Five suggestions for flattening India’s Covid-19 second wave by a Mumbai doctor

The second wave of Covid has hit India more like a tsunami, with a deadly toll. Much has been written on what is going wrong. Here are some ways we make the best of the crisis we are facing.

1. The lethality of the new strain needs to be conveyed: Covid-inappropriate behavior was widely persistent across the country until February, when the numbers of cases were low. The Bihar elections, the winter wedding season, the farmers’ protests and other potential superspreader events did not cause much of an upstroke in Covid cases.

The main difference between then and now is the presence of more infectious variant strains, which when coupled with the complacent public behavior triggered this massive wave. This also explains why Maharashtra has been worst hit, as the B.1.617 double mutant strain probably originated in Maharashtra.

The UK experience had already showed us how more infectious strains may initially appear equally or less lethal, but eventually end up killing more people as the health system gets stretched. Yet we committed the same mistake, repeatedly mentioning on all news outlets that the newer variants are less lethal.

This made the public and the authorities remain complacent at a time when pulling up our socks and carrying out the vaccination campaign more urgently could have helped. It is now clear the new strains are causing more deaths than the previous one, and this must be categorically acknowledged many times over to undo the damage and start making people take the strain seriously.

2. It is all about masking up: The scientific community has learnt a lot about Covid-19 transmission the past year, but unfortunately our preventive strategies haven’t evolved based on the new information. For example, it is now clear that:

a. Fomites or surface transmission are not major modes of Covid transmission. Both the World Health Organisation and the Centre for Disease Control in the US categorically say so. In fact, the Centre for Disease Control recently stated that less than 1 in 10,000 cases occur due to fomites. And yet, we see deep cleaning and surface sanitisation across the board.

b. Aerosol transmission is much more common than droplet transmission, which means that masking and improved ventilation are key to containing spread.

c. RT-PCR screening for intra-country travel misses many cases and only lulls travelers into a false sense of security. Remember, RT-PCR will only catch seven of ten cases anyway. Yet, we have mandatory RT-PCR testing within 72 hours of air or road travel across states, overburdening our already stressed testing infrastructure, with genuine patients now getting their reports three or four days later and home testing stopped in most places.

d. Temperature checks don’t seem to ever catch anyone with fever, but thermal guns remain the most visible strategy anywhere from airports to offices and housing societies.

Such mixed messaging makes people feel safe in having a wedding of 200 people after rapid antigen tests on the attendees, deep cleaning of the hall, and hand sanitisers scattered across the venue. The guests spend hours together chatting and eating with the masks down; they feel they have done three out of the four things possible to be safe!

Indians are now anyway used to hand washing and cough etiquette. It is time to move towards singularly focused undiluted preventive message: mandatory proper masking is pretty much the only thing for preventing Covid, with the importance of good ventilation as an small add-on. Everything else should be significantly toned down. All narratives and promotional strategies need to be built around masking and masking alone.

3. Vaccination: Assuming that public behaviour still doesn’t change to the extent it should, there remains the Rambaan or Ram’s arrow – vaccination. Data from other countries (though with different vaccines) clearly shows that rapid vaccination drives have helped them flatten the curve.

Many people feel that vaccination can only help avoid or minimise the effects of the third wave. This again is faulty and incorrect messaging, and has led to vaccinations drop by 16% last week in India. The mistake we make is in assuming that the present wave is going to get over in a month or two. It will probably last longer.

Besides, a single dose of vaccine also provides decent protection, which is why it is all the more important to vaccinate as many people as we can right now. The UK has used this very strategy to control its Covid wave. Finally, most importantly, vaccines are highly effective in preventing hospitalisation and death, which is essentially the main goal for everyone.

India clearly needs its own version of Operation Warp Speed, that is. promoting public-private partnerships and funding to accelerate the production and distribution of vaccines. Some belated steps have already been taken in that direction with respect to financial support for Bharat Biotech and the Serum Institute of India and certain public sector units for vaccine production.

But we need to be faster and aim higher. For example, the Serum Institute of India’s Novavax production needs to be hastened (Novavax has higher efficacy than Covishield and Covaxin) by waiving the completely unnecessary demand for a bridging trial and helping procure the relevant raw material, which is currently not easily available from the US due to a temporary export ban. The Johnson and Johnson vaccine approval and production needs to be fast-tracked as well, perhaps in clinical trial mode.

We need to perform serosurveillance tests that show how many people have been infected in an area and figure out targeted vaccination strategies accordingly to make the most of the limited supplies we have right now.

4. Dissemination of clear guidelines on managing Covid-19 at home: More than 80% of Covid patients can be safely managed at home under medical guidance. Identifying those who need hospital admission is not very difficult either, as the patients simply need to monitor their oxygen saturation at rest and after the six-minute walk test, and get admitted to hospital if it falls below 94%-95%. We don’t need a cocktail of drugs or expensive lab tests or CT scans.

And yet, we see patient after patient reaching the hospital at an advanced stage, with saturation being below 80%-90%, perhaps not properly instructed due to shortage of doctors.

To make matters worse, patients are on an unprecedented cocktail of unnecessary medications like Ivermectin, Azithromycin, Doxycycline, Fabiflu, and Coronil. None of these drugs are recommended for treatment anywhere across the world.

At this stage, it is important to give patients the right information and instructions. We need to have a set of patient-directed easily understood evidence-based national guidelines available on the health ministry website, along with a more detailed set of guidelines for the medical community.

The ideal way to disseminate these would be a national address by Prime Minister Narendra Modi where he introduces a doctor of repute like the All India Institute for Medical Sciences Director Dr Randeep Guleria (he is no less than Dr Anthony Fauci, the director of the U.S. National Institute of Allergy and Infectious Diseases) who then explains these basics of home management of Covid-19 to viewers. This single step will probably save more lives than anything else.

5. Strict criteria for hospital admission and discharge: Unnecessary admissions due to high-profile patients or mild lung involvement caught on a CT scan, some abnormal lab tests or the fear that beds won’t be available later are rampant. Unfortunately, these take the bed away for those with low oxygen saturation who really need the bed. Many hospitals in Mumbai currently have a waitlist of over 100, partly due to such reasons.

This leads to a vicious cycle, where those with low saturation levels deteriorate in the two or three days it takes for them to get admission. It then become difficult to save them once admitted, and someone else who would more likely be saved if admitted right away gets added to the waitlist.

Unfortunately, our current hospital system essentially allows doctors to admit any patient if so requested, without an effective oversight on whether the admission is really needed. This needs to change in these war times. Only those patients who follow strict admission criteria should be given beds by an overseeing hospital team.

Similarly, doctors may sometimes end up discharging the patient a day or two later than they potentially can, so as to be extra sure that everything is fine. Discharging a patient as soon as we safely can must be prioritised by all in these times. Both doctors and patients must realise that holding an unnecessary bed for an additional day is equivalent to killing another patient who could have been otherwise saved.

The second wave is here to stay for more than a few weeks. It is imperative that we build on to what we previously did right and rectify our past mistakes so as to flatten the curve as soon as possible.

Dr Akshay Baheti is an associate professor in radiology at a hospital in Mumbai. Views are personal.