When Mukhtar Ahmed, a 106-year-old man from the Nawabganj area of Delhi, recovered from COVID-19, hope coursed through the entire neighbourhood. The same people who not so long ago would lay out every currency note in the sun to rid it of any possible virus lurking around and sanitise even their newspapers could now be seen walking around without masks while shopping for groceries. If Ahmed at his age could survive corona, surely they would too.
Yet, it is exactly this kind of complacency or ‘optimism bias’ that doctors and analysts warn against as the disease continues to rage across the world. On June 6, India became the fifth worst-affected country in the world, its tally of 245,670 cases on that day overtaking that of Spain. “We should still be scared,” warns Dr Balram Bhargava, director-general of the Indian Council of Medical Research (ICMR), as India emerges from a prolonged lockdown. “We cannot return to a post-Covid world overnight.” (See interview: ‘The main thing now is to save lives’.)
Even though community transmission has not been announced officially in India, it is clear that we are past the point of eradicating the virus let alone containing the contagion. With 276,583 cases as on June 10, around five of every 100 individuals tested in India are currently reporting positive for the virus, a rate that is less than the 9.4 per cent of the United States but more than double the 2.3 per cent of South Korea.
However, as on June 10, our recovery rate of 48.8 per cent and the case fatality ratio (CFR) of 2.8 per cent compares favourably with the global CFR of 5.7 per cent, 5.6 per cent of the United States or 5.2 per cent of Brazil. Even the reproduction number (R0), or the average number of new infections an infectious person can generate in a totally naïve population, has come down from 2.0 on May 6 to 1.2 on June 6. This could well be a result of the 70-day lockdown India was under. But the lower reproduction number could also be due to the fact that a majority of the Covid cases in India are asymptomatic. Seventy-five per cent of Delhi’s 30,000-odd cases showed no symptoms while in Maharashtra, 83 per cent of cases were asymptomatic. And asymptomatic carriers of the virus are believed to be less infectious. As World Health Organization epidemiologist Maria Van Kerkhove said at a press briefing in Geneva on June 9, asymptomatic spread of Covid is ‘very rare’. In a clarification the next day, she added that it did not mean cases of asymptomatic individuals spreading the disease could be ruled out entirely, and that a modelling study had estimated their chances of spreading the infection between six and 44 per cent. A study from China published in the April 15 issue of the journal Nature Medicine estimated this to be 44 per cent.
Source: ICMR , MoHFW, Covid Tracking Project, Delhi and Maharashtra state departments
A majority of asymptomatic carriers are the young, who have no co-morbid conditions. Dr Richa Narang, a doctor in the ICU ward of the LNJP Hospital in Delhi, recounts: “I remember in April, when we got these patients, they wouldn’t believe they were sick because they didn’t even have a cough.”
Yet, the number of infections is also the highest in this demographic. Younger members who spent the most time outdoors were the first to have contracted the disease, as several examples of families getting infected show. “Those going to work or shop are largely the young, so we see a greater share of them infected,” says Dr Om Shrivastava, head of infectious diseases at the Jaslok Hospital in Mumbai.
It is also becoming increasingly clear that people over the age of 60 and with comorbidities have the highest risk of developing severe symptoms and succumbing to the disease. In Delhi, for example, the fatality rate of those over 60 is 4.8 per cent while for those below 50, it is just 0.3 per cent (see graphic: The slow march of a pandemic). In Maharashtra, the state worst hit by the pandemic, 85 per cent of the cases are in the below-60 age group but 47 per cent of the fatalities have been in the 60-plus demographic. “Three months ago, there were only a handful of elderly patients; now [their numbers are] increasing. Such cases are more severe due to poor immune responses, and take longer to test negative,” says Dr B.L. Sherwal, director of the Rajiv Gandhi SS Hospital in Delhi, which treated 106-year-old Ahmed.
Comorbidity, doctors now confirm with certainty, is a major contributor in fatalities. In Delhi and Maharashtra, 86.8 per cent and 69 per cent of Covid deaths, respectively, were on account of underlying conditions. In Delhi, 80 per cent of the under-50 and 93 per cent of the over-60 Covid deaths had comorbidities. The Maharashtra figures show that 32 per cent of those who died had both diabetes and hypertension. “We are finding that those who have not taken care of their diabetes are unable to fight off the infection. Uncontrolled blood sugar limits immune responses and not just in the case of coronavirus,” says Dr Ambrish Mithal, head of the diabetes division at Max Healthcare, Saket.
“We are still getting a very large number of asymptomatic cases,” says Dr Sudhir Bhandari, director of SMS Hospital in Jaipur, “which is less concerning. It is those with breathlessness or chronic cough that need more monitoring because they can suddenly take a turn for the worse. Why or when this happens still needs answering.”
Eventually, though, it is only 4-5 per cent of the infected who go on to require critical care. In Delhi, only 3 per cent needed critical care, of which 2.3 per cent needed oxygen care and 0.3 per cent required ventilator support. In Maharashtra, on the other hand, 4 per cent of the infected cases ended up needing critical care.
Taking note of this, the Union ministry of health has advised home isolation for those deemed to be low risk based on their age and the symptoms as determined by a doctor. This can take nearly 70 per cent load off the hospitals. In a city like Delhi, which crossed 30,000 cases on June 8, this means around 21,000 can manage symptoms at home with paracetamol, rest, increased fluid intake and oxygen monitoring. The medical system can then focus on those with moderate to severe symptoms.
This has become crucial as India’s limited health infrastructure is beginning to creak under the weight of the rising number of cases. On May 27, only eight Covid beds were available in the national capital across seven private hospitals. “We were begging for a hospital bed, pleading with doctors. My uncle (aged 63) died of hypoxia in front of us, not one single hospital in the city gave us a bed when his health started to fail. They had 48 hours to save him, but there was no bed,” recounts Apurva Singh, 37, a resident of Delhi. It’s an ordeal many others recount. Even as Delhi chief minister Arvind Kejriwal went into quarantine, his plea to reserve beds in Delhi for the locals was overturned by the lieutenant governor, Anil Baijal.
“The anxiety,” says Malini Aisola, co-convenor of the All India Drug Action Network, “has shifted from the disease [itself] to its management. Now that there are over 200,000 cases, were I to get Covid, what am I to do? Will I get a bed? Will I be able to afford treatment?” Dr Mona Desai, president of the Ahmedabad Medical Association, sees the same public reactions. “The bottlenecks start to emerge with the first step itself—diagnosis. There is a backlog in results and the testing criteria still exclude asymptomatics with no contact history. How does one prove they have met a positive case? People aren’t scared of just Covid [any more], they are worried about their test results, if they will get a hospital bed, if they will get plasma.”
Meanwhile, as doctors recognise critical patterns in the disease, they have begun standardising the protocol for treatment. From focusing on antivirals and anti-HIV medication, as was the case in April, blood thinners are now being given to prevent blood clots, oxygen levels and critical organs are being monitored. “The most common treatment remains antibiotics, paracetamol and flu medication. But monitoring is more stringent—we now monitor markers such as high levels of Interluken or D-Dimer, which indicate inflammation or a cytokine storm. The disease is still erratic and differs from person to person. One positive development is that doctors and nurses are more comfortable with working in the Covid ward. Earlier, there was apprehension, even fear; now, they have adjusted to the new normal in health services,” says Dr Sherwal.
With most Covid drug trials yet to prove the efficacy of various repurposed molecules, treatment in India is still being decided based on symptoms. Antiviral drug Remdesivir has shown some promise, with a five-day course approved for use in ‘severe’ cases on June 2. Gilead, the company that holds the patent for the drug in India and abroad, announced the results from its Phase 3 SIMPLE (Shockless IMPLant Evaluation) trial on June 1. It showed that hospitalised Covid-19 patients on Remdesivir were 65 per cent more likely to see clinical improvement by the 11th day as opposed to those who were not on the drug. However, the drug holds certain risks for those with renal and hepatic impairment; these will be better understood once the results of additional clinical trials are released (expected within nine months).
Some hospitals, such as ESI Gurgaon and the Kottayam Medical College in Kerala, have reported that patients often request non-allopathic medication as well. “Haldi doodh (turmeric milk) is a common request, especially among older patients,” says Dr Renjin R.P., medical superintendent of the Kottayam Medical College. So far, four Ayurvedic herbs have been listed for clinical trials with the AYUSH ministry, while on the allopathic front, major trials are being carried out for Favipiravir (a Japanese flu drug), Itolizumab (shown to have lower mortality in Cuba) and, most recently, for the Bangladesh ‘wonder drug’ Ivermectin and Doxycycline. Favipiravir trials by Glenmark are the first to have reached Stage 3 trials in India.
In the meantime, we can learn from the experiences of the Covid survivors, like those profiled in the following pages. What was their experience and what did they wish they had done differently? Some, like Patna path lab owner Sanjay Kumar Bhunia, found it difficult to handle the stigma. Others learned valuable life lessons which they want to offer as useful advice to others. Prepare better, say the Bhatis in Ghaziabad. “We just didn’t believe we would get infected ourselves. We took precautions, but didn’t prepare the home for it,” says Naresh Bhati. “So when we left, we had to leave our children behind alone. That added a lot of avoidable stress.” Get prompt diagnosis, advocates Dr Sumedh Kesaria of Mumbai. “Covid symptoms overlap with those of the common cold. If you come in contact with a positive case, or your symptoms don’t go away in three days, get a test,” he advises. Keep your mental spirits up, says Haryana banker Ashok Takkar. “The virus plays with your mind as much as with your body. Bimari hai, go quickly to a doctor and follow his advice,” he proffers. So the next time you pass by a front gate that has been pasted with a red sign saying ‘Quarantined Premises’, be cautious but do not be afraid.