India in the grip of deadly Covid 19
Dr Asha Shah.M.D (Medicine)
Professor of medicine, GCS Medical college, Ahmedabad
India is going through its worst possible nightmare in this COVID-19 pandemic. We saw the same situation in Europe in the beginning of the pandemic few months back. But that time cases in India were far less compared to its population and also compared to the other countries and every one tried to justify and analyze the reasons for that. We all postulated various theories which included role of BCG vaccination in India, repeated infections in childhood and adolescents conferring the population with some form of inmate immunity, genetic susceptibility and what not .We also gave credit to early lock down and good administrative steps but all the time the hidden volcano was trying to explode and prove everyone wrong and ultimately it did in end of March this year and everyone was caught unaware.
People had totally become complacent. ”corona to gayo,” they kept on saying and started behaving like that. Once I went to a shop wearing my mask and head shield and the shopkeeper who knows me was surprised and asked me why I am still wearing all this when corona is over. He said we have all stopped wearing masks. Most of the people behaved that way. They all lived in fool’s paradise. There were long lines in restaurants and people flocked to eat out sitting in close environment and not maintaining social distance as if corona didn’t exist anymore.
The deadly new wave
The cases started surging since the late march and they soared. They are still going up daily .Yesterday more than 250000 in a single day and in Gujarat around 12000 /day. It is the worst wave ever. It was explosion of cases. As it happened so fast and in such a large number that no state is able to cope. Health system crashed. There were queues for RT-PCR tests, delay in reports, delay of emergency services for Covid patients, lack of medicines, lack of oxygen and the list goes on. This time younger patients and children are also commonly affected.30–35 year patients without any comorbidity also develop breathing difficulty and adverse outcome. Mortality in less in children and that is a consolation.
Scenario in real life
For the first time in my life as a physician for more than 35 years, I feel so frustrated and sad, and it is same with all the doctors. We are not able to help any patient get a bed in hospital when they request us to help or help them getting Remdesivir or Toscillizumab(the injections used to treat covid) or oxygen concentrator. We feel helpless. The disease has now spread to rural areas also, In smaller town places the facility of testing is limited, the reports are not received for 2–3 days which is important to start the treatment. CT scan machines are not available in many of smaller towns. In some towns the rush is so much that if the whole family is affected which is the scenario, they would give appointment to only one person in the family in a day. What kind of pathetic scene is this?. If the four members in family are affected, they will have to run all the days for the scan. Even after positive diagnosis of COVID-19 pneumonia, the beds are not available, if the saturation drops, oxygen is not available .I know a close friend’s 79 year old father who did not get a bed in spite of need of ICU admission in a town place. The son himself also positive ran around pillar to post for 3 days for getting his father admitted while the father was suffering due to severe pneumonia and they could barely get oxygen cylinder and the patient passed away without treatment. How sad the situation can be? Yes we know mortality is high in elderly patients but he at least deserved a chance .The son could not help him though he tried his best. Granddaughters aged 13 and 9 witnessed the whole sequence in their one bedroom house. I tried to somehow get him admitted but could not. It is unimaginable and I am sure this is not the isolated case. With limited medical facility, many people will not get the right and timely treatment and there will be lot of suffering. Not only that, people still face great difficulty in crematorium where there are so many bodies .A person cannot get proper treatment and even the final journey is not dignified. What a pity! I know the same situation was present in 1918 Spanish flu pandemic but surely 100 years would have made a difference!
It is a very depressing situation. So who is to blame? Is it the time to play blame game? But one needs to know the truth.
What went wrong?
There were large public gatherings which should not have happened in the situation of pandemic. We cannot justify them in any way. Religious gathering ,where 35 lakh people gathered, election rally’s were thousands gathered, cricket match with 50000 spectators, festivals were celebrated where also many persons got together. All these people did not follow any COVID-19 protocol. No social distancing, no masks, no nothing, how can these situation justified? It would produce ripple effect as R0 of this mutated strain is more than the previous strain.4 students who went to see the match infected the entire institute. The people gathered in all these religious or political gathering will go back to their place carrying the virus which will affect multiple persons who again will spread it. Where is the end to it?
People also became careless. Get-together, parties, eating at restaurants, shopping, everything happened without a care for corona. I know a wedding from which almost around 100 people got affected.
Double mutant or triple mutant virus
The virus mutated as they always do. The new variant, called B.1.617, was initially detected in India with two mutations — the E484Q and L452R. It was first reported late last year. The Indian SARS-CoV-2 Consortium on Genomics (INSACOG), a group of 10 national laboratories under India’s health ministry, carried out genomic sequencing on the latest samples. Genomic sequencing is a testing process to map the entire genetic code of an organism — in this case, the virus. The government said that an analysis of the samples collected from India’s western Maharashtra state showed “an increase in the fraction of samples with the E484Q and L452R mutations” compared with December last year. As per statement of health ministry, such double mutations confer immune escape and increased infectivity. Mutations in the spike gene can make the virus inherently “better” at infecting people or can help the virus to escape neutralising antibodies.
This means if the virus mutates in the “right way”, it can reinfect someone who has already recovered from Covid-19.
But scientists say reinfections will be very mild compared to primary infections in people who are vaccinated or who recovered already from an earlier case of Covid-19.
But if the virus can use reinfection to spread, then it would be “penetrating” herd immunity
Though this new double mutant virus is VOCs [variants of concern], as per the health ministry, these have not been detected in numbers sufficient to either establish a direct relationship or explain the rapid increase in cases in some states. We need larger number of samples to come to a conclusion but the way this wave is behaving, it is probably this double mutant virus.
Third mutation in the B.1.167 has been identified now and experts have called for a faster genome sequencing, to understand the mutant. A triple mutant strain could be the next challenge for India and to beat it before it wreaks havoc, as much information on it is the need of the hour. Simply put, a triple mutant refers to variants which have three different strains that have combined together to form a new variant and it seems more in west Bengal. This triple mutation is outside the spike protein and may require modification of vaccine.
What is happening to pandemic in India?
Worst of all, this mutated virus became easily transmissible. Case numbers are increasing fast, deaths are increasing and chaos is increasing, suffering is increasing and so are grief, frustration, anger, helplessness and sadness. People keep on asking and wondering when all these will end. The answer to that is not there. Nobody can say with confidence. The virus has proved all of us wrong. No epidemiologist, astrologer or administrator or doctors can predict it.
This disease is going to stay. The transmission will lessen when sufficient number of population will have immunity, either through infection or through vaccination. It will take probably longer time due to sheer number of people in our country. We have still covered only 6–7% of population. The end of pandemic will be declared by WHO only and that is still a long way, probably not in 2021 as the situation is equally bad in many countries across the world and we have to be prepared for a long course. Even when pandemic will be over, there are chances that it will become endemic, meaning low level of infection will persist in community with intermittent or seasonal exacerbation like flu
What now?
Please stop all gathering whatever it may be, political, social or religious. That is the most important step. If needed, lock down may be the good step. After all, lives are more important than livelihood.
SMS- social distancing, mask and sanitization
Vaccination drive- just now I saw in news that it will be available to all above 18 years of age. Every one eligible should take vaccines. We have seen in this wave that those who had completed two doses of vaccines and two weeks have passed, they were found to be safe. Of course not from acquiring disease and having mild symptoms but it did prevent severe disease and hospitalization or death. Nobody is safe as far as this disease is concerned. There is lot of misconceptions in people regarding the vaccines in the people. Some people who have taken one dose and have developed this disease may blame it on vaccine. One dose does not protect, it does not cause disease but it will not prevent disease if a person is not taking precaution or if he is already in incubation period of disease when he took the first dose.
If you are feeling sick, have only symptoms of common cold, fatigue or low grade fever or diarrhea, you still should consider COVID-19 first .Many persons when having above mentioned symptoms and test is suggested ,they will be reluctant. Many will say it looks like cold or “shardi” but that is the symptoms of COVID-19.Any febrile illness or cold like symptoms, Covid has to be ruled out.
Improve health infrastructure
There are not enough hospitals in the country. As it is the number of doctors per population is very less in India and more so in rural areas, just now the enormous patient load is simply impossible to handle. Health system is overstretched .There is a system failure. There is urgent need for more hospital beds, medicines, oxygen etc. There is need to build makeshift hospital or take over hotels which are otherwise also not having much business and temporarily convert them to hospitals .but then also the problem is of medical and paramedical staff. Where do you get the extra personnel? We can train Ayurvedic or homeopathic doctors and they can work under medical doctor’s supervision .Unemployed willing persons can be hired as volunteers. Already the help of dental students and physiotherapy students is being taken. I do know that government is trying hard as I was in the system for 35 years and was key person during swine flu pandemic but the cases have exploded and it is beyond anyone or the whole system to cope. There is no option however to gear up and try to match the onslaught of the virus. There should be large scale studies to know the mutation of virus and preparedness to modify vaccines quickly if need arises. We could do with more number of doses of existing brands or can have more brands of vaccines so that it is freely available for public.
Conclusion
There is a lot of uncertainty regarding the future .We don’t know when and how this latest wave will end or how many waves of this Covid tsunami will hit. We don’t know how many mutations will take place of the virus or how it will affect the pandemic. We don’t know how long will the effect of vaccine last or if it will become ineffective with mutated virus. What we do know is that there is a lot of research going on for newer and more effective medicines and universal flu vaccine. We do know that all previous pandemics ended and so will this. I think that is a good thought to hang on. This too shall pass.
References
https//www.bbc.com
indian express-via inshorts
