As the country’s health infrastructure is engulfed by a second wave of COVID-19 infections, adequate home-based care and physical distancing during testing, treatment and vaccination are two issues that need urgent attention.
Testing, treatment and vaccination are three major tasks the health services are performing at this point in the second wave of the COVID-19 epidemic. How these are organised can make them saviours or super-spreaders.
The large number of symptomatic persons at the present time and the addition of vaccinations to last year’s tasks of testing-tracking-surveillance-isolation and treatment require a revised approach. The Centre and states would do well to review their management protocols with all that has been learnt over the past year. Understandably, the shortage of oxygen and hospital-based respiratory support systems are the present priority. Two urgent issues also needing attention are being flagged here.
One is syndromic diagnosis and home care. Testing for diagnosis is not of much value at the large scale spread at this point in the pandemic. Insistence on a positive COVID-19 Rapid Antigen Test or RT-PCR before hospitalisation is actually denying care to many who have persistent symptoms and declining oxygen levels, but a negative test result. A delay of several days is being experienced in sample collection, followed by delays in getting results, because facilities are over-worked, testing kits are in short supply and laboratories are over-loaded with samples. And such delays may mean loss of lives. Syndromic diagnosis, using an epidemiologically robust case definition and well-developed algorithms, based on a person’s symptoms is the need of the hour, with point-of-treatment testing for those who require it. Surveillance systems are, in any case, in need of review for generating real estimates of infected persons and cases.
For the mild cases, which are the majority, testing does not effectively mean much, since treatment is primarily supportive to the body’s immune response that limits the virus and leads to recovery. Syndromic diagnosis, adequate rest, hot fluids at frequent intervals, and psychological support and reassurance are what is required. In fact, the effort to get tested in the present situation may only add to the stress and lower the immune system’s capacity to respond. For the moderately affected, it is important that they monitor oxygen levels in the blood using a home (pulse) oximeter and take appropriate treatment so as not to degenerate into a serious state. Medicines for preventing added infections, steroids and anti-coagulants for hyper-immune complications, postural lung exercises may be required. Anti-viral medicines may give some added benefit, but none so far are showing any appreciable level of effectiveness.
All this is possible with home-based care and will cover over 85 per cent of the cases. During the first spike of cases last year, states set up separate first-contact treatment/isolation centres which went under-utilised in many areas since people preferred home isolation and care. However, isolation/care centres may have some role in areas of the urban poor, where constrained space at home pushes them to the centre. Largely, what needs strengthening is home and community-based supportive services that are organised through online resources as well as physical facilities. While this is being undertaken in most states, it needs to be scaled up. In addition to existing primary health staff and generalist practitioners, mobilising health personnel as well as community volunteers and civil society groups at local levels should be a part of a well-planned and monitored strategy. The Pulse Polio drives and the HIV control strategies provide lessons which health services are already familiar with and can draw upon.
Only moderate cases with declining oxygen levels and serious cases require hospitalisation and emergency services to see the patients through until their lung functions and any other affected organs are adequately restored. But the assurance that this will be available if and when one requires it is necessary for all, at whatever level of severity. This assurance is missing in the present crisis.
In addition to ramping up specialised hospital services, lowering the demand for hospitalisation by enhanced and adequate home-based services, allaying anxieties, providing adequate services and timely referral to all who need it, will take some pressure off the besieged hospitals and decrease people’s distress.
The second urgent issue is physical distancing in testing, treatment and vaccination. The health service system has to be organised such that it does not escalate the spread of COVID-19. Overcrowded facilities for COVID testing, treatment and vaccination are evident across the country. Those coming for the three services are distinctly different in their status of COVID infection. The vaccination group is largely uninfected and is coming for prevention. Those coming for testing are generally symptomatic, and those requiring treatment are already diagnosed. Additionally, each person is generally accompanied by one or two healthy persons. So, in a crowded setting, mixing of these different groups could spread the infection from a large number of infected persons to the non-infected with high viral load.
Health services for each of these tasks must, therefore, be organised such that there is least intermingling. This requires separate designated centres for vaccination, preferably in the community and for small numbers. Test sample collection sites, too, should be located outside the treatment centres or at least have completely separate entry points from those coming for treatment, with no possibility of intermixing. Let the health services not be sites for spreading the virus.
This organisational dimension is an added one in this second wave since the vaccination was initiated only in January 2021. Addressing it now is essential to prevent the health services from being deluged on the one hand and becoming super-spreaders on the other. Some states, such as Chhattisgarh and Kerala, seem to have planned appropriately. Others need to urgently review and ensure that their COVID services-related arrangements are adequate and safe.
This column first appeared in the print edition on April 29, 2021 under the title ‘Saviours or super-spreaders’. The writer is professor, Centre of Social Medicine and Community Health, JNU.
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