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McXtra Care Newsletter | April 2021

Section A

MAIN FEATURE

What is New in the 2nd Wave?

The 2^nd wave of the COVID pandemic has gripped India since March 2021, with more than 2 lakh daily cases. India had seen a drop in the number of COVID cases towards the last 2-3 months of 2020 and early 2021. Vaccination drives have also begun in January 2021. However there has been a sudden increase in cases, in a small span of time starting March-April 2021. Not only has the daily growth of cases increased but the doubling time has decreased significantly compared to 2020. There are some striking differences between the 1^st wave in 2020 and the 2^nd wave in 2021.

Age group affected

The predominant population being affected in the 2nd wave of COVID is the younger population (70% being 50 years or less, and 50% below 40 years of age) therefore, fortunately, there has not been a significant increase in severity or deaths, and the majority of the people affected are recovering. A large number of such people are also asymptomatic and diagnosed incidentally due to travel or contact with a known case. (Children comprise about 10% of such asymptomatic/mild COVID positive cases).

However atypical symptoms, and delayed testing/diagnosis can result in people requiring initial hospitalization for improving blood oxygen levels, treating lung involvement or COVID pneumonia, and avoiding complications. Also, many young asymptomatic or mildly symptomatic young patients can infect senior citizens and those with comorbidities, causing more severe illness (especially in those incompletely or not vaccinated) requiring a higher level or hospital care. Therefore, the burden on the healthcare system has increased enormously, leading to a growing shortage of hospital beds in many areas. In addition, the long-term impact on the health and work capacity of the people who have been infected is yet to be ascertained.

Presence of Variants

Mutant variant COVID strains have also been identified which are far more infective and transmissible, though whether they necessarily increase severity or mortality is still not conclusive. The variants of concern (VOCs) identified in different parts of the world including parts of India are the B.1.1.7 from the UK (N501Y mutation), B.1.351 from South Africa (E484K and N501Y mutation) and P.1 from Brazil (K417T, E484K, N501Y mutation). In India, new variants like the B.1.167 (E484Q and L452R double mutations) from Maharashtra, and B.1.36 (N440K mutation) from other South Indian states suggest that these are more transmissible and less susceptible to neutralizing antibodies and immunity (show immune escape). It cannot be said with certainty yet that the 2^nd wave of COVID is attributed mainly to these variants, however, these may be contributing to a much faster rise, as well as to repeat infections in many. These variants are being tracked by gene sequencing in areas showing significant resurge of cases.

Symptoms

Many people getting infected at this time may or may not show typical COVID symptoms like fever, sore throat and cough. They can present with more non-specific and vague symptoms like persistent headache, general body ache, tiredness and weakness, or digestive complaints like nausea, indigestion and diarrhea. Loss of smell and/or taste are useful and suggestive signs.

Therefore, even if fever is not present, it is advisable to contact one’s family physician for the other symptoms and get tested in case there has been possible recent exposure to a COVID positive person or improper precautions taken in public places. This is a must especially in people incompletely or not vaccinated.

Testing

The RT-PCR which has been considered the gold standard test for diagnosing COVID, can be negative initially in some cases even when symptoms are present. The test subsequently turns positive some days later when repeated, but by then there can be significant lung involvement and worsening of the person’s condition.

Therefore, if symptoms are present, pulse oximetry for oxygen saturation (maintained >95%) should be meticulously monitored and this is considered the most important indicator for disease severity, progress and clinical decisions. A high-resolution CT scan (HR-CT) chest is sometimes advised in case of significant and persistent symptoms, as it can pick up the infection even when RT-PCR is negative, establish severity of lung involvement, and help in timely initiation of treatment, and hospitalization where needed.

Routine blood tests as well as specific inflammatory markers like CRP, D-dimer, ferritin, LDH, IL-6 and cardiac troponin I, along with an abnormally high neutrophil to lymphocyte ratio (NLR), can also help identify people with higher risk for complications, and poorer prognosis. The presence of comorbidities should always prompt thorough investigation.

In cases where RT-PCR is positive, in addition to cycle threshold (Ct), gene sequencing for variants of random samples maybe advocated in places where such variants of concern (VOCs) have been documented to be spreading.

Section B

TRENDING FEATURE

Covid Management at Home

Treatment for most cases can be done at home with isolation, care, and appropriate medicines. Home care for COVID wherever possible is the cornerstone for effective recovery in most cases and also reducing the burden on hospitals which can manage the severe cases. Digital/virtual/online platforms are being increasingly used by doctors as an effective way for monitoring and treating COVID patients at home. Panic creates unnecessary hospitalization and deprivation of hospital beds to the people who have severe disease and complications.

The treating doctor will prescribe the appropriate antiviral medicine, along with other medicines for fever-body pain, cough or any other symptoms. Vitamin-mineral supplements are also given. The important thing is self-care, self-monitoring, and knowing the red flag signs to decide on hospitalization.

SELF-CARE

– Eat a nutritious diet with vegetables, fruits, and proteins (eggs/pulses)
– Drink lots of water
– Take steam twice daily
– Do conscious proning by lying on your belly for half to 1 hour 2-3 times a day, and taking a few deep breaths every 10-15 minutes.

trending_feature

– Do breathing exercises to improve oxygen saturation and lung function (described later)
– Every 2-3 hours in the day, walk around the room for 5-10 minutes
– Take all medicines and supplements regularly as prescribed by the doctor and complete the full course. Do not stop, skip or start any medicine on your own
– Always be in touch with your doctor on WhatsApp or digital means
– Read and watch interesting and cheerful content, and listen to soothing music
– Have regular video conversations with family and friends
– Complete full duration of minimum 14 days isolation before stepping out in public, even if symptoms are absent or gone.

SELF-MONITORING

Monitor oxygen saturation by pulse oximetry and temperature 4 hourly.

Pulse oximetry, done by an instrument called the pulse oximeter, measures the pulse rate, and the percentage saturation of oxygen in the blood.

self_monitoring

Pulse oximetry should be taken in the sitting position. The index or middle finger inserted in the pulse oximeter should be done properly (not partially, upside down or tilted sideways). The oximeter should close appropriately (not too tightly pressed upon the finger, and not too loosely due to damaged spring or closing levers). Once put on, one should wait for the waves to be regular, and the reading values to stabilize. This can take up to 30-60 seconds.

Low battery, irregular waves, and rapidly fluctuating readings can imply possible inaccuracy. Constant movement, shaking the finger, or even tremors/shivering can affect the accuracy of the readings. Nail polish and varnishes, especially if dark should preferably be removed. Readings may be inaccurate in the lying position or if hands are cold.

For people who have contact history or symptoms suggestive/suspicious of COVID, or those who are confirmed COVID-positive asymptomatic or symptomatic cases, 4 hourly pulse oximetry is recommended. SpO2 value of ≥ 95% at all times is considered satisfactory. Lower values are an alarm sign.

For people with COVID being treated in a non-hospitalized/home care setting, pulse oximetry can be done in combination (just before and after) with the 6-minute walk test (performed at normal walking pace), at least once daily. A drop in SpO2 by 3% or <94% after the test is an alarm sign. (One should stop if experiencing any lightheadedness, breathlessness, or tiredness; Elderly>60 years can perform shorter 3-minute tests). Lying on one’s belly (prone position) and taking few deep breaths can sometimes bring up the oxygen saturation (conscious proning).

If the SpO2 value still drops <95% consistently in a day, it is recommended to have a medical consultation immediately. Arrangement for giving oxygen would need to be made, by shifting to the hospital or if a bed is not immediately available, in an appropriate COVID-care setup, or even at home (with oxygen cylinder/concentrator and non-rebreather mask NRBM).

SpO2<90% should be treated as a medical emergency for oxygen therapy and hospitalization.

For people suffering from chronic respiratory diseases, it is advised to perform pulse oximetry once daily or as advised by their physician. For them, SpO2 cut-off values are typically lower than that of the rest of the population (ideal 92% and above, to maintain with therapy at 88-92%, and oxygen to be administered at <88%).

HOSPITALIZATION

Hospitalization should be considered if the person has the following:

– breathlessness and/or oxygen saturation constantly <95%
– associated comorbidities (diabetes, illness of heart, lung, kidney, liver, cancer or post-surgery/transplant)
– severe HR-CT chest score
– high or rapidly rising levels of inflammatory markers like CRP, D-dimer, ferritin, LDH, IL6
– not showing any improvement of fever, cough, body pain and other major symptoms in 3 days
– feeling very sick or weak, not able to eat or take medicines orally
– not having proper isolation facilities or care at home

In the absence of immediate hospitalization bed available, oxygen can be given at home also.

Section C

SPECIAL FEATURE

Covid Precautions and Care

As has been said repeatedly through the pandemic, dropping one’s guard and disregarding COVID appropriate behavior is not an option till at least 60-70% population has been vaccinated, herd immunity has been achieved and disease spread and the number of active cases reduced.

In all public places, wearing masks properly, avoiding crowding, maintaining social distancing, and proper sanitation is most important. This needs to be stressed upon not only by workplace leaders, public officials and health administrators but by each and every person for themselves, their family and community.

It is understandable that fatigue and impatience have set in which led many to conclude that the pandemic will not affect them as restrictions and the number of cases began to reduce. Experience through the pandemic has taught us that restricting people’s livelihood and normal activities can have dire economic consequences, as well as adverse psycho-social and health impact. However, if COVID appropriate behavior is not followed in public places, and the rise in COVID cases stretches the healthcare system to its limits, forced regulations become the only option for administrators.

Restricting travel by public transport to minimum and essential, and utilizing digital and online methods of work, interaction, and conferencing wherever possible is highly recommended. Testing by RT-PCR has now become a requirement for flying and entry into many cities/states and countries. In addition, rapid antigen tests (RATs) are being used to screen at airports, malls and case-cluster areas or hotspots.

Contact Tracing is very crucial to limit spread, and people who are diagnosed with COVID, should share the details with health administrators on inquiry, of people they have been in close contact with, in the previous 7-10 days,

Completing the isolation period of 2 weeks is important for asymptomatic or mildly symptomatic COVID positive people, and they should avoid mingling in public in a few days itself when their symptoms are gone, or they feel fit and recovered. This is the time they can experience sudden worsening and also infect several others.

Maintain good physical and mental health by eating a nutritious diet, doing regular exercise (including some breathing exercises), and mentally engaging in relaxing activities to avoid stress and depression. This helps in preventing and fighting diseases better. Make sure comorbidities like BP, diabetes, etc. if present, are well controlled with appropriate medicines and treatment under medical guidance.

COVID vaccine should be taken by every person once eligible by their country norms. Vaccination can protect against severe COVID, complications and death, therefore has been initiated in high-risk elderly, and those with comorbidities. As of achievement of herd immunity by ramping up vaccination is the only way to curb the spread and surge of COVID in the times to come.

Section D

Simple breathing exercises for maintaining good health and lung function

Nasal breathing: Pranayamais a well-known beneficial alternate nasal breathing (anulom vilom) technique. It can be practiced by sitting in a comfortable posture with back straight. Use the right-hand thumb to close your right nostril and take a long breath from the left nostril. Then remove the thumb from the right nostril and place the ring finger on the left nostril and slowly release the breath from the right nostril.
Pursed-lipbreathing: This is a useful breathing technique that helps to slow the breathing rate and reduce breathlessness. First, inhale slowly through the nose, and then exhale through tightly pressed (pursed) lips for twice as long as the time taken to inhale. This technique is not only helpful with exercise but may be beneficial during other daily tasks like lifting, bending forward, or climbing stairs.

nasal_breathing

Abdominal breathing: It is also called diaphragmatic or belly breathing. It is practiced by lying on the back on a flat surface with knees bent. One hand is placed on the upper chest and the other on the belly. Breathe in slowly through the nose, letting the air in towards the lower belly. The hand on the belly will rise, while the hand on the chest remains still. Then tighten abdominal muscles taking them inward and breathe out through pursed lips, making the hand on belly moving down to the original position.

abdominal_breathing

All the above breathing exercises should be done 2 hours post meals. Take a 20-second gap after every one minute of practicing any of these exercises, then start again. Initially practice for 5 minutes, increasing gradually to 10 minutes daily.