CME INDIA Presentation by Admin.

The second wave in India is spreading faster.

The situation needs an innovative approach. Mutants evading diagnostic tests, infections after vaccines, early lung and thrombotic complications and fast deterioration appear to be the “Hallmark of the New Wave.”

Maharashtra ground situation shows

Age pattern Shifting

• Shift in age group of critical patients towards more elderly age group.
• Younger patients not getting critical.

Bypassing rtPCR

• New Covid cases are not being able to detect by routine RT PCR TESTS. The strains are evading the diagnostic test also.

More Thrombotic complications

• More thrombotic complications as compared to earlier patients.

No one is superhero after 2 doses of vaccination

• Patients getting admitted with symptoms to the hospital after 2 doses of vaccines.
• At Nanded, at least 4 doctors have it after 2 doses.

High society is affected more

•  Business community in trouble

Mortality more?

• Nanded: Today on 24th march 21, more than 10 died.
• Comorbidity not accompanying always.
• Deterioration is fast.
• The strain this time appears to be more virulent.
• The ICU admissions and deaths are a sensitive indicator regarding the lethality.

CT lesions are baffling radiologists

• The worrisome thing is that the % of cases showing CT lesions are far more this time than during the first peak.

The feeling at ground level

We have to wait for another 3 weeks to understand better as it lags behind by 3 weeks from the time cases built up.

(Inputs by Dr Noaman Shirolkar, Intensivist at MCGM, Kurla, Maharashtra, India and Dr Santosh Malpani, Diabetologist, Nanded, Maharasthra)

Dr Anand Malani MD, Sangli (Maharashtra) observes

• Cases are increasing in our region although very slowly.
• Personally, I don’t find any difference clinically or mortality wise.
• I don’t think they are testing aggressively for the variants or mutations.
• Few months ago, I had notified authorities to test a patient for the UK variant as travel history was favourable. He was tested but the results never got conveyed to the patient or treating doctor.

Ministry of Health and Family Welfare Press Briefing on 24.03.2021

• Genome Sequencing by (Indian SARS-CoV-2 Consortium on Genomics) INSACOG shows variants of concern and a Novel variant in India.
• Genomic variants of various viruses are a natural phenomenon and are found in almost all countries.

Know the Variant of Concern

• Since INSACOG initiated its work, 771 variants of concerns (VOCs) have been detected in a total of 10787 positive samples shared by States/UTs.
• These include 736 samples positive for viruses of the UK (B.1.1.7) lineage. 34 samples were found positive for viruses of the South African (B.1.351) lineage.
• 1 sample was found positive for viruses of the Brazilian (P.1) lineage. The samples with these VOCs have been identified in 18 States of the country.

Maharashtra facing Variant Storm?

• The analysis of samples from Maharashtra has revealed that compared to December 2020, there has been an increase in the fraction of samples with the E484Q and L452R mutations. 
• Such mutations confer immune escape and increased infectivity.
• These mutations have been found in about 15-20% of samples and do not match any previously catalogued VOCs.

Kerala in trouble?

• From Kerala 2032 samples (from all 14 districts) have been sequenced.
• The N440K variant that is associated with immune escape has been found in 123 samples from 11 districts.
• This   variant was earlier found in 33% of samples from Andhra Pradesh, and in 53 of 104 samples from Telangana.
• This variant has also been reported from 16 other countries including UK, Denmark, Singapore, Japan and Australia.
• As of now these can be at best said to be variant under investigation.

No direct relationship established with NEW WAVE?

• Though VOCs and a new double mutant variant have been found in India, these have not been detected in numbers sufficient to either establish or direct relationship or explain the rapid increase in cases in some States.
•  Genomic sequencing and epidemiological studies are continuing to further analyse the situation.

(HFW/Genome Sequencing by INSACOG /24thMarch2021/2, Release ID: 1707177) 

How physicians are treating?

• Azithromycin/ Doxycycline
• Ivermectin is being used at large
• Cetirizine and Montelukast
• Steam Inhalation
• If CRP D dimer in increasing trend
• Remdesivir
• Steroids
• And in hospital care

No New Guidelines, manage as it was during 1st wave

Remember 12 Pearls again

1. Older age, male sex, and comorbidities increase the risk for severe disease.
2. For people hospitalized with covid-19, 15-30% will go on to develop covid-19 associated acute respiratory distress syndrome (CARDS).
3. When used appropriately, high flow nasal cannula (HFNC) may allow CARDS patients to avoid intubation, and does not increase risk for disease transmission.
4. Dexamethasone treatment improves mortality for the treatment of severe and critical covid-19
5. Remdesivir may have modest benefit in time to recovery in patients with severe disease but shows no statistically significant benefit in mortality or other clinical outcomes.
6. Active symptomatic support remains the key treatment for mildly to moderately ill patients, such as maintaining hydration, nutrition, and controlling fever and cough.
7. Hospitalized for mild to moderate covid-19 (not hypoxemic) Supportive care:
   • No clear benefit for Remdesivir or convalescent plasma.
   • Steroids have no demonstrated benefit and may cause harm.
8. Hospitalized for severe covid-19, but not critical (hypoxemic needing low flow supplemental oxygen):
   • Corticosteroids (dexamethasone 6 mg/day × 10 days or until discharge or an equivalent dose of hydrocortisone or methylprednisolone).
   • May consider Remdesivir.
   • May benefit from use of tocilizumab.
9. Hospitalized for covid-19 and critically ill (needing HFNC, NIV, IMV, or ECMO) Supportive care:
   • Corticosteroids (dexamethasone 6 mg/day × 10 days or until discharge or an equivalent dose of hydrocortisone or methylprednisolone).
   • May consider Remdesivir.
   • May benefit from use of tocilizumab.
10. Timely and accurate diagnostic SARS‐CoV‐2 testing is a crucial step in managing.
11. Avoid Fancy anti-viral and HCQS. At present Ivermectin is also not scientifically supported.
12. Low molecular weight heparin, Aspirin, NOACs, (novel oral anticoagulants: dabigatran, rivaroxaban, apixaban, and edoxaban) to be used as it was earlier. Colchicine might help.

CME INDIA Alert

• Multiple Variants Can ‘Escape’ Vaccines still vaccines raise other kinds of immune responses which could protect against developing severe disease.
• New Preliminary data from a study conducted at the University of Oxford indicates that the COVID-19 vaccine developed by AstraZeneca PLC is effective against the P1, or Brazilian, variant, Oxford Study Indicates AstraZeneca Effective Against Brazil Variant, Source Says – Medscape – Mar 05, 2021. The COVISHIELD data indicates that the vaccine will not need to be modified in order to protect against the variant.
• COVAXIN demonstrates high clinical efficacy trend against COVID-19 but also significant immunogenicity against the rapidly emerging variants.

CME INDIA Tail Piece

(By Dr S K Gupta, MBBS MD(Med) CFM (France), Senior Consultant Physician, Max Hospital, New Delhi)

Covid Update – 101

What is Mutation?

Mutation is the property of a virus to undergo changes in its genetic sequence  when it multiplies.

What is a Variant?

Variant is virus whose genetic sequence differs from its parents.

What is a Strain?

It is a variant with (many) mutation(s) which significantly alter it’s behaviour like Kent (UK) Strain, South African Strain etc.

What is Variant of Concern (VoC)?

When the changed behaviour of a Strain becomes Cause on Concern for population it is called VoC. Some mutations can even become lethal to virus.

Reading Mutation Names?

Mutation names denote changes in the virus’s genetic sequence. So, N501Y means the 501st amino acid in the coronavirus’s spike protein has changed from N (asparagine) to Y (tyrosine). Likewise, E484K means the 484th amino acid has changed from E (glutamic acid) to K (lysine).

Why mutations occur?

Longer stay of virus in body of (immunocompromised) hosts -allowing multiple replication cycles increases the chances of mutations.

Can we stop mutation of Sars Cov-2 Virus?

Since there is no proven anti-viral medication, effective containment strategies like mask, social distancing, early testing, isolation and mass vaccination remain the key.

Second wave in India is due to Mutant Strains or still original Wuhan Virus predominates? 🏹🏹

Govt is of the opinion that number of cases of variants detected so far, are not enough to attribute second wave  to mutant strains. However, as long as enough testing analysis is not done these words may not appear convincing.

In wake of second wave in Europe and USA – On 24th Dec 2020 Indian government took initiative of INSACOG, (Indian SARS- CoV-2 Consortium of Genomics) aimed to sequence 5 per cent of all positive cases, to address the concern that India has not been sequencing SARS-CoV-2 isolates to full capacity.

How many samples have been tested?

Total of 10787 positive samples have been analysed. It is noteworthy that more than 16 lakh new cases have been added in India since 25th Dec 2020.

How many cases of VoC found?

Since INSACOG initiated its working, 771 variants of concerns (VOCs) have been detected in a total of 10787 positive samples shared by States/UTs.

Cases of Mutations so far in India?

• 736 positive for viruses of the UK (B.1.1.7) lineage.
• 34 positive South African (B.1.351) lineage.
• 1 positive for Brazilian (P.1) lineage.

Are mutations confined to one state?

No, the samples with these VOCs have been identified in 18 States of the country,”

How can we Control the Second Wave?

Balram Bhargava, Director-General ICMR said that COVID-19 tests, masks and vaccination are key to overcome the early second wave.  First wave strategy of Test Treat and Trace remains at the core though.

Which Vaccines are effective against New Strains?

“There is an evidence that both vaccines in the country (Covishield and Covaxin) act against both Brazilian and the UK variants too. Research is ongoing about effectiveness of use in South African variants*” – Dr Balram Bhargav.

mRNA vaccines Pfizer and Moderna not found effective as proportion of neutralizing antibodies dropped 5- to 6-fold against the Brazil variants. And neutralization fell 20- to 44-fold against the South Africa Variant.

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