CME INDIA Presentation by Admin.

Understanding the Second Covid Wave.

Now it is obvious

A new double mutated strain of SARS CoV2 has been detected in second wave. This is in addition to Brazilian, South African and UK strain. This new mutated virus has the potential to skip the immunity and even vaccine. This is the reason for re-infection cases & cases among vaccinated people. It is more infectious & affecting younger population of 18 to 45 years group and this group is “super spreader.” Bypassing RT-PCR – new COVID cases may not be detected by routine RT-PCR test. R- value is increasing.

We present here the observations from physicians of India about how second wave is rippling and what could be the fate in days to come

Read also CME INDIA Tail Piece to Understand Tree and Leaf method to estimate second wave again

Important Alert

Ranchi

Dr Nishith Kumar, Pulmonologist:

1. Do not wait for SpO2 to fall below 93%. Patients who have good lung reserve (young patients) rarely show desaturation unless & until their lung involvement is more than 50%.
2. I have seen 100s of cases where the patient is maintaining normal oxygen saturation & more than 35-40% lung is affected on CT Scan.
3. If feasible try to get a CT Scan done between Day 5-7 of symptom onset.

What Ranchi is witnessing, never happened in history

1. Fever, Malaise, cough New symptoms: unlike last wave this time I am seeing lots of patients with nasal congestion/rhinorrhoea.
2. More & more youngsters (22-35 yrs.) are presenting with pneumonia this time.
3. Remdesivir doesn’t seems to be working this time even if it’s given early i.e., 1st week of symptom onset/viraemic phase.
4. Close monitoring & timely supportive care remains the mainstay of treatment.
5. RT PCR may remain negative in many cases. It’s better to rely on HRCT Thorax in such cases if clinics picture is suggestive of Covid 19.
6. Most of patients who remained kind of ok in 1st week deteriorated rapidly between Day 7-10, so one should be super cautious while dealing with such cases. Monitor vitals, blood parameters & repeat HRCT Thorax if there’s new onset fever/fall in saturation etc.
7. Try awake proning/NIV support in serious patients. Avoid intubation as long as possible. Outcome post intubation is really bad.
8. Happy Hypoxia state is more common this time. There are lots of patients who are kind of ok even if their saturation is hovering around 88-92%.

Chennai

 Dr T Rekha MD med Salem, TN:

1. So far in the admitted cases most of the age groups are between 30 – 40.
2. Most of the cases are mild to moderate, though we had admitted 2 of them in ICU (age 30 plus).
3. All the mild to moderate cases were treated with Remdesivir, low dose steroids, anticoagulants, & vitamins. Responded well, became asymptomatic & discharged on days 6_7.
4. There is no typical GGO in many of the cases. Looks like bronchitis picture.
5. One whole family (4 members) admitted following post vaccination 1 st dose following vaccination.
6. Severe cough and fatigue were the most common symptoms rather than fever.
7. RT PCR was positive around 60% 0f the cases.

Kolkata

Dr Arvind Ojha:

1. Only serious cases are being admitted. But as I can see majority of infected persons are having mild symptoms. Families are infected in one go, possibly the strain is more contagious and by the times symptoms develop in one member, others are already exposed.

Fever, myalgia and cough are 3 initial symptoms.  Dyspnoea is always present on admission. Not seeing much gastrointestinal symptoms on presentation.

I have heard about joint pain and skin symptoms being the presenting symptoms, but not seeing in my practice.  But let me admit that I don’t see many opd patients of Covid-19.

2. Compared to last time (before January), more and more young and middle-aged subjects are affected. Probably effect of various factors like negligence, callousness toward preventing measures, need to move out for economic reasons and gathering because of festivals.

3. No major change in treatment since last time.  Treating on the same line. But use of Tocilizumab and CCP has been minimized and very rational. Almost no use of favipiravir. Not seeing much of this molecule being prescribed by others as well.

4. No specific new intervention is available. But good no of patients are coming very late, maybe due to bed crisis and presenting with secondary infection and usage of higher antibiotics and anti-fungal has gone up a bit. I have not used pulse steroid therapy in any of the patients this time, which was used earlier by my colleagues in few cases. Results were disappointing. I have noticed very liberal and indiscriminate use of oral steroid in mild cases at home. This may be the reason for secondary infections.

My take is that though no. are more and fast this time, but the disease is not alarmingly different and difficult from the last wave. With the experience gained, management is more straight forward this time, at least in hospital. My real concern is, can we have resources to handle the patients, if no. keeps going up like this?

Dr Bijay Patni:

Data from my 312 patients.

1. Younger age group are more infected. (6- 75yrs with less than 50 more than 80percent of cases)

2. If symptomatic, symptoms persisting for more than 7-10 days particularly fever and loose motions. Vomiting is another feature. Weakness is another constant. Mild cough is also a universal companion. Ear pain, tinnitus is a new finding in some.

3. D-Dimer is found to be elevated in most cases. CRP is usually less than 7-8. N L ratio is usually more than 2.5 on presentation.

4. Oxygen saturation usually remains stable in spite of high fever and raised CRP/IL6. 5. Very infectious. Almost all near contacts are positive if traced.

Bhagalpur

Dr Rajkamal Chaudhary, Asso. Prof Med JLNMCH:

• Patients are coming with more rare symptoms presenting with Joint involvement which is mostly difficulty in their movement.
• Loose Motions
• Extreme weakness of their Body.
• Muscle Cramps mostly in their calf muscles and Tetany like symptoms.
• Fever, Cough, Breathlessness, Loss of Taste and smell are the usual symptoms which are present as of Last year.
• Atypical Symptoms -Tingling sensation was observed by me and RT-PCR test was positive in that case.
• It has been observed by contact tracing that there are Random sampling of RT-PCR investigation there are about 15 to 20 % cases without any symptoms or signs of COVID-19 though they are positive which is a reason for being their SUPER SPREADERS and increasing of COVID-19 Cases everywhere in India.
• Age group is also typical this time from Children 1 years to 30 years.
• This time we are not giving Dexamethasone from beginning and also Enoxaparin. We start usually when the patient needs ICU and his Oxygen Saturation starts falling.
• We give Doxycycline 100 mg BD for 7 days
• Remdesivir still not available in open market and still no government supply.
• This time RT-PCR reports are only 67 to 70 % Positive and RAT around 89% Positive.
• In whom the RT-PCR or RAT are not present positive and we suspect that the patient is clinically Positive we suggest HRCT and Ground Glass opacity is observed with (Pleural Effusion in some cases)
• This time due to lack of definite Signs and symptoms of Corona we are missing cases which is the reason of Creating Super Spreader and increase of large cases in India.
• Mutations is Second reason. May be Vaccine not Acting in Already immunized in Mutated Virus (Antibodies present after Vaccination not acting on the new Antigen or T cells).

Delhi

Dr Anil Motta:

• Last year symptoms: Dry cough, fever, weakness, breathing problems, loss of smell.
• Current symptoms: Apart from above symptoms, many new symptoms are indicating Covid. These includes: – Only headache – only loose motions – Only body ache – Only weakness – Uneasy feeling – Vomiting – Hearing problems – Conjunctivitis or in combinations. This virus is so infectious that if one member of the family is affected, the whole family also getting infected.

CME INDIA Illumination

• The Jharkhand health department on 13th April 2021 confirmed the presence of the UK mutant and double variant strain of the coronavirus. According to an official press release, out of 52 samples sent for genome sequencing to the Institute of Life Sciences (ILS), Bhubaneswar:
• 9 were found to have the UK mutant strain
• 4 with the double mutant. 
• The new variants of coronavirus have been detected in at least 18 states including Jharkhand.

A: In Second Wave Virus Shows faster transmission but is it really more Virulent?

(By Dr S.K. Gupta, Internist, Max Hospital, Delhi)

• During country’s second Covid-19 wave faster transmission of virus is well evident from rapid peaking of cases and involvement whole of family from one member.

But is the virus more virulent? Since second wave number of reported daily deaths steadily increasing, but can virus be accused of becoming more virulent? Probably, only if deaths increase out of proportion to number of cases i.e., Case fatality rate goes up.

💐What is the real colour of this Virus? Let’s analyse…

• In India initial case fatality rate (CFR) was ~3% in nearly 2020 but as health infra improved, treatment protocols got standardized CFR stabilised around 1.3%. In last the six months before the start of the second wave (from September 2020 to January 2021), around 1.1% of cases resulted in deaths. So, this 1.1% could be good comparison point in the current scenario.
• Despite steep second wave CFR in Maharashtra has shown a constant decline from 0.77% in March 2021 to ~0.55 % in first fortnight of April 21 at the peak of Second wave, negating all theories of high virulence of Virus.
• Kerala too had reported a similar trend with a mortality rate of 0.4% during second wave.
• All India trends too show a marginal decline in Death rate despite the rapidly rising second wave all over the country to around ~1.38%.
• Moreover, this death rate comes at the peak of the second wave when hospitals and doctors are burdened and resources such as ventilators and hospital beds are stretched leading to higher mortality as the limitations of the system.
• For Covid-19, during Second wave mortality rate has been low in India and CFR is below 1 as recommended by the World Health Organisation.

Darker side of the coin

• Rates may have a story to tell but more the number of people affected, more are the deaths devastating larger number of families.
• Virus seems not only seems to be affecting younger population and but also appears to causing early complications leading to much concern.
• Thirdly larger number of infections in Society remain untraced, untested and hence under reported. But eventually such cases too add to curve of mortality.  Also, true data of deaths is yet to be released by local municipal authorities.
• So, the real relief comes from control of pandemic not just rates and figures. 
• Stay safe.

B: Varients and Lab Testing – Are we missing cases?

(By Dr S.K. Gupta, Internist, Max Hospital, Delhi)

Food and Drug Administration had earlier warned that new mutations in the coronavirus could render some tests less effective

Polymerase chain reaction, or RT PCR, test, are designed to detect specific gene sequences of the coronavirus. If mutations appear in these “target” sequences, the tests may no longer be able to detect the virus, yielding false negatives.

What does a test detect?

Most of available RT RCR assays detect three coronavirus specific genes including a corona family gene e.g. E Gene whuch codes for E envelope protein. Two other genes, ORF-1a and RdRp, are found only in SARS-CoV-2. So finding only the envelope E gene would make test inconclusive for SARS-CoV-2. Family genes like E gene/ S Gene/ N Genes are included to make test more sensitive while ORF -1a and RdRp genes make test specific to Covid 19 Virus.

Which genes undergo mutation?

Gene for the spike protein, known as the S gene, has been particularly prone to mutation, and Kits that target this S gene may miss certain variants.
For instance, Thermo Fisher’s TaqPath test fails to detect the mutated S gene of the B.1.1.7 variant

PCR test does not rely on the S gene alone; it has three targets and can still return accurate results by detecting two other stretches of the coronavirus genome.

There is no evidence that the known variants of concern are causing tests to fail completely. “The tests today work very, very well- Govt of India confirmed on 16 April 2021

Antigen tests
Most antigen tests target the nucleocapsid protein. gene, known as the N gene, which is more stable and less likely to mutate than the S gene.

So if an antigen test is Negative and Later PCR comes positive a high index of suspicion be maintained for variant strain

How to identify Variants of Concern?

Identifying a variant is typically a two-step process. First, a standard PCR test. If positive, the sample is sent for genomic sequencing.

A single PCR test that can detect specific combinations of mutations that characterise three variants of concern: UK B.1.1.7; South African B.1.351and Brazil P.1, has been developed by Grubaugh and his colleagues. (work is yet to be published in a scientific journal)

How many cases of variants have been found in India?

As on 15/04/2021, 13,614 samples have been processed in India. Of these, 1,189 (8.73%) have tested positive for variants of concern in India. This includes 1109 UK variants; 79 South African variant and 1case of Brazil variant. These variants have higher transmissibility.

The Double mutation (2 mutations) is another variant and has been found in several countries like Australia, Belgium, Germany, Ireland, Namibia, New Zealand, Singapore, United Kingdom, USA. Higher transmissibility of this double mutation variant is not established as yet.

Dr H D Sharan, Ranchi responds to this:

Does not address the concern with the B.1.167 double mutant strain. Probably responsible for today’s steep surge. UK has been able to control the B.1.1.7 and they are not getting cases that are bypassing the immunity generated by the Astra Zeneca vaccine. We are not only seeing breakthrough infections but severe disease and death also. Recently, samples sent from Jharkhand to Bhuvneshwar showed presence of B.1.167 in 30 % samples. Yes, the sample size was small( a little more than 300 samples) but it definitely points towards the double mutant strain being a strong reason for this sharp surge. The early development of CoViD Pneumonia in youngsters, rapid deterioration, increased incidence of reinfections, death of fully vaccinated people all indicate towards B.1.167.

Big question now is, how do we stop this strain. I strongly feel that we may have to take another shot of rejigged vaccine to cover theis strain. Till that happens, we should be extremely careful while treating the patients.

With the increased incidence of false negative cases, HRCT Chest should be advised to all and all positive cases be admitted to the CoViD ward. We will need an advisory from ICMR on this.
In this context, I strongly feel that taking rounds in the CoViD ward is much safer than the non CoViD wards as a lot of mixing of cases is taking place. OPD is the worst.

CME INDIA Hope

(By Dr Suryawanshi, in charge Phoenix Multi Speciality Hospital (Shared by Dr Santosh Malpani, Nanded, Maharashtra)/As on 15^th April 2021.)

• Covid 19 cases have started to reduce since last 4 days.
• Number of critical patients have gone down.
• The number of Inquiries about ventilator beds have come to negligible level.
• As far as Nanded is concerned we have stated with decent of 2nd wave.
• It’s the time we should encourage our staff and boost our morals that we have faced hard days and the critical cases will go to negligible level by next two weeks. So, don’t panic.
• We are getting Inj Remdesivir for Indicated cases.
• We have adequate oxygen supply to treat hypoxic patients.
• We have almost 40 plus pvt Covid centres in Nanded so we can take help of our colleagues in emergency about Remdesivir or Oxygen cylinders too.
• We had 1800 plus cases 4 days back…reduced to 1600 …1400 and today it’s 1200.
• Now every Covid Centre will have vacant beds in icu and wards in next week onwards.
• Situation has improved and will definitely improve further.
• Let’s keep united to help each other’s. 👍🏻

Dr Santosh Malpani Nanded: ☝️ first positive thing after a month

CME INDIA Tail Piece

How to estimate the spread of SARS-CoV-2 virus in a region? (The tree 🌳 and leaf 🍁 method)

(Dr Rajeev Jayadevan, Gastroenterologist, Kochi.)

This is one way to do it without depending on officially reported numbers. The idea is to check the % of sick COVID-19 patients in the area’s hospitals, especially the % of COVID ICU beds that are occupied.

How does this work?

• Imagine: We are visiting a park. Can we estimate the size of a tree or the number of leaves on it by looking at only at the ground underneath it?

Yes. Larger trees have more leaves on the ground.

• On the example above, if the amount of COVID-19 in a community (large geographical area) is a tree, then the sickest people are the dried leaves on the ground.
• The larger the tree, the more the dried leaves seen on the ground. If we look under each tree, we can tell the size of the tree by counting just this.
• This example is used to demonstrate that without looking up at the tree, we can estimate the size of the tree. (this is a metaphor for the amount of disease in the community, please assume all the trees in the park are of the same type for this example)
• Although all positive cases are not discovered or reported, the sick 5-10% patients will invariably reach the nearby hospitals. “If you can’t breathe, you cannot hide.”
• Thus, if we look at % of sick among those admitted in the hospital, we know the extent of spread in the commute it serves. The more the spread, the greater the % of really sick among those who are admitted.

How does the % change?

• Imagine a time of low pandemic spread. There will be patients admitted to hospitals anyway, but the fraction (%) of sick among them will be small. Most of them will be mild cases. But when community spread is high, more sick patients arrive, yet the beds are constant. Therefore the % of sick increases.

Why use this method?

• The criteria and amount of Covid testing and reporting is variable between regions. Hence it is often difficult to estimate the exact amount of virus burden in a community. Hence the example above.

What is the limitation?

• There is a 4-week lag period between an outbreak (e.g., large social event) and ICU patients. Hence, the ICU situation of today will only represent the outbreak situation 4 weeks prior. Data must be obtained from those hospitals that are actively treating category C patients. (We effectively used this parameter in Cochin to alert the government in January2020, and got a swift response, with visible results within weeks).

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