A crisis of these proportions call for a combination of basic practices, innovative measures, and radical thinking.
As India enters the phase of community transmission, the first part of this series explored efforts on protection and isolation, as well as testing strategy that could help the fight against the pandemic. This part continues the discussion focusing on the organisation of healthcare as well as administrative and pharmacological approaches.
This has already been tried in many places in China and Australia. It could be further optimised by using telemedicine and algorithms run by trained nurses which will minimise patient contact and free up doctors.
All elective operation theatres should be freed up and separate viral pneumonia/Covid19 ICUs be created to minimise risk of cross-infection. Experts in intubation and ventilation should provide training to other healthcare workers. The critical patients are highly infective and therefore a hub and spoke model should be followed to refer critical Covid19 patients to a Covid ICU Hospital.
Telemedicine should be optimised and many non-respiratory patients and those needing routine care should be managed by telemedicine so that people with other illnesses like myocardial infarction and stroke will not be exposed to Covid19.
The numbers of fever/respiratory clinics in an area should be updated daily on a central dashboard. The spike in numbers should be used to optimise testing, isolation and quarantine strategies (ranging from bi-weekly to odd-even days to regular curfews).
Short courses in sterilisation, critical care (IV line, intubation, ventilator) must be started on a mass scale. All anaesthesia and critical care personnel should be stationed at Covid19 critical care hubs in the city.
Fever clinics (like Mohalla clinics) should be uniformly distributed across districts to avoid movement (PCR can be done in these clinics). Positive Mild cases (which constitute 80 percent of cases, no hypoxemia and mild symptoms) would be sent to smaller hospital or central quarantines; moderate severity (10-15 percent of all cases, hypoxemic, amongst other symptoms) ones to district hospitals or 70-100 bed private nursing homes with Covid19 isolation wards; and patients requiring ventilators should be sent to Covid19 critical care hubs( 5-10 percent cases, which could be developed by repurposing existing government hospitals or 750-1,000 bedded bigger corporate hospitals) which would need significant ventilator back up and critical care expertise. This would keep separation of patients in response to resources and expertise. The Italian experience shows that lack of severity triage can be disastrous. Similarly, Wuhan experience shows the risks of allowing mixing of Covid19 patients with others.
i. There is limited evidence that heat and humidity may reduce the pace of spread of Covid19. All public places must have their air-conditioners shut and ways should be found to increase humidity.
ii. Daily wage labourers should be discouraged from going to their hometowns by offering them temporary basic income. They may carry infection to the villages, where medical care will be an even more difficult challenge.
iii. Syndrome Surveillance or Domestic Test percentage guided curfews should be used locally.
iv. As the number of contacts rises, central quarantines need to be enforced. Administration has to be strict as all people/contacts cannot be trusted to keep home quarantine, after several reported instances of violations. We also erred in subjecting to quarantine those travellers only from certain countries; travellers from all countries should have been quarantined strictly.
v. Quasi-lockdown in states/cities with high prevalence.
vi. Other states/cities to be protected as well by banning domestic transport from areas of high prevalence.
vii. Mini Swachhata Abhiyan: People should be exhorted to clean/disinfect their homes twice daily.
viii. In overcrowded areas/slums, fever clinics should be opened and high vigil maintained. Mass prophylaxis with drugs (Chloroquine derivatives, Protease inhibitors which have shown promise in RCTS) should be considered. Government should consider doing routine disinfection and distributing free masks to people in low-income areas.
ix. The dashboards should be made public with names anonymised so common people can avoid contact or communication with areas with high number of cases as has been done in Hong Kong.
i. Vaccine: Approaches to develop vaccine should be encouraged.
ii. Faster RCTs: Faster RCTs can be performed using Bayesian Adaptive design and daily viral load as primary outcome. The data collection should be kept minimum so that RCTs are less bloated and fast and can be conducted in busy clinical centres. Many drugs have shown promise in open label RCTs and other studies. Lopinvir-Ritonavir combination, Hydroxychloroquine, and Chloroquine are notable drugs that are orally administered. While the above principles apply to all drugs, Hydroxychloroquine Sulphate in particular is safe and well tolerated. Immediate RCT of HCQ should be started, as it a relatively cheap/safe drug. Till results are out, all health workers and contacts should take HCQS prophylaxis, which is now commonly used in the US by healthcare workers managing Covid19 on off-label basis.
iii. Price caps: All drugs (potential candidates) should be made essential and price cap invoked.
iv. Fortification: If above trials are successful, approaches to deliver drugs even using tap water must be tried. Mass Prophylaxis (Chloroquine, Hydroxychloroquine) and Fortification have been essential elements of our public health campaigns against malaria, trachoma and cholera and they must be leveraged this time around.
v. Serology-guided therapy: Convalescent Sera from people who have recovered (diagnosed on basis of serological test) in India, China, South Korea amongst others should be sought. The passive antibodies donated by recovered patients can be used for post-exposure prophylaxis as is often done in tetanus and rabies.
A crisis of these proportions call for a combination of basic practices, innovative measures, and radical thinking. The imperative is an amalgamation of old-fashioned core epidemiology, efficient use of technology, and integration of clinical best practices of other nations to optimally fight the pandemic. Along with innovative measures, basic steps like wearing masks, handwashing, household disinfection, and media-run educational campaigns are also important in the battle against Covid19.
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Anupam Singh MD is an Assistant Professor of Medicine at Santosh Medical College. He is a member of the coronavirus outbreak response committee of Ghaziabad ...Read More +