Updated September 2021
Important Read: COVID Home care, Isolation and Treatment
The COVID resurge or the 2nd wave of COVID gripped several parts of the world like the USA, countries in South America, EU, and Asia, and India in a very big way.
After the first wave in 2020, India had seen a drop in the number of COVID cases towards the last 3 months of 2020 and early 2021. Vaccination drives had also begun in January 2021. However, there was a sudden increase in cases, in a small span of time starting mid-February, crossing the 1 lakh daily threshold by early April 2021 and averaging over 2 lakh cases daily thereafter in April-May 2021. Not only did the daily growth of cases greatly increase but so did the doubling time decrease significantly in India, as compared to 2020.
WHAT WAS MEDICALLY NEW IN THE 2ND WAVE?
Medically some facts were of importance to understand.
Apart from the typical COVID signs of fever, cough, and sore throat, people getting infected in the 2nd wave sometimes showed 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 was still a useful and characteristic sign.
Therefore, it was advised to contact one’s family physician even if fever or cough is not present, for the other symptoms and get tested in case there had been possible recent exposure to a COVID-positive person or improper precautions taken in public places. Also, entire families including children getting infected and showing symptoms, even if one member tests positive for COVID, was commonly seen.
The RT-PCR which has been considered the gold standard test for diagnosing COVID, can be negative initially especially in the first 48 hours, 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. Due to high caseload, RT-PCR reports may get delayed over 24-48 hours. A home testing low-cost Rapid Antigen Test (RAT) kit is now available which can give the result in a few minutes and a positive result is taken as diagnostic of COVID. A negative result in symptomatic people needs confirmation by RT-PCR.
In symptomatic patients, oxygen saturation by pulse oximetry (maintained >94%) should be meticulously monitored. A high-resolution CT scan (HR-CT) chest is sometimes advised in case of significant or severe symptoms, as it can pick up the infection even when RT-PCR is negative, establish the severity of lung involvement, and help in timely initiation of treatment and decision for hospitalization where needed.
Routine blood tests like CBC as well as specific inflammatory markers like CRP, D-dimer, ferritin, LDH, IL-6 and cardiac troponin I, can also help identify people with a higher risk of disease progression and complications especially in hospitalized patients, when done at the appropriate time. 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 should be advocated where such variants of concern (VOCs) have been documented to be spreading.
The predominant population affected in the 2nd wave of COVID was the younger population (70% being 50 years or less, and 50% being 40 years or less). Overall the percentage of severe cases (requiring hospitalization), and deaths (case fatality rate) was seen to be less than 15% and 1.5% respectively. However, when the overall number of cases is alarmingly large, these percentages constitute a very significant and worrying number, imparting a huge load on healthcare and other resources.
The majority of the people affected recovered with home care and isolation. A large number of the affected people were also asymptomatic and diagnosed incidentally due to travel or contact with a known case (children were seen to comprise about 10% of such asymptomatic or mild-moderate COVID positive cases). Atypical symptoms, delayed testing and diagnosis, or a higher symptom and disease severity in some can result in an increase in the number of people requiring oxygen therapy for improving blood oxygen saturation, and hospitalization for treating lung involvement/COVID pneumonia and other complications. Prolonged fever for up to 7-10 days was increasingly seen as a pattern even in mild-moderate cases.
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 of care and/or hospitalization. Therefore, the burden on the healthcare system increased enormously, leading to an acute shortage of hospital beds, oxygen, and medicines in many areas during the peak of the 2nd wave. In addition, the long-term impact on the health and work capacity of the people who have been infected is yet to be fully ascertained, and post-COVID health issues are being seen for many weeks to months.
Treatment for most cases was done with home care and isolation, taking appropriate medicines. If home isolation or care was not possible, then isolation in COVID healthcare centers was preferred. It is important to note that the disease course consists of the first week of viremia (viral replication) and the second week of inflammation (due to the body’s immune response). The 7th -10th-day post symptom onset is crucial as that is the time some people doing well in home care can deteriorate with falling oxygen saturation. Hospitalization should be considered if the person has the following:
- breathlessness or chest pain/pressure
- oxygen saturation constantly <94% not improving by proning, or dropping anytime below 90%
- high-grade fever (>101 deg F), cough with phlegm, and body pain beyond the first week of illness, non-responsive to medications
- feeling very sick or weak, not able to eat or take medicines orally
- associated comorbidities (uncontrolled diabetes, illness of heart, lung, kidney or liver, cancer and post-surgery/transplant)
- severe lung involvement and high HR-CT chest score
- high or rapidly rising levels of inflammatory markers like CRP, D-dimer, etc. suggesting increasing inflammation or clinical deterioration.
WHAT HAS CAUSED THE 2ND WAVE OF COVID?
Increase in the physical interaction of people who were earlier not exposed much
The resurge of cases has been seen to a large extent in the younger urban population aged 20-50 years, who are yet to be vaccinated.
Many workplaces and offices started running at full strength along with the supporting public transport systems. Few were able to follow proper wearing of masks and social distancing norms sincerely. Closed, indoor air-conditioned, unventilated spaces where people mingle closely from different parts of the city are high-risk areas for the spread of infections. A great increase in travel locally (trains/buses etc.) and intercity by flights have also added to this risk, especially when proper protection and precautions were disregarded.
Eating in common cafeterias, pubs, and restaurants without social distancing or staggering meal timings have also been seen to be a significant factor, as masks cannot be worn while eating/drinking, and many such eating joints have been running packed to full capacity. Large indoor social gatherings with food and drinks have been possible contributing high-risk activities. Shops and malls have also seen large crowds without people using masks or maintaining distance appropriately.
Mutant variant COVID strains were also identified which are more infective and transmissible, though whether they necessarily increase severity or mortality is not conclusive. Variants of concern (VOCs) have been identified in different parts of the world which are the Alpha variant (B.1.1.7 first found in the UK), Beta variant (B.1.351 first seen in South African), and the Gamma variant (P.1 first seen in Brazil). In India, the Alpha variant has been found in parts of North India, while a new variant emerged, mainly the Delta strain (B.1.167.2 first found in Maharashtra) and then spreading all over India, with some other variants in small pockets (B.1.167.1 in Maharashtra, B.1.168 in Bengal, and B.1.36 in South India).
Studies suggest that these variants are more transmissible and less susceptible to neutralizing antibodies and immunity (can show ‘immune escape’). It cannot be said with certainty that the 2nd wave of COVID is attributed mainly to these variants, however, these may be majorly contributing to a much faster rise of cases, as well as re-infections in many. The unpredictable nature of the variant strains leading to an increased usage of oral/injectable steroids, along with the propensity of the virus itself and the steroids to increase blood sugar, is postulated to have caused the rise in cases of black fungus (mucormycosis) seen in COVID patients in some parts of India. These variants are continuously being tracked by gene sequencing in areas showing significant resurge of cases by the respective countries and the WHO.
WHAT ARE THE PRECAUTIONS TO BE TAKEN?
As has been said repeatedly through the pandemic, dropping one’s guard and disregarding COVID appropriate behavior is not an option till at least >50% population has been vaccinated, and herd immunity achieved in key areas which had shown high disease spread, positivity rate, and active cases.
During the 2nd COVID wave, in all public places, wearing masks properly, avoiding crowding, maintaining social distancing, and proper sanitation was given utmost importance. This was required to be emphasized not only by workplace leaders, public officials, and health administrators but by each and every person for themselves, their family, and the community.
It is understandable that fatigue and impatience had set in that led many to conclude that the pandemic will not affect them as restrictions and the number of cases had begun 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 impacts. 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 and restrictions 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 was 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) and RT-PCRs 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 14 days 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 everyone should take whichever vaccine is available to them as soon as possible. It is a tricky balance to achieve between ramping up vaccination to maximum capacity along with the precautions of wearing mask, avoiding overcrowding and maintaining social distancing at the vaccination centers. This can only be achieved by an increase in people’s discipline and adherence to COVID appropriate behavior, and also by increasing vaccine production along with the number of centers and daily hours (24×7 availability) of vaccination, which is a logistical challenge. Vaccination and COVID appropriate behavior are the cornerstones of preventing a significant and imposing 3rd wave.
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