Third wave of Covid19 in India

A Glance Back at Covid19 Management esp Home Isolation

China gifted Wuhan virus to the world after having suffered to some extent for own misadventure of allegedly making the nCoV2 as a bio-warfare weapon for their PLA, that unintentionally caused pandemic on their own populace. It is widely believed that Ms ZhengLi, director of Wuhan Virus lab supervised and conducted the ‘Enhancement of Functions’ genetic reformation of the bat virus that accidentally infected some of their lab workers followed by the civilian population. WHO is believed to have colluded with the Chinese administration in hiding the flaring epidemic from the public. Both Chinese administration and DG, WHO Dr Tedros did everything possible to resist investigate the source of the virus.

The Corona Virus was first identified in a patient in Wuhan on 9 Jan 2019. Strangely Wuhan lab published the genome of the virus in 2 days on 11 Jan 20 and Commercially available RT-PCR test kit was available in Wuhan Hospitals on 16 Jan 2020. It is firmly believed that virus specimen used for developing the genome and the RT-PCR test kit were provided by Wuhan Lab much before the infection broke out. It used to take weeks/months for preparing genome and the test Kits. Govt of India did well to set-up the Covid Task Force in the very beginning with dual task of Covid patients and Covid S&T management (for test kits, drugs, PPEs, Oximeter, Ventilators, Vaccination and so on). Within months, India not only became self-reliant in Covid19 provisions but became an exporter with numerous start-up taking up the challenges.

In the initial months of the immense stress on the healthcare system, a lock-down became inevitable but it had substantial financial and humanitarian implications. Business shutdown, manufacturing shutdown and economic shutdown of the nation were harsh on all employees mostly in the unorganized sector. PM Modi was sensitive enough to implement free provision supply for the BPL category of people but numerous well-to-do families too exploited the Public Distribution System. As a result, where 8 Cr poor people should have been provided with free provisions, about 80 Cr people are behaving like parasites, sucking out the blood of the nation (क्या मोदी सरकार ने देश में बहुतों को मुफ्तखोर बना दिया है? Lockdown of the entire nation was a logical decision in the beginning that became painful in the weeks and months to come. As on now, lessons learnt suggests of lockdowns only if the health services are expected to get unduly strained / overwhelmed. Vaccination in our democratic set-up is proving challenging with many individuals showing hesitation following doubts created by some opposition politicians for the reasons unknown. Despite all these, the Govt has done commendable job to vaccinate >150 Cr doses (as on 09 Jan'22 at 7 AM). This indicates of herd immunity to be present in Indian communities. However, data from UK and other nations in Europe show little effect of herd immunity in preventing their populace of the rampaging 3rd or 4th wave of Covid19 esp with newer variants. Surely severity of the new infections is less. Table below shows the extent of vaccination in the entitled population of India.

Vaccination status in India

Spread of Infection

In the initial stages of 2020, following exposure to outsiders/Spreaders/Confirmed cases in the prior 3-10 days, routine & mild symptoms of Covid manifested that included Influenza like illness (ILI), fever, bodyache, headache, throat irritation, cough, loss of smell/taste, unexplained diarrhea, weakness, dry mouth…that either gradually recovered or progressed to multi-system complications and failures incl blood coagulation disorder. The later Delta strain had added manifestations of joint pain, red eyes and gross hypoxemia without commensurate respiratory involvements. Elderly and those having comorbidities (Obesity, Hypertension, COPD, Diabetes, Coronary Artery diseases, Chr Renal & Liver diseases, Cancer) were at significantly higher risk for complications and multi-organ failures. The newer Omicron variant shows infectivity almost 5 times higher than the Delta. However, its virulence seems to be lesser with lesser morbidity and mortality esp among the vaccinated population.

The main management related problem was of the high infectivity at the prodromal stage even before the manifestation of the symptoms or diagnosis. The diagnosis in the initial stages was marred by lack of test kits that had to be imported from China, limited test centres and limited sensitivity of the test kits. The RT-PCR test results took upto 3 days and lesser sensitivity caused false negative that had to be supported by seromarkers or X-Ray/HRCTC scan. Within a short span of 3 months, indigenous lab 'test kits' were approved and more than 100 labs were set-up all over India that are by now >200. This has reduced the test time from 3 days to ~1 day. Today, scientists have come-up with multiple options for the Covid tests that include rRTPCR, TrueNat, CBNAAT, CRISPR, RT-LAMP, Rapid Molecular testing system besides point-of-care RAT...all having excellent sensitivity and specificity. The capacity of testing too has been ramped up to >1.5 Cr / day. Hence it could be said with reasonable confidence that India can face the 'new-wave' challenge with reasonable lease.

In the initial stages lab tests were being used as corollary parameters for diagnosis Covid19 but later, it was carried out mostly from assessing the severity and as management tools based on its Hematological, Inflammatory, Immunological and Biochemical markers. There was no specific anti-viral treatment in the initial stages but by now, many drugs are available; some with debatable efficacies though.

Lab tests for Covid19

Treatment Logic

In the initial days, all cases of Covid and their close contacts were admitted for quarantine/investigations. Those testing positive were treated symptomatically and conservatively the world over. Complications and organ failure were treated on merit. However, asymptomatic cases have been a problem, freely spreading infection. Soon overwhelming infection and patient load compelled the healthcare managers to treat the mild cases at home or at dedicated ‘Covid Centres’ conservatively and transfer to hospital if complications developed. The treatment logics were mostly based on its severity of Mild, moderate and severe; with the mild cases being treated under Home Isolation.

Delta variant with its immense virulence to cause hypoxemia overwhelmed the entire healthcare system first in India and now elsewhere in the world. This wave compelled even moderate cases to be treated at home as hospital beds fell short of requirement despite make-shift hospitals coming up. Doctors on the national Telemedicine helpline did everything that they could do for the patients at home. More than the disease itself, panic had gripped the individuals and families. Shortage of supplemental Oxygen Cylinders saw the usage of other cylinders the hygienic & cleaning status of which were unknown. Under those chaotic situations, no one can assure whether the cylinders had medical grade oxygen or not. Black marketeers and hoarders too played havoc in the supply chain whether it was the gas cylinders, Oxygen concentrators or essential drugs. Thanks to efficient Indian diplomacy that the international community came up with quick aid with cylinders, Oxygen concentrators and essential drugs.

Covid19 categorisation

Mild cases (without systemic involvement, RR <24/min; SPO2 >93%).

Treatment were with antipyretic, good hydration and nutrition. Supplemental Vit C, D and Zinc and Immune-booster preparations/drinks suggested by Ayush Dte Govt of India. Initially, there was no role for Antibiotics/ Ivermectin/HCQ/Flavipir for mild cases. The treatment for mild cases was advocated under 'Home Isolation' or dedicated 'Covid centres' conservatively.

Chloroquine was one of the drugs of choice in the initial days for both treatment and Prophylaxis. It was a cheap and effective measure both for outpatient and inpatient. Proven efficacy was debatable. It has been hence discontinued. Next came Fabipir (200 mg tablet); 1800 mg twice a day on day1 followed by 800 mg twice a day from day 2 up to 14th day. The full 14-day treatment cycle cost anything from Rs 14,000 to 36000 per patients with questionable benefit among moderate cases. Glenmark, the drug company made its fortune and middlemen and black marketers in India ruled the roost, to loot the Covid19 victims.

Panic of the deadly 2nd wave in India by Delta variant causing debilitating hypoxemia and deaths compelled the health administration to prescribe all possible oral medications in Home Isolation too, that included even steroids (both oral and inhaler if cough persisted) with massive misuse of OTC drugs as mentioned below (these are no longer recommended now):-

Tab Azithromycin 500 mg OD x 5d OR Doxycycline 100 mg BD on day 1 then OD for 4 days.

Tab Ivermectin (12 mg) 1-0-0 x 3 days OR Tab HCQ 400 mg; 1 BD x 1d f/b 1 OD x 4d.

Tab Zinco-Vit C 1-0-1 for 10 days

Tab Paracetamol (500 mg) 6-8 hrly if febrile or 1 SOS (fever, aches & pains).

Warm Saline Gargle with Turmeric & salt or 2% Betadine gargle if available.

Budesonide Inhaler, 2 puffs BD (& SOS) if cough persisted >5 days.

Fresh Kadhaa (Tulsi, Ginger, Turmeric, black pepper, clove, cardamom or as advised by Min of Ayush) as warm drinks morning & evening; preferably for the entire family.

(Optional : Warm water drinking, Steam inhalation esp if has throat congestion)

Record Temp, Pulse, SPO2 & Respiratory rates 4-6 hrly.

Some of the state govts made a Covid medical kit with above drugs that Covid positive even asymptomatic and very mild subjects consumed in the panic. There were gross misuse of the OTC drugs esp the anti-biotics and steroids. Under present guidelines, anti-biotics and steroid inhaler could be prescribed with telemedicine consultation for continuing symptoms/cough.

An unprecedented delayed appearance of Mucor Mycosis (Black Fungus) in the 2nd wave has now restricted the use of OTC drugs. The new guidelines recommend only anti-pyretic for Home Isolation cases. A consulting doctor may prescribe additional medication for nose and throat congestions. Home Isolation is now for at least 7 days (plus 3 successive days remaining afebrile). A repeat of or a negative RT-PCR test is not required after Home Isolation as per Min of Health, GOI guidelines of 05 & 09/01/2022.

The appearance of new symptoms esp fever >103 deg F or persists beyond 3 days, difficulty in breathing, worsening of cough, Pain chest while breathing, giddiness, extreme weakness, intense headache, fall in SPO2 below 93% are signs of worsening, must shift to hospital.

Moderate Cases

High Fever continuing >5 days, RR>24/min, SPO2 90-93%, Derangement in Inflammatory/Immunological/ biochemical parameters. Presence of Pneumonia/Ground-glass appearances.

Treatment in Hospital with adequate antibiotics, anti-viral (Remdisvir 200 mg i/v on day1 followed by 100 mg from day 2-5) or Oxygenation and other supportive measures. Delta variant showed high hypoxemic impact on large percentage of population necessitating supplemental oxygenation. 2-Deoxy Glucose (2-DG) reduced the viral replication in the initial days and lowered hypoxemic tendency. It was cleared under EUA trials. Antiviral cocktail of Casirivimab and Imdevimab 120 mg/ml each (Regeneron) iv injection claimed to lower viral load substantially and reduced hospitalization period but it is unaffordable by most costing as much as Rs 60000 per injection. Inj Tocilizumab 400 mg iv infusion over 60 min has been useful among those heading for acute hypoxemia.

A newer drug Molnupiravir has been marketed recently for those who are unable to take other medications for some reasons. Its efficacy is debatable. Anticoagulant was recommended to prevent clotting disorders (if D-Dimer was high). In the initial days, plasma therapy from Covid-recovered convalescent patients was recommended in the first few days of the infection to reduce the viremia but its efficacy was highly questionable and later discontinued.

Severe Cases

Compromised Oxygenation, Derangement in Inflammatory/Immunological/biochemical parameters, evidence of multi-organ involvement and occasional cytokine storms.

All body-systems needed to be evaluated and supported with conservative/interventional measures. The treatment measures mentioned above under ‘moderate category’ were also useful. Respiratory failure necessitated ventilator support through Oro-nasal mask, Breathing machines, endotracheal intubation or Tracheal cut-down either at ambient pressure or IPPBR.

The treatment objectives were largely to sustain the patients for 4-6 weeks by which time, their own immune systems started overcoming the viral infection. Experience show some delayed symptoms among those having recovered fully. These include reduced effort tolerance, Tachycardia, loss of concentration, unexplained aches & pains, neurological symptoms of occasional pains and few others.

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