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 now India in a very big way.
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 mid-February, crossing the 1 lakh daily threshold by early April 2021. The daily growth of cases has greatly increased and the doubling time has decreased significantly in India, as compared to 2020.
WHAT IS MEDICALLY NEW IN THE 2ND WAVE?
Medically some facts are of importance to understand.
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 characteristic 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.
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 >94%) should be meticulously monitored. A high-resolution CT scan (HR-CT) chest is sometimes advised in case of significant persistent 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 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. 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 being affected in the 2nd wave of COVID is 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) has 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 are recovering with home care and isolation. A large number of the affected people are also asymptomatic and diagnosed incidentally due to travel or contact with a known case. (Children are being 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 10-14 days is being 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 has increased enormously, leading to a growing shortage of hospital beds, oxygen, and medicines 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.
Treatment for most cases can be done with home care and isolation, taking appropriate medicines. If home isolation or care is not possible, there are COVID healthcare centers. 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 are being seen to 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 HR-CT chest score (>50% lung involvement or score of 13 or more)
- high or rapidly rising levels of inflammatory markers like CRP, D-dimer, ferritin, LDH, IL6, 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 have also been identified which are far more infective and transmissible, though whether they necessarily increase severity or mortality is not conclusive. The variants of concern (VOCs) identified in different parts of the world, and now in parts of India are the B.1.1.7 UK strain (N501Y mutation) seen more in North India and to a much lesser extent the B.1.351 South African strain (E484K and N501Y mutation) and P.1 Brazilian strain (K417T, E484K, N501Y mutation). In India, new variants have emerged, mainly the B.1.167 (VOC with E484Q and L452R double mutation) from Maharashtra now spreading all over the country, and to a much lesser extent the B.1.168 from Bengal (additional D614G triple mutation) and B.1.36 (N440K mutation) from South India. Studies suggest that these global and Indian variants are more transmissible and less susceptible to neutralizing antibodies and immunity (can show ‘immune escape’). It cannot be said with certainty yet 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 to repeat infections in many. These variants are being tracked by gene sequencing in areas showing significant resurge of cases.
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 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 emphasized 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 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 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 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 has been initiated in high-risk elderly, and those with comorbidities. 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 the number of centers and daily hours (24×7 availability) of vaccination, which is a logistical challenge.
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