We may have to learn to live with the novel coronavirus, because it can last a lot longer than predicted if people fail to follow Covid guidelines and get vaccinated, and the spread of the virus is not contained, emphasised Dr Neeraj Nischal, Associate Professor, Medicine, All India Institute of Medical Sciences (AIIMS), Dr Anjan Trikha, Chairman of Clinical Managerial Group, Covid Centre at AIIMS, and Dr Arunesh Kumar, HoD, Respiratory Medicine at Paras Hospital.
Dr Arunesh KumarDr Anjan TrikhaDr Neeraj Nischal
Q: A study that says that the second wave of Covid-19 is going to continue for 100 or 150 days. How would you comment on this?
Dr Trikha: Yes, I think it could go on for 100 or 150 days. It is all speculation. Studies like this have a lot of mathematical equations with which they make such predictions. But what is important is that we are having a second stage and unless we take care we don’t know what is going to happen. So let’s not try to predict how many days it’s going to last, let us try to see how we can shorten it. If I say it is going to last 200 days, would people start wearing masks? No. So, the idea is not to predict the number of days, but to see how we can stop it. We have already lowered our guards. Each one of us has attended weddings or religious ceremonies or parties. We have seen the cricket matches – there were about 20,000 to 50,000 people there.
Q: People are not ready to follow guidelines. Do you think this is one of the biggest reasons for the mutation of this virus?
Dr Nischal: First of all, I would like to echo Dr. Anjan’s comment. You can make a prediction, but we all know that how long this particular infection or wave continues for will entirely depend upon how we react to this situation. Even last year, many doomsday predictions were made. Some rosy pictures were painted. All were proven wrong because of the behaviour of the people. So, this 100-day prediction may not come true if we behave properly, and if we become irresponsible, it could last for 1000 days. We have been discussing this thing for almost a year now, so it all depends on our behaviour. If you ask who is responsible for the mutation of this virus: we all know this virus uses a human host for multiplication and if we are not going to rent out our body as an experiment lab for this virus, we are not going to see any mutant variants in our country. But if we keep on providing our bodies for this virus, if the population keeps getting infected, this virus will mutate. These mutations could be fatal too because the virus is trying to evolve so as to survive. Though most species try to coexist with its source – maybe this virus is trying that too – but since this mechanism is not foolproof, there could be a variant which could be fatal for humans. And till it achieves that, we are at risk of catching a dangerous strain which may cause complicated diseases. So it all depends on us and our behaviour. If we behave properly and responsibly, we can control it. Or else, we will keep seeing these mutant strains frequently.
Q: What is the double mutant variant?
Dr Kumar: We know about mutation, it is nothing new about this virus or any virus. All viruses are mutated now and mutations sometimes happen for good because the virus becomes less effective. But sometimes mutations can be bad because they become more virulent. That’s what this double mutation is. There are the South African and Brazilian variants, soon there will be an Indian variant as well because the virus will mutate. As we do genetic studies, we find out a new name for it. But even the mutated variants have the same mode of transmission as the native mutant. They are transmitted by secretions or droplets when you cough and don’t wear masks. So, whatever the virus, people should be tested and treated and we should contain the spread. The principle remains the same. I think let us treat it as any other virus. It is no different and it also behaves in the same way. The good thing is that we are not seeing many sick patients as we were a year back. Believe me, there are hardly 2%-3% of patients who are very sick. The rest are the same, so we are actually seeing a better trend. As the vaccinations are being rolled out, I appeal to people to come get themselves vaccinated. Let’s use the knowledge which we have and not be alarmists about double or triple mutations. Let this be for biologists to deal with. Let’s take the positives and move forward.
Q: Do you think this variant is the reason behind the increasing number of Covid-19 cases in India or the ‘second wave’?
Dr Kumar: There is no such evidence. We need to wait further. You know there was a dip 2-3 months back because people were a bit more disciplined and started putting on masks and observing all the Covid-appropriate behaviours. So, I don’t think this surge is because of a particular strain and that’s why I want to downplay the mutations. Let virologists think about that. For the public, let us treat this virus the same as it was a year ago. Even for us general physicians and practitioners, we don’t treat anybody differently according to whether it is a variant from the UK or Hong Kong or Africa. They just have Covid-19. I’m saying it again, emphatically, that there is no evidence that this increase is related to the new mutant variants. In the coming days, we’ll have more information. More genotyping and molecular studies will be done. But the treatment remains the same, the precautions remain the same, and the mask remains of the utmost importance. To reduce the chain of spread, we have to contain it. If you are sick, you stay home, quarantine yourself for 17 days, and you’ll be alright. If you are breathless or have a bit of fever, you need to seek early help. If you have co-morbidities, you should be extra careful. That’s what we have been saying for the last one year and we are still saying the same. Do not take it for granted because we don’t have a treatment for this condition. All we are doing is symptom control. There is no accurate antiviral. The onus is on the people to follow Covid guidelines. Vaccine skepticism also has to go down. This is the only way out.
Q: Do you think it is high time to start mass vaccinations in India?
Dr Trikha: That is easier said than done. We must not forget that we are a 1.4 billion strong country. I think the vaccination program of the government is doing excellently. It is seamless. I have seen it in Delhi – you can go anywhere, there is no rush, and they are doing an excellent job of it. The government is doing its job. But the government cannot come to my house and put a mask on my face or stop me from going out. This is what you and I have to do. Sarojini Nagar, Lajpat Nagar, Chandni Chowk, Karol Bagh – the markets are all overflowing because people think Holi will never come back again. Chances are, if they get a virus and become very sick and land with a ventilator, Holi might never come back. Meanwhile, there is such a big discussion about the vaccines going on in our country. People who are not even graduates are trying to discuss whether they should take Covishield or Covaxin. Let the government decide that. There are knowledgeable people sitting in the planning commissions at various hospitals. Let them decide what is good or bad for the country. There will always be grey areas in a pandemic, especially with a disease which is evolving like this. The virus will mutate but that’s not a problem. Hopefully, it will mutate and become non-infected, which we are already seeing. But that doesn’t mean people are not dying.
Q: Do you think we need more vaccines?
Dr Nischal: As sir said, it’s a pandemic and we cannot be choosy. They may be more than sufficient to save your life. We don’t know who is going to land up on a ventilator. Many people over 90 years have come out without any problems, while we have also not been able to save somebody in their 20s. The blame ultimately lands on healthcare workers but there is nothing we can do about this virus, apart from providing support and care. For the two vaccines which are available, even if the efficacy is between 60% and 80%, as long as they are safe, one should not hesitate and come forward and take it as soon as possible. You cannot generate a vaccine overnight. These vaccines have come very fast but they have taken at least one year. Of course, there are a number of other vaccines in the pipeline. One of the most promising is the nasal vaccine, and once it is launched the immunization program will be easier to carry forward. But till the time we have other vaccines, we have to rely on what we have and I think these two are perfect and one should not delay or hesitate about taking them.
Dr Trikha: I would just like to add that Neeraj and I work at the same place and he is totally right in saying that, from 1 April 2020 to this year, we have had about four people above the age of 90 who have gone back home, while some of the most powerful or rich or youngest people have died. So, this can happen to each one of us. That kind of feeling should be there – you can call it fear. It is something like thinking “I won’t get cancer”. Anybody can get cancer. So, precaution and treatment and prevention is the thumb rule.
Q: Do you think a time will come when this particular virus will become like the common flu?
Dr Trikha: I am telling you today that we’ll have to live with this virus like we live with so many viruses. The last pandemic took about two to three decades to go. I know science has improved, but this pandemic is just one year old. A time will come when we will live with it and we will get used to it. It will be like getting our jabs every year. There is already a jab by Johnson & Johnson who have brought out a single short vaccine in the USA, where it has been given to homeless people because they can’t be traced for the second shot. So there will be many options available. Neeraj has talked about a nasal drop that will also come. Maybe every one year or 14 months, we will get a shot like you do for influenza. Not many people in India take an influenza shot, but if you go to an office in Europe or America, they advise you to take an influenza shot because that is what prevention is. Even if you get influenza after that, the severity will be less. The same is true with vaccines. Let’s not talk about efficacy in terms of 74% or 82%. These are numbers that pharmaceuticals will push. Let us be honest. If you have had the jab and have the antibodies – and it takes some time after the second jab – and you contract the disease, it is likely to be less severe.
Q: Are you getting Covid-19 patients with any different symptoms?
Dr Nischal: I will carry forward the discussion about mutations. One has to understand that you can’t just blame mutations for the rise in cases. If there had been an increase in cases of re-infection among patients who already had the infection in the past, we could have blamed the mutant variants as a cause. But we believe it’s the mutation in the behaviour of people which is the prime reason for this increase in the number of cases. What we had been seeing in the past, it has been almost the same. Luckily, to be very frank, we are not seeing much sicker patients. Many people are also opting for home isolation which is why the rise in cases is not reflecting in hospitals. But it may increase because if we are not careful and do not monitor our disease progression, we might get sicker patients. The rise in cases and the number of patients in hospitals takes some time to reflect. So if we don’t follow Covid-appropriate behaviour then more cases will start coming after two to three weeks. If we start behaving properly now, the effect will start somewhere in April. This is the only way we can fight this pandemic.
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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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