Citizens and the pandemic

Padmashree Dr Ravi Kannan

(The writer is Director, Cachar Cancer Hospital and Research Centre, Silchar. He can be at ravi.kannan.@cacharcancerhospital.org)

The second wave of the COVID-19 pandemic is knocking at the doors of the northeastern parts of India.

The number of infected individuals is rising and is likely to accelerate. What is playing out in other parts of the country is likely to be replayed in our region as well. The extent of the problem will depend on the citizens who, through their actions or inactions, are responsible for their health and the well being of those around them.

The country has been reporting increasing numbers of new infections daily for over five days consecutively. Even with a low Infection Fatality Ratio (IFR), increasing numbers of infections will translate into increasing numbers of deaths. While we do not yet understand the impact of the newer variants including the double and triple mutants, this rise is fuelled largely by human behaviour.

Elsewhere in the country, men and women are in trouble and we are watching helplessly. We can, however, try and be prepared for the onslaught if and when it strikes our communities in full force.

About 90% of those getting infected will have only minor symptoms including fever, headache, body ache, diarrhoea, malaise and conjunctivitis. They can be cared for in their homes in isolation. Only about 10% will merit hospitalization for breathlessness and/ or fall in oxygen saturation or blood pressure. Older people and individuals with co-morbidities like diabetes mellitus, cardiovascular diseases, morbid obesity, smokers with lung disorders and patients with cancers are likely to develop serious illness.

The risk of death is less than 1%.

Vaccinated individuals could still contract the infection and need to observe all the personal safety measures to avoid this. Vaccinations are, however, nearly completely effective in preventing serious illness from developing. All the vaccines currently available are safe for use in humans. All citizens should receive their vaccination shots at the earliest opportunity.

Following personal safety measures, like wearing masks covering the nose and the mouth in public, maintaining social distances and avoiding crowds and congregations, is a social and civic responsibility. Individuals get infected and in turn, spread the infection when they breach safety measures in their communities. The attitude of "This cannot happen to me" or "I cannot be spreading the infection" has to be shelved. Behaviour change, especially in a short time, cannot be implemented by force of law. Members of the community have to take it upon themselves to exert peer pressure to make it happen. Not doing so would mean failing our people.

Treatment of infected individuals with mild symptoms is largely supportive- paracetamol for fever, fluids, frequent small feeds, rest and of course, isolation. People with moderate symptoms (breathlessness and oxygen saturation below 94%) need hospitalization, early institution of oxygen supplementation, steroids and blood thinners. Oxygen and low dose dexamethasone are the only proven agents with proven benefit in large scientifically conducted studies in this situation.

More seriously ill patients will need more intensive care including antibiotics, drugs to maintain blood pressure and ventilator support for breathing and maintaining oxygen levels in the blood. The emphasis is to try and maintain patients on non-invasive ventilator support. It has been the experience world over that sick COVID patients needing invasive ventilator support (where a breathing tube is inserted into the airway which is connected to a breathing machine) tend to do badly with very high death rates. Robust evidence supporting the use of anti-virals like Remdesevir, plasma therapy and monoclonal antibodies is lacking at present.

These, therefore, have been given Emergency Use Authorization (EUA) in most countries and their use is left to the discretion of the treating physicians. The WHO does not recommend their use. The ICMR has given off-label EUA for conditional consideration to these options and does not include these in its standard guidelines.

For a quick back of the envelope calculation, let us consider a 40,00,000 strong community that has 2,000 hospital beds (India has 5 beds per 10,000 population). It is estimated that 70% of the population has to be vaccinated or infected for herd immunity to develop sufficiently to halt the pandemic, that is 28,00,000 people.

Currently, the infection rate in several parts of the country is around 10% of those tested, which would mean 4,00,000 individuals in this community. 10% of them would need hospitalization, which would translate into about 40,000 individuals.

1% of those could eventually die despite adequate and appropriate care is made available, which would be about 400 individuals. These estimated figures have important lessons for planning the way forward for our region to minimize preventable deaths.

Every effort should be made to reduce the rate of spread of infection. This is only possible by rigid adherence to public health measures of wearing masks properly, maintaining social distances and avoiding crowds. This is to ensure that all infections do not occur at the same time. This depends only on the community and not on any government or hospital. This will reduce the mismatch between the available hospital beds and the number of infected individuals needing hospitalization at any given point in time.

The vaccinations need to be ramped up.

Every symptomatic individual, howsoever mild, must get tested. There are several testing facilities in the region. Everybody who tests positive and more importantly, everyone with COVID-like symptoms (even if tested negative) must isolate themselves for 2 weeks.

Hospitalization must be strictly reserved only for those with symptoms of breathlessness or those with oxygen saturations below 94%. This will ensure that individuals who would recover easily on home isolation and care do not occupy hospital beds that would prevent people needing hospitalization from getting admitted. Optimal use of available resources will reduce the number of preventable deaths greatly. The measures that have the greatest benefit, namely early oxygen therapy when oxygen saturations drop below 94% and dexamethasone are inexpensive and easy to administer even in low resource hospital settings.

While managing low-risk patients at home is safe and scientific, a small number may deteriorate rapidly at home and die before reaching the hospital. It is important to understand that such individuals who deteriorate rapidly are at a very high risk of dying even if this were to happen in an ICU setting. Enhanced communication between healthcare providers, patients and their families could help reduce the mental and emotional trauma of such events.

Every available hospital bed needs to be pressed into use for sick COVID patients. All elective procedures should be deferred till the situation improves. Emergency medical treatment including surgery and care of chronic illnesses must continue uninterrupted.

Temporary and floor beds can be easily organised in most hospitals at short notice. Every available oxygen cylinder, oxygen manufacturing facility and oxygen concentrator must be made available 24 x 7 for use in hospitals. Availability of personal protective gear including masks and gloves must be ensured. Hoarding of oxygen cylinders, concentrators and protective gear must be minimised jointly by a heightened sense of civic responsibility and law enforcement. More expensive options like antiviral drugs, plasma therapy and monoclonal antibodies should be left to the individual patient and their families. These should not be considered the responsibility of the public health system because of their limited utility.

Alternate remedies of steam inhalations, hot water, cow urine, herbal remedies, and the like have no scientific sanction.

Perhaps most imperative for everyone is refraining from creating waves of panic. It is important to pause for a second before pressing the forward button on social media platforms and to ponder over the veracity of the content to be forwarded. Such platforms can be very effectively harnessed for disseminating scientific and factual information to the public and building solidarity. They can also be used with great efficiency to spread misinformation, fear and mistrust which will instigate individuals into irrational behaviour that can result in great harm. Use the information only from trusted resources like the website of the ICMR, the WHO and the CDC.

Please stay safe and keep your near and dear ones secure.

Wear masks covering the nose and mouth whenever in public, practise social distancing, avoid crowds and gatherings and wash or sanitise your hands frequently. Please go out only for essentials.