In Covid-19: The doctors can now attend to providing good clinical care.

An unusual gloom elbowed the spirit of spring this year. Even though invisible, the tiny Virus has derided hope as well as optimism. It has pushed the human race under the glare of fear—either of infection or of dying. In India, as of July 24, the virus has caused 30601 deaths.

The novel corona virus appeared in December 2019 in Wuhan, China. The World Health Organisation declared it a pandemic on March 11. Indian government imposed a lockdown, the first of many, from March 25. Sadly, it brought to the surface the challenges of India’s medical infrastructure.

Corona is not totally alien. The virus was isolated almost six decades ago. It is known to cause the bothersome common cold. There are four types of the beta-coronavirus family which can cause the disease. But, like the influenza virus, it has the sinister ability to change its structure often. This deceptive façade is the primary cause—and the reason behind its lethal spread globally.

The first such case of a perilous mutation was noticed in 2002 when Hong Kong experienced the eruption of SARS (Severe Acute Respiratory Syndrome). It afflicted more than 8,000 people and caused 800 deaths.

The virus is believed to have originated in bats, which are, incidentally, asymptomatic. It is presumed to have travelled to humans via civet cats. The second disaster was the mutation resulting in MERS (Middle Eastern Respiratory Syndrome). It too had its journey from bats, and affected humans through an intermediate host, the dromedary camels, in Saudi Arabia. By last counts, there have been around 2,500 cases with over 750 deaths—a mortality of 35%.

The present eruption is again due to a mutated corona virus labelled by WHO as SARS-CoV-2, which is believed to have come from bats in a live animal and sea-food market in Wuhan, and infected man through an intermediary host (probably the pangolin). The virus has the capacity to infect lung cells through a receptor known as ACE-2, leading to complications of pneumonia and respiratory failure. The disease is now called COVID-19.
Apart from causing physical illness, COVID-19 has brought emotional and social suffering as well such as fear, anxiety, uncertainty of jobs and income. Respiratory droplets of an infected person carry the virus. Maintaining a physical distance of one metre, face coverings, washing of hands and limited group interaction are recommended preventive measures.

Interestingly, the symptoms of COVID-19, the common cold, and the flu are similar to each other. The symptoms begin with a low-grade fever followed by a sore throat and body pain. The doctors were flummoxed. They relied on nothing but blind instinct in the initial days of the pandemic.

“At first, we had no idea how to treat severely ill patients when we (ventilate),” stated Dr Satoru Hashimoto, who directs the intensive care division at Kyoto Prefectural University of Medicine in Japan. “We treated them in the fashion we treated influenza,” only to see those patients suffer serious kidney, digestive and other problems, he shared.

The majority of infected people experience only mild flu-like symptoms, but some can develop severe pneumonia, stroke and neurological disease. The significant learning has been how the disease can place patients at much higher risk for blood clots. The blood type might influence how the body reacts to the virus. “We developed specific protocols, such as when to start blood thinners, that are different from what would be done for typical ICU patients,” noted recently Dr Jeremy Falk, pulmonary critical care specialist at Cedars-Sinai Medical Center in Los Angeles.

In medical education, change is often slow, as long years of studies are required before recommendations are altered. As the virus has spread insidiously world over, the doctors were exposed to various experiences. The lessons drawn from them were shared widely through informal as well as formal networks. Team work within hospitals has also improved.

The protocols for COVID-19 have evolved, as a consequence, at an unbelievably fast face. In Brazil, São Paulo-based Hospital Israelita Albert Einstein, one of the country’s leading private hospital networks, has updated its internal guidelines for treating coronavirus patients some 50 times since the outbreak of the pandemic, according to Dr Moacyr Silva Junior, an infectious disease specialist at the center. The internet and social media has catalyzed the dissemination. As a consequence, doctors around the world are more confident than before.
Experimentation at many hospitals have helped, such as guidelines for “proning” patients—positioning them on their stomachs to relieve pressure on the lungs. It helps avoid mechanical ventilation, which many doctors feel that the device has done more harm than good.

Knowledge on testing also improved. The rRT-PCR antigen test is the best diagnostic test to identify if someone is infected and active with SARS-CoV-2. A nasopharyngeal (nasal) or oropharyngeal (mouth) swab is taken and sent in a cold storage box to the central laboratory, where the viral RNA is converted to complimentary DNA (cDNA) using reverse transcriptase. It then is amplified following the addition of a primer and fluorescent dye and DNA building enzymes. A positive test will be indicated by the raise in fluorescence. Depending on the equipment and method used, the time taken may vary between a few hours to a day to get the reports.

Adoption of faster and wider testing helped in optimization of available resources, such as conserve PPE by identifying the negative patients around whom doctors don’t have to wear as much gear. Focus on testing helped hospitals around the world to restructure operations, including floor layouts, to isolate coronavirus patients and reduce exposure to others.

The shift to such a mode of operation wasn’t always smooth, but doctors agree that it raised efficiency. Unlike in the initial phase, the doctors now can to attend to their primary task of providing good clinical care to reduce morbidity and prevent deaths.

New treatments like convalescent plasma hold promise. It is based on the premise that people who survive an infectious disease like COVID-19 are generally left with blood containing antibodies, which are proteins made by the body’s immune system to fight off a virus.

The blood component that carries the antibodies, known as convalescent plasma, can be collected and given to new patients. At several hospitals, it has been found to stabilize and minimize the need for oxygen support.
A steroid known as dexamethasone is found to reduce death rates by around a third among the most severely ill COVID-19 patients. Another drug, remdesivir, has shown reduce the length of hospital stays but hasn’t been proven to improve survival.

Remdesivir is designed to immobilize the mechanism by which certain viruses, including the new coronavirus, make copies of themselves and potentially overwhelm their host’s immune system. Earlier it was recommended for most critically ill patients. But doctors in the past few months have noticed that administering it earlier give the best results.

Although many facets of the coronavirus remain unknown, the publishing of scientific knowledge drawn from the experiences of past few months throws some light amidst the gloom. It equips the doctors with better ammunition. But also reminds gently the necessity to improve investment in public health care.

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