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How has Covid-19 affected urology? Top doctors explain

Healthcare experts and doctors answer queries around the impact of the pandemic on urology, the latest developments in this branch of medicine as well as risks and challenges of a kidney transplant.

Shalini Bhardwaj

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Top healthcare experts discuss the roadblocks and latest advancements in urology, urology cancer and more. Dr Anup Kumar, HoD of urology, Safdarjung Hospital, Dr Anand Kumar, head of urology and kidney transplant division, Max Hospital, Dr Rajiv Sood, dean of PGIMER, RML Hospital and chairman of Indian School of Urology, and Dr Amlesh Seth, HoD of urology at AIIMs, put forth their views. Excerpts:

Q. What are the challenges involved in kidney transplant?

Dr Anand Kumar: Kidney transplant involves two people, one person who is going to get the kidney and the other who will donate it. This is a unique situation in the medical field as it is the only operation in which a healthy person is undergoing an operation to give one of the organs or part of the organ to someone else to live. Somebody who has just died has agreed to donate his organ then his organ can also be given to others. It is a big challenge. Nowadays there are nuclear families, suppose someone has kidney disease, previously in the family there used to be at least three to four children but now usually there are only two children. If they are not matching there is a problem and if one has gone outside the country or some other thing then there is a problem in finding a particular donor for kidney transplantation. Apart from this, it is also a financially and emotionally draining situation. Your treatment is expensive, it goes throughout life and the initial preparation is also required as the patient undergoes dialysis and a lot of tests. We have to see if the patient is fit or not to undergo the transplant. His donor also has to go through a lot of tests. All these issues are there and then we go for the transplantation. Sometimes no family member is fit to donate even if they want to. Only a healthy person can donate, suppose the donor has got some liver disease, both his kidneys are not good, he has diabetes, has major pressure issues or heart disease so even if he is willing to donate and wants to save the other person, he still can’t do that. We can’t risk his life while taking out his kidney in donation as our job is to make sure that the person who is donating should remain healthy, he should not suffer and the one who got the kidney should also do well. 

Q. How much risk is involved in a kidney transplant?

Dr Anand Kumar: Kidney transplant nowadays has become a very routine procedure. Firstly, we will take the kidney donation, it is done electroscopically. The patient is admitted for three to four days. The procedure usually takes one to two hours, the next day the patient needs only a small procedure to take the kidney out, the next step is walking around, moving around, and on the third-fourth day, the patient is discharged. Within two to three weeks, he is fit and fine after which he doesn’t need to take any medication or precaution. He can do anything except two things, he cannot join the army and police force. Besides that, he can go hiking, cycling, and produce children so the donor has no risk. The operation has become very safe but in one out of 3000 cases there can be some complication.

Q. Do you think we need awareness as people still feel that they should not donate a kidney, especially family members and there is some hesitation?

Dr Anand Kumar: Yes, it needs awareness and we salute those who donate their kidney, it is not an easy decision. If I ask somebody to give Rs 100 he would think a few times before giving it. If I ask somebody to donate his blood, it would not be a problem as when you give the blood nothing happens, within a few hours your blood is replaced. Still, people are hesitating to donate. Asking somebody to undergo some major operation to donate their kidney is not at all that simple but still, people do it. It takes a lot of courage and self-determination to donate and help somebody. They are doing a very altruistic act to save somebody’s life; it is not an easy decision and takes time. We counsel them, give them literature to read and build their confidence. A lot of people come forward so I salute them that they have done a great job, and saved somebody’s life. It needs awareness that donation is simple and safe, there is no disfiguration of the abdomen and very soon you will be back to your work and can do anything. Another thing that needs a lot of awareness is cadaver donation. Many people are dying because of roadside accidents, brain haemorrhage, a clot in the brain, and sudden cardiac death so when they are in the hospital their family agrees to donate their organs. One person can save many people’s lives, you can donate eyes, liver, lungs, heart, kidneys, pancreases, small bowel, cartilage and other organs. One person can save seven lives when the family allows it. There is the system, law, many foundations, and NOTO (National Organ Transplant Organisation), so there’s nothing to fear about. The family just has to give consent. 

Q. What is urology cancer? Does a urologist treat cancer?

Dr Anup Kumar: Yes, urology cancer is treated by a urologist, we call them urooncologist. It is a separate speciality these days and that includes cancer, soft kidney, and bladder, etc. All these cancers have various presentations, various stages and a lot of advances have taken place in the field of urology. Earlier it used to be open surgeries for all cancers. Then there are laparoscopic surgeries, minimally invasive surgeries, but then laparoscopic surgeries had some disadvantages and limitations especially in certain challenging cases. Then came the era of robotics and this era came in the last 20 years, we are seeing its benefits in terms of least mobility to the patients and decrease in mortality. Patients don’t have long insurgents which we give in the open surgery so there is less pain, less blood loss, lesser need for the blood transfusion and the patient recovers faster. In terms of the outcome, we recover cancer totally, not leaving cancer behind. That is known as R0 resection efficacy is also increased, enhanced and is equivalent to open surgery. Functional outcomes and quantity of life outcomes are very important in today’s era. The patients are aware of these things and demand a good quality of life which we can give them. Talking about radical prostatectomy, earlier the patient feared that they would leak the urine continuously after surgery and had many other fears. Nowadays with the robotic approach, we can not only give them excellent continence and many of the patients are immediately continent after surgery and almost 80-90% will become continent in three months which is a very good number. We can also preserve the nerves which give normal life after surgery.

Q. How Artificial intelligence (AI) is useful in urology?

Dr Anup Kumar: AI is a big field that is going to be there in the robotic field. Right now, we are not using AI, but we have the robots which are coming, these robots don’t have haptic feedback, i.e. no tactile sensation which we have in open or lab. In AI we are going to have haptic feedback again and that will improve the outcome of the surgery. AI is the future of all these technologies, especially robotics.

Q. What are the latest developments in urology?

Dr Amlesh Seth: There are so many developments that it is very difficult to talk about one or two. Dr Anup has already talked about robotics and AI. In urological cancer, gene therapy is coming up and targeted therapy has already been there and there are multi-mortality treatments for urological cancer which becomes more and more streamlined. The cure rates for testicular cancer is 99% and good longevity is provided in patients with prostate cancer, kidney cancer, and bladder cancer. In bladder cancer, a new bladder formation has been going on and in about two to three decades, if the urinary bladder is taken out then the new bladder can be formed from the intestine. The patients avoid it almost as if the patient has an inactive bladder. People fear the bladder being removed. 

Q. How Covid-19 has affected urology?

Dr Rajiv Sood: In urology we have all kinds of exposures to the health workers which are there in any other discipline also but the special thing is that in urology we are having a lot of diseases which are very common like UTI, cancer, the kidney stones, or any disease ureteric disease for the elderly where the comorbidities are also there. We have elderly patients, a patient profile that should not be exposed to the Covid pandemic and also they are pre-disposed because of the comorbidities occurring side by side. Now in urology heavy rush is managed by using the face screen and a screen between patients and doctors, besides sanitising and keeping distance. Firstly, the last March onwards tele-counselling has been legalised and if you see a patient you are already examined for the next six months. You can do tele-counselling through any social platform or any dedicated platform. Secondly, we have modified certain guidelines in urology, all OPD indoor, OT protocols and cancer guidelines are modified. In prostate cancer, everybody should treat it once we recognise it is cancer. Unless it is very slow-growing, safe, or low risk but when there is a chance we have to decide whether we are going for a biopsy or not. We have to decide their imaging, not the therapy protocols as we have modified the radiotherapy i.e. the radiation protocols. Also initially there were a lot of apprehends for the laparoscopic surgeries as aerosol spread were also feared. Now because of certain precautions and special protocols we can perform those also. Urological surgeries sometimes are very small as they last for just cystoscopy which is a very short duration and sometimes they are very time consuming and may last for seven to nine hours. We know that in Covid for the long procedure the exposure is long and the viral dose is also high so we have to decide whether we are going for the short procedure, long procedure, short exposure, long exposure and how many times we are calling the patient if we are giving chemotherapy. As Dr Amlesh was saying, that there is target therapy also or the pills for some alternate treatment. Maybe the second line hormones treatments for cancer there are pills. We were preferring that we do not hospitalise the patients and give more of the outdoor treatments and home cure whenever it is possible. What is the effect of Covid on the pre-existing renal or the urological conditions and condition caused by covid? That is also very important as we have identified a lot many biomarkers. If biomarkers are present in the organ we know that these organs are expressed to more damage. Now there are ACE2 receptors. ACE is the angiotensin-converting enzyme that is very important and is present in different organs like the entry point of the nose, eyes, and intestine but in the urological tissues like the kidney, especially in the proximal tubules, they are present. This is the entry point for coronavirus and once they enter through this they start replicating. Therefore, urologists become important because in no previous commodity also patients are exposed to acute kidney injuries which are very serious. If the pulmonary lungs are affected they go high, their morbidity, motility also go high. So maximum acute kidney injuries are occurring in ICUs indoors compared to the outdoor or homecare covid patients and this may have long term consequences. There are certain procedures like kidney stone and we don›t have a table to accommodate them as a lot of OT’s were shut and there are a lot of backlog patients suffering whom we have to take care of. In cancer, radiations like you give the doses you go for hypofractionation means you give small doses. Also in surgeries, we have to decide whether we can postpone the surgery and also there is an effect on fertility because of the inflammatory reactions of the Leydig cells which are important in the spermiogenesis and also because of direct inflammation which is the main problem in covid infection and testis gets damage so fertility gets affected. It has been found that the fertility rates go down, not only that there is another angle another at the end of the spectrum—i.e. because of the undesired conceptions you are not able to go for MTP the Medical Termination of Pregnancy. Due to the different work from home and social conditions in some advanced countries, educated countries, there had been a decrease in the population due to the involvement of mental health also.

Q. Has it affected mental health also?

Dr Rajiv Sood: Yes, it is connected with the population also. In India, it was found that a 3.1% increase in the birth rate and that is called the baby boom. The population is going down and going up in many countries, directly sexual organs and genital organs are getting affected.

Q. Why is infertility increasing in men, especially in the younger generation?

Dr Anup Kumar: The causes for increasing infertility are increased use of alcohol and tobacco in the younger generation. We are also seeing an increase in the trend of diabetes, type 1 diabetes, and hypertension in the younger population. This is all because these are lifestyle diseases and the younger generation do not take healthy food, do not exercise and are having obesity. Just like in the USA an obesity pandemic going on, we can see the number of obese patients in India is also increasing. Other than that, there are some other idiopathic genetic factors also which are increasing infertility cases in India. Therefore, it is very important to have a healthy lifestyle, do not take alcohol and tobacco, workout for at least 30 minutes per day, do not take frozen meat as the meat contains very toxic chemicals which can impair your sperm production, avoid extreme heat exposures as it can lead to the failure of the spermatogenesis. Also, certain chemotherapist drugs can directly affect sperm production. There is a production decrease after the drugs and these patients can preserve the sperms before starting chemotherapy.

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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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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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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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COVAXIN PRODUCTION TO INCREASE TO 10 CRORE DOSES PER MONTH BY SEPTEMBER

Shalini Bhardwaj

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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.

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DR HARSH VARDHAN REVIEWS HEALTH FACILITIES AT AIIMS TRAUMA CENTRE

Shalini Bhardwaj

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Harsh Vardhan

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.

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NINE COVID TIPS TO KEEP IN MIND THIS NAVRATRI

Dr Deepak Gupta

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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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