The Covid-19 challenge in India

A recent conversation with an acquaintance made me realise the degree of prevailing misinformation. He had tested positive despite two doses of vaccination, and hence concluded that the vaccine does not work. It is imperative to know that as per current data, vaccine prevents severe disease and death, though it may not prevent infection.

If educated people are not able to comprehend the need for vaccination and its benefits, how do we expect the less educated to do so? This misinformation combined with pandemic fatigue and lack of civic responsibility is a lethal combination. Oxygen supplies need to be seamless; reports of stock-outs of a basic medical gas like oxygen are heartbreaking. Industry may be roped in to see if medical grade oxygen production can be enhanced. This would include increasing the existing production as well as repurposing other industries to produce medical grade oxygen.

Government tendering processes need to be simplified and expedited. Issues around storage, transport and distribution need detailed attention. We need to ensure a continuous supply of drugs like Remdesivir and Tocilizumab. Steps must be taken to increase manufacture, stop exports and come down heavily on black marketeering.

Most important are national protocols around usage. Guidelines posted on the website are out of date (AIIMS Covid website, dated March 17, 2020 and at the Union health ministry website dated July 3, 2020). We are seeing irrational use of these drugs even in the hospital set up. National guidelines will help streamline use by medical professionals. The PPE supplies need to be monitored closely.

Intensive care beds are at full use now, though ward beds can be buffered by repurposing areas like hotels, but intensive care beds will be critical. If it comes to the crunch, hospitals may need to suspend elective work till the situation settles. Use of telemedicine and digital healthcare for eligible patients will ease the burden on stretched resources. Further, in the unfortunate event of shortage of doctors and nurses, we will need medical and para-medical students for supporting the medical teams.

The use of rapid antigen as a quick screening mechanism must be increased. It can be used to quickly identify and isolate positive patients while RT-PCR may take longer. Due to the lower sensitivity of the antigen tests, an RT-PCR may still be necessary for those testing negative with the antigen test. This will reduce RT-PCR need, and the time lag in instituting treatment and isolation measures can be reduced.

Given the rapid transmission of the variant, transmission within the same household is not only inevitable, but also guaranteed. It is worth remembering that transmission usually happens before onset of symptoms, and on the first day. By the time the patient comes for testing on day 3 or 4, transmission has already happened.

Therefore, data on domestic contacts should be captured at the time of testing; in the event of a positive result, all members of the family should be placed in isolation/quarantine, but they can continue to live together. This is what South Korea did: supplies were given to these families to prevent them from coming out. Contact tracing is not going to be practical in this surge.

The government’s sudden announcement closing vaccination for healthcare workers was knee-jerk and missed those who did not have the opportunity to get vaccinated as they were pregnant, lactating, unwell, or had not yet joined the healthcare force (new entrants).

Knee-jerk responses combined with vaccine hesitancy is complicating the vaccine rollout. The correct messaging through vernacular dailies, community leaders, social media etc, will help. We also need to ensure minimal wastage of the vaccine; so far, we have seen 6.5% vaccines going waste which accounts for about two million doses.

Vaccine options

The decision to increase the basket of vaccine options is key to increasing vaccine supplies and availability, but we also need to utilise our existing manufacturing capabilities for increasing production.

The recent announcement to expand vaccine coverage to all above 18 is welcome, as this mirrors the demographic group being affected more in this wave. However, given that about 40% of India’s population is below this age group and ineligible for the vaccine, this intervention, though an important one, alone will be inadequate to fully control the transmission of the virus.

It will be useful to have health insurance companies work round the clock instead of the current practice of working with minimal manpower over the weekends and at night. This will help ensure faster discharge insurance patients from hospital so that the beds are freed up faster for patients who desperately need them. Discouraging mass gatherings, encouraging, and even enforcing Covid-appropriate behaviour and coming together as a country is the need of the hour.

The most extreme form of containment is a lockdown, and this should be used with extreme caution. The use of a calibrated response like containment zones can bend the curve without need for a lockdown and can postpone the need for the same.

In our fight against this virus, let us refrain from taking out our anger on the hapless frontline workers who are exhausted, at high risk and face mental health issues seeing death and disease around them at such scale.

We need a national Covid action plan; health maybe a state subject, but the virus does not understand state boundaries. And to my acquaintance, I would like to say that making armchair assessments by crude simplification of a complex problem is often wrong, and the reason why the study and practise of medicine needs years of hard work, perseverance, and an ability to change based on ever-evolving data.

(Dr Arora is Vice President-Asia, DayToDay Health; Dr Swaminathan is Director, Infectious Diseases and Infection Control, Gleneagles Global group)