1. COVID-19 & Cancer
Q. Should patients with cancer receive the COVID-19 vaccine?
A.The data on efficacy and safety of COVID-19 vaccination in patients with cancer is limited. However, as patients with cancer are more prone to contract a severe form of illness due to COVID-19 infection, the benefits of getting vaccinated are more than the risks.
Q. Should people who have completed their treatment for cancer receive the COVID-19 vaccine?
A.Patients who have completed their treatment for cancer should receive the COVID-19 vaccine as soon as it is available to them as long as there are no major allergies.
Q. What does it mean to be immune-compromised?
A.‘Immune compromised’ refers to individuals whose immune system is considered weaker, more impaired, or less robust than that of the average healthy adult. The primary role of the immune system is to help fight off infection. Individuals with compromised immune systems are at a higher risk of getting infections, including viral infections such as COVID-19. There are many reasons that a person might be immune-compromised. Health conditions such as cancer, diabetes, or heart disease, older age, or lifestyle choices such as smoking can all contribute to weakened immune systems.
Q. Does receiving chemotherapy or radiation raise your risk of getting COVID-19 or having a more serious course of illness?
A.To date, limited evidence is available to suggest that any cancer treatment raises your risk for getting COVID-19 any more or less than anyone else who is exposed to the virus. There is some evidence that patients with cancer may experience more serious COVID-19 infection if they acquire it, more so because cancer and cancer treatment can contribute to weakened immune systems, which can then lead to a reduced ability to fight off infections. It is not clear at this point if cancer patients who have received chemotherapy or radiation in the past are at increased risk for COVID-19. The risk of infection may depend, in part, on the specific treatment received, the type of cancer treated, and how much time has passed since the treatment was completed.
Q. Should people who are on cancer-directed therapy receive the COVID-19 vaccine?
A.Patients who are on cancer-directed therapy can receive the vaccine after discussing it with their treating oncologist. The oncologist will suggest a suitable time based on the ongoing therapy (surgery, radiation, chemotherapy, immunotherapy, or stem cell transplant). Please inform the treating oncologist if you have had any drug allergies in the past.
Q. Which COVID-19 vaccine is the best for patients with cancer?
A.All the approved vaccines have been shown to be effective. There are no direct comparisons between the available vaccines for efficacy or safety. Therefore, it is suggested that you take any vaccine approved for use and available in your vaccination centre.
Q. Is there any contraindication for the COVID-19 vaccine in patients with cancer?
A.Patients who are allergic to polyethylene glycol (PEG) should not receive the COVID-19 vaccine. Individuals with a known history of polysorbate-80 allergy (used as excipient in certain chemotherapeutic drugs) should not receive COVID-19 vaccine.
Q. Should patients with a previous history of COVID-19 infection be vaccinated?
A.Yes, cancer patients who had been infected and recovered from the illness should also receive the COVID-19 vaccine as it will protect from re-infection.
Q. Should the vaccine be given to patients with positive COVID-19 antibodies?
A.The COVID-19 vaccine should be given to all patients with cancer irrespective of their antibody status. Serological testing should not be used to guide the decision and timing of vaccination.
What are the side effects that may occur after the COVID-19 vaccine?
A.. You may expect some minor side effects like soreness of the shoulder (injection site) for a few days after the vaccination. Also, you may have mild fever, tiredness for a day or two after the injection. Serious side effects are extremely rare, but we advise you to consult your doctor in case of any troublesome symptoms.
2. COVID-19: OMICRON Variant
Q. What is Omicron and why is it a Variant of Concern (VoC)?
A.This new variant of SARS-CoV-2, named B.1.1.529 or Omicron (based on Greek alphabets such as alpha, beta, delta, etc.) has recently been reported in South Africa. There are a large number of mutations in this variant, especially more than 30 in the viral spike protein, which is the major target for immune responses. The World Health Organization has declared Omicron as a Variant of Concern (VoC) because of the combination of mutations that previously individually have been associated with increased infectivity or immune evasion, and the sudden rise in number of positive cases in South Africa.
Q. Why is it called Omicron?
A.The WHO named the B.1.1.529 variant Omicron in the tradition of giving variants a Greek letter name.
Q. How easily does Omicron spread?
A.The Omicron variant is more likely to spread than the original SARS-CoV-2 virus. How quickly Omicron spreads, compared to Delta, is unknown. The CDC expects that anyone infected with Omicron will be able to spread the virus to others, even if they have been vaccinated or do not have symptoms.
Q. Can the currently used diagnostics methods, detect Omicron?
A.The RT-PCR method is the most widely accepted and used diagnostic method for SARSCoV-2 variant. To confirm the presence of the virus, this method detects specific genes in the virus, such as Spike (S), Enveloped (E), and Nucleocapsid (N), among others. However, because the S gene in Omicron is heavily mutated, some of the primers may produce results indicating the absence of the S gene (called S gene drop out). This specific S gene dropout, along with the detection of other viral genes, could be used as an Omicron diagnostic feature. However, genomic sequencing is required for the final confirmation of the Omicron variant.
Q. Should we be concerned about the new VoC?
A. It is important to note that Omicron has been declared as a VoC based on the observed mutations, their predicted characteristics of increased transmission and immune evasion, and preliminary evidence of a negative change in COVID-19 epidemiology, such as increased reinfections. The definitive proof of increased remission and immune evasion is still awaited.
Q. Will Omicron cause more severe illness?
A.More research is needed to determine whether Omicron infections, particularly re-infections and breakthrough infections in fully vaccinated people, cause more severe illness or death than infection with other variants.
Q. What precautions should we take?
A. Individuals can reduce the spread of the COVID-19 virus by keeping a physical distance of at least 1 metre from others, wearing a well-fitting mask, opening windows to improve ventilation, avoiding poorly ventilated or crowded spaces, keeping hands clean, coughing or sneezing into a bent elbow or tissue, and getting vaccinated when their turn comes.
Q. Will there be a third wave?
A.. Cases of Omicron are increasingly being reported from countries outside of South Africa, and given its characteristics, it is likely to spread to more countries, including India. However, the magnitude and extent of the increase in cases and, more importantly, the severity of the disease that will be caused, are still unclear. In addition, given the rapid pace of vaccination in India and the high exposure to the delta variant as evidenced by the high seropositivity, the severity of the disease is expected to be low. However, the scientific evidence is still evolving.
Q. Will the existing vaccines be effective against Omicron?
A.Although there is no evidence to suggest that existing vaccines do not work on Omicron, some of the mutations reported in the Spike gene may reduce the effectiveness of existing vaccines. However, vaccine protection also involves antibodies and cellular immunity, which should be relatively better preserved. Therefore, vaccines are always expected to provide protection against serious disease, and vaccination with available vaccines is crucial. If you are eligible, but not vaccinated, you must be vaccinated.
Q. Why do variants occur?
A.Variants are an integral part of evolution and as long as the virus is able to infect, replicate, and transmit, they will continue to evolve. Also, not all variants are dangerous and most of the time we don’t notice them. It is only when they are more contagious, or can re-infect people, etc., that they gain importance. The most important step in avoiding the generation of variants is to reduce the number of infections.
Q. Is the Omicron transmission capacity higher than that for the COVID-19 Delta variant?
A.The Omicron version has raised alarm amongst epidemiologists who’re involved that the mutations within the new version ought to make it greater transmissible than the preceding variants. Further researches are being conducted to decide whether or not the Omicron version is greater transmissible than different variants, which includes the Delta version. The variety of checks for COVID-19 has been regularly growing across the world. Another extreme subject is that the Omicron version has already been detected in numerous countries, which includes Japan, Belgium, Botswana, Hong Kong, Australia, the Netherlands, South Africa, and Israel.
In addition to increasing the variety of COVID-19 checks, epigenetic researchers are urgently trying to make clear any hard elements related to the COVID-19 Omicron version. It is uncertain whether or not the Omicron version will increase COVID-19 severity. However initial researches have pronounced that the Omicron version elevated hospitalisation for COVID-19 sufferers in South Africa, which may be associated with COVID-19 complications. In addition, it remains uncertain as to whether or not the Omicron version might also additionally sell different variants, which includes the Delta version, thereby suggesting that in addition research might be wanted for complete clarification.
Q. Is there any impact of the Omicron variant on the COVID-19 severity in cancer patients?
A.. Previous studies have stated that the Delta variant or other variants can sometimes increase the severity of COVID-19 in cancer patients. COVID-19 has been reported to promote cell senescence and oxidative stress, which is linked to complications of COVID-19 in cancer patients. Additionally, various studies have reported that COVID-19 can cause increased cytokine secretion, which is linked to the aggressiveness of COVID-19. However, more studies are needed to better understand the impact of the Omicron variant in cancer patients.
Q. Is the Omicron variant having an effect on monoclonal antibody treatments?
A.There is currently no virus-specific data available to determine whether monoclonal antibody treatments will continue to be effective against the Omicron variant. Based on data from other variants with significantly fewer changes in the RBD, the Omicron variant is expected to remain susceptible to some monoclonal antibody treatments, while others may be less effective.
Q. How is India responding?
A.The Indian government is monitoring the situation closely and issuing appropriate guidelines from time to time. Meanwhile, the scientific and medical community is prepared for the development and implementation of diagnostics, genomic surveillance, generation of evidence on viral and epidemiological characteristics, and development of therapies.
3. SARS-CoV-2 surveillance in India
Q. What is INSACOG?
A.The Indian SARS-CoV-2 Genomics Consortium (INSACOG) is a national multi-agency consortium of Regional Genome Sequencing Laboratories (RGSLs) established by the Government of India on 30th December 2020. Initially, this consortium had 10 laboratories. Subsequently, the scope of laboratories under INSACOG was expanded and at present there are 28 laboratories under this consortium, which monitor the genomic variations in SARS-CoV-2.
Q. What is the objective of INSACOG?
A.The SARS-CoV-2 virus, commonly known as COVID-19 virus, posed unprecedented public health challenges globally. To fully understand the spread and evolution of this virus, its mutations and resulting variants, the need for in-depth sequencing and analysis of the genomic data was felt. Against this backdrop, INSACOG was established to expand whole genome sequencing of SARS-CoV-2 virus across the nation, aiding understanding of how the virus spreads and evolves. Any changes to the genetic code, or mutations in the virus, can be observed based on the analysis and sequencing of samples done in the laboratories under INSACOG. INSACOG has the following specific objectives:
- To ascertain the status of variants of interest (VoI) and variants of concern (VoC) in the country
- To establish sentinel surveillance and surge surveillance mechanisms for early detection of genomic variants and assist in formulating effective public health response
- To determine the presence of genomic variants in samples collected during superspreader events and in areas reporting increasing trend of cases/deaths, etc.
Q. When did India start SARS-CoV-2 viral sequencing?
A.. India started sequencing SARS-CoV-2 viral sequencing of genomes in 2020. Initially, National Institute of Virology (NIV) and Indian Councilof Medical Research (ICMR) sequenced samples of international passengers who arrived in India from the UK, Brazil or South Africa or transited through these countries, which reported a sudden surge in cases. RTPCR positive samples from states reporting sudden surges in cases were sequenced on priority. This was further expanded through the efforts of Council of Scientific and Industrial Research (CSIR), Department of Biotechnology (DBT) and National Centre for Disease Control (NCDC), as well as individual institutions.
The initial focus of India was on restricting the spread of global variants of concern in the country – Alpha (B.1.1.7), Beta (B.1.351) and Gamma (P.1) – which had high transmissibility. The entry of these variants was carefully tracked by INSACOG. Subsequently, the Delta and Delta Plus variants were also identified based on whole genome sequencing analysis conducted in the INSACOG laboratories.
Q. What is the strategy for SARS-CoV-2 surveillance in India?
A. Initially, genomic surveillance was focused on the variants carried by international travellers and their contacts in the community through sequencing three to five per cent of the total RTPCR positive samples.
Subsequently, the sentinel surveillance strategy was also communicated to the States/UTs in April 2021. Under this strategy, multiple sentinel sites are identified to adequately represent the geographic spread of a region, and RT-PCR positive samples are sent from each sentinel site for whole genome sequencing. Detailed Standard Operating Procedures (SOPs) for sending samples from the identified sentinel sites regularly to the designated RGSLs were shared with States/UTs. The list of INSACOG RGSLs tagged to States was also communicated to the States. A dedicated nodal officer was also designated by all States/UTs for coordinating the activity of whole genome sequencing.
- Sentinel Surveillance (for all States/UTs/): This is an ongoing surveillance activity across India. Each State/UT has identified sentinel sites (including RT-PCR labs and tertiary health care facilities) from where RT-PCR positive samples are sent for whole genome sequencing.
- Surge Surveillance (for districts with COVID-19 clusters or those reporting a surge in cases): A representative number of samples (as per the sampling strategy finalised by a state surveillance officer/central surveillance unit) are collected from the districts, which show a surge in the number of cases and are sent to RGSLs.
Q. What is the standard operating procedure (SOP) for sending samples to INSACOG laboratories?
A. The SOPs for sending samples to INSACOG laboratories and subsequent action based on genome sequencing analysis are as follows:
- The Integrated Disease Surveillance Project (IDSP) machinery coordinates sample collection and transportation from the districts/sentinel sites to RGSLs. The RGSLs are responsible for genome sequencing and identification of VoCs/VoIs, potential VoIs, and other mutations. Information on VOCs/ VOIs is submitted to the Central Surveillance Unit, IDSP,to establish clinico-epidemiological correlation in coordination with state surveillance officers.
- Based on discussions in the Scientific and Clinical Advisory Group (SCAG) established to support the INSACOG, it was decided that upon identification of a genomic mutation, which could be of public health relevance, RGSL will submit the same to SCAG. SCAG discusses the potential VoIs and other mutations and, if felt appropriate, recommends to the Central Surveillance Unit for further investigation.
- The genome sequencing analysis and clinico-epidemiological correlation established by IDSP is shared with MOH&FW, ICMR, DBT, CSIR and States/UTs for formulating and implementing requisite public health measures.
- The new mutations/VoCs are cultured, and genomic studies are undertaken to see the impact on vaccine efficacy and immune escape properties.
Source:
https://dbtindia.gov.in/pressrelease/qa-indian-sars-cov-2-genomics-consortium-insacog
4. COVID-19: Delta and Delta Plus variants
Q. Why are frequent mutations seen in SARS-CoV-2 virus? When will the mutations stop?
A. SARS-CoV-2 can mutate due to the following reasons:
- Random error during replication of virus
- Immune pressure faced by the viruses after treatments such as convalescent plasma, vaccination or monoclonal antibodies (antibodies produced by a single clone of cells with identical antibody molecules)
- Uninterrupted transmission due to lack of COVID appropriate behaviour. Here the virus finds an excellent host to grow and becomes more fit and transmissible.
The virus will continue to mutate as long as the pandemic remains. This makes it all the more crucial to follow COVID appropriate behaviour.
Q. What are variants of interest (VoIs) and variants of concern (VoCs)?
A.When mutations happen – if there is any previous association with any other similar variant, which is felt to have an impact on public health – then it becomes a variant under investigation (VuI).
Once genetic markers are identified, which can have an association with a receptor binding domain or which have an implication on antibodies or neutralising assays, we call them variants of interest (VoIs).
The moment we get evidence for increased transmission through field-site and clinical correlations, it becomes a variant of concern (VoC). VoCs are those that have one or more of the following characteristics:
- Increased transmissibility
- Change in virulence/disease presentation
- Evading diagnostics, drugs and vaccines
The first VoC was announced by the UK where it was found. Currently there are four VoCs identified by the scientists – Alpha, Beta, Gamma and Delta.>
Q. What are Delta and Delta Plus variants?
A.These are the names given to variants of SARS-CoV-2 virus, based on the mutations found in them. The World Health Organization (WHO) has recommended using letters of the Greek Alphabet, i.e., Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), Delta (B.1.617), etc., to denote variants, for easier public understanding.
Delta variant, also known as SARS-CoV-2 B.1.617, has about 15-17 mutations. It was first reported in October 2020. More than 60 per cent of cases in Maharashtra in February 2021 pertained to Delta variants.
It is the Indian scientists who identified the Delta variant and submitted it to the global database. The Delta variant is classified as a VoC and has now spread to 80 countries, as per the WHO.
The Delta variant (B.1.617) has three subtypes B1.617.1, B.1.617.2 and B.1.617.3, of which B.1.617.1 and B.1.617.3 have been classified as VoI, while B.1.617.2 (Delta Plus) has been classified as a VoC.
Compared to the Delta variant, the Delta Plus variant has an additional mutation. This mutation is called the K417N mutation. ‘Plus’ means an additional mutation has happened to the Delta variant. It does not mean that the Delta Plus variant is more severe or highly transmissible than the Delta variant.
Q. Why has the Delta Plus variant (B.1.617.2) been classified as a VoC?
A. It has been classified as a VoC because of the following characteristics:
- Increased transmissibility
- Stronger binding to receptors of lung cells
- Potential reduction in monoclonal antibody response
- Potential post vaccination immune escape
How often are these mutations studied in India?
A. Indian SARS-CoV-2 Genomics Consortium (INSACOG), coordinated by the Department of Biotechnology (DBT) along with the Union Health Ministry, ICMR, and CSIR, monitors the genomic variations in SARS-CoV-2 on a regular basis through a pan-India multi-laboratory network. It was set up with 10 national labs in December 2020 and has been expanded to 28 labs and 300 sentinel sites from where genomic samples are collected. The INSACOG hospital network looks at samples and informs INSACOG about the severity, clinical correlation, breakthrough infections and re-infections.
More than 65,000 samples have been taken from states and processed, while nearly 50,000 samples have been analysed of which 50 per cent have been reported to be VoCs.
Q. On what basis are the samples subjected to genome sequencing?
A.Sample selection is done under three broad categories:
- International passengers (during the beginning of the pandemic)
- Community surveillance (where RT-PCR samples report CT value less than 25)
- Sentinel surveillance where samples are obtained from labs (to check transmission) and hospitals (to check severity)
When there is any public health impact noticed because of genetic mutation, then the same is monitored.
Q. What is the trend of VoCs circulating in India?
A.As per the latest data, 90 per cent of samples tested have been found to have Delta variants (B.1.617). However, B.1.1.7 strain, which was the most prevalent variant in India in the initial days of the pandemic, has decreased.
Q. Why is action regarding public health not taken immediately after noticing mutations in the virus?
A. It is not possible to say whether the mutations noticed will increase transmission. Also, until there is scientific evidence that proves a correlation between the rising number of cases and variant proportion, we cannot confirm there is a surge in the particular variant. Once mutations are found, it is analysed every week to find out if there is any such correlation between the surge of cases and variant proportion. Public health action can be taken only if scientific proofs for such correlation are available.
Once such correlation is established, it will help greatly to prepare in advance when such a variant is seen in another area/region.
Q. Do Covishield and Covaxin work against the variants of SARS-CoV-2?
A.Yes, Covishield and Covaxin are both effective against the Alpha, Beta, Gamma and Delta variants. Lab tests to check vaccine effectiveness on Delta Plus variants are ongoing.
Delta Plus variants: The virus has been isolated and is now being cultured at ICMR’s National Institute of Virology, Pune. Laboratory tests to check vaccine effectiveness are ongoing and the results will be available in 7 to 10 days. This will be the first result in the world.
Q. What are the public health interventions being carried out to tackle these variants?
A.The public health interventions needed are the same, irrespective of the variants. The following measures are being taken:
- Cluster containment
- Isolation and treatment of cases
- Quarantining of contacts
- Ramping up vaccination
Q. Do public health strategies change as the virus mutates and more variants arise?
A.No, public health prevention strategies do not change with variants.
Q. Why is continuous monitoring of mutations important?
A.Continuous monitoring of mutations is important to track potential vaccine escape, increased transmissibility and disease severity.
Q. What does a common man do to protect self from these VoCs?
A.One must follow COVID appropriate behaviour, which includes wearing a mask properly, washing hands frequently and maintaining social distancing. The second wave is not over yet. It is possible to prevent a big third wave provided individuals and society practice protective behaviour. Further, test positivity rate must be closely monitored by each district. If the test positivity goes above 5 per cent, strict restrictions must be imposed.
Source:
https://pib.gov.in/PressReleseDetailm.aspx?PRID=1730875
5. COVID-19 vaccination for pregnant women
Q. Why is COVID-19 vaccine being recommended for pregnant women?
A. Pregnancy does not increase the risk to COVID-19 infection. Most pregnant women will be asymptomatic or have mild disease, but their health may deteriorate rapidly and that might affect the foetus too. It is important that they take all precautions to protect themselves from COVID-19, including taking the vaccination against the same. It is, therefore, advised that a pregnant woman should take the COVID-19 vaccine.
Q. Who are at higher risk of getting infected with COVID-19?
A. Higher risk of infection involves with:
- A healthcare worker or a frontline worker
- A community with high or increasing rate of COVID-19 infections
- Those frequently exposed to people outside the household
- Those who have difficulty in complying with social distance if living in a crowded household
Q. How does COVID-19 affect the health of a pregnant woman?
A.Although most (>90 per cent) infected pregnant women recover without hospitalization, rapid deterioration in health may occur in a few. Symptomatic pregnant women appear to be at increased risk of severe disease and death. In severe disease, like all other patients, pregnant women may also need hospitalisation. Pregnant women with underlying medical conditions, for example, high blood pressure, diabetes, obesity, and age over 35 years are at higher risk of severe illness due to COVID-19.
Q. How does COVID-19 infection of pregnant women affect the baby?
A.Most (over 95 per cent) of newborns of COVID-19 positive mothers have been in good condition at birth. In some cases, COVID-19 infections in pregnancy may increase the possibility of a premature delivery; the baby’s weight may be less than 2.5 kg; and in rare situations, the baby might die before birth.
Q. Which pregnant women are at a higher risk of developing complications after COVID-19 infection?
A.Pregnant women who are:
- Older than 35 years of age
- Obese
- Have an underlying medical condition such as diabetes or high blood pressure
- Have a history of clotting in the limbs
Q. If a pregnant woman has already had COVID-19, when should she be vaccinated?
A. In case a woman is infected with COVID-19 during the current pregnancy, then she should be vaccinated soon after the delivery
Q. Are there any side effects of the COVID-19 vaccines that can either harm the pregnant woman or her foetus?
A.The available COVID-19 vaccines are safe and the vaccination protects pregnant women against COVID-19 like other individuals. Like any medicine a vaccine may have side effects, which are normally mild. After getting the vaccine, she can get mild fever, pain at the injection site, or feel unwell for 1-3 days. The long-term adverse effects and safety of the vaccine for the foetus and the child born is not established yet. Very rarely, (one in one to five lakh people) the beneficiary may, after the COVID-19 vaccination, experience some of the following symptoms within 20 days after getting the injection, which may need immediate attention.
Q. When should the vaccine be given to the pregnant woman?
A.The COVID-19 vaccination schedule can be started any time during pregnancy.
Q. What other precautions should the pregnant woman take after vaccination?
A. Counsel the pregnant woman and her family members to continue to practice COVID appropriate behaviour: wearing double masks, frequent hand washing, maintaining physical distance, and avoiding crowded areas, to protect themselves and those around from spreading the COVID-19 infection.
Q. How does a pregnant woman register herself for the Covid-19 vaccination?
A.All pregnant women need to register themselves on the Co-WIN portal or may get themselves registered on-site at the COVID-19 vaccination centre. The process of registration for pregnant women remains the same as of the general population and as per the latest guidelines provided by the Ministry of Home and Family Welfare (MoHFW) from time to time.
Source:
https://www.mohfw.gov.in/pdf/OperationalGuidanceforCOVID19vaccinationofPregnantWoman.pdf
6. COVID-19 & Children
Q. What is the possibility of a third wave of COVID-19 in the coming months?
A.Pandemics are likely to occur in multiple waves, and each wave could vary in the number of cases and its duration. Eventually, most of the population may get immune by asymptomatic or symptomatic infections (herd immunity). Over time, the disease may die out or may become endemic in the community with low transmission rates.
Key Message:There is a possibility of a third wave, but it is difficult to predict its timing and severity.
Q. Are children at greater risk if the third wave strikes?
A.In the first wave, primarily the elderly and individuals with co-morbidities were affected with severe disease. In the current (second) wave, a large number of younger population (30-45 years) have developed severe disease as also those without co-morbidities. After the second wave is over, if we do not continue following COVID appropriate behaviour, the third wave, if it occurs, is likely to infect the remaining non-immune individuals and that may include children also. The latest sero survey (December 2020 to January 2021) showed that the percentage of infected children in the age group of 10-17 years was around 25 per cent, the same as adults. This indicates that while children are being infected like adults, they are not getting the severe disease.
Key Message:Children are as susceptible as adults and older individuals to develop an infection but not a severe disease. It is highly unlikely that the third wave will predominantly or exclusively affect children.
Q. Are children likely to suffer from severe disease as being witnessed in the adult population in the current wave?
A. Fortunately, children have been relatively less affected so far due to several factors. The most important reason is the lesser expression of specific receptors to which this virus binds to enter the host and also the immune system of the children. A very small percentage of infected children may develop moderate to severe disease. If there is a massive increase in the overall numbers of infected individuals, a larger number of children with moderate to severe disease may be seen. Apart from the infection, parents should watch out for mental health issues in children and keep a watch to prevent child abuse and violence. Also, it is worth limiting screen time and prepare children for safe school reopening as per the Indian Academy of Pediatrics (IAP) guidelines.
Key Message: Almost 90 per cent of the infections in children are mild/asymptomatic. Therefore, the incidence of severe disease is not high in children.
Q. Can we rule out the possibility of severe infections in children in the third wave?
A. As explained, the spectrum of illness is likely to be much less severe in children than adults; there is only a remote possibility of children being more severely affected than adults in the next wave. As per data collected during the first and second waves, severe COVID-19 infections in children were not reported and only in few cases they were admitted to ICU. However, we need to be watchful about how the mutant strains will behave. The dictum here is: better be ready and prepared for the worst and hope for the best!
Key Message: Severe COVID-19 cases in children are rare. Further, there is no evidence indicating that children will have severe disease in the third wave.
Q. Severe disease due to COVID-19 is already occurring in children. Why it is so?
A.Yes, a severe illness related to COVID-19 is known to occur in children. This includes pneumonia and multisystem inflammatory syndrome in children (MIS-C). However, COVID-19 pneumonia in children is uncommon as compared to adults. In some cases, after 2-6 weeks of asymptomatic or symptomatic COVID-19 infection, MIS-C may be seen due to immune dysregulation with the incidence of 1-2 cases per 100,000 population; some of these cases also may be severe. It’s a treatable condition with a good outcome if diagnosed early. Also, most children suffering from MIS-C cannot transmit the infection to others.
Key Message: Children occasionally get the severe disease and may need ICU care, both during the acute illness and after 2-6 weeks due to MIS-C caused by COVID-19. But the majority are likely to recover if treated on time.
Q. What preparations are being made in case the third wave comes and affects the children?
A.Most affected children get a mild disease with fever and need supervised home care with monitoring. We have learned a lot about COVID-19 illness from our shared experiences in adult medicine in the last 15 months. IAP guidelines on the management of COVID-19 in children are in place, and paediatricians have been sensitised and trained on its management. We need to be ready for a more significant number of patients seeking consultations; educating the parents on different platforms regarding illness and warning signs; and arranging more COVID-19 wards for children with more special wards such as high-dependency units (HDUs) and intensive care units (ICUs). The preventive behaviours are the same for children. Parents should also be ideal role models for their children regarding mask etiquette, hand hygiene, and social distancing. Children above the age of two to five years can be trained to use a mask; however, the adults have to follow the COVID-appropriate behaviour. IAP has also set guidelines for the safe reopening of schools for the safety of the children.
Key Message: We need to be prepared with more in-patient beds and intensive care beds for children. IAP has already developed the management protocol for disease categories in children. There is no reason to panic. Our preparations are in full swing.
Q. What is the plan for vaccinating children?
A.So far, the global data show that compared to children, older adults are a thousand times more likely to die from COVID-19 disease. So, it has been a priority to vaccinate the high-risk elderly age group first. Thereafter, the emphasis should be on adults who also have more severe diseases as compared to children. When there is the remote possibility of children getting affected, some countries consider vaccinating children and adolescents. The same vaccines being used in adults can be used in children only after adequate trials. One of the India-made vaccines will soon undergo trials in children, and if proven immunogenic and safe, it could be fast-tracked for mass vaccination in children.
Key Message: Children do get the severe disease, even if the number is small. Thus, there is no harm in considering vaccination for them. The safety and efficacy, however, are being assessed in trials for this age. The national expert group on vaccine administration for COVID-19 will develop a plan as and when new scientific data emerge.
7. COVID-19 & White Fungus infection
Q. What is White Fungus?
A.White Fungus, also known as candidiasis, is an opportunistic infection, which could spread fast to various body parts and, if not treated, could be serious. According to the Centre for Diseases Control and Prevention (CDC), White Fungus or invasive candidiasis can affect the blood, heart, brain, eyes, bones, or other parts of the body.
Q. Who are at high risk to get White Fungus infection?
A. White Fungus is all around us as it is found naturally in the environment. It primarily affects people with low immunity, who come in contact with objects that contain these fungal spores. For instance, COVID-19 patients on oxygen support can come in contact with these fungal spores if their ventilators and oxygen support equipment are not sanitised properly. Further, overuse of steroids and use of tap water in the humidifier attached to an oxygen cylinder can also heighten the risk of contracting White Fungus.
Q. Who can get infected by white fungus?
A. Invasive candidiasis is caused by a yeast (a type of fungus) called Candida. Candida can normally live inside the body, in areas like the mouth, throat, gut, and vagina, without causing any problems. However, individuals with low immunity, like patients recovering from a serious COVID-19 infection, are particularly at risk of contracting this fungal infection. In their bodies, the fungus can enter the bloodstream or internal organs to cause an infection.
People who are at high risk for developing this infection include those who:
- Have been admitted in the intensive care unit (ICU) for a prolonged period.
- Have weakened immune system (for example, people on cancer chemotherapy, people
- who have had an organ transplant, and people with low white blood cell counts).
- Have recently had surgery, especially multiple abdominal surgeries.
- Have recently received lots of antibiotics or steroids in the hospital.
- Receive total parenteral nutrition (food through a vein).
- Have kidney failure or are on hemodialysis.
- Have diabetes.
- Have a central venous catheter
Q. Is White Fungus contagious?
A.White Fungus is not contagious in most cases, as it cannot spread directly from person to person. However, there exist some species of fungus that cause this infection on the skin. In such instances of external infection, the fungus can possibly be transferred from the patient to another individual who is at risk.
Q. What are the symptoms of White Fungus?
A.Only CT scans or X-rays can reveal and completely confirm the White Fungus infection. Health experts report that it is more dangerous than Black Fungus, as it affects the lungs as well as other parts of the body like the nails, skin, stomach, kidney, brain, private areas, and mouth.
Moreover, the White Fungus can also infect the lungs the same way COVID-19 does. In fact, patients who get infected with White Fungus displayed COVID-19-like symptoms despite having tested negative for the virus. According to some reports, the oxygen saturation level of one of the four patients infected with White Fungus dropped from normal levels. However, the oxygen levels became normal after the antifungal medication was administered.
Q. How can White Fungus be treated?
A.Patients infected with White Fungus should be examined carefully, perhaps with a fungus culture test of their phlegm or mucus, to detect the extent of fungal infection in their body. After detection of the infection, antifungal medications can be used to treat the patients. Such medications have led to an improvement in their condition. The type and dose of antifungal medication used to treat White Fungus will depend on the patient’s age, immune status, location, and severity of the infection.
8. COVID-19 & Use of oxygen
Q. What is the normal respiratory rate of a healthy adult person?
A.Standard respiratory rates for a healthy adult range from 12 to 20 breaths per minute.
Are 8 breaths per minute normal?
A.No. A patient needs to be evaluated medically.
Q. How many litres of oxygen per minute do we breathe?
A.The average tidal volume, i.e., the average amount of air inhaled and exhaled per breathing cycle, is 0.5 litre (500 ml). Minute Ventilation (VE) is the total volume of air entering the lungs in a minute, which is 6 litres per minute.
Q. What should be the normal oxygen saturation as recorded by a Pulse Oximeter?
A.The normal oxygen saturation level in the blood (SpO2 ) should be 95 per cent or higher. Some people with chronic lung disease, such as Chronic Obstructive Pulmonary Disease (COPD) or sleep apnea, may have normal levels of around 90 per cent. The ‘SpO2 ’ reading on a pulse oximeter shows the percentage of oxygen in the blood. If your home SpO2 reading is lower than 94 per cent, call your healthcare provider.
Q. How do I check my oxygen level at home without a Pulse Oximeter?
A.If you do not have a portable finger pulse oximeter in your home, you can also learn how to assess signs and symptoms of low oxygen levels. Two classic signs of a low oxygen level are a rapid heart rate and a fast breathing rate. An average heart rate is 60–100 beats per minute and an average breathing rate is 12–20 breaths per minute. However, under low oxygen conditions, body responses include an increase in heart rate and breathing rate. Another sign of a low blood oxygen level is cyanosis or a bluish colour change on your lips, nose, or fingertips. As your body loses oxygen, the blood cells in your body change colour in your bloodstream to a dark blue, which can be seen from the outside of your skin if it is severe. Cyanosis is typically a late sign of low oxygen levels and is considered a medical emergency. If you notice this bluish discolouration, you should immediately visit the nearest hospital.
Q. Do we see many cases of silent hypoxia in this wave? How can this be addressed?
A.Silent hypoxia or happy hypoxia is referred to as the early stage of COVID-19. As the oxygen level drops, one may start feeling shortness of breath, confusion, and other symptoms. Keep watching for these signs and do not ignore them. This is true for young people as well. If you monitor low oxygen level, change in lip colour from natural to blue or persistent sweating, consult the COVID helpline or doctor. They could be the early sign of silent hypoxia.
Q. In brief, how can proning help enhance blood oxygen levels?
A.Proning is a medically accepted process to improve the distribution and exchange of oxygen in the lungs. A patient is safely placed from their back onto their abdomen (stomach), i.e., face down to improve breathing and oxygenation. It has been shown as beneficial for COVID-19 patients with compromised breathing comfort, especially during home isolation.
Q. Is pure oxygen used in hospitals?
A.Medical oxygen contains high purity oxygen used for medical treatments and is developed for use in human body. Cylinders contain a compressed oxygen gas and no gases are allowed in the cylinder to prevent contamination.
Q. What is the use of medical oxygen?
A.Oxygen is used for treatment in hospitals. Hence, it is considered a drug or a pharmaceutical product.
Q. What is the need for medical oxygen?
A.The human body requires oxygen to survive, and typically, we breathe in from air. However, if you have lung disease or other medical conditions such as COVID-19, you may not get enough oxygen due to compromised lungs. That can leave you short of breath and cause problems with your heart, brain, and other parts of your body.
Q. Can breathing 100 per cent oxygen harm your body?
A.Yes. Breathing 100 per cent oxygen also eventually leads to collapse of the alveoli (atelectasis).
Q. Can you get excess (more than required) oxygen from an oxygen concentrator?
A.It is possible to get excess (more than required) oxygen from an oxygen concentrator. However, this is quite rare when oxygen concentrators are used as directed and prescribed. All supplemental oxygen requires a prescription from a doctor, who carefully chooses your oxygen requirement.
Q. What is the role of oxygen during COVID-19 disease?
A.The demand for medical oxygen increases in COVID-19 as the disease primarily affects the lungs and, in severe cases, causes death due to Acute Respiratory Distress Syndrome (ARDS) and pneumonia.
Q. When does a patient require medical oxygen in a COVID-19 positive case?
A. As per AIIMS/ICMR-Covid-19/National Task Force/Joint Monitoring Group (Dte.GHS), MoHFW, Government of India, Clinical Guidelines for Management of Adult COVID-19 Patient issued on 22nd April 2021, moderate and severe cases of COVID-19 where the infection induces shortage of oxygen in the body due to its impact on lungs require medical oxygen and immediate oxygen therapy. Oxygen acts as a life-saver for COVID-19 patients.
Q. What are moderate COVID-19 cases?
A. In moderate COVID-19 cases, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than or equal to 24/minute and SpO2 90 per cent to 93 per cent with ambient air.
Q. What is severe COVID-19 cases?
A.A. In severe COVID-19 case, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than 30/minute and SpO2 less than 90 per cent in room air.
Q. When does a patient require mechanical ventilator support?
A. A patient may be put on a mechanical ventilator if it becomes very difficult to breathe or get enough oxygen into their blood. This condition is called respiratory failure. Mechanical ventilators are machines that act as bellows to move air in and out of the patient’s lungs. The respiratory therapist and doctor set the ventilator to control how often it pushes air into the lungs and how much air the patient gets. The patient may be fitted with a mask to get air from the ventilator into the lungs. Or, they may need a breathing tube if their breathing problem is more serious.
Q. Can mechanical ventilation be given at home?
A.Mechanical ventilators are mainly used in hospitals and transport systems such as ambulances and medical evacuation by air transport, etc. In some cases, they can be used at home if the illness is long-term and the caregivers at home receive training and have adequate nursing and other resources at home. Being on a ventilator may make a patient more susceptible to pneumonia, damage to the vocal cords, or other problems.
Q. What is the six minute walk test for COPD?
A.The six minute walk test (6MWT) is an exercise test that measures functional status in chronic obstructive pulmonary disease (COPD) patients and provides information on oxygen desaturation. This test is also being used for COVID-19. In case of COVID-19 symptoms, SpO2 level must be checked before taking a walk. Now, walk for six minutes without a break on an even surface and measure the SpO2 level. It may fall 1-2 per cent, but consult a medical professional if it falls below 93 per cent.
Source:
https://ndma.gov.in/sites/default/files/2021-03/FAQs-on-Use-of-oxygen-.pdf
9. COVID-19 & Therapeutics
Q. Is Remdesivir effective in the treatment of COVID-19?
A.. No study has conclusively been able to prove that Remdesivir is beneficial in the treatment of COVID-19. However, India has approved Remdesivir under the National Clinical Management Protocol for COVID-19, which was developed after many interactions by a committee of experts. The protocol acts as the guiding document for the treatment of COVID-19 patients in India. Remdesivir is listed as an investigational therapy in the protocol, i.e., where informed and shared decision-making is essential, besides noting contraindications mentioned in the detailed guidelines.
Q. What is Remdesivir? How does Remdesivir work?
A.Remdesivir is an investigational drug used to treat viral infections. It is classified as a broadspectrum antiviral with potential antiviral activity against a variety of RNA viruses.
The drug works against the novel coronavirus by inhibiting replication of the virus in the body. Remdesivir functions as a pro-drug that is modified in the body before it becomes an active drug. It is classified as a nucleoside analog, one of the oldest classes of antiviral medications, and resembles the RNA base adenosine. In general, nucleoside and nucleotide analogues simulate the structure of a true nucleoside or nucleotide. The simulated structure may then be incorporated into the virus. Remdesivir works when the enzyme replicating the genetic material for the novel coronavirus − RNA polymerase − incorporates the adenosine analogue in place of the natural molecule into the growing RNA strand. By introducing the modified agent, Remdesivir, replication of the novel coronavirus is interrupted, and the virus ceases to multiply and cannot infect more cells in the body
Q. When should a patient of COVID-19 take Remdesivir?
A.The timing of the drug, when it is administered, is most important. Taking it too early or too late could do more harm than good. Remdesivir is applicable only in hospitalised patients who showed very low oxygen saturation and infiltrated their chest X-ray or CT scan. The optimal timing for Remdesivir is usually after five to seven days of having the virus. Early to mild or asymptomatic patients should not take Remdesivir. Also, it is of no use if it’s given very late because it would create a cytokine storm. A cytokine storm is when the immune system goes into overdrive. The body starts to attack its cells and tissues instead of just the virus.
Q. Can Remdesivir be taken at home?
A.Remdesivir comes in a vial and has to be injected only after prescription and in the presence of a health practitioner. It is for patients who are hospitalised and severe. Therefore, it should not be given at home. It is for patients who need to be admitted and need hospital care.
Q. Are steroids effective in the treatment of COVID-19?
A.There is no evidence to support the use of steroids in the treatment of COVID-19. The World Health Organization (WHO) recovery trial showed that steroids do have a beneficial effect. But again, the timing is critical. The recovery trial clearly showed that if we give steroids too early, it showed a harmful effect before oxygen saturation. Steroids are most effective during the later part of the disease when there is more inflammation and oxygen saturation is falling. Steroids are only helpful for moderate or severe cases.
Q. Is plasma a good way to fight off COVID-19?
A.Convalescent plasma has been a therapy devised to passively transfer antibodies from a recovered person to a new patient. While the therapy has been received with different opinions by the medical community, the important aspect is timing. It’s better if plasma therapy is used early before clinical worsening. Also, plasma with high titer neutralising antibodies would have better results. Hence, to achieve good results, correct patient selection, timing and a good quality plasma donor are needed for success in this form of treatment
Q. Should a person with COVID-19 take Tocilizumab?
A.Tocilizumab is a drug of last resort. It should only be used when a COVID-19 infection in a patient is worsening despite steroids, Remdesivir and other treatments like anticoagulants. Tocilizumab is required in less than 2 per cent of COVID-19 patients. Very few patients need this drug because it’s only for treating a cytokine storm and has a limited role.
Q. Is Favipiravir effective in treating COVID-19?
A.Favipiravir is another antiviral that is being promoted for the treatment of COVID-19. It was initially doled out as a treatment of influenza after the H1N1 pandemic. There is not enough evidence in robust studies to show that it is a good drug. Since it’s not a proven treatment, India’s national guidelines also don’t recommend its use.
Q. Is it possible to treat COVID-19 without any of the drugs mentioned above?
A.People with mild COVID-19 or those who are asymptomatic will improve with just symptomatic treatment. Mild COVID-19 infection can be treated with paracetamol, good hydration and multivitamins − without any treatment. Giving treatment when it is not required may be doing more harm than good.
10. COVID-19 & Black Fungus Disease
Q. What is Black Fungus?
A.Black Fungus, also known as mucormycosis, is a rare fungal infection. It is called ‘black’ because of the colour of the fungal growth. It is caused by exposure to mucor mold found in soil, manure, and rotten/decaying fruits and vegetables. It is ubiquitous and even present in the nose/mucosa of healthy individuals. This disease usually affects the sinuses, eye orbit, and brain. That is why it is also called ‘rhino-orbital-cerebral’ mucormycosis. It may be life-threatening in immuno-compromised individuals (cancer patients, HIV/AIDS) and people with uncontrolled diabetes.
Q. What are the risk factors for acquiring Black Fungus infection?
A.Risk Factors are:
- Uncontrolled Diabetes Mellitus
- Treated for COVID-19 with corticosteroids
- Treated for COVID-19 with immunomodulators
- Treated for COVID-19 with mechanical ventilation
- Prolonged oxygen therapy
- Prolonged ICU stay
- Immuno-compromised state
Q. Why the sudden increase in Black Fungus cases?
A.It may be triggered by extensive use of steroids, which is a life-saving treatment for moderate to severe COVID-19 infection. Steroids lower the immunity and cause a sudden up-shooting of blood sugar levels in diabetes and non-diabetic patients. For patients on humidified oxygen, care should be taken to make sure there is no water leak to prevent the growth of the fungus.
Q. How serious is Black Fungus?
A.Black fungus infection causes a vision-threatening and life-threatening condition.
Q. Do all COVID-19 patients need to be worried about Black Fungus infection?
A.No. As discussed, high-risk patients need to be alert. Also, during COVID-19 recovery, everyone should watch out for early signs and symptoms.
Q. What are the precautions one can take to avoid this disease?
A. One can take the following precautions:
- Boost immune system with diet, hydration and exercise.
- Rational use of steroids by follow guidelines.
- Strict blood sugar monitoring and control in all patients who are on steroids.
Q. What are the early signs of Black Fungus?
A.Some of the early signs are:
- Facial pain
- Facial swelling/puffiness/discolouration
- Sinus headache
- Stuffy nose
- The blurring of vision/decreased vision
- Double vision
- Drooping of eyelid
- Blood-stained nasal discharge
- Dental pain
Q. Is Black Fungus treatable?
A.Yes. Early diagnosis and a prompt multi-speciality team of medical professionals can manage it.
Q. Which specialist should I visit for Black Fungus?
A. ENT and eye specialists are central to this disease. The team includes care coordination with neurosurgeon, endocrinologist and microbiologist.
Source:
https://www.eyeqindia.com/frequently-asked-questions-on-covid-and-black-fungus/#toggle-id-9
11. COVID-19 & Indoor Air
Q. Will running an evaporative cooler help protect my family and me from COVID-19?
A. Evaporative coolers (or ‘swamp coolers’) can help protect people indoors from the airborne transmission of COVID-19 because they increase ventilation with outside air to cool indoor spaces. Evaporative coolers are used in dry climates. They use water to provide cooling and improve relative humidity in indoor microenvironments. When operating as intended (with open windows), these devices produce substantial increases in ventilation with outdoor air. Some evaporative coolers can be performed without using water when temperatures are milder to increase ventilation indoors. Avoid using evaporative coolers if air pollution outside is high and the system does not have a high-efficiency filter
Q. Is ventilation important for indoor air quality when cleaning and/or sanitising for COVID-19 indoors?
A.When cleaning and disinfecting for COVID-19, ventilation is essential − in general, increasing ventilation during and after cleaning helps to reduce exposure to cleaning and disinfection products and by-products. Increasing ventilation, for example, by opening windows or doors, can also reduce risks from particles resuspended during cleaning, including those potentially carrying SARS-CoV-2 (or other contaminants). Avoid ventilation with outdoor air when outdoor air pollution is high or when it makes your home too cold, hot, or humid.
Q. Will an air cleaner or air purifier help protect my family and me from COVID-19 in my home?
A.When appropriately used, air purifiers can help reduce airborne contaminants, including viruses, in a home or confined space.
Q. How can I increase ventilation at home to help protect my family from COVID-19?
A.Ensuring proper ventilation with outside air is a standard best practice for improving indoor air quality. To increase ventilation in your home, one can:
- Open the windows or screened doors, if possible;
- Operate an air conditioner that has an outdoor air intake or vent; and
- Operate a bathroom fan when the bathroom is in use and continuously, if possible.
A.However, the practices mentioned here are not enough to protect people from COVID-19. When used along with other best practices recommended by the Ministry of Health and Family Welfare, Government of India, the above methods can be part of a plan to protect yourself and your family.
Source:
https://www.epa.gov/coronavirus/indoor-air-and-coronavirus-covid-19
1. COVID-19 & Cancer
Q. Should patients with cancer receive the COVID-19 vaccine?
A. The data on efficacy and safety of COVID-19 vaccination in patients with cancer is limited. However, as patients with cancer are more prone to contract a severe form of illness due to COVID-19 infection, the benefits of getting vaccinated are more than the risks.
Q. Should people who have completed their treatment for cancer receive the COVID-19 vaccine?
A. Patients who have completed their treatment for cancer should receive the COVID-19 vaccine as soon as it is available to them as long as there are no major allergies.
What does it mean to be immune-compromised?
A. ‘Immune compromised’ refers to individuals whose immune system is considered weaker, more impaired, or less robust than that of the average healthy adult. The primary role of the immune system is to help fight off infection. Individuals with compromised immune systems are at a higher risk of getting infections, including viral infections such as COVID-19. There are many reasons that a person might be immune-compromised. Health conditions such as cancer, diabetes, or heart disease, older age, or lifestyle choices such as smoking can all contribute to weakened immune systems.
Q. Does receiving chemotherapy or radiation raise your risk of getting COVID-19 or having a more serious course of illness?
A. To date, limited evidence is available to suggest that any cancer treatment raises your risk for getting COVID-19 any more or less than anyone else who is exposed to the virus. There is some evidence that patients with cancer may experience more serious COVID-19 infection if they acquire it, more so because cancer and cancer treatment can contribute to weakened immune systems, which can then lead to a reduced ability to fight off infections. It is not clear at this point if cancer patients who have received chemotherapy or radiation in the past are at increased risk for COVID-19. The risk of infection may depend, in part, on the specific treatment received, the type of cancer treated, and how much time has passed since the treatment was completed.
Q. Should people who are on cancer-directed therapy receive the COVID-19 vaccine?
A. Patients who are on cancer-directed therapy can receive the vaccine after discussing it with their treating oncologist. The oncologist will suggest a suitable time based on the ongoing therapy (surgery, radiation, chemotherapy, immunotherapy, or stem cell transplant). Please inform the treating oncologist if you have had any drug allergies in the past.
Q. Which COVID-19 vaccine is the best for patients with cancer?
A. All the approved vaccines have been shown to be effective. There are no direct comparisons between the available vaccines for efficacy or safety. Therefore, it is suggested that you take any vaccine approved for use and available in your vaccination centre.
Q. Is there any contraindication for the COVID-19 vaccine in patients with cancer?
A. Patients who are allergic to polyethylene glycol (PEG) should not receive the COVID-19 vaccine. Individuals with a known history of polysorbate-80 allergy (used as excipient in certain chemotherapeutic drugs) should not receive COVID-19 vaccine.
Q. Should patients with a previous history of COVID-19 infection be vaccinated?
A. Yes, cancer patients who had been infected and recovered from the illness should also receive the COVID-19 vaccine as it will protect from re-infection.
Q. Should the vaccine be given to patients with positive COVID-19 antibodies?
A. The COVID-19 vaccine should be given to all patients with cancer irrespective of their antibody status. Serological testing should not be used to guide the decision and timing of vaccination.
Q. What are the side effects that may occur after the COVID-19 vaccine?
A. You may expect some minor side effects like soreness of the shoulder (injection site) for a few days after the vaccination. Also, you may have mild fever, tiredness for a day or two after the injection. Serious side effects are extremely rare, but we advise you to consult your doctor in case of any troublesome symptoms.
2. COVID-19: OMICRON Variant
Q. What is Omicron and why is it a Variant of Concern (VoC)?
A. This new variant of SARS-CoV-2, named B.1.1.529 or Omicron (based on Greek alphabets such as alpha, beta, delta, etc.) has recently been reported in South Africa. There are a large number of mutations in this variant, especially more than 30 in the viral spike protein, which is the major target for immune responses. The World Health Organization has declared Omicron as a Variant of Concern (VoC) because of the combination of mutations that previously individually have been associated with increased infectivity or immune evasion, and the sudden rise in number of positive cases in South Africa.
Q. Why is it called Omicron?
A. The WHO named the B.1.1.529 variant Omicron in the tradition of giving variants a Greek letter name.
Q. How easily does Omicron spread?
A. The Omicron variant is more likely to spread than the original SARS-CoV-2 virus. How quickly Omicron spreads, compared to Delta, is unknown. The CDC expects that anyone infected with Omicron will be able to spread the virus to others, even if they have been vaccinated or do not have symptoms.
Q. Can the currently used diagnostics methods, detect Omicron?
A. The RT-PCR method is the most widely accepted and used diagnostic method for SARSCoV-2 variant. To confirm the presence of the virus, this method detects specific genes in the virus, such as Spike (S), Enveloped (E), and Nucleocapsid (N), among others. However, because the S gene in Omicron is heavily mutated, some of the primers may produce results indicating the absence of the S gene (called S gene drop out). This specific S gene dropout, along with the detection of other viral genes, could be used as an Omicron diagnostic feature. However, genomic sequencing is required for the final confirmation of the Omicron variant.
Q. Should we be concerned about the new VoC?
A. It is important to note that Omicron has been declared as a VoC based on the observed mutations, their predicted characteristics of increased transmission and immune evasion, and preliminary evidence of a negative change in COVID-19 epidemiology, such as increased reinfections. The definitive proof of increased remission and immune evasion is still awaited.
Q. Will Omicron cause more severe illness?
A. More research is needed to determine whether Omicron infections, particularly re-infections and breakthrough infections in fully vaccinated people, cause more severe illness or death than infection with other variants.
Q. What precautions should we take?
A. Individuals can reduce the spread of the COVID-19 virus by keeping a physical distance of at least 1 metre from others, wearing a well-fitting mask, opening windows to improve ventilation, avoiding poorly ventilated or crowded spaces, keeping hands clean, coughing or sneezing into a bent elbow or tissue, and getting vaccinated when their turn comes.
Will there be a third wave?
A. Cases of Omicron are increasingly being reported from countries outside of South Africa, and given its characteristics, it is likely to spread to more countries, including India. However, the magnitude and extent of the increase in cases and, more importantly, the severity of the disease that will be caused, are still unclear. In addition, given the rapid pace of vaccination in India and the high exposure to the delta variant as evidenced by the high seropositivity, the severity of the disease is expected to be low. However, the scientific evidence is still evolving.
Q. Will the existing vaccines be effective against Omicron?
A. Although there is no evidence to suggest that existing vaccines do not work on Omicron, some of the mutations reported in the Spike gene may reduce the effectiveness of existing vaccines. However, vaccine protection also involves antibodies and cellular immunity, which should be relatively better preserved. Therefore, vaccines are always expected to provide protection against serious disease, and vaccination with available vaccines is crucial. If you are eligible, but not vaccinated, you must be vaccinated.
Q. Why do variants occur?
A. Variants are an integral part of evolution and as long as the virus is able to infect, replicate, and transmit, they will continue to evolve. Also, not all variants are dangerous and most of the time we don’t notice them. It is only when they are more contagious, or can re-infect people, etc., that they gain importance. The most important step in avoiding the generation of variants is to reduce the number of infections.
Q. Is the Omicron transmission capacity higher than that for the COVID-19 Delta variant?
A. A. The Omicron version has raised alarm amongst epidemiologists who’re involved that the mutations within the new version ought to make it greater transmissible than the preceding variants. Further researches are being conducted to decide whether or not the Omicron version is greater transmissible than different variants, which includes the Delta version. The variety of checks for COVID-19 has been regularly growing across the world. Another extreme subject is that the Omicron version has already been detected in numerous countries, which includes Japan, Belgium, Botswana, Hong Kong, Australia, the Netherlands, South Africa, and Israel.
In addition to increasing the variety of COVID-19 checks, epigenetic researchers are urgently trying to make clear any hard elements related to the COVID-19 Omicron version. It is uncertain whether or not the Omicron version will increase COVID-19 severity. However initial researches have pronounced that the Omicron version elevated hospitalisation for COVID-19 sufferers in South Africa, which may be associated with COVID-19 complications. In addition, it remains uncertain as to whether or not the Omicron version might also additionally sell different variants, which includes the Delta version, thereby suggesting that in addition research might be wanted for complete clarification.
Q. Is there any impact of the Omicron variant on the COVID-19 severity in cancer patients?
A. Previous studies have stated that the Delta variant or other variants can sometimes increase the severity of COVID-19 in cancer patients. COVID-19 has been reported to promote cell senescence and oxidative stress, which is linked to complications of COVID-19 in cancer patients. Additionally, various studies have reported that COVID-19 can cause increased cytokine secretion, which is linked to the aggressiveness of COVID-19. However, more studies are needed to better understand the impact of the Omicron variant in cancer patients.
Q. Is the Omicron variant having an effect on monoclonal antibody treatments?
A. There is currently no virus-specific data available to determine whether monoclonal antibody treatments will continue to be effective against the Omicron variant. Based on data from other variants with significantly fewer changes in the RBD, the Omicron variant is expected to remain susceptible to some monoclonal antibody treatments, while others may be less effective.
Q. How is India responding?
A. The Indian government is monitoring the situation closely and issuing appropriate guidelines from time to time. Meanwhile, the scientific and medical community is prepared for the development and implementation of diagnostics, genomic surveillance, generation of evidence on viral and epidemiological characteristics, and development of therapies.
3. SARS-CoV-2 surveillance in India
Q. What is INSACOG?
A. The Indian SARS-CoV-2 Genomics Consortium (INSACOG) is a national multi-agency consortium of Regional Genome Sequencing Laboratories (RGSLs) established by the Government of India on 30th December 2020. Initially, this consortium had 10 laboratories. Subsequently, the scope of laboratories under INSACOG was expanded and at present there are 28 laboratories under this consortium, which monitor the genomic variations in SARS-CoV-2.
Q. What is the objective of INSACOG?
A. The SARS-CoV-2 virus, commonly known as COVID-19 virus, posed unprecedented public health challenges globally. To fully understand the spread and evolution of this virus, its mutations and resulting variants, the need for in-depth sequencing and analysis of the genomic data was felt. Against this backdrop, INSACOG was established to expand whole genome sequencing of SARS-CoV-2 virus across the nation, aiding understanding of how the virus spreads and evolves. Any changes to the genetic code, or mutations in the virus, can be observed based on the analysis and sequencing of samples done in the laboratories under INSACOG. INSACOG has the following specific objectives:
- To ascertain the status of variants of interest (VoI) and variants of concern (VoC) in the country
- To establish sentinel surveillance and surge surveillance mechanisms for early detection of genomic variants and assist in formulating effective public health response
- To determine the presence of genomic variants in samples collected during superspreader events and in areas reporting increasing trend of cases/deaths, etc.
Q. When did India start SARS-CoV-2 viral sequencing?
A. India started sequencing SARS-CoV-2 viral sequencing of genomes in 2020. Initially, National Institute of Virology (NIV) and Indian Councilof Medical Research (ICMR) sequenced samples of international passengers who arrived in India from the UK, Brazil or South Africa or transited through these countries, which reported a sudden surge in cases. RTPCR positive samples from states reporting sudden surges in cases were sequenced on priority. This was further expanded through the efforts of Council of Scientific and Industrial Research (CSIR), Department of Biotechnology (DBT) and National Centre for Disease Control (NCDC), as well as individual institutions.
The initial focus of India was on restricting the spread of global variants of concern in the country – Alpha (B.1.1.7), Beta (B.1.351) and Gamma (P.1) – which had high transmissibility. The entry of these variants was carefully tracked by INSACOG. Subsequently, the Delta and Delta Plus variants were also identified based on whole genome sequencing analysis conducted in the INSACOG laboratories.
Q. What is the strategy for SARS-CoV-2 surveillance in India?
A. Initially, genomic surveillance was focused on the variants carried by international travellers and their contacts in the community through sequencing three to five per cent of the total RTPCR positive samples.
Subsequently, the sentinel surveillance strategy was also communicated to the States/UTs in April 2021. Under this strategy, multiple sentinel sites are identified to adequately represent the geographic spread of a region, and RT-PCR positive samples are sent from each sentinel site for whole genome sequencing. Detailed Standard Operating Procedures (SOPs) for sending samples from the identified sentinel sites regularly to the designated RGSLs were shared with States/UTs. The list of INSACOG RGSLs tagged to States was also communicated to the States. A dedicated nodal officer was also designated by all States/UTs for coordinating the activity of whole genome sequencing.
- Sentinel Surveillance (for all States/UTs/): This is an ongoing surveillance activity across India. Each State/UT has identified sentinel sites (including RT-PCR labs and tertiary health care facilities) from where RT-PCR positive samples are sent for whole genome sequencing.
- Surge Surveillance (for districts with COVID-19 clusters or those reporting a surge in cases): A representative number of samples (as per the sampling strategy finalised by a state surveillance officer/central surveillance unit) are collected from the districts, which show a surge in the number of cases and are sent to RGSLs.
Q. What is the standard operating procedure (SOP) for sending samples to INSACOG laboratories?
A. The SOPs for sending samples to INSACOG laboratories and subsequent action based on genome sequencing analysis are as follows:
- The Integrated Disease Surveillance Project (IDSP) machinery coordinates sample collection and transportation from the districts/sentinel sites to RGSLs. The RGSLs are responsible for genome sequencing and identification of VoCs/VoIs, potential VoIs, and other mutations. Information on VOCs/ VOIs is submitted to the Central Surveillance Unit, IDSP, to establish clinico-epidemiological correlation in coordination with state surveillance officers.
- Based on discussions in the Scientific and Clinical Advisory Group (SCAG) established to support the INSACOG, it was decided that upon identification of a genomic mutation, which could be of public health relevance, RGSL will submit the same to SCAG. SCAG discusses the potential VoIs and other mutations and, if felt appropriate, recommends to the Central Surveillance Unit for further investigation.
- The genome sequencing analysis and clinico-epidemiological correlation established by IDSP is shared with MOH&FW, ICMR, DBT, CSIR and States/UTs for formulating and implementing requisite public health measures.
- The new mutations/VoCs are cultured, and genomic studies are undertaken to see the impact on vaccine efficacy and immune escape properties.
Website link:
https://dbtindia.gov.in/pressrelease/qa-indian-sars-cov-2-genomics-consortium-insacog
4. COVID-19: Delta and Delta Plus variants
Q. Why are frequent mutations seen in SARS-CoV-2 virus? When will the mutations stop?
A. SARS-CoV-2 can mutate due to the following reasons:
- Random error during replication of virus
- Immune pressure faced by the viruses after treatments such as convalescent plasma, vaccination or monoclonal antibodies (antibodies produced by a single clone of cells with identical antibody molecules)
- Uninterrupted transmission due to lack of COVID appropriate behaviour. Here the virus finds an excellent host to grow and becomes more fit and transmissible.
The virus will continue to mutate as long as the pandemic remains. This makes it all the more crucial to follow COVID appropriate behaviour.
Q. What are variants of interest (VoIs) and variants of concern (VoCs)?
A. When mutations happen – if there is any previous association with any other similar variant, which is felt to have an impact on public health – then it becomes a variant under investigation (VuI).
Once genetic markers are identified, which can have an association with a receptor binding domain or which have an implication on antibodies or neutralising assays, we call them variants
of interest (VoIs). The moment we get evidence for increased transmission through field-site and clinical correlations, it becomes a variant of concern (VoC). VoCs are those that have one or more of the following characteristics:
- Increased transmissibility
- Change in virulence/disease presentation
- Evading diagnostics, drugs and vaccines
The first VoC was announced by the UK where it was found. Currently there are four VoCs identified by the scientists – Alpha, Beta, Gamma and Delta.
Q. What are Delta and Delta Plus variants?
A. These are the names given to variants of SARS-CoV-2 virus, based on the mutations found in them. The World Health Organization (WHO) has recommended using letters of the Greek Alphabet, i.e., Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), Delta (B.1.617), etc., to denote variants, for easier public understanding.
Delta variant, also known as SARS-CoV-2 B.1.617, has about 15-17 mutations. It was first reported in October 2020. More than 60 per cent of cases in Maharashtra in February 2021 pertained to Delta variants.
It is the Indian scientists who identified the Delta variant and submitted it to the global database. The Delta variant is classified as a VoC and has now spread to 80 countries, as per the WHO.
The Delta variant (B.1.617) has three subtypes B1.617.1, B.1.617.2 and B.1.617.3, of which B.1.617.1 and B.1.617.3 have been classified as VoI, while B.1.617.2 (Delta Plus) has been classified as a VoC.
Compared to the Delta variant, the Delta Plus variant has an additional mutation. This mutation is called the K417N mutation. ‘Plus’ means an additional mutation has happened to the Delta variant. It does not mean that the Delta Plus variant is more severe or highly transmissible than the Delta variant.
Q. Why has the Delta Plus variant (B.1.617.2) been classified as a VoC?
A. It has been classified as a VoC because of the following characteristics:
- Increased transmissibility
- Stronger binding to receptors of lung cells
- Potential reduction in monoclonal antibody response
- Potential post vaccination immune escape
Q. How often are these mutations studied in India?
A. Indian SARS-CoV-2 Genomics Consortium (INSACOG), coordinated by the Department of Biotechnology (DBT) along with the Union Health Ministry, ICMR, and CSIR, monitors the genomic variations in SARS-CoV-2 on a regular basis through a pan-India multi-laboratory network. It was set up with 10 national labs in December 2020 and has been expanded to 28 labs and 300 sentinel sites from where genomic samples are collected. The INSACOG hospital network looks at samples and informs INSACOG about the severity, clinical correlation, breakthrough infections and re-infections.
More than 65,000 samples have been taken from states and processed, while nearly 50,000 samples have been analysed of which 50 per cent have been reported to be VoCs.
Q. On what basis are the samples subjected to genome sequencing?
A. Sample selection is done under three broad categories:
- International passengers (during the beginning of the pandemic)
- Community surveillance (where RT-PCR samples report CT value less than 25)
- Sentinel surveillance where samples are obtained from labs (to check transmission) and hospitals (to check severity)
When there is any public health impact noticed because of genetic mutation, then the same is monitored.
Q. What is the trend of VoCs circulating in India?
A. As per the latest data, 90 per cent of samples tested have been found to have Delta variants (B.1.617). However, B.1.1.7 strain, which was the most prevalent variant in India in the initial days of the pandemic, has decreased.
Why is action regarding public health not taken immediately after noticing mutations in the virus?
A. . It is not possible to say whether the mutations noticed will increase transmission. Also, until there is scientific evidence that proves a correlation between the rising number of cases and variant proportion, we cannot confirm there is a surge in the particular variant. Once mutations are found, it is analysed every week to find out if there is any such correlation between the surge of cases and variant proportion. Public health action can be taken only if scientific proofs for such correlation are available.
Once such correlation is established, it will help greatly to prepare in advance when such a variant is seen in another area/region.
Q. Do Covishield and Covaxin work against the variants of SARS-CoV-2?
A. Yes, Covishield and Covaxin are both effective against the Alpha, Beta, Gamma and Delta variants. Lab tests to check vaccine effectiveness on Delta Plus variants are ongoing.
Delta Plus variants: The virus has been isolated and is now being cultured at ICMR’s National Institute of Virology, Pune. Laboratory tests to check vaccine effectiveness are ongoing and the results will be available in 7 to 10 days. This will be the first result in the world.
Q. What are the public health interventions being carried out to tackle these variants?
A. The public health interventions needed are the same, irrespective of the variants. The following measures are being taken:
- Cluster containment
- Isolation and treatment of cases
- Quarantining of contacts
- Ramping up vaccination
Q. Do public health strategies change as the virus mutates and more variants arise?
A. No, public health prevention strategies do not change with variants.
Q. Why is continuous monitoring of mutations important?
A. Continuous monitoring of mutations is important to track potential vaccine escape, increased transmissibility and disease severity.
Q. What does a common man do to protect self from these VoCs?
A. One must follow COVID appropriate behaviour, which includes wearing a mask properly, washing hands frequently and maintaining social distancing. The second wave is not over yet. It is possible to prevent a big third wave provided individuals and society practice protective behaviour. Further, test positivity rate must be closely monitored by each district. If the test positivity goes above 5 per cent, strict restrictions must be imposed.
Source:
https://pib.gov.in/PressReleseDetailm.aspx?PRID=1730875
5. COVID-19 vaccination for pregnant women
Q. Why is COVID-19 vaccine being recommended for pregnant women?
A. Pregnancy does not increase the risk to COVID-19 infection. Most pregnant women will be asymptomatic or have mild disease, but their health may deteriorate rapidly and that might affect the foetus too. It is important that they take all precautions to protect themselves from COVID-19, including taking the vaccination against the same. It is, therefore, advised that a pregnant woman should take the COVID-19 vaccine.
Q. Who are at higher risk of getting infected with COVID-19?
A. Higher risk of infection involves with:
- A healthcare worker or a frontline worker
- A community with high or increasing rate of COVID-19 infections
- Those frequently exposed to people outside the household
- Those who have difficulty in complying with social distance if living in a crowdedhousehold
Q. How does COVID-19 affect the health of a pregnant woman?
A. Although most (>90 per cent) infected pregnant women recover without hospitalization, rapid deterioration in health may occur in a few. Symptomatic pregnant women appear to be at increased risk of severe disease and death. In severe disease, like all other patients, pregnant women may also need hospitalisation. Pregnant women with underlying medical conditions, for example, high blood pressure, diabetes, obesity, and age over 35 years are at higher risk of severe illness due to COVID-19.
Q. How does COVID-19 infection of pregnant women affect the baby?
A. Most (over 95 per cent) of newborns of COVID-19 positive mothers have been in good condition at birth. In some cases, COVID-19 infections in pregnancy may increase the possibility of a premature delivery; the baby’s weight may be less than 2.5 kg; and in rare situations, the baby might die before birth.
Q. Which pregnant women are at a higher risk of developing complications after COVID-19 infection?
A. Pregnant women who are:
- Older than 35 years of age
- Obese
- Have an underlying medical condition such as diabetes or high blood pressure
- Have a history of clotting in the limbs
Q. If a pregnant woman has already had COVID-19, when should she be vaccinated?
A. In case a woman is infected with COVID-19 during the current pregnancy, then she should be vaccinated soon after the delivery
Q. Are there any side effects of the COVID-19 vaccines that can either harm the pregnant woman or her foetus?
A. The available COVID-19 vaccines are safe and the vaccination protects pregnant women against COVID-19 like other individuals. Like any medicine a vaccine may have side effects, which are normally mild. After getting the vaccine, she can get mild fever, pain at the injection site, or feel unwell for 1-3 days. The long-term adverse effects and safety of the vaccine for the foetus and the child born is not established yet. Very rarely, (one in one to five lakh people) the beneficiary may, after the COVID-19 vaccination, experience some of the following symptoms within 20 days after getting the injection, which may need immediate attention.
Q. When should the vaccine be given to the pregnant woman?
A. The COVID-19 vaccination schedule can be started any time during pregnancy.
Q. What other precautions should the pregnant woman take after vaccination?
A. Counsel the pregnant woman and her family members to continue to practice COVID appropriate behaviour: wearing double masks, frequent hand washing, maintaining physical distance, and avoiding crowded areas, to protect themselves and those around from spreading the COVID-19 infection.
Q. How does a pregnant woman register herself for the Covid-19 vaccination?
A. . All pregnant women need to register themselves on the Co-WIN portal or may get themselves registered on-site at the COVID-19 vaccination centre. The process of registration for pregnant women remains the same as of the general population and as per the latest guidelines provided by the Ministry of Home and Family Welfare (MoHFW) from time to time.
Source:
https://www.mohfw.gov.in/pdf/OperationalGuidanceforCOVID19vaccinationofPregnantWoman.pdf
6. COVID-19 & Children
Q. What is the possibility of a third wave of COVID-19 in the coming months?
A. Pandemics are likely to occur in multiple waves, and each wave could vary in the number of cases and its duration. Eventually, most of the population may get immune by asymptomatic or symptomatic infections (herd immunity). Over time, the disease may die out or may become endemic in the community with low transmission rates.
Key Message: There is a possibility of a third wave, but it is difficult to predict its timing and severity.
Q. Are children at greater risk if the third wave strikes?
A. In the first wave, primarily the elderly and individuals with co-morbidities were affected with severe disease. In the current (second) wave, a large number of younger population (30-45 years) have developed severe disease as also those without co-morbidities. After the second wave is over, if we do not continue following COVID appropriate behaviour, the third wave, if it occurs, is likely to infect the remaining non-immune individuals and that may include children also. The latest sero survey (December 2020 to January 2021) showed that the percentage of infected children in the age group of 10-17 years was around 25 per cent, the same as adults. This indicates that while children are being infected like adults, they are not getting the severe disease.
Key Message: Children are as susceptible as adults and older individuals to develop an infection but not a severe disease. It is highly unlikely that the third wave will predominantly or exclusively affect children.
Q. Are children likely to suffer from severe disease as being witnessed in the adult population in the current wave?
A. Fortunately, children have been relatively less affected so far due to several factors. The most important reason is the lesser expression of specific receptors to which this virus binds to enter the host and also the immune system of the children. A very small percentage of infected children may develop moderate to severe disease. If there is a massive increase in the overall numbers of infected individuals, a larger number of children with moderate to severe disease may be seen. Apart from the infection, parents should watch out for mental health issues in children and keep a watch to prevent child abuse and violence. Also, it is worth limiting screen time and prepare children for safe school reopening as per the Indian Academy of Pediatrics (IAP) guidelines.
Key Message: Almost 90 per cent of the infections in children are mild/asymptomatic. Therefore, the incidence of severe disease is not high in children.
Q. Can we rule out the possibility of severe infections in children in the third wave?
A. As explained, the spectrum of illness is likely to be much less severe in children than adults; there is only a remote possibility of children being more severely affected than adults in the next wave. As per data collected during the first and second waves, severe COVID-19 infections in children were not reported and only in few cases they were admitted to ICU. However, we need to be watchful about how the mutant strains will behave. The dictum here is: better be ready and prepared for the worst and hope for the best!
Key Message: Severe COVID-19 cases in children are rare. Further, there is no evidence indicating that children will have severe disease in the third wave.
Q. Severe disease due to COVID-19 is already occurring in children. Why it is so?
A. Yes, a severe illness related to COVID-19 is known to occur in children. This includes pneumonia and multisystem inflammatory syndrome in children (MIS-C). However, COVID-19 pneumonia in children is uncommon as compared to adults. In some cases, after 2-6 weeks of asymptomatic or symptomatic COVID-19 infection, MIS-C may be seen due to immune dysregulation with the incidence of 1-2 cases per 100,000 population; some of these cases also may be severe. It’s a treatable condition with a good outcome if diagnosed early. Also, most children suffering from MIS-C cannot transmit the infection to others.
Key Message: Children occasionally get the severe disease and may need ICU care, both during the acute illness and after 2-6 weeks due to MIS-C caused by COVID-19. But the majority are likely to recover if treated on time.
Q. What preparations are being made in case the third wave comes and affects the children?
A. Most affected children get a mild disease with fever and need supervised home care with monitoring. We have learned a lot about COVID-19 illness from our shared experiences in adult medicine in the last 15 months. IAP guidelines on the management of COVID-19 in children are in place, and paediatricians have been sensitised and trained on its management. We need to be ready for a more significant number of patients seeking consultations; educating the parents on different platforms regarding illness and warning signs; and arranging more COVID-19 wards for children with more special wards such as high-dependency units (HDUs) and intensive care units (ICUs). The preventive behaviours are the same for children. Parents should also be ideal role models for their children regarding mask etiquette, hand hygiene, and social distancing. Children above the age of two to five years can be trained to use a mask; however, the adults have to follow the COVID-appropriate behaviour. IAP has also set guidelines for the safe reopening of schools for the safety of the children.
Key Message: We need to be prepared with more in-patient beds and intensive care beds for children. IAP has already developed the management protocol for disease categories in children. There is no reason to panic. Our preparations are in full swing.
Q. What is the plan for vaccinating children?
A. So far, the global data show that compared to children, older adults are a thousand times more likely to die from COVID-19 disease. So, it has been a priority to vaccinate the high-risk elderly age group first. Thereafter, the emphasis should be on adults who also have more severe diseases as compared to children. When there is the remote possibility of children getting affected, some countries consider vaccinating children and adolescents. The same vaccines being used in adults can be used in children only after adequate trials. One of the India-made vaccines will soon undergo trials in children, and if proven immunogenic and safe, it could be fast-tracked for mass vaccination in children.
Key Message: Children do get the severe disease, even if the number is small. Thus, there is no harm in considering vaccination for them. The safety and efficacy, however, are being assessed in trials for this age. The national expert group on vaccine administration for COVID-19 will develop a plan as and when new scientific data emerge.
7. COVID-19 & White Fungus infection
Q. What is White Fungus?
A. White Fungus, also known as candidiasis, is an opportunistic infection, which could spread fast to various body parts and, if not treated, could be serious. According to the Centre for Diseases Control and Prevention (CDC), White Fungus or invasive candidiasis can affect the blood, heart, brain, eyes, bones, or other parts of the body.
Q. Who are at high risk to get White Fungus infection?
A. White Fungus is all around us as it is found naturally in the environment. It primarily affects people with low immunity, who come in contact with objects that contain these fungal spores. For instance, COVID-19 patients on oxygen support can come in contact with these fungal spores if their ventilators and oxygen support equipment are not sanitised properly. Further, overuse of steroids and use of tap water in the humidifier attached to an oxygen cylinder can also heighten the risk of contracting White Fungus.
Q. Who can get infected by white fungus?
A. . Invasive candidiasis is caused by a yeast (a type of fungus) called Candida. Candida can normally live inside the body, in areas like the mouth, throat, gut, and vagina, without causing any problems. However, individuals with low immunity, like patients recovering from a serious COVID-19 infection, are particularly at risk of contracting this fungal infection. In their bodies, the fungus can enter the bloodstream or internal organs to cause an infection.
People who are at high risk for developing this infection include those who:
- Have been admitted in the intensive care unit (ICU) for a prolonged period.
- Have weakened immune system (for example, people on cancer chemotherapy, people
- who have had an organ transplant, and people with low white blood cell counts).
- Have recently had surgery, especially multiple abdominal surgeries.
- Have recently received lots of antibiotics or steroids in the hospital.
- Receive total parenteral nutrition (food through a vein).
- Have kidney failure or are on hemodialysis.
- Have diabetes.
- Have a central venous catheter.
Q. Is White Fungus contagious?
A. . White Fungus is not contagious in most cases, as it cannot spread directly from person to person. However, there exist some species of fungus that cause this infection on the skin. In such instances of external infection, the fungus can possibly be transferred from the patient to another individual who is at risk.
Q. What are the symptoms of White Fungus?
A. Only CT scans or X-rays can reveal and completely confirm the White Fungus infection. Health experts report that it is more dangerous than Black Fungus, as it affects the lungs as well as other parts of the body like the nails, skin, stomach, kidney, brain, private areas, and mouth.
Moreover, the White Fungus can also infect the lungs the same way COVID-19 does. In fact, patients who get infected with White Fungus displayed COVID-19-like symptoms despite having tested negative for the virus. According to some reports, the oxygen saturation level of one of the four patients infected with White Fungus dropped from normal levels. However, the oxygen levels became normal after the antifungal medication was administered.
Q. How can White Fungus be treated?
A. Patients infected with White Fungus should be examined carefully, perhaps with a fungus culture test of their phlegm or mucus, to detect the extent of fungal infection in their body. After detection of the infection, antifungal medications can be used to treat the patients. Such medications have led to an improvement in their condition. The type and dose of antifungal medication used to treat White Fungus will depend on the patient’s age, immune status, location, and severity of the infection.
8. COVID-19 & Use of oxygen
Q. What is the normal respiratory rate of a healthy adult person?
A. Standard respiratory rates for a healthy adult range from 12 to 20 breaths per minute.
Q. Are 8 breaths per minute normal?
A. No. A patient needs to be evaluated medically
Q. How many litres of oxygen per minute do we breathe?
A. The average tidal volume, i.e., the average amount of air inhaled and exhaled per breathing cycle, is 0.5 litre (500 ml). Minute Ventilation (VE) is the total volume of air entering the lungs in a minute, which is 6 litres per minute.
Q. What should be the normal oxygen saturation as recorded by a Pulse Oximeter?
A. The normal oxygen saturation level in the blood (SpO2 ) should be 95 per cent or higher. Some people with chronic lung disease, such as Chronic Obstructive Pulmonary Disease (COPD) or sleep apnea, may have normal levels of around 90 per cent. The ‘SpO2 ’ reading on a pulse oximeter shows the percentage of oxygen in the blood. If your home SpO2 reading is lower than 94 per cent, call your healthcare provider.
How do I check my oxygen level at home without a Pulse Oximeter?
A. If you do not have a portable finger pulse oximeter in your home, you can also learn how to assess signs and symptoms of low oxygen levels. Two classic signs of a low oxygen level are a rapid heart rate and a fast breathing rate. An average heart rate is 60–100 beats per minute and an average breathing rate is 12–20 breaths per minute. However, under low oxygen conditions, body responses include an increase in heart rate and breathing rate. Another sign of a low blood oxygen level is cyanosis or a bluish colour change on your lips, nose, or fingertips. As your body loses oxygen, the blood cells in your body change colour in your bloodstream to a dark blue, which can be seen from the outside of your skin if it is severe. Cyanosis is typically a late sign of low oxygen levels and is considered a medical emergency. If you notice this bluish discolouration, you should immediately visit the nearest hospital.
Q. Do we see many cases of silent hypoxia in this wave? How can this be addressed?
A. Silent hypoxia or happy hypoxia is referred to as the early stage of COVID-19. As the oxygen level drops, one may start feeling shortness of breath, confusion, and other symptoms. Keep watching for these signs and do not ignore them. This is true for young people as well. If you monitor low oxygen level, change in lip colour from natural to blue or persistent sweating, consult the COVID helpline or doctor. They could be the early sign of silent hypoxia.
Q. In brief, how can proning help enhance blood oxygen levels?
A. Proning is a medically accepted process to improve the distribution and exchange of oxygen in the lungs. A patient is safely placed from their back onto their abdomen (stomach), i.e., face down to improve breathing and oxygenation. It has been shown as beneficial for COVID-19 patients with compromised breathing comfort, especially during home isolation.
Q. Is pure oxygen used in hospitals?
A. Medical oxygen contains high purity oxygen used for medical treatments and is developed for use in human body. Cylinders contain a compressed oxygen gas and no gases are allowed in the cylinder to prevent contamination.
Q. What is the use of medical oxygen?
A. Oxygen is used for treatment in hospitals. Hence, it is considered a drug or a pharmaceutical product.
Q. What is the need for medical oxygen?
A. The human body requires oxygen to survive, and typically, we breathe in from air. However, if you have lung disease or other medical conditions such as COVID-19, you may not get enough oxygen due to compromised lungs. That can leave you short of breath and cause problems with your heart, brain, and other parts of your body
Q. Can breathing 100 per cent oxygen harm your body?
A. Yes. Breathing 100 per cent oxygen also eventually leads to collapse of the alveoli (atelectasis).
Q. Can you get excess (more than required) oxygen from an oxygen concentrator?
A. It is possible to get excess (more than required) oxygen from an oxygen concentrator. However, this is quite rare when oxygen concentrators are used as directed and prescribed. All supplemental oxygen requires a prescription from a doctor, who carefully chooses your oxygen requirement.
Q. What is the role of oxygen during COVID-19 disease?
A. The demand for medical oxygen increases in COVID-19 as the disease primarily affects the lungs and, in severe cases, causes death due to Acute Respiratory Distress Syndrome (ARDS) and pneumonia.
Q. When does a patient require medical oxygen in a COVID-19 positive case?
A. As per AIIMS/ICMR-Covid-19/National Task Force/Joint Monitoring Group (Dte.GHS), MoHFW, Government of India, Clinical Guidelines for Management of Adult COVID-19 Patient issued on 22nd April 2021, moderate and severe cases of COVID-19 where the infection induces shortage of oxygen in the body due to its impact on lungs require medical oxygen and immediate oxygen therapy. Oxygen acts as a life-saver for COVID-19 patients.
Q. What are moderate COVID-19 cases?
A. In moderate COVID-19 cases, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration
Q. What is severe COVID-19 cases?
A. In severe COVID-19 case, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than 30/minute and SpO2 less than 90 per cent in room air.
Q. When does a patient require mechanical ventilator support?
A. A patient may be put on a mechanical ventilator if it becomes very difficult to breathe or get enough oxygen into their blood. This condition is called respiratory failure. Mechanical ventilators are machines that act as bellows to move air in and out of the patient’s lungs. The respiratory therapist and doctor set the ventilator to control how often it pushes air into the lungs and how much air the patient gets. The patient may be fitted with a mask to get air from the ventilator into the lungs. Or, they may need a breathing tube if their breathing problem is more serious.
Q. Can mechanical ventilation be given at home?
A. Mechanical ventilators are mainly used in hospitals and transport systems such as ambulances and medical evacuation by air transport, etc. In some cases, they can be used at home if the illness is long-term and the caregivers at home receive training and have adequate nursing and other resources at home. Being on a ventilator may make a patient more susceptible to pneumonia, damage to the vocal cords, or other problems.
Q. What is the six minute walk test for COPD?
A. The six minute walk test (6MWT) is an exercise test that measures functional status in chronic obstructive pulmonary disease (COPD) patients and provides information on oxygen desaturation. This test is also being used for COVID-19. In case of COVID-19 symptoms, SpO2 level must be checked before taking a walk. Now, walk for six minutes without a break on an even surface and measure the SpO2 level. It may fall 1-2 per cent, but consult a medical professional if it falls below 93 per cent.
Source:
https://ndma.gov.in/sites/default/files/2021-03/FAQs-on-Use-of-oxygen-.pdf
9. COVID-19 & Therapeutics
Q. Is Remdesivir effective in the treatment of COVID-19?
A. No study has conclusively been able to prove that Remdesivir is beneficial in the treatment of COVID-19. However, India has approved Remdesivir under the National Clinical Management Protocol for COVID-19, which was developed after many interactions by a committee of experts. The protocol acts as the guiding document for the treatment of COVID-19 patients in India. Remdesivir is listed as an investigational therapy in the protocol, i.e., where informed and shared decision-making is essential, besides noting contraindications mentioned in the detailed guidelines.
Q. What is Remdesivir? How does Remdesivir work?
A. Remdesivir is an investigational drug used to treat viral infections. It is classified as a broadspectrum antiviral with potential antiviral activity against a variety of RNA viruses.
The drug works against the novel coronavirus by inhibiting replication of the virus in the body. Remdesivir functions as a pro-drug that is modified in the body before it becomes an active drug. It is classified as a nucleoside analog, one of the oldest classes of antiviral medications, and resembles the RNA base adenosine. In general, nucleoside and nucleotide analogues simulate the structure of a true nucleoside or nucleotide. The simulated structure may then be incorporated into the virus. Remdesivir works when the enzyme replicating the genetic material for the novel coronavirus − RNA polymerase − incorporates the adenosine analogue in place of the natural molecule into the growing RNA strand. By introducing the modified agent, Remdesivir, replication of the novel coronavirus is interrupted, and the virus ceases to multiply and cannot infect more cells in the body.
Q. When should a patient of COVID-19 take Remdesivir?
A. The timing of the drug, when it is administered, is most important. Taking it too early or too late could do more harm than good. Remdesivir is applicable only in hospitalised patients who showed very low oxygen saturation and infiltrated their chest X-ray or CT scan. The optimal timing for Remdesivir is usually after five to seven days of having the virus. Early to mild or asymptomatic patients should not take Remdesivir. Also, it is of no use if it’s given very late because it would create a cytokine storm. A cytokine storm is when the immune system goes into overdrive. The body starts to attack its cells and tissues instead of just the virus.
Q. Can Remdesivir be taken at home?
A. Remdesivir comes in a vial and has to be injected only after prescription and in the presence of a health practitioner. It is for patients who are hospitalised and severe. Therefore, it should not be given at home. It is for patients who need to be admitted and need hospital care.
Q. Are steroids effective in the treatment of COVID-19?
A. There is no evidence to support the use of steroids in the treatment of COVID-19. The World Health Organization (WHO) recovery trial showed that steroids do have a beneficial effect. But again, the timing is critical. The recovery trial clearly showed that if we give steroids too early, it showed a harmful effect before oxygen saturation. Steroids are most effective during the later part of the disease when there is more inflammation and oxygen saturation is falling. Steroids are only helpful for moderate or severe cases.
Q. Is plasma a good way to fight off COVID-19?
A. Convalescent plasma has been a therapy devised to passively transfer antibodies from a recovered person to a new patient. While the therapy has been received with different opinions by the medical community, the important aspect is timing. It’s better if plasma therapy is used early before clinical worsening. Also, plasma with high titer neutralising antibodies would have better results. Hence, to achieve good results, correct patient selection, timing and a good quality plasma donor are needed for success in this form of treatment.
Q. Should a person with COVID-19 take Tocilizumab?
A. Tocilizumab is a drug of last resort. It should only be used when a COVID-19 infection in a patient is worsening despite steroids, Remdesivir and other treatments like anticoagulants. Tocilizumab is required in less than 2 per cent of COVID-19 patients. Very few patients need this drug because it’s only for treating a cytokine storm and has a limited role.
Q. Is Favipiravir effective in treating COVID-19?
A. Favipiravir is another antiviral that is being promoted for the treatment of COVID-19. It was initially doled out as a treatment of influenza after the H1N1 pandemic. There is not enough evidence in robust studies to show that it is a good drug. Since it’s not a proven treatment, India’s national guidelines also don’t recommend its use.
Q. Is it possible to treat COVID-19 without any of the drugs mentioned above?
A. People with mild COVID-19 or those who are asymptomatic will improve with just symptomatic treatment. Mild COVID-19 infection can be treated with paracetamol, good hydration and multivitamins − without any treatment. Giving treatment when it is not required may be doing more harm than good.
10. COVID-19 & Black Fungus Disease
Q. What is Black Fungus?
A. Black Fungus, also known as mucormycosis, is a rare fungal infection. It is called ‘black’ because of the colour of the fungal growth. It is caused by exposure to mucor mold found in soil, manure, and rotten/decaying fruits and vegetables. It is ubiquitous and even present in the nose/mucosa of healthy individuals. This disease usually affects the sinuses, eye orbit, and brain. That is why it is also called ‘rhino-orbital-cerebral’ mucormycosis. It may be life-threatening in immuno-compromised individuals (cancer patients, HIV/AIDS) and people with uncontrolled diabetes.
Q. What are the risk factors for acquiring Black Fungus infection?
A. Risk Factors are:
- Uncontrolled Diabetes Mellitus
- Treated for COVID-19 with corticosteroids
- Treated for COVID-19 with immunomodulators
- Treated for COVID-19 with mechanical ventilation
- Prolonged oxygen therapy
- Prolonged ICU stay
- Immuno-compromised state
Q. Why the sudden increase in Black Fungus cases?
A. It may be triggered by extensive use of steroids, which is a life-saving treatment for moderate to severe COVID-19 infection. Steroids lower the immunity and cause a sudden up-shooting of blood sugar levels in diabetes and non-diabetic patients. For patients on humidified oxygen, care should be taken to make sure there is no water leak to prevent the growth of the fungus.
Q. How serious is Black Fungus?
A. Black fungus infection causes a vision-threatening and life-threatening condition.
Q. Do all COVID-19 patients need to be worried about Black Fungus infection?
A. No. As discussed, high-risk patients need to be alert. Also, during COVID-19 recovery, everyone should watch out for early signs and symptoms.
Q. What are the precautions one can take to avoid this disease?
A. One can take the following precautions:
- Boost immune system with diet, hydration and exercise.
- Rational use of steroids by follow guidelines.
- Strict blood sugar monitoring and control in all patients who are on steroids.
Q. What are the early signs of Black Fungus?
A. Some of the early signs are:
- Facial pain
- Facial swelling/puffiness/discolouration
- Sinus headache
- Stuffy nose
- The blurring of vision/decreased vision
- Double vision
- Drooping of eyelid
- Blood-stained nasal discharge
- Dental pain
Q. Is Black Fungus treatable?
A. Yes. Early diagnosis and a prompt multi-speciality team of medical professionals can manage it.
Q. Which specialist should I visit for Black Fungus?
A. ENT and eye specialists are central to this disease. The team includes care coordination with neurosurgeon, endocrinologist and microbiologist.
Source:
https://www.eyeqindia.com/frequently-asked-questions-on-covid-and-black-fungus/#toggle-id-9
11. COVID-19 & Indoor Air
Q. Will running an evaporative cooler help protect my family and me from COVID-19?
A. Evaporative coolers (or ‘swamp coolers’) can help protect people indoors from the airborne transmission of COVID-19 because they increase ventilation with outside air to cool indoor spaces. Evaporative coolers are used in dry climates. They use water to provide cooling and improve relative humidity in indoor microenvironments. When operating as intended (with open windows), these devices produce substantial increases in ventilation with outdoor air. Some evaporative coolers can be performed without using water when temperatures are milder to increase ventilation indoors. Avoid using evaporative coolers if air pollution outside is high and the system does not have a high-efficiency filter.
Q. Is ventilation important for indoor air quality when cleaning and/or sanitising for COVID-19 indoors?
A. When cleaning and disinfecting for COVID-19, ventilation is essential − in general, increasing ventilation during and after cleaning helps to reduce exposure to cleaning and disinfection products and by-products. Increasing ventilation, for example, by opening windows or doors, can also reduce risks from particles resuspended during cleaning, including those potentially carrying SARS-CoV-2 (or other contaminants). Avoid ventilation with outdoor air when outdoor air pollution is high or when it makes your home too cold, hot, or humid.
Q. Will an air cleaner or air purifier help protect my family and me from COVID-19 in my home?
A. When appropriately used, air purifiers can help reduce airborne contaminants, including viruses, in a home or confined space.
Q. How can I increase ventilation at home to help protect my family from COVID-19?
A. Ensuring proper ventilation with outside air is a standard best practice for improving indoor air quality. To increase ventilation in your home, one can:
- Open the windows or screened doors, if possible;
- Operate an air conditioner that has an outdoor air intake or vent; and
- Operate a bathroom fan when the bathroom is in use and continuously, if possible.
However, the practices mentioned here are not enough to protect people from COVID-19. When used along with other best practices recommended by the Ministry of Health and Family Welfare, Government of India, the above methods can be part of a plan to protect yourself and your family.
Source:
https://www.epa.gov/coronavirus/indoor-air-and-coronavirus-covid-19
1. COVID-19 & Cancer
Q. Should patients with cancer receive the COVID-19 vaccine?
A. The data on efficacy and safety of COVID-19 vaccination in patients with cancer is limited. However, as patients with cancer are more prone to contract a severe form of illness due to COVID-19 infection, the benefits of getting vaccinated are more than the risks.
Q. Should people who have completed their treatment for cancer receive the COVID-19 vaccine?
A. Patients who have completed their treatment for cancer should receive the COVID-19 vaccine as soon as it is available to them as long as there are no major allergies.
Q. What does it mean to be immune-compromised?
A. 'Immune compromised' refers to individuals whose immune system is considered weaker, more impaired, or less robust than that of the average healthy adult. The primary role of the immune system is to help fight off infection. Individuals with compromised immune systems are at a higher risk of getting infections, including viral infections such as COVID-19. There are many reasons that a person might be immune-compromised. Health conditions such as cancer, diabetes, or heart disease, older age, or lifestyle choices such as smoking can all contribute to weakened immune systems.
Q. Does receiving chemotherapy or radiation raise your risk of getting COVID-19 or having a more serious course of illness?
A. To date, limited evidence is available to suggest that any cancer treatment raises your risk for getting COVID-19 any more or less than anyone else who is exposed to the virus. There is some evidence that patients with cancer may experience more serious COVID-19 infection if they acquire it, more so because cancer and cancer treatment can contribute to weakened immune systems, which can then lead to a reduced ability to fight off infections. It is not clear at this point if cancer patients who have received chemotherapy or radiation in the past are at increased risk for COVID-19. The risk of infection may depend, in part, on the specific treatment received, the type of cancer treated, and how much time has passed since the treatment was completed.
Q. Should people who are on cancer-directed therapy receive the COVID-19 vaccine?
A. 'Immune compromised' refers to individuals whose immune system is considered weaker, more impaired, or less robust than that of the average healthy adult. The primary role of the immune system is to help fight off infection. Individuals with compromised immune systems are at a higher risk of getting infections, including viral infections such as COVID-19. There are many reasons that a person might be immune-compromised. Health conditions such as cancer, diabetes, or heart disease, older age, or lifestyle choices such as smoking can all contribute to weakened immune systems.
Q. Does receiving chemotherapy or radiation raise your risk of getting COVID-19 or having a more serious course of illness?
A. To date, limited evidence is available to suggest that any cancer treatment raises your risk for getting COVID-19 any more or less than anyone else who is exposed to the virus. There is some evidence that patients with cancer may experience more serious COVID-19 infection if they acquire it, more so because cancer and cancer treatment can contribute to weakened immune systems, which can then lead to a reduced ability to fight off infections. It is not clear at this point if cancer patients who have received chemotherapy or radiation in the past are at increased risk for COVID-19. The risk of infection may depend, in part, on the specific treatment received, the type of cancer treated, and how much time has passed since the treatment was completed.
Which COVID-19 vaccine is the best for patients with cancer?
A. All the approved vaccines have been shown to be effective. There are no direct comparisons between the available vaccines for efficacy or safety. Therefore, it is suggested that you take any vaccine approved for use and available in your vaccination centre.
Q. Is there any contraindication for the COVID-19 vaccine in patients with cancer?
A. Patients who are allergic to polyethylene glycol (PEG) should not receive the COVID-19 vaccine. Individuals with a known history of polysorbate-80 allergy (used as excipient in certain chemotherapeutic drugs) should not receive COVID-19 vaccine.
Q. Should patients with a previous history of COVID-19 infection be vaccinated?
A. Yes, cancer patients who had been infected and recovered from the illness should also receive the COVID-19 vaccine as it will protect from re-infection.
Q. Should the vaccine be given to patients with positive COVID-19 antibodies?
A. The COVID-19 vaccine should be given to all patients with cancer irrespective of their antibody status. Serological testing should not be used to guide the decision and timing of vaccination.
Q. What are the side effects that may occur after the COVID-19 vaccine?
A.You may expect some minor side effects like soreness of the shoulder (injection site) for a few days after the vaccination. Also, you may have mild fever, tiredness for a day or two after the injection. Serious side effects are extremely rare, but we advise you to consult your doctor in case of any troublesome symptoms.
2. COVID-19: OMICRON Variant
Q. What is Omicron and why is it a Variant of Concern (VoC)?
A.This new variant of SARS-CoV-2, named B.1.1.529 or Omicron (based on Greek alphabets such as alpha, beta, delta, etc.) has recently been reported in South Africa. There are a large number of mutations in this variant, especially more than 30 in the viral spike protein, which is the major target for immune responses. The World Health Organization has declared Omicron as a Variant of Concern (VoC) because of the combination of mutations that previously individually have been associated with increased infectivity or immune evasion, and the sudden rise in number of positive cases in South Africa.
Q. Why is it called Omicron?
A.The WHO named the B.1.1.529 variant Omicron in the tradition of giving variants a Greek letter name.
Q. How easily does Omicron spread?
A.The Omicron variant is more likely to spread than the original SARS-CoV-2 virus. How quickly Omicron spreads, compared to Delta, is unknown. The CDC expects that anyone infected with Omicron will be able to spread the virus to others, even if they have been vaccinated or do not have symptoms.
Q. Can the currently used diagnostics methods, detect Omicron?
A.The RT-PCR method is the most widely accepted and used diagnostic method for SARSCoV-2 variant. To confirm the presence of the virus, this method detects specific genes in the virus, such as Spike (S), Enveloped (E), and Nucleocapsid (N), among others. However, because the S gene in Omicron is heavily mutated, some of the primers may produce results indicating the absence of the S gene (called S gene drop out). This specific S gene dropout, along with the detection of other viral genes, could be used as an Omicron diagnostic feature. However, genomic sequencing is required for the final confirmation of the Omicron variant.
Q. Should we be concerned about the new VoC?
A.It is important to note that Omicron has been declared as a VoC based on the observed mutations, their predicted characteristics of increased transmission and immune evasion, and preliminary evidence of a negative change in COVID-19 epidemiology, such as increased reinfections. The definitive proof of increased remission and immune evasion is still awaited.
Q. Will Omicron cause more severe illness?
A.More research is needed to determine whether Omicron infections, particularly re-infections and breakthrough infections in fully vaccinated people, cause more severe illness or death than infection with other variants.
Q. What precautions should we take?
A. Individuals can reduce the spread of the COVID-19 virus by keeping a physical distance of at least 1 metre from others, wearing a well-fitting mask, opening windows to improve ventilation, avoiding poorly ventilated or crowded spaces, keeping hands clean, coughing or sneezing into a bent elbow or tissue, and getting vaccinated when their turn comes.
Q. Will there be a third wave?
A.Cases of Omicron are increasingly being reported from countries outside of South Africa, and given its characteristics, it is likely to spread to more countries, including India. However, the magnitude and extent of the increase in cases and, more importantly, the severity of the disease that will be caused, are still unclear. In addition, given the rapid pace of vaccination in India and the high exposure to the delta variant as evidenced by the high seropositivity, the severity of the disease is expected to be low. However, the scientific evidence is still evolving.
Q. Will the existing vaccines be effective against Omicron?
A. Although there is no evidence to suggest that existing vaccines do not work on Omicron, some of the mutations reported in the Spike gene may reduce the effectiveness of existing vaccines. However, vaccine protection also involves antibodies and cellular immunity, which should be relatively better preserved. Therefore, vaccines are always expected to provide protection against serious disease, and vaccination with available vaccines is crucial. If you are eligible, but not vaccinated, you must be vaccinated.
Q. Why do variants occur?
A.Variants are an integral part of evolution and as long as the virus is able to infect, replicate, and transmit, they will continue to evolve. Also, not all variants are dangerous and most of the time we don’t notice them. It is only when they are more contagious, or can re-infect people, etc., that they gain importance. The most important step in avoiding the generation of variants is to reduce the number of infections.
Q. Is the Omicron transmission capacity higher than that for the COVID-19 Delta variant?
A. The Omicron version has raised alarm amongst epidemiologists who’re involved that the mutations within the new version ought to make it greater transmissible than the preceding variants. Further researches are being conducted to decide whether or not the Omicron version is greater transmissible than different variants, which includes the Delta version. The variety of checks for COVID-19 has been regularly growing across the world. Another extreme subject is that the Omicron version has already been detected in numerous countries, which includes Japan, Belgium, Botswana, Hong Kong, Australia, the Netherlands, South Africa, and Israel.
In addition to increasing the variety of COVID-19 checks, epigenetic researchers are urgently trying to make clear any hard elements related to the COVID-19 Omicron version. It is uncertain whether or not the Omicron version will increase COVID-19 severity. However initial researches have pronounced that the Omicron version elevated hospitalisation for COVID-19 sufferers in South Africa, which may be associated with COVID-19 complications. In addition, it remains uncertain as to whether or not the Omicron version might also additionally sell different variants, which includes the Delta version, thereby suggesting that in addition research might be wanted for complete clarification.
Q.Is there any impact of the Omicron variant on the COVID-19 severity in cancer patients?
A. Previous studies have stated that the Delta variant or other variants can sometimes increase the severity of COVID-19 in cancer patients. COVID-19 has been reported to promote cell senescence and oxidative stress, which is linked to complications of COVID-19 in cancer patients. Additionally, various studies have reported that COVID-19 can cause increased cytokine secretion, which is linked to the aggressiveness of COVID-19. However, more studies are needed to better understand the impact of the Omicron variant in cancer patients.
Q.Is the Omicron variant having an effect on monoclonal antibody treatments?
A. There is currently no virus-specific data available to determine whether monoclonal antibody treatments will continue to be effective against the Omicron variant. Based on data from other variants with significantly fewer changes in the RBD, the Omicron variant is expected to remain susceptible to some monoclonal antibody treatments, while others may be less effective.
Q. How is India responding?
A. The Indian government is monitoring the situation closely and issuing appropriate guidelines from time to time. Meanwhile, the scientific and medical community is prepared for the development and implementation of diagnostics, genomic surveillance, generation of evidence on viral and epidemiological characteristics, and development of therapies.
3. SARS-CoV-2 surveillance in India
Q. What is INSACOG?
A.The Indian SARS-CoV-2 Genomics Consortium (INSACOG) is a national multi-agency consortium of Regional Genome Sequencing Laboratories (RGSLs) established by the Government of India on 30th December 2020. Initially, this consortium had 10 laboratories. Subsequently, the scope of laboratories under INSACOG was expanded and at present there are 28 laboratories under this consortium, which monitor the genomic variations in SARS-CoV-2.
Q. What is the objective of INSACOG?
A.The SARS-CoV-2 virus, commonly known as COVID-19 virus, posed unprecedented public health challenges globally. To fully understand the spread and evolution of this virus, its mutations and resulting variants, the need for in-depth sequencing and analysis of the genomic data was felt. Against this backdrop, INSACOG was established to expand whole genome sequencing of SARS-CoV-2 virus across the nation, aiding understanding of how the virus spreads and evolves. Any changes to the genetic code, or mutations in the virus, can be observed based on the analysis and sequencing of samples done in the laboratories under INSACOG. INSACOG has the following specific objectives:
- To ascertain the status of variants of interest (VoI) and variants of concern (VoC) in the country
- To establish sentinel surveillance and surge surveillance mechanisms for early detection of genomic variants and assist in formulating effective public health response
- To determine the presence of genomic variants in samples collected during superspreader events and in areas reporting increasing trend of cases/deaths, etc.
Q. When did India start SARS-CoV-2 viral sequencing?
A.India started sequencing SARS-CoV-2 viral sequencing of genomes in 2020. Initially, National Institute of Virology (NIV) and Indian Councilof Medical Research (ICMR) sequenced samples of international passengers who arrived in India from the UK, Brazil or South Africa or transited through these countries, which reported a sudden surge in cases. RTPCR positive samples from states reporting sudden surges in cases were sequenced on priority. This was further expanded through the efforts of Council of Scientific and Industrial Research (CSIR), Department of Biotechnology (DBT) and National Centre for Disease Control (NCDC), as well as individual institutions.
The initial focus of India was on restricting the spread of global variants of concern in the country – Alpha (B.1.1.7), Beta (B.1.351) and Gamma (P.1) – which had high transmissibility. The entry of these variants was carefully tracked by INSACOG. Subsequently, the Delta and Delta Plus variants were also identified based on whole genome sequencing analysis conducted in the INSACOG laboratories.
Q. What is the strategy for SARS-CoV-2 surveillance in India?
A.. Initially, genomic surveillance was focused on the variants carried by international travellers and their contacts in the community through sequencing three to five per cent of the total RTPCR positive samples.
Subsequently, the sentinel surveillance strategy was also communicated to the States/UTs in April 2021. Under this strategy, multiple sentinel sites are identified to adequately represent the geographic spread of a region, and RT-PCR positive samples are sent from each sentinel site for whole genome sequencing. Detailed Standard Operating Procedures (SOPs) for sending samples from the identified sentinel sites regularly to the designated RGSLs were shared with States/UTs. The list of INSACOG RGSLs tagged to States was also communicated to the States. A dedicated nodal officer was also designated by all States/UTs for coordinating the activity of whole genome sequencing.
- Sentinel Surveillance (for all States/UTs/): This is an ongoing surveillance activity across India. Each State/UT has identified sentinel sites (including RT-PCR labs and tertiary health care facilities) from where RT-PCR positive samples are sent for whole genome sequencing.
- Surge Surveillance (for districts with COVID-19 clusters or those reporting a surge in cases): A representative number of samples (as per the sampling strategy finalised by a state surveillance officer/central surveillance unit) are collected from the districts, which show a surge in the number of cases and are sent to RGSLs.
What is the standard operating procedure (SOP) for sending samples to INSACOG laboratories?
A. The SOPs for sending samples to INSACOG laboratories and subsequent action based on genome sequencing analysis are as follows:
- The Integrated Disease Surveillance Project (IDSP) machinery coordinates sample collection and transportation from the districts/sentinel sites to RGSLs. The RGSLs are responsible for genome sequencing and identification of VoCs/VoIs, potential VoIs, and other mutations. Information on VOCs/ VOIs is submitted to the Central Surveillance Unit, IDSP, to establish clinico-epidemiological correlation in coordination with state surveillance officers.
- Based on discussions in the Scientific and Clinical Advisory Group (SCAG) established to support the INSACOG, it was decided that upon identification of a genomic mutation, which could be of public health relevance, RGSL will submit the same to SCAG. SCAG discusses the potential VoIs and other mutations and, if felt appropriate, recommends to the Central Surveillance Unit for further investigation.
- The genome sequencing analysis and clinico-epidemiological correlation established by IDSP is shared with MOH&FW, ICMR, DBT, CSIR and States/UTs for formulating and implementing requisite public health measures.
- The new mutations/VoCs are cultured, and genomic studies are undertaken to see the impact on vaccine efficacy and immune escape properties.
Source: https://dbtindia.gov.in/pressrelease/qa-indian-sars-cov-2-genomics-consortiuminsacog
4. COVID-19: Delta and Delta Plus variants
Q. Why are frequent mutations seen in SARS-CoV-2 virus? When will the mutations stop?
A. SARS-CoV-2 can mutate due to the following reasons:
- Random error during replication of virus
- Immune pressure faced by the viruses after treatments such as convalescent plasma, vaccination or monoclonal antibodies (antibodies produced by a single clone of cells with identical antibody molecules)
- Uninterrupted transmission due to lack of COVID appropriate behaviour. Here the virus finds an excellent host to grow and becomes more fit and transmissible.
The virus will continue to mutate as long as the pandemic remains. This makes it all the more crucial to follow COVID appropriate behaviour.
Q.What are variants of interest (VoIs) and variants of concern (VoCs)?
A.When mutations happen – if there is any previous association with any other similar variant, which is felt to have an impact on public health – then it becomes a variant under investigation (VuI).
Once genetic markers are identified, which can have an association with a receptor binding domain or which have an implication on antibodies or neutralising assays, we call them variants of interest (VoIs).
The moment we get evidence for increased transmission through field-site and clinical correlations, it becomes a variant of concern (VoC). VoCs are those that have one or more of the following characteristics:
- Increased transmissibility
- Change in virulence/disease presentation
- Evading diagnostics, drugs and vaccines
The first VoC was announced by the UK where it was found. Currently there are four VoCs identified by the scientists – Alpha, Beta, Gamma and Delta.
Q. What are Delta and Delta Plus variants?
A.These are the names given to variants of SARS-CoV-2 virus, based on the mutations found in them. The World Health Organization (WHO) has recommended using letters of the Greek Alphabet, i.e., Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), Delta (B.1.617), etc., to denote variants, for easier public understanding.
Delta variant, also known as SARS-CoV-2 B.1.617, has about 15-17 mutations. It was first reported in October 2020. More than 60 per cent of cases in Maharashtra in February 2021 pertained to Delta variants.
It is the Indian scientists who identified the Delta variant and submitted it to the global database. The Delta variant is classified as a VoC and has now spread to 80 countries, as per the WHO.
The Delta variant (B.1.617) has three subtypes B1.617.1, B.1.617.2 and B.1.617.3, of which B.1.617.1 and B.1.617.3 have been classified as VoI, while B.1.617.2 (Delta Plus) has been classified as a VoC.
Compared to the Delta variant, the Delta Plus variant has an additional mutation. This mutation is called the K417N mutation. 'Plus' means an additional mutation has happened to the Delta variant. It does not mean that the Delta Plus variant is more severe or highly transmissible than the Delta variant.
Q. Why has the Delta Plus variant (B.1.617.2) been classified as a VoC?
A.It has been classified as a VoC because of the following characteristics:
- Increased transmissibility
- Stronger binding to receptors of lung cells
- Potential reduction in monoclonal antibody response
- Potential post vaccination immune escape
Q. How often are these mutations studied in India?
A.Indian SARS-CoV-2 Genomics Consortium (INSACOG), coordinated by the Department of Biotechnology (DBT) along with the Union Health Ministry, ICMR, and CSIR, monitors the genomic variations in SARS-CoV-2 on a regular basis through a pan-India multi-laboratory network. It was set up with 10 national labs in December 2020 and has been expanded to 28 labs and 300 sentinel sites from where genomic samples are collected. The INSACOG hospital network looks at samples and informs INSACOG about the severity, clinical correlation, breakthrough infections and re-infections.
More than 65,000 samples have been taken from states and processed, while nearly 50,000 samples have been analysed of which 50 per cent have been reported to be VoCs.
Q. On what basis are the samples subjected to genome sequencing?
A.Sample selection is done under three broad categories:
- International passengers (during the beginning of the pandemic)
- Community surveillance (where RT-PCR samples report CT value less than 25)
- Sentinel surveillance where samples are obtained from labs (to check transmission) and hospitals (to check severity)
When there is any public health impact noticed because of genetic mutation, then the same is monitored.
Q. What is the trend of VoCs circulating in India?
A.As per the latest data, 90 per cent of samples tested have been found to have Delta variants (B.1.617). However, B.1.1.7 strain, which was the most prevalent variant in India in the initial days of the pandemic, has decreased.
Why is action regarding public health not taken immediately after noticing mutations in the virus?
A.It is not possible to say whether the mutations noticed will increase transmission. Also, until there is scientific evidence that proves a correlation between the rising number of cases and variant proportion, we cannot confirm there is a surge in the particular variant. Once mutations are found, it is analysed every week to find out if there is any such correlation between the surge of cases and variant proportion. Public health action can be taken only if scientific proofs for such correlation are available.
Once such correlation is established, it will help greatly to prepare in advance when such a variant is seen in another area/region.
Q. Do Covishield and Covaxin work against the variants of SARS-CoV-2?
A.Yes, Covishield and Covaxin are both effective against the Alpha, Beta, Gamma and Delta variants. Lab tests to check vaccine effectiveness on Delta Plus variants are ongoing.
Delta Plus variants: The virus has been isolated and is now being cultured at ICMR’s National Institute of Virology, Pune. Laboratory tests to check vaccine effectiveness are ongoing and the results will be available in 7 to 10 days. This will be the first result in the world.
Q. What are the public health interventions being carried out to tackle these variants?
A.The public health interventions needed are the same, irrespective of the variants. The following measures are being taken:
- Cluster containment
- Isolation and treatment of cases
- Quarantining of contacts
- Ramping up vaccination
Q. Do public health strategies change as the virus mutates and more variants arise?
A.No, public health prevention strategies do not change with variants.
Q. Why is continuous monitoring of mutations important?
A.Continuous monitoring of mutations is important to track potential vaccine escape, increased transmissibility and disease severity.
Q. What does a common man do to protect self from these VoCs?
A. One must follow COVID appropriate behaviour, which includes wearing a mask properly, washing hands frequently and maintaining social distancing. The second wave is not over yet. It is possible to prevent a big third wave provided individuals and society practice protective behaviour. Further, test positivity rate must be closely monitored by each district. If the test positivity goes above 5 per cent, strict restrictions must be imposed.
Source: https://pib.gov.in/PressReleseDetailm.aspx?PRID=1730875
5. COVID-19 vaccination for pregnant women
Q.Why is COVID-19 vaccine being recommended for pregnant women?
A. Pregnancy does not increase the risk to COVID-19 infection. Most pregnant women will be asymptomatic or have mild disease, but their health may deteriorate rapidly and that might affect the foetus too. It is important that they take all precautions to protect themselves from COVID-19, including taking the vaccination against the same. It is, therefore, advised that a pregnant woman should take the COVID-19 vaccine.
Q.Who are at higher risk of getting infected with COVID-19?
A. Higher risk of infection involves with:
- A healthcare worker or a frontline worker
- A community with high or increasing rate of COVID-19 infections
- Those frequently exposed to people outside the household
- Those who have difficulty in complying with social distance if living in a crowded household
Q. How does COVID-19 affect the health of a pregnant woman?
A. Although most (>90 per cent) infected pregnant women recover without hospitalization, rapid deterioration in health may occur in a few. Symptomatic pregnant women appear to be at increased risk of severe disease and death. In severe disease, like all other patients, pregnant women may also need hospitalisation. Pregnant women with underlying medical conditions, for example, high blood pressure, diabetes, obesity, and age over 35 years are at higher risk of severe illness due to COVID-19.
Q. How does COVID-19 infection of pregnant women affect the baby?
A. Most (over 95 per cent) of newborns of COVID-19 positive mothers have been in good condition at birth. In some cases, COVID-19 infections in pregnancy may increase the possibility of a premature delivery; the baby’s weight may be less than 2.5 kg; and in rare situations, the baby might die before birth.
Q. Which pregnant women are at a higher risk of developing complications after COVID-19 infection?
A. Pregnant women who are:
- Older than 35 years of age
- Obese
- Have an underlying medical condition such as diabetes or high blood pressure
- Have a history of clotting in the limbs
Q. If a pregnant woman has already had COVID-19, when should she be vaccinated?
A. In case a woman is infected with COVID-19 during the current pregnancy, then she should be vaccinated soon after the delivery.
Q. Are there any side effects of the COVID-19 vaccines that can either harm the pregnant woman or her foetus?
A. The available COVID-19 vaccines are safe and the vaccination protects pregnant women against COVID-19 like other individuals. Like any medicine a vaccine may have side effects, which are normally mild. After getting the vaccine, she can get mild fever, pain at the injection site, or feel unwell for 1-3 days. The long-term adverse effects and safety of the vaccine for the foetus and the child born is not established yet. Very rarely, (one in one to five lakh people) the beneficiary may, after the COVID-19 vaccination, experience some of the following symptoms within 20 days after getting the injection, which may need immediate attention.
Q.When should the vaccine be given to the pregnant woman?
A. The COVID-19 vaccination schedule can be started any time during pregnancy.
Q.What other precautions should the pregnant woman take after vaccination?
A. Counsel the pregnant woman and her family members to continue to practice COVID appropriate behaviour: wearing double masks, frequent hand washing, maintaining physical distance, and avoiding crowded areas, to protect themselves and those around from spreading the COVID-19 infection.
Q.How does a pregnant woman register herself for the Covid-19 vaccination?
A. All pregnant women need to register themselves on the Co-WIN portal or may get themselves registered on-site at the COVID-19 vaccination centre. The process of registration for pregnant women remains the same as of the general population and as per the latest guidelines provided by the Ministry of Home and Family Welfare (MoHFW) from time to time.
Q.What other precautions should the pregnant woman take after vaccination?
Source: https://www.mohfw.gov.in/pdf/OperationalGuidanceforCOVID19vaccinationofPregnantWoman.pdf
6. COVID-19 & Children
Q. What is the possibility of a third wave of COVID-19 in the coming months?
A. Pandemics are likely to occur in multiple waves, and each wave could vary in the number of cases and its duration. Eventually, most of the population may get immune by asymptomatic or symptomatic infections (herd immunity). Over time, the disease may die out or may become endemic in the community with low transmission rates.
Key Message: There is a possibility of a third wave, but it is difficult to predict its timing and severity.
Q. Are children at greater risk if the third wave strikes?
A. In the first wave, primarily the elderly and individuals with co-morbidities were affected with severe disease. In the current (second) wave, a large number of younger population (30-45 years) have developed severe disease as also those without co-morbidities. After the second wave is over, if we do not continue following COVID appropriate behaviour, the third wave, if it occurs, is likely to infect the remaining non-immune individuals and that may include children also. The latest sero survey (December 2020 to January 2021) showed that the percentage of infected children in the age group of 10-17 years was around 25 per cent, the same as adults. This indicates that while children are being infected like adults, they are not getting the severe disease.
Key Message: Children are as susceptible as adults and older individuals to develop an infection but not a severe disease. It is highly unlikely that the third wave will predominantly or exclusively affect children.
Q. Are children likely to suffer from severe disease as being witnessed in the adult population in the current wave?
A.Fortunately, children have been relatively less affected so far due to several factors. The most important reason is the lesser expression of specific receptors to which this virus binds to enter the host and also the immune system of the children. A very small percentage of infected children may develop moderate to severe disease. If there is a massive increase in the overall numbers of infected individuals, a larger number of children with moderate to severe disease may be seen. Apart from the infection, parents should watch out for mental health issues in children and keep a watch to prevent child abuse and violence. Also, it is worth limiting screen time and prepare children for safe school reopening as per the Indian Academy of Pediatrics (IAP) guidelines.
Key Message:Almost 90 per cent of the infections in children are mild/asymptomatic.Therefore, the incidence of severe disease is not high in children.
Q. Can we rule out the possibility of severe infections in children in the third wave?
A.As explained, the spectrum of illness is likely to be much less severe in children than adults;there is only a remote possibility of children being more severely affected than adults in the next wave. As per data collected during the first and second waves, severe COVID-19 infections in children were not reported and only in few cases they were admitted to ICU. However, we need to be watchful about how the mutant strains will behave. The dictum here is: better be ready and prepared for the worst and hope for the best!
Key Message:Severe COVID-19 cases in children are rare. Further, there is no evidence indicating that children will have severe disease in the third wave.
Q.Severe disease due to COVID-19 is already occurring in children. Why it is so?
A. Yes, a severe illness related to COVID-19 is known to occur in children. This includes pneumonia and multisystem inflammatory syndrome in children (MIS-C). However, COVID-19 pneumonia in children is uncommon as compared to adults. In some cases, after 2-6 weeks of asymptomatic or symptomatic COVID-19 infection, MIS-C may be seen due to immune dysregulation with the incidence of 1-2 cases per 100,000 population; some of these cases also may be severe. It’s a treatable condition with a good outcome if diagnosed early. Also, most children suffering from MIS-C cannot transmit the infection to others.
Key Message:Children occasionally get the severe disease and may need ICU care, both during the acute illness and after 2-6 weeks due to MIS-C caused by COVID-19. But the majority are likely to recover if treated on time.
Q.What preparations are being made in case the third wave comes and affects the children?
A.Most affected children get a mild disease with fever and need supervised home care with monitoring. We have learned a lot about COVID-19 illness from our shared experiences in adult medicine in the last 15 months. IAP guidelines on the management of COVID-19 in children are in place, and paediatricians have been sensitised and trained on its management. We need to be ready for a more significant number of patients seeking consultations; educating the parents on different platforms regarding illness and warning signs; and arranging more COVID-19 wards for children with more special wards such as high-dependency units (HDUs) and intensive care units (ICUs). The preventive behaviours are the same for children. Parents should also be ideal role models for their children regarding mask etiquette, hand hygiene, and social distancing. Children above the age of two to five years can be trained to use a mask; however, the adults have to follow the COVID-appropriate behaviour. IAP has also set guidelines for the safe reopening of schools for the safety of the children.
Key Message:We need to be prepared with more in-patient beds and intensive care beds for children. IAP has already developed the management protocol for disease categories in children. There is no reason to panic. Our preparations are in full swing.
Q.What is the plan for vaccinating children?
A.. So far, the global data show that compared to children, older adults are a thousand times more likely to die from COVID-19 disease. So, it has been a priority to vaccinate the high-risk elderly age group first. Thereafter, the emphasis should be on adults who also have more severe diseases as compared to children. When there is the remote possibility of children getting affected, some countries consider vaccinating children and adolescents. The same vaccines being used in adults can be used in children only after adequate trials. One of the India-made vaccines will soon undergo trials in children, and if proven immunogenic and safe, it could be fast-tracked for mass vaccination in children.
Key Message:Children do get the severe disease, even if the number is small. Thus, there is no harm in considering vaccination for them. The safety and efficacy, however, are being assessed in trials for this age. The national expert group on vaccine administration for COVID-19 will develop a plan as and when new scientific data emerge.
7. COVID-19 & White Fungus infection
Q.What is White Fungus?
A.White Fungus, also known as candidiasis, is an opportunistic infection, which could spread fast to various body parts and, if not treated, could be serious. According to the Centre for Diseases Control and Prevention (CDC), White Fungus or invasive candidiasis can affect the blood, heart, brain, eyes, bones, or other parts of the body.
Q.Who are at high risk to get White Fungus infection?
A.White Fungus is all around us as it is found naturally in the environment. It primarily affects people with low immunity, who come in contact with objects that contain these fungal spores. For instance, COVID-19 patients on oxygen support can come in contact with these fungal spores if their ventilators and oxygen support equipment are not sanitised properly. Further, overuse of steroids and use of tap water in the humidifier attached to an oxygen cylinder can also heighten the risk of contracting White Fungus.
Q. Who can get infected by white fungus?
A.Invasive candidiasis is caused by a yeast (a type of fungus) called Candida. Candida can normally live inside the body, in areas like the mouth, throat, gut, and vagina, without causing any problems. However, individuals with low immunity, like patients recovering from a serious COVID-19 infection, are particularly at risk of contracting this fungal infection. In their bodies, the fungus can enter the bloodstream or internal organs to cause an infection.
People who are at high risk for developing this infection include those who:
- Have been admitted in the intensive care unit (ICU) for a prolonged period.
- Have weakened immune system (for example, people on cancer chemotherapy, people who have had an organ transplant, and people with low white blood cell counts).
- Have recently had surgery, especially multiple abdominal surgeries.
- Have recently received lots of antibiotics or steroids in the hospital.
- Receive total parenteral nutrition (food through a vein).
- Have kidney failure or are on hemodialysis.
- Have diabetes.
- Have a central venous catheter.
Q. Is White Fungus contagious?
A. White Fungus is not contagious in most cases, as it cannot spread directly from person to person. However, there exist some species of fungus that cause this infection on the skin. In such instances of external infection, the fungus can possibly be transferred from the patient to another individual who is at risk.
Q. What are the symptoms of White Fungus?
A. Only CT scans or X-rays can reveal and completely confirm the White Fungus infection. Health experts report that it is more dangerous than Black Fungus, as it affects the lungs as well as other parts of the body like the nails, skin, stomach, kidney, brain, private areas, and mouth.
Moreover, the White Fungus can also infect the lungs the same way COVID-19 does. In fact, patients who get infected with White Fungus displayed COVID-19-like symptoms despite having tested negative for the virus. According to some reports, the oxygen saturation level of one of the four patients infected with White Fungus dropped from normal levels. However, the oxygen levels became normal after the antifungal medication was administered.
Q. How can White Fungus be treated?
A. Patients infected with White Fungus should be examined carefully, perhaps with a fungus culture test of their phlegm or mucus, to detect the extent of fungal infection in their body. After detection of the infection, antifungal medications can be used to treat the patients. Such medications have led to an improvement in their condition. The type and dose of antifungal medication used to treat White Fungus will depend on the patient’s age, immune status, location, and severity of the infection.
8. COVID-19 & Use of oxygen
Q. What is the normal respiratory rate of a healthy adult person?
A. Standard respiratory rates for a healthy adult range from 12 to 20 breaths per minute.
Q. Are 8 breaths per minute normal?
A. No. A patient needs to be evaluated medically.
Q. How many litres of oxygen per minute do we breathe?
A.The average tidal volume, i.e., the average amount of air inhaled and exhaled per breathing cycle, is 0.5 litre (500 ml). Minute Ventilation (VE) is the total volume of air entering the lungs in a minute, which is 6 litres per minute.
Q. What should be the normal oxygen saturation as recorded by a Pulse Oximeter?
A. The normal oxygen saturation level in the blood (SpO2 ) should be 95 per cent or higher. Some people with chronic lung disease, such as Chronic Obstructive Pulmonary Disease (COPD) or sleep apnea, may have normal levels of around 90 per cent. The ‘SpO2 ’ reading on a pulse oximeter shows the percentage of oxygen in the blood. If your home SpO2 reading is lower than 94 per cent, call your healthcare provider.
Q. How do I check my oxygen level at home without a Pulse Oximeter?
A.If you do not have a portable finger pulse oximeter in your home, you can also learn how to assess signs and symptoms of low oxygen levels. Two classic signs of a low oxygen level are a rapid heart rate and a fast breathing rate. An average heart rate is 60–100 beats per minute and an average breathing rate is 12–20 breaths per minute. However, under low oxygen conditions, body responses include an increase in heart rate and breathing rate. Another sign of a low blood oxygen level is cyanosis or a bluish colour change on your lips, nose, or fingertips. As your body loses oxygen, the blood cells in your body change colour in your bloodstream to a dark blue, which can be seen from the outside of your skin if it is severe. Cyanosis is typically a late sign of low oxygen levels and is considered a medical emergency. If you notice this bluish discolouration, you should immediately visit the nearest hospital.
Q. Do we see many cases of silent hypoxia in this wave? How can this be addressed?
A.Silent hypoxia or happy hypoxia is referred to as the early stage of COVID-19. As the oxygen level drops, one may start feeling shortness of breath, confusion, and other symptoms. Keep watching for these signs and do not ignore them. This is true for young people as well. If you monitor low oxygen level, change in lip colour from natural to blue or persistent sweating,consult the COVID helpline or doctor. They could be the early sign of silent hypoxia.
Q. In brief, how can proning help enhance blood oxygen levels?
A. Proning is a medically accepted process to improve the distribution and exchange of oxygen in the lungs. A patient is safely placed from their back onto their abdomen (stomach), i.e., face down to improve breathing and oxygenation. It has been shown as beneficial for COVID-19 patients with compromised breathing comfort, especially during home isolation.
Q. Is pure oxygen used in hospitals?
A.Medical oxygen contains high purity oxygen used for medical treatments and is developed for use in human body. Cylinders contain a compressed oxygen gas and no gases are allowed in the cylinder to prevent contamination.
Q. What is the use of medical oxygen?
A.Oxygen is used for treatment in hospitals. Hence, it is considered a drug or a pharmaceutical product.
Q.What is the need for medical oxygen?
A.The human body requires oxygen to survive, and typically, we breathe in from air. However, if you have lung disease or other medical conditions such as COVID-19, you may not get enough oxygen due to compromised lungs. That can leave you short of breath and cause problems with your heart, brain, and other parts of your body.
Q. Can breathing 100 per cent oxygen harm your body?
A.Yes. Breathing 100 per cent oxygen also eventually leads to collapse of the alveoli (atelectasis).
Q. Can you get excess (more than required) oxygen from an oxygen concentrator?
A. It is possible to get excess (more than required) oxygen from an oxygen concentrator. However, this is quite rare when oxygen concentrators are used as directed and prescribed. All supplemental oxygen requires a prescription from a doctor, who carefully chooses your oxygen requirement.
Q. What is the role of oxygen during COVID-19 disease?
A.The demand for medical oxygen increases in COVID-19 as the disease primarily affects the lungs and, in severe cases, causes death due to Acute Respiratory Distress Syndrome (ARDS) and pneumonia.
Q. When does a patient require medical oxygen in a COVID-19 positive case?
A. As per AIIMS/ICMR-Covid-19/National Task Force/Joint Monitoring Group (Dte.GHS), MoHFW, Government of India, Clinical Guidelines for Management of Adult COVID-19 Patient issued on 22nd April 2021, moderate and severe cases of COVID-19 where the infection induces shortage of oxygen in the body due to its impact on lungs require medical oxygen and immediate oxygen therapy. Oxygen acts as a life-saver for COVID-19 patients.
Q. What are moderate COVID-19 cases?
A. In moderate COVID-19 cases, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than or equal to 24/minute and SpO2 90 per cent to 93 per cent with ambient air.
Q. What is severe COVID-19 cases?
A. In severe COVID-19 case, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than 30/minute and SpO2 less than 90 per cent in room air.
Q. When does a patient require mechanical ventilator support?
A. A patient may be put on a mechanical ventilator if it becomes very difficult to breathe or get enough oxygen into their blood. This condition is called respiratory failure. Mechanical ventilators are machines that act as bellows to move air in and out of the patient’s lungs. The respiratory therapist and doctor set the ventilator to control how often it pushes air into the lungs and how much air the patient gets. The patient may be fitted with a mask to get air from the ventilator into the lungs. Or, they may need a breathing tube if their breathing problem is more serious.
Q. Can mechanical ventilation be given at home?
A. Mechanical ventilators are mainly used in hospitals and transport systems such as ambulances and medical evacuation by air transport, etc. In some cases, they can be used at home if the illness is long-term and the caregivers at home receive training and have adequate nursing and other resources at home. Being on a ventilator may make a patient more susceptible to pneumonia, damage to the vocal cords, or other problems.
Q. What is the six minute walk test for COPD?
A.The six minute walk test (6MWT) is an exercise test that measures functional status in chronic obstructive pulmonary disease (COPD) patients and provides information on oxygen desaturation. This test is also being used for COVID-19. In case of COVID-19 symptoms, SpO2 level must be checked before taking a walk. Now, walk for six minutes without a break on an even surface and measure the SpO2 level. It may fall 1-2 per cent, but consult a medical professional if it falls below 93 per cent.
Source: https://ndma.gov.in/sites/default/files/2021-03/FAQs-on-Use-of-oxygen-.pdf
9. COVID-19 & Therapeutics
Q. Is Remdesivir effective in the treatment of COVID-19?
A.No study has conclusively been able to prove that Remdesivir is beneficial in the treatment of COVID-19. However, India has approved Remdesivir under the National Clinical Management Protocol for COVID-19, which was developed after many interactions by a committee of experts. The protocol acts as the guiding document for the treatment of COVID-19 patients in India. Remdesivir is listed as an investigational therapy in the protocol, i.e., where informed and shared decision-making is essential, besides noting contraindications mentioned in the detailed guidelines.
Q. What is Remdesivir? How does Remdesivir work?
A.Remdesivir is an investigational drug used to treat viral infections. It is classified as a broadspectrum antiviral with potential antiviral activity against a variety of RNA viruses.
The drug works against the novel coronavirus by inhibiting replication of the virus in the body. Remdesivir functions as a pro-drug that is modified in the body before it becomes an active drug. It is classified as a nucleoside analog, one of the oldest classes of antiviral medications, and resembles the RNA base adenosine. In general, nucleoside and nucleotide analogues simulate the structure of a true nucleoside or nucleotide. The simulated structure may then be incorporated into the virus. Remdesivir works when the enzyme replicating the genetic material for the novel coronavirus − RNA polymerase − incorporates the adenosine analogue in place of the natural molecule into the growing RNA strand. By introducing the modified agent, Remdesivir, replication of the novel coronavirus is interrupted, and the virus ceases to multiply and cannot infect more cells in the body
Q. When should a patient of COVID-19 take Remdesivir?
A. The timing of the drug, when it is administered, is most important. Taking it too early or too late could do more harm than good. Remdesivir is applicable only in hospitalised patients who showed very low oxygen saturation and infiltrated their chest X-ray or CT scan. The optimal timing for Remdesivir is usually after five to seven days of having the virus. Early to mild or asymptomatic patients should not take Remdesivir. Also, it is of no use if it’s given very late because it would create a cytokine storm. A cytokine storm is when the immune system goes into overdrive. The body starts to attack its cells and tissues instead of just the virus.
Q. Can Remdesivir be taken at home?
A. Remdesivir comes in a vial and has to be injected only after prescription and in the presence of a health practitioner. It is for patients who are hospitalised and severe. Therefore, it should not be given at home. It is for patients who need to be admitted and need hospital care.
Q. Are steroids effective in the treatment of COVID-19?
A. There is no evidence to support the use of steroids in the treatment of COVID-19. The World Health Organization (WHO) recovery trial showed that steroids do have a beneficial effect. But again, the timing is critical. The recovery trial clearly showed that if we give steroids too early, it showed a harmful effect before oxygen saturation. Steroids are most effective during the later part of the disease when there is more inflammation and oxygen saturation is falling. Steroids are only helpful for moderate or severe cases.
Q. Is plasma a good way to fight off COVID-19?
A. Convalescent plasma has been a therapy devised to passively transfer antibodies from a recovered person to a new patient. While the therapy has been received with different opinions by the medical community, the important aspect is timing. It’s better if plasma therapy is used early before clinical worsening. Also, plasma with high titer neutralising antibodies would have better results. Hence, to achieve good results, correct patient selection, timing and a good quality plasma donor are needed for success in this form of treatment.
Q. Should a person with COVID-19 take Tocilizumab?
A.Tocilizumab is a drug of last resort. It should only be used when a COVID-19 infection in a patient is worsening despite steroids, Remdesivir and other treatments like anticoagulants. Tocilizumab is required in less than 2 per cent of COVID-19 patients. Very few patients need this drug because it’s only for treating a cytokine storm and has a limited role.
Q. Is Favipiravir effective in treating COVID-19?
A. Favipiravir is another antiviral that is being promoted for the treatment of COVID-19. It was initially doled out as a treatment of influenza after the H1N1 pandemic. There is not enough evidence in robust studies to show that it is a good drug. Since it’s not a proven treatment, India’s national guidelines also don’t recommend its use.
Q. Is it possible to treat COVID-19 without any of the drugs mentioned above?
A.People with mild COVID-19 or those who are asymptomatic will improve with just symptomatic treatment. Mild COVID-19 infection can be treated with paracetamol, good hydration and multivitamins − without any treatment. Giving treatment when it is not required may be doing more harm than good.
10. COVID-19 & Black Fungus Disease
Q. What is Black Fungus?
A. Black Fungus, also known as mucormycosis, is a rare fungal infection. It is called ‘black’ because of the colour of the fungal growth. It is caused by exposure to mucor mold found in soil, manure, and rotten/decaying fruits and vegetables. It is ubiquitous and even present in the nose/mucosa of healthy individuals. This disease usually affects the sinuses, eye orbit, and brain. That is why it is also called ‘rhino-orbital-cerebral’ mucormycosis. It may be life-threatening in immuno-compromised individuals (cancer patients, HIV/AIDS) and people with uncontrolled diabetes.
Q. What are the risk factors for acquiring Black Fungus infection?
A. Risk Factors are:
- Uncontrolled Diabetes Mellitus
- Treated for COVID-19 with corticosteroids
- Treated for COVID-19 with immunomodulators
- Treated for COVID-19 with mechanical ventilation
- Prolonged oxygen therapy
- Prolonged ICU stay
- Immuno-compromised state
Q. Why the sudden increase in Black Fungus cases?
A.It may be triggered by extensive use of steroids, which is a life-saving treatment for moderate to severe COVID-19 infection. Steroids lower the immunity and cause a sudden up-shooting of blood sugar levels in diabetes and non-diabetic patients. For patients on humidified oxygen, care should be taken to make sure there is no water leak to prevent the growth of the fungus.
Q.How serious is Black Fungus?
A.Black fungus infection causes a vision-threatening and life-threatening condition.
Q. Do all COVID-19 patients need to be worried about Black Fungus infection?
A.No. As discussed, high-risk patients need to be alert. Also, during COVID-19 recovery, everyone should watch out for early signs and symptoms.
Q. What are the precautions one can take to avoid this disease?
A.One can take the following precautions:
- Boost immune system with diet, hydration and exercise.
- Rational use of steroids by follow guidelines.
- Strict blood sugar monitoring and control in all patients who are on steroids.
Q. What are the early signs of Black Fungus?
A.Some of the early signs are:
- Facial pain
- Facial swelling/puffiness/discolouration
- Sinus headache
- Stuffy nose
- The blurring of vision/decreased vision
- Double vision
- Drooping of eyelid
- Blood-stained nasal discharge
- Dental pain
Q. Is Black Fungus treatable?
A.Yes. Early diagnosis and a prompt multi-speciality team of medical professionals can manage it.
Q. Which specialist should I visit for Black Fungus?
A.ENT and eye specialists are central to this disease. The team includes care coordination with neurosurgeon, endocrinologist and microbiologist.
Source: https://www.eyeqindia.com/frequently-asked-questions-on-covid-and-blackf...
11. COVID-19 & Indoor Air
Q. Will running an evaporative cooler help protect my family and me from COVID-19?
A.Evaporative coolers (or 'swamp coolers') can help protect people indoors from the airborne transmission of COVID-19 because they increase ventilation with outside air to cool indoor spaces. Evaporative coolers are used in dry climates. They use water to provide cooling and improve relative humidity in indoor microenvironments. When operating as intended (with open windows), these devices produce substantial increases in ventilation with outdoor air. Some evaporative coolers can be performed without using water when temperatures are milder to increase ventilation indoors. Avoid using evaporative coolers if air pollution outside is high and the system does not have a high-efficiency filter.
Q.Is ventilation important for indoor air quality when cleaning and/or sanitising for COVID-19 indoors?
A.When cleaning and disinfecting for COVID-19, ventilation is essential − in general, increasing ventilation during and after cleaning helps to reduce exposure to cleaning and disinfection products and by-products. Increasing ventilation, for example, by opening windows or doors, can also reduce risks from particles resuspended during cleaning, including those potentially carrying SARS-CoV-2 (or other contaminants). Avoid ventilation with outdoor air when outdoor air pollution is high or when it makes your home too cold, hot, or humid.
Q. Will an air cleaner or air purifier help protect my family and me from COVID-19 in my home?
A.When appropriately used, air purifiers can help reduce airborne contaminants, including viruses, in a home or confined space.
Q. How can I increase ventilation at home to help protect my family from COVID-19?
A.Ensuring proper ventilation with outside air is a standard best practice for improving indoor air quality. To increase ventilation in your home, one can:
- Open the windows or screened doors, if possible;
- Operate an air conditioner that has an outdoor air intake or vent; and
- Operate a bathroom fan when the bathroom is in use and continuously, if possible.
However, the practices mentioned here are not enough to protect people from COVID-19. When used along with other best practices recommended by the Ministry of Health and Family Welfare, Government of India, the above methods can be part of a plan to protect yourself and your family.
Source: https://www.epa.gov/coronavirus/indoor-air-and-coronavirus-covid-19
1. FAQs on OMICRON
Q. is Omicron and why is it a Variant of Concern (VoC)?
A. This new variant of SARS-CoV-2, named B.1.1.529 or Omicron (based on Greek alphabets such as alpha, beta, delta, etc.) has recently been reported in South Africa. There are a large number of mutations in this variant, especially more than 30 in the viral spike protein, which is the major target for immune responses. The World Health Organization has declared Omicron as a Variant of Concern (VoC) because of the combination of mutations that previously individually have been associated with increased in
Q. Why is it called Omicron?
A. The WHO named the B.1.1.529 variant Omicron in the tradition of giving variants a Greek letter name.
Q. How easily does Omicron spread?
A. The Omicron variant is more likely to spread than the original SARS-CoV-2 virus. How quickly Omicron spreads, compared to Delta, is unknown. The CDC expects that anyone infected with Omicron will be able to spread the virus to others, even if they have been vaccinated or do not have symptoms.
Q. Can the currently used diagnostics methods, detect Omicron?
A. The RT-PCR method is the most widely accepted and used diagnostic method for SARSCoV-2 variant. To confirm the presence of the virus, this method detects specific genes in the virus, such as Spike (S), Enveloped (E), and Nucleocapsid (N), among others. However, because the S gene in Omicron is heavily mutated, some of the primers may produce results indicating the absence of the S gene (called S gene drop out). This specific S gene dropout, along with the detection of other viral genes, could be used as an Omicron diagnostic feature. However, genomic sequencing is required for the final confirmation of the Omicron variant.
Q. Should we be concerned about the new VoC?
A. It is important to note that Omicron has been declared as a VoC based on the observed mutations, their predicted characteristics of increased transmission and immune evasion, and preliminary evidence of a negative change in COVID-19 epidemiology, such as increased reinfections. The definitive proof of increased remission and immune evasion is still awaited.
Q. Will Omicron cause more severe illness?
A. More research is needed to determine whether Omicron infections, particularly re-infections and breakthrough infections in fully vaccinated people, cause more severe illness or death than infection with other variants.
Q. precautions should we take?
A. Individuals can reduce the spread of the COVID-19 virus by keeping a physical distance of at least 1 metre from others, wearing a well-fitting mask, opening windows to improve ventilation, avoiding poorly ventilated or crowded spaces, keeping hands clean, coughing or sneezing into a bent elbow or tissue, and getting vaccinated when their turn comes.
Q. Will there be a third wave?
A. Cases of Omicron are increasingly being reported from countries outside of South Africa, and given its characteristics, it is likely to spread to more countries, including India. However, the magnitude and extent of the increase in cases and, more importantly, the severity of the disease that will be caused, are still unclear. In addition, given the rapid pace of vaccination in India and the high exposure to the delta variant as evidenced by the high seropositivity, the severity of the disease is expected to be low. However, the scientific evidence is still evolving.
Q. Will the existing vaccines be effective against Omicron?
A. Although there is no evidence to suggest that existing vaccines do not work on Omicron, some of the mutations reported in the Spike gene may reduce the effectiveness of existing vaccines. However, vaccine protection also involves antibodies and cellular immunity, which should be relatively better preserved. Therefore, vaccines are always expected to provide protection against serious disease, and vaccination with available vaccines is crucial. If you are eligible, but not vaccinated, you must be vaccinated.
Q. Why do variants occur?
A. Variants are an integral part of evolution and as long as the virus is able to infect, replicate, and transmit, they will continue to evolve. Also, not all variants are dangerous and most of the time we don’t notice them. It is only when they are more contagious, or can re-infect people, etc., that they gain importance. The most important step in avoiding the generation of variants is to reduce the number of infections.
Q. Is the Omicron transmission capacity higher than that for the COVID-19 Delta variant?
A. The Omicron version has raised alarm amongst epidemiologists who’re involved that the mutations within the new version ought to make it greater transmissible than the preceding variants. Further researches are being conducted to decide whether or not the Omicron version is greater transmissible than different variants, which includes the Delta version. The variety of checks for COVID-19 has been regularly growing across the world. Another extreme subject is that the Omicron version has already been detected in numerous countries, which includes Japan, Belgium, Botswana, Hong Kong, Australia, the Netherlands, South Africa, and Israel.
In addition to increasing the variety of COVID-19 checks, epigenetic researchers are urgently trying to make clear any hard elements related to the COVID-19 Omicron version. It is uncertain whether or not the Omicron version will increase COVID-19 severity. However initial researches have pronounced that the Omicron version elevated hospitalisation for COVID-19 sufferers in South Africa, which may be associated with COVID-19 complications. In addition, it remains uncertain as to whether or not the Omicron version might also additionally sell different variants, which includes the Delta version, thereby suggesting that in addition research might be wanted for complete clarification.
Q. Is there any impact of the Omicron variant on the COVID-19 severity in cancer patients?
A. Previous studies have stated that the Delta variant or other variants can sometimes increase the severity of COVID-19 in cancer patients. COVID-19 has been reported to promote cell senescence and oxidative stress, which is linked to complications of COVID-19 in cancer patients. Additionally, various studies have reported that COVID-19 can cause increased cytokine secretion, which is linked to the aggressiveness of COVID-19. However, more studies are needed to better understand the impact of the Omicron variant in cancer patients.
Q. Is the Omicron variant having an effect on monoclonal antibody treatments?
A. There is currently no virus-specific data available to determine whether monoclonal antibody treatments will continue to be effective against the Omicron variant. Based on data from other variants with significantly fewer changes in the RBD, the Omicron variant is expected to remain susceptible to some monoclonal antibody treatments, while others may be less effective.
Q. How is India responding?
A. The Indian government is monitoring the situation closely and issuing appropriate guidelines from time to time. Meanwhile, the scientific and medical community is prepared for the development and implementation of diagnostics, genomic surveillance, generation of evidence on viral and epidemiological characteristics, and development of therapies.
2. SARS-CoV-2 surveillance in India
Q. is INSACOG?
A. The Indian SARS-CoV-2 Genomics Consortium (INSACOG) is a national multi-agency consortium of Regional Genome Sequencing Laboratories (RGSLs) established by the Government of India on 30th December 2020. Initially, this consortium had 10 laboratories. Subsequently, the scope of laboratories under INSACOG was expanded and at present there are 28 laboratories under this consortium, which monitor the genomic variations in SARS-CoV-2.
Q. is the objective of INSACOG?
A. The SARS-CoV-2 virus, commonly known as COVID-19 virus, posed unprecedented public health challenges globally. To fully understand the spread and evolution of this virus, its mutations and resulting variants, the need for in-depth sequencing and analysis of the genomic data was felt. Against this backdrop, INSACOG was established to expand whole genome sequencing of SARS-CoV-2 virus across the nation, aiding understanding of how the virus spreads and evolves. Any changes to the genetic code, or mutations in the virus, can be observed based on the analysis and sequencing of samples done in the laboratories under INSACOG. INSACOG has the following specific objectives:
• To ascertain the status of variants of interest (VoI) and variants of concern (VoC) in the country
• To establish sentinel surveillance and surge surveillance mechanisms for early detection of genomic variants and assist in formulating effective public health response
• To determine the presence of genomic variants in samples collected during superspreader events and in areas reporting increasing trend of cases/deaths, etc.
Q. When did India start SARS-CoV-2 viral sequencing?
A. India started sequencing SARS-CoV-2 viral sequencing of genomes in 2020. Initially, National Institute of Virology (NIV) and Indian Councilof Medical Research (ICMR) sequenced samples of international passengers who arrived in India from the UK, Brazil or South Africa or transited through these countries, which reported a sudden surge in cases. RTPCR positive samples from states reporting sudden surges in cases were sequenced on priority. This was further expanded through the efforts of Council of Scientific and Industrial Research (CSIR), Department of Biotechnology (DBT) and National Centre for Disease Control (NCDC), as well as individual institutions.
The initial focus of India was on restricting the spread of global variants of concern in the country – Alpha (B.1.1.7), Beta (B.1.351) and Gamma (P.1) – which had high transmissibility. The entry of these variants was carefully tracked by INSACOG. Subsequently, the Delta and Delta Plus variants were also identified based on whole genome sequencing analysis conducted in the INSACOG laboratories.
Q. is the strategy for SARS-CoV-2 surveillance in India?
A. Initially, genomic surveillance was focused on the variants carried by international travellers and their contacts in the community through sequencing three to five per cent of the total RTPCR positive samples.
Subsequently, the sentinel surveillance strategy was also communicated to the States/UTs in April 2021. Under this strategy, multiple sentinel sites are identified to adequately represent the geographic spread of a region, and RT-PCR positive samples are sent from each sentinel site for whole genome sequencing. Detailed Standard Operating Procedures (SOPs) for sending samples from the identified sentinel sites regularly to the designated RGSLs were shared with States/UTs. The list of INSACOG RGSLs tagged to States was also communicated to the States. A dedicated nodal officer was also designated by all States/UTs for coordinating the activity of whole genome sequencing.
1. Sentinel Surveillance (for all States/UTs/): This is an ongoing surveillance activity across India. Each State/UT has identified sentinel sites (including RT-PCR labs and tertiary health care facilities) from where RT-PCR positive samples are sent for whole genome sequencing.
2. Surge Surveillance (for districts with COVID-19 clusters or those reporting a surge in cases): A representative number of samples (as per the sampling strategy finalised by a state surveillance officer/central surveillance unit) are collected from the districts, which show a surge in the number of cases and are sent to RGSLs.
Q. is the standard operating procedure (SOP) for sending samples to INSACOG laboratories?
A. The SOPs for sending samples to INSACOG laboratories and subsequent action based on genome sequencing analysis are as follows:
1. The Integrated Disease Surveillance Project (IDSP) machinery coordinates sample collection and transportation from the districts/sentinel sites to RGSLs. The RGSLs are responsible for genome sequencing and identification of VoCs/VoIs, potential VoIs, and other mutations. Information on VOCs/ VOIs is submitted to the Central Surveillance Unit, IDSP, to establish clinico-epidemiological correlation in coordination with state surveillance officers.
2. Based on discussions in the Scientific and Clinical Advisory Group (SCAG) established to support the INSACOG, it was decided that upon identification of a genomic mutation, which could be of public health relevance, RGSL will submit the same to SCAG. SCAG discusses the potential VoIs and other mutations and, if felt appropriate, recommends to the Central Surveillance Unit for further investigation.
3. The genome sequencing analysis and clinico-epidemiological correlation established by IDSP is shared with MOH&FW, ICMR, DBT, CSIR and States/UTs for formulating and implementing requisite public health measures.
4. The new mutations/VoCs are cultured, and genomic studies are undertaken to see the impact on vaccine efficacy and immune escape properties.
Source:
https://dbtindia.gov.in/pressrelease/qa-indian-sars-cov-2-genomics-consortium-insacog
3. Delta and Delta Plus variants
Q. Why are frequent mutations seen in SARS-CoV-2 virus? When will the mutations stop?
A. SARS-CoV-2 can mutate due to the following reasons:
• Random error during replication of virus
• Immune pressure faced by the viruses after treatments such as convalescent plasma, vaccination or monoclonal antibodies (antibodies produced by a single clone of cells with identical antibody molecules)
• Uninterrupted transmission due to lack of COVID appropriate behaviour. Here the virus finds an excellent host to grow and becomes more fit and transmissible.
The virus will continue to mutate as long as the pandemic remains. This makes it all the more crucial to follow COVID appropriate behaviour.
Q. are variants of interest (VoIs) and variants of concern (VoCs)?
A. When mutations happen – if there is any previous association with any other similar variant, which is felt to have an impact on public health – then it becomes a variant under investigation (VuI).
Once genetic markers are identified, which can have an association with a receptor binding domain or which have an implication on antibodies or neutralising assays, we call them variants of interest (VoIs).
The moment we get evidence for increased transmission through field-site and clinical correlations, it becomes a variant of concern (VoC). VoCs are those that have one or more of the following characteristics:
• Increased transmissibility
• Change in virulence/disease presentation
• Evading diagnostics, drugs and vaccines
The first VoC was announced by the UK where it was found. Currently there are four VoCs identified by the scientists – Alpha, Beta, Gamma and Delta.
Q. are Delta and Delta Plus variants? A. These are the names given to variants of SARS-CoV-2 virus, based on the mutations found in them. The World Health Organization (WHO) has recommended using letters of the Greek Alphabet, i.e., Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), Delta (B.1.617), etc., to denote variants, for easier public understanding.
Delta variant, also known as SARS-CoV-2 B.1.617, has about 15-17 mutations. It was first reported in October 2020. More than 60 per cent of cases in Maharashtra in February 2021 pertained to Delta variants.
It is the Indian scientists who identified the Delta variant and submitted it to the global database. The Delta variant is classified as a VoC and has now spread to 80 countries, as per the WHO. The Delta variant (B.1.617) has three subtypes B1.617.1, B.1.617.2 and B.1.617.3, of which B.1.617.1 and B.1.617.3 have been classified as VoI, while B.1.617.2 (Delta Plus) has been classified as a VoC.
Compared to the Delta variant, the Delta Plus variant has an additional mutation. This mutation is called the K417N mutation. ‘Plus’ means an additional mutation has happened to the Delta variant. It does not mean that the Delta Plus variant is more severe or highly transmissible than the Delta variant.
Q. Why has the Delta Plus variant (B.1.617.2) been classified as a VoC?
A. It has been classified as a VoC because of the following characteristics:
• Increased transmissibility
• Stronger binding to receptors of lung cells
• Potential reduction in monoclonal antibody response
• Potential post vaccination immune escape
Q. How often are these mutations studied in India?
A. Indian SARS-CoV-2 Genomics Consortium (INSACOG), coordinated by the Department of Biotechnology (DBT) along with the Union Health Ministry, ICMR, and CSIR, monitors the genomic variations in SARS-CoV-2 on a regular basis through a pan-India multi-laboratory network. It was set up with 10 national labs in December 2020 and has been expanded to 28 labs and 300 sentinel sites from where genomic samples are collected. The INSACOG hospital network looks at samples and informs INSACOG about the severity, clinical correlation, breakthrough infections and re-infections.
More than 65,000 samples have been taken from states and processed, while nearly 50,000 samples have been analysed of which 50 per cent have been reported to be VoCs.
Q. On what basis are the samples subjected to genome sequencing?
A. Sample selection is done under three broad categories:
1. International passengers (during the beginning of the pandemic)
2. Community surveillance (where RT-PCR samples report CT value less than 25)
3. Sentinel surveillance where samples are obtained from labs (to check transmission) and hospitals (to check severity)
When there is any public health impact noticed because of genetic mutation, then the same is monitored.
Q. is the trend of VoCs circulating in India?
A. As per the latest data, 90 per cent of samples tested have been found to have Delta variants (B.1.617). However, B.1.1.7 strain, which was the most prevalent variant in India in the initial days of the pandemic, has decreased.
Q. Why is action regarding public health not taken immediately after noticing mutations in the virus?
A. It is not possible to say whether the mutations noticed will increase transmission. Also, until there is scientific evidence that proves a correlation between the rising number of cases and variant proportion, we cannot confirm there is a surge in the particular variant. Once mutations are found, it is analysed every week to find out if there is any such correlation between the surge of cases and variant proportion. Public health action can be taken only if scientific proofs for such correlation are available.
Once such correlation is established, it will help greatly to prepare in advance when such a variant is seen in another area/region.
Q. Do Covishield and Covaxin work against the variants of SARS-CoV-2?
A. Yes, Covishield and Covaxin are both effective against the Alpha, Beta, Gamma and Delta variants. Lab tests to check vaccine effectiveness on Delta Plus variants are ongoing.
Delta Plus variants: The virus has been isolated and is now being cultured at ICMR’s National Institute of Virology, Pune. Laboratory tests to check vaccine effectiveness are ongoing and the results will be available in 7 to 10 days. This will be the first result in the world.
Q. are the public health interventions being carried out to tackle these variants?
A. The public health interventions needed are the same, irrespective of the variants. The following measures are being taken:
• Cluster containment
• Isolation and treatment of cases
• Quarantining of contacts
• Ramping up vaccination
Q. Do public health strategies change as the virus mutates and more variants arise?
A. No, public health prevention strategies do not change with variants.
Q. Why is continuous monitoring of mutations important?
A. Continuous monitoring of mutations is important to track potential vaccine escape, increased transmissibility and disease severity.
Q. does a common man do to protect self from these VoCs?
A. One must follow COVID appropriate behaviour, which includes wearing a mask properly, washing hands frequently and maintaining social distancing. The second wave is not over yet. It is possible to prevent a big third wave provided individuals and society practice protective behaviour. Further, test positivity rate must be closely monitored by each district. If the test positivity goes above 5 per cent, strict restrictions must be imposed.
Source:
https://pib.gov.in/PressReleseDetailm.aspx?PRID=1730875
4. COVID-19 vaccination for pregnant women
Q. Why is COVID-19 vaccine being recommended for pregnant women?
A. Pregnancy does not increase the risk to COVID-19 infection. Most pregnant women will be asymptomatic or have mild disease, but their health may deteriorate rapidly and that might affect the foetus too. It is important that they take all precautions to protect themselves from COVID-19, including taking the vaccination against the same. It is, therefore, advised that a pregnant woman should take the COVID-19 vaccine.
Q. Who are at higher risk of getting infected with COVID-19?
A. Higher risk of infection involves with:
• A healthcare worker or a frontline worker
• A community with high or increasing rate of COVID-19 infections
• Those frequently exposed to people outside the household
• Those who have difficulty in complying with social distance if living in a crowded household
Q. How does COVID-19 affect the health of a pregnant woman?
A. Although most (>90 per cent) infected pregnant women recover without hospitalization, rapid deterioration in health may occur in a few. Symptomatic pregnant women appear to be at increased risk of severe disease and death. In severe disease, like all other patients, pregnant women may also need hospitalisation. Pregnant women with underlying medical conditions, for example, high blood pressure, diabetes, obesity, and age over 35 years are at higher risk of severe illness due to COVID-19.
Q. How does COVID-19 infection of pregnant women affect the baby?
A. Most (over 95 per cent) of newborns of COVID-19 positive mothers have been in good condition at birth. In some cases, COVID-19 infections in pregnancy may increase the possibility of a premature delivery; the baby’s weight may be less than 2.5 kg; and in rare situations, the baby might die before birth.
Q. Which pregnant women are at a higher risk of developing complications after COVID-19 infection?
A. Pregnant women who are:
• Older than 35 years of age
• Obese
• Have an underlying medical condition such as diabetes or high blood pressure
• Have a history of clotting in the limbs
Q. If a pregnant woman has already had COVID-19, when should she be vaccinated?
A. In case a woman is infected with COVID-19 during the current pregnancy, then she should be vaccinated soon after the delivery.
Q. Are there any side effects of the COVID-19 vaccines that can either harm the pregnant woman or her foetus?
A. The available COVID-19 vaccines are safe and the vaccination protects pregnant women against COVID-19 like other individuals. Like any medicine a vaccine may have side effects, which are normally mild. After getting the vaccine, she can get mild fever, pain at the injection site, or feel unwell for 1-3 days. The long-term adverse effects and safety of the vaccine for the foetus and the child born is not established yet. Very rarely, (one in one to five lakh people) the beneficiary may, after the COVID-19 vaccination, experience some of the following symptoms within 20 days after getting the injection, which may need immediate attention.
Q. When should the vaccine be given to the pregnant woman?
A. The COVID-19 vaccination schedule can be started any time during pregnancy.
Q. other precautions should the pregnant woman take after vaccination?
A. Counsel the pregnant woman and her family members to continue to practice COVID appropriate behaviour: wearing double masks, frequent hand washing, maintaining physical distance, and avoiding crowded areas, to protect themselves and those around from spreading the COVID-19 infection.
Q. How does a pregnant woman register herself for the Covid-19 vaccination?
A. All pregnant women need to register themselves on the Co-WIN portal or may get themselves registered on-site at the COVID-19 vaccination centre. The process of registration for pregnant women remains the same as of the general population and as per the latest guidelines provided by the Ministry of Home and Family Welfare (MoHFW) from time to time.
Source:
https://www.mohfw.gov.in/pdf/OperationalGuidanceforCOVID19vaccinationofPregnantWoman.pdf
5. The third wave of COVID-19 in India and protecting children
Q. is the possibility of a third wave of COVID-19 in the coming months?
A. Pandemics are likely to occur in multiple waves, and each wave could vary in the number of cases and its duration. Eventually, most of the population may get immune by asymptomatic or symptomatic infections (herd immunity). Over time, the disease may die out or may become endemic in the community with low transmission rates.
Key Message: There is a possibility of a third wave, but it is difficult to predict its timing and severity.
Q. Are children at greater risk if the third wave strikes?
A. In the first wave, primarily the elderly and individuals with co-morbidities were affected with severe disease. In the current (second) wave, a large number of younger population (30-45 years) have developed severe disease as also those without co-morbidities. After the second wave is over, if we do not continue following COVID appropriate behaviour, the third wave, if it occurs, is likely to infect the remaining non-immune individuals and that may include children also. The latest sero survey (December 2020 to January 2021) showed that the percentage of infected children in the age group of 10-17 years was around 25 per cent, the same as adults. This indicates that while children are being infected like adults, they are not getting the severe disease.
Key Message: Children are as susceptible as adults and older individuals to develop an infection but not a severe disease. It is highly unlikely that the third wave will predominantly or exclusively affect children.
Q. Are children likely to suffer from severe disease as being witnessed in the adult population in the current wave?
A. Fortunately, children have been relatively less affected so far due to several factors. The most important reason is the lesser expression of specific receptors to which this virus binds to enter the host and also the immune system of the children. A very small percentage of infected children may develop moderate to severe disease. If there is a massive increase in the overall numbers of infected individuals, a larger number of children with moderate to severe disease may be seen. Apart from the infection, parents should watch out for mental health issues in children and keep a watch to prevent child abuse and violence. Also, it is worth limiting screen time and prepare children for safe school reopening as per the Indian Academy of Pediatrics (IAP) guidelines.
Key Message: Almost 90 per cent of the infections in children are mild/asymptomatic. Therefore, the incidence of severe disease is not high in children.
Q. Can we rule out the possibility of severe infections in children in the third wave?
A. As explained, the spectrum of illness is likely to be much less severe in children than adults; there is only a remote possibility of children being more severely affected than adults in the next wave. As per data collected during the first and second waves, severe COVID-19 infections in children were not reported and only in few cases they were admitted to ICU. However, we need to be watchful about how the mutant strains will behave. The dictum here is: better be ready and prepared for the worst and hope for the best!
Key Message: Severe COVID-19 cases in children are rare. Further, there is no evidence indicating that children will have severe disease in the third wave.
Q. Severe disease due to COVID-19 is already occurring in children. Why it is so?
A. Yes, a severe illness related to COVID-19 is known to occur in children. This includes pneumonia and multisystem inflammatory syndrome in children (MIS-C). However, COVID-19 pneumonia in children is uncommon as compared to adults. In some cases, after 2-6 weeks of asymptomatic or symptomatic COVID-19 infection, MIS-C may be seen due to immune dysregulation with the incidence of 1-2 cases per 100,000 population; some of these cases also may be severe. It’s a treatable condition with a good outcome if diagnosed early. Also, most children suffering from MIS-C cannot transmit the infection to others.
Key Message: Children occasionally get the severe disease and may need ICU care, both during the acute illness and after 2-6 weeks due to MIS-C caused by COVID-19. But the majority are likely to recover if treated on time.
Q. preparations are being made in case the third wave comes and affects the children?
A. Most affected children get a mild disease with fever and need supervised home care with monitoring. We have learned a lot about COVID-19 illness from our shared experiences in adult medicine in the last 15 months. IAP guidelines on the management of COVID-19 in children are in place, and paediatricians have been sensitised and trained on its management. We need to be ready for a more significant number of patients seeking consultations; educating the parents on different platforms regarding illness and warning signs; and arranging more COVID-19 wards for children with more special wards such as high-dependency units (HDUs) and intensive care units (ICUs). The preventive behaviours are the same for children. Parents should also be ideal role models for their children regarding mask etiquette, hand hygiene, and social distancing. Children above the age of two to five years can be trained to use a mask; however, the adults have to follow the COVID-appropriate behaviour. IAP has also set guidelines for the safe reopening of schools for the safety of the children.
Key Message: We need to be prepared with more in-patient beds and intensive care beds for children. IAP has already developed the management protocol for disease categories in children. There is no reason to panic. Our preparations are in full swing.
Q. is the plan for vaccinating children?
A. So far, the global data show that compared to children, older adults are a thousand times more likely to die from COVID-19 disease. So, it has been a priority to vaccinate the high-risk elderly age group first. Thereafter, the emphasis should be on adults who also have more severe diseases as compared to children. When there is the remote possibility of children getting affected, some countries consider vaccinating children and adolescents. The same vaccines being used in adults can be used in children only after adequate trials. One of the India-made vaccines will soon undergo trials in children, and if proven immunogenic and safe, it could be fast-tracked for mass vaccination in children.
Key Message: Children do get the severe disease, even if the number is small. Thus, there is no harm in considering vaccination for them. The safety and efficacy, however, are being assessed in trials for this age. The national expert group on vaccine administration for COVID-19 will develop a plan as and when new scientific data emerge.
6. COVID-19 and White Fungus infection
Q. is White Fungus?
A. White Fungus, also known as candidiasis, is an opportunistic infection, which could spread fast to various body parts and, if not treated, could be serious. According to the Centre for Diseases Control and Prevention (CDC), White Fungus or invasive candidiasis can affect the blood, heart, brain, eyes, bones, or other parts of the body.
Q. Who are at high risk to get White Fungus infection?
A. White Fungus is all around us as it is found naturally in the environment. It primarily affects people with low immunity, who come in contact with objects that contain these fungal spores. For instance, COVID-19 patients on oxygen support can come in contact with these fungal spores if their ventilators and oxygen support equipment are not sanitised properly. Further, overuse of steroids and use of tap water in the humidifier attached to an oxygen cylinder can also heighten the risk of contracting White Fungus.
Q. Who can get infected by white fungus?
A. Invasive candidiasis is caused by a yeast (a type of fungus) called Candida. Candida can normally live inside the body, in areas like the mouth, throat, gut, and vagina, without causing any problems. However, individuals with low immunity, like patients recovering from a serious COVID-19 infection, are particularly at risk of contracting this fungal infection. In their bodies, the fungus can enter the bloodstream or internal organs to cause an infection.
People who are at high risk for developing this infection include those who:
• Have been admitted in the intensive care unit (ICU) for a prolonged period.
• Have weakened immune system (for example, people on cancer chemotherapy, people who have had an organ transplant, and people with low white blood cell counts).
• Have recently had surgery, especially multiple abdominal surgeries.
• Have recently received lots of antibiotics or steroids in the hospital.
• Receive total parenteral nutrition (food through a vein).
• Have kidney failure or are on hemodialysis.
• Have diabetes.
• Have a central venous catheter.
Q. Is White Fungus contagious?
A. White Fungus is not contagious in most cases, as it cannot spread directly from person to person. However, there exist some species of fungus that cause this infection on the skin. In such instances of external infection, the fungus can possibly be transferred from the patient to another individual who is at risk.
Q. are the symptoms of White Fungus?
A. Only CT scans or X-rays can reveal and completely confirm the White Fungus infection. Health experts report that it is more dangerous than Black Fungus, as it affects the lungs as well as other parts of the body like the nails, skin, stomach, kidney, brain, private areas, and mouth.
Moreover, the White Fungus can also infect the lungs the same way COVID-19 does. In fact, patients who get infected with White Fungus displayed COVID-19-like symptoms despite having tested negative for the virus. According to some reports, the oxygen saturation level of one of the four patients infected with White Fungus dropped from normal levels. However, the oxygen levels became normal after the antifungal medication was administered.
Q. How can White Fungus be treated?
A. Patients infected with White Fungus should be examined carefully, perhaps with a fungus culture test of their phlegm or mucus, to detect the extent of fungal infection in their body. After detection of the infection, antifungal medications can be used to treat the patients. Such medications have led to an improvement in their condition. The type and dose of antifungal medication used to treat White Fungus will depend on the patient’s age, immune status, location, and severity of the infection.
7. Related to use of oxygen during current COVID-19 pandemic
Q. is the normal respiratory rate of a healthy adult person?
A. Standard respiratory rates for a healthy adult range from 12 to 20 breaths per minute.
Q. Are 8 breaths per minute normal?
A. No. A patient needs to be evaluated medically
Q. How many litres of oxygen per minute do we breathe?
A. The average tidal volume, i.e., the average amount of air inhaled and exhaled per breathing cycle, is 0.5 litre (500 ml). Minute Ventilation (VE) is the total volume of air entering the lungs in a minute, which is 6 litres per minute.
Q. should be the normal oxygen saturation as recorded by a Pulse Oximeter?
Q. How do I check my oxygen level at home without a Pulse Oximeter?
A. If you do not have a portable finger pulse oximeter in your home, you can also learn how to assess signs and symptoms of low oxygen levels. Two classic signs of a low oxygen level are a rapid heart rate and a fast breathing rate. An average heart rate is 60–100 beats per minute and an average breathing rate is 12–20 breaths per minute. However, under low oxygen conditions, body responses include an increase in heart rate and breathing rate. Another sign of a low blood oxygen level is cyanosis or a bluish colour change on your lips, nose, or fingertips. As your body loses oxygen, the blood cells in your body change colour in your bloodstream to a dark blue, which can be seen from the outside of your skin if it is severe. Cyanosis is typically a late sign of low oxygen levels and is considered a medical emergency. If you notice this bluish discolouration, you should immediately visit the nearest hospital.
Q. Do we see many cases of silent hypoxia in this wave? How can this be addressed?
A. Silent hypoxia or happy hypoxia is referred to as the early stage of COVID-19. As the oxygen level drops, one may start feeling shortness of breath, confusion, and other symptoms. Keep watching for these signs and do not ignore them. This is true for young people as well. If you monitor low oxygen level, change in lip colour from natural to blue or persistent sweating, consult the COVID helpline or doctor. They could be the early sign of silent hypoxia.
Q. In brief, how can proning help enhance blood oxygen levels?
A. Proning is a medically accepted process to improve the distribution and exchange of oxygen in the lungs. A patient is safely placed from their back onto their abdomen (stomach), i.e., face down to improve breathing and oxygenation. It has been shown as beneficial for COVID-19 patients with compromised breathing comfort, especially during home isolation.
Q. Is pure oxygen used in hospitals?
A. Medical oxygen contains high purity oxygen used for medical treatments and is developed for use in human body. Cylinders contain a compressed oxygen gas and no gases are allowed in the cylinder to prevent contamination.
Q. is the use of medical oxygen?
A. Oxygen is used for treatment in hospitals. Hence, it is considered a drug or a pharmaceutical product.
Q. is the need for medical oxygen?
A. The human body requires oxygen to survive, and typically, we breathe in from air. However, if you have lung disease or other medical conditions such as COVID-19, you may not get enough oxygen due to compromised lungs. That can leave you short of breath and cause problems with your heart, brain, and other parts of your body.
Q. Can breathing 100 per cent oxygen harm your body?
A. Yes. Breathing 100 per cent oxygen also eventually leads to collapse of the alveoli (atelectasis).
Q. Can you get excess (more than required) oxygen from an oxygen concentrator?
A. It is possible to get excess (more than required) oxygen from an oxygen concentrator. However, this is quite rare when oxygen concentrators are used as directed and prescribed. All supplemental oxygen requires a prescription from a doctor, who carefully chooses your oxygen requirement.
Q. is the role of oxygen during COVID-19 disease?
A. The demand for medical oxygen increases in COVID-19 as the disease primarily affects the lungs and, in severe cases, causes death due to Acute Respiratory Distress Syndrome (ARDS) and pneumonia.
Q. When does a patient require medical oxygen in a COVID-19 positive case?
A. As per AIIMS/ICMR-Covid-19/National Task Force/Joint Monitoring Group (Dte.GHS), MoHFW, Government of India, Clinical Guidelines for Management of Adult COVID-19 Patient issued on 22nd April 2021, moderate and severe cases of COVID-19 where the infection induces shortage of oxygen in the body due to its impact on lungs require medical oxygen and immediate oxygen therapy. Oxygen acts as a life-saver for COVID-19 patients.
Q. are moderate COVID-19 cases?
A. In moderate COVID-19 cases, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than or equal to 24/minute and SpO2 90 per cent to 93 per cent with ambient air.
Q. is severe COVID-19 cases?
A. In severe COVID-19 case, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than 30/minute and SpO2 less than 90 per cent in room air.
Q. When does a patient require mechanical ventilator support?
A. A patient may be put on a mechanical ventilator if it becomes very difficult to breathe or get enough oxygen into their blood. This condition is called respiratory failure. Mechanical ventilators are machines that act as bellows to move air in and out of the patient’s lungs. The respiratory therapist and doctor set the ventilator to control how often it pushes air into the lungs and how much air the patient gets. The patient may be fitted with a mask to get air from the ventilator into the lungs. Or, they may need a breathing tube if their breathing problem is more serious.
Q. Can mechanical ventilation be given at home?
A. Mechanical ventilators are mainly used in hospitals and transport systems such as ambulances and medical evacuation by air transport, etc. In some cases, they can be used at home if the illness is long-term and the caregivers at home receive training and have adequate nursing and other resources at home. Being on a ventilator may make a patient more susceptible to pneumonia, damage to the vocal cords, or other problems.
Q. is the six minute walk test for COPD?
A. The six minute walk test (6MWT) is an exercise test that measures functional status in chronic obstructive pulmonary disease (COPD) patients and provides information on oxygen desaturation. This test is also being used for COVID-19. In case of COVID-19 symptoms, SpO2 level must be checked before taking a walk. Now, walk for six minutes without a break on an even surface and measure the SpO2 level. It may fall 1-2 per cent, but consult a medical professional if it falls below 93 per cent.
Source:
https://ndma.gov.in/sites/default/files/2021-03/FAQs-on-Use-of-oxygen-.pdf
8. Related to drugs and medications to fight the disease
Q. Is Remdesivir effective in the treatment of COVID-19?
A. No study has conclusively been able to prove that Remdesivir is beneficial in the treatment of COVID-19. However, India has approved Remdesivir under the National Clinical Management Protocol for COVID-19, which was developed after many interactions by a committee of experts. The protocol acts as the guiding document for the treatment of COVID-19 patients in India. Remdesivir is listed as an investigational therapy in the protocol, i.e., where informed and shared decision-making is essential, besides noting contraindications mentioned in the detailed guidelines.
Q. is Remdesivir? How does Remdesivir work?
A. Remdesivir is an investigational drug used to treat viral infections. It is classified as a broadspectrum antiviral with potential antiviral activity against a variety of RNA viruses.
The drug works against the novel coronavirus by inhibiting replication of the virus in the body. Remdesivir functions as a pro-drug that is modified in the body before it becomes an active drug. It is classified as a nucleoside analog, one of the oldest classes of antiviral medications, and resembles the RNA base adenosine. In general, nucleoside and nucleotide analogues simulate the structure of a true nucleoside or nucleotide. The simulated structure may then be incorporated into the virus. Remdesivir works when the enzyme replicating the genetic material for the novel coronavirus − RNA polymerase − incorporates the adenosine analogue in place of the natural molecule into the growing RNA strand. By introducing the modified agent, Remdesivir, replication of the novel coronavirus is interrupted, and the virus ceases to multiply and cannot infect more cells in the body
Q. When should a patient of COVID-19 take Remdesivir?
A. The timing of the drug, when it is administered, is most important. Taking it too early or too late could do more harm than good. Remdesivir is applicable only in hospitalised patients who showed very low oxygen saturation and infiltrated their chest X-ray or CT scan. The optimal timing for Remdesivir is usually after five to seven days of having the virus. Early to mild or asymptomatic patients should not take Remdesivir. Also, it is of no use if it’s given very late because it would create a cytokine storm. A cytokine storm is when the immune system goes into overdrive. The body starts to attack its cells and tissues instead of just the virus.
Q. Can Remdesivir be taken at home?
A. Remdesivir comes in a vial and has to be injected only after prescription and in the presence of a health practitioner. It is for patients who are hospitalised and severe. Therefore, it should not be given at home. It is for patients who need to be admitted and need hospital care.
Q. Are steroids effective in the treatment of COVID-19?
A. There is no evidence to support the use of steroids in the treatment of COVID-19. The World Health Organization (WHO) recovery trial showed that steroids do have a beneficial effect. But again, the timing is critical. The recovery trial clearly showed that if we give steroids too early, it showed a harmful effect before oxygen saturation. Steroids are most effective during the later part of the disease when there is more inflammation and oxygen saturation is falling. Steroids are only helpful for moderate or severe cases.
Q. Is plasma a good way to fight off COVID-19?
A. Convalescent plasma has been a therapy devised to passively transfer antibodies from a recovered person to a new patient. While the therapy has been received with different opinions by the medical community, the important aspect is timing. It’s better if plasma therapy is used early before clinical worsening. Also, plasma with high titer neutralising antibodies would have better results. Hence, to achieve good results, correct patient selection, timing and a good quality plasma donor are needed for success in this form of treatment.
Q. Should a person with COVID-19 take Tocilizumab?
A. Tocilizumab is a drug of last resort. It should only be used when a COVID-19 infection in a patient is worsening despite steroids, Remdesivir and other treatments like anticoagulants. Tocilizumab is required in less than 2 per cent of COVID-19 patients. Very few patients need this drug because it’s only for treating a cytokine storm and has a limited role.
Q. Is Favipiravir effective in treating COVID-19?
A. Favipiravir is another antiviral that is being promoted for the treatment of COVID-19. It was initially doled out as a treatment of influenza after the H1N1 pandemic. There is not enough evidence in robust studies to show that it is a good drug. Since it’s not a proven treatment, India’s national guidelines also don’t recommend its use.
Q. Is it possible to treat COVID-19 without any of the drugs mentioned above?
A. People with mild COVID-19 or those who are asymptomatic will improve with just symptomatic treatment. Mild COVID-19 infection can be treated with paracetamol, good hydration and multivitamins − without any treatment. Giving treatment when it is not required may be doing more harm than good.
9. Related to Black Fungus and COVID-19 disease
Q. is Black Fungus?
A. Black Fungus, also known as mucormycosis, is a rare fungal infection. It is called ‘black’ because of the colour of the fungal growth. It is caused by exposure to mucor mold found in soil, manure, and rotten/decaying fruits and vegetables. It is ubiquitous and even present in the nose/mucosa of healthy individuals. This disease usually affects the sinuses, eye orbit, and brain. That is why it is also called ‘rhino-orbital-cerebral’ mucormycosis. It may be life-threatening in immuno-compromised individuals (cancer patients, HIV/AIDS) and people with uncontrolled diabetes.
Q. are the risk factors for acquiring Black Fungus infection?
A. Risk Factors are:
• Uncontrolled Diabetes Mellitus
• Treated for COVID-19 with corticosteroids
• Treated for COVID-19 with immunomodulators
• Treated for COVID-19 with mechanical ventilation
• Prolonged oxygen therapy
• Prolonged ICU stay
• Immuno-compromised state
Q. Why the sudden increase in Black Fungus cases?
A. It may be triggered by extensive use of steroids, which is a life-saving treatment for moderate to severe COVID-19 infection. Steroids lower the immunity and cause a sudden up-shooting of blood sugar levels in diabetes and non-diabetic patients. For patients on humidified oxygen, care should be taken to make sure there is no water leak to prevent the growth of the fungus.
Q. How serious is Black Fungus?
A. Black fungus infection causes a vision-threatening and life-threatening condition.
Q. Do all COVID-19 patients need to be worried about Black Fungus infection?
A. No. As discussed, high-risk patients need to be alert. Also, during COVID-19 recovery, everyone should watch out for early signs and symptoms.
Q. are the precautions one can take to avoid this disease?
A. One can take the following precautions:
• Boost immune system with diet, hydration and exercise.
• Rational use of steroids by follow guidelines.
• Strict blood sugar monitoring and control in all patients who are on steroids.
Q. are the early signs of Black Fungus?
A. Some of the early signs are:
• Facial pain
• Facial swelling/puffiness/discolouration
• Sinus headache
• Stuffy nose
• The blurring of vision/decreased vision
• Double vision
• Drooping of eyelid
• Blood-stained nasal discharge
• Dental pain
Q. Is Black Fungus treatable?
A. Yes. Early diagnosis and a prompt multi-speciality team of medical professionals can manage it.
Q. Which specialist should I visit for Black Fungus?
A. ENT and eye specialists are central to this disease. The team includes care coordination with neurosurgeon, endocrinologist and microbiologist.
Source:
https://www.eyeqindia.com/frequently-asked-questions-on-covid-and-black-fungus/#toggle-id-9
10. Related to indoor air and COVID-19 disease
Q. Will running an evaporative cooler help protect my family and me from COVID-19?
A. Evaporative coolers (or ‘swamp coolers’) can help protect people indoors from the airborne transmission of COVID-19 because they increase ventilation with outside air to cool indoor spaces. Evaporative coolers are used in dry climates. They use water to provide cooling and improve relative humidity in indoor microenvironments. When operating as intended (with open windows), these devices produce substantial increases in ventilation with outdoor air. Some evaporative coolers can be performed without using water when temperatures are milder to increase ventilation indoors. Avoid using evaporative coolers if air pollution outside is high and the system does not have a high-efficiency filter
Q. Is ventilation important for indoor air quality when cleaning and/or sanitising for COVID-19 indoors?
A. When cleaning and disinfecting for COVID-19, ventilation is essential − in general, increasing ventilation during and after cleaning helps to reduce exposure to cleaning and disinfection products and by-products. Increasing ventilation, for example, by opening windows or doors, can also reduce risks from particles resuspended during cleaning, including those potentially carrying SARS-CoV-2 (or other contaminants). Avoid ventilation with outdoor air when outdoor air pollution is high or when it makes your home too cold, hot, or humid.
Q. Will an air cleaner or air purifier help protect my family and me from COVID-19 in my home?
A. When appropriately used, air purifiers can help reduce airborne contaminants, including viruses, in a home or confined space.
Q. How can I increase ventilation at home to help protect my family from COVID-19?
A. Ensuring proper ventilation with outside air is a standard best practice for improving indoor air quality. To increase ventilation in your home, one can:
• Open the windows or screened doors, if possible;
• Operate an air conditioner that has an outdoor air intake or vent; and
• Operate a bathroom fan when the bathroom is in use and continuously, if possible.
However, the practices mentioned here are not enough to protect people from COVID-19. When used along with other best practices recommended by the Ministry of Health and Family Welfare, Government of India, the above methods can be part of a plan to protect yourself and your family.
Source:
https://www.epa.gov/coronavirus/indoor-air-and-coronavirus-covid-19
1. SARS-CoV-2 surveillance in India
Q. What is INSACOG?
A. The Indian SARS-CoV-2 Genomics Consortium (INSACOG) is a national multi-agency consortium of Regional Genome Sequencing Laboratories (RGSLs) established by the Government of India on 30th December 2020. Initially, this consortium had 10 laboratories. Subsequently, the scope of laboratories under INSACOG was expanded and at present there are 28 laboratories under this consortium, which monitor the genomic variations in SARS-CoV-2.
Q. What is the objective of INSACOG?
A. The SARS-CoV-2 virus, commonly known as COVID-19 virus, posed unprecedented public health challenges globally. To fully understand the spread and evolution of this virus, its mutations and resulting variants, the need for in-depth sequencing and analysis of the genomic data was felt. Against this backdrop, INSACOG was established to expand whole genome sequencing of SARS-CoV-2 virus across the nation, aiding understanding of how the virus spreads and evolves. Any changes to the genetic code, or mutations in the virus, can be observed based on the analysis and sequencing of samples done in the laboratories under INSACOG. INSACOG has the following specific objectives:
- • To ascertain the status of variants of interest (VoI) and variants of concern (VoC) in the country
- • To establish sentinel surveillance and surge surveillance mechanisms for early detection of genomic variants and assist in formulating effective public health response
- • To determine the presence of genomic variants in samples collected during superspreader events and in areas reporting increasing trend of cases/deaths, etc.
Q. When did India start SARS-CoV-2 viral sequencing?
A. India started sequencing SARS-CoV-2 viral sequencing of genomes in 2020. Initially, National Institute of Virology (NIV) and Indian Councilof Medical Research (ICMR) sequenced samples of international passengers who arrived in India from the UK, Brazil or South Africa or transited through these countries, which reported a sudden surge in cases. RTPCR positive samples from states reporting sudden surges in cases were sequenced on priority. This was further expanded through the efforts of Council of Scientific and Industrial Research (CSIR), Department of Biotechnology (DBT) and National Centre for Disease Control (NCDC), as well as individual institutions.
The initial focus of India was on restricting the spread of global variants of concern in the country – Alpha (B.1.1.7), Beta (B.1.351) and Gamma (P.1) – which had high transmissibility. The entry of these variants was carefully tracked by INSACOG. Subsequently, the Delta and Delta Plus variants were also identified based on whole genome sequencing analysis conducted in the INSACOG laboratories.
Q. What is the strategy for SARS-CoV-2 surveillance in India?
A. Initially, genomic surveillance was focused on the variants carried by international travellers and their contacts in the community through sequencing three to five per cent of the total RTPCR positive samples.
Subsequently, the sentinel surveillance strategy was also communicated to the States/UTs in April 2021. Under this strategy, multiple sentinel sites are identified to adequately represent the geographic spread of a region, and RT-PCR positive samples are sent from each sentinel site for whole genome sequencing. Detailed Standard Operating Procedures (SOPs) for sending samples from the identified sentinel sites regularly to the designated RGSLs were shared with States/UTs. The list of INSACOG RGSLs tagged to States was also communicated to the States. A dedicated nodal officer was also designated by all States/UTs for coordinating the activity of whole genome sequencing.
1. Sentinel Surveillance (for all States/UTs/): This is an ongoing surveillance activity across India. Each State/UT has identified sentinel sites (including RT-PCR labs and tertiary health care facilities) from where RT-PCR positive samples are sent for whole genome sequencing.
2. Surge Surveillance (for districts with COVID-19 clusters or those reporting a surge in cases): A representative number of samples (as per the sampling strategy finalised by a state surveillance officer/central surveillance unit) are collected from the districts, which show a surge in the number of cases and are sent to RGSLs.
Q. What is the standard operating procedure (SOP) for sending samples to INSACOG laboratories?
A. The SOPs for sending samples to INSACOG laboratories and subsequent action based on genome sequencing analysis are as follows:
1. The Integrated Disease Surveillance Project (IDSP) machinery coordinates sample collection and transportation from the districts/sentinel sites to RGSLs. The RGSLs are responsible for genome sequencing and identification of VoCs/VoIs, potential VoIs, and other mutations. Information on VOCs/ VOIs is submitted to the Central Surveillance Unit, IDSP, to establish clinico-epidemiological correlation in coordination with state surveillance officers.
2. Based on discussions in the Scientific and Clinical Advisory Group (SCAG) established to support the INSACOG, it was decided that upon identification of a genomic mutation, which could be of public health relevance, RGSL will submit the same to SCAG. SCAG discusses the potential VoIs and other mutations and, if felt appropriate, recommends to the Central Surveillance Unit for further investigation.
3. The genome sequencing analysis and clinico-epidemiological correlation established by IDSP is shared with MOH&FW, ICMR, DBT, CSIR and States/UTs for formulating and implementing requisite public health measures.
4. The new mutations/VoCs are cultured, and genomic studies are undertaken to see the impact on vaccine efficacy and immune escape properties.
Source: https://dbtindia.gov.in/pressrelease/qa-indian-sars-cov-2-genomics-consortium-insacog
2. Delta and Delta Plus variants
Q. Why are frequent mutations seen in SARS-CoV-2 virus? When will the mutations stop?
A. SARS-CoV-2 can mutate due to the following reasons:
- • Random error during replication of virus
- • Immune pressure faced by the viruses after treatments such as convalescent plasma, vaccination or monoclonal antibodies (antibodies produced by a single clone of cells with identical antibody molecules)
- • Uninterrupted transmission due to lack of COVID appropriate behaviour. Here the virus finds an excellent host to grow and becomes more fit and transmissible.
The virus will continue to mutate as long as the pandemic remains. This makes it all the more crucial to follow COVID appropriate behaviour.
Q. What are variants of interest (VoIs) and variants of concern (VoCs)?
A. When mutations happen – if there is any previous association with any other similar variant, which is felt to have an impact on public health – then it becomes a variant under investigation (VuI).
Once genetic markers are identified, which can have an association with a receptor binding domain or which have an implication on antibodies or neutralising assays, we call them variants of interest (VoIs).
The moment we get evidence for increased transmission through field-site and clinical correlations, it becomes a variant of concern (VoC). VoCs are those that have one or more of the following characteristics:
- • Increased transmissibility
- • Change in virulence/disease presentation
- • Evading diagnostics, drugs and vaccines
The first VoC was announced by the UK where it was found. Currently there are four VoCs identified by the scientists – Alpha, Beta, Gamma and Delta.
Q. What are Delta and Delta Plus variants?
A. . These are the names given to variants of SARS-CoV-2 virus, based on the mutations found in them. The World Health Organization (WHO) has recommended using letters of the Greek Alphabet, i.e., Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), Delta (B.1.617), etc., to denote variants, for easier public understanding.
Delta variant, also known as SARS-CoV-2 B.1.617, has about 15-17 mutations. It was first reported in October 2020. More than 60 per cent of cases in Maharashtra in February 2021 pertained to Delta variants.
It is the Indian scientists who identified the Delta variant and submitted it to the global database. The Delta variant is classified as a VoC and has now spread to 80 countries, as per the WHO. The Delta variant (B.1.617) has three subtypes B1.617.1, B.1.617.2 and B.1.617.3, of which B.1.617.1 and B.1.617.3 have been classified as VoI, while B.1.617.2 (Delta Plus) has been classified as a VoC.
Compared to the Delta variant, the Delta Plus variant has an additional mutation. This mutation is called the K417N mutation. ‘Plus’ means an additional mutation has happened to the Delta variant. It does not mean that the Delta Plus variant is more severe or highly transmissible than the Delta variant.
Q. Why has the Delta Plus variant (B.1.617.2) been classified as a VoC?
A. It has been classified as a VoC because of the following characteristics:
- • Increased transmissibility
- • Stronger binding to receptors of lung cells
- • Potential reduction in monoclonal antibody response
- • Potential post vaccination immune escape
Q. How often are these mutations studied in India?
A. Indian SARS-CoV-2 Genomics Consortium (INSACOG), coordinated by the Department of Biotechnology (DBT) along with the Union Health Ministry, ICMR, and CSIR, monitors the genomic variations in SARS-CoV-2 on a regular basis through a pan-India multi-laboratory network. It was set up with 10 national labs in December 2020 and has been expanded to 28 labs and 300 sentinel sites from where genomic samples are collected. The INSACOG hospital network looks at samples and informs INSACOG about the severity, clinical correlation, breakthrough infections and re-infections.
More than 65,000 samples have been taken from states and processed, while nearly 50,000 samples have been analysed of which 50 per cent have been reported to be VoCs.
Q. On what basis are the samples subjected to genome sequencing?
A. Sample selection is done under three broad categories:
- • International passengers (during the beginning of the pandemic)
- • Community surveillance (where RT-PCR samples report CT value less than 25)
- • Sentinel surveillance where samples are obtained from labs (to check transmission) and hospitals (to check severity)
When there is any public health impact noticed because of genetic mutation, then the same is monitored.
Q. What is the trend of VoCs circulating in India?
A. As per the latest data, 90 per cent of samples tested have been found to have Delta variants (B.1.617). However, B.1.1.7 strain, which was the most prevalent variant in India in the initial days of the pandemic, has decreased.
Q. Why is action regarding public health not taken immediately after noticing mutations in the virus?
A. t is not possible to say whether the mutations noticed will increase transmission. Also, until there is scientific evidence that proves a correlation between the rising number of cases and variant proportion, we cannot confirm there is a surge in the particular variant. Once mutations are found, it is analysed every week to find out if there is any such correlation between the surge of cases and variant proportion. Public health action can be taken only if scientific proofs for such correlation are available.
Once such correlation is established, it will help greatly to prepare in advance when such a variant is seen in another area/region.
Q. Do Covishield and Covaxin work against the variants of SARS-CoV-2?
A. Yes, Covishield and Covaxin are both effective against the Alpha, Beta, Gamma and Delta variants. Lab tests to check vaccine effectiveness on Delta Plus variants are ongoing.
Delta Plus variants: The virus has been isolated and is now being cultured at ICMR’s National Institute of Virology, Pune. Laboratory tests to check vaccine effectiveness are ongoing and the results will be available in 7 to 10 days. This will be the first result in the world.
Q. What are the public health interventions being carried out to tackle these variants?
A. The public health interventions needed are the same, irrespective of the variants. The following measures are being taken:
- • Cluster containment
- • Isolation and treatment of cases
- • Quarantining of contacts
- • Ramping up vaccination
Q. Do public health strategies change as the virus mutates and more variants arise?
A. No, public health prevention strategies do not change with variants.
Q. Why is continuous monitoring of mutations important?
A. Continuous monitoring of mutations is important to track potential vaccine escape, increased transmissibility and disease severity.
Q. What does a common man do to protect self from these VoCs?
A. One must follow COVID appropriate behaviour, which includes wearing a mask properly, washing hands frequently and maintaining social distancing. The second wave is not over yet. It is possible to prevent a big third wave provided individuals and society practice protective behaviour. Further, test positivity rate must be closely monitored by each district. If the test positivity goes above 5 per cent, strict restrictions must be imposed.
Source: https://pib.gov.in/PressReleseDetailm.aspx?PRID=1730875
3. COVID-19 vaccination for pregnant women
Q. Why is COVID-19 vaccine being recommended for pregnant women?
A. Pregnancy does not increase the risk to COVID-19 infection. Most pregnant women will be asymptomatic or have mild disease, but their health may deteriorate rapidly and that might affect the foetus too. It is important that they take all precautions to protect themselves from COVID-19, including taking the vaccination against the same. It is, therefore, advised that a pregnant woman should take the COVID-19 vaccine.
Q.Who are at higher risk of getting infected with COVID-19?
A. Higher risk of infection involves with:
- • A healthcare worker or a frontline worker
- • A community with high or increasing rate of COVID-19 infections
- • Those frequently exposed to people outside the household
- • Those who have difficulty in complying with social distance if living in a crowded household
Q. How does COVID-19 affect the health of a pregnant woman?
A. Although most (>90 per cent) infected pregnant women recover without hospitalization, rapid deterioration in health may occur in a few. Symptomatic pregnant women appear to be at increased risk of severe disease and death. In severe disease, like all other patients, pregnant women may also need hospitalisation. Pregnant women with underlying medical conditions, for example, high blood pressure, diabetes, obesity, and age over 35 years are at higher risk of severe illness due to COVID-19.
Q. How does COVID-19 infection of pregnant women affect the baby?
A. Most (over 95 per cent) of newborns of COVID-19 positive mothers have been in good condition at birth. In some cases, COVID-19 infections in pregnancy may increase the possibility of a premature delivery; the baby’s weight may be less than 2.5 kg; and in rare situations, the baby might die before birth.
Q. Which pregnant women are at a higher risk of developing complications after COVID-19 infection?
A. Pregnant women who are:
- • Older than 35 years of age
- • Obese
- • Have an underlying medical condition such as diabetes or high blood pressure
- • Have a history of clotting in the limbs
Q. If a pregnant woman has already had COVID-19, when should she be vaccinated?
A. In case a woman is infected with COVID-19 during the current pregnancy, then she should be vaccinated soon after the delivery.
Q. Are there any side effects of the COVID-19 vaccines that can either harm the pregnant woman or her foetus?
A. The available COVID-19 vaccines are safe and the vaccination protects pregnant women against COVID-19 like other individuals. Like any medicine a vaccine may have side effects, which are normally mild. After getting the vaccine, she can get mild fever, pain at the injection site, or feel unwell for 1-3 days. The long-term adverse effects and safety of the vaccine for the foetus and the child born is not established yet. Very rarely, (one in one to five lakh people) the beneficiary may, after the COVID-19 vaccination, experience some of the following symptoms within 20 days after getting the injection, which may need immediate attention.
Q. When should the vaccine be given to the pregnant woman?
A. The COVID-19 vaccination schedule can be started any time during pregnancy
Q. What other precautions should the pregnant woman take after vaccination?
A. Counsel the pregnant woman and her family members to continue to practice COVID appropriate behaviour: wearing double masks, frequent hand washing, maintaining physical distance, and avoiding crowded areas, to protect themselves and those around from spreading the COVID-19 infection.
Q. How does a pregnant woman register herself for the Covid-19 vaccination?
A. All pregnant women need to register themselves on the Co-WIN portal or may get themselves registered on-site at the COVID-19 vaccination centre. The process of registration for pregnant women remains the same as of the general population and as per the latest guidelines provided by the Ministry of Home and Family Welfare (MoHFW) from time to time.
Source:
https://www.mohfw.gov.in/pdf/OperationalGuidanceforCOVID19vaccinationofPregnantWoman.pdf
4. The third wave of COVID-19 in India and protecting children
Q. What is the possibility of a third wave of COVID-19 in the coming months?
A. Pandemics are likely to occur in multiple waves, and each wave could vary in the number of cases and its duration. Eventually, most of the population may get immune by asymptomatic or symptomatic infections (herd immunity). Over time, the disease may die out or may become endemic in the community with low transmission rates.
Key Message: There is a possibility of a third wave, but it is difficult to predict its timing and severity.
Q. Are children at greater risk if the third wave strikes?
A. In the first wave, primarily the elderly and individuals with co-morbidities were affected with severe disease. In the current (second) wave, a large number of younger population (30-45 years) have developed severe disease as also those without co-morbidities. After the second wave is over, if we do not continue following COVID appropriate behaviour, the third wave, if it occurs, is likely to infect the remaining non-immune individuals and that may include children also. The latest sero survey (December 2020 to January 2021) showed that the percentage of infected children in the age group of 10-17 years was around 25 per cent, the same as adults. This indicates that while children are being infected like adults, they are not getting the severe disease.
Key Message: Children are as susceptible as adults and older individuals to develop an infection but not a severe disease. It is highly unlikely that the third wave will predominantly or exclusively affect children.
Q. Are children likely to suffer from severe disease as being witnessed in the adult population in the current wave?
A. Fortunately, children have been relatively less affected so far due to several factors. The most important reason is the lesser expression of specific receptors to which this virus binds to enter the host and also the immune system of the children. A very small percentage of infected children may develop moderate to severe disease. If there is a massive increase in the overall numbers of infected individuals, a larger number of children with moderate to severe disease may be seen. Apart from the infection, parents should watch out for mental health issues in children and keep a watch to prevent child abuse and violence. Also, it is worth limiting screen time and prepare children for safe school reopening as per the Indian Academy of Pediatrics (IAP) guidelines.
Key Message: Almost 90 per cent of the infections in children are mild/asymptomatic. Therefore, the incidence of severe disease is not high in children.
Q. Can we rule out the possibility of severe infections in children in the third wave?
A. As explained, the spectrum of illness is likely to be much less severe in children than adults; there is only a remote possibility of children being more severely affected than adults in the next wave. As per data collected during the first and second waves, severe COVID-19 infections in children were not reported and only in few cases they were admitted to ICU. However, we need to be watchful about how the mutant strains will behave. The dictum here is: better be ready and prepared for the worst and hope for the best!
Key Message: Severe COVID-19 cases in children are rare. Further, there is no evidence indicating that children will have severe disease in the third wave.
Q. Severe disease due to COVID-19 is already occurring in children. Why it is so?
A. Yes, a severe illness related to COVID-19 is known to occur in children. This includes pneumonia and multisystem inflammatory syndrome in children (MIS-C). However, COVID-19 pneumonia in children is uncommon as compared to adults. In some cases, after 2-6 weeks of asymptomatic or symptomatic COVID-19 infection, MIS-C may be seen due to immune dysregulation with the incidence of 1-2 cases per 100,000 population; some of these cases also may be severe. It’s a treatable condition with a good outcome if diagnosed early. Also, most children suffering from MIS-C cannot transmit the infection to others.
Key Message: Children occasionally get the severe disease and may need ICU care, both during the acute illness and after 2-6 weeks due to MIS-C caused by COVID-19. But the majority are likely to recover if treated on time.
Q. What preparations are being made in case the third wave comes and affects the children?
A. Most affected children get a mild disease with fever and need supervised home care with monitoring. We have learned a lot about COVID-19 illness from our shared experiences in adult medicine in the last 15 months. IAP guidelines on the management of COVID-19 in children are in place, and paediatricians have been sensitised and trained on its management. We need to be ready for a more significant number of patients seeking consultations; educating the parents on different platforms regarding illness and warning signs; and arranging more COVID-19 wards for children with more special wards such as high-dependency units (HDUs) and intensive care units (ICUs). The preventive behaviours are the same for children. Parents should also be ideal role models for their children regarding mask etiquette, hand hygiene, and social distancing. Children above the age of two to five years can be trained to use a mask; however, the adults have to follow the COVID-appropriate behaviour. IAP has also set guidelines for the safe reopening of schools for the safety of the children.
Key Message: We need to be prepared with more in-patient beds and intensive care beds for children. IAP has already developed the management protocol for disease categories in children. There is no reason to panic. Our preparations are in full swing.
Q. What is the plan for vaccinating children?
A. So far, the global data show that compared to children, older adults are a thousand times more likely to die from COVID-19 disease. So, it has been a priority to vaccinate the high-risk elderly age group first. Thereafter, the emphasis should be on adults who also have more severe diseases as compared to children. When there is the remote possibility of children getting affected, some countries consider vaccinating children and adolescents. The same vaccines being used in adults can be used in children only after adequate trials. One of the India-made vaccines will soon undergo trials in children, and if proven immunogenic and safe, it could be fast-tracked for mass vaccination in children.
Key Message: Children do get the severe disease, even if the number is small. Thus, there is no harm in considering vaccination for them. The safety and efficacy, however, are being assessed in trials for this age. The national expert group on vaccine administration for COVID-19 will develop a plan as and when new scientific data emerge.
5. COVID-19 and White Fungus infection
Q. What is White Fungus?
A. White Fungus, also known as candidiasis, is an opportunistic infection, which could spread fast to various body parts and, if not treated, could be serious. According to the Centre for Diseases Control and Prevention (CDC), White Fungus or invasive candidiasis can affect the blood, heart, brain, eyes, bones, or other parts of the body.
Q. Who are at high risk to get White Fungus infection?
A. White Fungus is all around us as it is found naturally in the environment. It primarily affects people with low immunity, who come in contact with objects that contain these fungal spores.
For instance, COVID-19 patients on oxygen support can come in contact with these fungal spores if their ventilators and oxygen support equipment are not sanitised properly. Further, overuse of steroids and use of tap water in the humidifier attached to an oxygen cylinder can also heighten the risk of contracting White Fungus.
Q. Who can get infected by white fungus?
A. Invasive candidiasis is caused by a yeast (a type of fungus) called Candida. Candida can normally live inside the body, in areas like the mouth, throat, gut, and vagina, without causing any problems. However, individuals with low immunity, like patients recovering from a serious COVID-19 infection, are particularly at risk of contracting this fungal infection. In their bodies, the fungus can enter the bloodstream or internal organs to cause an infection.
People who are at high risk for developing this infection include those who:
- • Have been admitted in the intensive care unit (ICU) for a prolonged period.
- • Have weakened immune system (for example, people on cancer chemotherapy, people who have had an organ transplant, and people with low white blood cell counts).
- • Have recently had surgery, especially multiple abdominal surgeries.
- • Have recently received lots of antibiotics or steroids in the hospital.
- • Receive total parenteral nutrition (food through a vein).
- • Have kidney failure or are on hemodialysis.
- • Have diabetes.
- • Have a central venous catheter.
Q. Is White Fungus contagious?
A. White Fungus is not contagious in most cases, as it cannot spread directly from person to person. However, there exist some species of fungus that cause this infection on the skin. In such instances of external infection, the fungus can possibly be transferred from the patient to another individual who is at risk.
Q. What are the symptoms of White Fungus?
A. Only CT scans or X-rays can reveal and completely confirm the White Fungus infection. Health experts report that it is more dangerous than Black Fungus, as it affects the lungs as well as other parts of the body like the nails, skin, stomach, kidney, brain, private areas, and mouth.
Moreover, the White Fungus can also infect the lungs the same way COVID-19 does. In fact, patients who get infected with White Fungus displayed COVID-19-like symptoms despite having tested negative for the virus. According to some reports, the oxygen saturation level of one of the four patients infected with White Fungus dropped from normal levels. However, the oxygen levels became normal after the antifungal medication was administered.
Q. How can White Fungus be treated?
A. Patients infected with White Fungus should be examined carefully, perhaps with a fungus culture test of their phlegm or mucus, to detect the extent of fungal infection in their body. After detection of the infection, antifungal medications can be used to treat the patients. Such medications have led to an improvement in their condition. The type and dose of antifungal medication used to treat White Fungus will depend on the patient’s age, immune status, location, and severity of the infection.
6. Related to use of oxygen during current COVID-19 pandemic
Q. What is the normal respiratory rate of a healthy adult person?
A. Standard respiratory rates for a healthy adult range from 12 to 20 breaths per minute.
Q. Are 8 breaths per minute normal?
A. No. A patient needs to be evaluated medically.
Q. How many litres of oxygen per minute do we breathe?
A. The average tidal volume, i.e., the average amount of air inhaled and exhaled per breathing cycle, is 0.5 litre (500 ml). Minute Ventilation (VE) is the total volume of air entering the lungs in a minute, which is 6 litres per minute.
Q. What should be the normal oxygen saturation as recorded by a Pulse Oximeter?
A. The normal oxygen saturation level in the blood (SpO2 ) should be 95 per cent or higher. Some people with chronic lung disease, such as Chronic Obstructive Pulmonary Disease (COPD) or sleep apnea, may have normal levels of around 90 per cent. The ‘SpO2 ’ reading on a pulse oximeter shows the percentage of oxygen in the blood. If your home SpO2 reading is lower than 94 per cent, call your healthcare provider.
Q. How do I check my oxygen level at home without a Pulse Oximeter?
A. If you do not have a portable finger pulse oximeter in your home, you can also learn how to assess signs and symptoms of low oxygen levels. Two classic signs of a low oxygen level are a rapid heart rate and a fast breathing rate. An average heart rate is 60–100 beats per minute and an average breathing rate is 12–20 breaths per minute. However, under low oxygen conditions, body responses include an increase in heart rate and breathing rate. Another sign of a low blood oxygen level is cyanosis or a bluish colour change on your lips, nose, or fingertips. As your body loses oxygen, the blood cells in your body change colour in your bloodstream to a dark blue, which can be seen from the outside of your skin if it is severe. Cyanosis is typically a late sign of low oxygen levels and is considered a medical emergency. If you notice this bluish discolouration, you should immediately visit the nearest hospital.
Q. Do we see many cases of silent hypoxia in this wave? How can this be addressed?
A. Silent hypoxia or happy hypoxia is referred to as the early stage of COVID-19. As the oxygen level drops, one may start feeling shortness of breath, confusion, and other symptoms. Keep watching for these signs and do not ignore them. This is true for young people as well. If you monitor low oxygen level, change in lip colour from natural to blue or persistent sweating, consult the COVID helpline or doctor. They could be the early sign of silent hypoxia.
Q. In brief, how can proning help enhance blood oxygen levels?
A. Proning is a medically accepted process to improve the distribution and exchange of oxygen in the lungs. A patient is safely placed from their back onto their abdomen (stomach), i.e., face down to improve breathing and oxygenation. It has been shown as beneficial for COVID-19 patients with compromised breathing comfort, especially during home isolation.
Q. Is pure oxygen used in hospitals?
A. Medical oxygen contains high purity oxygen used for medical treatments and is developed for use in human body. Cylinders contain a compressed oxygen gas and no gases are allowed in the cylinder to prevent contamination.
Q. What is the use of medical oxygen?
A. Oxygen is used for treatment in hospitals. Hence, it is considered a drug or a pharmaceutical product.
Q. What is the need for medical oxygen?
A. The human body requires oxygen to survive, and typically, we breathe in from air. However, if you have lung disease or other medical conditions such as COVID-19, you may not get enough oxygen due to compromised lungs. That can leave you short of breath and cause problems with your heart, brain, and other parts of your body
Q. Can breathing 100 per cent oxygen harm your body?
A. Yes. Breathing 100 per cent oxygen also eventually leads to collapse of the alveoli (atelectasis).
Q. Can you get excess (more than required) oxygen from an oxygen concentrator?
A. It is possible to get excess (more than required) oxygen from an oxygen concentrator. However, this is quite rare when oxygen concentrators are used as directed and prescribed. All supplemental oxygen requires a prescription from a doctor, who carefully chooses your oxygen requirement.
Q. What is the role of oxygen during COVID-19 disease?
A. The demand for medical oxygen increases in COVID-19 as the disease primarily affects the lungs and, in severe cases, causes death due to Acute Respiratory Distress Syndrome (ARDS) and pneumonia.
Q. When does a patient require medical oxygen in a COVID-19 positive case?
A. As per AIIMS/ICMR-Covid-19/National Task Force/Joint Monitoring Group (Dte.GHS), MoHFW, Government of India, Clinical Guidelines for Management of Adult COVID-19 Patient issued on 22nd April 2021, moderate and severe cases of COVID-19 where the infection induces shortage of oxygen in the body due to its impact on lungs require medical oxygen and immediate oxygen therapy. Oxygen acts as a life-saver for COVID-19 patients.
Q. What are moderate COVID-19 cases?
A. In moderate COVID-19 cases, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than or equal to 24/minute and SpO2 90 per cent to 93 per cent with ambient air.
Q. What is severe COVID-19 cases?
A. In severe COVID-19 case, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than 30/minute and SpO2 less than 90 per cent in room air
Q. When does a patient require mechanical ventilator support?
A. A patient may be put on a mechanical ventilator if it becomes very difficult to breathe or get enough oxygen into their blood. This condition is called respiratory failure. Mechanical ventilators are machines that act as bellows to move air in and out of the patient’s lungs. The respiratory therapist and doctor set the ventilator to control how often it pushes air into the lungs and how much air the patient gets. The patient may be fitted with a mask to get air from the ventilator into the lungs. Or, they may need a breathing tube if their breathing problem is more serious.
Q. Can mechanical ventilation be given at home?
A. Mechanical ventilators are mainly used in hospitals and transport systems such as ambulances and medical evacuation by air transport, etc. In some cases, they can be used at home if the illness is long-term and the caregivers at home receive training and have adequate nursing and other resources at home. Being on a ventilator may make a patient more susceptible to pneumonia, damage to the vocal cords, or other problems.
Q. What is the six minute walk test for COPD?
A. The six minute walk test (6MWT) is an exercise test that measures functional status in chronic obstructive pulmonary disease (COPD) patients and provides information on oxygen desaturation. This test is also being used for COVID-19. In case of COVID-19 symptoms, SpO2 level must be checked before taking a walk. Now, walk for six minutes without a break on an even surface and measure the SpO2 level. It may fall 1-2 per cent, but consult a medical professional if it falls below 93 per cent.
Source:
https://ndma.gov.in/sites/default/files/2021-03/FAQs-on-Use-of-oxygen-.pdf
7. COVID-19 and White Fungus infection
Q. What is the normal respiratory rate of a healthy adult person?
A. Standard respiratory rates for a healthy adult range from 12 to 20 breaths per minute.
Q. Are 8 breaths per minute normal?
A. No. A patient needs to be evaluated medically.
Q. How many litres of oxygen per minute do we breathe?
A. The average tidal volume, i.e., the average amount of air inhaled and exhaled per breathing cycle, is 0.5 litre (500 ml). Minute Ventilation (VE) is the total volume of air entering the lungs in a minute, which is 6 litres per minute.
Q. What should be the normal oxygen saturation as recorded by a Pulse Oximeter?
A. The normal oxygen saturation level in the blood (SpO2 ) should be 95 per cent or higher. Some people with chronic lung disease, such as Chronic Obstructive Pulmonary Disease (COPD) or sleep apnea, may have normal levels of around 90 per cent. The ‘SpO2 ’ reading on a pulse oximeter shows the percentage of oxygen in the blood. If your home SpO2 reading is lower than 94 per cent, call your healthcare provider.
Q. How do I check my oxygen level at home without a Pulse Oximeter?
A. If you do not have a portable finger pulse oximeter in your home, you can also learn how to assess signs and symptoms of low oxygen levels. Two classic signs of a low oxygen level are a rapid heart rate and a fast breathing rate. An average heart rate is 60–100 beats per minute and an average breathing rate is 12–20 breaths per minute. However, under low oxygen conditions, body responses include an increase in heart rate and breathing rate. Another sign of a low blood oxygen level is cyanosis or a bluish colour change on your lips, nose, or fingertips. As your body loses oxygen, the blood cells in your body change colour in your bloodstream to a dark blue, which can be seen from the outside of your skin if it is severe. Cyanosis is typically a late sign of low oxygen levels and is considered a medical emergency. If you notice this bluish discolouration, you should immediately visit the nearest hospital.
Q. Do we see many cases of silent hypoxia in this wave? How can this be addressed?
A. Silent hypoxia or happy hypoxia is referred to as the early stage of COVID-19. As the oxygen level drops, one may start feeling shortness of breath, confusion, and other symptoms. Keep watching for these signs and do not ignore them. This is true for young people as well. If you monitor low oxygen level, change in lip colour from natural to blue or persistent sweating, consult the COVID helpline or doctor. They could be the early sign of silent hypoxia.
Q. In brief, how can proning help enhance blood oxygen levels?
A. Proning is a medically accepted process to improve the distribution and exchange of oxygen in the lungs. A patient is safely placed from their back onto their abdomen (stomach), i.e., face down to improve breathing and oxygenation. It has been shown as beneficial for COVID-19 patients with compromised breathing comfort, especially during home isolation.
Q. Is pure oxygen used in hospitals?
A. Medical oxygen contains high purity oxygen used for medical treatments and is developed for use in human body. Cylinders contain a compressed oxygen gas and no gases are allowed in the cylinder to prevent contamination.
Q. What is the use of medical oxygen?
A. Oxygen is used for treatment in hospitals. Hence, it is considered a drug or a pharmaceutical product.
Q. What is the need for medical oxygen?
A. The human body requires oxygen to survive, and typically, we breathe in from air. However, if you have lung disease or other medical conditions such as COVID-19, you may not get enough oxygen due to compromised lungs. That can leave you short of breath and cause problems with your heart, brain, and other parts of your body.
Q. Can breathing 100 per cent oxygen harm your body?
A. Yes. Breathing 100 per cent oxygen also eventually leads to collapse of the alveoli (atelectasis).
Q. Can you get excess (more than required) oxygen from an oxygen concentrator?
A. It is possible to get excess (more than required) oxygen from an oxygen concentrator. However, this is quite rare when oxygen concentrators are used as directed and prescribed. All supplemental oxygen requires a prescription from a doctor, who carefully chooses your oxygen requirement.
Q. What is the role of oxygen during COVID-19 disease?
A. The demand for medical oxygen increases in COVID-19 as the disease primarily affects the lungs and, in severe cases, causes death due to Acute Respiratory Distress Syndrome (ARDS) and pneumonia.
Q. When does a patient require medical oxygen in a COVID-19 positive case?
A. As per AIIMS/ICMR-Covid-19/National Task Force/Joint Monitoring Group (Dte.GHS), MoHFW, Government of India, Clinical Guidelines for Management of Adult COVID-19 Patient issued on 22nd April 2021, moderate and severe cases of COVID-19 where the infection induces shortage of oxygen in the body due to its impact on lungs require medical oxygen and immediate oxygen therapy. Oxygen acts as a life-saver for COVID-19 patients.
Q. What are moderate COVID-19 cases?
A. In moderate COVID-19 cases, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than or equal to 24/minute and SpO2 90 per cent to 93 per cent with ambient air
Q. What is severe COVID-19 cases?
A. In severe COVID-19 case, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than 30/minute and SpO2 less than 90 per cent in room air.
Q. When does a patient require mechanical ventilator support?
A. A patient may be put on a mechanical ventilator if it becomes very difficult to breathe or get enough oxygen into their blood. This condition is called respiratory failure. Mechanical ventilators are machines that act as bellows to move air in and out of the patient’s lungs. The respiratory therapist and doctor set the ventilator to control how often it pushes air into the lungs and how much air the patient gets. The patient may be fitted with a mask to get air from the ventilator into the lungs. Or, they may need a breathing tube if their breathing problem is more serious.
Q. Can mechanical ventilation be given at home?
A. Mechanical ventilators are mainly used in hospitals and transport systems such as ambulances and medical evacuation by air transport, etc. In some cases, they can be used at home if the illness is long-term and the caregivers at home receive training and have adequate nursing and other resources at home. Being on a ventilator may make a patient more susceptible to pneumonia, damage to the vocal cords, or other problems
Q. What is the six minute walk test for COPD?
A. The six minute walk test (6MWT) is an exercise test that measures functional status in chronic obstructive pulmonary disease (COPD) patients and provides information on oxygen desaturation. This test is also being used for COVID-19. In case of COVID-19 symptoms, SpO2 level must be checked before taking a walk. Now, walk for six minutes without a break on an even surface and measure the SpO2 level. It may fall 1-2 per cent, but consult a medical professional if it falls below 93 per cent.
Source: https://ndma.gov.in/sites/default/files/2021-03/FAQs-on-Use-of-oxygen-.pdf
7. Related to drugs and medications to fight the disease
Q. Is Remdesivir effective in the treatment of COVID-19?
A. No study has conclusively been able to prove that Remdesivir is beneficial in the treatment of COVID-19. However, India has approved Remdesivir under the National Clinical Management Protocol for COVID-19, which was developed after many interactions by a committee of experts. The protocol acts as the guiding document for the treatment of COVID-19 patients in India. Remdesivir is listed as an investigational therapy in the protocol, i.e., where informed and shared decision-making is essential, besides noting contraindications mentioned in the detailed guidelines.
Q. What is Remdesivir? How does Remdesivir work?
A. Remdesivir is an investigational drug used to treat viral infections. It is classified as a broadspectrum antiviral with potential antiviral activity against a variety of RNA viruses.
The drug works against the novel coronavirus by inhibiting replication of the virus in the body. Remdesivir functions as a pro-drug that is modified in the body before it becomes an active drug. It is classified as a nucleoside analog, one of the oldest classes of antiviral medications, and resembles the RNA base adenosine. In general, nucleoside and nucleotide analogues simulate the structure of a true nucleoside or nucleotide. The simulated structure may then be incorporated into the virus. Remdesivir works when the enzyme replicating the genetic material for the novel coronavirus − RNA polymerase − incorporates the adenosine analogue in place of the natural molecule into the growing RNA strand. By introducing the modified agent, Remdesivir, replication of the novel coronavirus is interrupted, and the virus ceases to multiply and cannot infect more cells in the body.
Q. When should a patient of COVID-19 take Remdesivir?
A. The timing of the drug, when it is administered, is most important. Taking it too early or too late could do more harm than good. Remdesivir is applicable only in hospitalised patients who showed very low oxygen saturation and infiltrated their chest X-ray or CT scan. The optimal timing for Remdesivir is usually after five to seven days of having the virus. Early to mild or asymptomatic patients should not take Remdesivir. Also, it is of no use if it’s given very late because it would create a cytokine storm. A cytokine storm is when the immune system goes into overdrive. The body starts to attack its cells and tissues instead of just the virus.
Q. Can Remdesivir be taken at home?
A. Remdesivir comes in a vial and has to be injected only after prescription and in the presence of a health practitioner. It is for patients who are hospitalised and severe. Therefore, it should not be given at home. It is for patients who need to be admitted and need hospital care.
Q. Are steroids effective in the treatment of COVID-19?
A. There is no evidence to support the use of steroids in the treatment of COVID-19. The World Health Organization (WHO) recovery trial showed that steroids do have a beneficial effect. But again, the timing is critical. The recovery trial clearly showed that if we give steroids too early, it showed a harmful effect before oxygen saturation. Steroids are most effective during the later part of the disease when there is more inflammation and oxygen saturation is falling. Steroids are only helpful for moderate or severe cases.
Q. Is plasma a good way to fight off COVID-19?
A. Convalescent plasma has been a therapy devised to passively transfer antibodies from a recovered person to a new patient. While the therapy has been received with different opinions by the medical community, the important aspect is timing. It’s better if plasma therapy is used early before clinical worsening. Also, plasma with high titer neutralising antibodies would have better results. Hence, to achieve good results, correct patient selection, timing and a good quality plasma donor are needed for success in this form of treatment.
Q. Should a person with COVID-19 take Tocilizumab?
A. Tocilizumab is a drug of last resort. It should only be used when a COVID-19 infection in a patient is worsening despite steroids, Remdesivir and other treatments like anticoagulants. Tocilizumab is required in less than 2 per cent of COVID-19 patients. Very few patients need this drug because it’s only for treating a cytokine storm and has a limited role.
Q. Is Favipiravir effective in treating COVID-19?
A. Favipiravir is another antiviral that is being promoted for the treatment of COVID-19. It was initially doled out as a treatment of influenza after the H1N1 pandemic. There is not enough evidence in robust studies to show that it is a good drug. Since it’s not a proven treatment, India’s national guidelines also don’t recommend its use.
Q. Is it possible to treat COVID-19 without any of the drugs mentioned above?
A. People with mild COVID-19 or those who are asymptomatic will improve with just symptomatic treatment. Mild COVID-19 infection can be treated with paracetamol, good hydration and multivitamins − without any treatment. Giving treatment when it is not required may be doing more harm than good.
8. Related to Black Fungus and COVID-19 disease
Q. What is Black Fungus?
A. Black Fungus, also known as mucormycosis, is a rare fungal infection. It is called ‘black’ because of the colour of the fungal growth. It is caused by exposure to mucor mold found in soil, manure, and rotten/decaying fruits and vegetables. It is ubiquitous and even present in the nose/mucosa of healthy individuals. This disease usually affects the sinuses, eye orbit, and brain. That is why it is also called ‘rhino-orbital-cerebral’ mucormycosis. It may be life-threatening in immuno-compromised individuals (cancer patients, HIV/AIDS) and people with uncontrolled diabetes.
Q. What are the risk factors for acquiring Black Fungus infection?
A. Risk Factors are:
- • Uncontrolled Diabetes Mellitus
- • Treated for COVID-19 with corticosteroids
- • Treated for COVID-19 with immunomodulators
- • Treated for COVID-19 with mechanical ventilation
- • Prolonged oxygen therapy
- • Prolonged ICU stay
- • Have diabetes.
- • Immuno-compromised state
Q. Why the sudden increase in Black Fungus cases?
A. It may be triggered by extensive use of steroids, which is a life-saving treatment for moderate to severe COVID-19 infection. Steroids lower the immunity and cause a sudden up-shooting of blood sugar levels in diabetes and non-diabetic patients. For patients on humidified oxygen, care should be taken to make sure there is no water leak to prevent the growth of the fungus.
Q. How serious is Black Fungus?
A. Black fungus infection causes a vision-threatening and life-threatening condition.
Q. Do all COVID-19 patients need to be worried about Black Fungus infection?
A. No. As discussed, high-risk patients need to be alert. Also, during COVID-19 recovery, everyone should watch out for early signs and symptoms.
Q. What are the precautions one can take to avoid this disease?
A. One can take the following precautions:
- • Boost immune system with diet, hydration and exercise.
- • Rational use of steroids by follow guidelines.
- • Strict blood sugar monitoring and control in all patients who are on steroids./li>
Q. What are the early signs of Black Fungus?
A. Some of the early signs are:
- • Facial pain
- • Facial swelling/puffiness/discolouration
- • Sinus headache
- • Stuffy nose
- • The blurring of vision/decreased vision
- • Double vision
- • Drooping of eyelid
- • Blood-stained nasal discharge
- • Dental pain
Q. Is Black Fungus treatable?
A. Yes. Early diagnosis and a prompt multi-speciality team of medical professionals can manage it.
Q. Which specialist should I visit for Black Fungus?
A. ENT and eye specialists are central to this disease. The team includes care coordination with neurosurgeon, endocrinologist and microbiologist.
Source:
https://www.eyeqindia.com/frequently-asked-questions-on-covid-and-black-fungus/#toggle-id-9
9. Related to indoor air and COVID-19 disease
Q. Will running an evaporative cooler help protect my family and me from COVID-19?
A. Evaporative coolers (or ‘swamp coolers’) can help protect people indoors from the airborne transmission of COVID-19 because they increase ventilation with outside air to cool indoor spaces. Evaporative coolers are used in dry climates. They use water to provide cooling and improve relative humidity in indoor microenvironments. When operating as intended (with open windows), these devices produce substantial increases in ventilation with outdoor air. Some evaporative coolers can be performed without using water when temperatures are milder to increase ventilation indoors. Avoid using evaporative coolers if air pollution outside is high and the system does not have a high-efficiency filter.
Q. Is ventilation important for indoor air quality when cleaning and/or sanitising for COVID-19 indoors?
A. When cleaning and disinfecting for COVID-19, ventilation is essential − in general, increasing ventilation during and after cleaning helps to reduce exposure to cleaning and disinfection products and by-products. Increasing ventilation, for example, by opening windows or doors, can also reduce risks from particles resuspended during cleaning, including those potentially carrying SARS-CoV-2 (or other contaminants). Avoid ventilation with outdoor air when outdoor air pollution is high or when it makes your home too cold, hot, or humid.
Q. Will an air cleaner or air purifier help protect my family and me from COVID-19 in my home?
A. When appropriately used, air purifiers can help reduce airborne contaminants, including viruses, in a home or confined space.
Q. How can I increase ventilation at home to help protect my family from COVID-19?
A. Ensuring proper ventilation with outside air is a standard best practice for improving indoor air quality. To increase ventilation in your home, one can:
- • Open the windows or screened doors, if possible;
- • Operate an air conditioner that has an outdoor air intake or vent; and
- • Operate a bathroom fan when the bathroom is in use and continuously, if possible.
However, the practices mentioned here are not enough to protect people from COVID-19. When used along with other best practices recommended by the Ministry of Health and Family Welfare, Government of India, the above methods can be part of a plan to protect yourself and your family.
Source: https://www.epa.gov/coronavirus/indoor-air-and-coronavirus-covid-19
1. Related to Use of Oxygen during current COVID-19 Pandemic
Q. What is the normal respiratory rate of a healthy adult person?
A. Standard respiratory rates for a healthy adult range from 12 to 20 breaths per minute.
Q. Are 8 breaths per minute normal?
A. No. A patient needs to be evaluated medically.
Q. How many litres of oxygen per minute do we breathe?
A. The average tidal volume, i.e., the average amount of air inhaled and exhaled per breathing cycle, is 0.5 litre (500 ml). Minute ventilation (VE) is the total volume of air entering the lungs in a minute is 6 litres per minute.
Q. What should be the normal oxygen saturation as recorded by a Pulse Oximeter?
A. The normal oxygen saturation level in the blood (SpO2) should be 95% or higher. Some people with chronic lung disease, such as Chronic Obstructive Pulmonary Disease (COPD) or sleep apnea, may have normal levels of around 90%. The “SpO2” reading on a pulse oximeter shows the percentage of oxygen in the blood. If your home SpO2 reading is lower than 94%, call your healthcare provider.
Q. How do I check my oxygen level at home without a Pulse Oximeter?
A. If you do not have a portable finger pulse oximeter in your home, you can also learn how to assess signs and symptoms of low oxygen levels. Two classic signs of a low oxygen level are a rapid heart rate and a fast breathing rate. An average heart rate is 60–100 beats per minute and an average breathing rate is 12–20 breaths per minute. However, under low oxygen conditions, body responses include an increase in heart rate and breathing rate. Another sign of a low blood oxygen level is cyanosis or a bluish color change on your lips, nose, or fingertips. As your body loses oxygen, the blood cells in your body change colour in your bloodstream to a dark blue, which can be seen from the outside of your skin if it is severe. Cyanosis is typically a late sign of low oxygen levels and is considered a medical emergency. If you notice this bluish discolouration, you should immediately visit the nearest hospital.
Q. Do we see many cases of silent hypoxia in this wave? How can this be addressed?
A. Silent hypoxia or happy hypoxia is referred to as the early stage of COVID-19. As the oxygen level drops, one may start feeling shortness of breath, confusion, and other symptoms. Keep watching for these signs and do not ignore them. This is true for young people as well. If you monitor low oxygen level, change in lip colour from natural to blue or persistent sweating, consult the covid helpline or doctor. They could be the early sign of silent hypoxia.
Q. In brief, how can proning help enhance blood oxygen levels?
A. Proning is a medically accepted process to improve the distribution and exchange of oxygen in the lungs. A patient is safely placed from their back onto their abdomen (stomach), i.e., having face down to improve breathing and oxygenation. It has been shown beneficial for COVID-19 patients with compromised breathing comfort, especially during home isolation.
Q. Is pure oxygen used in hospitals?
A. Medical oxygen contains high purity oxygen used for medical treatments and is developed for use in human body. Cylinders contain a compressed oxygen gas and no gases are allowed in the cylinder to prevent contamination.
Q. What is the use of Medical Oxygen?
A. Oxygen is used for treatment in hospitals. Hence, it is considered a drug or a pharmaceutical product.
Q. What is the need for Medical Oxygen?
A. The human body requires oxygen to survive, and typically, we breathe in from air. However, if you have lung disease or other medical conditions such as COVID-19, you may not get enough oxygen due to compromised lungs. That can leave you short of breath and cause problems with your heart, brain, and other parts of your body.
Q. Can breathing 100 per cent oxygen harm your body?
A. Yes. Breathing 100% oxygen also eventually leads to collapse of the alveoli (atelectasis).
Q. Can you get excess (more than required) oxygen from an Oxygen Concentrator?
A. It is possible to get excess (more than required) oxygen from an oxygen concentrator. However, this is quite rare when oxygen concentrators are used as directed and prescribed. All supplemental oxygen requires a prescription from a doctor, who carefully chooses your oxygen requirement.
Q. What is the role of oxygen during COVID-19 Disease?
A. The demand for medical oxygen is increased in COVID-19 as the disease primarily affects the lungs and, in severe cases, causes death due to Acute Respiratory Distress Syndrome (ARDS) and pneumonia.
Q. When does a patient require medical oxygen in a COVID-19 positive case?
A. As per AIIMS/ICMR-Covid-19/National Task Force/Joint Monitoring Group (Dte.GHS), MoHFW, Government of India, Clinical Guidelines for Management of Adult COVID-19 Patientissued on 22 Apr 2021, moderate and severe cases of COVID-19 where the infection induces shortage of oxygen in the body due to its impact on lungs require medical oxygen and immediate oxygen therapy. Oxygen acts as a life-saver for COVID patients.
Q. What is Moderate COVID-19 cases?
A. In moderate COVID-19 cases a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than or equal to 24/minute and SpO2 90% to 93% with ambient air.
Q. What is severe COVID-19 cases?
A In severe Covid-19 case, a patient has upper respiratory tract symptoms (and/or fever) with shortness of breath. They have a respiration rate more than 30/minute and SpO2 less than 90% in room air.
Q. When does a patient require Mechanical Ventilator Support?
A. A patient may be put on a mechanical ventilator if it becomes very difficult to breathe or get enough oxygen into their blood. This condition is called respiratory failure. Mechanical ventilators are machines that act as bellows to move air in and out of the patient's lungs. The respiratory therapist and doctor set the ventilator to control how often it pushes air into the lungs and how much air the patient gets. The patient may be fitted with a mask to get air from the ventilator into there lungs. Or they may need a breathing tube if their breathing problem is more serious.
Q. Can Mechanical Ventilation be given at home?
A. Mechanical ventilators are mainly used in hospitals and transport systems such as ambulances and medical evacuation by air transport etc. In some cases, they can be used at home if the illness is long-term and the caregivers at home receive training and have adequate nursing and other resources at home. Being on a ventilator may make a patient more susceptible to pneumonia, damage to the vocal cords, or other problems.
Q. What is the 6-minute walk test for COPD?
A. The 6-min walk test (6MWT) is an exercise test that measures functional status in chronic obstructive pulmonary disease (COPD) patients and provides information on oxygen desaturation. This test is also being used for COVID-19. In case of COVID-19 symptoms, SpO2 level must be checked before taking a walk. Now, walk for 6 minutes without a break on an even surface and measure the SpO2 level. It may fall 1-2%, but consult a medical professional if it falls below 93%. (Source: https://ndma.gov.in/sites/default/files/2021-03/FAQs-on-Use-of-oxygen-.pdf)
2. Related to drugs and medications fighting the disease
Q. Is Remdesivir effective in the treatment of COVID-19?
A. No study has conclusively been able to prove that Remdesivir is beneficial in the treatment of COVID-19. However, India has approved Remdesivir under the National Clinical Management Protocol for COVID-19, which was developed after many interactions VIGYAN PRASAR 95 by a committee of experts. The protocol acts as the guiding document for the treatment of COVID-19 patients in India. Remdesivir is listed as an investigational therapy in the protocol, i.e., where informed and shared decision-making is essential, besides noting contraindications mentioned in the detailed guidelines.
Q. What Is Remdesivir? How Does Remdesivir Work?
A. Remdesivir is an investigational drug used to treat viral infections. It is classified as a broadspectrum antiviral with potential antiviral activity against a variety of RNA viruses. The drug works against the novel coronavirus by inhibiting replication of the virus in the body. Remdesivir functions as a prodrug that is modified in the body before it becomes an active drug. It is classified as a nucleoside analog, one of the oldest classes of antiviral medications, and resembles the RNA base adenosine. In general, nucleoside and nucleotide analogues simulate the structure of a true nucleoside or nucleotide. The simulated structure may then be incorporated into the virus. Remdesivir works when the enzyme replicating the genetic material for the novel coronavirus—RNA polymerase—incorporates the adenosine analogue in place of the natural molecule into the growing RNA strand. By introducing the modified agent, Remdesivir, replication of the novel coronavirus is interrupted, and the virus ceases to multiply and cannot infect more cells in the body.
Q. When should a patient of COVID-19 take Remdesivir?
A. The timing of the drug, when it is administered, is most important. Taking it too early or too late could do more harm than good. Remdesivir is applicable only in hospitalised patients who showed very low oxygen saturation and infiltrated their chest X-ray or CT scan. The optimal timing for Remdesivir is usually after five to seven days of having the virus. Early to mild or asymptomatic patients should not take Remdesivir. Also, it is of no use if it’s given very late because it would create a cytokine storm. A cytokine storm is when the immune system goes into overdrive. The body starts to attack its cells and tissues instead of just the virus.
Q. Is Remdesivir can be taken at home?
A. Remdesivir comes in a vial and has to be injected only after prescription and in the presence of a health practitioner. It is for patients who are hospitalised and severe. Therefore, it should not be given at home. It is for patients who need to be admitted and need hospital care.
Q. Are steroids effective in the treatment of COVID-19?
A. There is no evidence to support the use of steroids in the treatment of COVID-19. World Health Organization (WHO) recovery trial showed that steroids do have a beneficial effect. But again, the timing is critical. The recovery trial clearly showed that if we give steroids too early, it showed a harmful effect before oxygen saturation. Steroids are most effective during the later part of the disease when there is more inflammation and oxygen saturation is falling. Steroids are only helpful for moderate or severe cases.
Q. Is plasma a good way to fight off COVID-19?
A. Convalescent plasma has been a therapy devised to passively transfer antibodies from a recovered person to a new patient. While the therapy has been received with different opinions by the medical community, the important aspect is timing. It’s better if plasma therapy is used early before clinical worsening. Also, plasma with high titer neutralising antibodies would havebetter results. Hence, to achieve good results, correct patient selection, timing and a good quality plasma donor are needed for success in this form of treatment.
Q. Should a person with COVID-19 take Tocilizumab?
A. Tocilizumab is a drug of last resort. It should only be used when a COVID-19 infection in a patient is worsening despite steroids, Remdesivir and other treatments like anticoagulants. Tocilizumab is required in less than 2% of COVID-19 patients. Very few patients need this drug because it’s only for treating a cytokine storm and has a limited role.
Q. Is Favipiravir effective in treating COVID-19?
A. Favipiravir is another antiviral that is being promoted for the treatment of COVID-19. It was initially doled out as a treatment of influenza after the H1N1 pandemic. There is not enough evidence in robust studies to show that it is a good drug. Since it’s not a proven treatment, India’s national guidelines also don’t recommend its use.
Q. Is it possible to treat COVID-19 without any of the drugs mentioned above?
A. People with mild COVID-19 or those who are asymptomatic will improve with just symptomatic treatment. Mild COVID-19 infection can be treated with paracetamol, good hydration and multivitamins —without any treatment. Giving treatment when it is not required may be doing more harm than good.
3. Related to Black Fungus and COVID-19 Disease
Q. What is Black Fungus?
A. Black fungus, also known as MUCORMYCOSIS, is a rare fungal infection. It is called “black” because of the colour of the fungal growth. It is caused by exposure to mucor mould found in soil, manure, and rotten/decaying fruits and vegetables. It is ubiquitous and even present in the nose/mucosa of healthy individuals. This disease usually affects the sinuses, eye orbit, and brain. That is why it is also called “rhino-orbital-cerebral” mucormycosis. It may be lifethreatening in immunocompromised individuals (cancer patients, HIV/AIDS) and people with uncontrolled diabetes.
Q. What are the risk factors for acquiring Black Fungus infection?
A. Risk Factors are: • Uncontrolled Diabetes Mellitus • Treated for COVID-19 with corticosteroids • Treated for COVID-19 with immunomodulators • Treated for COVID-19 with mechanical ventilation • Prolonged oxygen therapy • Prolonged ICU stay • Immunocompromised state
Q. Why the sudden increase in Black Fungus cases?
A. It may be triggered by extensive use of steroids, which is a life-saving treatment for moderate to severe COVID-19 infection. Steroids lower the immunity and cause a sudden up-shooting of blood sugar levels in diabetes and non-diabetic patients. For patients on humidified oxygen, care should be taken to make sure there is no water leak to prevent the growth of the fungus.
Q. How serious is Black Fungus?
A. Black fungus infection causes a vision-threatening and life-threatening condition.
Q. Do all COVID-19 patients need to be worried about Black Fungus infection?
A. No. As discussed, high-risk patients need to be alert. Also, during COVID-19 recovery, everyone should watch out for early signs and symptoms.
Q. What are the precautions one can take to avoid this disease?
A. Following precautions one can take: • Boost immune system with diet, hydration and exercise. • Rational use of steroids by follow guidelines. • Strict Blood sugar monitoring and control in all patients who are on steroids.
Q. What are the early signs of Black Fungus?
A. some of the early signs are: • Facial pain • Facial swelling/puffiness/discolouration • Sinus headache • Stuffy nose • The blurring of vision/decreased vision • Double vision • Drooping of eyelid • Blood-stained nasal discharge • Dental pain
Q. Is Black Fungus treatable?
A. Yes. Early diagnosis and a prompt multi-speciality team of medical professionals can manage it.
Q. Which specialist should I visit for Black Fungus?
A. ENT and eye specialists are central to this disease. The team includes care coordination with neurosurgeon endocrinologist and microbiologist. (Source: https://www.eyeqindia.com/frequently-asked-questions-on-covid-and-blackf...)
4. Related to Indoor Air and COVID-19 Disease
Q. Will running an evaporative cooler help protect my family and me from COVID-19?
A. Evaporative coolers (or “swamp coolers”) can help protect people indoors from the airborne transmission of COVID-19 because they increase ventilation with outside air to cool indoor spaces. Evaporative coolers are used in dry climates. They use water to provide cooling and improve relative humidity in indoor microenvironments. When operating as intended (with open windows), these devices produce substantial increases in ventilation with outdoor air. Some evaporative coolers can be performed without using water when temperatures are milder to increase ventilation indoors. Avoid using evaporative coolers if air pollution outside is high and the system does not have a high-efficiency filter.
Q. Is ventilation important for indoor air quality when cleaning and/or sanitising for COVID-19 indoors?
A. When cleaning and disinfecting for COVID-19, ventilation is essential—in general, increasing ventilation during and after cleaning help to reduce exposure to cleaning and disinfection products and by-products. Increasing ventilation, for example, by opening windows or doors, can also reduce risks from particles resuspended during cleaning, including those potentially carrying SARS-CoV-2 (or other contaminants). Avoid ventilation with outdoor air when outdoor air pollution is high or when it makes your home too cold, hot, or humid.
Q. Will an air cleaner or air purifier help protect my family and me from COVID-19 in my home?
A. When appropriately used, air purifiers can help reduce airborne contaminants, including viruses, in a home or confined space.
Q. How can I increase ventilation at home to help protect my family from COVID-19?
A. Ensuring proper ventilation with outside air is a standard best practice for improving indoor air quality. To increase ventilation in your home, one can: • Open the windows or screened doors, if possible; • Operate an air conditioner that has an outdoor air intake or vent; and • Operate a bathroom fan when the bathroom is in use and continuously, if possible. However, the practices mentioned here are not enough to protect people from COVID-19. When used along with other best practices recommended by the Ministry of Health and Family Welfare, Govt. of India, the above methods can be part of a plan to protect yourself and your family. (Source: https://www.epa.gov/coronavirus/indoor-air-and-coronavirus-covid-19)