New Delhi: The Indian Medical Association (IMA) has urged everyone to follow the mantra of 3T—Trace, Test and Treatment—to overcome the second Covid wave in the country. In an official statement, the IMA warned against the unscientific drugs and procedures to treat Covid-19, “IMA urges all to come forward with more dedicated Test, trace and carry on appropriate protocol for treating without falling prey to unscientific, selfish-centred promotion of certain drugs and procedures.”
“IMA appeals to the people to not get panic as India is fully powered to treat the acute effects of this disease and hence use designated centres of excellence for early treatment if you contact the disease and also avoid unnecessary travel and public gatherings.” it stated
The association also requested people to take vaccination at the earliest. “We request all our people to kindly take vaccination at the earliest, spiritually adopt the principles of Covid-appropriate behaviours like physical distancing, hand hygiene, respiratory hygiene and appropriate masking to protect the people from the spread of the infection. Test, trace and appropriate treatments, as promoted by the Prime Minister, shall be our tool to protect us from this pandemic. Vaccination drive should be promoted with much more fastness and even to the extent of providing them at doorsteps without any payments.”
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ASTRAZENECA VACCINE, BLOOD CLOTS LINK ‘PLAUSIBLE’ BUT UNCONFIRMED: WHO
New Delhi: A link between AstraZeneca’s Covid-19 jabs and blood clots is plausible but unconfirmed, the World Health Organization’s vaccine experts said, stressing that reported occurrences were “very rare”.
“Based on current information, a causal relationship between the vaccine and the occurrence of blood clots with low platelets is considered plausible but is not confirmed,” the WHO Global Advisory Committee on Vaccine Safety said in a statement. “Specialised studies are needed to fully understand the potential relationship between vaccination and possible risk factors.”
There have been 79 cases of rare blood clots, resulting in 19 deaths, in people who received the AstraZeneca vaccine in Britain, the country’s medicines regulator who is chief executive of MHRA reported on Wednesday.
JOHNSON & JOHNSON SET TO BEGIN INDIA TRIAL OF ITS SINGLE-SHOT VACCINE
New Delhi: US pharma giant Johnson and Johnson will soon begin clinical trials of its single-shot Covid-19 vaccine in India, the company told Indian regulators. In a letter to India’s Central Drugs Standard Control Organization (CDSCO), the US-based company said that it would “very shortly to apply for permission to conduct clinical bridging trials in India”. The news has come at a time when India is going through second Covid wave. India is looking to ramp up its vaccine doses amidst high demand due to the second surge of coronavirus in the country, with several states saying they are running out of supplies. In February, the US regulators had issued Emergency Use Authorization for the Covid vaccine developed by J&J’s Janssen Pharmaceutical Companies.
Stress caused by Covid-19 can lead to diabetes: Top doctors
Healthcare experts and doctors discuss the impact of novel coronavirus on diabetic patients.
What is the impact of Covid-19 on diabetic patients? Dr Nikhil Tondon, HoD and endocrinologist at AIMS, Dr Pankaj Agarwal, senior endocrinologist, and Dr Ashok Jhingan, chairman of Delhi Diabetic Research Centre, share their views on this and more. Excerpts:
Q. What is the commonest form of diabetes?
Dr Tondon: The commonest form of diabetes is non-insulin-dependent diabetes or type 2 diabetes. 85% or more of all people with diabetes have this particular type, which in earlier years used to be starting at the 30s, 40s, and 50s and was invariably associated with being overweight and responded to oral medication. The part about responding to oral medication remains intact but unfortunately, the age at which it is starting to appear in our population has progressively reduced with time so much so that even people in their late teens have now started developing this particular problem.
Q. Why are Indians prone to diabetes?
Dr Tondon: To understand that we need a little bit of historical context. There is a study or an editorial which is the Journal called Lancet. Lots of paper came out in 1907, about 115 years ago, which is around the time of the aristocracy of Britain. Diabetes is to the aristocracy of India, suggesting that this is a diabetes of the affluent, the disease of the rich who ate and put on weight. Over time that has changed with which improvement developed indices or disease which seemed to have been restricted to the extreme right of social-economic growth has now spread across. We possibly have all genetic trait predispositions. We were not exposed to the role of environment, eating habits, or lack of exercise before, now we possibly have the same genetic exposure. The disease is becoming progressively adverse with environmental exposure. By putting on weight, eating the wrong food, and exercising very little, people who are prexposed are getting this disease.
Q. What are the common symptoms of diabetes?
Dr Jhingan: The common symptoms are excessive thirst, frequent urination, and increased appetite, or loss of weight at times. These were quite common earlier. But now so many people are experiencing other symptoms like fatigue, excessive tiredness, weakness, lethargy and sometimes itching all over the body and many times that’s why we always say it’s a silent disease as people say they’re not having any symptoms. They are going for some executive health checkup or going abroad and then they get examined. A routine examination is required but a large number of hypertensive people are overweight and obese. As Doctor Nikhil has said, they all are prone to developing diabetes and these symptoms are quite common many times in the males and females itching around the genitals. That’s one of the important manifestations because of which the person goes for an investigation and then it is found that he/she has diabetes. Many times when young married girls are not getting pregnant or have frequent abortions and after an investigation, they get to know that they have diabetes.
Q. What are the common types of diabetes?
Dr Jhingan: I think as Dr Nikhil has said very clearly about 85% of patients have type 2 diabetes, while 10% of patients have type 1 diabetes. There are gestational diabetes and diabetes mellitus which is caused by pancreatic exocrine disease. There are other types of diabetes besides these as well.
Q. India has around 77 million diabetic people which makes it the second most affected in the world after China. What is the reason behind it?
Dr Agarwal: Yes, this is a big issue for Indians. At one time we used to top the list in the world, now China is heading. The reason is that we are genetically predisposed, which has been mentioned by Dr Nikhil. But we were genetically predisposed for a pretty long period. What happened in recent years that it has manifested in terms of diabetes is because of our change in lifestyle from an active lifestyle to so much mental stress, superseded by this covid era, all this led to having a sedentary lifestyle. All these things are bringing this problem earlier in our lives and increasing its incidents as Dr Ashok has said. The commonest symptom of diabetes is having no symptoms. So, most of the Covid cases are asymptomatic. Lots of patients we were having initially as well were undiagnosed. Now with improved diagnostic techniques and more awareness about the disease, we are detecting quite a good number of those patients. So, genetic predisposition, our lifestyle changes superseded by mental stress and if at all there is any physical distress in terms of infections and other things, then that has led to the increased privilege of diabetes in India, especially in recent days.
Q. Can Covid-19 cause diabetes?
Dr Tondon: No, Covid-19 can’t cause diabetes by itself. It is with any stress, physical or mental in terms of any injury, infection like pregnancies is the stress on the body so it predisposes the likelihood of diabetes. Similar is the case with Covid-19, it may precipitate diabetes in predisposed individuals who already have increased chances of having diabetes. Also, a more precipitous or severe form of infection in some individuals imposes a severe chance of getting diabetes. We use some agents like glucocorticoids to prevent certain complications of this infection. For many individuals, the use of those also increases the likelihood of having diabetes. The stress caused by Covid infection and the use of some medicines to prevent its complications can lead to diabetes.
Q. How has it affected Covid-19 patients?
Dr Tondon: If I tend to diabetes or pre-diabetes, infections will then unmask of that value. That’s one thing and the other equally important thing is, suppose a person with diabetes develops Covid-19, what do we need to do? We need to be worried that a person with diabetes is more likely to have a serious disease, require hospitalisation, intensive care and unfortunately that person is also more likely to die as a result of the infection. Firstly, as opposed to the appearance, he does not have that. Secondly, a person who has diabetes on exposure to certain drugs which are now an essential part of the Covid-19 treatment will also worsen their sugar and thus will need much more aggressive management. Thirdly, there are not two categories, one where people do have diabetes and developed Covid and another where they didn’t know about diabetes and develop Covid. The first category of people can take appropriate metrics. Also, your likelihood of catching infection becomes less and your doctor will be able to treat you much better. But what about the second category? During the treatment, coming to know that they have diabetes is even more dangerous. The message for doctors is that anybody who comes across a Covid patient measures the blood sugar, even if they don’t have diabetes as he might be unaware that he has diabetes. So that the doctors can aggressively manage them.
Q. What are the latest treatments for diabetes?
Dr Jhingan: With diabetes, there has been much more improvement but lifestyle change is the basic requirement. So these genetic backgrounds get precipitated with the environmental factors like change in food habits and exercise. The disease can get aggravated because of physical and mental stress. A balanced diet and exercise are a crucial part of the treatment strategy. Do 50 minutes of regular exercise. Then comes the role of oral medications. There had been a paradigm shift in the management part. There’s been a different type of class of drugs. Now very good drugs are there which have good control over sugar but there is again a limitation on the part of each group. So now we have plenty of drugs looking after the various pathways by which diabetes happened and these drugs are quite effective. And once these drugs also with all these things, if we are not able to get our target levels of Hba 1C to 7% that means we have to now try insulin and again in the insulin category, we have all those latest analogues. There is very good insulin which helps to control diabetes. Different types of regimes are there by which today we are in a position to keep the blood sugar levels around 7% Hba1C. This is there as higher HB1C increases the chance of complications of diabetes. With the latest available medications and insulins, we can keep the blood sugar under control.
Q. How gene therapy can be useful for diabetes. Are we doing it in India?
Dr Agarwal: This isn’t still in the investigational phase so the therapy is very promising. No doubt the problem lies with type 2 diabetes. There is no single gene that is leading to the development of type 2 diabetes which is happening in around 85% of cases. For type 2 diabetes, there is no single cause that can lead to diabetes. There is no single gene causing diabetes, so by intervening with one gene only, we cannot cure it. But for type 1 diabetics, there are certain promising things. Not exactly in terms of gene therapy but otherwise, the damage is being inflicted in the same target areas in type 1 diabetes. Those can be prevented to a large extent by some information. By interfering with the immune mechanism of the body, it can be changed by pancreatic beta-cell transplantation or distant cell therapy.
Q. If diabetes is not treated timely, how chronic can it be?
Dr Jhingan: Yes, the problem and significance of diabetes lie in the complications which are produced because of it. If somebody is having diabetes without symptoms, it doesn’t mean he is fine. It will create more impact on the body and will affect many of the systems and it will be a problem forever and once anything happens, once the target organ, nothing can be done. Every organ is unique and once damaged it can’t be repaired. So we have to maintain the glucose level at its normal limit throughout life to protect those organs and the symptoms or the features associated with organ involvement are unique with their setup. Like for eyes, it will be blurred vision and blindness. With kidneys, it will reduce your urine formation, swelling and then later on kidney failure. With nerves, the feeling of burning sensation of cold, not feeling anything, pricking sensation and later on developing frequent ulcerations. And gangrene leading to the importation of limb with heart, pain, breathlessness, and heart attack. With brain stroke, paralysis and all these things may happen. All this can happen due to continuously raised glucose status which needs to be tackled in its early stages. Once it affects our organ of the body, nothing will change, there can be no cure. It won’t be too clear what the problem is but even if you lower down, even if you normalise global levels thereafter, once destroyed it will be destroyed forever, so we must treat diabetes, control diabetes to prevent the target organ from getting damaged which may happen in future.
Q. What are the five tips to manage diabetes?
Dr Jhingan: Do regular exercise for 50 minutes and to control the stress, do meditation and yoga. Also, have a balanced diet; have regular intake of medicine; regular monitoring; and regular treatment for sugar to be under control. After all, prevention of a complication is most important. Expenses for the treatment are high but once the complications develop it will be very expensive. The person who knows about his diabetes and keeps it under control can live the longest. Awareness and education are the cornerstone of the treatment of diabetes
Q. Would you like to give any message?
Dr Tondon: The statement made by Dr Pankaj that the most common symptom of diabetes is a lack of symptoms is the message. People should periodically get tested for diabetes or blood pressure so that they are identified early and treatment starts. Awareness is needed, if your parents have diabetes or some uncle or aunt has diabetes, it means that there is a problem in the family. So they should get themselves checked even more frequently as they are more likely to have diabetes. Earlier women who got pregnant, it was mandatory to get checked for gestational diabetes but it’s not done very often now. They should get tested. Screening is required; one must incorporate a healthy lifestyle right from childhood. It’s very difficult if people over 40 often have fried food, they should change their diet and eating habits. Regular exercise will help from the beginning so that you don’t encounter it. Also, you are much more likely to have diabetes if your periods postpone. You will be able to handle diabetes well with a balanced diet and healthy living and regular physical activity. These things should be a part of our lives from the start and not only after we develop diabetes.
VACCINATION AT WORKPLACES FROM 11 APRIL FOR THOSE WHO ARE 45 YEARS
The government on Wednesday said that it will allow—from 11 April—Covid-19 vaccination at workplaces (public and private offices) to ramp up the fight against the pandemic in the country. The offices that have more than 100 beneficiaries are allowed get vaccines at their workplaces.
The Union Ministry of Health and Family Welfare decided on Wednesday to increase the accessibility to the vaccines amid surge of Covid-19 infection. The programme will be launched on 11 April, and states and UTs have been asked to make adequate preparations.
According to a letter from the Union Health Secretary, “With support of the state governments and UT’s administration the efforts have been to consistently make the vaccination drive more pragmatic and also more acceptable and purposeful to the beneficiaries.”
AVOID COVID RUMOURS, GET VACCINATED
Two worries are bothering recipients of the Covishield vaccine. One is of getting “breakthrough infections” and the second about thrombosis post vaccination (in young females). Irresponsible statements from various agencies/social media are adding to the confusion surrounding these issues.
Use of the vaccine has been suspended for individuals younger than 55 or 60 years in several European countries and in Canada after reports of a prothrombotic disorder and thrombocytopenia, mainly in younger individuals. Now, more information on the prothrombotic disorder has become available. The vaccine appears to be linked to a condition that clinically resembles heparin-induced thrombocytopenia (HIT) and that occurs mainly in younger women.
Researchers have described clinical and laboratory details of nine patients from Germany and Austria who developed this condition 4 to 16 days after receiving the AstraZeneca vaccine in a preprint article published March 28 on Research Square. They found that serum from four patients who were tested showed platelet-activating antibodies directed against platelet factor 4 (PF4), similar to what is seen in HIT. They are proposing naming the condition “vaccine-induced prothrombotic immune thrombocytopenia (VIPIT)” to avoid confusion with HIT.
Till date, we understand that these “breakthrough infections” are not severe and complications of thrombosis are very rare. Though the risk-benefit ratio still favours use of the AstraZeneca vaccine, the question should be analysed systematically in India. In India, the maximum number of Covishield jabs has been given and our genetic constitution is different from Europe. Also, this problem can be solved by availability of other vaccines like Johnson and Johnson, Pfizer in Indian markets. The Indian government already has all the data of vaccines recipients. Without delay, they should immediately conduct a survey regarding “breakthrough infections”. This is very easy to conduct as all positive reports are reported / linked with Aadhaar cards and phone numbers. The government just needs to link both data.
We need to put an end to these rumours to decrease vaccine hesitancy.
Dr Dhiren Gupta is Senior paediatrician, Sir Ganga Ram Hospital.
HOW INDIA IS TACKLING THE OUTBREAK OF COVID-19 PANDEMIC
Thirteen months ago, looking at the devastating speed of Covid 19, I had dared to quote Malthus (1798), a British classical economist: “When man fails, nature takes over”. By now, it is in the public domain that Covid-19, an offspring of SARS-I Coronavirus, is not only going to stay but could be still in ‘circulation’. It may be due to the detection of 770-odd variants and the unwanted advent of neo-colonial tendencies of business-minded, so-called “developed” countries.
HOW IT ALL BEGAN
If we count from ‘ground zero’ of a live animal unhygienic market of Wuhan (31 December 2019), 1.3 years has passed by. Vital origin data, however, could not be extracted even by WHO experts. But owing to the unquestioned might of some UN veto-wielding powers, 219 countries have entered into a state of subjugation and barely ten developed countries have pocketed the vaccines.
WHAT WHO DID DURING COVID
WHO, on the contrary, after embarrassing itself during the painful phases of 2020, is unable to make a dent even now when it comes to a fair distribution of vaccines to needy and suffering poor countries of Africa and Asia. What transpired after setting up a special fund for the purpose?
INDIA’S HUMANITARIAN GESTURE
On the other hand, India after crossing limits of the belligerence of having supplied vaccines to 84 countries, may not be regretting the out of the way humanitarian gesture. But looking at the coverage of our barely less than 10% population, don’t we take a cue from a time-tested dictum? “Light the Candle at home prior to a mosque”.
MEASURES NEEDED ON WAR-FOOTING
By bringing up the issue at a crucial juncture of the second Covid wave or fourth one according to inimitable Arvind Kejriwal, one is not casting any aspersion but certainly one is hinting towards addressing more immediate issues, such as:
• Control over social and e-media, issue quick rebuttals
• Check unnecessary visits
• Swift coverage of the entire 45 plus population
• Locating missed out initial front-liners
• Intensive counselling about the efficacy of vaccines
• Zero tolerance towards rule and instruction violators
• Out of turn-taking up serious cases
• Further improving health infrastructure
• Drawing a roadmap for students and uncovered categories on a war footing.
8.40 CRORE VACCINATIONS VS 25 CRORE TESTS, A POOR REFLECTION
The element of war footing has to be taken by making available 24×7 fully equipped vaccination centres and ensuring safety and rest to medics and front liners of identified and tried categories. Reporting of record 42 lakh vaccinations on 5 April indicates that we can perform.
VILLAINS IN THE CURRENT SCENARIO
Also, not only bowing to pressures of economic revival has to be ignored, people of all “caste and creed” have to be suitably fined, punished and also denied the right to have vaccination when non-conforming to the Covid protocol.
Having recorded 7,88,000 active cases, 1,65000 deaths and 103,796 new cases nationally (surpassing 10 September’s record) under the “leadership” of apparently “mismanaged” Maharashtra, Chhattisgarh, Karnataka, Delhi, Tamil Nadu, Madhya Pradesh, Gujarat, and Kerala, if we are still toying with “partial lockdown”, “night curfew”, “weekend lockdown” only, there is something wrong with our administrative acumen.
IMPOSE LOCKDOWN IN VULNERABLE POCKETS
Inspired by affected West Europe in the first half of 2020 if we could enforce an effective country-wide lockdown, why are we hesitating to repeat it for a month or two in the above-named states? Also uncalled for philanthropy towards “friendly or needy countries” should be done only after meeting our domestic obligations. Do Pakistan, China, and Canada qualify?
MIGRANT LABOUR PLAYS A CRUCIAL ROLE
In the ultimate analysis, if our valuable manpower loses track again, the crucial plan of the revival of the national economy or a trillion-dollar economy will be a misnomer. After all, of four factors of production, labour is vitally important.
At this stage, it is our profound duty to display the characteristic features of welfare economics rather than reverting towards state capitalism.
“Aatmanirbharta” for whom? That’s the question one may pose before withdrawing the elusive mouse. I may be again tempted to quote from Classical Economics: “In the long run we will be dead.”
The writer is the ex-Chief Secretary, the Government of Sikkim. The views expressed are personal.
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