Updated: June 27, 2021 8:28:27 am
The ferocious second wave of Covid-19 saw a very large number of hospitalisations, a crippling shortage of oxygen, and many more deaths than in the first wave last year. What have we learnt, and what should we do in our battle against the pandemic here onward? Veteran medical practitioner Dr Mathew Varghese, Consultant, St Stephen’s Hospital, spoke to Kaunain Sheriff M and Monojit Majumdar at an online Explained.Live event last week. Edited excerpts:
On the widespread fall in oxygen levels in the second wave:
A large number of people were infected (in the second wave) and in this, the subset of people who needed oxygenation was bigger as expected. At the peak of the surge it was difficult to get an appointment for testing, so there were delays… The numbers were way beyond our capacity for testing and for handling in hospitals, so [among] the numbers that came up, most had a selection bias of cases that needed oxygenation. These statistics can be accurate only if you do population-based surveys, house-to-house surveys, and find out how many of them had Covid, how many of them had breathlessness, and then if you compare that percentage with the previous [wave’s] percentage, you will have accurate data… But I think that is a matter of detail, it doesn’t matter; breathlessness was the most important symptom and it confirms the fact that this virus leads to a problem in your lungs, that’s the number one problem, that’s what we needed to address. That’s the baseline, I would say.
Also, in the over 350 cases that I was following… in the earlier wave, loose motions were happening usually on the ninth or tenth day; in this phase, loose motions was the first symptom, after the second or third day… The other thing was anosmia and ageusia, the loss of smell and the loss of taste. In the last wave it was seen on the seventh, eighth, or ninth day. This time, they had anosmia on the third, fourth, day. So, symptoms were getting fast forwarded to the earlier part of the disease… The spectrum remained the same, there may have been minor differences in percentages, but the importance was that symptoms were occurring at a much earlier phase in the disease [in this wave] than in the previous wave…
Again, the virus was far more effective, far more contagious and aggressive [in this wave]. In the last wave, one member, or at worst two members, in the family were infected; in this wave, every member, including maybe the help and the driver in upper-class homes, was affected…
On creating awareness about effective home isolation:
The protocols were based on ‘mild’, ‘moderate’, and ‘severe’. For moderate disease, the criteria was respiratory rate more than 24 per minute, but how do you count the respiratory rate? You need to have an education campaign for people how to count, or a healthcare volunteer who could be trained to do that… The other criteria was looking at the oxygen saturation, based on that we had our mild-moderate disease criteria. The disease has clear timeline patterns, so to keep people at home based purely on breathlessness — you stay at home until your breathlessness reaches the level where the oxygen saturation drops to such-and-such level — is wanting people to have a digital censor or wanting people to know how to count your breaths… Most people don’t know how to count, you need to train people how to do it, you need to train your family members how to do that…
You could have had real time research by clinicians and clinical research workers, but here we had the entire system overwhelmed…and because the numbers were so overwhelming, we had no choice but to take care of it in such a way that we limited the number of patients coming in…
To keep patients at home based on breathlessness or saturation was, in my understanding, not scientific enough, because for a person to have a drop in saturation to 92 per cent, your lungs have to be compromised by between 50 per cent and two-thirds… That is the time you definitely need hospitalisation, you definitely need to be having oxygenation…
On the absence of consensus on when to administer repurposed antivirals:
A drug which has been invented for a particular disease, if it is investigated for another disease it’ll be a repurposed drug, and if it is being allowed to be used in another disease it is called ‘off-label’ use. Both these have been done in the case of coronavirus. The problem in the proof generation in any of these activities is, when do you start the medicine? At what stage? Remdesivir is an antiviral, it is modifying virus-replication or virus-entry or virus in your body circulation, so that phase is a very narrow window of opportunity of five or six days; if you wait beyond that, your primary problem in Covid is the auto-immune reaction triggered by the virus. So if you give remdesivir after the auto-immune reaction has been triggered, it’s not going to work; before the triggering, maybe it can work, but to prove that is difficult… You have to have a very large sample size and very large studies of various phases of the disease; very difficult to do especially in the situation of a pandemic, very difficult to manage and document… If you look at the guidelines (by CDC, etc.), there is insufficient evidence to show that remdesivir is beneficial in changing the outcome.To categorically say that it is useful and that too when it is such an expensive drug…there lies my problem. By doing these unreachable things and telling people to get these unreachable, unprocurable drugs and deliverables, you are creating guilt in a large number of people’s minds…
On the learnings from use of oxygen:
Everything has a limit to its availability; when you say that you are ready for capacity, full capacity, you may still get a surge beyond capacity. The whole idea of disaster preparation is that when your capacity is overwhelmed…there will be several grades where your existing supply-chain management can take care of reallocation, redeployment, rephasing of deliverables — that is one way. The other is when those supply chain logistics are also overwhelmed, what do you do? If you think there is likely to be a third wave, you have to be prepared for a capacity beyond what we saw even in this wave. My hunch is it won’t be that bad. But your preparation has to be robust enough…
On the insistence of a positive RT-PCR test before hospital admission:
This is why it is said that in such a situation your decision-making protocols have to be dynamic. Many of these patients were brought in not by relatives — who were [probably] all positive too — but by some good samaritan, and they would wait in the ambulance and the ambulance would be running out of oxygen. These are real-time things which need real-time helplines, monitored, where is the problem, what is happening, how do we deal with it… Should have been done right in the beginning. We needed help maybe from states that were not affected, because the upswing of the graph was clearly telling you that you were in for big trouble… Every hospital, every doctor, every ward should have a tablet or similar device with real-time connectivity… We need to create systems that are dynamic, which can capture data in real time across the city, and there should be a nodal control centre. I don’t believe in fault-finding; you need to have a system correction through system evaluation. Intelligent system evaluation will come from people who know how to gather and analyse large data… Some of the best clinical departments in the West don’t just have clinicians, they have clinical research professors associated with them. How many research professors are there in our medical colleges and healthcare infrastructure who do only research? This is what could have been done, we could have leapfrogged to the next level of medical record-keeping in the last one and a half years.
On the mucormycosis infections surge:
I wish I knew the full answer, we can only guess the possible reasons. An average doctor two years back wouldn’t have seen a case (of mucormycosis). The numbers were very few, and the critically ill even fewer. We are seeing patients in tertiary care facilities who are diabetics, who need the support system for ventilation or oxygenation, and broad spectrum antibiotics to correct their septicaemia who are in probably in renal shutdown, multi-organ failure, immunity is really down, and then they developed this (mucormycosis). The fungus is not, as some people were saying, from industrial oxygen or humidifiers; it is ubiquitous, it is there in the soil, it is there in the plants, it is there in the air… A patient who is immunocompromised because of diabetes, gets into acidosis and that is an ideal environment for the fungus to grow, the spores which are ubiquitous in the air, that’ll then multiply in your mucosa and that is wet and it is warm, and it (the fungus) multiplies.
But in this particular case, why did we see so many? There are many patients on steroids, many diabetics, many renal disease patients, many patients of cancer or those on immunosuppressive therapy, but we do not normally see this… I wish we knew the answer.
On a possible third wave and vulnerability of children:
In history, no plague has gone on forever, no influenza has gone on forever. This virus has been around for one and a half years now; it has taken such a large toll and so many have been infected; so many have been symptomatic, many more may have been asymptomatic and infected. That would have contributed to immunity, herd immunity… The disease dynamics will need to be studied.
And therefore, my next answer, will the next wave come? Looking at the surge, last wave, this wave, and the protection from the vaccines that are being rolled out, we will reasonably have a manageable wave, barring an unforeseen, a devilish strain that comes up which I cannot predict… But barring that I don’t think there will be a massive surge like this. And if at all it is coming, it will not come in the near future.
Why am I saying that? In the 350-odd cases that I have been following up, I have had three cases who got re-infection. So they are having a reasonable protection after the infection for at least five-six months. The large mobile population who are taking the virus from one human being to the other, from one home to the other, most of them have been infected — and they would have sufficient immunity to protect them at least for five-six months. But having said that, that should not make us complacent; it is our complacency which will land us in trouble. Don’t think that you are vaccinated and therefore you are protected 100 per cent, no vaccine gives you 100 per cent protection…
Even if there is another wave, it will not be this big as far as I understand, and to conjecture that children will be affected is absolutely shooting in the dark. There is no evidence, there are no signs that children are going to be affected. Even in this wave, a large number of children were affected, much more than last time. But the total numbers were also more, so we need to look at the full data, analyse it intelligently to say if the number of children affected is more. But to predict the future is going to be like that… If they couldn’t predict this wave, on what scientific basis do they say they’ll predict the next wave, and that it is going to be children?
I can think of something else… The under-15 population in India is 38 per cent, and that, out of 1.3 billion, is over 400 million…400 million who can have the vaccine. We have started testing vaccines in children, very rightly so, we should do it… So if somebody internationally wants to spread a rumour that children are going to be affected, out of parents’ love for their children, they’ll do anything, they’ll get the money and get that vaccine which is tested in children abroad and give it to their children… I don’t think that this fear psychosis needs to be created… We need to clearly say there is no evidence, there has to be clear policy coming out…that we don’t believe in this.
The next wave itself is hypothetical and children is pure conjecture.
What is ‘Long Covid’, and what is your advice for those suffering from it?
We are still understanding the symptoms of ‘Long Covid’; when patients are coming in, we are finding that they had Covid. The most common that we are seeing is tiredness, bodyaches, painful muscles, so when they try to do something, it aches and pains. A lot of them have tiredness — this could be because they have bodyaches; it could also be because their lungs were compromised significantly… These are often those who’ve had significant illness, needed hospitalisation and oxygenation… We tell these people not to do vigorous exercise; the tendency for clotting of blood in these patients remains for three-four weeks that is why anti-coagulants are given; steroids are given for a week to 10 days… We are also seeing another pattern of patients presenting with — it’s rare — Miller Fisher Syndrome. We are also seeing in children, Kawasaki Disease. So there are all kinds of problems and most are related to auto-immune reaction. A Long Covid symptom like clotting of the intestine can present after two-three weeks with an intestinal obstruction or the dead portion of the intestine needing surgical intervention.
What is your vaccination advice for pregnant women?
When we look at risk versus benefit, the benefits of having the vaccine are far greater than having the disease. The outcome of pregnancy after a virus infection from Covid is really bad because you are dealing with two lives here. In a number of cases that we dealt with in our hospital, we had stillbirths, we had mother and child both dying, we had the child dying and the mother surviving — all bad situations. We want to prevent that, and the only safety precaution that we say is, if you know you are pregnant and within the first 10 weeks of that knowledge… then avoid the vaccination in the first 10 weeks, after that take the vaccine. It is recommended that you take the vaccine because the protection from the vaccine is far better than having the risk of the disease.
Transcribed by Mehr Gill
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