THEEXPERTSERI

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COVI
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CALEXPERTSON DEALI
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THECORONAVIRUSPANDEMIC
The Expert Series
on COVID-19
A compilation of articles written by medical experts on dealing with the
pandemic

Edited by: Mandira Moddie

Research: Meenakshi Radhakrishnan

Cover Design: Sivanandha G

Cover Photo: Getty images/ iStock photo

© The Hindu Group of Publications 2020

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Contents
INTRODUCTION ..................................................................................................................... 4
MEDICAL MANAGEMENT....................................................................................................... 5
A look into key aspects of virus pandemic....................................................................................... 6
Dr. Sudha Seshayyan
Dr. G. Srinivas
Scripting a new narrative for COVID control ................................................................................... 8
M.S. Seshadri
T. Jacob John
It’s OK to be smart ....................................................................................................................... 12
Dr. V. Ramasubramanian
Fighting a virus with dedicated health cadre ................................................................................. 16
Dr. P. Kuganantham
Dr. Hamsadvani Anand
A prescription of equitable and effective care .............................................................................. 18
Anand Zachariah
George Thomas
The tests reveal all ....................................................................................................................... 20
Dr. Rajaram Anantharaman
What is convalescent plasma therapy? ......................................................................................... 22
Dr. Joy Varghese
The role of palliative care ............................................................................................................. 24
Dr. Mallika Tiruvadanan
Palliative care is the answer ......................................................................................................... 26
Dr. Republica Sridhar

MANAGING YOUR OWN HEALTH ......................................................................................... 27

In search of Vitamin D .................................................................................................................. 28
Dr. V. Mohan
Aches and pains and a spot of exercise ......................................................................................... 30
Dr. Madhu Thottapillil
Boosting immunity is the need of the hour ................................................................................... 31
Dr. Bhuvaneswari Shankar
Why everyone should wear masks ............................................................................................... 35
T. Jacob John
Masks are mandatory for all now ................................................................................................. 37
Dr. D. J. Christopher
Dr. Prathap Tharyan
Will Vitamin C be of any help? ...................................................................................................... 42
Dr. Rajan Ravichandran
Insomnia going viral ..................................................................................................................... 44
N. Ramakrishnan
Non-COVID-19 emergencies in pandemic times............................................................................ 46
Dr. Aslesha Sheth
Do not ignore non-COVID-19 medical emergencies ...................................................................... 48

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Dr. Aravindan Selvaraj

Postponing elective surgeries can save lives ................................................................................. 50
Dr. S.M. Chandramohan

THE BODY AND COVID-19 .................................................................................................... 53

It’s important to protect skin........................................................................................................ 54
Dr. D. Dinesh Kumar
Dr. Ishwarya R.
Breathing hard ............................................................................................................................. 56
Dr. R. Narasimhan
Does SARS-CoV-2 affect the liver? ................................................................................................ 58
Dr. Harikumar R. Nair
What does COVID-19 mean for kidneys? ...................................................................................... 60
Dr. Rajan Ravichandran
COVID-19’s gut connection .......................................................................................................... 62
Dr. T.S. Chandrasekar
Dr. K. Raja Yogesh
Don’t ignore abdominal symptoms............................................................................................... 63
Dr. Deepak Subramanian
Does COVID-19 have a link with the eyes? .................................................................................... 65
Mohan Rajan
Are diabetics more prone to COVID-19? ....................................................................................... 67
Dr. V. Mohan
Some tips to avoid diabetic amputations during lockdown ........................................................... 69
Dr. Vijay Viswanathan
Can DPP-4 inhibitors play a role? .................................................................................................. 71
Prof. Vijayam Balaji
COVID-19 and the nervous system ............................................................................................... 73
Prof. K. Ganapathy
Judiciously managing brain tumour patients ................................................................................. 75
Dr. Rakesh Jalali
Stroke is an exception, rush to hospital ........................................................................................ 77
Dr. K. Sridhar

MENTAL HEALTH AND COVID-19 ......................................................................................... 79

Because the mind matters ........................................................................................................... 80
Dr. Lakshmi Vijayakumar
Dr. R. Thara
Be alert, not anxious .................................................................................................................... 82
Dr. Suresh Rao K.G.
‘How I fought COVID-19 and won!’ ............................................................................................... 84
Dr. Arulvel Kathiravan

PREGNANCY, CHILDBIRTH AND CHILDREN ........................................................................... 86

Managing pregnancy and childbirth ............................................................................................. 87
Dr. A. Jaishree Gajaraj

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COVID-19 in neonates and infants ................................................................................................ 90

Dr. Rahul Yadav
Will COVID-19 be polite with children? ......................................................................................... 92
Dr. S.Balasubramanian
Sensitising parents of children with special needs......................................................................... 94
Dr. B. Balaji

SOCIETY ............................................................................................................................... 96
Needed, a transfusion for public health care ................................................................................ 97
Raj B. Singh
We need social physicians .......................................................................................................... 100
Soham D. Bhaduri
India’s disease surveillance system needs a reboot ..................................................................... 102
Maya John
Private sector and patient safety ................................................................................................ 105
Dr. S. Asokan
COVID-19 enhances reliance on telemedicine ............................................................................ 107
K. Ganapathy
The virus versus women ............................................................................................................. 109
Dr. Usha Sriram
Retaining the humanitarian approach in times of COVID-19........................................................ 111
Dr. V. Shanta

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INTRODUCTION
The world, outside of China, woke up to the seriousness of the novel coronavirus outbreak in March
this year. The World Health Organisation declared it a pandemic on March 11, and Prime Minister
Narendra Modi imposed a lockdown, the first of many, from March 25.

In the subsequent weeks and months, the spread of the virus has been dramatic. So, even as the
lockdown has been eased in many parts of the country, at the time of writing this, India has well over
150,000 active cases. And the country has seen over 9,000 deaths due to COVID-19. The numbers are
increasing rapidly.

Over the past few months, The Hindu’s exhaustive coverage of the pandemic has included articles
written by medical experts who have addressed a host of concerns regarding physical and mental
health as well as medical management of the disease and the impact on society. The overarching
theme of all these articles is simply how to protect oneself against the virus.

We have compiled all these articles into an e-book, which you are currently reading. You can read
these articles under the following themes: medical management of the disease, managing one’s own
health, the impact of the virus on the body, mental health, pregnancy, childbirth and children, and the
impact of the virus on society.

We hope you will find this compilation a useful guide.

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MEDICAL MANAGEMENT

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A look into key aspects of virus pandemic

There are a lot of scientific terms being bandied about during the
COVID-19 pandemic. Here’s a short primer on the key aspects
everyone should be aware of.

What is ‘social distancing’?

‘Social distancing’ refers to a way of creating a barrier of physical
distance between two or more people so that transmission of
infectious agent can be prevented or halted. It may also be
Dr. Sudha Seshayyan termed as physical distancing. It is a traditional public health
measure of separating people to curb the outbreak of infectious
disease, aimed to prevent person-to-person spread of disease to
interrupt transmission and checking community transmission.

When does the need for social distancing occur?

Infectious diseases such as COVID-19, transmitted by respiratory
droplets require a certain proximity of people. Social distancing
reduces transmission, mitigates COVID-19 outbreak, particularly
useful in settings where community transmission is believed to
have occurred, but where the linkages between cases is unclear,
and where restrictions placed only on persons known to have
been exposed is considered insufficient to prevent further
transmission.
Dr. G. Srinivas

Dr. Sudha Seshayyan is the What is ‘isolation’?

Vice-Chancellor, Tamil Nadu Dr. ‘Isolation’ is the separation of ill persons with contagious
MGR Medical University, and diseases from non-infected persons to protect non-infected
Dr. G. Srinivas is the persons. This usually occurs in hospital settings. It is particularly
Epidemiology department effective in interrupting transmission if early detection is possible
head, Tamil Nadu Dr. MGR before overt viral shedding.
Medical University
What is ‘quarantine’?
Quarantine demands movement restriction of persons who are
presumed to have been exposed to a contagious disease but are
not ill, either because they did not become infected or because
they are still in the incubation period.

Quarantine may be applied at the individual or group level and

usually involves restriction to the home or a designated facility.
During quarantine, all individuals should be monitored for the
occurrence of any symptoms. Quarantining is most successful in
settings where detection of cases is prompt, contacts can be
listed and traced within a short time frame with prompt issuance
of quarantine. It is one of the oldest, most effective tools of
controlling outbreaks & was implemented successfully as an
effective measure during the SARS epidemic in 2003.

Is there evidence that physical distancing has been effective to

control infectious disease?

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Since the flu pandemic in September 1918, studies have showed

the importance of distancing measures. Social distancing was the
key in reversing the outbreak in Wuhan and the wider Hubei
region. The earlier a lockdown is put in place in the epicentre of
an outbreak, the smaller it ends up being.

Are ‘isolation & quarantine’ not a form of social

distancing?
While isolation and quarantine are forms of social distancing,
there is an important distinction to be made.

Isolation and quarantine are aimed at preventing people who are

infected or are known to have had contact with people who are
infected from passing on the virus.

Social distancing is a wider measure aimed at stopping the kind

of mixing of people that allows infections to spread through a
population. They range from ending mass gatherings, closing
public spaces like educational establishments (schools,
universities), gyms, museums, cultural and social centres,
swimming pools and theatres and may be a total lockdown with
people forced to stay indoors (community containment).

What are the different periods in the natural history of

COVID-19 from a public health angle
There are four periods:

1. Infected, but not contagious and not symptomatic.

2. Infected and contagious, but not symptomatic.
3. Infected, contagious, and symptomatic.
4. Recovering (assuming survival), where you may still have
symptoms but are no longer contagious.

How does social distancing help in reversing the

epidemic?
Even with an ignorance of who’s infectious, who's contagious,
and how widespread the infection actually is, social distancing
can crush the exponential growth phase of COVID-19 and
support reversing the transmission of the disease. One of the
main aims of social distancing is to “flatten the curve”, which
means delaying the spread of the virus so it reaches people more
slowly.

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Scripting a new narrative for COVID control

India had warning about the COVID-19 epidemic in China

spreading to neighbouring countries well ahead of virus
importations; yet, the nation faltered. In epidemics as in war,
underestimating the enemy is a costly mistake.

Strategy planning is dynamic, with revisions as the ground reality

changes. What is appropriate in the beginning may become
redundant midway. Eisenhower said: “In preparing for battle, I
have always found that plans are useless but planning is
indispensable.”

India’s early strategy (traditional pandemic control: prevent virus

M.S. Seshadri importations from China and neighbouring countries and
interrupt importation-related local spread) succeeded, but
importations from the West and West Asian countries before
they were red flagged seeded local outbreaks in several places.

As transmission is through social contacts, social distancing in its

extreme form (a nation-wide lockdown) was declared early and
abruptly, from March 24 midnight.

Indigenous wisdom
Indian experts are skilful to imbibe, distil and translate
information into practical, socio-culturally appropriate action
T. Jacob John plans. When HIV importations and local spread were detected,
Indian experts studied the situation, and, rejecting advice from
M.S. Seshadri is Retired the World Health Organization (WHO) for only “syndromic
Professor of Medical diagnosis” of AIDS, devised multi-pronged interventions —
Endocrinology, Christian “social vaccine” including hospital infection control and
Medical College, Vellore and
innovative laboratory-testing tactic called sentinel surveillance.
now Medical Director,
Thirumalai Mission Hospital,
For safe blood transfusion, lab-testing was mandatory. Sensitivity
Ranipet, Tamil Nadu and and specificity of HIV lab tests were near 100%.
T. Jacob John is Retired
Professor of Clinical Virology,
For COVID-19, polymerase chain reaction (PCR) tests were
Christian Medical College, necessary to detect importations and contact screening. For
Vellore and Past President of disease diagnosis by physicians, clinical criteria are adequate.
the Indian Academy of Epidemics were asynchronous in different States; the simplest
Paediatrics. way to monitor epidemic growth was criteria-based clinical
diagnosis and confirmation by PCR when deemed necessary.
Instead, India blindly continues WHO advice: “test, test, test”.

Openly admitting community transmission of HIV was the signal

for the public to change behaviour and take precautions. Social
vaccine included public education and social mobilisation; its
legacy is red ribbon clubs in schools and colleges.

COVID-19 community spread was denied for too long, promoting

epidemic expansion and deaths particularly among health-care

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personnel. Early warning and public education would have

slowed the epidemic and saved lives. Everyone needed
behaviour modification to protect themselves when in physical
closeness in clinics and crowds.

Lockdown vs. mask wearing

Jain munis, realising there are organisms in aerosols and
droplets, wear masks to avoid inhaling them — a unique
preventive measure born out of ancient wisdom. Hong Kong and
Taiwan demonstrated the value of universal mask-wearing to
mitigate the current pandemic.

With our mindset of “big solutions” for ‘big problems’, we err.

Mask wearing is a simple solution; if practised by every man,
woman and child when out of home, it is twice superior to
lockdowns: it flattens the epidemic curve better than leaky
lockdowns; preserves socio-economic basics which a lockdown
destroys. Let us look at another simple solution — oral
rehydration for cholera, developed by H.N. Chatterjee in 1957,
was accepted by medical professionals and administrators only
decades later.

Wise clinicians make presumptive clinical diagnosis of infectious

diseases, informed by the epidemiologic setting, the patient’s
history, physical findings, simple laboratory tests, and initiate
treatment. Laboratory tests, used to confirm clinical diagnosis,
identify causative organisms in only about 50-60% of cases in
many instances. Why should COVID-19 be managed differently?

Specific epidemiologic and clinical criteria and basic blood tests

provide a clinical diagnosis of COVID-19; PCR is useful to confirm
this. Home quarantine of all with mild symptoms is simple and
safe. Their medical supervision should be through daily phone
calls with the assigned doctor. For those with breathing difficulty,
a chest X ray or CT scan identifies pneumonia. This approach
would have fetched us more gains for less expense.

As of June 23, we have tested 73,52,911 samples (incurring a

cost of ₹73,52,911,000 by assuming ₹1,000 for all costs per test;
private laboratories charge ₹4,500). Only 4, 57,369 were positive;
remember PCR may miss up to half of infected subjects. The
original testing policy was essential at first, but became
redundant and misleading by end-March. Why evaporate the
public exchequer for little or limited public benefit? Now the best
use of tests is to confirm clinical diagnosis.

Superficially, flattening the curve sounds attractive — infected

subjects trickle in rather than as an avalanche. Lockdowns hurt
lives, livelihoods and economy, while non-COVID-19 problems go
unattended.

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Risk identification
What we need to flatten is the steep mortality curve. Who are
those at risk of high mortality? Those over 60 years, and those
with diabetes, hypertension, heart disease, chronic respiratory
disease and obesity. This demanded cocooning (reverse
quarantine) the elderly and the vulnerable.

Countries with their elderly living in institutions have witnessed a

veritable disaster: large numbers succumbed, unprotected by
cocooning; hospitals were overwhelmed.

We have far fewer citizens above 60 than the United States and
Europe; flattening the mortality curve is eminently feasible and
culturally appropriate. The norm in urban middle class and rural
families is to protect old parents and vulnerable family members.
Flattening the mortality curve by cocooning them would have
resonated well with our people and found nation-wide
acceptance.

“Social vaccine” stimulates society’s protective knowledge and

practices countering major health threats. Social mobilisation
subsumes public education for attitudinal and behavioural
changes to overcome social determinants of microbial
transmission. When children and adults realise that mask
wearing is to protect their family, none will refuse to wear one. If
it is only to obey orders, many flout; even feel good flouting.

Social vaccine keeps citizens updated with authentic information

and convinces them that their behaviour makes a change to the
nation’s health and economy. For this to happen, the
government must do its utmost to suppress social toxins and
convince people about a genuine concern for their health and
welfare.

Social mobilisation, our mainstay against community

transmission of HIV from 1986, ensured clear guidelines for
medical professionals about preventing hospital-related
transmission. Educational efforts, integral to social vaccine,
galvanised society to resist HIV transmission, like immunity
resisting progression of infection within the body.

If social vaccine is the legacy of HIV control, the legacy of COVID

control ought to be more far-reaching. The convenience of
districts as units for colour zoning emphasises that they can be
more self-assertive in planning for unlocking the lockdown.

A practical platform
A COVID-19 committee as a practical platform in every district,
with representation from civil administration, health
management professionals, industry, businesses, educational

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institutions, major non-governmental organisations, voluntary

organisations such as the Rotary and Lions Club can identify
facilitators and deterrents of preventive processes and practices
and evolve locally relevant solutions for COVID-19 control now. It
can evolve into a district development committee in the post-
COVID-19 future. With a wider agenda, the fruits of their labour,
improved health and education, nation-wide implementation of
visionary concepts such as Swachh Bharat for microbiological
cleanliness at home and in all places of human congregation, will
be ready for harvest.

We have a unique opportunity to script a new narrative to win

the present struggle and perpetuate its legacy, with will and
wisdom.

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It’s OK to be smart

It probably began in the East and crossed borders and oceans, as

it devastated several countries till it reached Rome. The only
thing that spread faster than the contagion was the fear and the
rumours. People were terror-stricken. Doctors were clueless.
Government officials vacillated and losses mounted. Travel was
crippled. Festivals, gatherings, sporting events—all cancelled.
The economy plunged. Bodies piled up. The world was
bewildered.

I am, of course, referring to the Antonine Plague of 165 CE, a

Dr. V. Ramasubramanian global pandemic with a mortality rate of 2-3%. It also began with
flu-like symptoms until it escalated and became a catastrophe of
Dr. V. Ramasubramanian is a unbelievable proportions, in which over 15 million people
senior consultant Infectious eventually died.
Diseases, Apollo Hospitals,
Chennai “Those who do not remember the past are condemned to repeat
it” – George Santayana

I was confronted with these words as I walked into the Nazi

concentration camp at Auschwitz in 2004 and they have
continued to haunt me ever since.

History repeats.

The whole world is in the grip of the coronavirus now. The

pandemic started in December 2019 in Wuhan, China and has
spread insidiously world over. Coronaviruses have been
identified over 60 years ago as one of the agents which cause the
annoying common cold. There are 4 types of the beta-
coronavirus family which can cause the disease. But, like the
influenza virus, it has the uncanny ability to mutate often.

The first such instance of a dangerous mutation was in 2002,

resulting in the SARS (Severe Acute Respiratory Syndrome)
outbreak from Hong Kong, which afflicted over 8,000 people and
resulted in around 800 dead (a mortality of 10%). It is believed to
have originated in bats, which are, incidentally, asymptomatic
and transmitted via civet cats to humans. The second
catastrophe was the mutation resulting in MERS (Middle Eastern
Respiratory Syndrome), which originated again from bats, and
affected humans through an intermediate host, the dromedary
camels, in Saudi Arabia. By last counts, there have been around
2,500 cases with over 750 deaths (a mortality of 35%).

The current outbreak is again due to a mutated coronavirus

labelled by WHO as SARS-CoV-2, which is believed to have
originated from bats in a live animal and sea-food market in
Wuhan, and infected man through an intermediary host (perhaps

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the pangolin). The virus has the ability to infect lung cells through
a receptor known as ACE-2, leading to complications of
pneumonia and respiratory failure.

How does the virus spread?

The virus spreads through respiratory droplets of an infected
person. It could directly spread through inhalation of droplets
when you are within a metre of a coughing patient, but more
often, it is by touching inanimate objects contaminated by these
droplets and taking our hands near our nose and mouth. This
essentially means that if we are at least a metre away from
anyone, and wash our hands frequently, it is highly unlikely that
we would be infected. This is the rationale behind the concept of
social / physical distancing. Even though the virus can survive for
substantial periods on inanimate objects (a day on cardboard
and 2-3 days on plastic and steel, under ideal conditions), it dies
on drying.

What are the symptoms?

The symptoms of COVID-19, the common cold, and the flu are
akin to each other. The symptoms start with a low-grade fever
followed by a sore throat and body pain. Nausea and diarrhoea
may then occur with worsening throat pain, malaise and joint
pains. Severe body pain with nausea, high grade fever and
diarrhoea may follow. Breathlessness may occur with severe
cough after a week. One needs to consider visiting a hospital only
when there is high grade fever and difficulty in breathing.

What are the complications of COVID-19?

Almost 80% of people may not require hospitalization. Around
20% may require admission and oxygen support. About 5% of
infected people end up in ICU on a ventilator. The risk of
complications is higher in the elderly (over 60yrs of age),
diabetics and persons with co-morbidities like uncontrolled
hypertension, lung disease, liver or kidney disease and an
immune-suppressed status. The case fatality rate is around 2%,
but can be as high as 15% in persons over the age of 80. This is
because of weakening immunity with age. In some situations, the
immune system fights back aggressively, goes berserk and causes
more damage. This damaging overreaction is called a ‘cytokine
storm’ and can lead to multi-organ failure and death.

Experts, however, believe that the mortality may be lower than

1% in the general population. Surprisingly, the infections have
been very mild in young children, but they seem to spread the
virus for longer. Pregnant women have also not shown features
of severe infection.

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Does the summer help in stopping the pandemic?

The concept of seasonality for viral infections, especially the flu,
is based on evidence and experience from the west. This has
been extrapolated to other viruses which may die when exposed
to the heat and humidity. The incidence of flu wanes in the
summer in the West because most of transmission in winter
occurs indoors, where people stay in close quarters to escape
from the cold outside. When summer arrives, they start moving
out and lack of proximity causes the flu to die down. In tropical
countries, the flu is prevalent throughout the year with
outbreaks happening even in the peak of summer. In Chennai,
people tend to venture out less in summer and the ambient
temperature and humidity indoors can cause the infection to be
transmitted, even though it may die more readily outside.

Is there a role of Vitamin C or other food supplements

in the prevention and treatment of COVID-19?
At present there is no scientific evidence to recommend Vitamin
C or any other food supplements specifically to improve
immunity or to protect against COVID-19.

What should every citizen of India do to help control

this pandemic?
Since this infection spreads by respiratory droplets, the only way
to block transmission is by physical distancing. This means all of
us have to avoid crowds and stay at home.

• Avoid any kind of travel – international or domestic –

unless absolutely necessary
• Avoid visiting any public spaces unless absolutely
necessary
• Keep all commercial activity at a distance of one metre
between customers. Places of worship and restaurants
should also ensure that these norms are followed
• Limit hospital visits
• Postpone work meetings. Encourage work from home
• Any gathering of over 10 persons should be deferred

What do I do if I have sore throat or fever?

Since most infections are mild, the current recommendations are
to stay at home under isolation and take only symptomatic
treatment with Paracetamol. Contact your doctor or hospital
only if the fever is high or if difficulty in breathing ensues.

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How do I quarantine myself at home?

• Stay in a well-ventilated single-room preferably with an
attached / separate toilet. If another family member
needs to stay in the same room, it is advisable to
maintain a distance of at least 1 meter between the
two.
• Stay away from elderly people, pregnant women,
children and persons with co-morbidities within the
household.
• Under no circumstances should one attend any social
/religious gathering e.g. wedding, condolences, etc.
• Wash hands often with soap and water or with alcohol –
based hand rub.
• Avoid sharing household items e.g. dishes, drinking
glasses, cups, eating utensils, towels, bedding, or other
items with other people at home.
• Wear a disposable surgical mask at all times, if
symptomatic. The mask should be changed every 6-8
hours and disposed of. Disposable masks are never to be
reused.
• Use disposable gloves and surgical mask when cleaning
surfaces or handling soiled linen.
• Clean and disinfect frequently touched surfaces in the
isolated person’s room (e.g. bed frames, tables etc.) daily
with 1% Sodium Hypochlorite solution.

“Never let a good crisis go to waste” said Churchill.

The risks of doing nothing are greater at this point, which is why
we must use this pandemic as an opportunity to learn. We have
to act quickly and decisively. We should revisit our practices of
yore and re-educate ourselves. Maybe we should begin with not
spitting in public places, washing our hands more often, and
improving personal hygiene. We need to instil personal and
societal responsibility for our actions.

As a doctor, I would strongly encourage people to place their

trust in the science of medicine and put to rest the spreading
baseless conspiracy theories and rumours. The media should play
a responsible role in presenting facts based on scientific
evidence.

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Fighting a virus with dedicated health cadre

Never have we seen an epidemic on the scale of what the world

witnessed since February 2020 beginning in China, and then,
moving across the world. India has been witnessing epidemics
and pandemics in the past two centuries and these are well-
documented. With a dedicated public health cadre and
infrastructure, Tamil Nadu has been well-armed and prepared
for the past 100 years.

Epidemics in Tamil Nadu

Dr. P. Kuganantham The history of Tamil Nadu public health practitioners handling
epidemics and pandemics dates back to the era of small pox
which killed millions in the early 1900s, Plague in 1938 and 1995,
Vibrio Cholerae in 1987 and 1992, Flu H1N1 in 1918,
Leptospirosis in 1996 etc,. More than half of these outbreaks
happened before antibiotics were discovered and millions of
people were killed. This became better after the development of
newer antibiotics, advanced diagnostics and infection prevention
and control measures.

From what the experts have observed, very rarely does a disease
turn out to be a pandemic in a short period of time — 3-4 weeks.
Dr. Hamsadvani Anand It causes great human suffering in the form of morbidity,
mortality and has a huge impact on nations with low resources
Dr. P. Kuganantham was — which may be poor data systems, inadequate healthcare
former Corporation Health professionals and low access to medicines and diagnostics.
Officer, Chennai and Dr.
Hamsadvani Anand is a Public China was able to stabilize and bring the epidemic to a halt by
health expert in Geneva adapting the best methods of prevention and control —
‘cordoning’ and fast action in terms of adopting IPC strategies.

Swine flu epidemic, 2009

Roughly 10 years ago, in 2009, as a City Health Officer of
Chennai, my team admitted about 3,500 passengers from the
Chennai international airport, railway stations and inter-state bus
terminals who were suffering from fever, cold and cough
following the declaration of the pandemic of H1N1by WHO. We
identified and quarantined people with fever, cold and cough
and who had travelled from the affected areas. Subsequently, we
did a contact tracing exercise to identify people and followed up
with them for symptoms.

We observed them for 10 days. All our sanitary inspectors were

instructed to do epidemiological investigations on all these
patients with contact tracing and the contacts were brought to
the hospital for symptoms and if required, investigations were
done following treatment at Communicable Diseases Hospital
(CDH).

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Admitted suspects were given throat wash for use 5 times daily
with warm saltwater followed by nutritious diet which included
vegetable soup with pepper, ginger, garlic and coriander which
was prepared in large quantities every day. They were put on
mild antibiotics, antihistamines and mucolytic agents, followed
by Tamiflu (branded drug), if they were positive along with
Vitamin A therapeutic dosage. None of the quarantined patients
went in for complications and there were nil deaths.

The same procedure was followed in 1992 and 1993 during

outbreak of new cholera NON O139, that we named as MADRAS
STRAIN, which became a pandemic affecting many countries. The
Chennai city epidemic task force was developed under IAS officer
R. Poornalingam with experts (physicians, public health
personnel, microbiologists, environmental/water engineers) and
a similar state task force was developed under the State Health
Secretary.

Similarly, this unusual epidemic, which has spread to over 200

countries, could be controlled in India through implementing and
practising ‘personal distancing’ to prevent the spread of the
strain. China and Germany, the countries seem to be successfully
containing this disease with quarantining, testing a large number
of symptomatic and vulnerable people, apart from physical
distancing.

There is a need to move ahead swiftly, here, what with the

number of cases rising rapidly:

• India with the second highest population needs to have

one testing centre per district including all medical
colleges (732 districts) and quarantine/treatment
centres well established in all the 536 medical college
hospitals and all private hospitals with more than 100
beds to test and treat for free as it is a pandemic
preparedness strategy.
• The vulnerable population, especially elders, diabetics,
those with cardiovascular diseases, respiratory diseases,
people on chemotherapy, retro-viral drugs for HIV etc.,
have to be supported by our health system with an
uninterrupted supply of drugs.
• Hospitals should be regulated with the stringent
measures of practising Universal Work Precautions,
control of nosocomial infections, strengthening barrier
nursing procedures, establishing sufficient negative
pressure rooms in all the hospitals and sufficient number
of ventilators and required gadgets for critical care.

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A prescription of equitable and effective care

Medical care has been disrupted by the novel coronavirus. Fear,

anxiety, uncertainty and confusion have all overtaken clinical
services. The private sector, which delivers the major part of
medical services, is now functioning at a skeletal level and
patients have considerable difficulty in accessing medical care.
Tamil Nadu has one of the better health systems in the country
and has demonstrated that it can provide high quality care
through public-private collaboration in the areas of maternity,
cardiac and trauma care. As the number of COVID-19 cases in
Anand Zachariah Tamil Nadu has crossed 64,000, with over 800 deaths (as of June
24), there is a need to pull together the resources of the public
and private sectors into a functioning partnership, to provide
good clinical care, ameliorate suffering and prevent deaths.

A neglect of the primary task

Until now, the focus of the government has been on prevention
of the epidemic through testing of suspects, isolation of cases
and institutional quarantine of contacts. Hospitals have focused
their efforts on prevention by admitting asymptomatic contacts
and mild infections. With the focus on prevention, doctors have
been unable to attend to their primary task of providing good
clinical care to reduce morbidity and prevent deaths.

The majority of COVID-19 infections are mild and resolve on their

own. Serious illness occurs in the elderly and those with multiple
co-morbidities such as diabetes, heart disease and respiratory
problems. The primary cause of death in COVID-19 pneumonia is
respiratory failure. The mainstay of treatment in moderate and
George Thomas severe illness is clinical monitoring, oxygen therapy to correct
hypoxemia (low oxygen levels in the blood), and good supportive
Dr. Anand Zachariah is a care. Even in those above the age of 80 years, the mortality rate
Professor of Medicine at the is only 15%. Patients who require ventilator treatment have a
Christian Medical College, mortality rate of over 50%. Good supportive care for sick
Vellore and Dr. George Thomas patients is essential in preventing deaths.
is an Orthopaedic Surgeon at
St. Isabel’s Hospital, Chennai. Hospital services have to focus on in-patient management of
moderate and severe pneumonia, prioritising intensive care unit
(ICU) beds for potentially reversible illness. We need to ensure
that every patient with moderate and severe COVID-19
pneumonia has access to the optimum level of care, to prevent
deaths and ameliorate suffering.

Combating fear
Because of the labelling and stigmatisation of those diagnosed
with COVID-19, the public are reluctant to come to hospital and
may come late or die at home. We need to send out a clear
message that hospitals will provide good quality care for COVID-
19, at affordable cost and ensuring confidentiality.

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For this to happen, the government must work with the private
sector to make care accessible and affordable. The Tamil Nadu
government’s efforts to cap the cost for different levels of
COVID-19 care in private hospitals is a positive step. The
government should financially assist the private sector by
reimbursing basic patient care costs for providing COVID-19 care.

Medical staff taking care of COVID-19 patients are anxious that

they may acquire the infection and transmit it to their family
members. Deaths of hospital staff due to COVID-19 have been
reported, although the mortality risk is lower than that of the
general population. Medical staff involved in COVID-19 care
should be adequately protected with appropriate personal
protective equipment, or PPE, and should be trained in infection
control and clinical care protocols. They should be encouraged to
communicate with a patient and the family within the
restrictions.

A wish list
In Tamil Nadu, we should shift the discourse from the focus on
prevention and reducing the number of cases to an equal priority
for providing COVID-19 care. Every citizen in Tamil Nadu who has
serious COVID-19 pneumonia should be able to access high
quality care. In order to implement a universal COVID-19 care
programme, the government health system should collaborate
with private hospitals.

Towards this we suggest that: all private hospitals which have the
potential, should take care of COVID-19. They should be given
requisite incentives and subsidies to that end; every patient
should be able to access medical care for COVID-19 from a
private or public hospital; only patients with moderate to severe
COVID-19 pneumonia should be admitted; ICU care should be
prioritised for COVID-19 patients who have potentially reversible
illness; confidentiality of the patient should be protected; the
government should support the basic cost of COVID-19 care in
private hospitals as well; city hospitals should pool their ICU
resources for the care of COVID-19 pneumonia; staff providing
COVID-19 care, should receive adequate training and be
provided appropriate PPE, and, finally, families of staff who die
due to COVID-19 should receive appropriate compensation.

These initiatives can only be realised with appropriate leadership

from the government. The private sector has to be fully involved
in clinical care of the COVID-19 epidemic. We should work
towards making COVID-19 treatment available, affordable and
effective. Our response to the epidemic must combine good
science, clinical reasoning and a humane response to save the
lives of the people of our country.

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The tests reveal all

What are the important timelines and symptoms

characteristic of COVID-19 infection we need to
understand before testing?
After exposure to SARS-CoV-2, the incubation period is typically 5
to 6 days. It can range from 2 to 14 days. In the first week, only
viral RNA and antigen particles will be present.

During the second to third weeks, the initial antibody response in

the form of IgM will be seen which may be present for another 2
weeks. IgG antibody response will appear after 2 weeks in the
blood and provides long term immunity. Currently we do not
know how long the long-term immunity lasts as this is a novel
Dr. Rajaram Anantharaman
virus.
Dr. Rajaram Anantharaman is
a Senior Consultant From the available literature, the COVID-19 infection will be
Cardiologist and Lead for TAVR asymptomatic/mild in 81%, severe in 14% and critical in 5% of
/ Heart Transplant / Stem Cell cases. But the infection can be transmitted from persons through
Therapy and Cardiomyopathy, droplets, even from those with mild symptoms or asymptomatic
Frontier Lifeline Hospital. carriers.

What are the two major types of tests?

The antigen test is the diagnostic test for COVID-19 in which the
viral RNA is directly identified by real time reverse transcriptase
polymerase chain reaction (rRT-PCR).

This is an extremely sensitive test to identify whether someone is

currently infected and active.

The antibody test is to identify the immune response to earlier

infection. By identifying the type of antibody positivity (IgM or
IgG or both or none) we can determine whether the individual
had exposure to infection or not, still has active infection or has
developed long-term immunity.

What is the best diagnostic test to identify if a person

is currently having active COVID-19 infection?
The rRT-PCR antigen test is the best diagnostic test to identify if
someone is currently infected and active with SARS-CoV-2. In
this, a nasopharyngeal (nasal) or oropharyngeal (mouth) swab is
taken and sent in a cold storage box to the central laboratory,
where the viral RNA is converted to complimentary DNA (cDNA)
using reverse transcriptase, and amplified following the addition
of a primer and fluorescent dye and DNA building enzymes.

A positive test will be indicated by the raise in fluorescence.

Depending on the equipment and method used, the time taken

may vary between a few hours to a day to get the reports.

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This test is very sensitive and specific and can detect even if a
single viral RNA particle is present in the swab.

Some of the reasons why we get a false negative (negative test

when the patient is actually COVID-19 positive) may be improper
swab sampling, prolonged time to get sample to lab causing
degradation of RNA.

What is the best test to identify if a person had

exposure (with or without symptoms) to COVID-19 and
their immunity response?
The test for antibodies will give information on whether a person
had exposure to SARS-CoV-2 at any point in time and whether
immunity has developed. When exposed to SARS-CoV-2 our
immune system will form proteins called antibodies to neutralize
the virus, initially antibody response will be IgM and long-term
durable response will be IgG. Presence of IgG antibody alone will
indicate development immunity.

Why are the currently available point of care (POC)

rapid testing kit (COVID-19 antibody test) results
variable?
There has been a lot of interest in the POC rapid antibody testing
as it is quick (under 15 minutes). It can be done by anyone
without much training, and if the antibody test is positive and if
the individual is shown to be immune, he or she can be
reassured. At healthcare providers’ and business level, they can
return to work, ánd at government policymakers’ level, they can
come out of lockdown and plan future vaccination programs. The
currently available POC rapid testing kits have been brought into
the market without quality assurance by the regulatory
authorities of the countries in which they were manufactured
and they lack the validation process.

Several of the testing kits have been fast-tracked due to

increasing demand, hence lacking in quality, with variable
sensitivity from 30% to 80%. The main concerns raised by several
European countries and India are that these kits are showing a
higher percentage of false negative reports (i.e. results of the
test is negative while the patient is COVID-19-positive).

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What is convalescent plasma therapy?

Convalescent plasma treatment involves injecting the COVID-19

patient with convalescent sera of people who recovered from
the infection recently. The patient cured of the disease will have
antibodies that drive coronavirus away, says the report of the
WHO-China Joint Mission on COVID-19.

What is the meaning of convalescent sera for COVID-

19 and how does it act?
The serum of COVID-19 cured individuals will have virus-
neutralising antibodies which will act as a passive antibody
therapy. It is called convalescent sera of COVID-19.

Dr. Joy Varghese How can we collect convalescent sera?

We can collect it in two ways:
Dr. Joy Varghese is Director -
Hepatology & Transplant (i) Using routine blood withdrawal followed by centrifuge
Hepatology, Gleneagles Global
technique. Here we can collect 180 ml to 220 ml of convalescent
Hospital, Chennai, working in
the field of plasma exchange sera and we can store it in -60 degree C up to one year.
therapy for over five years
(ii) Using aphresis machine/cell separator machine, we can
collect even 600 ml of convalescent sera at one time and safely
store for a year.

Who will be a suitable candidate to receive

convalescent sera of COVID-19?
Those who are suffering from SARS-CoV-2 infection with
moderate/severe sepsis with or without ventilator support.

What is the dose, frequency and duration of

convalescent sera?
At present, there is no available literature in the World. Based on
our previous experience (more than 5 years in hepatitis B virus), I
would recommend 180 ml to 220 ml of convalescent sera of
COVID 19, once a day for a minimum three to five consecutive
days.

Which is the meaning of therapeutic plasma exchange?

The process of removal of abnormal substances from circulation
which are either present in plasma or are tightly bound to
plasma proteins is known as therapeutic plasma exchange. In
COVID-19 patients, their plasma will contain enormous
inflammatory mediators which cause severe lung injury.

What will be the better proposed model for COVID-19

sick patients?
Based on previous experiences with other diseases, in COVID-19
severe cases, a combination of therapeutic plasma exchange

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technique using convalescent sera will reduce the “cytokine

storm” which will help recovery.

Advantages of the therapy are that it is the viable option in our

healthcare system; it is quickly doable and there are no major
side effects. The most important thing is that convalescent sera
is easily transportable to any part of the country/worldwide by
maintaining adequate cold-chain process similar to vaccine

Adding therapeutic plasma exchange in tertiary care centres

using convalescent sera of COVID-19 will be the more effective
way of therapy in COVID-19 patients.

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The role of palliative care

How can palliative care help when the world is reeling under this
most unexpected and unprecedented pandemic, COVID-19?
Palliative care is part and parcel of treatment for any patient for
any disease at any stage, for any age. It is simply a ‘whole person’
approach to improving health in any patient.

To allay fears and anxieties in patients and families alongside

treatment of any illness is not something new in the medical
profession.

A 16th century aphorism describes the duty of every physician:

“To cure sometimes, to relieve often, to comfort always”.

The literal meaning of the word ‘palliate’ is ‘to alleviate pain —

physical and emotional’, meaning, relief of suffering. ‘Suffering’
literally means ‘the state of undergoing pain, distress, or
Dr. Mallika Tiruvadanan hardship’.
Dr. Mallika Tiruvadanan is a
palliative care expert who Social suffering
heads Lakshmi Pain and COVID-19, because of its unique nature and magnitude has
Palliative Care Clinic, Chennai brought in its wake, not only physical illness, but more of
emotional and social suffering — fear, anxiety, uncertainty, loss
of loved ones and social distress such as losing jobs and income,
inability to move freely to work and other places, frustrations,
staying long hours at home and other hardships, all leading to
psychological disturbances for many.

‘Palliative Medicine’ is a medical specialty, which involves the

treatment of pain, breathing difficulty and other distressing
physical symptoms caused by chronic and life-limiting diseases
and also addressing the psychological issues of both patient and
family, with the sole aim of improving quality of life. It is most
beneficial when started early in the disease trajectory.

It is also a form of supportive care, giving that extra layer of

support a patient needs, to alleviate suffering, alongside disease
treatment even in acute illness.

In the present scenario, in addition to what physicians are toiling

with to cure patients, and the government and health care
policies and strategies, palliative care can play a supportive role.

The care may be needed right from the time of diagnosis, during
treatment of the disease or when treatment does not help
anymore to cure.

Supportive role
Distressing physical symptoms like pain, breathing difficulty,
restlessness (delirium) and others can be well relieved or
palliated with medicines in consultation with the specialists.

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Similarly, skilled counselling is an integral part of the palliative

approach. It helps address the psychological, social and spiritual
issues, which both patient and family are experiencing in the
present scenario.

There is a way of responding to their fears, anxieties and to

questions. They rarely need antidepressants when we
acknowledge their emotions as normal. Active listening is by far
the most important part of counselling.

Taking a nonjudgmental attitude without assuming or being

philosophical, teaching them special skills in coping with the
situation, with the illness or death of a loved one, but always
maintaining hope are some basic aspects of communication
skills.

These skills can be availed of from psychologists, specialists in

palliative medicine, as well as those from medical organisations
who have the expertise and willingness to render their services.

Common thread
Palliative care is really the essence of all good medical care. It is
the reinstatement of the humane aspects of medical care and is
complementary to all medical specialties, a common thread
running through the total care of all patients.

Anyone who needs help to overcome their psychological issues

can avail of this care by contacting us,
lakshmipaincare@gmail.com. We can also put you onto experts
who are willing to offer their time and service.

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Palliative care is the answer

These incidents happened recently:

A patient, undergoing dialysis twice a week, wanted an opinion

regarding the continuation of dialysis. Whether COVID-19 will
affect him if he does? An elderly couple, dependent on help, who
are living with their son who is working in essential service, were
anxious. They said they did not know how to handle it if one of
them, or their caregivers tested positive for a COVID-19
infection. What is the next step? Is there any institutional care to
Dr. Republica Sridhar
look after such patients? The answer is yes. There are hospices
Dr. Republica Sridhar is or palliative or rehab care centres.
founder, RMD Pain and
Palliative Care Trust, Chennai Palliative care is a medical speciality dealing with medical
treatment for chronic and advanced diseases and care for elderly
people with multiple diseases. The need to create awareness is
much more in this group as these patients are people who are
suffering from chronic illnesses and advanced diseases and are
also severely immunocompromised. In these times they need to
avoid unnecessary visitors. We also need to provide them with
appropriate infection control measures — personal protective
equipment, handwash, sanitisers for the health workers and
those taking care of such patients.

The key goal of palliative care is to reduce suffering of patients

by early detection, intervention, complete protection, infection
control and personal care. Preventing the spread of infection
among patients who need palliative care is essential as their
immunity is low and super added respiratory issues may increase
the risk of the COVID-19 and the treatment may get complicated.
We need to handle the community looking at the social, financial
issues, and reduce their physical suffering by frequent
monitoring of symptoms. We need to look for respiratory
symptoms, encourage respiratory hygiene and cough etiquette.

The best method now is to avoid contact with high risk groups.
Family members must desist from visiting them and also save
themselves from possible exposure. Consultations, whenever
necessary, can be through telemedicine. We need to avoid
interventions or treatments that may not be urgently needed.

The risk groups include patients with illnesses such as

cardiovascular disease, diabetes, respiratory conditions, cancer,
patients who have a compromised immune system, smokers,
senior citizens, the elderly with multiple chronic conditions.

Emergency situations depend on the treatment and disease

phase, especially in cancer, dialysis, other rehabilitation
specialisations. Treatment is required only when the concerned
primary physician insists on it.

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MANAGING YOUR OWN HEALTH

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In search of Vitamin D

Summer is when we get an opportunity of being exposed to

sunlight to obtain our requisite dose of Vitamin D. Sadly, despite
India being a tropical country, most Indians (over 60% as shown
in a recent study done by my team) are deficient in (< 20 ng/ml)
or have insufficient (20-30 ng/ml) Vitamin D. Even the
recommended dietary allowance of Vitamin D (400-800 IU) is
arguably very low for Indians who probably need between 2,000
and 4,000 units of Vitamin D a day to maintain normal blood
levels of the vitamin.

Diet alone does not seem to be enough, for several reasons.

First, we do not eat the right food in adequate amounts,
Dr. V. Mohan processing of food over the years has reduced its micronutrient
content, and sometimes our cooking practices (excessive
cooking) might contribute to this national Vitamin D
Dr.V. Mohan is the chairman insufficiency. Added to this, many of us live or work within the
and Chief of Diabetology at Dr. air-conditioned environment at our home and in offices. Our
Mohan’s Diabetes Specialities dark skin (melanin) and the clothes we wear may make it difficult
Centre. for our skin to get enough vitamin D from the sun.

A micronutrient is required in small or micro quantities and yet

we Indians are deficient in micronutrients, which can lead to
macro consequences as micronutrients are co-factors for the
efficient catalytic action of many enzymes in our body, and they
enable us to optimally use our macronutrients as well.

Benefits of walking
We do not go for walk when we should (10 a.m. to 3 p.m. is the
best time for optimal sunlight of a particular wavelength, UV-B,
290-320 nm to reach our skin) and some of us apply sun screen
lotions with sun protection factor (SPF) that again impairs
production of adequate vitamin D precursor in the skin.

So, what has all this to do with COVID-19? The lockdown may
have eased but we will still need to stay at home as far as
possible, practise social distancing, and adhere to personal and
public hygiene standards. In such a situation, exposure to the sun
will further go down. Hence, it may be worthwhile to consult our
doctors, test our Vitamin D levels, and if deficient or insufficient,
then we must supplement our diet with vitamin D to meet our
body’s needs.

You would be interested to know that Vitamin D is not just a

vitamin or micronutrient. It is also a hormone in that it has
effects way beyond the well-known effects on bone mineral
metabolism. Incidentally, the bone is an endocrine organ. There
are Vitamin D receptors on many cells in our body and at a
genetic level, Vitamin D modulates cell function. It may be an
uncanny coincidence, but there is evidence to suggest that
Vitamin D may have some anti-coronavirus activity as well (e.g., it

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attenuates the Spike protein of this virus which is an obvious

advantage). Moreover, it has the potential to modulate the
cytokine storm seen in serious COVID-19 patients, and it can
improve innate immunity by increasing the production of
cathelicidins and defensins in our body.

But the more important point is that if we are deficient in

Vitamin D, then we need to take steps to detect and then treat
this problem. The prevalence of Vitamin D deficiency is higher in
people with diabetes. Hence, as people with diabetes are known
to have a more severe form of COVID-19 infection, they should
particularly pay attention to improving their Vitamin D levels.
Vitamin D can strengthen our immune system and our ability to
stay strong and healthy. On a lighter note, one of the simple
approaches to COVID-19 could be COVID –Correcting Vitamin D
Insufficiency and Deficiency!

Your doctor will tell you whether you need to take Vitamin D and
if yes, at what dose. Remember that it should never be taken
without the advice of a doctor. All medicines, including vitamins,
are double-edged swords and their indiscriminate use can lead to
side-effects and even toxicity.

Just as personal protective equipment (PPE) are life-saving for

health-care workers in hospitals treating serious COVID-19
patients, for patients with chronic conditions, such as those with
diabetes or hypertension, their doctors are their PPE. Hence
these patients should stick to their doctors’ advice on lifestyle
modification, take the prescribed medicines prescribed on time,
and check their BP, blood sugar level and so on to try and be at
goal so that they are better equipped to face the ravages of
COVID-19, just like people without these conditions.

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Aches and pains and a spot of exercise

Since the lockdown, with restricted movement in place, a

number of people have expressed concern about getting
adequate exercise, among other things to be worried about. If
you have a regimen in place and that is disrupted, anxiety may
follow. Some people also have to, for medical reasons, get
adequate exercise during the day.

We have also been flooded with calls, mainly from people with
chronic issues — pain mostly. Since they are probably sitting at
home in all kinds of odd postures and watching movies on the
net or phone. We have been getting an extraordinary amount of
calls from people complaining of backpain, shoulder and neck
pain.

Dr. Madhu Thottapillil The general tips that I would give all these people anxious about
getting exercise and those who must exercise, are:
Dr. Madhu Thottapillil is a
sports medicine specialist, 1. Involve your family member (could be spouse, parent,
National Sports Medicine sibling, child) in the exercise effort.
Centre, Chennai 2. Try to use any available space inside the house, around
the house or the terrace for exercises. About 30 to 40
minutes of brisk walk daily would be recommended.
3. Try to do some strength training too, using household
things that you can lay your hands on, like water bottles
(filled with water), bags, etc. Free weight or body weight
exercises such as squats, lunges, planks, etc., are helpful.
4. Do remember to warm up and stretch before the
exercises.
5. Try to assign a fixed time to your exercise activity, which
will ensure that you will follow your routine and won’t
skip it.
6. Keep an eye on your diet and temper it to suit your
activity levels. Following the same diet that you were on
when you were more active during the lockdown will
only result in weight gain and misery.
7. Post-surgery patients should stick to the physiotherapy
schedule prescribed by their surgeon or therapist.

When in doubt about anything, it is better to be cautious and call

your doctor and check.

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Boosting immunity is the need of the hour

When we are supposed to protect ourselves from the virus from

outside, we need to protect ourselves beginning right from
within our body by strengthening the immune system. The
immune system is indeed complex and is to a great extent
impacted by the environment around us.

There are many factors that affect the functioning of the immune
system.

A healthy lifestyle involves eating nutritious food, practising

hygienic habits, walking and exercising regularly, maintaining
good emotional and mental health and having adequate sleep.
Dr. Bhuvaneswari Shankar
It is important to understand that these factors play a significant
Dr. Bhuvaneswari Shankar is a role in regulating and boosting immunity.
dietitian and nutritionist at
Apollo Hospitals, Chennai Gut microbiome
A healthy body has a healthy gut. The microbes living in our gut,
collectively known as microbiomes play an important role in the
body’s response to infectious pathogens like coronavirus.

It is thus important to maintain a healthy gut which helps to

prevent impaired digestion that can damage the vital organs like
lungs causing respiratory failure.

This is the reason we should think of supporting rather than

‘boosting’ our immunity. Recent research has proved that that
the gut microbiomes can be controlled with a good food regime
and a healthy diet.

There are many uncertified and unverified claims made on

supplements to boost immunity. Instead of following those
prescriptions which do not have any scientific evidence, we
should consider eating time-tested foods routinely consumed by
us.

We are all very well aware that our home-made food recipes that
had been passed on to us through many generations are
definitely capable of providing and sustaining all that is essential
for us to strengthen our immunity. They have been found to
have the most desirable and positive impact on the gut microbes.

Recommended foods rich in antioxidants and minerals to

improve immunity:

Rich in Vitamin A:
Cereals, legumes, yellow and orange coloured vegetables and
green leafy vegetables

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Rich in Vitamin B (B6, B9, B12):

Cereals, legumes, green leafy vegetables, fruits, nuts, soy milk,
dairy products fish, chicken and egg

Rich in Vitamin C:
Orange, lemon, guava, kiwi, gooseberry, cauliflower, tomato,
capsicum and mint

Rich in Vitamin E:
Nuts, green leafy vegetables and vegetable oils

Rich in Vitamin D:
Egg, fatty fish, milk and its products

Exposure to sunlight is also helpful in improving Vitamin D levels.

Rich in iron:
Cereals, legumes, dry fruits, fish, and chicken

Rich in zinc:
Wheat germ, dried beans, nuts, tofu and Sea foods

Rich in selenium:
Cereals, nuts, mushrooms, meat and chicken

Rich in antioxidants, condiments and spices:

Garlic, onion, ginger, pepper and green tea.

It is preferred to include fish, chicken and egg instead of red

meat.

Apart from including the above, it is important to follow a

healthy lifestyle which involves, consuming nutritious foods,
abstaining from alcohol and smoking or moderate indulgence,
de-stressing /unwinding with hobbies, having adequate hours of
undisturbed sleep, exercising regularly, walking inside your
home, in the terrace or even in the balcony of your home and
doing simple floor exercises. Static jogging is also recommended

Home and healthy

Consider this as an opportunity to:

• Eat freshly-cooked home made food, which is the most

safe
• Have a fixed meal time which is impossible while at work
for many
• Develop the habit of eating fruits and vegetables which
are an important source of minerals and antioxidants
• Learn healthy cooking and new recipes
• Learn about food safety techniques and healthy food
choices,
• Get into the habit to avoid baked and fried foods, pre-
packaged snacks high in salt and fat

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• Try to cut down on salt and sugar intake for at least 2

weeks, leading the way for it to become a habit
• Try not to buy or store sugar rich candies, sweets,
chocolates, ice creams, fizzy drinks, energy and sports
drinks
• Keep yourself well hydrated. Get into the habit of
drinking more water than usual, at least 8-10 glasses

Have a positive mind

• Handle stress in a positive way through meditation, yoga,
breathing exercise, listening to music, reading or
developing hobbies missed out during hectic work
schedules
• Indulge in physical activity to lower stress, boost energy,
improve digestion and thereby reduce the risk of some
chronic disease that could weaken your immune system
further. Conserve your energy for essential activities.
• Ensure having a consistent sleep schedule that helps in
maintaining your cardiac rhythm. Try to have a restful
quality sleep time.
• This in turn helps to manage mood and appetite which in
turn facilitates to improve immunity. Seven to eight
hours of sleep is essential for us as sleep deprivation
significantly weakens our immunity.

Food safety
Concerns with regard to transmission of virus via food are being
rampantly spread across all sections.

There is no evidence to suggest that COVID-19 is transmitted

through food and water but considering the fact that food and
containers we use may hold and transmit the virus to others, it is
essential that we are cautious.

Sharing food by eating out of the same plate and sipping out of
the same cup are undesirable and dangerous too.

Anyone with suspected symptoms like cough and cold should

avoid cooking food for others

Food safety measures for refrigerated foods:

1. Separate the raw from the cooked foods to avoid
contamination
2. Cook the meat thoroughly
3. While reheating cooked food double check if it is still
fresh and suitable for consuming
4. Rinse the chopping board, knives and utensils used while
cutting raw meat, chicken and fish.
5. Practice hand hygiene especially after handling fish,
chicken and meat
6. All vegetables and fruits to be washed thoroughly

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Nutrition tips for athletes during this time at home:

For many athletes who are used to doing a lot of physical
activities like sports training and weight bearing exercises, the
same may not be possible now. They might have been on a high
calorie diet also. It is important to prevent fat gain during this
period — so the guidelines for them and those who regularly
exercise are:

• Avoid foods high in sugar and fat

• Reduce portion size
• Consume fewer calories than required
• Include adequate protein to maintain muscle
mass – soy chunk, tofu, unsweetened soy milk
sprouts, nuts, egg, meat, fish and chicken
• Switch to low fat milk, curd and buttermilk
• Include 4-5 servings of vitamins and mineral rich
fruits and vegetables
• Snack on low calorie nutritious foods like salad,
sprouts and roasted unsalted channa
• Drink adequate water to keep yourself hydrated
all the while
• Avoid tetra pack juice, fruit juices, sugary
carbonated drinks
• Avoid consuming pre and post workout drinks if
not presently keeping up with routine practice
sessions
• Avoid deep fried foods
• Do regular routine floor exercises, walking inside
home or on the Terrace and skipping
• Keep yourself active throughout the day, learn to
do household chores

Stay home, stay fit and stay positive and spread the positivity.

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Why everyone should wear masks

Flattening the epidemic curve (case distribution curve) is the

need of the day. On the curve, Y axis and X axis represent case
numbers and time, respectively. A normal epidemic curve is bell-
shaped, with an early ascending slope (first phase), a peak
(second phase) and a declining slope (third phase). The area
under the curve represents the total number of cases. India is
now in the first phase of the COVID-19 pandemic.

A rapid increase in cases will demand far more healthcare

T. Jacob John facilities than now available. Healthcare facilities were not
created in anticipation of a pandemic and are grossly inadequate
T. Jacob John, Retired Professor for India to tackle the first phase. A flattening of the curve will
of Clinical Virology, Christian reduce the demand on beds in intensive care units, respirators,
Medical College, Vellore and and specialists to manage acute respiratory distress syndrome.
Past President of the Indian The peak will be dwarfed and come after some breathing time;
Academy of Paediatrics
the pressure will be eased. However, the area under the curve,
the total number of cases, whether the curve is bell-shaped or
flattened, will be the same. This crucial information in the
epidemiology of the epidemic must be taken into account for
planning a response.

Flattening the curve

There are two ways of flattening the curve: imposing a strict
lockdown for a number of weeks or use of face masks all the
time when outside our homes. A lockdown physically distances
families from each other. The disadvantage is that family
members may not be able to keep a physical distance of two
metres from one another all the time. As a result, intra-familial
spread occurs, and more people are infected at the end of the
lockdown than at the beginning. But during a lockdown
community transmission is prevented.

There are four reasons for the universal use of masks. First, any
infected person will not infect others because the droplets of
fluids that we let out during conversations, coughing or sneezing
will be blocked by the mask. Remember, most infectious people
don’t have symptoms, or have mild symptoms, and are unaware
that they are infected. Second, uninfected people will have some
protection from droplet infection during interactions with others.
For those who wear eyeglasses, there is additional protection
from droplets falling on the conjunctiva. When both parties wear
masks, the probability of transmission is virtually zero. Third, the
mask-wearers will avoid inserting their fingertips into their
nostrils or mouths. Viruses deposited on surfaces may be carried
by hand if we touch such surfaces; if we do not touch our eyes,
nostrils or mouth, this mode of transmission is prevented.
Fourth, everyone will be reminded all the time that these are
abnormal days.

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In overcrowded areas such as slums, a lockdown will not be

efficient in slowing down transmission. In such places, universal
mask use is a simple way to slow down transmission. In India the
wise choice would have been to ensure universal mask use in
slums, bazaars, shops selling essential commodities, etc. before
the lockdown. But then, wisdom, proverbially, is slower than
adventure.

Making your own mask

Taiwan and the Czech Republic depended primarily on universal
mask use and slowed down the epidemic. In the Czech Republic,
people made their own masks. Cotton pieces, preferably coarse,
three layers, stitched with two straps, make masks of sufficient
quality. These masks should cover the nose from just below the
eye level and reach and cover the chin. All adults, and children
who are old enough to wear masks, should wear them. At the
end of the day, cotton masks can be washed in soapy water and
hung to dry for re-use.

COVID-19 mortality is due to three reasons. Virus virulence is the

given and cannot be altered. Co-morbidity (diabetes, chronic
diseases) is already prevalent. Then there is low-quality
healthcare. Slowing down the epidemic by imposing a lockdown
and ensuring universal mask use gives us the chance to protect
people from infection and improve healthcare quality; wherever
that was done, the mortality was less than 1%.

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Masks are mandatory for all now

The COVID-19 pandemic cannot be controlled by governments

alone. It needs the participation and passion of all the people of
India; and it needs clear, feasible measures that ordinary citizens
can undertake to help reduce transmission. The lockdown has
probably played a great role in making sure the figures aren’t
much higher than what they are. It remains an experimental
intervention not just for India, but for other countries as well.

Low-cost measures
It is therefore important to explore sustainable methods of
Dr. D. J. Christopher reducing community transmission. Along with the well-accepted
measures of physical distancing and frequent hand washing, the
use of face masks or face covering is now emerging as a third
pillar in community action — doable and low-cost.

The tide has turned since the beginning of epidemic, and even
the CDC (USA) changed its position and has issued an updated
set of guidelines advising the members of the general public to
wear non-medical face covering outside their homes, whether or
not they're sick.
Dr. Prathap Tharyan
Would a mass movement by the people of India to take this up
Dr. D. J. Christopher is a senior on a large scale serve to actually reduce transmission pressure in
pulmonary physician and Dr. the community?
Prathap Tharyan is a senior
psychiatrist, Christian Medical Before understanding the role of masks in the spread of
College, Vellore infection, it is important to understand the transmission
dynamics of COVID-19 infection. Similar to influenza and other
respiratory infections, the infection can be transmitted through
droplets of different sizes, mostly 5-10 m in diameter.

Droplet transmission occurs when a person is in close contact

(within 1 m) with someone who has respiratory symptoms (e.g.,
coughing, sneezing or even speaking), most commonly by
inhalation.

Transmission could also occur through fomites in the immediate

environment around the infected person. A fomite is an
inanimate object that, when contaminated with or exposed to
infectious agents (such as disease-causing bacteria, virus or
fungi), can transfer disease to another person. Fomites include
doorknobs, switches, computer keyboards etc. At hospitals, it
could be stethoscopes, neck ties, IV drips and other hospital
equipment. Fomite transmission could be important as the virus
may remain viable, depending on the surface, for hours and in
some cases, days. Frequent hand washing and cleaning
schedules are ways to reduce fomite transmission. But the
inhalation route remains the predominant mode of spread.

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Most people think that wearing a mask is for self-protection, and

that is partially true. But the main benefit of all people wearing
masks is that in infected persons, the mask will help prevent
these droplets from getting into the air and infecting others.
They are thus reducing the spread of infection to others.

Lingering presence
This assumes even more significance as there are reports coming
in suggesting that the virus can live in droplets in the air for up to
three hours after release from an infected individual, lingering
even much after the person has left the area.

Furthermore, many infected with COVID-19 virus are not

symptomatic and they may have started releasing viruses before
they developed symptoms.

This is a key factor in the ability of this virus to spread, and the
infected don’t even know they are infecting others.

Evidence has been mounting on the value of masks in reducing

community spread. In Mainland China, extreme forms of social
distancing and compulsory face mask wearing in public places
appears to have successful in reducing the incidence after the
initial outbreak in Hubei Province. Mask wearing also reduced
community transmission in other provinces after five million
people left Wuhan before the Chinese New Year. In Hong Kong,
although the government only advised the people to stay at
home, they voluntarily started wearing masks in public places.
Following this, the labs in Hong Kong reported a significant drop
in the detection of influenza and other respiratory viruses from
patient samples, strongly suggesting that there was reduction in
spread of these viruses.

During the present outbreak of COVID-19, one patient from

Chongqing, China, transmitted the COVID-19 infection to 5
people in one vehicle when he didn’t wear a face mask, while no
one was infected later in the second vehicle he took when he
wore a face mask. This indicates the importance of wearing face
masks for everyone in a closed space.

Wearing face masks therefore protects the user and also the
others around. Use of face masks in social spaces is therefore
likely to play a vital role in mitigating disease spread. We feel that
the use of the face masks should become mandatory when
people step out of their homes to any area where social
distancing is not practical. This is a sustainable and an affordable
intervention.

One reason why CDC and WHO initially recommended that the
public do not use disposable masks is because the public started
purchasing the medical masks (surgical or even N-95 masks)
meant for use by the health care workers. The latter is not even
meant for all health care workers, but only for those performing

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or assisting with high-infection-risk aerosol-generating

procedures. Consequently, there was an acute shortage of these
personal protection equipment for hospitals and the prices have
also shot up substantially. It would be foolish to continue this
practice. For the public, cloth masks are probably effective and
sufficient for this purpose.

In fact, some years ago, before disposable masks became easily

available in India, most surgeons used washable cloth masks
successfully during operations. These masks are simple to make
and instructions are available on social media for making them.

Recently, respiratory disease experts advocated in a medical

journal the use of traditional cloth coverings such as dupatta and
saree, towels, turban and even handkerchief as face cover.
Communities could be taught to use these to cover their mouth
and nose when they cough or sneeze and when they are in
places such as markets community gatherings where social
distancing may be impractical. The wearing of the masks or any
face cover could provide a barrier for transmission to and from
the user. However, cloth mask would serve the purpose better as
it is a specifically designed cover.

A show of success
For instance, the ‘mask for all campaign’ in a rural community in
south Odisha, the Bissamcuttack initiative is a show of success.
Bissamcuttack is a small town in Rayagada District of Odisha, 200
km from the nearest ICU and 400 km from the nearest COVID-
testing facility. Dr John Oommen, Community Health physician at
the Christian Hospital, Bissamcuttack (CHB), recognised that if
the COVID-19 epidemic reached a tribal region like this, it would
be a disaster.

From the technical discussions, it was clear that everything

depended on the proportion of the population getting infected in
a short time. If the predictions of experts of 50 % of the
population eventually contracting the infection comes true, or
even if half the number is affected, the damage would be very
heavy. The key therefore lay in getting the people to do
whatever is possible to reduce the transmission in the
community. With social distancing and hand washing already
being well communicated by the government and other
agencies, the CHB team felt a Mask For All Campaign could be a
possible value addition. Support was found from the Azim Premji
Philanthropic Initiatives, Bangalore.

Discussions were held with members of a local club, AFSA of

Bissamcuttack, and they quickly warmed up to the idea. Dilip
Kumar, Gourishankar Patra and other youth agreed to take it on
with guidance from CHB. And on 30th March, work began to
stimulate the movement. They organised 27 local tailors
including professionals, stay-at-home mothers and SHG
members, to take up the task of stitching 10,000 cloth masks,

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CHB provided the instructions, the cloth and a nominal sum of

sum of Rs 5 per mask stitched. The AFSA team took on the
distribution of the masks to every individual in every family in the
Bissamcuttack Panchayat, with instructions on its use. Staff of
CHB’s Mitra team took the initiative out to another 54 villages of
the block.

By April 15, over 25,000 cloth masks had been stitched by 63

tailors and over 22,000 distributed to people. From 6th of April,
the hospital (CHB) made it compulsory for anybody entering the
hospital campus to wash their hands and wear a mask – creating
one level of protection for the health personnel who would be
treating them. Cloth masks are made available at the entrance
for Rs 10 apiece. On the 9th of April, the Government of Odisha,
which has been very pro-active and organised in its COVID-19
management strategy, made the wearing of face masks
compulsory across the state, with a fine for non-compliance.

A simplified explanation
Volunteers handing out the masks at each home explain the logic
in simple language. For infected people, the virus has two Exit
Gates from the body – the nose and the mouth. For uninfected
people, the virus has three Entry Gates into the body; mouth,
nose and eyes.

The connection between one person’s exit gate and another’s

entry gates is usually air (if you are close to each other) or hands
(that pick it up by touching things). We do not know who is
infected and who isn’t. So covering the exit and the entry gates
of our body makes it safe for us and for others, thus decreasing
the chance of spread of the virus in the community.

The following instructions are given for the use of the

masks:
• Get a cloth mask or make one; write your name on it, so
that it doesn’t get mixed up with other family members.
You can wash and re-use the mask for months; don’t
throw it away. Wash it before you use it the first time.
• Wear a mask for as much time as you can, but
compulsorily if you have a cough or fever – even while
inside the house; and compulsorily if you step out of
your house.
• Your mask should cover your nose, mouth and chin – for
it to do the job. Don’t just hang it around your neck. Take
the mask off only to eat, drink, bathe etc.
• Once you put on your mask, handle your mask only by
the strings. Do not touch the front of the mask or the
inside surface. If you do, then wash your hands.
• At night, wash your mask with soap and water. If you
have an iron at home, iron the masks; the heat will kill
the virus if any. Or else, dry the mask in the sun. Make

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two masks for each family member if possible, so that

you can use them on alternate days.
• Try to maintain 6 feet distance from others as much as
possible; avoid crowding.
• Wash your hands with soap and water as many times a
day as possible, especially when you enter your house or
leave it, or after touching things.

Conclusion
The Prime Minister in his address to the nation on the 14th of
April said: "Completely adhere to the ‘Lakshman Rekha’ of
Lockdown and Social Distancing. Please also use homemade
face-covers and masks without fail". We endorse this call and
request all the people of India to help their neighbourhoods
reduce the risk of community transmission by taking this up as a
mass movement.

The proposition is that a community intervention comprising of

the 3 pillars - physical distancing, frequent hand-washing and
masks-wearing, if taken up on a mass scale as a people’s
movement, can possibly reduce the community transmission of
Covid-19. It is a cost-effective, participatory approach that can
channelize pent-up energy of youth into a positive community
activity, for the greater common good. And anybody with a
sewing machine can contribute, working from home, and earning
some income in the process. A win-win idea for all of us!

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Will Vitamin C be of any help?

Everybody wants to improve the immune system to avoid

infections, specially COVID-19. Vitamin C is the nutrient
connected with immune system. It is often prescribed in short
courses to promote wound healing and for faster recovery from
infections, including cold. So it has been the interest of
researchers in COVID-19 also.

Large doses of intravenous Vitamin C are being tried in COVID-19

critical patients on ventilators in China. The results are still not
out. In Australia, researchers reported that they did not find any
benefit in using Vit C, while the U.S. is planning to try a
combination of Vitamin C, Vitamin D, Zinc and
Dr. Rajan Ravichandran hydroxychloroquine for prevention. Many of the internet sites
Dr. Rajan Ravichandran heads
offer vitamin C as immune boosters. Caution is required in
the MIOT Institute of consuming mega doses of vitamins without prescriptions,
Nephrology and is also especially for long periods.
Chairman of Sapiens Health
Foundation A 74-year-old man in Belgium landed up in the hospital with
weakness and vomiting. He was found to have severe kidney
failure. He was dialysed and his kidney biopsy showed deposition
of oxalate crystals, responsible for the kidney failure. On probing
further, it was found that he had been consuming for one week a
“rejuvenating powder”, which he had bought online. The powder
on analysis was found to be Vitamin C.

Vitamin C or Ascorbic acid is a water-soluble essential nutrient.

Being water soluble, it is not stored in the body and requires
daily intake. It is a powerful antioxidant with an important role in
controlling infections and promoting healing of wounds. It has
numerous functions such as synthesis of collagen (important
component of bones, cartilage, nervous system, immune system
etc) chemical messengers in brain and hormones. Deficiency of
Vitamin C is rare and but when it occurs, it is called scurvy. It was
reported in sailors in the past since they had no access to fruit
and vegetables. It manifested with bleeding gums, delayed
wound healing, skin spots, hair loss and anaemia.

The daily requirement of Vitamin c is 90mg in adult males, 75mg

for females which increases to 120 mg in pregnancy. Smokers
require additional 35 mg since smoking depletes Vitamin C. The
source of Vitamin C is fruits, especially citrus fruits, and
vegetables. Sailors were given an orange daily to prevent scurvy.
Heat destroys Vitamin C. So prolonged cooking and leaching of
the water can reduce the intake of the Vitamin. The Vitamin C
consumed after absorption is metabolised in the body to oxalate
and is removed by the kidneys.

Large doses of Vitamin C called mega doses are popular to

improve the immunity and promote wound healing. The

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scientific evidence for this is lacking or at best, controversial.

Similarly, mega doses have been taken for common cold.

Normally the body can cope with this high dose by reducing the
absorption and increasing the oxalate loss in urine. But in some
people the oxalate can get deposited in the kidneys resulting in
kidney failure. This is likely in patients with intestinal disorders
and pre-existing kidney disease. The toxic dose reported has
been anywhere from 480 mg to several grams taken over
variable periods. Fortunately, this is a rare complication, but lay
people and physicians should be aware since there is popular
concept that extra vitamins in large doses are helpful during
stressful situations. Of course, the toxicity of large dose oil
soluble vitamins like Vitamin A and D are well known since they
produce high calcium in blood leading to stones and kidney
failure.

The Eskimos traditionally would never eat the polar bear whose
meat is very rich in vitamin A and D. It is very important that we
maintain a balanced diet, regular exercise, and exposure to
sunlight as a routine in life. Mega doses of vitamins are best
avoided without monitoring.

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Insomnia going viral

The World Health Organisation has increasingly focused on non-

communicable diseases such as obesity, hypertension, diabetes,
heart disease, stroke and cancer which could lead to long term
disability, complications and mortality. Sleep disorders which are
more common than these and can, in fact, lead to several of
these problems are often forgotten.

With the COVID-19 Pandemic, more people are sleepless and

now waking up to this issue. The fear of disease, travel
restrictions, social isolation and inactivity, financial losses and the
overall looming uncertainty contribute significantly to lack of
sleep. When the mind is disturbed, insomnia often follows and
N. Ramakrishnan may lead to psychosocial problems including anxiety and
depression. Untreated sleep disorders could also lead to poor
N. Ramakrishnan is the Director control of blood pressure and diabetes.
of Critical Care Services at
Apollo Hospitals, Chennai In these difficult times, simple measures could go a long way in
helping a person sleep better.

Inactivity in general can reduce sleep time. Public spaces such as

malls, gyms and parks are not accessible due to restrictions and
should be avoided. Simple stretches and yoga at home, walking
around the house or in the terrace (which could also help with
sunlight exposure) would help.

For those who are working from home, create an appropriate

work environment at home and work during specified hours. It is
important to have a scheduled sleep and wake up time even
though there is no compulsion to sleep on time or wake up early
while at home.

Healthy eating at the right time and particularly having dinner at

least 2 hours before bedtime is essential. Milk, honey and
banana have sleep promoting substances and may be consumed
before bedtime if there are no reasons not to. Families can also
take this opportunity to have meals together which often doesn’t
happen when each one is busy with their professional
commitments.

Engage in relaxing activities with the family (such as indoor

games), reading books and watching television. These would not
only prevent boredom but help to keep the mind distracted from
worries and fear.

Visiting family members locally if possible (unless anyone

involved is quarantined) may be an opportunity to connect and
relax. Communicating through video and audio calls with near

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and dear who are several miles away would help confirm their
wellbeing and allay fears.

While two or three cups of coffee or tea per day is acceptable, it

is best to avoid stimulants at least 4 to 5 hours before bedtime.
Reducing or preferably stopping smoking and alcohol
consumption would enhance quality sleep

Patients who have prior sleep problems should contact their

doctor early if they encounter any issues while on their current
treatment. If travel is a concern, options of tele-consultations
should be considered.

Disasters and mass tragedies can lead to Post-Traumatic Stress

Disorder (PTSD) which can be prevented by taking appropriate
measures during the Pandemic. Sleep well to stay healthy.

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Non-COVID-19 emergencies in pandemic times

Amongst the chaos of the COVID-19 pandemic across the world

and in our city, as emergency physicians we find that people are
delaying their visits to the hospital, thereby resulting in an
increase in complications and jeopardizing their own lives.

During the lockdown, emergencies that led to serious

complications could have been avoided if medical aid had been
obtained on time.

One such case was a burns patient brought to the hospital after
one week of self-medicating on a second-degree burn, with a
Dr. Aslesha Sheth huge infected blister over the right palm and wrist. If the patient
had availed early treatment, he could have easily avoided the
Dr. Aslesha Sheth is an complications.
emergency care physician at
Kauvery Hospital, Chennai People with chronic conditions such as hypertension and
diabetes might need immediate care and attention if symptoms
persist or heightened discomfort is experienced.

A hypertensive and diabetic patient, suffering from abdominal

pain, constipation, and vomiting, was brought to the hospital
after one week of self-medicating, that had led to complications
in her small intestine leading to an obstructed hernia and
disrupted kidney functions, which required emergency surgical
intervention and treatment.

The patient had to be hospitalised and was discharged after 5

days, once her kidney functions normalised.

The elderly are prone to infection and existing chronic conditions

can cause life-threatening complications if not treated
immediately. It is highly advisable for adults to not delay in
getting treatment for even minor symptoms.

To cite an instance, a 70-year-old male, diabetic and

hypertensive patient, was brought to our ER with multiple
episodes of seizures for two days and in an unresponsive state
with persistent seizures.

Extended treatment
He was found to have increased pressure within the brain cavity,
which caused the fits. He had to be in the ICU for a couple of
days and receive extended treatment for over a week to reach
normalcy.

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The list of medical and surgical emergencies is endless, these

time-critical emergencies if not treated on time could be life
threatening. For instance:

Acute heart attacks are best treated with good reversibility of

cardiac function if treated on time and the golden hour being
one hour from onset of pain. Delay in treatment can cause
complications like irreversible muscle damage leading to
pumping failure, fatal abnormalities in electrical conduction of
the heart, leading to very low or very high pulse rate, which can
lead to sudden death if not treated on time.

Acute onset strokes are best treated within 4.5 to 6 hours of

onset of symptoms, but delay in presentation to hospital beyond
this can lead to severe morbidity, disability and mortality.

Patients with trauma at home secondary to accidental falls or

RTAs — whether limb fracture or head injuries, they should be
addressed on time to prevent complications.

Any patient on dialysis needs timely intervention to ensure life-

threatening complications are avoided.

Never forget that complications of high and low blood sugar

need to be addressed in time, else that could lead to various
complications ending up with multi-organ dysfunction.

My only request to all would be — please don’t ignore your

symptoms. Act smart, act fast. Let the fear of COVID-19 not stop
people from treating what can be prevented.

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Do not ignore non-COVID-19 medical emergencies

Fear of coronavirus and the need for quarantine should not deter
people from seeking treatment for non-COVID acute medical and
surgical emergencies. In recent weeks, we have come across
several instances of patients and relatives seeking medical
attention very late for even emergencies because of fear. With
clinics and many smaller hospitals closed, we had seen quite a
high number of patients with cardiac, neuro, stroke, gastro,
diabetic and orthopedic emergencies presenting late with all
complications leading to delayed intervention and recovery.

What are the cardiac emergencies, which present late?

It is well known that cardiovascular death is the number one
Dr. Aravindan Selvaraj
cause of death globally. The intervention in golden hour after
Dr. Aravindan Selvaraj is acute cardiac events like heart attacks will reverse the harmful
Executive Director, Kauvery effects and save lives. In the last few days, we have seen patients
Hospital with acute coronary syndrome, heart rhythm abnormalities and
complete heart block presenting late with all complications.
Cardiac patients are also at increased risk of COVID-19
complications and they can present as heart attack, myocarditis
and heart failure. All these patients need to be treated in
hospitals with facilities for 24/7 Acute Coronary Care Units
(ACCU), managed by senior cardiologists.

How about stroke and neuro emergencies?

Stroke is another medical emergency, which if treated within the
window period of 4 hours will result in near complete resolution
of condition. Now, we see many patients with stroke presenting
late leading to complications, prolonged stay in ICU and delayed
recovery. The delay in seeking treatment in these patients is due
to several reasons like fear of Corona and lack of transport.

But, well equipped hospitals with facilities like Hyper Acute

Stroke Unit (HASU) are manned round the clock by stroke
physicians and nurses to take care even at this time of crisis. We
also see patients with epilepsy with fits presenting late.

What are the gastro-intestinal conditions one should

take prompt treatment for?
We also see patients with acute abdominal conditions like
appendicitis, cholecystitis due to gall stones and obstructed
hernia presenting late with gangrene and perforation leading to
peritonitis and sepsis. These patients needed emergency surgery
and prolonged stay in ICU because of delay in seeking treatment.
The complications could be avoided by early interventions.

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What are the emergencies you see in diabetic patients

now?
We see diabetic patients with very high blood sugar levels,
presenting acutely with diabetic keto acidosis. Also, we see
diabetic patients with cellulitis and sepsis presenting late.
Diabetic patients have to be extra careful at this time, monitor
glucose levels regularly and seek help early in case of abnormal
levels.

How about injuries and fractures?

Though we see a sharp reduction in road traffic accidents, the
number of people with fractures due to domestic fall have
remained the same.

In particular, the elderly with hip fractures present to the

hospital even a few days after the fracture with complications.
They should be treated promptly.

The patients presenting with COVID-19-like symptoms are

treated in isolation facilities so that the non-COVID emergencies
are managed in the main hospital in an uninterrupted way.
Please don’t ignore emergencies and call for help immediately.

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Postponing elective surgeries can save lives

The entire world is facing an unprecedented medical emergency

caused by the novel coronavirus disease (COVID-19). Medical
professionals and scientists are working hard to halt the spread
of COVID-19 and save lives. Many countries had gone into a
lockdown, to stop everyone except emergency services
personnel from moving about, in a bid to prevent transmission of
the infection.

Healthcare teams are struggling to treat patients who have

varying degrees of symptoms. Some may require treatment in
Dr. S.M. Chandramohan the Intensive Care Unit (ICU), and a few may warrant artificial
respiration with the use of a ventilator. The warriors at the
Dr. S.M. Chandramohan is a forefront are the intensivists, critical care specialists, critical care
senior gastroenterological nurses, and anaesthetists.
surgeon, and director,
International student program, Although most of the people have understood the seriousness of
Sri Ramachandra Medical the problem, a few still want to have planned or proposed
college elective surgeries done in this period, without realising the
possible risks and difficulties involved in getting operated now.

The concern and apprehension is multi-fold when the diagnosis

is cancer. As individuals and teams have not encountered such a
situation before, many organisations such as the International
Society for Diseases of Esophagus, the American College of
Surgeons, SAGES with inputs from WHO and CDC, are coming out
with guidelines to be followed to resolve dilemmas. These
professional medical societies are guarded in providing these
principles, adding a note that they are based on the evidence
available as on date and that the recommendations are subject
to change every day.

It is time we understood the implications of having a planned

elective surgery at the present time.

Any patient who has to undergo surgery has to consult the

surgeon and the physician to get medical fitness certified, and
the anaesthesiologist for an assessment. For this, he or she has
to visit a hospital or a laboratory, where the patient may not be
the only one going for tests. There would be people with
emergency situation waiting for tests. There is a need to
maintain social distancing too as one does not know the status of
the others waiting there. Moreover, in the wake of COVID-19,
there may be a need for additional testing.

Limited resources
The labs and diagnostic centres will be working with limited staff
to handle emergencies.

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After the tests are done and you wait for the fitness report from
the physician and anaesthetist, you will be intruding into the
time which they would like to devote to emergencies.

If you have to undergo surgery, even if it is an outpatient

procedure, you have to go with a relative to give consent,
subjecting them to the risk in the time of lockdown.

The situation becomes complex if the surgery is a major one

necessitating long operating hours, obviously warranting a full-
fledged surgical team, anaesthetic team, theatre sisters, theatre
technicians and workers from the sanitary department.

After the surgery, there may be need for ICU care and even
ventilator support, adding to the burden of the ICU staff. All
these resources may be needed for another patient in crisis.

Guidelines from most of the professional Societies across the

globe suggest: wherever there is a possibility to continue medical
therapy, to do so, and to plan surgery for a conducive time; even
if surgery is the only option and but not on emergency basis, it
can still wait. There is also a growing concern about doing
laparoscopy or open surgery, for which we do not have a clear
answer yet.

Patients diagnosed with cancers have different problems: their

concern will be about the potential advancing nature of the
disease if not operated immediately. The medical team’s concern
is about weighing the balance between the benefit and risk of
subjecting them to a major surgical procedure, which may
warrant long operating hours, involving a bigger team, ICU and
ventilator care.

Collective decision
In such circumstances, multi-disciplinary meetings are held via
video conferencing and a collective decision is made by the
experts on what is best for the patient in the current situation.
Sometimes, they resort to a treatment strategy like initial
chemotherapy and radiotherapy which halts the progression of
the disease.

This policy gives the patient and the team the “window period”,
buying time to operate at a favourable juncture. If the risk of
surgery, including ICU stay, outweighs the benefits, they may be
subjected to non-surgical treatment modalities.

The government and the entire medical fraternity is fighting a

serious pandemic, working hard to save society. If elective
surgery is postponed, it is only in the interest of the patient.

It is equally important to understand that their help is required

for patients who are in need of more immediate care.

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Today’s difficult situation calls for understanding from all of us.

That advice to postpone elective surgeries is given in the interest
of all concerned. We must understand that by waiting, we are
not wasting time.

By relieving unnecessary pressure on the health system, based

on sound medical evaluation, the patient is actually doing herself
a service - saving oneself and society by helping doctors save
more lives.

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THE BODY AND COVID-19

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It’s important to protect skin

It is imperative that we follow the guidelines laid down by the

World Health Organisation (WHO) and the government with
respect to personal protection against novel coronavirus disease
(COVID-19). Part of this is practising hand hygiene -- frequently
washing hands with soap and water or application of sanitisers.

While hand hygiene is an excellent method to prevent the

infection from spreading, it is also important to protect our skin
from adverse reaction to frequent hand-washing or use of
alcohol-based rubs. Even though COVID-19 is not skin loving, the
pandemic has affected dermatology specialty in more ways than
Dr. D. Dinesh Kumar one.

Dermatologists are noticing an increase in patients showing up

with hand eczema/dermatitis caused due to irritation by
exaggerated hand washing with soaps, predominantly made of
chemicals. As we cannot shy away from frequent hand washing,
it is highly recommended that such patients apply a moisturiser
cream after every hand wash. Also, there have been instances
where a few patients have mistakenly wiped their faces with
alcohol-based sanitisers, resulting in irritation of the facial skin or
aggravation of an existing skin condition.

Stress and anxiety

These problems are common in people with dry skin and with an
Dr. Ishwarya R. atopic (skin allergy) background. During the pandemic, it is likely
that we are under continuous stress and anxiety at a
Dr. D. Dinesh Kumar is the
subconscious level. Since, skin disorders also have a co-relation
Secretary General, Indian with emotional/mental stress, the current scenario is expected
Society of Teledermatology and to exacerbate the existing skin conditions in patients. Patients
Dr. Ishwarya R. is a public with chronic skin condition and who are on long-term medication
health specialist. for the same are advised to consult their dermatologists on
continuing the medicines.

Health care professionals, including doctors, nurses and other

paramedical staff, too develop skin problems due to prolonged
use of personal protection equipment (PPE).

Continuously wearing gloves can cause hand dermatitis and

wearing of occlusive masks, goggles for long hours has led to
facial itching, rash, and dermatitis and use of protective caps has
led to itching, folliculitis, and seborrheic dermatitis of scalp in
some professionals. Therefore, it is important to continue using
PPE along with skin emollients, barrier creams, moisturisers, and
skin-friendly soaps/shampoos.

With regard to direct manifestation of COVID-19, there have

been reports about skin changes in patients. The skin changes
were seen in 20.4% of the 88 patients in a study from Lombardy

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region of Italy (published in the Journal of European Academy of

Dermatology & Venereology by Relcalcati S.).

Another study from China by Guan W J. et al., in the New

England Journal of Medicine noted rash in only 0.2% of 1,099
COVID-19 patients.

Use teledermatology
Some skin disorders worsen with stress requiring immediate
attention of dermatologists. With lockdown in force, patients
were unable to access dermatological care, since most clinics
were temporarily closed as a precautionary measure.

It is prudent to provide teledermatology care to non-emergency

skin conditions and the dermatologist will be the right person to
decide whether a patient needs in-person consultation.

There are some general ways to keep your skin and body in good
health during this period. People should maintain a proper
schedule with respect to food, sleep and moderate physical
activity. One should engage in a constructive activity (like yoga,
meditation, reading, other hobbies), regulate their news feed,
stay positive and practise social distancing.

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Breathing hard

On one hand, COVID-19 infections are on the rise, and on the

other, people with chronic lung diseases are worried. This is
because the presentation of COVID-19 is with nasal symptoms,
loss or decrease in smell, chest pain and breathlessness. This is
always associated with fever, body pains and fatigue. Most of the
bronchial asthma and COPD patients too are present with these
symptoms, when they get an infective exacerbation.

In bronchial asthma, the symptoms are sporadic and patients

respond well to inhaled bronchodilators and if necessary, they
respond to antibiotics rapidly unlike in serious COVID-19. The
Dr. R. Narasimhan lungs get affected in serious COVID-19 when a cytokine storm
occurs with stiff lungs, small clots in lung vessels and the oxygen
Dr. R. Narasimhan is a Senior carrying capacity of the blood becomes low.
Respiratory Physician, Apollo
Hospitals, Chennai The combination of these factors pushes the person into full
blown respiratory failure and recovery from this becomes
difficult.

This is quite in contrast to what happens in infective

exacerbation of asthma. The response to treatment is quite
dramatic and within 48 hours they start finding symptomatic
relief. I advise most of my patients who call over the phone and it
is only if they don’t respond, do I ask them to come in for a
consultation. With this lockdown, the number of infective
exacerbations have come down significantly and most of them
do well with telephonic advice. I have not found any increase in
admissions due to this problem.

Cancer and COVID-19

This is in contrast to people who have suffered from lung cancer
or had treatment for cancer with chemotherapy or are on
treatment with biologicals, or those who have undergone
surgery and/or are on chemotherapy now. Most of these
individuals are around 60 years with their immunity
compromised. The symptoms of cough and breathlessness
cannot be brushed aside casually in them as COVID-19, if it
occurs, can proceed at a galloping pace. This is because of co-
morbidities that reduce the immunity along with the treatment
that reduces the immunity.

This somehow does not appear true of TB. I have not had any
patient who had treatment for tuberculosis regularly call me and
ask me whether he should undergo any tests for COVID. A lot of
talk about the correlation between BCG immunisation and
vulnerability to COVID-19 is going on.

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Although there may be an argument that we are not doing

enough tests to pick up more infections we have not seen any
unusual increase in mortality during this season in hospitals both
government and corporates put together. Mortality rates cannot
be hidden though there may be some undetected asymptomatic
infection in the country due to non-testing. Some are also
making a case that malarial endemicity and consequently the
persistent use of hydroxychloroquine might have offered India
some protection.

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Does SARS-CoV-2 affect the liver?

There have been few predecessor viruses for this one, which
share similarities in structure and in the way it inflicts damage to
human body. Viruses self-mutate periodically, change its
structure and form and take new avatars. The current avatar
inducing COVID-19 spreads rapidly and has more death rate than
previous generations. All previous coronaviruses were
respiratory pathogens.

Liver impairment has been reported in up to 60% of patients

with the preceding coronavirus — SARS-CoV. Given the fact that
Dr. Harikumar R. Nair this novel corona (SARS-CoV-2) has 80% genetic similarity to the
preceding strain of the virus (SARS-CoV), does it act similarly with
Dr. Harikumar R. Nair is a reference to the liver?
senior consultant hepatologist
and a liver transplant Let us look at information from China. Liver damage in mild cases
physician. He is a hepatologist of COVID-19 is often temporary and the organ can return to
at Gleneagles Global Health normal without any special treatment. This could be due to the
City, Chennai and Kinder Multi state of direct infection of liver cells or could as well be due to
speciality hospital, Kochi liver cells getting caught up in the immune war between body’s
immune system and the virus with chemicals produced by our
body, namely cytokines. More patients with severe disease had
abnormal liver function tests than did non-severe patients with
COVID. Those who tested positive for the virus (sub-clinical
phase, identified by contact tracing), but did not develop
symptoms had much less involvement of the liver. In short, liver
injury depends on severity of COVID-19.

Cases of acute liver failure have not been reported yet

from China or from other countries
What about people who already have liver disease? People with
non-alcoholic fatty liver disease (NAFLD) or its more severe form,
non-alcoholic steatohepatitis (NASH), often have cardiovascular
risk factors, including metabolic syndrome, obesity and diabetes,
raising the risk for severe COVID-19 complications.

Although hepatitis B virus (HBV) is common in China and other

Asian countries, studies so far have not reported whether HBV-
related liver disease influences COVID-19 outcomes. All these
liver diseases without advanced scarring or cirrhosis would not
have more chance to get the virus infection though.

That is not the case with cirrhosis of liver — cirrhosis per se may
be considered an immune dysfunctional state; those under
medical management and those in whom a liver transplant is
planned and waiting for organ allocation should also be
considered at more risk.

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Pre-existing disease
Those who have pre-existing liver disease, should they undergo
check-up and LFTs to see if coronavirus has entered the liver?
The answer is an emphatic NO. What has been mentioned here
is abnormality of LFT in those patients who already developed
COVID-19. COVID is a respiratory illness and will have symptoms
pertaining to lung. Severe cases who are hospitalised alone may
develop jaundice. Liver injury will not occur in the absence of
respiratory illness and hence no screening tests/ LFT are
indicated in patients with liver disease.

Are liver transplant recipients at higher risk for COVID-

19?
Certainly. Those who have undergone liver transplant and are on
immunosuppression medicines (anti-rejection medicines) are
certainly at higher risk of getting this infection and logically, can
end up with severe disease.

People with a weakened immune system may be unable to fight

off the virus. So transplant patients have more chance of getting
the virus, but paradoxically transplant recipients may not exhibit
symptoms — fever, breathlessness — to begin with. Apart from
the routine measures of frequent hand washing, hand sanitising,
cough etiquette and avoiding putting hands to mouth, they
should try to avoid crowds and non-essential travel.

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What does COVID-19 mean for kidneys?

First of all, the disease itself can damage the kidneys. Secondly,
the spread and isolation in dialysis units will be a problem.
Thirdly, dialysis and transplant patients may succumb to it more
easily.

What does the data from Wuhan show so far? The main causes
of death for patients infected with COVID-19 are pneumonia and
respiratory failure. Early reports from Wuhan showed only up to
9% kidney involvement in these patients. But a subsequent
report covering 59 patients showed that 34% had a protein leak
in urine on admission, which increased to 63% later. The kidney
function was reduced in 27% of the patients and in two-thirds of
Dr. Rajan Ravichandran those who died. Among the 710 hospitalised patients, 44% had a
Dr. Rajan Ravichandran heads
protein leak and 26% microscopic blood leak in urine.
the MIOT Institute of
The CT scan showed dense kidneys in those who died. The
Nephrology and is also
Chairman of Sapiens Health
reason for this was the direct involvement of the kidneys with
Foundation the virus and also the inflammatory toxins (cytokines) released in
sick patients.

One interesting finding was that among the patients who were
taking certain BP drugs like ARB and ACE inhibitors, the death
rate was higher. The treatment of patients with kidney failure is
not different from that of any other patient in ICCU, including
dialysis or CRRT.

There are no reports on patients who are not on dialysis. There

are 7,184 patients in 61 centres in Wuhan city. Only seven
deaths have been reported, with 37 out of a total of 230 patients
having been affected, besides four staff members. Reports from
other centres are not available. In the affected patients, the
disease seems to be milder. Dialysis centres are likely to spread
the infection due to close spacing between patients and frequent
visits by patients.

Both the Chinese Society of Nephrology and the Taiwanese

Society of Nephrology have issued guidelines for dialysis units,
including education and training of staff and patients, collection
of travel data, isolation of suspected cases, use of cap mask,
gowns and sanitisers, hand washing, disposal of waste,
sterilisation of machines, increasing the distance between
patients and cleaning and disinfection of units. It would be very
difficult to follow these guidelines in India due to the total non-
uniformity of dialysis units and the reuse of dialysers in many
centres. Universal precautions should be followed in dialysis
centres, irrespective of epidemics.

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Transplant patients
There are no reports of COVID-19 in transplantation patients.
Though we expect kidney transplantation to have special
concerns, immunosuppression late after transplantation may
result in less severe manifestations of the disease. Obviously,
these patients are required to follow the same precautions —
hand washing, fewer visits to hospitals and avoidance of travel.

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COVID-19’s gut connection

In the wake of the present the COVID-19 pandemic, there has

been a much-needed increase in awareness among the general
public of the importance of handwashing, social distancing and
observing cough and sneeze etiquette. Observing a healthy
‘toilet hygiene’ must also be stressed, in view of the fact that
COVID-19 affects the gastrointestinal tract too.

Most of us are aware that the COVID-19 presents with symptoms

such as fever, cough and difficulty in breathing.

What is to be noted is that recent scientific data suggests that

nearly 50% of the COVID-19 patients present with predominant
Dr. T.S. Chandrasekar
digestive symptoms as their primary complaint. The digestive
symptoms include lack of appetite (83.8%), loose stools (29.3%),
vomiting (0.8%) and abdominal pain (0.4%).

Although these patients usually do have coexisting respiratory

complaints as well, a few of them (3%) can present with only
digestive symptoms without any respiratory symptoms.

It appears that patients who report gastrointestinal symptoms

usually have a more severe course of the disease and
consequently a poorer outcome, compared to patients with
COVID-19 infection without gastrointestinal symptoms. As the
disease progresses in severity, digestive symptoms also increase.
Dr. K. Raja Yogesh

Dr. T.S. Chandrasekar is

Shed in stools
chairman, Medindia Hospitals Scientific studies have proven that apart from nasal and
and Dr. K. Raja Yogesh is a respiratory secretions, the COVID-19 virus is actively shed in the
gastroenterologist at Medindia stools of infected patients. This shedding may continue to occur
Hospitals for as long as five weeks after the patient recovers from the
respiratory symptoms.

Fact File In this regard, besides the already known measures such as
avoidance of close contact, social distancing, observing
50% of COVID-19 patients cough/sneeze hygiene etiquette and wearing personal protective
present with digestive symptoms gear, the importance of a proper handwashing protocol,
especially after bowel movements, must be stressed. Since there
Infected patients actively shed
is a likelihood of bioaerosols being released in the air during
the virus in the stools
flushing of the toilet (toilet plume), it is advisable to ensure that
Proper hand-washing protocol the commode lid is closed before flushing. Avoiding the lavatory
must be stressed after every immediately after it has been used by another may also reduce
bowel movement exposure to the virus. Since infected individuals may be
asymptomatic and testing everyone would not be feasible,
Ensure closure of commode lid assuming everyone to be potentially infective and observing the
before flushing to avoid bio- mentioned personal hygiene measures universally may be the
aerosols best way to break the chain of infection.

Avoid lavatory use immediately

after usage by another

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Don’t ignore abdominal symptoms

The abdomen is a “Pandora’s box” is a well-known phrase

described by many surgeons around the world. Abdominal pain
has always been a tricky symptom to assess. And now, during this
lockdown, we are getting a lot more calls from our patients
complaining of abdominal symptoms. These may vary from
simple gastritis-like pain to acute/severe abdominal pain. These
symptoms need to be evaluated and their medical history
studied before the diagnosis and appropriate treatment.

Abdominal discomfort has been identified as one of the less

common symptoms of the COVID-19 infection. Recent literature
has revealed that about 20% of patients report to the hospital
with a digestive symptom, such as diarrhoea, vomiting and/or
Dr. Deepak Subramanian pain, accompanying their respiratory symptoms. And roughly 5%
show up with abdominal complaints alone. A study in China
Dr. Deepak Subramanian is a found that a third of the people with mild COVID-19 experienced
laparoscopic and bariatric diarrhoea that lasted, on an average, five days. It took them
surgeon. He is the Clinical Lead longer to clear the virus from their bodies, compared to those
of the Department of Minimal without gastrointestinal symptoms.
Access and Bariatric Surgery at
MGM Healthcare So, when should a patient with abdominal symptoms visit a
hospital? If the pain or associated symptoms like vomiting,
diarrhoea, bloating or fever show an increasing trend over a few
hours since the onset, it is better to consult a specialist at the
hospital.

Any acute abdominal pain could mean that the patient may have
an intestinal obstruction, infection or inflammation of the
appendix, gallbladder stones causing infection and pus within the
biliary tract, intestinal perforations and more. These signs would
be intolerable and will limit regular activity or movement.

How do we diagnose once we see you? It’s a combination of

complete history taking and clinical examination with blood tests
and radiological tests like USG abdomen or CT abdomen. Once
diagnosed, treatment choices are offered which may be medical
or surgical in nature. In some situations, emergency surgery may
be recommended to avoid further sepsis as this may hamper the
overall outcome of the treatment and life of a person.

Delayed consultation
About 90% of these procedures can be completed by
laparoscopy (keyhole surgery) which is a minimally invasive
method of performing surgeries. Most of these patients get
discharged within two days and are able to do their routine work
soon. When there is a significant delay between onset of
symptoms and arrival at the hospital, that is where the chances
of performing these procedures through the keyhole method
decreases and the rate of complication rises.

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But during this current situation, I am sure you are probably

wondering how safe it is for people to visit the hospital. All
hospitals are taking utmost precautions to safeguard the health
and safety of their patients and, of course, the healthcare
workers. Effective screening of every person, including doctors
and staff, is performed as they enter the hospital daily. All
patients are screened and their attenders screened. If anyone
has any suspected symptom related to COVID-19, they are
isolated and admitted in specialised isolation suites till the test
results are out.

All patients undergoing surgery are tested for COVID-19 and all
healthcare staff dealing with the patients wear full personal
protective equipment while treating or handling these patients,
even if the results of tests for COVID-19 are negative. Patients
who are recuperating from surgery must take extra precautions
as their general immunity will be a bit more compromised.

People must stay at home if they are fine and healthy, eat
healthy food and indulge in some form of exercising like walking
and breathing exercises within the house to keep themselves fit.
Physical distancing is a very important principle to follow during
this period but in the case of an abdominal or a gastrointestinal
(GI) emergency, healthcare distancing need not be practised. The
best outcomes in all these GI emergencies can be fully achieved
if the patient reports early to the hospital.

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Does COVID-19 have a link with the eyes?

We ophthalmologists are used to the red/pink eye, called Madras

Eye, which is a viral conjunctivitis caused by Adenovirus.

This conjunctivitis used to be seasonal until a few years back, but

now it is seen right through the year. The symptoms of viral
conjunctivitis are red eye, sore throat, fever.

The infection spreads from droplet source (aerosol spread),

wherein it can spread from one person to another, in close
proximity/contact with the surface that is infected.

The virus is very contagious and spreads very easily in closed

spaces and air-conditioned rooms. The Adenoviral infection is
Mohan Rajan self-limiting and is generally not vision threatening or life
threatening.
Dr. Mohan Rajan is Chairman &
Medical Director, Rajan Eye COVID-19 also spreads from droplet source (aerosol spread) and
Care Hospital, Chennai has respiratory symptoms such as breathlessness which is not in
the case of adenoviral infections.

COVID-19 presents as fever, dry cough, breathlessness and can

be fatal.

Those affected experience symptoms such as fever, cough,

shortness of breath or conjunctivitis, which can appear between
two to 14 days, after being exposed to the virus. In addition to
this, according to a paper published in The Lancet, patients can
transmit the virus even before experiencing symptoms.

How is the new coronavirus related to your eyes?

Patients who have contracted the new coronavirus may have
ocular symptoms. Conjunctivitis is an inflammation of the
membrane covering the eyeball. It is often referred to as ‘pink
eye’. Conjunctivitis often presents as an infected/red, “wet and
weepy” eye. Viral conjunctivitis is known to present with upper
respiratory infections (colds, flu, etc.) and may be a symptom of
the COVID-19.

A recent study of hospitals across China, published in the New

England Journal of Medicine, found “conjunctival congestion” or
red, infected eyes in nine of 1,099 patients (0.8%) with a
confirmed diagnosis of COVID-19.

A study in The Journal of Medical Virology showed that of 30

patients hospitalised for COVID-19, only one was diagnosed with
conjunctivitis. Based on this information, the occurrence of
conjunctivitis is low. The American Academy of Ophthalmology
has released new recommendations regarding urgent and non-
urgent patient care on March 18. Patients typically present with
respiratory illness,

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including fever, cough and shortness of breath; conjunctivitis has

also been reported.

The only way is to follow regular hygiene practices — frequent

handwashing, sneezing or coughing onto a sleeve as
recommended by the WHO, and social distancing. Approach a
doctor if you notice any of these symptoms.

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Are diabetics more prone to COVID-19?

Because of the present scare due to the COVID-19 infection,

many people with diabetes have been contacting us asking
whether people with diabetes are more prone to COVID-19. It is
true that the people with diabetes are prone to all infections.

There are some emerging data to suggest that people with

diabetes are also more prone to COVID-19. Moreover, even in
those with infections such as COVID-19, which leads to
pneumonia, the chances of a secondary bacterial infection
complicating the viral pneumonia is there.

Hence, people with diabetes should take particular precautions

with respect to COVID-19, as they already have a slightly
Dr. V. Mohan
immuno- compromised state.
Dr.V. Mohan is the chairman
and Chief of Diabetology at Dr. What can be done?
Mohan’s Diabetes Specialities As with everyone else, it is important to maintain good hygiene,
Centre. especially frequent washing of hands with soap and water and
also with a sanitizer, especially in a health care setting. If you
know someone has cough, cold or fever, it is better to avoid
contact with them.

The spread of the virus is known to be through droplet infection.

Hence, if somebody with COVID-19 coughs or sneezes, you are
likely to catch the infection. It is not necessary to wear a mask
unless you already have an infection. However, if you have the
infection you should wear a mask to prevent infecting others.

Special precaution
It is important to keep your blood sugar under good control. Any
infection is likely to increase blood sugar levels and uncontrolled
diabetes can further lead to worsening of the infection.
Increased testing of the blood glucose levels with a glucometer
or Continuous Glucose Monitoring may be necessary. If blood
sugar levels are found to be very high, consult your doctor and
bring your sugar levels under good control as quickly as possible.

Unless you have type 1 diabetes or severe insulin-requiring type

2 diabetes, wherein the sugar levels tend to go very high and
signs of ketosis or diabetic ketoacidosis (DKA) develop, it is not
necessary to get admitted to hospital.

Follow all the usual precautions like washing your hands with
soap and water regularly and ‘social distancing’, i.e., keeping a
distance from people who are likely to be infected.

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Although spreading of the infection through a needle used for

blood glucose testing or insulin injections is highly unlikely, it is
better not to share your blood testing lancet or insulin needles
with anybody else.

To summarise, all people with diabetes should be aware of the

COVID-19 infection and avoid coming into contact with an
infected person. If by chance, you have already developed the
infection, please see that you keep yourself isolated and don’t
infect other family members or people whom you may be in
contact with. Most importantly, keep your diabetes under good
control and seek medical attention as soon as possible.

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Some tips to avoid diabetic amputations during lockdown

We are seeing an increased number of lower limb amputations

during the lockdown period among people with diabetes. The
reasons given by the people who underwent these amputations
were that they were not able to get proper wound care and
access to their regular doctors who were attending to their
‘diabetic foot’ infection.

In the last one week, we had 5 patients who required a major

Dr. Vijay Viswanathan below or above knee amputation due to diabetic foot infection.
Before the lockdown we used to get some 5 patients in 2 months
Dr. Vijay Viswanathan, Head who required a major lower limb amputation.
and Chief Diabetologist, M.V.
Hospital for Diabetes The warning signs that should alert someone with diabetes to
seek immediate help and avoid a major amputation are as
follows:

• High fever
• Redness and warmth in one foot compared to the other
foot
• A foot ulcer that changes colour and becomes
discoloured or appears yellow due to pus formation
• Pain in the foot
• Past history of reduced blood flow in the foot (peripheral
arterial disease)
• Swelling in one foot (indicating damage to the joints or
bones of the foot)
• Increased white cell count (WBC) in blood tests
• People with a foot ulcer whose blood sugar is not getting
under control

What should people do to prevent a major lower limb

amputation:
In people who have loss of sensation in their feet (neuropathy), it
is very necessary to take utmost care of their feet

Daily foot examination is necessary to detect any minor injury

which may go unnoticed

Avoid dry feet by applying a moisturiser cream on the feet but

avoid in the space between the toes

Look for fungal infection in between the toes

Do not cut nails with scissors and cause injury, but use a nail filer
to file the nails

If the warning signs are present, an immediate consultation with

the doctor is required

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People who have a foot ulcer must examine and dress the wound
regularly with the help of a local nurse

Use moist wound dressings which are available that will help the
patient to avoid daily dressing. It may be possible for a patient
with a foot ulcer to do dressing on their own with these modern
moist wound dressings which are available

Avoid putting pressure on the foot ulcer which will create more
damage to the ulcer. Proper offloading with a cast may be
recommended for some people

Start antibiotics after consulting the doctor if there are signs of

infection because this will help to contain the infection and help
to avoid spread of the infection upto the knee level

Visit the surgeon regularly if there is an active foot infection and

take intravenous antibiotics, if necessary

Control diabetes well with oral medications and use insulin, if

necessary, especially if there is evidence of foot infection

Check the blood sugar both before and after meals on a regular
basis and keep the fasting blood sugar between 110 and 120
mg/dl and the after-meal blood sugar between 160 and 180
mg/dl. This will help to prevent a serious foot infection

Therefore, proper foot care during this period will help to avoid
many lower limb amputations.

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Can DPP-4 inhibitors play a role?

The whole world has been shaken by the COVID-19 pandemic.

Scientists working in different fields such as epidemiology,
virology and immunology are struggling to find the remedy to
control and prevent this epidemic. A number of theories are
going around about the cause and effect of this virus on human
beings. The protective role of smallpox and BCG vaccination from
COVID-19 is also being analysed.

Morbidity and mortality due to COVID-19 is high in those with co-

Prof. Vijayam Balaji morbid conditions including Diabetes.

Type 2 diabetes is associated with low grade chronic

inflammation induced by the excessive visceral adipose tissue
(belly fat). Persistent hyperglycemia (high blood sugar) and
inflammation can cause ineffective immune response resulting in
decreased defense mechanism against any infection.

As a consequence, uncontrolled diabetes along with advanced

age is a major factor of poor outcome during an infection with
COVID-19.

Recently a ray of hope has appeared in the usefulness of the

Prof. V. Seshiah class of drug, DPP-4 inhibitors. DPP-4 inhibitors are used to
control blood sugar levels and widely used in the treatment of
Type 2 Diabetes.

Prof. Vijayam Balaji is We need to know the function of DPP-4 to understand the role
Chairman, and Prof. V. Seshiah of DPP-4 inhibitor. DPP-4 is a type 2 transmembrane glycoprotein
is founder, Dr. V. Balaji Dr. V. expressed in many tissues including immune cells. Although its
Seshiah Diabetes Care and functions are not fully understood, it plays a role in post meal
Research Institute
glucose regulation.

DPP-4 expression is high in visceral adipose tissues and increases

inflammation and insulin resistance.

In a simple way we can now understand a drug that inhibits DPP-

4 will reduce blood sugar, reduce insulin resistance, and reduce
inflammation.

Coming to COVID-19, excessive inflammatory response after an

infection has been shown to be the major cause of an adverse
outcome including acute respiratory distress syndrome and
acute kidney injury. So, harnessing the protective role of DPP-4
inhibitor in decreasing the profound inflammation seems logical.

Few studies published on the anti–inflammatory protective role

of DPP-4 inhibitors in diabetic mice with MERS –CoV infection
support this concept. A meta-analysis in human beings also

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showed that upper respiratory tract infection does not increase

significantly with DPP-4 inhibitors treatment.

It concluded that DPP-4 inhibitors have been associated with

anti-inflammatory and anti-adipogenic effect.

We need more data on the anti-inflammatory effect of DPP-4

inhibitors in minimising the risk and the progression of acute
respiratory complications in COVID-19 patients with Type 2
Diabetes.

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COVID-19 and the nervous system

In the last few weeks several articles have appeared from various
specialists pointing out how the novel coronavirus disease
(COVID-19) can affect their respective specialties. SARS-CoV-2,
the scientific name given to the virus, appears to be truly
omnipresent. Its signature appears in many parts of the human
body directly or indirectly. Initially, it was believed that SARS
CoV-2 was not neurotropic, or it has no preference to hitch on to
nerve cells, the nervous system is at a lesser risk than other
organs. Now, researchers are not sure.

Prof. K. Ganapathy
Neurological manifestations
Papers published in the most respected peer reviewed
Prof. K. Ganapathy is the past international journals from April 14 onwards indicate that
President of Neurological primary and secondary involvement of the nervous system is
Society of India, and the past gradually coming to light. A study of 214 COVID-19 patients from
president of the Telemedicine Wuhan, China, revealed that 36.4% had neurological
Society of India involvement. Symptoms included seizures, unsteadiness, stroke,
dizziness, impaired consciousness, confusion, agitation, cognitive
impairment, and localised neuralgia.

Loss of smell and taste (temporary or permanent) is being

increasingly recognised. The last could occur early or late. Some
patients did not initially have the classic diagnostic triad of fever,
cough, cold and breathing difficulty. More research is required.
The damaging effects of COVID-19 may extend beyond the lungs
to our brains and minds, scientists are warning.

In studies on mice, the SARS-CoV-2 has been shown to enter the

brain from the nose through the olfactory system, said Avindra
Nath, clinical director of the U.S. National Institute of
Neurological Disorders and Stroke, and chief of the section of
infections of the nervous system. In some countries where the
pandemic is spreading clinicians are being advised to consider
SARS-CoV-2 infection as a causative factor in the differential
diagnosis, even for primary neurological presentations. This is to
avoid delayed diagnosis, misdiagnosis and prevention of
transmission. Hopefully this will not apply to India.

Important repercussions
It is essential that serious neurological disorders are not over
shadowed by the COVID-19 crisis. Patients with critical head
injuries and stroke, normally accommodated in ICUs, may now
have to be transferred elsewhere. Interestingly, worldwide, as
per just published literature, there is a perception that a smaller
number of patients with stroke and brain haemorrhage (non-
COVID-19) are coming to hospitals. The significant reduction in
head injuries can, of course, be directly attributed to the

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lockdown. COVID-19 patients operated on for neurosurgical

problems had pulmonary complications more than expected.

Objective criteria are being drawn to prioritise patients with

brain tumours, whose surgery is being delayed. No doctor likes
to play God. Now, limited resources must be judiciously used.

Unfortunately, in the real world, “all are equal, but some are
more equal than others”. The tendency of super specialists to
know more and more about less and less will now change as
COVID-19 will make everyone view things holistically. It is no
longer only about technical competence to manage a brain
tumour. The new norm, more than ever before, will have to
factor in COVID-19 for each and every management decision.
Forty-five years ago, the concept of treating tumours in the base
of the skull, without opening the skull, was introduced. Operating
pituitary tumours through the nose became the accepted norm.
Last month, the British Society of Neurosurgeons suggested that,
as the viral load is high in the nose, this route may have to be
avoided. We are indeed coming a full circle. The world is turning
upside down.

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Judiciously managing brain tumour patients

Brain tumours affect people of all ages and can be benign or

malignant and require well-coordinated multi-specialist care.
Brain tumours in children are especially associated with very high
chance of cure and treatments have to be administered to
ensure tumour control as well as minimal late toxicity, to
maintain quality of life.

Like other cancer patients, brain tumour patients can be at an

increased risk of COVID-19 infection due to their
immunocompromised state caused by the tumour and
treatments given to them.

Our team recently published a collaborative effort with modified

recommendations as per available evidence for managing brain
Dr. Rakesh Jalali
tumour patients optimally during the COVID-19 pandemic.
Health care professional involved in management of brain
Dr. Rakesh Jalali is Medical tumour patients must take into cognisance the ongoing situation
Director of Apollo Proton with limited resources and optimise treatment strategies along
Cancer Centre (APCC), Apollo with prioritising patients based on disease severity. Here are
Hospitals, Chennai some suggestions:

Virtual clinics
Adequate screening needs to be done in clinics to take care of
brain tumour patients with suspected COVID-19 symptoms.
Adequate usage of PPE and distancing should be encouraged.
Visits of asymptomatic or mildly symptomatic patients and
patients with benign tumours can be rescheduled to later date.

Virtual consultations on various digital platforms must be put in

place to take care of brain tumour patients. Patients should be
called for follow-up consultations only when they are
symptomatic (moderate-to-severe headache, hemiplegia,
incessant vomiting, and seizures).

Proper prioritisation
For patients requiring definitive treatment, their management
can be discussed in virtual multi-disciplinary tumour boards
(MDT) with only key decision-making members. Surgical
management should be planned judiciously during this time and
should be done only for urgent cases, such as patients who have
increased pressure (e.g., hydrocephalus) and require measures
such as emergency shunt placement. Minimisation of
hospitalisation and critical care stay should be encouraged to
reduce burden on in-patient resources. Procedures where
aerosol risk is high should be avoided and alternative approaches
adopted. For brain tumour patient requiring radiation therapy,
identifying, and stratifying patients according to the priority of
treatment can be done as follows:

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Malignant brain tumour patients can be considered for

radiotherapy on high-priority basis.

Radiotherapy in benign tumour and low-grade gliomas can be

put on moderate to low priority.

Radiation dosage using fewer sittings should be employed

wherever applicable.

All staff administering treatment should use appropriate PPE.

Similarly, brain tumour patients requiring chemotherapy should

get priority based on their diagnosis (type and grade of brain
tumour).

Emergency care
In case of intractable seizures that may be life threatening, the
patient must be given intravenous anti-epileptics with due
COVID-19 precaution. In case of seizures in COVID-19 patients,
neurological symptoms due to COVID 19 should be considered as
a rare possibility of acute necrotizing encephalopathy also needs
to be kept in mind.

Compassionate Care
Health care professionals should be in touch with their brain
tumour patients more frequently during this time of the
pandemic through video and telephonic consultations and assure
them of continued care and support even if they are unable to
visit clinics.

Brain tumour patients may experience increased anxiety due to

the fear emanating from the COVID-19 pandemic situation,
hence adequate psychosocial support through virtual platforms
should be provided to alleviate their concerns. Patients should
be extremely careful and maintain adequate physical distancing
and their diet and physical activities even during the lockdown
restrictions.

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Stroke is an exception, rush to hospital

The COVID-19 pandemic has changed patient care protocols at

hospitals all over the world. However, it is important that, in
these difficult times, we do not forget the basics of staying
healthy and safe.

Stroke or brain attack still remains one of the main causes of

death and disability, even during the pandemic. One should not
forget the basic concept “time is brain” or the golden hour
emphasising that time is crucial in any brain emergency. The
reason for this emphasis on time is because the brain is
extremely dependant on a constant supply of oxygen and
nutrition, as it does not have any storage capacity. Its
requirements are also very high – almost 20% of the blood that is
pumped from the heart goes to the brain. A stroke may occur
Dr. K. Sridhar
because adequate amount of blood does not reach the brain, or
Dr. K. Sridhar is Director and because there is bleeding in the brain.
Group Head, Institute of
Neurosciences and Spinal Stroke recognition
Disorders, MGM Healthcare, Remember the mnemonic B (Balance), E (Eyesight), F (Face), A
Chennai (Arms and legs), S(Speech) T (Time to go immediately to the
hospital) – this will help in the early recognition of a stroke. Add
to this severe headache and loss of consciousness or fits.

The question asked is – should we go to hospital even when

there are only mild symptoms? The answer is that one has to go
to the appropriate hospital even when there is a doubt of
symptoms. These should be taken as a warning and treatment
started immediately.

While going to the hospital for minor ailments has been

discouraged currently, please remember that a stroke is an
exception. It is an emergency and therefore, even when in doubt,
one has to rush to hospital.

What happens when a patient reaches hospital?

A CT scan is done to see if there is bleeding and depending on

the clinical status of the patient and the time from onset of
symptoms, a clot dissolving medicine can be given intravenously.
A CT angiogram is also done which will show if there is any
involvement of a large vessel. If yes, then the patient will be
immediately shifted to the cath lab for a procedure called
Mechanical Thrombectomy, where through a small catheter
placed into the artery in the groin, the clot is removed.
Remember, for this to happen the patient must reach the
hospital at least within 4 hours from the onset of symptoms.

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Occasionally, surgery may be indicated as a life-saving procedure,

to remove a large blood clot or to prevent bleeding from
happening again. Decisions and actions are taken in a very short
period of time. For this to be effective it is necessary for the
concerned hospital to have not only the equipment and
infrastructure but also a comprehensive stroke team including
specialised doctors in Neurology, Neuro Critical Care, Neuro
Radiology, Neuro Intervention and Neurosurgery, other than
specialised nursing and technicians.

Currently many stroke teams are working on the concept of tele-

stroke, where the stroke team leader at the hospital can
remotely direct the general practitioner or family physician on
starting the treatment even before the patient reaches the
designated hospital. Education of, and good communication
between the different health care professionals is key to the
success of this initiative that promises to reduce the time taken
to initiate treatment of a stroke.

Safety in hospital
All hospitals are taking precautions to keep patients and
healthcare workers safe. Limitations on visitors, rational use of
PPEs and screening with segregation ensure that the stroke
patient is not exposed to a potential COVID-19 positive patient.
Sometimes patients may hesitate to go to the hospital for fear of
getting infected with corona virus, or that doctors would be too
busy treating COVID-19 patients. Both assumptions are untrue.

People in an extremely vulnerable group need to follow the

specific advice about their health condition. A healthy diet,
regular physical activity (at home) and reduction of anxiety and
stress will help maintain your brain health. Smoking and alcohol
are to be avoided at all costs.

While the anxiety of contracting the virus is understandable,

emergencies like a brain attack or stroke cannot wait – prompt
attention at the earliest is the only way to achieve the best
outcomes.

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MENTAL HEALTH AND COVID-19

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Because the mind matters

Pandemics have never been just medical events or crises, they

have affected lives of societies and nations in many ways. The
mental health sequel of many pandemics has been documented.

How one copes with an outbreak like COVID-19 depends on

three factors, the individual, the community and the health
system.

A study conducted in the early phase of the outbreak in China by

Wang and colleagues found that 53.8% of the respondents rated
the psychological impact as moderate or severe and 16.5%
Dr. Lakshmi Vijayakumar
reported moderate to severe anxiety.

The mental health issues have been related to how widespread

the pandemic is, how fast the spread is and lack of control over
it.

It is also related to the mortality rate due to the infection and

availability of good and effective treatments and vaccines.

Symptoms of stress can be:

1. Excess worry about one’s health and that of family,
Dr. R. Thara friends, etc
2. Difficulty in sleeping, loss of appetite and fatigue
Dr. R. Thara is Vice Chairman, 3. Some symptoms of depression including suicidal
Schizophrenia Research ruminations
Foundation, and Dr. Lakshmi 4. If isolated at home, the need to use more of alcohol and
Vijayakumar is founder of other substances of addiction
suicide prevention helpline,
5. Irritability, anger borne out of helplessness and
Sneha
disruption of routines
6. Exacerbation of physical ill health such as increase in
blood pressure / blood sugar etc
7. Need to hoard items like sanitisers or masks or some
essential medicines itself can result in anxiety
8. Fear of acquiring a novel, yet unpredictable disease can
increase negative thinking and behaviours

Who is more vulnerable?

The individuals who are likely to be more psychologically
distressed are:

1. Older people with chronic diseases such as diabetes or

hypertension who are more vulnerable to contracting
COVID-19.
2. Children/adolescents as their routines are disrupted and
they perceive the parent’s anxiety, stress, and change in
lifestyle.
3. Physicians and other health workers who face the
constant threat of exposure, overwork, inadequate
resources and experience secondary traumatic stress.

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4. Persons with pre-existing mental health conditions who

may experience new or exacerbation of their symptoms.
5. People in quarantine. They are confronted with
uncertainty about their state, fear for their family and
friends, guilty and depressed about their isolation.
Research during the previous SARS outbreak found 29%
of those quarantined showed signs of PTSD and 31% had
symptoms of depression.

The connectedness and resilience of the community is strongly

reflected in the mental health of the people during an outbreak.
When a member / family is stigmatised, isolated and ostracised,
mental health suffers.

Mental health consequences of short-term social distancing have

not been studied in detail. Dr. Lunstad suggests two competing
hypotheses. One, that it may exacerbate those who are already
isolated and might trigger others to connect less. The other is
that heightened awareness will prompt people to stay connected
and focus on reaching out to others.

Help yourself
1. Educate yourself about the infection
2. Maintain basic hygiene, but do not overdo it. Persons
with previous Obsessive-compulsive traits may have an
exacerbation due to constant washing
3. Do not over stimulate yourself with news from various
sources, especially social media. This can lead to fatigue,
anxiety, and stress. Do not constantly engage in
conversation on this subject
4. Find ways to relax — be it yoga, music, walks, reading,
family time etc
5. Healthcare professionals must ensure they do not burn
out in the process of caring
6. While physical social distancing is advocated, stay
connected with friends, family and well-wishers.
Emotional isolation does not help
7. Do not hesitate to seek help if you are not able to help
yourself

The schools have been closed and children at home also need
support. Talk to the child, share simple information, don’t
underplay the seriousness since they pick up information from
other sources also. Reassure them they are safe and have all the
support they need, do not make your own anxiety very evident
while you are around them, limit their sources of information
since they could get frightened or misinterpret what they hear
and plan home based activities together.

WHO chief Tedros Adhanom Ghebreyesus said that a crisis like

COVID-19 can bring out the worst or best in humanity. We hope
that it brings out the best in us.

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Be alert, not anxious

The COVID-19 pandemic is on everyone’s mind right now. A

majority of those infected recover from the disease. Twenty per
cent of the patients may require hospitalisation, especially when
there are complaints of breathlessness.

If they have coexisting conditions like chronic renal disease,

cardiac disease, respiratory disease, cerebrovascular diseases,
uncontrolled diabetes, or hypertension, they carry a higher risk
of mortality. Mortality in COVID-19 positive cases ranges from
2% to 8% worldwide.

When we talk about COVID-19 infections and heart diseases, we

face four scenarios — patients with known cardiac disease;
Dr. Suresh Rao K.G. cardiac patients developing COVID-19 infection; patients with
COVID-19 infection developing cardiac complications and
Dr. Suresh Rao K.G. is the Co- patients waiting for or have already had cardiac transplant
Director of the Institute of
Heart and Lung Transplant & For cardiac patients: The most important thing to remember is to
Mechanical Circulatory continue taking your medication if you have a known cardiac
Support, MGM Healthcare, condition. You must also take the following precautions: Avoid
Chennai physically visiting the hospital for your routine check-ups. Utilise
their online consultation facility, if available, to speak to your
doctor. Stay at home to prevent contact with carriers. Practise
social distancing in case you have to interact with others.

Consciously avoid touching your face. If it’s absolutely necessary,

wash your hands with soap and water for at least 20 seconds or
use a hand sanitiser containing at least 70% alcohol.

Work on optimising your immune system. Getting adequate

sleep, staying hydrated, eating a balanced diet, and exercising
every day are paramount.

Keep in touch with friends, colleagues, family, and others

remotely. Your mental health can affect your physical health, so
don’t neglect that!

Remember this: Even if you don't catch the infection, stressing

about the situation can worsen your heart condition. So, it's
important to be alert and not anxious.

For cardiac patients who develop an infection: Maybe you’ve

come to the hospital with chest pain. You may not have COVID-
19 but the hospital may have to test you for it. This is for
everyone’s safety. If you test positive, you and anyone you have
come in recent contact with you should be quarantined for two
weeks. There’s some evidence that shows a fever may actually
be beneficial to your immune system in fighting the infection. So,
for mild infections, fever can be treated with antipyretics.

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Antibiotics may be prescribed to you to treat secondary bacterial

infections if the symptoms are worse. Remember to consult your
physician and do not self-medicate!

If you develop breathlessness or other serious respiratory

symptoms, you may be admitted to the ICU. Any kind of infection
may worsen cardiac failure or cardiac disease as it can produce
inflammatory reactions that include vascular and myocardial
inflammation.

COVID-19 positive patients who develop cardiac complications

are conservatively managed. For example, a patient with Triple
Vessel Disease who is a candidate for coronary bypass surgery
may instead be managed by angioplasty or medically managed
with plaque stabilising drugs such as statins and antiplatelet
agents.

What about end-stage heart failure patients? End-stage heart

failure patients are medically managed at present as the
pandemic is making the logistics of transplantation difficult.

Patients who have already had heart transplantation are at a

much higher risk for infection as they are on immunosuppressive
drugs.

Our strategy is to prevent the infection among such patients by

advising them to stay at home, use personal protective devices
and maintain physical distancing. It’s normal to get worried
about the pandemic given all the free time you have now and the
exposure to several myths and misinformation. But worrying is
not good for your health. Let the healthcare workers do their job
and you focus on following the necessary precautions.
Remember — stay alert, not anxious.

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‘How I fought COVID-19 and won!’

As a doctor posted at the Apollo Emergency Clinic at the Chennai

Airport, I was worried about the exposure to the SARS-CoV-2
virus while on duty. However, I continued to work until
passenger operations stopped as part of the national lockdown,
taking precautions such as wearing a mask and washing hands
regularly.

My tryst with COVID-19 began on March 31 when I started to get

a fever and a sore feeling in my throat. It was okay with
paracetamol for a day or two but then the symptoms increased
in intensity — a high fever accompanied by chills, headache, and
Dr. Arulvel Kathiravan sore throat. The headache stood out in its severity. I had never
experienced such a severe headache in my life. The fever went
up to 102 degrees and left me feeling exhausted.
Dr. Arulvel Kathiravan is
Medical Officer, Apollo Keeping in view the situation and the fact that I had been
Emergency Clinic, Apollo working at the airport with the potential risk of exposure to the
Hospitals, Chennai virus from any infected passengers, I decided to get my COVID-
19 testing done immediately. I had already isolated myself in my
room and was taking all precautions to avoid contact with others.
I waited anxiously for the test results, which came back positive
for COVID-19. I right away informed the head of my department
at Apollo Hospitals, who advised me to go to our hospital at
Vanagaram that had been converted into a COVID-19 speciality
hospital.

Taking due care, I reached the hospital in Vanagaram, where I

was immediately admitted to the isolation ward on 4th April. I
underwent a complete medical check by a team of senior
consultants across specialities, with various tests for any other
existing co-morbidities. There was no other serious problem and
I was glad for my healthy lifestyle at 40 years of age.

Confirmatory test
The confirmatory test also came back as positive for COVID-19
and my treatment began. I was prescribed hydroxychloroquine
and other medicines for my symptoms as per the guidelines. The
medical staff took the utmost care of me. My condition was
monitored continuously. A team of doctors visited me every day
and gave updates about my health. Even though they used to be
dressed up in PPE with faces hidden behind masks, their visits
helped me a lot, as being in isolation is not easy. With no other
visitors and only a television for company, I looked forward to
the doctors’ visits. The staff nurses sincerely attended to me,
giving me my diet, and medications administered on time
without delay. The housekeeping staff ensured that my room
and the surroundings were clean and tidy.

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I was fortunate that my symptoms did not include any

respiratory complaint and there were no other complications. I
began to feel better. The fever subsided and the medication
stopped after the course was completed. On 13th April, I was re-
tested for COVID-19 and to my great relief, the result was
negative. The test was repeated after 24 hours as per the
protocol and guidelines from WHO and when that too came
negative; I was discharged on 15th April, after being successfully
treated for COVID-19.

It was while I was walking out of the hospital that the realisation
struck! I had been one of the over two million patients around
the world who were confirmed cases of COVID-19. I had been
successfully treated for this infection and discharged after a full
recovery. I raised a silent prayer of thanks from my heart to the
doctors, nurses, lab technicians, housekeeping staff and others
who took care of me. I wish them and the thousands of doctors
working round the clock all the best to continue their noble job
and keep saving lives!

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PREGNANCY, CHILDBIRTH AND CHILDREN

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Managing pregnancy and childbirth

“Doctor, I am in my 31st week of pregnancy; neighbours and

friends tell me that I am more prone to get the infection. I am
afraid. What should I do?”

As obstetricians taking care of mums-to-be, we have received

many a phone call seeking help and reassurance. The fear and
anxiety is understandable. Thorough knowledge of the infection
and its consequences will certainly help allay this fear and
anxiety.

Does pregnancy make a woman more susceptible to coronavirus

infection? Although pregnancy is an immuno-compromised
state, we know from years of experience that most pregnant
women go through pregnancy without any major compromise.
Dr. A. Jaishree Gajaraj Compared to the general population they are more likely to
Dr. A. Jaishree Gajaraj is a contract the infection and hence categorised as a high-risk
senior consultant, obstetrics & group. There is, therefore, a need for more strict measures to be
gynaecology, in MGM followed by both the pregnant women and their caregivers.
Healthcare, Chennai
Sneezing, running nose, sore throat, fever and sometimes cough
– extremely common symptoms. Then, how does one
differentiate the common cold from a possible corona infection?
Common treatment for such symptoms would be steam
inhalation, paracetamol and antihistaminics (for cold).

In the absence of exposure to or contact with a known COVID

suspect or history of travel within close contacts (family and
friends), the initial treatment should contain the infection. If
however your symptoms persist, become more severe or
recovery is delayed – it may be an indication of a more severe
respiratory infection and you should contact your doctor. Please
do not panic as this may still not be indicative of a COVID
infection. Kindly ascertain from your doctor regarding the place
of consultation. It may not be the clinic where you regularly visit.

The need for social distancing and self-isolation cannot be

overemphasized. Pregnant women should stay indoors, not
participate in social gatherings and postpone “baby showers”. If
a family member develops a cough or cold you should isolate
yourself for a minimum of two weeks in a separate room or until
he/she recovers.

Our knowledge of the infection itself and its spread is limited.

Given the limited information currently available, it would be
prudent to strictly adhere to social distancing, especially beyond
28 weeks of pregnancy.

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COVID infection and pregnancy

There is insufficient evidence at present to support vertical
transmission from mother to baby in utero, during delivery or
breast feeding. Reports of miscarriage, growth restriction in the
baby, especially when the infection occurs in the last trimester
and induced preterm labour, though occasional, should be kept
in mind.

Routine Antenatal (pregnancy) Care

You may be at various stages in your pregnancy. Trimester I or
upto 12 weeks, after pregnancy confirmed on ultrasound scan,
there is no need for an urgent AN visit.

Certain scans i.e., the first trimester scan, anomaly scan and
growth scan are time-bound, and you should contact your
doctor. If you do not have any significant risk factors i.e., age,
multiple pregnancy (twins), raised blood pressure, diabetes or
other medical or pregnancy related disorders, you can at your
doctor’s discretion reschedule your monthly visits. The aim
would be to minimise exposure to the women and their
caregivers. Routine clarification of doubts can be over telephone
or video calls.

Delivery and immediate post-partum

Your obstetrician and maternity unit may not be able to comply
with all aspects of care you may have agreed to in your birth
plan. Safety is of utmost importance and this will be definitely
ensured. Risks of airborne transmission is high during normal
delivery and precautions will be taken even if you are not a
COVID suspect. If an emergency caesarean section is required,
your doctor will advise you accordingly.

You can breastfeed your baby. Isolation may be advised only if

there is suspicion or history of exposure.

Home Delivery
We have had requests for “home delivery” as it is presumed to
be a “safer” place than a maternity unit in a hospital. Delivery at
home certainly has many attendant risks and should be strongly
discouraged in the current scenario. Monitoring of the mother
and foetus may be sub-optimal. Access to emergency care, if it
becomes necessary, i.e., transport, availability of blood and
maternity units and personnel may be very difficult to organise.

Working women
Working women without any co-morbid factors can continue to
work but must follow social distancing. If you are more than 28
weeks pregnant or have any risk factors it is best to coordinate
with your workplace and your doctor and make a decision.

There could be a number of asymptomatic individuals among us

who are carrying the virus.

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The care of pregnant women affected by the coronavirus will be

protocol driven and is not discussed here.

Remember, my dear parents to be. Our priority should be

reduction of transmission and safety first. My wishes to all of you
for a smooth, safe pregnancy and delivery.

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COVID-19 in neonates and infants

Here is some good news for pregnant and lactating mothers:

Coronavirus infection is less frequent and less severe in children

(Child Sparing Pattern)

During and after pregnancy, a woman is not at increased risk of

coronavirus

COVID-19 does not increase in severity in pregnancy as

compared to other people

Transmission from mother to baby before, during and after birth

can happen but it is less common than anticipated
Dr. Rahul Yadav
Most of the breastmilk samples tested for risks have negative
results. So most European counties, most international
Dr. Rahul Yadav is a practicing authorities such as WHO, UNICEF, many Indian professional
paediatrician and a bodies recommend continuing breastfeeding even if the mother
neonatologist at Rainbow has COVID-19.
Children’s Hospital, Chennai
Be careful with testing
COVID-19 in newborn infants is suspected in only two situations:

Born to mother with suspected or confirmed COVID-19

Related to cluster outbreak or exposed to infected relatives or

caregivers

Indiscriminate testing of all infants with respiratory symptoms is

not recommended. One should note that occasionally babies
infected before birth can have RT-PCR test negative and many
babies with RT-PCR test positive can be quite healthy.

Newborns and mothers

During this pandemic, no extra care is needed for a normal new-
born born to a normal mother. Regular precautions such as hand
washing and breastfeeding should be enough. Social events such
as baby shower before birth or naming ceremony after birth
should be performed in a symbolic way only. Crowding of
relatives and well-wishers near mother and baby should be
avoided till this pandemic is over. Vaccinations should be given as
usual, avoiding crowding in hospitals. Parents should not delay
visit to hospital if baby develops any medical complication.

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In summer season, dehydration is common. Please avoid over-

wrapping the baby and visit the paediatrician if the baby stops
feeding and urine output becomes less. They are treated like any
other pregnant women. Full medical and obstetrics care is given
by designated hospitals. An attempt is made to postpone the
delivery beyond the eighth month of pregnancy. If mother’s
health is at risk; then baby is delivered early. So far, Indian
perinatal and neonatal outcomes are satisfactory. After birth,
mothers must wear a mask and breast-feed the baby on
demand. The baby and mother can be kept in the same room or
different rooms depending on availability of accommodation and
nurses. If in same room, a 2-metre distance should be
maintained between mother and baby. The baby is monitored
for signs such as fever, difficulty in breathing, lethargy, rash, and
diarrhoea.

All over the world, mothers have mixed feelings. According to

UNICEF, 24 million babies are expected to be born in India during
next year. One can be optimistic of better perinatal and neonatal
care due to better awareness of hygiene, better health
infrastructure.

Even if COVID-19 lingers, good habits such as handwashing and

physical distancing can make our world a better place for
newborns.

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Will COVID-19 be polite with children?

With the looming threat of the COVID-19 pandemic,

paediatricians have been getting frequent queries from parents
on the risk of their children getting this new viral infection which
is threatening the entire world.

In the coming days, we can expect large number of children to be

brought to clinics and hospitals for trivial and major symptoms
alike because the fear of unknown diseases is obviously even
higher for children.

Dr. S.Balasubramanian In the first largest series of cases reported from China, only one
child aged 15 years was treated, indicating that there could be a
Dr. S.Balasubramanian is
children-sparing pattern in this infection.
Medical Director, and head of
the department of paediatrics, In 2003, during the SARS epidemic in Hong Kong, among over
Kanchi Kamakoti Childs Trust
1,700 infected individuals, 6.9% were under 18 years of age with
Hospital, Chennai
a case fatality rate of 0%. Similarly, when the Middle East
Respiratory Syndrome (MERS) spread in 2012, also caused by
corona virus, only 2% of cases occurred in children.

Coming to the hottest topic, worldwide data suggests that the

paediatric population, even in this very-high risk area, appears to
be at an unexpectedly low risk to develop COVID 19 infection. It
is unclear why this may happen.

Reports from China suggest that infection of children is possible,

although apparently extremely rare.

One possible reason is that children have fewer outdoor

activities and undertake less international travel, making them
less likely to contract the virus.

Are children cross-protected by having met other Coronaviruses?

Coronaviruses (CoVs) is one of the common viruses that invade
the lungs as rhinoviruses, respiratory syncytial virus (RSV), and
influenza, which all have an RNA genome and are very frequent
in children. Innate immune evasion links to the innate immune
responses elicited by respiratory and other (RNA) viruses. One
explanation could be that pneumonia results from virus-induced
immune response causing destruction of pulmonary tissue. Such
mechanisms could be less effective in children.

The good news so far is that children are apparently at a minimal

risk to develop this new disease, and at virtually no risk of a fatal
course.

Are children going to have different symptoms and signs in this

dreaded disease?

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Most infected children have mild clinical manifestations. They

have no fever or symptoms of pneumonia with a good outcome.
Most of them recover within 1–2 weeks after disease onset. Few
may progress to lower respiratory infections.

Children with infection can fall into any of the

following 4 categories:
1. Asymptomatic Infection
2. Acute Upper Respiratory Tract Infection
3. Mild Pneumonia
4. Severe Pneumonia

William Osler said “The only way to treat the common cold is
with contempt.” Ogden Nash defined Family as a “Unit
composed not only of children but also of men, women, an
occasional animal and the common cold.” Most children in our
country and across the world are going to get this Common Cold
due to COVID 19 for sure as the pandemic looks unstoppable.

However, we need to remember a few scientific facts in this

scenario. Even the most experienced paediatrician cannot
distinguish COVID 19 infection from other viral respiratory
infections with confidence. Only virus testing will confirm or
exclude the diagnosis. Treatment as of today is mainly supportive
and symptomatic in the majority of children. A wide variety of
drugs is being tried in desperation in critically ill without hard
evidence. Vaccine is not yet a reality.

Children may play a major role in community-based viral

transmission since quite a few of those infected may be
asymptomatic or mildly symptomatic. However, we need to
remember that children with chronic diseases, malnutrition,
immunodeficiencies may suffer from serious consequences of
this seemingly benign viral infection in children.

Balanced diet, oral health, adequate exercise, regular rest,

avoiding excessive fatigue, and boosting immunity are the
powerful measures to preventing infection, as well as
maintaining emotional stability and mental health.

It is necessary to stress that there is a need to practise

appropriate hand hygiene and cough hygiene practices
meticulously than ever before.

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Sensitising parents of children with special needs

During these challenging times, our children with needs are more
likely to be disorganised because of the sudden halt of their
routines.

These are testing times for every one of us, especially for
children with needs. Paediatric occupational therapists are allied
health professionals who focus on their resumption of age-
appropriate functions (occupation), be it eating, drinking,
sleeping, talking, or playing. During these challenging times, our
children with needs are more likely to be disorganised because
of the sudden halt of their routines. A change in routine leads to
deprived stimulus, which might hamper their development. This
Dr. B. Balaji may cause anxiety and distress even for the parents who may
run out of ideas.
Dr. B. Balaji is a senior
occupational therapist and Self-engagement is always a concern for children with autism,
founder, Buds to Blossom, slow learners and those who have praxis issues, since doing any
Chennai new task is a bother. So, parents are encouraged to facilitate
engagement in a more therapeutic way, using home resources.

The following are some of the suggestions to be incorporated

along with your given programme:

Hand hygiene is of paramount importance during these days, but

it is extremely challenging for our children since they tend to
mouth their hands, objects, frequently. So use of teethers, chewy
tubes, blowing toys, constant supervision, sanitising their toys,
objects and teaching them hand washing techniques through
physical cuing, visual scheduling (drawing simple icons in a step
by step sequence) will be of great help for visual learners.

Parents can lead by example like doing their regular chores of

waking up in time, carrying on morning rituals without any delay
or postponement. The above said modelling drives our children
to continue their morning chores without any fuss even if they
don’t have to go out.

Explaining the current situation in short, simple and in clear

phrases to nonverbal children with autism helps them reduce
unwanted anxious behaviour and facilitates the desired
behaviour; this technique is called social stories. A social story
makes them ready to anticipate the day’s new schedule and
makes them to acclimatise it imaginatively. Morning chores such
as brushing the teeth, toilet, and bathing can be facilitated
through modelling, physical cues, verbal prompts and including
various positive reinforcements over a period of time, since
these can well become part of their ritual.

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Sensory stimuli
Allowing children to observe the kitchen during meal preparation
gives those rich sensory stimuli through visual, touch, olfactory
(smell), and gustatory (taste) inputs. Precautionary measures for
hot, sharp objects must be factored in. Mothers can teach
children with real objects in more real-life situations like naming,
identifying vegetables, fruits, colours, feel different textures of
cereals, and smell various spices.

This can be followed by food play/ messy play during their lunch
time to desensitise touch, smell, and taste, visual over responses.

Avoid showing the child a mobile phone while feeding, instead go

to the balcony and point to things. Parents can gradually
substitute junk foods, with homemade organic and healthy
snacks.

Best time for stories

Early evening are the best time for listening to stories from their
grandparents or picture book stories which encourages good
sitting, listening skills and expressive language. Playing music
over speakers or wear noise cancelling headphones helps them
to counter auditory over responsiveness and organises them.
Letting loose to make funny movements and shake a bit relaxes
them immensely. Dads can take over evening sessions by taking
them to the balcony/terrace to water the plants, to encourage
loads of sensory motor activity such as running, jumping,
hopping, cycling, climbing, balancing, and ball skills. Children who
don’t have access to terraces can arrange furniture for an
obstacle course and climb over/crawl under to do picking and
dropping tasks. This will help with the much-needed
proprioceptive input. A cotton sari hammock suspended from
ceiling hooks can be provided to ensure vestibular inputs so as to
calm and facilitate muscle tone especially for children with tonal
imbalance, Down syndrome and Cerebral palsy. Tabletop
activities such as drawing, colouring, pattern writing, grid
diagrams, coping different geometric figures and shapes will
integrate visual and motor components which are the
prerequisites for academics and writing skills.

Sleep hygiene is very essential, so start with a warm bath,

followed by warm food, bedtime stories, lullabies in a less
distracted, cozy environment to put them to sleep. The above-
mentioned ideas are general guidelines and not individualised
and parents are encouraged to follow their respective
Occupational Therapist-given sensory diet for your specific
needs.

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SOCIETY

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Needed, a transfusion for public health care

A news channel in India alleged recently that several private

hospitals in the country were “exposed” by a “sting operation” to
be levying fees in excess when COVID-19 patients went to them
for care. It is not clear why a “sting operation” was necessary;
the high cost of medical care in the top hospitals of the country is
well known. Anyone who has had major surgery or received
intensive care in any of the hospitals can testify to that. The
debate now is whether such exorbitant rates are justified during
a pandemic such as the one we are amid, or indeed, ever.

Raj B. Singh Before we address this question, however, an equally important

question arises: why do we have so many private hospitals in a
poor country such as India? We have more hospital beds in the
Dr. Raj B. Singh is a private sector than in the public sector. It is estimated that there
pulmonologist in Chennai.
are 19 lakh hospital beds, 95,000 ICU beds and 48,000 ventilators
in India. Most of these are concentrated in seven States, Uttar
Pradesh, Maharashtra, Tamil Nadu, Kerala, Karnataka, Telangana
and West Bengal. Except for Tamil Nadu, Delhi and West Bengal,
there are far more beds and ventilators in the private sector than
in the public, according to the Center For Disease Dynamics,
Economics & Policy.

A mirror to public care

The reason for this abundance of private health care is obviously
the lack of adequate public health care. This situation has
developed due to two main reasons. Since Independence, India
has, quite rightly, focused attention on the larger picture. The
priority in a developing country would be the provision of
primary care at the peripheral level, preventive measures,
immunisation, maternity and paediatric care as well as dealing
with common infections such as tuberculosis. We have done this
well, resulting in impressive improvements in many health-care
indices in the last few decades. However, not enough hospital
beds and specialised facilities were provided by the public sector
during this time. At the same time, the burgeoning middle class
and increasing wealth produced an explosion in the demand for
good quality health care. Private medicine was quick to capitalise
on this demand.

The second reason for the dominance of private medicine in

India is the lack of adequate investment in public health. The
Indian government spends an abysmally low 1.3% of GDP on
public health care, which is woefully inadequate. Allocation has
to be at least double this to address some of our pressing needs.
Greater transparency and tighter administration are necessary to
ensure that our resources are utilised appropriately. Specialists
should be adequately compensated to obviate their need for
private practice.

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Private medicine in India is by no means uniform. It is estimated

that there are more than one million unqualified medical
practitioners, mostly in the rural areas. Most of them provide
basic health care, charging a modest fee. Some may have claims
of expertise (often unproven) in alternative systems of medicine
such as Ayurveda and Homoeopathy. It is not unheard of them to
sometimes venture into minor surgery. At the other end of the
spectrum are state-of-the-art corporate hospitals, that are well
equipped and well-staffed, and which provide excellent service
at high cost. These are often set up in metro cities at huge cost
and have successfully engineered a reverse brain drain of many
specialists from pursuing lucrative jobs abroad and staying back
in or returning to India. Between the two extremes are a large
number of private practitioners and institutions providing a wide
range of services of varying quality. Some are run by trusts,
charitable organisations and religious missions, often providing
excellent quality at modest costs.

The wide range of quality in medical services in India reflects the

wide range of income and wealth in India. It is estimated that the
wealth of the top 1% in India is four times the combined wealth
of the bottom 70%. The wealthy demand, pay for, and often get,
world-class health care. The middle class, seeing what is possible,
is beginning to demand similar care at affordable cost. The
poorer 70% are left to the vagaries and mercy of an
unpredictable public health-care system and low-cost charlatans.

What needs to be done

The public health-care system desperately needs higher
government spending. Health care cannot be left to private
medicine in a developing country, or indeed, in any country. The
United States, despite spending more than 15% of its enormous
GDP on health care in the form of largely insurance-based private
medicine, has poorer health-care indices than Europe, where
government-funded universal health care (e.g. The National
Health Service of the United Kingdom) is available, though the
per capita health-care expenditure in Europe is substantially less
than in the U.S.

Health-care spending by the government must be appropriate,

based on evidence, and transparent and accountable. Training of
doctors and health-care workers also need to be the
responsibility of the government mainly. Recent reforms in the
selection of medical students need to be scrutinised to see if
they are having the desired result.

Private hospitals and institutions will need to be regulated.

Costing and auditing of care and procedures need to be done by
independent bodies. This will not only ensure appropriate care at
the right cost but also prevent unreasonable demands of
suspicious patients and family.

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The crisis now

No hospital, business, institution or individual should profiteer
from a national calamity such as the COVID-19 pandemic.
Hospitals, like any other institution, have a social responsibility to
provide care in times of need. But one should be also aware of
the actual costs involved which have to be met. The cost of
medical care often follows the law of diminishing returns; as the
treatment gets more sophisticated, further and further
increments, although small, cost enormously more. Some of the
drugs used in the care of severely-ill COVID-19 patients may cost
more than ₹50,000 a shot, for example, and may provide only a
marginally better outcome. “Capping” costs may necessitate
sacrificing some of these expensive options. Private hospitals
should, and will, be prepared to forego profits and even suffer
losses during a national disaster. But if losses become
unsustainable, they may be forced to lay off employees, close
beds or even entire hospitals, like any other business. That will
hardly benefit anyone.

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We need social physicians

While medicine remains central to public health, medical

academia has never been a torchbearer for the public health
cause. Apart from the inherently individualistic character of
medicine, part of the reason can also be located in Indian
medical education originally “carrying the cultural accretions of
the West”, as D. Banerjee puts it. Multiple policy deliberations
have upheld the idea of training a socially oriented physician
responsive to community and public health needs. However, a
deficient social emphasis is still a stark feature of India’s medical
Soham D. Bhaduri curriculum.

This orthodox edifice of medicine has come under attack thanks

Dr. Soham D. Bhaduri is a to the COVID-19 pandemic, which is both a medical and a social
Mumbai-based doctor, calamity. The pandemic has served to water down the elitist and
healthcare commentator, and individualistic barriers of medicine that have hitherto kept apart
editor of ‘The Indian the private and the public, the rich and the poor, and the
Practitioner’ individual patient and the community. COVID-19 has delivered
one strong message: when it comes to a nation’s health, private
care is of public concern, and public health is of medicine’s
concern.

Creating ripples at the societal level

Early this year, there were debates on why elite professional
institutions such as top medical colleges rarely become the
centre of political ruckus and remain free of strong ideological
leanings, unlike many of their humanities counterparts. The
perception about medical academia is that it is too preoccupied
with cultivating scientific and professional excellence to cast an
eye upon politics. One reason given to explain leftist dominance
in humanities academia is the keen social orientation that
humanities education inculcates. By the very virtue of their
education, humanities students feel strongly about inequity,
stratification, and deprivation. This element remains missing in
technically oriented, competition-driven professional fields such
as engineering and medicine. But while engineering is
irredeemable in this respect, the same cannot be said for
medicine. Both the number and profundity of emotional
experiences that medical college-hospitals see on a regular basis
can scarcely be fathomed in any other category of educational
institution. The Competency-based Undergraduate Curriculum
applicable since 2019 emphasises on inculcating communication
skills and empathy in medical students to improve clinical
practice. However, that such empathy can create stronger
positive ripples at the societal level has been given little
attention.

This is not to suggest that medical colleges must be modelled

after the highly politicised humanities institutions. The idea is to
emulate purely the ‘social orientation’ element. The same

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empathy shown at the singular-patient level, and which improves

clinical practice, can manifest at the societal level to confront the
inequalities and deficiencies of public health. It is common
knowledge that public health has perennially been one of our
highly neglected items. It is also a concern that cuts across party
lines and stands little chance of being viciously contested and
politicised. Besides, a deficient social orientation among
physicians has significantly contributed to their maldistribution.

Remodelling the foundation

For this, the foundation of India’s medical education would need
to be radically remodelled along bio-social lines. There is need of
radically enhancing community exposure during both
undergraduate and postgraduate years. For this, medical training
will need to shift a considerable part of its base away from
medical colleges in cities to lower-level health facilities and the
community, along with seamless integration of medical colleges
with the health services system. Also, there is need to pep up the
community medicine curriculum and teach health policy to
medical students emphasising particularly the sociological and
political-economic aspects. All of this should confer the ability to
critically analyse how health and medicine function in the bigger
picture — creating a socially oriented physician capable of
relating with macro-level challenges in public health apart from
practising social medicine.

Some might say that that the biggest stumbling block to realising
socially oriented physicians is the commercialisation of the
medical profession. But commercialisation is something that has
largely arisen from within the profession. Given this, corrective
measures will also need to be effected from within. The
aforementioned measures can actually help us combat
commercialisation among multiple others, given an environment
conducive for the same. In the wake of the pandemic, we have
started entertaining ideas such as private hospital nationalisation
and mainstreaming of alternative medicine. A push for any
reform cannot do without acknowledging the imperative of
social physicians for better public health.

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India’s disease surveillance system needs a reboot

In its press briefings, the Ministry of Health and Family Welfare

have reported noticeable trends with respect to COVID-19 cases
in India. In May Its data showed that 75.3% of deaths had been
concentrated in the age group of 60 years and above, and in 83%
of deaths, the deceased were battling pre-existing identified
health conditions. Evidently, we have reason to fear the novel
coronavirus for which we have no established cure. However,
there is even more reason to fear a combination of COVID-19
with existing illnesses and medical complications. The disease is
lethal for those with compromised immunity brought on by age,
existing respiratory infections, or essentially, malnutrition. In
Maya John technical medical terms, this is a situation of comorbidity, which
in ways makes it difficult to differentiate between dying of
Maya John teaches in Jesus and COVID-19, or, dying with COVID-19.
Mary College, University of
Delhi, and is working on the Issue of disease watch
history of epidemics and
In comparison to many western countries combating the disease,
epidemiology.
India appears to have the advantage of a relatively young
population. This is, of course, negated by the poor health
conditions of the vast majority of Indians. It is then imperative
that we do not ignore already prevalent diseases and illnesses.
Unfortunately, the recent experiences of the public health-care
system in India indicate the side-stepping of precisely this issue.

There are many among the poor who are battling various
diseases but now have little access to major public hospitals in
the wake of the lockdown. Routine functioning, particularly of
out-patient department services in public hospitals, has been
severely affected, and largely, emergency cases are being
entertained. Patients now complain of even greater high-
handedness of hospital staff in the still functioning emergency
intensive care unit, labour rooms, tuberculosis (TB) wards, etc.
Ironically, cardiology and neurology departments that cater to
elderly sick patients are turning away many in the bid to
streamline “critical” cases. In such circumstances we can expect
an aggravation in the poor health conditions already affecting
large sections of people who have limited access to health-care
services.

Let us scrutinise this issue more closely. Many of the adverse

medical conditions prevalent among the vast majority of our
country are not even identified due to the lax disease
surveillance system. The failure of disease surveillance requires
explanation. For one, a significant number of the infected (poor
and marginalised people) do not have access to health-care
facilities and so fail to report their condition to certified medical
practitioners. Even when an infected person has access to such
facilities, their clinical case does not always culminate in the

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required testing (blood/serum, throat swab, sputum, stool,

urine). Third, there is a widespread practice among pathological
laboratories to categorise diseases on the basis of the pre-
existing classificatory system, which results in failure to identify
the definitive cause (aetiology) for an illness by differentiating
and separating pathogens (disease-causing microorganisms) on
the basis of variations in groups, subgroups, strains, etc.

Silent epidemics
There is, consequently, pervasive non-identification of a
definitive cause behind a number of illnesses. Many ailments are
simply clubbed together and referred to by generic names such
as ‘Respiratory Tract Infection’ (RTI), ‘Urinary Tract Infection’,
‘Acute Febrile Illness (AFI)’, ‘Acute Undifferentiated Fever’, ‘Fever
of Unknown Origin’ (FUO). Certain of these undifferentiated
illnesses are known to affect lakhs of people every year
worldwide. They claim many lives, especially of the poor who are
victims of low immunity and have limited access to health care.
Sources claim that RTI kills over 900 people in India every day.
Likewise, Acute Lower Respiratory Tract Infection (ALRTI), which
affects mostly children below the age of five years, has been
known to infect approximately 3.40 crore people every year
worldwide. In recent years it has led to roughly 66,000 to
199,000 deaths. Shockingly, 99% of these deaths are reported
from developing countries, and India has a larger share in it. The
large number of hospitalisations, enormous deaths and suffering
caused by contagious undifferentiated diseases indicate the
prevalence of persistent but undeclared silent epidemics.

Even if the definitive cause of an illness is identified, it does not

necessarily gain the focused attention of scientific research. As
the disease evolves but “interest” in it remains fleeting, the
differences developing in the sub-groups, strains in genotype of
the pathogen concerned fail to be consistently tracked.
Knowledge of the pathogen, and, consequently, the required
disease control soon lag behind. This overall process is due to the
selective, biased approach of mainstream scientific research that
is driven by the profits of private pharmaceutical companies, and
is the fallout of the lack of priority that governments assign to
general health care and diseases of the poor.

Even when the identity of a contagious disease and its treatment

are well known it does not mean that the disease’s prevalence
will generate the necessary reaction. TB is a suitable example.
According to public health experts, one person in every 10
seconds contracts TB, and up to 1,400 people in India die every
day of the disease. This indicates that TB has a R0 value (basic
reproduction number) and fatality rate that is way higher than
those attributed to COVID-19 so far. However, it is important to
note that TB and many other contagious diseases are ignored as
“ordinary” and elicit very low attention. In contrast, some

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diseases are quickly identified as epidemics of greater public

concern.

Diseases are being selectively discovered and have the

propensity to be identified as an epidemic when they have a
signalling effect for the scientific community. In a majority of
instances, it is only when there is a threat of transmission to the
well-to-do sections of society or wealthier regions that the
disease actually has such a signalling effect. It is not a
coincidence that a relatively downplayed disease such as TB is
largely a poor man’s disease.

Clearly, we are confronted by a skewed relationship between our

ways of knowing (social epistemology) and epidemiology. It is
precisely in this context that COVID-19 has gained singular
prominence over several other lethal diseases. Importantly, pre-
existing diseases have the potential to combine with COVID-19,
and with devastating consequences. It becomes imperative to
identify the comparative fatality rates of many of the silent
epidemics, which in their own right require urgent attention.

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Private sector and patient safety

Everyone has a family member who has some medical issues —

someone waiting to check his blood sugar levels, some waiting
for their pregnancy ultrasound scan and others waiting for a
surgery — the list is never ending.

The big question is, “Is it safe to go to a hospital for

consultation/procedure during these times?”

The private healthcare sector has also evolved its strategies in

the past few weeks.

A pandemic this large is a new learning experience for everyone

alive at this moment in the world. It’s important for the private
Dr. S. Asokan sector in India, being a major healthcare deliverer, to learn,
Dr. S. Asokan is the CEO of evolve and adapt newer strategies to cope up with the
GEM Hospital, Chennai unprecedented disaster.

The learning process and adaptation of knowledge in

implementation has kept India significantly proactive. The
patient safety measures and personal protective equipment
(PPEs) against the virus have been a result of the knowledge
shared across the continents after analysing the rapidly evolving
scientific data.

When the world is struggling with the availability of proper PPEs

for the healthcare workforce, thanks to our innovative and
indigenous textile infrastructure in the cities of Coimbatore and
Tiruppur, we could get sufficient international standard PPEs,
including Hazmat Suits, N95 protective masks etc., in a short
time. The synergy between the government and the private
healthcare sector has also been evident — from diagnostics to
treatment areas. These form the foundation behind the crusade
against COVID-19.

As more doctors are falling ill across the world and even in our
country, the question of patient safety takes no back foot in any
standard along with the safety of the healthcare workforce. As a
patient, the fear is understandable and inevitable, even in
emergency situations, leave alone the planned visits.

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However, with the increasing availability of the rapid screening

for COVID-19, and laboratories performing the PCR testing (some
with in-house collection facilities), the hospitals can literally
function as individual units with Safe Zones, free from COVID-19,
and designated COVID-19 isolation zones.

The entire structure of hospital operations has to be segregated,

minimising contact among patients, with the highest safety
standards with adequate PPEs for patient and healthcare teams
alike.

The safety measures implemented across our own chain of

hospitals is a standing proof of this evolution of our
understanding and implementation of patient safety measures.

Based on the data collated and analysed by more than 100

doctors, we have formulated ‘GEM Patient Safety Initiatives —
GPSI’, which are implemented across our facilities in Tamil Nadu
and Kerala. Identification, isolation, providing information,
educating the patients are the key functions of GPSI. Making all
facilities adopt a unidirectional flow, segregating the visitors with
physical distancing, sanitising the facilities, equipment and
personnel to maintain utmost safety for both the public and
healthcare workers is the idea behind this initiative. We are
happy to share our practices with others so that the public are
benefited more.

With the unavailability of a vaccine or proven antiviral

therapeutic option at present, the fight is still preventive but the
other medical issues plaguing the human race can’t wait or we
may equally lose lives over cancers, heart issues, strokes and
other critical issues. These preventive safety measures will guide
and help us, the medical professionals to continue the services in
these tough times safely.

Most medical conditions fall in the bracket of semi-emergences

(Eg: ulcer diseases, hernias, gallstone disease, obesity etc.,)
which may not require immediate attention, however with the
suffering prolonged and without medical attention may be left
undetected of something bigger going within. The flattening the
curve may take its time, but its time to move on, slowly, steadily
and more importantly safely and definitely. Most tertiary care
centres have evolved strategies to ensure the same.

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COVID-19 enhances reliance on telemedicine

What is telemedicine?
Telemedicine is an all-encompassing term for providing remote
virtual healthcare with the healthcare provider and the
beneficiary physically in different locations. Information and
communication technology (predominantly the internet) are
used for history taking, reasonable relevant clinical examination
and review of any investigations available. Telemedicine-enabled
devices such as the thermometer, torch, stethoscope, BP
apparatus, ECG, glucometers etc. convert the patient’s location
to a clinic. The diagnosis (provisional or final) is communicated to
the patient electronically along with specific advice including a
prescription.

When did telemedicine start?

K. Ganapathy The world’s first telephone call made by Alexander Graham Bell
on March 10, 1876 was actually a request for medical help.
“Watson, come here I want you,” he said after acid from a
The author is Director, Apollo Leclanche cell fell on his hand. From 1925, the radio was used on
Telehealth Services. He is the
and off to make medical diagnosis. In 1970, a telemedicine link
past President of Neurological
Society of India, and the past was established between Mass General Hospital Boston and the
president of the Telemedicine Logan Airport in Boston. In India formal telemedicine
Society of India commenced on March 24, 2000 when Bill Clinton commissioned
the world’s first VSAT (ISRO supplied)-enabled village hospital at
Aragonda, the birthplace of P.C. Reddy, chairman, Apollo
Hospitals.

What are the components of telemedicine?

Technical requirements include hardware, software,
connectivity, acquisition, storage, retrieval, display, while health
care providers have to be oriented, trained, helped with
customisations, to be cost effective, self-sustaining, and follow all
the regulations in order to be future-ready.

Can prescriptions be given remotely?

Yes. The recently notified Telemedicine Practice Guidelines
enables Registered Medical Practitioners to send prescriptions
electronically. There are several in-built safety methods to
prevent abuse of the system. Pharmacists have to dispense from
a digital screen with the doctor’s registration no and facsimile of
the signature.

What are the different types of telemedicine?

Different modalities includes a) Telephonic consultation, b) Chat
mode, c) WhatsApp, d) SMS, e) Video consult, f) Proper full-
fledged telemedicine using an approved EMR (Electronic Medical
Record) where case records, images, investigations, tele consults
can be stored, retrieved and a good video camera is used for

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interaction. Peripheral medical devices located remotely can be

controlled and results obtained in real time.

Are there any limitations in using telemedicine?

Technology is only an enabler, not an end by itself. The decision
when to limit use of Telemedicine and insist on a face-to-face
consult is always a clinical decision. The context, professional
judgement, and the patient’s interest alone matter. Some
doctors may be satisfied with an ultrasound image showing a
mass in the pelvis. Others may want to do a rectal examination.
Patients may not be comfortable without seeing the doctor face-
to-face at least for the first time.

What is the future of telemedicine?

The ‘future’ of Telemedicine started in December 2019.
Worldwide, Covid-19 is causing millions of people to try
telemedicine for the first time. Telemedicine will continue to
grow rapidly. Enforced habits of today will become the new
normal. Life will never again be the same in the AC (After
Corona) era. Gradually obligatory preferences of today will
switch to a default mode. Patients may not want to return to the
BC era when face-to-face consults were the norm and
telemedicine was a bystander!!

With technology becoming sophisticated and automated,

doctors can do what they really want to do – spend more time
with the patient – rather than spend time commuting, to go to
their offices. Overheads in establishing a posh office will come
down.

Patients too will now have more time, avoiding the hassles of
travel, and waiting outside the doctor’s room. Virtual visits can
make group care possible. Today considerable time is spent, and
effort has to be put in to get opinion of multiple specialists
sequentially. Imagine if all the specialists discuss various options
with the patient together. Transparency at its highest. Shift to
virtual care has always been there in India — after all the
Telemedicine Society of India was started 18 years ago! COVID-
19 has only accelerated the process.

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The virus versus women

We are just beginning to learn and feel the magnitude of the

direct and indirect impact that this pandemic is having on the
lives of women across the globe. COVID-19 is not just a health
issue. It has complex interactions at the social, economic,
cultural, political and gender relations level. Data reveals that the
virus does not impact women as severely as men. Women do get
infected and develop complications. Just less than men.

Women are bigger casualties due to the nature of their work, the
impact of the economic downturn, the lockdown and the stay-at-
home mandate, adding to the existing deep fissures in gender
parity. These will have a negative impact in the short term and
will be more pronounced in the long term.
Dr. Usha Sriram
Health workers
Dr. Usha Sriram is a senior Women make up nearly 70% of the global health care work
consultant endocrinologist and force. As nurses, doctors, therapists, cleaners and caregivers they
Director, ACEER, Chennai are in harm’s way with gruelling schedules, compromised safety,
lack of protective equipment and poor representation at
leadership levels. The thought of how the pandemic will affect
their own lives, and their families is a major source of anxiety and
stress. Watching many patients die is a heavy emotional burden
for many of these women with the potential for serious post-
traumatic stress disorders soon.

The economic downturn will have the harshest impact on

women. More women work part time, provide a major share of
childcare and elder care. They are under paid, unpaid,
unorganised and undervalued. Small businesses such as salons,
fruit and flower shops are often women-owned. This also
exacerbates the economic insecurities and gender inequalities
that already exist. The economic shocks felt by women can drive
them to take heavy interest loans, multiple jobs and low paying
or risky jobs.

It is well known that during times of crises, violence against girls

and women becomes real. We are seeing this yet again.
Lockdown, unemployment, financial hardship and access to
alcohol are making men/spouses angry and edgy, leading to
domestic abuse. The WHO and the UN Women are deeply
concerned and flagging this aspect of the pandemic regularly.

Pregnancy should be viewed as a high-risk state. Women missing

their antenatal visits/ scans and post-partum visits due to fear of
infection and lack of transportation will compound to the existing
crises. Maternal morbidity and mortality are likely to go higher
now. Gender based violence, economic insecurities, care giving,
front line health care work, loss of physical and emotional
support

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from family and friends due to physical distancing and lockdown,

concerns about pregnancy, contraception and abortion, worries
about the future of education, physical and mental well-being of
their children.

Nearly 700 million girls are out of school now and many
adolescent girls who are forced to stay at home run the real risk
of being burdened and exploited with domestic chores and
caregiving. Many may never return to school. It is important to
anticipate these challenges and begin the remedial measures at
local and the national levels.

Transwomen‘s lives have been upended even more during this

lockdown. Begging and commercial sex work are not options.
Discrimination and lack of family support for many have made
them more marginalised now. Many trans women on hormones
are unable to access and afford the medications and getting
good health care has always been a challenge for the LGBTQIA+
community.

Way forward
How can we make this pandemic a catalyst for building a better
tomorrow for our girls and our women? By taking a gendered
approach to the entire situation.

a) We need women included in decision making and in

leadership roles.

b) Healthcare workers need to have adequate Personal

Protective Equipment and mental health support.

c) Data needs to be disaggregated based on gender

d) Special needs of pregnant women to be addressed through a

hotline

e) A plan to offer Wellness Clinics post COVID for everyone,

particularly women

f) Transwomen and disabled women to be assisted through the

local government

g) Prioritising physical and mental health of women now and

beyond the pandemic

These are very unusual times. They need more than the usual
solutions. We need a bright light, a gender lens and good
leadership. What are we waiting for?

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Retaining the humanitarian approach in times of COVID-19

There are many questions that plague us every day, as health

care professionals. But in times of COVID-19 the very core of
medical practice – its humanitarian approach is under threat. The
questions now in front of health care professionals, for different
reasons are: “To treat, or not to treat”

“Is it right, or is it wrong?”

Further, “How long can we defer treatment?” This decision is

neither simple nor easy, as treating doctors, we have to think of
the patient and the family in the context of the pandemic, and
what we do based on strong evidence.
Dr. V. Shanta For instance, early common cancers are curable. In such cases, it
Dr. V. Shanta is the chairperson will be unethical to delay treatment. An advanced disease can be
of Cancer Institute (WIA), controlled, and if untreated, it might progress to the stage of
Chennai palliative care. Again, palliative care cannot and should not be
denied to patients.

And then, uncommon cancers with a doubtful outlook, advanced

age, and with multiple co-morbidities form a category all by
themselves. They have to be treated based on individual
decisions and are ideally deferred. The expenses involved, in
relation to survival, will not be either risk or cost beneficial.

Treating institutions
As of now, only partial, selected cases are being treated. Should
this continue?

NGOs, and voluntary charitable institutions providing free cancer

care, of which Cancer Institute is one, are facing a major crisis.

Patients have a serious problem, with the lockdown, they are not
able to find transportation to reach the centre for treatment.

While with residential staff, there are no issues, because they live
on campus. However, non–residential health care staff, too, face
the same problem – lack of transport to reach the hospital. As for
housekeeping staff, who are key to running a hospital well, the
institution has to make transport arrangements until the
condition improves. Some medical staff members too, who do
not have their own personal vehicles, need assistance to reach
the centre.

General criteria
We need specific guidelines or criteria for providing personal
protection equipment, masks, gown etc for professional and
paraprofessional workers. For one, it will be helpful to reduce

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staff fear/panic and convince them that they are well protected
with the gear.

This is for those who are not working with those who tested
positive, are on routine hospital duty, including doctors,
technicians and nurses who are working with patients who have
not been tested.

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