Dr. Rajeev Sharma
MBBS (PGI, Rohtak), PGDBA, MPA ( LKYSPP, Singapore), MD( Acu)
The corona virus(SARS-CoV2) upheaval has introduced us to the dynamic uncertainties in its prevention, transmission, virulence, treatment and cure. The challenge for we the people is to match our capabilities and capacities with the versatility of the virus; the existing threatening gap is widening with every new wave.
The brutality of the second wave in India has captured its people in fear-psychosis and the health system under utmost stress. Our health services plunged into the catastrophe. Semblance of coordinated protocols has been compromised beyond retrieval. Shortages in hospital beds, ICUs, ventilators, oxygen supplies are omnipresent. Families of those who succumb to the disease struggle to even get access to the cremation facilities. Hoarding of life saving essentials and their black-marketing is at its peak. With governance hibernating, human dignity is the biggest casualty; floating corpses in rivers reflect complete surrender to the pandemic.
Second wave of corona has also reported higher virulence and transmissibility of the virus as compared to the first wave. This has resulted in greater transmission of infections and indoor virus spread has become a significant contributor, as large chunk of population is asymptomatic and are potential sources of transmission. Several mutant strains have also emerged which have higher transmissibility and are also highly virulent. Further studies are required to fully understand and establish by how much. We should therefore be prepared for more mutant strains which have greater virulence and faster transmissibility.
One such variant is the Indian mutant B.1.617.2, which is spreading fast in the United Kingdom and poses serious concern to their health.
So the big question is how do we prepare our response to these threats in the next wave especially when experts have genuine apprehensions that the virus poses a threat to children.
The new variants have shifted our understanding of the health threat facing us and the urgency of addressing the gaps in the health care delivery. We cannot prevent further waves of infection and associated morbidities and mortalities but we definitely can reduce their quantum and more so the pain associated with the struggle to get access to already available health services.
One important dimension to this is the struggle faced by the patients’ relatives for the beds, ICUs, oxygen cylinders and lifesaving drugs during the first two waves. Here, I am not referring to the apparent demand and supply mismatch but to the logistical and administrative approach to avail them.
Two waves of corona has shown that most of the symptomatic cases can be easily managed at home. There are other cases which need medical support system like oxygen, blood oxygen saturation, laboratory tests of blood, X-Ray all of which can be managed at local levels and they need not go through the same ordeal of chasing admissions in the hospitals. Many a times hospital does not have the choice to take a call whether to admit ‘such’ patients or to revert them to some primary facility which has the capacity and capability to manage them. If the primary level of health services could treat this category of patients, it would help ease the burden on the health system. It would also help conserve precious medical treatment resources for the treatment of serious patients and save many precious lives.
Since the second wave spread to remote villages also, it is implied that the third wave would affect the rural areas as well. The third wave is indicated to infect children especially the younger ones. Is that a problem?
First lets examine why do the experts apprehend that children would be more vulnerable during the next wave! One simple reason is that all adults are in process of getting vaccinated, many have received two doses of vaccines. Children will soon be eligible for vaccination after the undergoing trials qualify for approval of vaccination. Pending approvals children become unprotected from the virus attack. This should not be a problem in the normal course because healthy children have better immunity and immune response as compared to adults. Children have reported milder symptoms and earlier and better recovery from Covid-2019 because of better immune mechanism in them Yaguang Zhang Y, Xu Jin, Wangpeng et al.,Protective humoral immunity in SARS-CoV-2 infected pediatric patients, Cellular & Molecular Immunology volume 17, pages 768–770 (2020) Published: 07 May 2020, accessed: 25.5.2021). Children also present with different set of symptoms varying from Multisystem Inflammatory Syndrome in Children presenting as high fever with or without chills, breathing difficulty, cough, loss of smell, sore throat, muscular aches, and inflamed skin or mucosa. They may present gastro-intestinal symptoms like loss of appetite, diarrhea and vomiting, lethargy and seizures
However it is a serious concern because children in rural areas and on urban fringes are differently placed. With rapid urbanization the population migration far exceeds the city’s infrastructure as a result several large cities in India have more than 40% of their population residing in slums.
Slums face bundle of challenges like poverty, informal incomes, overcrowding, lack of basic amenities, malnutrition, poor housing, limited access to healthcare and safe drinking water, and inadequate sanitation (Ezeh A, Oyebode O, Satterthwaite D, Chen YF, Ndugwa R, Sartori J, et al. The history, geography, and sociology of slums and the health problems of people who live in slums. Lancet 2017; 389:547–558. pmid:27760703, accessed 24.5.2021). Similar is the socio-economic fact-sheet in rural areas. About 15% of India’s population is undernourished (FAO, IFAD and WFP. Ibid; International Business Times. ‘India has most number of hungry people in the world: Report’, 31 May 2016, accessed 24.5.2021).
Poor health and hygiene, anemia and malnutrition make these children more vulnerable. Malnourished children have increased risk of dying from infectious diseases, and impaired immune response associated with malnutrition in children may contribute to increased mortality(Rytter MJ, Kolte L, Briend A, Friis H, Christensen VB. The immune system in children with malnutrition–a systematic review. PLoS One. 2014;9(8):e105017. Published 2014 Aug 25. doi:10.1371/journal.pone.0105017, accessed 25.5.2021 ).
The above variables have to be factored in when we talk of our strategy to mange the third wave of corona pandemic. Therefore In rural areas:
- A quarantine facility ‘chaupal’ with ten or more beds at the least must be created away from the habitation in every village or two adding villages. This should have provisions of good ventilation.
- Equip it with basic facilities like equipment for measuring vitals, oxygen cylinders, life saving drugs, IV lines, and disposables like masks, gloves, canals etc. for use of positive patients
- 24,855 Primary Health Centres (PHCs) out of 30,045 PHCs in India are located in rural areas. Each covering about 20,000-30,000 population.
- The PHC/CHC should be made the command centre over a few chaupals where doctors, medicines and transport facility are available round the clock
- Specialist doctors on call at PHC and also online should be earmarked as per roster to attend to these patients in chaupals on a rotational basis.
- Junior and Senior residents from medical colleges and hospitals can be attached to the PHCs/CHCs with training imparted to handle children.
- Proper transport facility for the contaminated disposables to a common tehsil level facility for final disposal
- Provisions for hypochlorite solution at the chaupals should be made.
- All the villagers in the catchment area should be well informed of this facility.
- Paramedics, ASHA workers and Aanganwadi workers should be given hands on training in managing initial symptoms and mild diseases.
- Retired medical doctors and health workers both civilians and Defence Personnels should also be involved in the training and management of Covid cases
- ‘test-trace-treat-vaccinate’ should be the goal.
- Contact tracing has to be strictly implemented by a team of volunteers from within the community wherever possible.
- Focus should be on all direct and high-risk contacts of confirmed cases whether they develop symptoms or are asymptomatic. They should be effectively quarantined for two weeks.
- Contacts are to be tested between day 5 and day 10 of coming into contact.
- Importance of SMS (social distance, Mask and Sanitize) as covid appropriate behavior for covid containment should be emphasized.
- Mock drills should be conducted once every week for the public, doctors and the paramedics in preparation towards the third wave
- Adequate awareness programme for the public about covid and also the indications of several cocktail of drugs in demand should be run routinely
- Green corridors for ambulances, oxygen delivery vehicles and essentials should be created and people made aware regularly
- Put in place formal channels of reporting any hoarding or black marketing by unscrupulous elements. If need be declare rewards for such information and informer’s identity should be strictly kept a secret
- All essential supplies including drugs and oxygen cylinders should be ear marked to the destined chaupal/PHC/CHC and secured by bar codes. Proper trail from the manufacturer to the end used should be recorded online
- Chaupals can be provided security cover by members of civil defence, homewards and village volunteers. They can also prevent or report social gatherings or even covid inappropriate behavior.
- Chaupals should report mandatorily to the PHC/CHC every 24 hours and also need based. A district nodal officer can coordinate with PHC/CHC for any further coordination or help required
Our understanding of the disease and the virus behavior per se is better than it was during the first wave. The data collected during the second wave will have to be objectively analyzed and introspected for better understanding of the virus behavior further. Such waves of viral surge will keep coming till over 70-80% of the population develops immunity (Herd Immunity) either through vaccination or contact.
This information is for general guidance and reflects the opinions and experience of the author. It is not intended to replace specialist consultation or provide treatment advice for specific cases.