” Actually it is like flu illness and 85% will have minor, self-limiting disease. What we need is hospitalization for the remaining 15% and we should be able to ensure them the maximum possible supportive care”,says Dr C Ravindran MD, DTCD, FRCP, MBA Professor &Head; Dept. of Pulmonary Medicine DM Wayanad Institute of Medical Sciences, Wayanad and Former Principal,Medical College,Kozhikode . In the wake of corona crisis,he points out the nature of the deadly virus,its impact in our lives;cares and cautions to be taken by public to contain this global pandemic etc.in an interview with M.Rajesh,News Director, CNM.
Read full interview :
Q As a senior physician, specialist in Respiratory Medicine and former Principal of Kozhikode Medical College, how do you look in to this pandemic?
A: The COVID-19 pandemic is a serious global health threat. Even though we have faced many epidemics in the past and pandemic like SARS, this pandemic behaves differently. The main reason is the rapidity by which it spreads and there is no effective treatment. When people are travelling extensively, the threat of spreading such a disease is very high. WHO and CDC are working together to contain this epidemic. But there are few things which are still not clear as far as corona virus is concerned. Number one is that the initial belief of transmission by contact is found to be incorrect. All the measures taken such as social distancing and face masks could not contain the spread. Being a respiratory tract virus spread through droplets and inhalation is
to be thought of before planning any strategy. I feel that initial reports which came from China were not fully correct regarding the behaviour of the virus and the measures taken based on these information failed to contain the infection in a proper manner.
Q: Corona virus impact is varied from one country to other. Why? Is there any difference in the virus detected in Kerala and other parts of the world?
A: Different countries have different statistics. This is based on their culture, life style and Govt. policy. For example Americans were not happy with lock down. Even though they practised social distancing, masks were not insisted and schools were closed very late. So naturally they had more cases. In UK they permitted to open tourist places and encouraged people to go to parks. Each country and people has their own practices. Regarding the virus, when such large scale infection take place there is every chance of mutation to take place. So behaviour of this virus may change. This becomes a practical problem only when we have vaccines. Otherwise too much of deviation in clinical presentation may not be evident.
Q) Who are the high risk groups?
A: High risk groups identified are those above 60 years, children below 10 years, pregnant women, people having hypertension, cardiac disease, chronic respiratory diseases and cancer.
Q) Are people with respiratory illnesses such as asthma, pneumonia and tuberculosis vulnerable to this virus?
A: About 85% of COVID-19 infection manifest as flu like illness. But 12-15% develops pneumonia. Out of this 5% develop severe pneumonia which necessitates ICU admission. There is high mortality chance for this group of patients. Since asthma, pneumonia and tuberculosis are respiratory illnesses, getting COVID pneumonia over and above this increases the risk of death.
Q) If allergy and asthma are well controlled with medication, can they go out of their homes with proper care?
A: Well controlled asthma and allergy behaves like normalcy. So no problem in pursuing routine work, but proper personal care should be strictly adhered to. Every person should think and behave in a way so that they will not contract the disease.
Q) What about cardiac disease, hypertension and cancer?
A: Initially hypertension was considered as a risk factor for development of corona infection. Later it is seen that there is an increased risk of myocarditis and myocardial ischemia in corona infection. So any disease affecting cardiovascular system becomes a risk factor for death in COVID. Similarly cancer causes low immunity and low immunity is the reason for rapid
spread and multiplication of virus leading to severe disease.
Q) How long it will take to come to normal condition in medical segment?
A: Experts predicted that the peak will be reached by the end of July and spread is likely to come down by September. I am not that much optimistic, and feel that this infection will be with us in this intensity till December 2020 and then seasonal out breaks may come and go like the influenza infection.
Q) Front runners in health sector have contracted this virus. Why such things happen in hospitals where such precautions are high?
A: The rate of infection in health care workers is much less. When such large scale infection is being cared for there is chance of complacency. Moreover we were not equipped to deal with such a high burden disease. So even if we insist on PPE and N95 masks, they were not freely available for use. Even in developed countries, protective equipment were not freely available in all hospitals. One thing is important here, whatever is said or ordered from administrative level are not strictly practised in the actual scenario.
Q) As a researcher in new development in Respiratory Medicine, What is your opinion on new medicines approved by WHO?
A: So far there are no specific drugs effective for SARS Corona Virus-2. Remdisivir and Favipinavir are approved antiviral drugs, but their effect in this virus is not definite. Initially hydroxychroquin was celebrated by media and we know that it has no antiviral property. It is an antimalarial drug and has anti-inflammatory property. So it controls joint pain and muscle pain associated with COVID-19. Many lives were lost due to this drug. Now dexamethasone is highlighted. Doctors know that it is a corticosteroid drug and should never be used in infections. The role is in severe disease with ARDS where it helps in reducing the inflammatory oedema WHO recommends plasma therapy which has some scientific basis to improve body defence against the virus. Research is going on to develop effective drugs and vaccines.
Q) UG NEET Medical entrance exam. Is scheduled on July 26.In this corona virus crisis is it advisable to conduct such a big national examination? How it will be possible to maintain social distancing in pen and paper examination?
A: UG NEET may be fixed for July 26, considering the early impression that COVID curve may flatten by July. In UK Royal college fixed all their MRCP exams for September 20. Now they are thinking of postponing all practical examinations to December. Still they are going for theory examinations in September. May be if conditions are the same, this dates may be pushed forward. Regarding NEET, they are thinking of online examination where the candidates need not go to examination halls and crowding is avoided. Pen and paper examination is out of question in the present situation.
Q) We are in a post lock-down time, what are the things to be remembered? What are the precautions to be taken?
A: Lock down was an effective measure initially and could contain the infection to a large extent. But how long people can be locked down? It is not possible. We initiated the lock down in the early part of the pandemic. That is following the way things were controlled in China. But we never thought that our people are spread all over the world. When disease spread in those regions, our people would like to come back. Those counties in which they are staying are also not in a position to treat and feed expatriates. So naturally we have to relax lock down, bring people from other states and other countries. We should understand that people are coming from high burden countries. So naturally when spread of infection is coming down in other countries we are having an up-surge. What can be done now is to avoid gatherings and social function. Public should follow the social distancing, using face mask, washing hands frequently,wash the clothes and take bath if you come from outside etc. strictly for the next 2-3 months.
Q) Wearing of masks, which one is safe?
A: For common public, cloth mask is enough. It should be a 3 layered mask having a cloth layer on both sides with a thin fabric inside. It should be worn closely on the face covering the mouth & nose. We should not touch the mask with our hands to adjust or for other purposes.
Mask available are not reusable and the maximum time a mask is work continuously is 6 hours. After that we have to replace it. For health care workers N95 mask is better. Those who do surgeries and procedures, in addition to N95, a face shield is advisable.
Q) How COVID affect an ordinary man who has to work daily for his livelihood?
A: We have seen the situation of labourers from other states. Initially they were not bothered. But once they lost their job and wages, they developed fear of existence and wanted to go home. This is what is happening to people working overseas and other states. Actually a panic situation was created all over the world. Instead of approaching it scientifically and trying to control, the feeling created was like there is no drug and all people getting COVID will die.
Actually it is like flu illness and 85% will have minor, self-limiting disease. What we need is hospitalization for the remaining 15% and we should be able to ensure them the maximum possible supportive care. This group can be divided in to that requiring ward admission and those requiring ICU admission. Separate protocol should be set up to treat these two groups. At the same time strict adherence to infection control measures is to be ensured. The death rate can be reduced to 2-3%. Instead of that all virus positive cases are admitted and resources were exhausted. So many patients requiring hospitalization were denied their right. This happened in Italy, Spain and now in Mumbai and Delhi. This could have been avoided by following strict selection criteria for admission. Look at the scenario in Kerala. Initially all symptomatic were
taken to institutional quarantine and if sample positive they were admitted. Later home quarantine for symptomatic and admission to first line treatment centre for positive cases. Tomorrow, when number of cases increases, positive cases will be sent home and only severe disease will be admitted. This should have been implemented from the beginning.
Q) Recently another deadly virus is reported in China. It is said to be more fatal than noval corona virus. How can we tackle virus threats in future? Do you there must be a reform in medical education?
A: Even though there were preliminary reports of another viral infection from China, recently, it was not conclusive. There are out breaks of emerging infections due to bacteria and viruses in different regions of the world. These are either locally controlled or definite measures are taken to prevent spread to remote regions. Now because of frequent international travel, it
is easy to spread the infection. Only solution is control the local outbreaks by clean atmosphere,hygiene practices and avoiding mixing with multiple carrier animals. China’s food habits are being referred as a cause for development and spread of new viruses. If that is correct, there should be some local environmental engineering practices to curtail such mutation and development of virulent viruses. All these infective agents are taught in medical curriculum for years together and we teach them to control and treat all these infections. Life style practices,international travel, tourism and urbanization are the reason for the recent outbreaks. For this we need to strengthen health surveillance and environmental engineering practices.