Dr Syed Mudasir Qadri, an Associate Professor of Internal and Pulmonary Medicine at the SKIMS, Srinagar has been in the thick of the fight against the Coronavirus pandemic since the contagion flew to Srinagar. Admitting complacency after the first wave, Dr Qadri tells Khalid Bashir Gura that the third wave can be disastrous if people do not adapt to the ‘Covid appropriate lifestyle’. He believes the contagion will coexist for some more time.
KASHMIR LIFE (KL): How is the second Covid-19 wave different from the first one?
SYED MUDASIR QADRI (SMQ): The second wave of Covid19 is different in many ways. Firstly, this time the virus has become more infectious. We are seeing whole families getting infected at the same time or in a few days.
Secondly, this time we are seeing lung involvement in a larger proportion of patients testing positive suggesting that the present strain is more virulent.
Thirdly, there is a shift in the age group of the people infected by the virus. This is causing increased morbidity (illness) and mortality (deaths). Last year it mainly troubled the elderly but this time the major brunt is being borne by the middle-aged and younger population.
The scenes at the hospitals are well known to most people through mainstream and social media. The patient load has tremendously increased leading to pressure on the hospital bed availability. To cater to the increasing rush of Covid19 patients, most of the beds in the major hospitals have been converted into Covid beds. The majority of these admitted patients require high flow oxygen support (15-60 LPM). This has put a lot of pressure on healthcare workers especially doctors and paramedics.
KL: Is it the same old virus or now different strains are around?
SMQ: The mutant strains that we have in the second wave seem to have evolved themselves to become more virulent and infect the younger population as well. This time the infectivity rate is much higher and the incubation period seems to have shortened. Now families test positive together. This is unlike last year when incubation periods varied and in certain cases, it took two weeks.
B.1.617 strain is the technical name of the variant first reported from India. This branch of the virus’s mutation tree has three offshoots, or sub-lineages: .1, .2, and .3. Of these, the Indian variant officially called B.1.617.2 is one of four mutated versions of Coronavirus, which have been designated as being “of concern” by UK public health bodies. Based on preliminary data, scientists have said that this variant could be 50 per cent more contagious than the B.1.1.7 variant, first reported from the UK.
It was reported in the first week of January 21 that two Kashmiris carrying the UK Coronavirus strain were admitted to a local hospital in Srinagar. In the third week of April 2021, 28 cases of the UK strain and other new strains were reported from Jammu and at the same time, the lesser-known N440K mutation was reported in a sample sent from Kashmir by the India SARS-CoV-2 Consortium on Genomics (INSACOG). So, in a nutshell, these are the predominant variants circulating in our population, at present.
“I think by now we should be shaken enough to understand that this virus is not going anywhere for now and is here to stay with us for quite some time in the future too. So, we need to adapt a lifestyle that keeps the virus out of our lives as much as possible.”
KL: On the testing and sampling front, where do we stand? Do you think it is effective?
SMQ: Right from the start of the pandemic in March 2020, Jammu and Kashmir was among the top-performing places in testing and sampling. We have always been a step ahead in this regard except for a short period at the beginning of the second wave when we were caught off guard by the sudden rise in the number of cases especially after a huge tourist footfall due to the opening of the Tulip garden and people thronging to other local gardens as well. Even then our numbers were good.
Regarding its effectiveness, of course, it is very effective and we can see the curve bending, and we are waiting for it to flatten before it crawls back to the baseline. Yes, there are many cases that are Covid19 positive and opt for home isolation without informing the authorities. They conduct self-tests (RAT) at home and do not report them, so the actual numbers may be more.
KL: Is there community transmission?
SMQ: The way patients are presenting without obvious contact history that too in groups, looks like we are already in the community transmission phase for quite some time now.
KL: What are the strategies government should adopt to contain the pandemic besides lockdown and what should the people do?
SMQ: I had written on this and shared my opinion in detail exactly a year back regarding how we should brace up, plan and proceed to tackle this dreaded virus in a planned way. Somehow, we became complacent and started celebrations even before the war was won. I think by now we should be shaken enough to understand that this virus is not going anywhere for now and is here to stay with us for quite some time in the future too. So, we need to adapt our lifestyle, our working style in a way that the virus stays out of our lives as much as possible and many of these steps have already been initiated at government and private levels as well.
We must adopt a “Covid appropriate lifestyle” that will include:
We should work from home, wherever and as much as possible
Decrease the attendance of employees and customers especially where overcrowding is expected. For these two weekly or three weekly rosters can be made by each department and acted upon for few months and maybe a year or so.
Local businesses must shift to the new regime – out of 20 shops in a street let only 5 intermittent shops remain open at a time as per the roster.
Online classes are another step in the same direction. Once things are under control we can start with the opening of schools or colleges only once or twice a week, that too only a fraction of students at one time. We need to plan these things right now so that later on once things improve; we have a plan in our hand and do not get lost in the hustle-bustle of life only to find ourselves in trouble again.
We can segregate the vulnerable groups in our homes from the rest of the family members, maybe to a different floor or a different room, whatever wherever possible and adopt complete social and physical distancing measures when dealing with them.
Use of mask should continue to be mandatory for everyone going out of their homes and it should stay so for many months or maybe a year even after things seems to be reasonably under control.
Social gatherings should be discouraged and festival celebrations be limited.
A “complete lockdown” can very well initiate the bending of the curve but to flatten and getting it back to baseline and preventing another wave shall need a sustained effort from all of us.
KL: If the virus is mutating, will it render the vaccine ineffective?
SMQ: Yes, the virus is mutating and we all know this is the main cause for this terrible second wave that we are in the middle of right now. Dr Soumya Swaminathan, the Chief Scientist at the WHO had also recently shared her fears regarding the new mutant virus strain’s (especially the Indian Double Mutant’s) capability to escape post-infection and post-vaccine immune response. But this shall not discourage us from promoting vaccination. So we need to double down on our efforts to get as much population vaccinated as possible in the shortest span of time as vaccination is our main weapon to fight this deadly pandemic, apart from adopting Covid appropriate behaviour.
“We were caught off guard by the sudden rise in the number of cases especially after a huge tourist footfall due to the opening of the Tulip garden and people thronging to other local gardens as well.”
KL: There are a lot of misconceptions and myths around the vaccine and people are reluctant to come forward for the jab?
SMQ: Yes, initially, there was a lot of reluctance due to misinformation, doubts about the way the vaccines were prepared in such a short span of time, and some reports of adverse effects from various parts of the world. But now it is the other way round. People are desperately looking for a jab; this is reflected by the increasing number of requisitions for vaccination and long queues for the same. Now everyone wants to get over the vaccination process quickly and feel safer in these frightening times.
KL: Are all age groups vulnerable to the infection?
SMQ: All the age groups are vulnerable to the infection. Its severity has been more in the younger population this time around, and who knows maybe in the third wave the virus may further evolve itself and cause severe disease in the kids as well. That’s why many countries like the USA have started vaccination drive among children (below 18 years of age) as well. Hopefully, we may also be following a similar path in the near future to ensure the safety of our children against this virus.
“We have observed that as if the virus attacks the mind first and then the body of a person probably because of the fear that it has been able to instil among people all over the globe.”
KL: Doctors say the second wave has brought sudden worsening of symptoms in many young patients, unlike 2020. What are the new symptoms?
SMQ: In the first wave the younger population tolerated the infection quite well but the older population were the ones becoming sicker and getting admitted. This time we see more and more young people getting admitted with bilateral pneumonia for oxygen therapy. Even the mortality in this population group has increased many times compared to 2020.
One of the different presentations this time is persistent fever followed by sudden worsening and fall in oxygen saturation. For this reason, as doctors, we need to counsel the patients and attendants properly so that they are alert to predict this worsening beforehand so that the patient is managed aggressively and the lung involvement and damage can be prevented or minimized.
KL: Does delayed admission contribute to the spike in deaths? When should one take a call on the need for hospitalization?
SMQ: One of the major causes of increased mortality is the late presentation to the hospital when the damage to the lungs has progressed to an irreversible stage. Few points that can help save lives and prevent or minimize the damage to the lungs:
- a) Acknowledge the problem. So, getting oneself tested at the right time and following the right advice of a doctor (not many) is the first step.
- b) Proper monitoring of oxygen saturation by a pulse oximeter about 4-8 times daily. In case the oxygen saturation starts to stay around 90-92% or less, it is time to go for a radiological and clinical assessment.
- c) Proper monitoring of body temperature by a standard digital or a mercury thermometer, at least twice or thrice daily. In case of persistent fever, consultation of a physician is warranted as it may be a sign of underlying worsening cytokine storm and needs investigations and aggressive management.
- d) Avoiding steroids very early in the disease especially when there are no mild symptoms.
KL: If someone is detected Covid19 positive, the first reaction is panic. What should be done?
SMQ: Somehow, we have observed that it seems as if the virus attacks the mind first and then the body of a person probably because of the fear that it has been able to instil among people all over the globe.
One should not panic as the majority of the patients (85-90%) have only mild illness and recover without any complications. Furthermore, if they follow their doctor’s advice and the above-mentioned points then there is every chance that they will defeat this virus. Yes, one should not hesitate to take a specialist opinion from a psychiatrist in case the problem becomes overwhelming.
KL: Now people go for self-medications or take advice from prescriptions and videos available on social media?
SMQ: It’s very important for each one of us to verify facts before we accept anything as truth and indulge in self-medication or adopt social media-based treatments as they may cause more harm than good. I would rather suggest you talk to a doctor who is known to you before embarking on such internet-derived protocols. The majority of the doctors at present are not only working in hospitals but are also trying to help the community through the virtual model. If I give you my example, on principle I am quite against the online mode of treatment as I belong to the old school of Medicine. But going through a Pandemic means, “special situations need special measures”.
KL: What is your opinion about Remdesivir?
SMQ: Remdesivir is an antiviral agent that has been in and out of the treatment protocol of Covid19 many a time. Remdesivir showed promise right from the beginning as it had shown good activity against SARS-Cov-1 and MERS (Middle East Respiratory Syndrome) virus, both Coronaviruses. Initial international trials (Published in NEJM, one of the top medical journals) showed benefit in terms of the hospital stay.
A solidarity trial by the WHO, however, showed no benefit in reducing mortality in patients hospitalised with Covid. There are many more trials on either side of the line and many are still going on. So, the final verdict is not out yet. When we analyzed our data at SKIMS Soura we also found results similar to the initial NEJM study so, we still use it in the first 10 days of illness in patients admitted with severe Covid illness.
KL: What about CT scans and how frequently should a scan be done?
SMQ: Yes, it is being over-prescribed, overused and most of the time it is because of self-advice. High-Resolution CT (HRCT) of the chest has definite diagnostic and more importantly prognostic importance in Covid19. It is a very important tool that is a guide to the treatment as well. The most important thing is that we need to “time” the CT chest.
We need to time it with:
- Duration of symptoms (the best time to do a CT is in the second week, the majority of the CTs done in the first week are wasted).
- The severity of the disease, (CT may be done when oxygen saturation dips to and stays less than 94%, and it should be surely done if SPO2 stays less than 92%).
The majority of the mild cases do not need the CT chest. At the most we may screen them with a CXR and if there is any doubt then go for HRCT chest.
“On Remdesivir the final verdict is not out yet”.
KL: How do you see the next few months panning out?
SMQ: The last one and a half month has been very tough and we have seen a lot of devastation all around us. Almost every family has lost a near or dear one. In order to avoid further damage and defeat the virus completely, we need to discipline ourselves. The good news is that for the last few days, the number of new infections is showing a downward trend. Hopefully, slowly the numbers shall decrease further and the curve shall flatten and then start dipping again. By June end to mid-July, we may again reach the pre-April status. We cannot afford to be complacent once again; if we do so the third wave may strike us even harder than the present one.
“When you see people, young and old, craving for each breath and many dying in the process, it really takes a toll on the psyche and challenges your emotional quotient.”
KL: In this pandemic, the new epidemic of Black Fungus has risen?
SMQ: Black Fungus is Mucormycosis, a rare fungal infection that imparts blackish colour to the site of infection. Its incidence in the pre-Covid era was very low and would mainly infect when the immunity of the body is going down, especially in poorly controlled diabetics in the paranasal sinuses and other areas of the head and neck. It has come to the fore because of the rising numbers of this fungal infection in the Covid patients. High numbers of infections have been particularly reported from western and central Indian states. No one knows the exact cause or relation of this fungus to Covid. Few postulates are there:
- a) Use of high dose steroids for a longer period of time while treating Covid. (Usual doses of steroids probably do not pose that great a risk as there are so many diseases like Rheumatological disorders, Vasculitis etc, where patients need to take corticosteroids for a much longer period of time, sometimes many years but would not contract this infection
- b) One possibility is that it is the Coronavirus infection per se that predisposes a patient to catch this fungal infection (But we did not see similar reports from other parts of the world).
- c) Unclean oxygen lines or the water supply for the humidifiers or even unclean sanitation may also be a source of the fungus.
- d) A huge cache of fake medicine was caught in many places throughout the country (e.g. few crore vials of fake Remdesivir racket busted in Gujarat) and some must-have skipped through. White sugar powder was being used in place of the drug in these vials. The fungus could have crept in from there.
- e) Few international experts have even speculated the use of cow dung as a protection against the virus by many people in the same regions, as a possible source of the fungus.
- f) As the demand for oxygen has gone so high that industrial oxygen had to be diverted for medical use, maybe this oxygen is a source for the fungus.
KL: Finally, is it mentally challenging to work as a frontline worker?
SMQ: We are all doing our jobs, nothing special. Yes, these are challenging times and we go to the areas where the risk of exposure to the virus and catching the disease is huge. Many of our colleagues caught the illness during work, some became very sick and got admitted in the same wards where they had been treating others, recovered one day, and joined work again the very following day. When you see people, young and old, craving for each breath and many dying in the process, it really takes a toll on the psyche and challenges your emotional quotient. Many of us have lost our dear ones, parents, siblings, grandparents, close relatives, friends, but that has not stopped us from doing our job.
On the domestic and social front, we have to maintain social distancing even from our own family members. It is very difficult to make your kids understand the complexity of the situation and the reason for you to keep a distance from them almost at all times. It often hurts a lot and the fear of its effect on a child’s psyche makes us worry. I don’t like to be called the corona warrior. Everyone who is following “Covid appropriate behaviour” is contributing to the fight against this bad disease so, for me, everyone is a corona warrior.
By calling us warriors, no one gets the right to abuse us. We don’t need any appreciations but yes please spare us from the abuse. That will be all that we request from everyone. Frankly speaking, the solace that we get from seeing a sick patient recover and go back to his family overrides all the hardships that we face from all corners.