Top healthcare experts and doctors discuss why India is again witnessing a massive spike in Covid-19 cases. Dr Anjan Trikha, Chairman of Clinical Managerial Group, Covid Centre at AIIMS, Dr Neeraj Nischal, Associate Professor, Department of Medicine at AIIMS, Dr Dhiren Gupta, Senior Consultant and Paediatric Intensivist at Sir Ganga Ram Hospital, and Dr Rakesh Mishra, Director at CSIR-CCMB, share their views. Excerpts:
Q. Why so many cases are increasing, particularly in states like Karnataka, Kerala, Punjab, Gujarat, and Tamil Nadu, 86% of the Covid-19 cases have been reported from these states. Do you think there is some kind of mutation of the virus?
Dr Rakesh Mishra: There is certainly a reason otherwise things won’t happen without any reason. Mutation of the virus is the most dreadful reason which we were afraid of. Probably that is not the reason as so far whatever the sequence we have seen it doesn’t look like a new variant is common in the new cases. This means it is not a new variant unless it is that subtle that we are not able to pick. Also, we have seen that while we detect a lot of UK variant and some South Africa variant in travellers who come from international travel, we have not seen a lateral spread of this beyond primary contact in a few cases. Either we are able to control well or these are not infectious for the entire population. or whatever reason, these are not posing any major concern. That leads us to the most likely possibility that most of us think is correct, the spread was not happening as we were taking the correct steps of wearing a mask, social distancing, not going to crowded places and taking care of ourselves, what we call covid appropriate behaviour. We have stopped doing that and once you don’t do that anymore, the virus is always waiting, leading to a big spike in cases. There is correlation to recent past, it might have happened due to a local election, marriage function and people in trains travelling without masks. Luckily, it is not the variant that is causing this as it can ring new surprises and new troubles. But if we continue doing things this way, a lot of people get infected and the virus keeps spreading, any variant will emerge in this population. That is the biggest fear I have that a new variant can come and create new kinds of problems and compromise the vaccine program and other things that we have achieved so far.
Q. What kind of implications can there be from the P1 virus which is a Brazilian virus?
Dr Rakesh Mishra: One thing is that it is not spreading in our population and we must be practising the Covid safety rules so that we are safe. But some studies show that strains require more antibodies to get neutralised and there is a report that shows it might be less effective against this. But it is only a quantitative difference and vaccines largely are more likely, particularly that we are using in India, effective against these variants. These are surprises that cannot be predicted, there may be a situation that this variant has acquired some resistance. If one more mutation happens on top of this in that direction it might be a problem. To prevent the spread as sufficiently as possible, particularly when we detect new variants like P1 or UK, we should be extremely careful and implement strict rules so that we don’t end up with one more lockdown which will be worse than the disease itself.
Q. BBMP has to deploy Marshalls at temples to control the crowd. Do you think that people are not that serious now and have taken things for granted?
Dr. Anjan Trikha: Yes, people have lowered their guard, they are taking things for granted. We have had hesitations; we have had elections and we have seen a lot of people getting together for various rallies and marriages. Earlier there were no marriages, then marriages with 20 people, which increased to 50 people and then further to 200 people. I have at least five wedding cards with five functions for each wedding, the way a big fat Indian wedding used to take place. I can assure you that all the people there will be having masks but in their pockets. The guard has been lowered. The same is with temples, we have to realise that God can only take care of people who take care of themselves. Wherever God may be, it could be a temple, a gurdwara, or a mosque, any religion for that matter, people have lowered their guard. We have to suffer because of that.
Q. What kind of precautions need to be taken by those who have been vaccinated for the first dose? A lot of cases have been seen that people are getting infected after a single dose and are blaming the vaccine. What would you like to say about it?
Dr Neeraj Nischal: Most of us are not aware of or not willing to learn that it is biological vaccination along with social vaccination that is going to save us during this pandemic. If we take the vaccine, it will take some time for us to develop immunities. After taking the first dose we rectify to take the second dose. Once you take the second dose, then after two weeks we anticipate that the adequate immunity level will come. Even after you have immunity the chances of getting infected is still there. It’s just that this vaccine most probably is going to prevent you from getting a severe form of the disease. That’s why getting one shot of a vaccine and thinking that you have become immune to this infection is wrong. We have to ensure that even if we have taken both sets of doses, we have to practice social vaccination after that. Otherwise, we will start saying the vaccine is not working. The idea of vaccination is to prevent morbidity and mortality due to this infection but chances of cutting down transmission may not be 100% or even 70-80% as efficacy is just against the severe disease. We have to keep our guard up even after taking the vaccine.
Dr Dhiren Gupta: What Dr Nischal has said is right. I witnessed five cases who got an infection after the second dose and all these cases were symptomatic though they were young medical students. In young you can’t say they are not severe as otherwise also they are not that severe in the elderly population, probably nobody knows the authenticity of these vaccines. These vaccines have been approved by just a very small trial which has never happened in the past, nobody knows what is the effect of the new strain and the constant mutating viruses. We don’t need any virus to be imported from Brazil, the UK, and South Africa. Recently there was a paper which stated that over 7,000 mutations have happened in India but we are just doing 0.6% entries for the mutation and 5% of the samplings. So we don’t know what is happening but we can’t lower the guard unless the whole population gets vaccinated which means it can still spread despite some people being vaccinated.
Q. Do you think Covid-19 is mild among children?
Dr Dhiren Gupta: Yes, it used to be mild but the problem with the paediatric age group is they can spread it and spoil the game. They may not suffer from severe covid infections especially classical Covid not very much prevails in the paediatric age group which we have seen in the previous two academics in Delhi and India. But in the UK strain, they have found that the prevalence was a little bit more in the paediatric age group than any other mutation. The post-Covid multi-organ inflammatory syndrome is quite life-threatening in this age group. We can say that it is rare but it is not that rare that we should not worry. We follow the cases among adults once the academic is in the adult as the adult population carries the infection to the home. Still, we don’t have the schools open. The Covid-positive children can spread the virus to the elderly, they become very well variables for the infection as the paediatric age group is very attached to their grandparents. It can spread to the most vulnerable population is worrisome.
Q. What can be done as some children have started going to schools, other schools will open in future including for toddlers?
Dr Anjan Trikha: Yes, we can’t have another year of schools not opening. They could be closed for a couple of months, say four to five more months but that is also unreasonable. One thing which we are forgetting is by closing schools we are trying to hinder the development of a child. A child develops a lot mentally when he goes to school, some kind of vaccine behaviour has to be brought to the child. Maybe in the class, they’ll have to be seen that they don’t share food and water, and have to be masked. They have to be told not to touch here and there and put their fingers in the nose, eyes and mouth after every hour. I know it is a tough call but we tend to teach our children not to pick their nose, so we have to teach them not to put things in their mouth. This kind of behaviour has to be taught to them and as I have been pointed out that kids would likely to be bigger spreaders than to be getting affected. We have got our share of children who got Covid and landed in ICU. That behaviour would have to be taught to children and it’s going to be another eight months to a year if not more before some kind of vaccine can be available as a mass vaccination for children.
Dr Dhiren Gupta: First adults have to follow that behaviour then only they can teach their children.
Dr Anjan Trikha: Adults have to get it but the earlier we start the better it is.
Dr Dhiren Gupta: I see that even the doctors are getting fed up with masks. The tolerance to have a mask for a whole day is not easy. We did a study if you wear a mask for a whole day, for a few hours without interruption, then it is leading to an actual problem in health and that we proved in our nurses. We know that recently it has been found that this virus doesn’t spread by touch but hand washing has to be there. Our vaccination is very slow which means it has almost been the third month of vaccination and we have got the best system in the world including the government and the private regarding vaccination and we couldn’t utilise that system very well to date. All we need to be is quick and fast or once a mutation arrives your existing vaccination would never be sufficient.
Q. What would you like to say about ramping up vaccination?
Dr Neeraj Nishal: Adults have to be role models for children. Once you are there in the home and following all the Covid appropriate behaviour, children are going to learn about that. Every parent has to make a conscious decision that if his/her child is not ok, they should not be sending them to school. Everyone has to pitch in not just children or adults, it has to be a combined effort including the school administration who can start telling this in online classes. They can guide the children and what is expected when they come to school for physical classes. As far as vaccination efficacy against strain is concerned, we should not be worried too much about this as the vaccine is there. We could have ramped up the vaccination on day one but are people going to come and take those vaccines so this vaccination program needed to be slowly implemented. People are taken into confidence so that there is no hesitancy whatsoever. When the time comes everybody will get a chance to take the vaccine, I’m sure they will come forward and take it. The support that the vaccine is getting is improving day by day. I feel the rate may be slow but it is effective and will be wrapped up in time. We should not be in a hurry to ramp up everything on day one and if something wrong would have happened then the whole program would have collapsed so it was a proper way.
Q. What can be the reason behind Maharashtra reporting more than 30,000 cases in a single day?
Dr Rakesh Mishra: That is how we began. The reason is most likely that the people have stopped taking precautions. We should be aware that this virus spreads very efficiently. The good thing is that we know how it spreads so we can stop that, and like other coronaviruses, it has a tendency to mutate and we have seen out of 6,000 variants or 6,000 isolates in India we have documented 7500 mutations, luckily most of them are not of much consequence they are just academic records.
Mutation and transmission are not correlated, those are just recorded in those isolated. Either it is very transmissible otherwise itself normal mutation.
Q. Do you think people are not following guidelines?
Dr Rakesh Mishra: Exactly, we are not behaving as we should and that is the best tool that we have, even if there are vaccines now maybe there will be many more but vaccines have limited benefits. 1000% people are not going to get 100% protection which means if we keep playing with the virus, allowing it to hang around in a larger number for a longer time we will certainly discover one day, which will trouble us heavily and the whole thing can become a big problem. The cause for the increase in the number of cases is most likely not a new variant although we have to keep monitoring everyday a large number of isolates by samples, at least 5% in particular where there is a large number of cases. Then very easily we can tell whether the new variant is happening or not. But since we haven’t seen something so far and there is a direct correlation to the people being careless it is very likely we are encouraging the virus and inviting trouble for ourselves. We have to go back to the social vaccine and trust in that and then only the full advantage of the real vaccine will be there otherwise all will go in vain and we will be back to the drive out.
Q. Do you believe the vaccine that is going to work is the social vaccine?
Dr Anjan Trikha: Yes, everything has been rightly said by Dr Gupta, Dr Nishal and Dr Mishra, I would like to add that injectable vaccines are a totally different ball game and a social vaccine is equally important. I also feel like Dr Nishal, the government has done a considerably good job in starting vaccination at a slow phase. If you realise that we people like to discuss a lot, everybody in the country is discussing which vaccine to take and not to take. Let us have faith in our government and they are doing a good job. There were a group of people who never took the vaccine in a state as somebody had told them they can’t have alcohol after taking the vaccination for 15 days. So the vaccination drives go for a dodge. These kinds of issues will be solved. We are one of those countries where lockdown and everything else was criticised but we did a good thing. The economy went for a toss and it has gone for a toss everywhere in the world. Even if you go to the USA it’s the same thing, my son who is 35 is not vaccinated in Cincinnati as only above 60 years are getting vaccinated. We are following the same thing and are on the right track. We have hiccups in India. There are going to be elections in West Bengal, Kerala, and Tamil Nadu, so this will go on.
Q. There are people who are thinking they should Covishield or Covaxin. What would you like to say about it?
Dr Neeraj Nischal:Theoretically there may be differences between these two vaccines but at the time of the pandemic, we cannot be choosing among these two. If you are eligible, go ahead and take the available vaccine. Don’t try to differentiate between these two vaccines and try to find out which vaccine you should take. Unless there are clear cut contraindications as far as one of the vaccines is concerned, say immune-compromised patients should avoid taking this vaccine, you should not be taking that vaccine but if this is not the case, go with whatever vaccine you are getting and don’t wait which is better and which is not. This is pandemic time and if we wait for the perfect solution then it might be too late. Everybody was worried about when the vaccine will come and now that the vaccine is here, we should know the vaccine is not going to end the pandemic, vaccination will. So, whenever the turn comes, irrespective of the vaccine you are getting, come forward, take it and help in ending this pandemic.
Q. What message would you like to give?
Dr Dhiren Gupta: I think what Dr Nischal said is true, we should not have any hesitations in getting vaccines, whatever type of vaccine is available you get it as soon as possible. Don’t go by the rumours. I would like to advise the media that there will be a reaction in adult vaccination and paediatrics patients as they do not react to vaccination much as compared to adults. But if you compare the disease severity, hardly any reactions are there. Get yourself vaccinated, practice social distancing, and wear a mask which we can’t forget even after vaccination.
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WORK PERFORMANCE MAY BE AFFECTED BY EATING LATE NIGHT SNACKS
Time to quit eating at night? According to the findings of a new study, unhealthy eating behaviours at night can make people less helpful and more withdrawn the next day at work.
The findings of the study were published in the Journal of Applied Psychology. “For the first time, we have shown that healthy eating immediately affects our workplace behaviours and performance,” said Seonghee “Sophia” Cho, corresponding author of the study and an assistant professor of psychology at North Carolina State University.
Cho added, “It is relatively well established that other health-related behaviours, such as sleep and exercise, affect our work. But nobody had looked at the short-term effects of unhealthy eating.”
Fundamentally, the researchers had two questions: Does unhealthy eating behaviour affect you at work the next day? And, if so, why?
For the study, researchers had 97 full-time employees in the United States answer a series of questions three times a day for 10 consecutive workdays. Before work on each day, study participants answered questions related to their physical and emotional well-being.
At the end of each workday, participants answered questions about what they did at work. In the evening, before bed, participants answered questions about their eating and drinking behaviours after work.
In the context of the study, researchers defined “unhealthy eating” as instances when study participants felt they’d eaten too much junk food; when participants felt they’d had too much to eat or drink; or when participants reporting having too many late-night snacks. The researchers found that, when people engaged in unhealthy eating behaviours, they were more likely to report having physical problems the next morning. Problems included headaches, stomachaches and diarrhea.
In addition, when people reported unhealthy eating behaviours, they were also more likely to report emotional strains the next morning – such as feeling guilty or ashamed about their diet choices. Those physical and emotional strains associated with unhealthy eating were, in turn, related to changes in how people behaved at work throughout the day.
Essentially, when people reported physical or emotional strains associated with unhealthy eating, they were also more likely to report declines in “helping behaviour” and increases in “withdrawal behaviour.”
Helping behaviour at work refers to helping colleagues and going the extra mile when you don’t have to, such as assisting a co-worker with a task that is not your responsibility. Withdrawal behaviour refers to avoiding work-related situations, even though you’re at your workplace.
The researchers also found that people who were emotionally stable suffered fewer adverse effects from unhealthy eating. Not only were emotionally stable people less likely to have physical or emotional strains after unhealthy eating, their workplace behaviours were also less likely to change even when they reported physical or emotional strains.
With ANI inputs
INDIA’S COVID-19 VACCINATION COVERAGE EXCEEDS 11 CRORE MARK
The total number of Covid-19 vaccine doses given in the country has surpassed 11 crore-mark on the fourth day of the ‘Tika Utsav’ or vaccination festival, the Union Ministry of Health and Family Welfare (MoHFW) said on Wednesday.
The four-day-long vaccination programme ‘Tika Utsav’ started on Sunday with an aim to inoculate the maximum number of eligible people against the coronavirus. According to the health ministry, cumulatively 11,11,79,578 vaccine doses have been administered through 16,53,488 sessions, as per the provisional report till 7 am on Wednesday. Over 40 lakh vaccination doses were administered in the last 24 hours.
“Eight states account for 60.16 per cent of the total doses given so far in the country,” it said. As of day 88 of the vaccination drive (April 13, 2021), 26,46,528 vaccine doses were given. Out of which, 22,58,910 beneficiaries were vaccinated across 44,643 sessions for first dose and 3,87,618 beneficiaries received the second dose of the vaccine.
“These includes 90,48,686 HCWs who have taken the 1st dose and 55,81,072 HCWs who have taken the 2nd dose, 1,01,36,430 FLWs (1stdose), 50,10,773 FLWs (2nddose), 4,24,66,354 1st dose beneficiaries and 24,67,484 2nd dose beneficiaries more than 60 years old and 3,56,50,444 (1st dose) and 8,18,335 (2nd dose) beneficiaries aged 45 to 60 years,” the ministry said.
As many as 26,06,18,866 Covid-19 tests have been conducted across the country so far. The tests conducted in the last 24 hours stand at 14,11,758 and the testing capacity has been ramped up to 15 lakh tests per day. India’s daily new cases continue to rise as 1,84,372 new cases were registered in the last 24 hours.
Maharashtra, Uttar Pradesh, Chhattisgarh, Delhi, Madhya Pradesh, Karnataka, Kerala, Tamil Nadu, Gujarat and Rajasthan have shown a rise in the Covid daily new cases and 82.04 per cent of the new cases are reported from these 10 states. Maharashtra has reported the highest daily new cases at 60,212 followed by Uttar Pradesh with 17,963 while Chhattisgarh reported 15,121 new cases.
Moreover, India’s total active caseload has reached 13,65,704 and now it comprises 9.84 per cent of the country’s total positive cases. A net incline of 1,01,006 cases recorded from the total active caseload in the last 24 hours.
Maharashtra, Chhattisgarh, Uttar Pradesh, Karnataka and Kerala cumulatively account for 68.16 per cent of India’s total active cases. Maharashtra alone accounts for 43.54 per cent of the total active caseload of the country. With 82,339 recoveries in the last 24 hours, thw country’s cumulative recoveries stand at 1,23,36,036 today. The national recovery rate is 88.92 per cent.
As per the health ministry data, 1,027 deaths were reported in the last 24 hours. “Ten States account for 86.08 per cent of the new deaths. Maharashtra saw the maximum casualties (281). Chhattisgarh follows with 156 daily deaths,” it added.
Ladakh (UT), Daman and Diu, Dadra and Nagar Haveli, Tripura, Meghalaya, Sikkim, Nagaland, Mizoram, Manipur, Lakshadweep, Andaman and Nicobar Islands and Arunachal Pradesh have not recorded have not reported any Covid-19 deaths in the last 24 hours.
WHY SOME PEOPLE ARE HUNGRY ALL THE TIME
Some people feel they are hungry all the time. A new research has come up with an explanation. It says that people who experience big dips in blood sugar levels, several hours after eating, end up feeling hungrier and consuming hundreds of more calories during the day than others.
The research team from King’s College London and health science company ZOE (including scientists from Harvard Medical School, Harvard T.H. Chan School of Public Health, Massachusetts General Hospital, the University of Nottingham, Leeds University, and Lund University in Sweden) found why some people struggle to lose weight, even on calorie-controlled diets, and highlight the importance of understanding personal metabolism when it comes to diet and health.
The research team collected detailed data about blood sugar responses and other markers of health from 1,070 people after eating standardised breakfasts and freely chosen meals over a two-week period, adding up to more than 8,000 breakfasts and 70,000 meals in total. The standard breakfasts were based on muffins containing the same amount of calories but varying in composition in terms of carbohydrates, protein, fat and fibre. Participants also carried out a fasting blood sugar response test (oral glucose tolerance test), to measure how well their body processes sugar.
Participants wore stick-on continuous glucose monitors (CGMs) to measure their blood sugar levels over the entire duration of the study, as well as a wearable device to monitor activity and sleep. They also recorded levels of hunger and alertness using a phone app, along with exactly when and what they ate over the day.
After analysing the data, the team noticed that some people experienced significant ‘sugar dips’ 2-4 hours after this initial peak, where their blood sugar levels fell rapidly below baseline before coming back up.
Big dippers had a 9 per cent increase in hunger, and waited around half an hour less, on average, before their next meal than little dippers, even though they ate exactly the same meals.
Big dippers also ate 75 more calories in the 3-4 hours after breakfast and around 312 calories more over the whole day than little dippers. This kind of pattern could potentially turn into 20 pounds of weight gain over a year.
Dr Sarah Berry from King’s College London said, “It has long been suspected that blood sugar levels play an important role in controlling hunger, but the results from previous studies have been inconclusive. We have now shown that sugar dips are a better predictor of hunger and subsequent calorie intake than the initial blood sugar peak response after eating, changing how we think about the relationship between blood sugar levels and the food we eat.”
Professor Ana Valdes from the School of Medicine at the University of Nottingham, who led the study team, said: “Many people struggle to lose weight and keep it off, and just a few hundred extra calories every day can add up to several pounds of weight gain over a year. Our discovery that the size of sugar dips after eating has such a big impact on hunger and appetite has great potential for helping people understand and control their weight and long-term health.”
Comparing what happens when participants eat the same test meals revealed large variations in blood sugar responses between people. The researchers also found no correlation between age, bodyweight or BMI and being a big or little dipper, although males had slightly larger dips than females on average.
There was also some variability in the size of the dips experienced by each person in response to eating the same meals on different days, suggesting that whether you are a dipper or not depends on individual differences in metabolism, as well as the day-to-day effects of meal choices and activity levels.
Choosing foods that work together with your unique biology could help people feel fuller for longer and eat less overall. With ANI inputs
‘Vaccination doesn’t give you the licence to go without a mask’
Dr N.K. Ganguly, former Director General of Indian Council of Medical Research, explains to The Sunday Guardian why vaccinated people are getting re-infected and other issues.
The resurgence of Covid-19 cases among vaccinated individuals has become one of the biggest concerns in recent times. Dr N.K. Ganguly, former Director General of the Indian Council of Medical Research (ICMR), talks about such issues. Excerpts:
Q: How will the Sputnik V vaccine be helpful?
A: Its global efficacy data is higher than the data of those vaccines which India is already using. The trial has been done in India also, they have gathered the data very nicely; it has got two major components, adenovirus vector, one from Johnson and Johnson and another one from Oxford. Using two vectors shows that it has better efficacy. But yes, those who have co-morbidities should take it under medical supervision only.
Q: Why are people getting re-infected even after getting inoculation? Do you still think vaccination is important?
A: Vaccination is important because the vaccine protects. Though the person may still get infected, the vaccine protects in a way that the person doesn’t get severe infection and the person is protected from hospitalisation and dying. This was a part of what was seen in the critical trial also, the two vaccines in India were protecting up to 70%. Those who got infected had a milder infection. Vaccination is important, but what is more important is that vaccination doesn’t give you the license to go without a mask; it doesn’t give you a license for large gatherings or not to maintain social distance. Sometimes it is not in our control, but that is what is happening in the Kumbh Mela, and it may happen in election rallies, it may happen in parties during the wedding season.
We need to get used to a new normal in our lives where we will have to do our economic activities, but we will have to take adequate care. The vaccine protects, but it does not give you a license for irresponsible behaviour.
Q: How many months of immunity can one get from a vaccine?
A: Up to now, we have Pfizer data which shows that it protects up to seven months. Since these vaccines have recently been introduced, we’ll know whether they protect after a year or not.
Q: How about the body developing antibodies?
A: Many of the places with which I am associated are measuring antibodies before and after the first injection and after the second injection to see that how much antibody is being made. Some people are not developing a good amount of antibodies. This is because every person is a different individual, so immune response depends on age, and on conditions like whether you have a kidney disease or whether you are old. Pregnant women respond differently.
Q: Are we doing this kind of research?
A: Yes, we need a lot of research. Research is being done constantly and we now know a lot of things from research. We now know that if you wear double masks, you are protected better; you are protected 85%. We also know that 6 feet distance was recommended, but 3 feet also works. We now know a lot of new things. We also know from research that antibiotics pass from mother to the child; so, when the mother is vaccinated, the child will be protected for up to 6 months minimum.
Q: Most of this research has been done by other countries; we also need to do research in India?
A: In India also, research has been carried out; some of the information has come from India. India has its mutation data; we have some idea of the mutants circulating in India.
Q: Do you think as of now we need to change our guidelines also?
A: The guidelines are constantly been changed and depends on vaccine availability. There are some countries which have been able to achieve vaccination for 60-80% of their population and these countries are very happy. We have a very large population, so vaccine availability is a very big thing.
Q: Do we have other choices for vaccines in future like you were talking about the Johnson and Johnson vaccine? How is this particular vaccine going to be useful?
A: The Johnson and Johnson vaccine has got an advantage in that it is a one-shot vaccine. It is a good vaccine that protects up to 80% and sometimes even more. The Johnson and Johnson vaccine can be stored in an ambient temperature and it has worked against the South African strain. Johnson and Johnson vaccine will be manufactured by Bio-E and this vaccine will be available in India.
PREDIABETES CAN BE REVERSED, SAYS DR PANKAJ AGGARWAL
Senior endocrinologist Dr Pankaj Aggarwal tells The Sunday Guardian why the idea of prediabetes is getting popular and it is so important. Excerpts:
Q. What is prediabetes?
A. As the name suggests, it is the stage between normalcy and frank diabetes. Actually, the three entities are in a continuum. When blood glucose value starts rising above normal, initially it enters the zone of prediabetes and when it progresses further, it enters the zone of frank diabetes.
Q. Why is it gaining so much popularity? Is there any clinical significance of this entity?
A. Traffic light has three colours and the same is true for the spectrum of blood glucose levels as well. The green zone is normal wherein you are free to move; then comes yellow, which warns to be careful; and then it turns red, which orders you to stop, else you will be punished. Prediabetes is the intermediary warning zone before reaching the zone of actual harm or punishment.
Q. Does it mean that prediabetes itself is a harmless entity?
A. No, many population studies have proved that some complications of diabetes actually begin in the stage of prediabetes. It is particularly true for similar lifestyle disorders such as high blood pressure, high blood cholesterol and even heart attack or paralysis. Controlling blood glucose level and decreasing it from this zone to normal, can prevent development or progression of these dieters.
Q. What is normal blood glucose levels and their cut-offs for prediabetes and diabetes?
A. We derive glucose mainly from our food and so our blood glucose levels actually vary with intake of food. After an overnight fast, it is between 70 mg/dl and 100 mg/dl which increases to 100-140 mg/dl after 2 hours of having a meal. When blood glucose level rises beyond 126 mg/dl in fasting state and 200 mg/dl after 2 hours of meals, it is termed diabetes. Values between 100 mg/dl and 126 mg/dl (fasting) and 140 mg/dl and 200 mg/dl (after meals) are labelled prediabetes.
Q. Is it certain that a person who has become prediabetes will progress certainly to diabetes?
A. No, actually here lies the importance of detecting it at the level of prediabetes. It is the warning zone or ‘no man’s land’ between the borders of two countries. You can’t come back to your motherland easily after entering the neighbour’s territory but can still be brought back from the intermediate no man’s land. Prediabetes can be reversed.
Q. So what are the ways through which it can be reversed?
A. The two most common factors behind development of diabetes of adults or type 2 diabetes are, genetic predisposition and faulty lifestyle. The former is non-modifiable as we can’t choose our parents. But if one has a family history of diabetes, it should serve a warning signal that one should resort to adoption of a healthy lifestyle to prevent its progression into the state of diabetes. Correction of faulty lifestyle is actually the major route through which prediabetes can be reversed.
Q. Can you please detail upon the healthy lifestyle here?
A. Management of diabetes or prediabetes revolves around management of calories. If calorie intake is more than required, it accumulates in the body and predisposes a person towards development of diabetes, hypertension, high blood cholesterol and heart attack. Since fats in our diet are most calorigenic, it increases these probabilities to its maximum. So, reducing extra calories in diet in the form of paratha, poori, kachori, namkeen, samosa, pakoras, meat and sweets, remains the cornerstone of this management. Instead, one should have plenty of whole grain cereals (roti, daliya), dal, green leafy vegetables, fruits, low fat milk and milk products and white of egg. One should avoid frying or adding extra ghee or butter in the food to prevent weight gain. Regular exercises are most helpful in reducing the extra body fat if it has accumulated. These measures can help in reversing prediabetes.
Q. Do we have any medicine as well to help in reversing prediabetes?
A. Frankly speaking, medicines are meant for treating a disorder and not for preventing it. Though some anti-diabetic medicines like metformin, thiazolidinediones and acarbose have been tried to prevent the progression of prediabetes into diabetes but lifestyle interventions have been found to be most successful in this regard.
Q. Has any study been tried to see whether reversal of prediabetes is possible or not?
A. A number of studies have been conducted so far wherein reversal of prediabetes and even diabetes has been studied. The Diabetes Prevention Programme, both global as well as national, is pioneer amongst all to show that this is possible and achievable.
Death rate also increasing with cases this time: Dr Guleria
Covid-appropriate behaviour and vaccines are the two weapons needed to fight the war against the novel coronavirus, says AIIMS director Dr Randeep Guleria.
In an exclusive interview with The Sunday Guardian, Dr Randeep Guleria, Director of the All India Institute of Medical Sciences (AIIMS), explained the reasons behind the recent record surge in Covid-19 cases, the susceptibility of youngsters and people with comorbidities, and how the infection can be tackled by a combination of isolating and treating patients and vaccinating others.
An artist makes a mural of Monalisa wearing a face mask to spread awareness for the prevention of the coronavirus in Mumbai on Thursday. (ANI Photo)
Q: Why is the second wave of Covid-19 in India progressing so quickly and why is it targeting so many people?
A: One of the two main reasons for this is that when cases started decreasing and the vaccines started rolling out in January and February, people thought that Covid has ended and ignored Covid-appropriate behaviour like wearing masks and socially distancing. As a result, the virus got another chance to spread. Secondly, the mutant viruses, especially the UK mutant, are more infectious and spreading faster than the previous one. We can see that the spike is very steep and cases are increasing at a very fast pace as we have now crossed an average of 1.5 lakh cases per day.
Q: When talking about specific mutants, like the UK variant, why are they spreading more in metropolitan cities?
A: The coronavirus is a respiratory virus that spreads through droplet infections. Wherever the population density is greater, like in metropolitan areas, urban slums or metro stations, the virus spreads faster. An asymptomatic person can also cause infections when present in a crowd. Moreover, in rural areas, the air is fresh and people tend to stay outdoors and maintain social distancing due to which the virus cannot survive for long in the environment.
Q: Keeping in mind the pace of the spread of the virus, do you think we need to make some changes in the guidelines?
A: We don’t need to change the guidelines, but need to follow them strictly. We have been testing, tracking, treating and isolating. If there is a Covid-positive case in the family, we need to isolate the patient. If they cannot be isolated, admit them to a Covid care centre so they don’t spread infections in their area. We have to see where the most cases are being reported from and divide areas into red, orange and green zones, just like we did before. The more the cases, the more the people will fall ill and need ICUs and hospital beds.
Q: More youngsters are getting affected by the infection this time. What should we do in this situation?
A: This time, cases in the younger age group are comparatively higher. This is because we saved children from the infection last time but just as we became more casual and ignored Covid-appropriate behaviour later, they got exposed to the virus immediately. Secondly, the younger age group thinks that the disease is not as severe in their age group and so they need not worry due to which they have started partying and clubbing again. However, if they are infected and unaware about it, they may spread the infection to more friends and colleagues.
Q: How can we protect kids?
A: Since the vaccine has still not been approved for kids, we need to take precautions just as we did before. Avoid crowds and non-essential activities, wash hands properly and wear masks when going out. We have started behaving casually and the virus has grown more infectious, due to which entire families are getting infected together.
Q: What is the reason for the increased mortality rate this time?
A: Last time we assumed, and the figures also showed, that the death rate is low. This time, as the cases increase, the death rate is also increasing. When a person gets infected, they go home and infect their family as well. In case any of them has a comorbidity, it may get more serious and hence chances of mortality are greater. Many people are not taking the infection seriously and visiting hospitals only when it gets serious. This is causing a delay in treatment and getting medicines, hence increasing the risk of death.
Q: Do you think a second lockdown is a solution?
A: Weekend lockdowns are okay but we need to take aggressive action. We have to contain the areas reporting the most number of Covid cases and test and treat the people in those areas. Also, we need to keep a check on travel because people travelling from red to green zones can spread infections.
Q: People, including many doctors, are getting infected after taking the second dose of the vaccine. What is the reason behind this?
A: First of all, we need to understand the purpose of the vaccine. After we receive the vaccine, we will not catch the disease even after getting the infection. Catching an infection means coming in contact with a Covid-positive person, when the virus may enter our nostrils and throat. But since we are vaccinated, the antibodies in our body will not allow the virus to spread further in our body. Therefore, we need to follow Covid-appropriate behaviour as the vaccines may save us from serious illness, but we are still able to spread the infection among others who are not vaccinated.
Q: We talked to a lot of professionals about the lack of antibodies in many people, even after vaccination. What is the reason for this?
A: Nowadays, we test upon G-antibodies, whereas we need to look for neutralizing antibodies. Cell-mediated immunity is long-lasting immunity created by the vaccine. There is another cell called the T-cell, that is also called a memory cell, which starts creating antibodies once exposed to the virus. Looking for antibody creation after vaccination is one thing but there are a lot of things apart from it like cell-mediated immunity and T-cell immunity. Research is being conducted for a booster dose vaccine which might be needed after 1.5 years.
Q: If someone receives Covishield, can the person receive Covaxin or other vaccine?
A: Right now, that is not possible due to a lack of stock of vaccines, but once everyone gets all the doses of the vaccines, we will see if we can inoculate people with a third dose as well. Some studies are being conducted upon the mixing of the vaccines and whether that will create more immunity. Until now, only a single dose was being administered during the vaccine trials.
Q: Do you think we should reduce the age limit for inoculation in view of the increasing Covid cases?
A: When talking about the vaccine, the first criterion is to reduce the mortality rate. Thus, we started by vaccinating people above 60 years of age as they are at the highest risk. Then we came down to people 45 years of age with comorbidities and covered healthcare workers and frontline workers, also to ensure that the healthcare system remains efficient. After this we have to vaccinate people who are of lower priority. But if we open vaccinations for all, we won’t be able to cover everybody because we will need a minimum of 2 billion doses to vaccinate a population of over 1 billion in our country. And if we inoculate people in the age group of 25-45 years and have no doses for people above 60, it will increase the risk factor for the country. Thus, we need to balance out the vaccine doses among the population.
Q: A lot of states are reporting a lack of vaccine doses. Many people could not get the second dose. How can we deal with this?
A: This issue is arising due to a supply-demand issue and it is not a matter of a lack of doses. Also take into account the eligibility of the people taking the doses. If at a centre, 50-75 people are visiting, we keep a record of those people and maintain the chain. But if 500 people arrive suddenly at the same centre on a given day, the chain cannot be scaled. At first, there was vaccine hesitancy but due to the sudden spike in cases, people started crowding immediately at the centres. It can so happen that if there is vaccine hesitancy at some place, we can move the surplus vaccines from there to a place with higher demand.
Q: How can vaccine wastage be controlled?
A: Vaccine is supplied in vials. A vial contains 10-20 doses. This means that we need to use all the doses when a vial is opened. Each vaccination centre needs to make a strategy and check if there are people waiting for doses before opening a vial.
Q: Do you think people need to get some tests done before receiving the first dose of the vaccine?
A: Many people tend to get their blood tests done, take Crocin and anti-allergy medicines, which are not at all needed. No tests need to be done before getting inoculated. Even if you get any side-effects after the vaccines, they can be treated. The side-effects are not major and are usually treatable.
Q: How can people with cardiac disease, high blood pressure, diabetes or any such issues take care of themselves?
A: 80% of such people are above the age of 45 and should get vaccinated quickly as these people may get severe Covid. Also, they should follow Covid-appropriate behaviour and avoid crowded places. Also, they should take proper precautions at home like maintaining hygiene and maintaining distance from people with possible symptoms of Covid.
Q: When will the curve flatten? What would you say about the future possibilities of the disease?
A: The curve may not flatten in the upcoming days and it is difficult to say anything about the future. It completely depends upon us. If we follow Covid-appropriate behaviour, work from home and avoid going to public places, cases may reduce. 80% of people in India are still susceptible to the infection. The fight against Covid can only be won with the active participation of people. If we stop the droplet infection by maintaining social distancing, wearing masks, sanitising and washing hands, we can stop cases from increasing. Thus, everyone must take precautions.
Q: When is the Remdesivir injection needed and how does it work?
A: The timing of a drug is very necessary to be taken care of. Remdesivir is anti-viral but has not shown reduced mortality rates till now. It does reduce hospital admission. It only works when you have a moderate illness and your oxygen saturation is reducing, fever is high or there is a patch in the X-ray or CT Scan. In later stages, Remdesivir does not work. A treatment strategy needs to be implemented.
Q: As hospitals do not have enough beds, how can one treat Covid at home?
A: First, we need to check if the person has a home isolation facility or not. If not, they should be sent to a Covid care centre. Next, see the condition of the patient. Does the person need hospitalization, what are his/her symptoms, and do they have any comorbidities? The government has demonstrated the process of home isolation already. 85%-90% people catch mild symptoms of Covid and can be treated at home. Only 10%-15% of people need to get hospitalised and out of them, only 5% need to get admitted to the ICU. Thus, many can treat themselves at home.
Q: What last message do you want to give?
A: The fight against Covid is not yet over and we have to fight it together. Covid-appropriate behaviour is very necessary in this pandemic. The vaccine is a great weapon against this virus and it will assist us in this fight. If we use both these weapons together, we will get rid of this pandemic quickly.
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