The world’s greatest medical disaster is upon us in spite of all the available technology, and advance warnings like the mock drills of the 2016 UK Exercise Cygnus. It started in the wet markets of Wuhan, and transported to Northern Italy by the fashion industry’s Chinese workers returning from Wuhan after Chinese New Year holidays. It took hold in the elderly local population, and the open Schengen borders did the rest.
This virus is particularly lethal because of rapid spread, coupled with an increased capacity to cause damage. MERS and SARS displayed one of the two; COVID-19 displays both. A domino effect was inevitable with air travel. As in China, there was an initial phase of denial. By the time reality struck home people were dying by the thousands as the virus spreads by geometric progression. Each patient infected between 2-3 others in contrast to the previous epidemics where each patient infected one more. Each of these three then passed it on to three others; and so on. One infected lady in S. Korea is believed to be responsible for infecting 8000 others. The virus provokes a violent auto-immune reaction which affects mainly the lungs, the gut, and, as recent evidence suggests, the heart. Common symptoms are fever, dry cough and difficulty in breathing. The reaction in the lungs severely compromises the oxygen exchange capacity, with a sensation “like drowning”, and eventually death. Being an entirely new disease, there is no known cure or vaccine. Both are subjects of intense research; and our defence mechanisms are basic, relying on available information. At present these are mainly physical distancing, (the term “social” has connotations of caste-based untouchability), protective personal equipment (PPE), including masks, isolation/quarantine and lockdown. Each of these is based on sound clinical rationale.
The virus spreads by droplets expelled by a coughing patient which have a range of about six feet. Hence the rationale of physical distancing. The virus survives in airborne droplets for about 3 hrs weakening gradually; hence isolation and the use of masks. There are two types of masks; the usual surgeon’s masks curb the range of expired air, and therefore more useful for a patient infected by the virus. With new evidence of patients being infective during a five-day silent incubation period, their use in hot spots for asymptomatic patients is now recommended. The N95 masks filter inspired air to protect the wearer; and in view of their scarcity, for use mainly by frontline healthcare workers. These have an efficiency of over 95%. However, the public is now encouraged to use homemade masks of layers of cloth as these, if made with the right material could have efficiency levels over 60%. A simple test for efficacy is inability to blow a candle out at 1ft wearing a mask; or spray air freshener in front of you; if you can’t smell it, the mask is effective. The virus survives on steel and plastic for 3 days, copper for 4 hrs, and cardboard for 24 hrs. However, in cruise liners it has been found 17 days after evacuation, probably because of the favourable conditions created by the ventilation systems. This survival forms the basis of sanitising procedures which inactivate the virus, using compounds with 62-71% alcohol, 0.5% hydrogen peroxide or 0.1% Sodium hypochlorite (bleach). It also stresses the importance of frequent hand-washing and not touching one’s face; because virus picked up from any of these surfaces can be transferred to the nasal area. Two types of tests are currently available for patients exposed to the virus. A rapid test for antibodies whose waiting time for results is shrinking by the day, and a more accurate RT PCR test which takes more time. The former can be used to identify suspect cases for isolation and initial treatment pending confirmation with the RT PCR test.
Being a new disease, effective therapy has yet to be agreed upon. In the absence of more valid data, anti-viral and supportive therapy are the current mainstays of treatment. The use of Chloroquines (anti-malarials) is a matter of controversy, fuelled by the recent ICMR recommendations for prophylaxis and Trumps proclamations. They have toxic effects on the heart, eyes and liver and should be used only on medical advice, preferably after a cardiac assessment. Fortunately, the WHO has ongoing mega trials for four regimes and the results are keenly awaited. Age provides no protection, with even infants and children being affected. There is no doubt that those over 60 yrs and with pre-existing diabetes, heart, or lung conditions have very unfavourable outcomes. Our current defences therefore revolve around physical distancing; an impossibility in slum areas with densities of one person/10sq.ft. Frequent, hand-washing is a pipe dream when NSS surveys have shown that 26% don’t wash their hands after (often open) defecation; only 35.8% wash before meals and 60% with water alone. The virus survives in stool for 11 days, and there is not much choice when water is supplied once in 3 days, or food is a greater concern than soap. Screening and quarantine are abused, and do not apply to VIPs ever ready to bend the rules. The recent lock down was a total disaster, bereft of any planning. It defeated the very purpose of distancing, subjected thousands to inhuman conditions without food or shelter; forced them to walk for miles and treated them like animals, spraying them with hazardous chemicals. Our politicians have abused the concept of distancing with their pre-election campaigns, political, religious and even social gatherings, in total contempt for the PM’s directives. Testing, therefore has to be the mainstay of our approach, given the shortcomings of all other measures, and requires urgent extension, supplementing selective lockdowns.
Dr Laxminarayan, a renowned epidemiologist made some sobering assessments. He expects three to five hundred million positive cases before the disease burns itself out; with 1-2 two million fatalities. Let us hope better sense prevails.
(The writer is a
founder member of VHAG)
