Satchit Balsari, Assistant Professor in Emergency Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center and Steering Committee member of the Mittal Institute, co-authored a comment in The Lancet on evidence-based, affordable interventions to manage COVID-19 in India. His co-authors include a range of other medical professionals: Zarir Udwadia, Department of Pulmonary Medicine, P.D. Hinduja Hospital and Medical Research Center, Mumbai, India and Department of Pulmonary Medicine, Breach Candy Hospitals & Research Centers, Mumbai, India; Ahmed Shaikh, Department of Emergency Medicine, New York Presbyterian Hospital, New York, NY, USA; Abdul Ghafur, Department of Infectious Diseases, Apollo Cancer Hospital, Chennai, India; and Sushila Kataria, Department of Internal Medicine, Medanta Hospital, Gurgaon, India.
The text of the comment is below – please view the comment online to access accompanying charts/graphics.
During the second wave of the COVID-19 pandemic in India, which began in March, 2021, demand on the health-care system has far exceeded capacity. Despite crippling shortages, patients are prescribed a battery of ineffective therapeutic interventions. Ivermectin, hydroxychloroquine, and herbal cocktails continue to receive state patronage. On May 8, 2021, 2-deoxy-D-glucose was given emergency authorisation, stating that it will “save precious lives” without any published evidence that it impacts mortality. An entrenched culture of polypharmacy and gestalt-driven practice among physicians has resulted in indiscriminate and unwarranted use of remdesivir, favipiravir, azithromycin, doxycycline, plasma therapy, and most recently baricitanib and bevacizumab, regardless of disease severity or drug efficacy. Excessive and inappropriate use of steroids could be contributing to the alarming rise of mucormycosis in patients recovering from COVID-19.
In rural India, where health-care infrastructure is threadbare, and families are poor, patients can ill afford such expensive mistakes. Honing in on the most high yield and affordable interventions, we propose recommendations for testing and management, optimised to India’s current resource-constrained context. Every clinical touchpoint should be used to underscore masking, distancing, and vaccination.
Where RT-PCR test turnaround time is lengthy, or when tests are unavailable, CT scans are being routinely prescribed for diagnosing infection from SARS-CoV-2. Serial scans are prescribed for prognostication; high CT severity scores—regardless of clinical presentation—then inadvertently trigger unwarranted hospitalisations. This practice is neither standard of care nor an option for most patients. In fact, we argue that in the throes of this surge, it would be prudent to initiate treatment for presumed infection if clinically warranted, and have all with mild symptoms isolate for 14 days or until a test result is available. In early May, 2021, national guidelines were finally relaxed to allow such syndrome-based diagnosis, ending a year of delayed or denied hospital admissions due to slow or unavailable testing.
When options for oxygenation or timely transport to higher levels of care are available, oxygen saturation, a reliable predictor of mortality in COVID-19, and measured via cheaply and widely available pulse-oximeters, should suffice for risk stratification. Routinely prescribed expensive laboratory tests such as C-reactive protein, ferritin, interleukin-6, and D-dimer, will have little bearing on clinical outcomes where there are no viable options for basic therapeutic care. Even in urban India, physicians must consider recommending such tests only when there is evidence that interventions are based on their interpretation change outcomes and are actually feasible.
For nearly a year, patients were being advised institutional isolation, regardless of disease severity or ability to isolate at home. For patients with mild disease, home-based care and self-monitoring with a pulse oximeter—as has long been appropriate—has finally gained widespread traction, from sheer necessity. Clear directives (and telemedicine support, where possible) will prevent unwarranted presentations to the hospital. Most patients with hypoxia might only need oxygenation and proning. Current evidence supports the use of steroids such as dexamethasone only among those needing oxygen or invasive respiratory support. A few patients might also benefit from prophylactic doses of anticoagulation that can be administered by trained family members. Patients can be taught pronation via effective educational aids. A severe shortage of beds and unreliable power availability threaten other key treatment possibilities in rural India, as oxygen concentrators will need continuous electricity or back-up generators, and oxygen cylinders are expensive to procure and transport. The justified, ad hoc, and self-organised measures to procure and administer oxygen, however, risk inadequate oxygen therapy, rendering these often Herculean efforts clinically futile. A vast number of oxygen concentrators and ventilators have been mobilised internationally. On May 8, 2021, the Supreme Court of India appointed a task force to oversee oxygen allocation. It is imperative that recommendations for distribution be coupled with human-in-the-loop solutions where technical know-how to operate these devices is expanded expeditiously via online adjuncts. The government has also directed India’s non-allopathic AYUSH doctors to provide COVID-19 care. It is crucially important that this expanded workforce not amplify missteps from the preceding year.
Hypoxic patients who do not need invasive mechanical ventilation can be cared for at makeshift but monitored, protocolised health-care facilities. Despite the bed shortage, and revised national guidelines, many patients are not being discharged home until their RT-PCR test is negative. There is no evidence that patients need hospitalisation once they are clinically stable for discharge. When isolating at home is unfeasible, they could be sent to recovery centres. Indigenous rural solutions such as isolating patients elsewhere on the farm are not unreasonable, provided family members can provide care.
It is time to double down on effective interventions. The lack of critical care capacity necessitates open discussions about goals of care. We are all practicing physicians and recognise how hard it is to communicate futility to family members, especially in these desperate times. Truth, however, will protect families from crushing debt, and in some cases, financial ruin. Adherence to science, even now, will probably be the least destructive path forward.
ZU serves on the Maharashtra Covid Task Force and National Task Force constituted by the Supreme Court of India; and has received honoraria or grants from AstraZeneca and Glenmark. AG has received grants from Cipla, Glenmark, Pfizer, Sanofi, Astellas, Mylan, Natco, Biomerioux, Bharath Serum, and GlaxoSmithKline. All other authors declare no competing interests.