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COVID-19 Indian Perspectives and Challenges: The TIP Approach

Authors:
  • Dr Varsha's Health Solutions

Abstract

COVID-19 (Coronavirus Disease), caused by the novel Coronavirus designated 2019-nCoV (and thereafter called SARS-CoV-2), first seen in Wuhan, China in December 2019, has now swept across most countries and surfaced as one of the major pandemics the world has seen.1 India too has been impacted with the first few cases emerging in end January-early February 2020 and the disease gaining a foothold across the country by March 2020.
The Indian Practitioner qVol.73. No.4. April 2020
Editorial
COVID-19 Indian Perspectives and Challenges: The TIP
Approach
Overview
COVID-19 (Coronavirus Disease), caused by the
novel Coronavirus designated 2019-nCoV (and
thereafter called SARS-CoV-2), rst seen in Wu-
han, China in December 2019, has now swept across
most countries and surfaced as one of the major pan-
demics the world has seen.1 India too has been impact-
ed with the rst few cases emerging in end January-ear-
ly February 2020 and the disease gaining a foothold
across the country by March 2020.
COVID has a Reproductive number (R0) of around
2.3, and is transmied by droplets emied from infect-
ed individuals through direct contact or close proxim-
ity (about 1 meter) and infected surfaces (on which vi-
rus can remain for around up to 12 hours or longer).2,3
From the time of geing infected, COVID symptoms
can take from 2 days to 2 weeks to manifest. Symp-
toms include sore throat, cough and fever which may
be sometimes accompanied by nasal congestion, run-
ning nose, loss of smell, sneezing, headache, fatigue,
body pain and rarely vomiting or diarrhea. The virus
can spread to the lower respiratory tract and lungs in
about 4-5 days causing breathlessness due to bronchitis
and pneumonia. Death occurs from ARDS (Acute Re-
spiratory Distress Syndrome) or sepsis and multi-organ
failure.4
Almost 80% of people have mild symptoms. The
overall global mortality rate from COVID-19 is around
2-3% as has been seen in India as well. Risk of serious
disease, complications, and death is higher in patients
>60 years and those suering from other underlying
medical illnesses like Diabetes, Hypertension, Cancers,
and diseases of the Airway, Heart, Kidney, Liver or Im-
mune system.5
Currently there are no specic drugs validated by
large randomized clinical trials for COVID-19, but
based on small studies, case reports and anecdotal ev-
idence, Hydroxychloroquine and its combination with
Azithromycin, and antiretrovirals Lopinavir-Ritonavir
are being selectively used with ADR monitoring, along
with symptomatic therapy in India.6,7 The global SOL-
IDARITY trial may shed more light and conviction on
these therapies in the near future.8 COVID RNA vac-
cine trials are underway with the hope of its availability
by early 2021.9
Tackling COVID-19 in India
India represents one of the most unique countries in
terms of diversity and disparity. While instituting uni-
form COVID-19 measures and policies, an array of oc-
cupational, cultural, educational and economic issues
presents themselves. There are also challenges related
to types of housing and living, as well as distribution
and availability of health care facilities. The approach
being a country like India would be TIP – Testing
and Tracing contacts, Isolation of conrmed and sus-
pected cases as well as high risk contacts, and Precau-
tions and Preventive measures for the population.
Testing for COVID-19 and Tracing Contacts
Testing criteria in India include symptomatic pa-
tients (fever with cough or breathlessness) with trav-
el history (in past 14-21 days), or contact history with
symptomatic travelers or high suspicion/conrmed
COVID cases. Asymptomatic persons in these catego-
ries undergo minimum 14-day quarantine to observe
for symptoms. In addition, testing asymptomatic peo-
ple living in the same household as a COVID positive
case (high risk contacts) is also an important part of the
criteria, as these people carry high risk of contracting
and transmiing infection.10 Testing this last group is
challenging in urban slums and clustered residential
areas with several sharing a room, common balconies,
toilets and water lling sources. In such areas more ro-
bust testing of possible COVID contacts becomes very
important to limit the rapid spread and spike in cases
which can make these areas hotspots. In addition, me-
ticulously tracing and quarantining of contacts though
of high importance to prevent and contain outbreaks,
can prove to be a major task due to close proximity of
living, mixing and working in these areas, thereby ne-
cessitating sealing and cordoning o huge population
clusters.
Other groups to be tested include hospitalized pa-
tients with severe acute respiratory symptoms or inu-
enza like illness and pneumonia, symptomatic Health
Dr Varsha Narayanan
Health and Pharmaceutical Consultant, Dr Varsha’s Health Solutions, Andheri West, Mumbai.
Email: info@drvarsha.com
7
The Indian Practitioner qVol.73. No.4. April 2020
Editorial
Care Workers (HCWs) handling COVID positive pa-
tients and asymptomatic HCWs if they have handled
a COVID positive case without adequate protection.
Contact tracing for positive HCWs can be a daunt-
ing task considering patient volumes in India, result-
ing in decisions to temporarily close many OPDs and
non-emergency consulting clinics. However, this can
establish and propagate E-consulting and Tele-medi-
cine, that can play a very positive role in the future of
health care in the 2020 decade.11
More and more testing and tracing contacts is cen-
tral to tackling and containing COVID-19 in India.
Currently testing in suspected cases is done with na-
sopharyngeal and/or oropharyngeal swab samples for
presence of the nCoV-2019 RNA by RTPCR (Real-time
Polymerase Chain Reaction).12 Domestic production
and approval of testing kits which can reduce testing
time to under 2.5-3 hours has been a major step. (Rapid
5-minute tests launched globally will be on their way in
the near future). Expanding testing centers to involve
both government and private hospitals and laborato-
ries has been an encouraging move. Currently there
are more than 125 government testing centers spread
across India with at least one in most states, and more
in pipeline. Over 50 private hospitals and labs have
stepped in with more than 15,000 country wide collec-
tion centers, with introduction testing kiosks and even
drive-through testing recently. However, shortage of
testing kits and handling gear, hurdles in home sam-
ple collection, high test cost and dierential directives
have been some of the challenges faced by private labs
in contributing to greatly scaling up testing, which is
the need of the hour.
The rapid blood serological testing for antibodies
to 2019-nCoV in blood has been now developed and
approved in India, which can give results within 15-30
minutes.13 This can aid as a quick screening test (to be
followed by conrmatory swab test) in hotspots, or in
dense clusters or interiors (where migrant population
from cities has returned) when there are suspected/
known positive cases. In combination with the RTPCR
swab test, the rapid antibody test can help detect active
symptomatic cases, asymptomatic carriers, and those
with immunity developed to the virus.
Till domestic production of testing kits and gear
scales up, the challenging option of importing these in
bulk is being taken up.
Chest CT scan is being recommended as an import-
ant diagnostic tool for COVID-19 due to high sensitiv-
ity, however feasibility, availability and cost remain
important limitations for its generalized usage in our
country.14
Isolation of Cases
There are two types of Isolation which are important.
Firstly, isolation by quarantining of patients who have
risk of exposure and being infected with COVID-19, like
people recently returned from travel, those exposed to
symptomatic people with recent travel history, and
those possibly exposed to known positive COVID cas-
es. Such people are either isolated in their home/home
room (with intimation of the housing society adminis-
tration) or in assigned approved quarantining facilities.
These group of people are under observation for a min-
imum period of 14 days (extendable in specic situa-
tions) and swab tested when symptomatic.
The second type of isolation is of those who have test-
ed positive for COVID-19. All such patients were being
hospitalized in India in isolation wards. There are now
many government hospitals and apex institutes, along
with private hospitals also being commissioned recent-
ly, which have established COVID Isolation wards and
ICUs. To prevent overwhelming and overloading of
healthcare workers and facilities, a triple level of isola-
tion will be seen coming into play, with patients having
mild symptoms and no risk factors or pre-existing med-
ical illness, isolated in COVID-Care Centers, (self-care/
basic care repurposed stay centers like hostels, lodges,
stadia, guest houses, etc.) until their symptoms resolve
and laboratory tests for COVID-19 virus are negative.10
Moderate and Severe cases having breathlessness
(increased RR with SpO2<94% and evidence of Pneu-
monia on imaging, at presentation) are to be imme-
diately taken up for admission to COVID isolation
wards in Dedicated COVID Health Centers or Hospital
blocks/Hospitals with oxygen and life support/ventila-
tor availability. Severe high-risk cases with SpO2<90%
or RR≥30, or evidence of ARDS/septic shock, should be
admied in designated COVID-only hospitals/hospital
blocks with ICU. Patients can be discharged once they
test COVID negative, and are asymptomatic and stable.
During such segregation it is of utmost importance
that suspect cases being tested and conrmed cases be-
ing taken up for medical treatment, are kept well sepa-
rated at all times. Going further Isolation at home/home
rooms and home care should be considered where fea-
sible for mild cases to ease load o the HCWs and facil-
ities as seen in some other countries.15
Such segregation can also help in reducing exposure
and infection of HCWs due to lack of adequate Personal
Protective Equipment (PPE), and help several hospitals
and health care centers cater eectively to other medi-
cal care which should not be compromised during the
ongoing COVID pandemic. Another appreciable move
has been free of cost testing and treatment for COVID-19
for Ayushman Bharat beneciaries at private laborato-
ries and empaneled hospitals, by the National Health
Authority (NHA).16
Precautions and Preventive measures
Precautionary measures by and for the general
population which encompass hygiene, self-discipline,
8
The Indian Practitioner qVol.73. No.4. April 2020
Editorial
adherence-compliance to directives, awareness and
understanding of the disease, and display of patience,
rationality and tolerance, form the base on which any
kind of management and containment strategy can
be built and implemented for a pandemic such as
COVID-19.
Actions like restricting ights, sealing airports and
borders, closing all public places and institutions, lim-
iting public transport, imposing lockdown, and discon-
tinuing all non-essential and non-emergency services
are some of the commendable and timely measures tak-
en in India before the onset of any signicant COVID-19
community spread. Maintenance of essential services,
food and medicine supplies and emergency health
services in India during the period of lockdown, in a
streamlined manner has also been internationally ap-
plauded. In addition, there have been continued and
immense eorts in educating, guiding and updating
the public about frequent hand washing, covering nose/
mouth while sneezing/coughing, avoiding facial touch-
ing, practicing social distancing, avoiding crowds and
staying home, appropriate usage of masks and sanitiz-
ers, and discarding of used tissues etc. There have also
been repeated mandates put out for 14-day self quaran-
tining post travel.10
The most important point is for the people to fol-
low and adhere to these advisories and recommenda-
tions along with respecting, allowing and ensuring the
smooth functioning and duty execution of all HCWs
and municipal sta. The laer includes not only in hos-
pitals, health centers and labs but also in their premises,
residential complexes and locality during sanitization
activities, contact tracing, quarantining implementation
and test sample collection. As discussed, social distanc-
ing is a luxury and privilege in low-income urban clus-
ter-housing areas (with some clusters having a densi-
ty of >1 lakh/sq km), while educational and economic
barriers along with socio-cultural factors may impede
certain hygienic and health measures, requiring impo-
sition of extra restrictions and administrative measures.
There is some initial evidence to suggest a protective
eect of BCG vaccine, which is part of the immuniza-
tion schedule in India, unlike the western world. This
may be due to its immune stimulatory eect thereby
enhancing anti-viral protection, however more conclu-
sive research is still awaited.17
India is a country of diverse beliefs, cultures, sys-
tems and practices. With digitalization and widespread
access to social media, a gamut of information is avail-
able, shared and spread in a short period which can not
only adversely impact positive eorts, but also lead to
misplaced fear, panic and undesirable social repercus-
sions. Therefore repeatedly, the importance of social
responsibility and refraining from spreading medically
and scientically unvalidated information, needs to be
emphasized. The Ministry of Health and Family Wel-
fare (MoHFW) of India along with the Indian Council
of Medical Research (ICMR), has one of the most updat-
ed online sites with all information, FAQs, advisories
and recommendations in place for COVID-19. In ad-
dition, the AarogyaSetu app, launched for installation
in smart phones aids calculation of the risk of COVID
based on parameters of positive cases in the vicinity,
enabling taking necessary timely steps for assessing
risk of spread of COVID-19 infection, and ensuring iso-
lation where required.18
Protection and Precautions for HCWs is a paramount
and concerning factor in the ght against COVID-19.
Ensuring availability of PPEs for all HCWs and N-95/
Triple layer masks (for both patients and HCWs) is cur-
rently a pertinent challenge being addressed. Consid-
eration and use of Hydroxychloroquine prophylaxis
in HCWs and household members handling COVID
patients has been recently approved in India.19 Twice
daily temperature and symptom self-monitoring has
also been advised for frontline HCWs along with metic-
ulous personal hygiene and protective gear.20
Conclusion
COVID-19 in India is being tackled with, and further
requires a combination of meticulous and organized
testing and contact tracing, quarantining of at-risk and
possibly exposed/suspect cases, multilevel isolation and
management of COVID positive patients, and above all
precautions, compliance and solidarity of India’s peo-
ple. India, with its set of diversity in cultures, systems,
healthcare access and economic disparities, presents
unique challenges and demands. Very encouraging
and eective containment actions have already been
taken, along with systematic advisories and recommen-
dations being put in place. Further enhancing health
care facilities, protective gear and testing kits, as well
as streamlining patient management would be focus
areas for tackling this pandemic. Preventing outbreaks
especially in cluster living areas and existing/potential
hotspots would be crucial to prevent large scale com-
munity spread. Maintaining the trust, compliance and
cooperation of the people along with preventing spread
of panic and misinformation are winning factors. The
role of all Doctors and HCWs whether frontline or not,
is of great importance in imparting right awareness and
guidance on COVID-19, as well as maintaining com-
munity health and management of medical illnesses
by eectively using digital platforms, e-consulting and
telemedicine.
Disclaimer: Information is dated 7th April 2020
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10
... On May 1, 2020 drug Remdesivir gained emergency use authorization (EUA), from FDA [18] and was repurposed to treat severe, hospitalized COVID-19 patients with oxygen supplementation therapy [19]. Another treatment that proved effective is to choose individuals from the previous pandemic with a significant reduction in the relative risk of mortality, and get convalescent plasma or antibody and use against severe acute respiratory infections [20]. Most importantly, the current guidelines in The Lancet emphasize that systematic corticosteroids should not be given routinely for the treatment of COVID-19 [21] that can result in delayed clearance of viral RNA (from the previous report of SARS-CoV and MERS-CoV) and other complications such as psychosis [22]. ...
... Later on, as the number of cases started increasing the Indian Council of Medical Research (ICMR) approved 176 government and 78 private hospitals [34] to undertake coronavirus testing [35]. However, after the introduction of testing kiosks and even drive-through testing recently, shortage of testing kits and handling gear and high-test cost have been some of the problems faced by private hospitals after scaling up of coronavirus testing [20]. Healthcare workers approaching the patients are instructed to wrap themselves with a PPE (personal protective equipment) kit hence the availability of the gowns must be monitored by the store and inventory control. ...
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Backgrounds: Up to February 16, 2020, 355 cases have been confirmed as having COVID-19 infection on the Diamond Princess cruise ship. It is of crucial importance to estimate the reproductive number (R0) of the novel virus in the early stage of outbreak and make a prediction of daily new cases on the ship. Method: We fitted the reported serial interval (Mean and standard deviation) with a gamma distribution and applied "earlyR" package in R to estimate the R0 in the early stage of COVID-19 outbreak. We applied "projections" package in R to simulate the plausible cumulative epidemic trajectories and future daily incidence by fitting the data of existing daily incidence, a serial interval distribution, and the estimated R0 into a model based on the assumption that daily incidence obeys approximately Poisson distribution determined by daily infectiousness. Results: The Maximum-Likelihood (ML) value of R0 was 2.28 for COVID-19 outbreak at early stage on the ship. The median with 95% confidence interval (CI) of R0 values was 2.28 (2.06-2.52) estimated by the bootstrap resampling method. The probable number of new cases for the next ten days would gradually increase, and the estimated cumulative cases would reach 1514 (1384-1656) at the tenth day in the future. However, if R0 value was reduced by 25% and 50%, the estimated total number of cumulative cases would be reduced to 1081 (981-1177) and 758 (697-817), respectively. Conclusion: The median with 95% CI of R0 of COVID-19 was about 2.28 (2.06-2.52) during the early stage experienced on the Diamond Princess cruise ship. The future daily incidence and probable outbreak size is largely dependent on the change of R0. Unless strict infection management and control are taken, our findings indicate the potential of COVID-19 to cause greater outbreak on the ship.
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Understanding The ABCD of the future of health care.
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Importance Coronavirus disease 2019 (COVID-19) is an emerging infectious disease that was first reported in Wuhan, China, and has subsequently spread worldwide. Risk factors for the clinical outcomes of COVID-19 pneumonia have not yet been well delineated. Objective To describe the clinical characteristics and outcomes in patients with COVID-19 pneumonia who developed acute respiratory distress syndrome (ARDS) or died. Design, Setting, and Participants Retrospective cohort study of 201 patients with confirmed COVID-19 pneumonia admitted to Wuhan Jinyintan Hospital in China between December 25, 2019, and January 26, 2020. The final date of follow-up was February 13, 2020. Exposures Confirmed COVID-19 pneumonia. Main Outcomes and Measures The development of ARDS and death. Epidemiological, demographic, clinical, laboratory, management, treatment, and outcome data were also collected and analyzed. Results Of 201 patients, the median age was 51 years (interquartile range, 43-60 years), and 128 (63.7%) patients were men. Eighty-four patients (41.8%) developed ARDS, and of those 84 patients, 44 (52.4%) died. In those who developed ARDS, compared with those who did not, more patients presented with dyspnea (50 of 84 [59.5%] patients and 30 of 117 [25.6%] patients, respectively [difference, 33.9%; 95% CI, 19.7%-48.1%]) and had comorbidities such as hypertension (23 of 84 [27.4%] patients and 16 of 117 [13.7%] patients, respectively [difference, 13.7%; 95% CI, 1.3%-26.1%]) and diabetes (16 of 84 [19.0%] patients and 6 of 117 [5.1%] patients, respectively [difference, 13.9%; 95% CI, 3.6%-24.2%]). In bivariate Cox regression analysis, risk factors associated with the development of ARDS and progression from ARDS to death included older age (hazard ratio [HR], 3.26; 95% CI 2.08-5.11; and HR, 6.17; 95% CI, 3.26-11.67, respectively), neutrophilia (HR, 1.14; 95% CI, 1.09-1.19; and HR, 1.08; 95% CI, 1.01-1.17, respectively), and organ and coagulation dysfunction (eg, higher lactate dehydrogenase [HR, 1.61; 95% CI, 1.44-1.79; and HR, 1.30; 95% CI, 1.11-1.52, respectively] and D-dimer [HR, 1.03; 95% CI, 1.01-1.04; and HR, 1.02; 95% CI, 1.01-1.04, respectively]). High fever (≥39 °C) was associated with higher likelihood of ARDS development (HR, 1.77; 95% CI, 1.11-2.84) and lower likelihood of death (HR, 0.41; 95% CI, 0.21-0.82). Among patients with ARDS, treatment with methylprednisolone decreased the risk of death (HR, 0.38; 95% CI, 0.20-0.72). Conclusions and Relevance Older age was associated with greater risk of development of ARDS and death likely owing to less rigorous immune response. Although high fever was associated with the development of ARDS, it was also associated with better outcomes among patients with ARDS. Moreover, treatment with methylprednisolone may be beneficial for patients who develop ARDS.
Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial
  • P Gautret
  • J C Lagier
  • P Parola
  • V T Hoang
  • L Meddeb
  • M Maihe
Gautret P, Lagier JC, Parola P, Hoang VT, Meddeb L, Maihe M et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. March 20, 2020. https://www.sciencedirect.com/science/article/pii/S0924857920300996
Sensitivity of Chest CT for COVID-19: Comparison to RT-PCR. RSNA Radiology
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  • H Zhang
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  • P Pang
Fang Y, Zhang H, Xie J, Lin M, Ying L, Pang P et al. Sensitivity of Chest CT for COVID-19: Comparison to RT-PCR. RSNA Radiology Feb 19, 2020. https://pubs.rsna.org/doi/10.1148/radiol.2020200432