Managing post-Covid will be a huge challenge for hospitals

Interview/ Dr Randeep Guleria, director, AIIMS

randeep-guleria Dr Randeep Guleria | Aayush Goel

You told The WEEK recently that AIIMS has paid the price for excellence. How has the institute dealt with the Covid challenge?

With our mandate for both research, academics and treating patients, we had our task cut out early on. To begin with, I designed a protocol where we would have early morning meetings each day, where the faculty, nursing officers, residents, would come and discuss their problems and find immediate solutions. Those were the early days...we were all still learning. We also formed our own groups—a Covid task force, our own diagnostic committee, and groups for IEC and training.

The need of the hour is to have basic strategies in place—oxygen, some degree of ICU management as well as a referral system.

The thing that we realised early on is that infection control for health care workers would be very important; suddenly, there would be a deluge of cases, and certain groups such as technicians, nursing officers, sanitation workers, would not have a proper idea of how to protect themselves from Covid. So, we focused on developing three-hour modules for them, and held trainings for infection control practices every day. In the early days, all Covid positive patients (including asymptomatic) would be admitted, because that was the government policy then. So, to build capacity, we converted our National Cancer Institute at Jhajjar into a Covid hospital, and two of our hostels into Covid care centres. That helped address the first spike in Covid cases in Delhi [referring to the Markaz incident] where we had to admit over 100 patients. We also converted our 260-bedded trauma centre into Covid hospital. We were able to build our Covid capacity from 0-1,500 beds, and currently, we have a capacity of 1,750 beds that we can give for Covid patients.

At the peak of Covid in Delhi in June, we had about 900 Covid patients, and even now, we are handling over 500 patients for Covid as Delhi is witnessing a rise in cases. For research, in March, we formed a Covid research group, and from our own funds, we gave some seed money for research on basic science issues, patient management and other areas. In the first phase, we sanctioned 48 projects. We also did webinars for doctors, and students for infection control and addressing stigma. We also developed e-ICUs to address the lack of uniform management for Covid patients across the country’s hospitals, and we have covered 300 hospitals across the country through this initiative.

What have been the key learnings from handling Covid at a hospital such as AIIMS?

The important thing is to have a streamlined mechanism in place. All patients coming to hospitals won’t have a definite Covid diagnosis, so triaging became very important. There have been issues such as how to segregate patients, what to do if a patient becomes positive in a Covid negative area, how to sanitise that area, so developing strategies and treatment protocol, too, is crucial. The other thing is that everyone has to be involved; when you have a huge surge, you wouldn’t have specialists to manage all the patients. There have been cases where the team leader is a clinician, but the people with him are from the orthopedics department, ophthalmology department and so on. These people won’t have the required experience, and so, it’s important that SOPs are developed, so that it becomes easier to manage the patient load.

The pandemic has put the public health sector at the centre-stage, like never before. It has shown how important the public health sector is, at all levels—primary, secondary and tertiary. The pandemic doesn’t differentiate between those in cities and towns, and so, health systems have to be developed at each level. The need of the hour is to have basic strategies in place—oxygen, some degree of ICU management, as well as a referral system. We need to leverage technology also, such as teleconsultations, so that good quality care can reach rural areas, too. Besides that, we also need self-reliance in medical equipment – the shortage of PPEs was mitigated by our indigenous manufacturers, and so that has to be done sustainably for other equipment, too. This helps from the economy point of view as well as, cost effectiveness point of view.

From the patient perspective, high prices at private hospitals have been a huge factor. How do you see that aspect of our health systems?

If you would recall, it is the public health system that rose to the occasion and started treating Covid patients in the early days. The private hospitals shut down and turned patients away for fear of infection. It is only later that they started treating them, and the government stepped in to cap prices for treatment. This has also highlighted the need for a higher investment in the public health system. We need a vibrant and good public health system, to ensure that people don’t have to be subjected to high out-of-pocket expenses.

Testing is key to India’s Covid strategy. However, a large number are rapid antigen tests, which have low sensitivity. Is that a matter of concern for the Covid task force?

 It needs to be understood that the rapid and RT-PCR tests are not meant to replace each other. In the early days, we were doing less than 10,000 tests a day; now we are doing 15 lakh tests a day, a large number of which are RT-PCR tests. The rapid test is useful in community settings, where you need results early, and so, subsequently you can isolate the person quickly and they don’t go around infecting others.

It can be used as a complement to the RT-PCR test. We know that if the viral load is high, the rapid test works well, and so it can be used to decrease the RT-PCR load because in some places, for the RT-PCR test, it may take two or three days for reports to come. The study at AIIMS on rapid tests too had shown that the test sensitivity is 70-80 per cent which is good. However, the patients were symptomatic and had a high chance of turning positive. Even the data from Delhi had suggested the same Broadly, though I would say that the rapid test is not as sensitive as the RT-PCR, because it doesn't multiply the virus, and so if the viral load is less, it will give a false negative. The tests should complement each other, and be used depending on need. In fact, I would even say that when the positivity rate is being calculated, it should be calculated separately [for RT-PCR and RAT] and not combined. Else, the low positivity rate may be inaccurate. It is suggested that – and some states are doing it – that two swabs be taken at once. This is so that if the RAT turns out to be negative, then the patient doesn’t have to be inconvenienced.

What about using CT scans for diagnosis as some doctors are doing?

The CT scans have to be used on a case-to-case basis. The scan has its own side effects, it is not a simple test, given the fact that there is exposure to radiation. They can also give false results. In many cases, we have found that the those who were thought to have Covid because of viral pneumonia and a shadow on the CT scan turned out to be RT-PCR negative, and then when a lavage was done it turned out to be another infection called legionella. Other infections such as pneumocystosis can display a similar shadow on the scan, too.

How serious is the concern about post-Covid or long Covid that is being reported now among recovered cases?

The cases of long Covid that we are seeing now are getting us concerned, because as our recovery rate goes up, we are seeing more and more patients with some features of post Covid sequelae or long Covid. For a majority of the patients, it is a mild illness, body ache, fatigue, cough, classical chronic fatigue syndrome, brain fog, and they usually recover within 6-8 weeks. But a small fraction among them are being seen to have undergone significant damage such as lung fibrosis, extensive pneumonia in the lung that leads to a lot of scarring, and thereby damage to lung, cases where there’s cardiac involvement, and poor cardiac function, and strokes. Many hospitals are starting long Covid clinics, and it has to be a multidisciplinary approach. But it is going to be a big challenge for us, given that our numbers are increasing and we still need to focus on managing our acute cases. There will also be non-Covid cases, and hence the burden will be challenging on hospital systems.

What about vaccines? You pointed out at a recent webinar on vaccines that at times, the vaccine rollout is preceded by the pandemic slowing down and so a decreased uptake for vaccines. Is that a concern this time round, too?

The concern that all vaccine manufacturers have is that once the vaccine is available and comes out into the market, what will be the uptake. But the way, Covid has behaved until now, it seems that there will be a significant demand for the vaccine to really get the numbers down. However, we will have to see how things evolve in the coming months..6-7 months from now. We will also have to see which vaccine is the best, as each vaccine will have its own challenges, ranging from doses to maintaining a cold chain, immunogenicity, and regional and ethnic variations, too. The next few months will help us to better define the role of different vaccines in different areas.

Could you give us a sense of the expert group's discussions with respect to cold chain and other logistical issues with the Covid-19 vaccine rollout?

The discussion about accessories such as syringes, needles, training of healthcare workers, maintaining a cold chain right from manufacturing up till those in rural India are ongoing; it will be like polling booths, where a vaccine is being given, those given the vaccine will be line listed, etc. Hopefully, by the time the vaccine comes, all those processes will be in place.Prioritisation for those getting the vaccine will also need to be approached from two perspectives—one to administer tot the high risk groups to decrease death rate, and then those who are at higher risk of getting the infection. The prioritisation will also need to be done according to the numbers of these people and the available doses. Cost may not be that much of an issue given that the vaccine would be made in India, and the government would be providing some degree of subsidy for those who can not afford it. The timing of the vaccine would depend on the number of doses available and how the pandemic behaves. The combination of the two events would help bring the numbers under control.

In your recent book,'Till We Win', you mention the concern with pre-symptomatic cases.

Yes, that’s a cause of concern because one can be infectious even two-three days before getting the symptoms and end up spreading to others. The status of the person is difficult to pick up at that point [because of low viral load] and so you cannot isolate these people. Which is why wearing masks is important for both asymptomatic and symptomatic people.

What about the various treatment modalities that are being discussed for Covid?

The treatment modalities are still evolving. The important point is what to give and when to give. Certain treatments will not work if they are given late. What we do know is that certain things work— steroids in patients requiring oxygen and more support, there is some evidence blood thinners do work, oxygen therapy works, while the role of plasma therapy, Remdesivir and Tocilizumab is debatable. However, the three do have a role when given at a proper time, but more data is needed. Remdesivir works if given early in the disease to decrease viral multiplication, Tocilizumab works in a small number of patients where there’s a cytokine storm, and for plasma therapy, we need more data since some data suggests that it works, whereas others have found it not to be useful.