CME INDIA Presentation by Admin.

“There are 100 or more small epidemics in different states and cities, rising and falling at different times.” – T. Jacob John, CMC, Vellore.

COVID-19 and Diwali:

CME INDIA tried to understand the COVID situation in India. CME INDIA WhatsApp group members give the snapshot of scenario at large on 12.11.2020.

• Daily new infections in India have fallen from a high of 90,000 a day in mid-September to fewer than 50,000 now.
• Deaths have also gone down, from a peak of 1275 per day in mid-September to about 500 now.
• National Supermodel Committee says – 380 million Indians had already been infected by mid-September and that there might be “minimal active symptomatic infections” by late February 2021, if control measures continue.
• We may have reached herd immunity??
• Colder temperatures and several religious holidays approaching, India may well see a second wave.
• Everybody is exhausted and fed-up.
• It’s become a never-ending health-care problem?
•  “Without question, we’ve noticed a drop in mortality,” says Angus. “All things being equal, patients have a better chance of getting out alive.” – Derek Angus at the University of Pittsburgh.

Dr Anil Motta, Sr. Consultant, Delhi:

• More no of tests being conducted – more positive cases.
• Fear of COVID-19 seems to have taken a backseat…
  1. Most people find there are lot of positive patients around them who have mild illness or even asymptomatic.
  2. Unlocking.
  3. Tiredness of being tied down.
  4. Social functions esp. marriage season & festivals.
  5. High recovery rates shown on the media.
• However, hospitals are again fully occupied but with pts of less severity.

Dr Shashank Joshi, DM Endo, Mumbai:

• We still have COVID-19 but numbers are down. Icu beds are still not easy to get at times.
• Maharashtra has no masking, distancing and testing – as well as tracking is not great.
• Markets are overcrowded.
• But Mumbai is on the decline, two possibility – one it may spring back post Diwali or it has due to large exposure with Sero positivity in some slums above 80 percent may have some immunity. This may be really interesting if it beats the peak this time.

Dr Keyur Acharya, Intensivist, Royal United hospital, Bath, UK:

• Mortality has gone down. 2nd wave in Europe.  Now we have learnt when and how to give steroids. (Dexamethasone is used here as it is a clean steroid with no / minimal mineralocorticoid activity and auto taper). US will surge around Dec end January.  To come out of this we need our weakest link to improve without which we cannot go back to our previous functioning.

Dr Sanjeev Kapoor, Consultant physician, Faridabad:

•  At Delhi and surrounding NCR, the numbers of COVID pts have increased for about 10-12 days. Most of icu beds are full. Non COVID medical emergency pts are shunning the hospitals and many times they present late. This category of pts suffers further because till their reports of COVID being negative, these pts are kept in COVID suspect wards along with other people who will test positive for COVID.
• The gross indiscipline among the public at large, festival shopping, wrong way to wear mask, premature opening of various institutions is some of the causes of reappearance of COVID in my area. The government services (specially the contact tracking) are only lip service.
•  Incidentally the no of cases from rural areas are less than urban areas.
• There are examples of elderly who never ventured out in last 8 months, but still catching the disease.
• The incidence of collagen vascular disease pts. catching this disease has been interestingly extremely low (I had posted on this aspect earlier. I still believe HCQS may have a role).
• Despite so much cumulative experience in treatment of this disease, still there are lots of loopholes in management. There is pts who were treated in institutions absolutely as per rulebook and followed up in hospital, still they developed complications and died. Still, we don’t understand this disease.
• The COVID pandemic fatigue and possibly masked depression in the health care providers – now a big issue.

Dr Venkatesh Molio, Maregoan, Goa:

• We may see a flare post Diwali.
• People behave as if COVID has disappeared. Till we get a vaccine – Mask/Social distancing/Sanitiser.
• And COVID appropriate behaviour is our only vaccine.
• Situation in Goa, if u compare September: Much better – 150 to 180 cases per day as compared to 600 per day

Dr Rajesh Naik, Internist, Goa:

• Goa has significant decline now. Not a single death recorded after June. About forty percent ICU beds are empty. Most of people taking home isolation. Masks – people are using but no social distancing followed.

Dr Rajkamal Chaudhary, Asso. Prof. Med., Bhagalpur, Bihar:

• I don’t agree that COVID cases are going down in India, as we can see that Delhi, Bangalore, Mumbai, West Bengal, Kerala, Tamil Nadu and few more States are fluctuating between very high to average high cases of COVID-19.
• Regarding ICU Beds occupancy I can say when cases are on rise ICU beds won’t remain empty or less.
• Bihar, I can see the COVID-19 cases are going down but even then, ICU beds are not getting empty because the oxygen demand for number of days stay has gone up, there by discharge of patients are going less in number at least in JLNMCH, BHAGALPUR.
• The death incidence has not changed, now also you have 3 to 4 deaths per week as before.
• Herd immunity is slowly developing but I can’t say that it has gone to a level for protection to 60%, it must have been around 20% to 30%.
• Bihar will have a definite rise after the festive season finishes.
• Vaccines you can expect in 2022, by that time herd immunity can be there which will help you to finish Corona.
• 9% of cases are having relapse of COVID-19 to those who have less immunity or Premorbid conditions.
• The only thing which is less and that is havoc among patients and doctors have gone less, people have understood the importance of Mask and hand washing.
• Some are taking precautions while others are not.
• Many patients don’t come to you for treatment but like to stay in their house and get treatment for simple flu like symptoms and go to hospital only when symptoms get worse.

Dr Atri Gangopadhyay, Pomologist, Ranchi: 

• It is true, that with every passing week, the virus is weakening in severity, and the huge chunk of moderate to severe cases, out of the total proportion of cases has come down. But infectivity has not decreased and still multiple family members getting affected in the majority.
• Whichever states have opened up the most, and sadly whichever state has majority disobeying health instructions are getting increased case load because the infectivity has in no way decreased, this shows the trend of fall in certain states and resurge in certain states.
• Due to festivals there is crowd in market in my locality, but it’s the onus of many businessmen, who are mandating masks inside their establishments.
• Please remember, COVID has not yet gone. Please practice mask etiquette and social distancing to stay safe.

Dr Nishith Kumar, Pulmonogist, Ranchi:

• We are also seeing a sharp decline in COVID-19 cases here in Ranchi. Majority of people with mild symptoms are opting for home quarantine as they are no longer in panic mode. Just a few weeks back we were having 40 beds solely dedicated for managing COVID-19 cases. Now we have reduced the numbers of beds to 20. I am also seeing lesser number of COVID suspects in my OPD but the number of patients with post-COVID sequelae has surely gone up.
• New Delhi/Maharashtra etc. are experiencing a resurgence of COVID-19 cases after lockdowns this spring had brought the disease under control. It seems the second wave has occurred because businesses reopened too soon and public gatherings were held without proper safety precautions. Second tier cities are still coping with 1st wave. We might see a resurgence in rest of the country in Dec/Jan.
• The situation is pretty much same all across India. COVID-19 has not proved a dampener for festive shopping spree. Huge crowds can be seen flocking to the city’s markets with little or no regard for masks and social distancing norms.

Dr Akash Kumar Singh, Consultant Diabetologist, Baroda:

• The COVID19 epidemic which was raging like a bull till last month tapered off abruptly by the October end much to our relief. Our 65 bedded hospital which was full with COVID-19 admissions has now gradually started services for non COVID patients too and we decreased our COVID19 bed capacity to 40 from the earlier 65 beds, opening up 25 beds to non COVID patients. However, since the last few days there is again increase in number of patients. This increase is not as big as it was during the period of peak COVID cases but still we have 35-40 indoor COVID patients now. My COVID19 opd which had 10 plus patients earlier is now running at 4-6 patients per day. Hence the decline in COVID19 incidence is certainly there
• As far as the ICU beds are concerned, we have definitely less patients in ICU compared to earlier period and the inquiry for the COVID19 related ICU admissions is also less thus making us pretty clear that we have less complicated COVID19 patients in our patient population as a whole.
• The public attitude has taken a U turn. In the morning run or walk, >90% are not wearing the masks. The markets are overcrowded and people are either not wearing the mask or the mask has been pulled down leaving them with no protection. And the Diwali shopping crowd being so rampant, it is very clear that post Diwali we will definitely have the cases of COVID19 on the upswing.
• My definite observation is that people are now firm on COVID19 home based care. Most do not want to get admitted. Many are resorting to treatment from doctors who are giving steroids and other medications at home. I run a covid19 OPD and have seen the literal reluctance of patients to get admitted even when it is needed. So, the patients presently in our hospital who require oxygen and are getting into moderate to severe category of illness are those who were taking treatment at home without proper blood monitoring, radiology and have already landed up in crisis before they arrived in hospital. Hence, I feel that initial public phobia about covid19 infection has given way to near dogmatic insistence for home based covid19 care in majority of my patients. And this reason is the major reason for genesis of moderate to severe COVID cases in our city.
• Also, in our ICU we are seeing a good number of fevers with raised CRPs, D-Dimers with normal saturation looking like COVID but covid19 by RT PCR being repeatedly negative. Also increase in other non COVID ICU and non-ICU admissions.

Dr P R Parthsarathy, Chest Physician, Chennai:

• The number of cases in ICU doesn’t reflect the prevalence of the disease outside. It only reflect the no of severely ill COVID patients. We know that only 1-2% of those infected gets into ICU and again the no of days the ICU bed is occupied also has to be taken into consideration.
• Increase in the incidence in some states, – the no of active cases today reflects the occurrence of infection earlier (incubation period). The active cases are usually symptomatic or the contacts of infected /symptomatic patients. So, the increase in the cases roughly correlate with pooja holidays. Again, one can expect another increase by the 3/4 th week of November because of Diwali.
• In our city roughly 25 to 30% of individuals do not wear mask. Social distancing has also been forgotten.

Dr Ravi A, Prof. Med., Stanley Med College, Chennai:

• In Tamil Nadu COVID-19 cases are declining. In Stanley, we are having only 2/5th patients. Mortality is proportional to the case load.
• Increase in cases in certain States may be due to infection of the vulnerable people who were earlier protected by lockdown.
• Many areas in TN, people are going without masks. Fear of COVID is fast disappearing.
• In long haulers, as soon as they become swab negative yet depend upon NIV, BD nebulisation with N-acetyl cysteine showed improvement in the form of reduction in O2 requirement. Similarly, awake prone breathing too had good improvement.

Dr T Rekha, MD Med., Salem, TN:

• In Tamil Nadu we have a rapid decline in admission rate in private sector too. Hardly we get any mild to moderate cases. Those admissions coming on & off are severe cases requiring ICU care.
• People here are going for shopping in crowds, even without masks, not maintaining social distance for past few days. Even then case load is grossly reduced to about 1/10 th.

Dr Kamal Jain, Guwahati:

• COVID-19 cases are on decline mostly mild cases managed on home quarantine.
• Hospital beds are available only with only 5 percentage occupancy. Markets are crowded with mask down.

Dr Meenakshi Sahapathi, DNB Family Medicine, Faridabad:

• COVID cases are increasing in Faridabad. Mostly being managed at home. All corporates COVID hospitals full, no beds available. None of them want to wear masks. Still 2 to 3 attendants with most of opd patients. So, we don’t expect any decline in cases in near future

Dr Anu Jain, Ambala Cant.:

• In Ambala, we are again seeing some pts of COVID, many of whom come after a week & with lung involvement. Masking almost negligible in markets.

Dr Harish Darla, Endocrinologist, Mysore:

• Cases are REDUCED IN Mysore – we are now in double digits new cases after long time,
• ICU beds are vacant and lots of CCC — have been closed due to less patient and hotels handed back to the owners.
• I think could be a little premature as we might know the exact situation by month end – Post DIWALI. In lots of places and in Mysore too markets are crowded and many don’t use mask and most of them who use, use it inappropriately. Until we get vaccines, the only vaccine for now is MASK/ Hand Washing and social distancing. Never let down the guard — be vigilant and brace for 2/3rd wave.
• There is no contact tracing done now, and people who go for testing are tested for but otherwise no random testing is done. There are instances where pt. who was admitted with COVID, no one from health dept. approached and got contact tracing done or tested other family members.
• My personal thought was to keep the CCC running as once we close down then it will be a big task again to make it functional.

Dr Meena Chhabra, Diabetologist, Delhi:

• Delhi is too bad, Previous patients don’t get rid of every symptom new one multiplying.
• No beds in hospitals.
• People requesting for beds.

Dr Chandra Bhushan Prasad, Bihar:

• It’s rural verses urban, 99% without masks (rural) 40% (urban). But cases are too low in rural areas 🙄

Dr Basab Ghosh, Agartala:

• Maharashtra, Delhi, were initially affected states if you remember April May!
• Regarding present scenario of those states, same will be repeated in all states in the same chronological order like first wave! January will be crucial for India as a whole.
• Overall cases and mortality have come down in Tripura.
• We have seen the transition of SARS COV 2 from winter to summer and that was dangerous!
• Now the transition from summer to winter would be a new experience for us!

Dr V P Youmash, Assistant Professor, KAPV Medical College, Trichy:

• Definitely COVID cases have declined to a good extent but not completely.
• These states witnessed early surge, then decline, now probably second wave.
• People are roaming without mask, purchasing for Diwali.
• COVID-19 has become a treatable condition now with better knowledge on the drugs usage and timing. Even with late presentation, few pts are recovering well if treated appropriately.

Dr Bijay Patni, Diabetologist, Kolkata:

See this, today, Kolkata:

• No decline in Kolkata
• Not much safety measures followed. High court guidelines are not being followed in toto. People have become very casual as everything has opened up including local trains.
• Most of the busy markets are working as it used to do in pre-COVID-19 era.
• Number of cases in Bengal must be at least three times of what is being reported.

Dr Arvind Ojha, Internist, Kolkata:

• In my state of West Bengal, it was thought that there would be a surge in no. of COVID cases, but it was no so. Of course, there was a marginal rise. A similar trend is expected during Deepawali and Chat puja.
• We are not witnessing any decline in no. of cases like in many parts of India and it is unlikely to be so in near future.
• Overall mortality is definitely declining, also in critical cases. Pts with multiple co-morbidities and with features of severe ARDS are most vulnerable. 
• ITU beds are still not easily available because of lower turnover rates.
• Don’t know about Maharashtra or Delhi exactly, but in our place probably the attitude of people may be responsible for the continuing high no. None of the preventive norms are followed properly. Maybe we are witnessing 2nd wave without 1st wave ebbing.
• Markets are crowded and wearing mask is an exception. All around you the same scenario is visible.
• My personal thought is that we are now better managing the clinical cases compared to 2 months back.
• Less tocilizumab uses nowadays, but Remdesivir still going strong along with steroid and LMWH.

Col. Dr S K Singh, Asso. Prof. Dept of Int. Medicine, CH, NC, Udhampur:

• As far my hospital is concerned – that is Command Hospital Udhampur, which is a tertiary care hospital and designated COVID hospital also for Army personnel, we have almost 1300 admission so far. 1150 cases have been discharged. We have almost 150 active cases at present.
• Although the rate of admission has declined in last one month including positivity rate but severe COVID cases in geriatric and immune-compromised patients are still being admitted in icu.
• COVID phobia has gone down in general population and crowded markets with 50 percent population without mask is a regular feature in civil community here.
• We have 15 bedded COVID ICU which is still with maximum occupancy.
• Our lab has tested more than 1.10 lakh persons so far (Civilians and army personnel both)
• We have positivity rate of 12 percent.
• The average time taken in admitted COVID patient to turn negative was 12.5 days.

Col., Dr Ashutosh Ojha, Jamshedpur:

• Extreme paucity of ICU, ventilator and oxygen, in our region. Jharkhand cases are on rise.
• No adherence of mask, social distancing in the marketplace.
• Antigen based sero survey has unnecessary inflated false sense of security.

Dr Shailesh Trivedi, Chairman RSSDI, Gujrat:

• From 16th November onwards, North, Central & Western India may have a huge surge in view of Massive Celebrations of Diwali. Do you anticipate such phenomenon?

Dr Alok Rai, Chairman RSSDI, Chatishgarh, Raipur:

• Your observations are correct. There may be a second wave of COVID-19 in winter. We need to be alert.

Dr Rajeev Kumar Gupta, MD Medicine, IMS BHU, Varanasi:

• In Varanasi cases are decreasing in number and cases which are mildly symptomatic are being managed at home, ICU beds are relatively vacant.
• Market crowded with public. As usual, no masks.

Dr Sagar Dudeja, Delhi:

• Delhi police is strict against people not wearing mask in public places.
• ICU beds are full.
• Mild to moderate cases are being managed at home.

Dr Monica Gupta, Varanasi:

• COVID-19 is being managed at home by medical stores quacks, medical reps, and google savvy people.
• People are sharing treatments on WhatsApp.
• That anxiety of COVID scare has come down.
• Favipiravir is back in use more than Remedesvir.

Dr Bela Sharma, MD Med., Fortis, Gurgaon, Haryana:

• In Gurgaon, number of cases has increased in past few weeks, beds are not available in most hospitals.

Dr Umesh Kumar Soni, Consultant Physician, Jaipur:

• In Jaipur, the condition is really bad.
• People are not wearing masks and no social distancing is being maintained during OPD hours. COVID positive patients are coming to take medicines, even though we have told that their family members can collect medicines.
• No beds are available either in govt. or private hospitals, even for doctors, beds are not available.
• Looking at such situation, it looks like that it will be really difficult to control the spread of COVID.

Dr Soma Shekhar, CGHS, Mumbai:

• In Mumbai, also same situation.

Dr Sunil Kumar Kejriwal, MD DM., Gastro, Gorakhpur:

• In Gorakhpur too many people on road or market no social distancing, no mask. However, for last 1 month no of COVID-19 cases are at decline significantly beds are easily available as off now both in Government or Private sector. Great fear for second wave in future.

Dr Viksit Jaipuriyar, Physician, Dhanbad:

• Post Diwali and chath there could be a surge in cases in Jharkhand also because we will have many native citizens of Jharkhand working in other states and cities visiting Jharkhand on the occasion of Chath. Many of them would be from metro cities. That could lead to a surge of cases in Jharkhand also. Relaxation in lockdown and the process of unlock has brought out people on the roads and given the high population density of these cities, the rate of spread there would be much faster and could be one of the reasons for the rise in number of cases. Poor AQI of Delhi could be another factor, more conducive to the virus.

Dr M Pavan Kumar, Associate Professor, MGM Hospital, Warangal, Telengana:

• In one way we should appreciate the daring attitude of common man who are doing their regular works without masks… All the fruit wenders, daily labourers were not wearing mask since long time… By looking at them some more are following them… All the supermarkets are very busy with customers….Though wearing masks… Fear about corona has come down in all including doctors and educated personal…. As the disease process is understood, availability of treatment….Can be reasons. Hope it’s a good sign though underlying pressure is there…. Appreciation to the positive attitude of one and all.

 Dr Swati Srivastava.Sr Prof Med, SMS Med College, Jaipur

• We are not seeing a decline in covid cases
• The number of cases among the people around us, colleagues are increasing.
• The number of admissions may not be so many due to following factors being observed:

1. Now many mildly symptomatic people prefer day care treatment or stay at home.

2. This has been possible following treatment protocols being in place and guidelines for monitoring.

3. Many of the educated class are now well aware of the monitoring methods and the warning signs which should be notified to the treating doctor

4. Also, with the legality of the digital consultation, doctors are relatively easily approachable on WhatsApp etc and patients develop confidence as they are well in touch with the treating physician

• However, the ICUs are still full. There has been a sudden surge in cases observed by Hospitals in past 1 month following the dip seen in October.  This may be due to the increasing number of people coming out together in crowded regions and reduction in masking.
• What will be the impact of the temperature fall on covid is yet to be seen? Low temperatures are usually associated with increased flu viruses. But the coming months will show the pattern with covid 19

Dr Vinay Dhandhania, Diabetologist, Ranchi:

• There are many postulates on the reason for decrease in incidence of COVID-19:

(1) Slowly people are getting exposed to SARS-COV-2, are the either asymptomatic or mildly symptomatic (and don’t get tested) and hence have developed antibodies

(2) Fatigue in community health care workers in contact tracing, resulting in less testing

(3) Pressure on health care system to report low incidence

(4) Rapid Antigen Testing receiving priority (because of its rapidness) over RT-PCR. Thus, missing significant positive cases.

(5) Cases that are Negative in RAT and RT-PCR, but HR-CT reveals ground glass appearance are not accounted in the reporting system.

• COVID-19 is here to stay (just live swine flu, avian influenza. How long will people wear masks and follow distancing. Hence vaccine is the only answer right now. However, after the few years once the attention towards COVID-19 goes down, what is needed is epidemiological monitoring of data from various sources.

CME INDIA Learning Points

• Some case studies have been done in Andhra Pradesh and Tamil Nadu indicating that almost 70 percent of people infected with COVID-19 have stopped passing the viral infection to others.
• The virus was spreading through a small set of people also known as super-spreaders. Now it has been hypothesized that super spreaders usually get the infection in the early stages of outbreak adding that there is a possibility that these super-spreaders got the infection earlier and now they have become immune. A very few are left to transmit the viral infection to others. This could be a possible reason for decline in India’s Coronavirus declining numbers. (Expert View)
• There is still a lot that is unclear and more data is required to establish the reason. The reasons are not entirely obvious. There have been no miracle drugs, no new technologies and no great advances in treatment.

CME INDIA Tail Piece:

• So far, steroids are the only medicine that has been shown to have a dramatic effect on COVID-19 mortality.
• Anyone who’s very sick should get steroids. And everything else is a crapshoot. (In Nature)

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