It has been a little over a month since the SARS-CoV-2 hit Maharashtra. Mumbai has now become the epicentre of the outbreak in the country, with its number of COVID-19 cases crossing the 3,000 mark. But, the virus continues to puzzle the medical fraternity. The Hindu spoke to the city’s leading infectious disease expert, Dr. Tanu Singhal from Kokilaben Dhirubhai Ambani Hospital, about the challenges, the line of treatment with no specific cure at hand, and the behaviour of the virus in Indian patients.
The disease is a month old in the city now. What is your impression of the virus and its behaviour?
Well, it has behaved like we expected it to. The virus is readily transmissible. Many people who harbour the virus are asymptomatic and hence prevention and control is difficult. While most people have had mild illnesses, there are some who have had severe disease and died. While deaths have been more in the elderly and those with other illnesses, some healthy and young people have succumbed. The indirect damage caused by the virus is more than the direct damage. The lockdown has had severe social and financial repercussions, and patients with other illnesses are suffering.
Do you think there is anything drastically different here than what has been seen in other countries?
No, there is nothing drastically different. However, we have not seen that steep a curve as has been seen in the U.S. and some parts of Europe. This could be related to climatic conditions and difference in the immune response. However, the actual numbers in India may be higher than what are being reported.
What are the biggest challenges in treating COVID-19 patients?
The biggest challenge is infection control. Transmission to healthcare workers is worrying. It is becoming increasingly difficult to motivate doctors, nurses and other staff to look after these patients. The other problem is very fast deterioration in some patients, which does not give one time to intervene effectively.
What are the frontline treatment strategies you are using to manage patients with mild disease and those who are critical due to co-morbid conditions?
For patients with mild disease we use hydroxychloroquine, after doing a baseline ECG, with or without azithromycin. We keep a close watch on these patients, especially if they are elderly or have co-morbidities, to detect symptoms/ signs of pneumonia. A test we have found particularly useful is to make patients walk and check saturation levels. An early sign of worsening is exercise-related desaturation. We also monitor their blood counts and C-reactive protein levels to separate patients that may have problems later. Some patients who have mild symptoms to begin with deteriorate even after seven-eight days, so prolonged monitoring is important, especially if the fever has not resolved.
Patients who are sick are those who are short of breath and have low levels of oxygen in their blood. These patients are admitted to the intensive care unit and initiated on antibiotics and hydroxychloroquine. We have found that early administration of moderate doses of corticosteroids for three-seven days is helpful in stabilisation and prevention of disease progression. These patients also need medicines to prevent blood clotting, as COVID-19 is frequently associated with excessive clotting in blood vessels. In some patients who do not improve despite corticosteroids, we have used an anti-inflammatory drug called tocilizumab. The only anti-viral drug that seems to help is remdesivir, which is not available in India. Patients with severe disease need very good critical care support.
There is a lot of hope pinned on hydroxychloroquine. Have you found it beneficial for your patients?
We have not observed any significant benefit with hydroxychloroquine.
Across the State, many patients have succumbed within hours of being admitted to a tertiary centre. Is there anything peculiar about the manifestations of the disease in Indian patients?
No, this has also be seen in other countries too. The disease is such that any delay in care-seeking in sick patients is fatal.
At the pace at which Mumbai is seeing cases, how soon can we expect some semblance of normalcy?
[We] can’t predict which way it will go. We are taking one day at a time. If numbers are not escalating, that in itself is a good sign.
