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Be AHEAD OF THE CURVE – Make decisions amidst uncertainties

Covid pandemic has thrown the world out of gear completely. Despite all the panic, anger, frustration and helplessness it is time for us to introspect and support each other. We must find quick solutions based on the available data, experience and come up with a guideline for the country. This can be suitably modified as and when required. We must anticipate and be prepared ahead of time, before the situation goes out of control. The decisions for now and tomorrow should be implemented collectively with uniformity and spirit of winning the war. Let’s look at some of the key determinants.

CURRENT REALITY

Lock down – the purpose of lock down is to implement social distancing thereby to flatten the initial curve. A laudable decision that has helped immensely in comparison to the rest of the world. But challenges are not yet over.

  • Exit from Lock down – we should not create an exodus next day after the lifting of lock down. The date is not going to make any difference for the virus. The goal is to have self restraint and self discipline till we are sure that the virus threat is completely eliminated from the community. Till then all educational institutions should remain closed. All social engagements have to be banned. Public transport has to be minimized.
  • People should be allowed to come out only for highly essential works and should have strict discipline of wearing a face masks all the time in addition to social distancing. Those with obvious cold, cough and fever should not come out at all. People who can work from home should continue to do so. One must be honest enough to follow this without supervision. This contribution by every citizen to them, Nation comes by doing nothing. In addition it prevents load on the health system.
  • Social distancing may not be possible strictly especially in crowded cities and slums. A strong policy of supplying soaps, and face masks to all of them with an uncompromised enforcement, special N95 masks to all those at high risk and administrative staff working in the field.
  • Bulk manufacturing of soaps, sanitizers and face masks with a proper distribution system is the need of the hour. Adequate training to use them correctly is equally important. Otherwise the whole purpose will get defeated. Violation must to be dealt with strict laws. The onus is vested on all of us to avoid recycling of Virus and repeat waves of community infection.
  • Preparedness – We must have a plan of prophylaxis like Hydroxychloroquine at least in high risk areas proactively. The evidence may not be robust right now and might take time to get the results of all the ongoing trials. We must act on interim results and suitably modify further. We must identify places for a good temporary isolation with a capacity to handle large numbers as a priority. Based on the experience from my colleagues from abroad, isolation of certain areas within the hospital has never worked. Therefore we need totally separate buildings dedicated for this purpose. Temporary tents on the open grounds can be a make shift arrangement. For full fledged treatment we need designated hospitals.
  • Clinicians must focus and try out all innovative possibilities to prevent the progression to respiratory failure. And we must look at all the experience from different countries and be aggressive in implementing. Once respiratory failure occurs mortality is almost 85 percent.
  • Going forward we need measures to combat all three clinical levels. a) preventing the intra cellular penetration of the virus b) stopping the viral multiplication c) and Immuno modulation to avoid life threatening complications. Cell penetration of the virus depends upon the virulence and host immunity. Perhaps Chloroquine should be used at this phase itself. . Additional measures like repeated steam inhalation’s, googling of throat, drinking hot water with turmeric , “Tulasi and honey have been recommended. There is evidence that Zinc prevents replication of viruses inside so zinc supplements and garlic that enhances the intra cellular zinc concentration have been advocated. Disturbances of Haem inducing hypoxia is being reported increasingly of late. Improving oxygenation, reducing haem disturbance can be considered. In fact deep breathing exercises also have some protective role.
  • As per the current evidence around many centres around the world the anti viral drug “Remidesivir” is effective in reducing the mortality. It has helped 2/3rd of people to come out of ventilators and ICU according to a study from Cambridge.
  • Majority of the deaths are said to be due to the persons intense Immunological response leading to “Cytokine Storm “ producing tissue inflammation, necrosis, ARDS ( acute respiratory distress syndrome) and multi organ failure. At this stage apart from ventilatory support we need to consider Immuno modulation targeting IL6( interleukin6). Steroids like Methyl Prednesalone and other immune suppressants need to be tested based on the clinical situation as well the experience from the Spain group.
  • a) Convalescent plasma inoculation is the fastest method of modifying excessive immune response and also to provide antibodies. Serum from the convalescent patients who had definite infection but recovered will be collected, processed and administered to those who are critically ill. Their serum is the high source of antibodies. This method is already time tested and validated during the previous viral epidemics. b) Similarly Attenuated Corona virus can be given to select volunteers to generate large scale serum loaded with antibodies. Many countries have already started recruiting. c) The same attenuated virus can also be administered to select animals and the antibodies can be harvested and retrieved from the serum. This might be quicker method and can be clinically used after proper processing.
  • Developing a Vaccine is laborious and time consuming. Yet we should continue this in parallel. We need immediate solutions to face the eventuality if it arises.

TEN POINT ACTION PLAN - FOR NOW

  • Prevent exodus of people suddenly and phase wise release of lock down with compulsory social distancing and face masking.
  • Lock down to continue for high risk people and areas.
  • Implement mask India programme.
  • Seal down the high risk areas.
  • Hydroxy chloroquine prophylaxis and zinc supplements for people at high risk.
  • Personal protection gear for the health professionals treating Covid patients.
  • Early treatment for symptomatic patients- Remidesivir
  • ICU care for breathing difficulty and hypoxia – supportive ventilation
  • Immuno Modulation for the critical ones – Steroids, Immuno suppressants, Convalescent Serum, Mesenchymal Stromal cells,
  • Future plan- large scale antibody production, drug discovery, and development of Vaccine.

ROLE OUT PLAN FROM GOVERNMENT

  • Identification of high risk groups
  • Identification of high risk areas
  • Seal down the high risk areas
  • Provide the supply chain and support mass production
  • Cost control of all essential medical items.
  • Encourage Pharma for drug discovery as well as bulk production, similarly other relevant industries for other essential items.
  • Support research organizations for quick innovations. Bringing out a product for immediate use is the goal.
  • Government should simplify the methods, processes and permissions. A reasonable compromise is a must and justified to fast track the system
  • Preparedness for any eventuality in terms infrastructure, ventilators, materials and Human Resource.
  • Create a data base of our own experience to generate real time authentic data that helps in modifying the guidelines and to find indigenous solutions.
  •  Special help line to collect fee back from various sources directly for better monitoring.
  •  Simple and relevant National guidelines must emerge out of such data.
  • Ensure availability of food and vegetables.
  • Media should pay a pivotal role and must focus on mass awareness and education.
  • No one actually knows the future of economic situation correctly. So it is better to refrain from speculations, predictions and projections.
  • Morale of the society should be kept high by all means at the same time passing on the relevant realistic information.
  • Unrest in the society should be avoided to make the entire programme effective.
  • Do not entertain criticism, debate, and unnecessary discussions.

This is not the time to wait for the hard core evidence. We must explore every possibility. Use innovations judiciously with discretion and with reasonable safety. In dealing with such large scale operations no decision will be perfect. Right decisions based on the current situation and demand keeping the interest of the Nation at large is crucial .

So far we have done wonderfully well. Hope we will succeed in all our endeavours and bring the Nation back on its wheels.

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