime Minister Narendra Modi had stated at the United Nations General Assembly that the disease would be eradicated in India by 2025. With that deadline coming up soon, medical experts—Dr Dalbir Singh, president of the Global Coalition Against Tuberculosis, Dr Raghuram Rao, Deputy Additional Director General, Tuberculosis and Public Health Specialist, Government of India (under the Ministry of Health and Family Welfare), and Dr Vijay Hadda, Associate Professor, Pulmonology Medicine at AIIMS—spoke to The Sunday Guardian, reflecting on how India has fared so far and how much it still has to do.
Q: How common is TB in India?
Dr Vijay Hadda: TB is still a menace affecting almost 4.5 million people per year and taking the lives of almost 1,500 patients per day. So you can imagine how common it is. Whenever a patient comes in with any respiratory symptoms like cough or fever, we always think there is a high possibility that the patient can have tuberculosis. So, yes, tuberculosis is very common and can present itself in any form. Pulmonary tuberculosis gets more attention as it spreads very fast. But we also come across other types like lymph node tuberculosis, bone tuberculosis, and even abdominal tuberculosis. So, almost every physician, irrespective of their subspeciality, manages TB patients. Tuberculosis is one of the most common diseases and is responsible for a significant number of lives lost, disabilities as well as a significant consumption of resources in our country.
Q: What kind of health policies do we have in India for tuberculosis patients?
Dr Dalbir Singh: I have always maintained that policy is fundamental to everything. Almost a decade ago, in 2012, what we had in terms of diagnostics and serological tests were absolutely outmoded and not even 10% accurate. I was driven by passion at a very personal level because I had suffered from tuberculosis twice. The second time, my treatment went over 18 months and I nearly lost my life. My driver would go on coughing and wouldn’t listen to me, and I got the infection from him. I still remember I had had a tough time then because we had tests like “TB Gold” banned in 2012. The world has moved on since then. We were also set upon getting GeneXpert machines, but there were not a lot of things that happened at the policy level. We didn’t have any research so we had that established. There has been sustained advocacy for 8-9 years now. I began with four members. Today, I have 36 Members of Parliament, cutting across party lines, who talk only about TB, not ideology.
TB happens in every constituency in India. We lose 1,500 people every day, which is almost three times the figure of Covid. If we do not catch TB today, we are in serious trouble. It is something that has troubled the planet for nearly 9000 years and in the last two centuries we have lost millions of people to TB. There are a number of factors specific to India too. But the RNTCP has done phenomenal work in the last few years and is arguably the biggest project in the world. They have treated more than 50 million people, which is not a small figure, but our problem is that we have 1.3 billion people and a number of social, economic, and political factors which come into play. We have a vast population living in rural areas. How do we get these people to come and get the diagnosis done? How do you reach every man, do active case finding, and if you find them, how do you get them to reach the centre for diagnostics? Then, if they get their diagnosis, how do we ensure that they do not break the treatment routine? You will be surprised to know that even in the public sector, one-third of the people who seek care drop out.
People are better off in the private sector and that’s a fundamental problem. We have to integrate the private sector very effectively with the government sector. We made an attempt six years ago with the support of the government. I started a pilot project in Patna and then we took it to Maharashtra. Today, based on that model, the Government of India and even The Global Fund are doing a similar public-private interface. It is necessary and we have to refine that model for each of the states because each state has known characteristics. And unless we engage the private sector productively, we cannot end this disease.
India has been aiming to achieve TB eradication five years before the UN Sustainable Development Goals deadline of 2030. 2025 is our deadline and the Prime Minister gave a statement about it. The government has the will and we have the resources – we have done a lot of advocacy to increase it. We have a wonderful National Strategic Plan which can take us through, but what we need to do now is to integrate the private sector and utilise local governments. India has 2.2 lakh local governments and we can use them. One of our shortcomings has been that we have not engaged the community effectively. We should engage them, give them respect, create a legal framework and an administrative framework, and tell them that they are our partners, not subordinates. Without community engagement, we cannot reach our target.
Q: From where we are in 2021, can TB be eliminated in India by 2025? How prepared are we?
Dr Raghuram Rao: When we first made this National Strategic Plan, which Dr Dalbir mentioned, in 2017, we actually decided that we will make an attempt to achieve the SDGs for TB five years ahead of 2030. As per the WHO’s estimates then, there were 217 cases per lakh of the population. The latest WHO report says that in India, we now have 193 cases per lakh population. So there has been a significant reduction. This matches our coverage under the program. In 2017, we were losing almost a million cases, which were not being reported. That gap has now dropped to less than 2 lakhs. So once we find a TB case and put the patient under the right treatment, transmission to the next person doesn’t happen and we are able to break the chain of transmission. That is the agenda which we are pushing.
A lot of effort has been made in terms of man, material and money. All the infrastructure that is required has been put in place, molecular diagnostics have been scaled up, we have the indigenous TrueNat machine that is available in every district of the country, newer drugs are available across the country – so we are pushing hard and trying to find every TB case and achieve our goals.
What we are also doing is integrating this with the Health and Wellness Centres under the Ayushman Bharat program. There is a population of around 500 at the village level, so at these centres we are decentralising the services to be able to provide them to that population. The community health officer manning that centre would be in charge of making sure that the TB population is in control. By 2022, we would be saturating almost every sub-centre in this country and the comprehensive primary healthcare service provided will take TB in sync. So, we are confident that we will achieve our targets by 2025.
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AGE DISTRIBUTION SAME IN SECOND WAVE, OXYGEN DEMAND HIGH, SAYS ICMR DIRECTOR GENERAL
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.
A COCKTAIL OF DRUGS CAN BE MORE HARMFUL FOR COVID: AIIMS DIRECTOR
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.
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.
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.
COVAXIN PRODUCTION TO INCREASE TO 10 CRORE DOSES PER MONTH BY SEPTEMBER
New Delhi: The Centre on Friday said that it is taking steps to boost production of indigenous Covid-19 vaccines, and the production capacity of Bharat Biotech’s Covaxin will increase 6-7 times by July. The government is taking steps under Aatmanirbhar Bharat 3.0 Mission Covid Suraksha to accelerate the development and production of indigenous vaccines. The Centre’s Department of Biotechnology is providing financial support as grant to vaccine manufacturing facilities to enhance their production capacities, a release said.
“The current production capacity of indigenously developed Covaxin vaccine will be doubled by May-June 2021 and then increased nearly 6-7 fold by July-August 2021 i.e increasing the production from 1 crore vaccine doses in April 2021 to 6-7 crore vaccine dose/month in July- August. It is expected to reach nearly 10 crore doses per month by September 2021,” it said.
DR HARSH VARDHAN REVIEWS HEALTH FACILITIES AT AIIMS TRAUMA CENTRE
New Delhi: In the wake of a massive spike in Covid-19 cases during the second wave, Union Health Minister Dr Harsh Vardhan visited AIIMS to review the facilities available at its Trauma Centre, including the availability of oxygen for the Covid patients. In the review meeting, AIIMS director Dr Randeep Guleria and other doctors were present.
“The implementation of Covid-appropriate behaviour is the biggest challenge before us. People have become casual during the second wave. We are doing everything to speed up vaccination and bring more vaccines into the country. We have already given ventilators to the states and they are not demanding more because they are not able to use the current ones because of lack of space. In the last week we took many decisions to strengthen the supply of oxygen on the same dynamic pattern as we did last year,” Dr Harsh Vardhan said.
NINE COVID TIPS TO KEEP IN MIND THIS NAVRATRI
The ongoing Navratri celebrations in India are nine holy days when the nine incarnations of Goddess Durga are worshipped. In the spirit of the occasion, senior neurosurgeon at AIIMS Dr Deepak Gupta shared nine important tips to remember during the current Covid-19 ‘wave’ so people can be better equipped in the fight against the infection.
DON’T TAKE STEROIDS FOR MILD CASES
Steroids dexamethasone, hydrocortisone and MPA may have some benefit, but they are only useful for patients who are on oxygen therapy or ventilator support. Don’t give the patients steroids early or in the first week of the course of the infection. More importantly, don’t use them for mild cases as they might do more harm. Avoid steroids in case of asymptomatic and just RT-PCR positive cases.
REMDESIVIR CAN BE EFFECTIVE IF GIVEN EARLY
Remdesivir with or without Baricitinib can be effective if administered within the first ten days of the illness for patients on ventilator support, non-invasive ventilation or HFNC. It can speed up the time taken for recovery but has no effect on mortality.
WHEN TO USE ANTICOAGULANTS
Anticoagulants (LMWH) followed by oral anticoagulants (Apixaban for three weeks) are useful if D-dimer is high.
PLASMA THERAPY MIGHT NOT BE AS BENEFICIAL
Plasma therapy has no benefits. If at all, plasma must be given within the first three days of the infection from a donor who has very high antibody titers.
OXYGEN THERAPY IS RECOMMENDED
Oxygen therapy, HFNC or ventilator support is highly recommended, if levels of oxygen saturation fall in a Covid patient.
KNOW WHICH MEDICINES MAY BE USEFUL FOR COVID
Inhaled nebulised interferons may be useful, if available. Favipiravir can also improve time taken for clinical cure and help in the cessation of viral shedding by two or three days in mild to moderate cases. MoAb can be used in mild but high-risk cases as it helps in recovery but it is very expensive.
TAKE NOTE OF WHAT DOES NOT WORK FOR COVID
Antibiotics like azithromycin and doxycycline, antivirals like lopinavir, HCQS (chloroquine), ivermectin, and vitamins are not useful for treating Covid-19. Tocilizumab (IL-6 antagonist) is not effective for preventing death in moderate or severe cases and has a risk of sepsis. If one does use it, take only one dose of 400 mg (but only in select cases).
YOUR IMMUNITY MIGHT BE ENOUGH
A majority of patients are improving on their own and developing body immunity, without any treatment. In India, with over a million cases being reported in the last year and the vaccination drive running at its best, people might be likely to achieve natural herd immunity soon.
OPT FOR THE VACCINES
The vaccines available for Covid-19 in India—Covaxin and Covishield—are recommended for all. Two doses are to be taken with a gap of minimum four weeks between them. The Sputnik V is also in the coming, while the Pfizer and Moderna vaccines are available elsewhere.
The novel coronavirus is going to keep spreading and infect everybody it possibly can, until the vaccines can protect everyone or the population develops natural herd immunity. Until then, it would be wise to practise Covid-appropriate behaviour like wearing masks (preferably the N95 kind) washing hands, distancing from each other, and avoiding any unnecessary travel.
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