key: cord-1042536-pi9r9qi9
authors: Balsari, Satchit; Udwadia, Zarir; Shaikh, Ahmed; Ghafur, Abdul; Kataria, Sushila
title: Contextualising evidence-based recommendations for the second wave of the COVID-19 pandemic in India
date: 2021-06-08
journal: Lancet Infect Dis
DOI: 10.1016/s1473-3099(21)00329-7
sha: 0e71628c3b86c2a470d9255b04f178eda143e128
doc_id: 1042536
cord_uid: pi9r9qi9

nan

Where How (impact optimisation strategies) 6 In early May, 2021, national guidelines were finally relaxed to allow such syndrome-based diagnosis, ending a year of delayed or denied hospital admissions due to slow or unavailable testing.

When options for oxygenation or timely transport to higher levels of care are available, oxygen saturation, a reliable predictor of mortality in COVID-19, and measured via cheaply and widely available pulse-oximeters, should suffice for risk stratification. 7 Routinely prescribed expensive laboratory tests such as C-reactive protein, ferritin, interleukin-6, and D-dimer, will have little bearing on clinical outcomes where there are no viable options for basic therapeutic care. Even in urban India, physicians must consider recommending such tests only when there is evidence that interventions are based on their interpretation change outcomes and are actually feasible.

For nearly a year, patients were being advised institutional isolation, regardless of disease severity or ability to isolate at home. For patients with mild disease, home-based care and self-monitoring with a pulse oximeter-as has long been appropriate-has finally gained widespread traction, from sheer necessity. Clear directives (and telemedicine support, where possible) will prevent unwarranted presentations to the hospital. Most patients with hypoxia might only need oxygenation and proning. Current evidence supports the use of steroids such as dexamethasone only among those needing oxygen or invasive respiratory support. 8, 9 A few patients might also benefit from prophylactic doses of anticoagulation that can be administered by trained family members. 10 Patients can be taught pronation via effective educational aids. A severe shortage of beds and unreliable power availability threaten other key treatment possibilities in rural India, as oxygen concentrators will need continuous electricity or back-up generators, and oxygen cylinders are expensive to procure and transport. The justified, ad hoc, and self-organised measures to procure and administer oxygen, however, risk inadequate oxygen therapy, rendering these often Herculean efforts clinically futile. A vast number of oxygen concentrators and ventilators have been mobilised internationally. On May 8, 2021, the Supreme Court of India appointed a task force to oversee oxygen allocation. It is imperative that recommendations for distribution be coupled with human-in-the-loop solutions where technical know-how to operate these devices is expanded expeditiously via online adjuncts. The government has also directed India's non-allopathic AYUSH doctors to provide COVID-19 care. It is crucially important that this expanded workforce not amplify missteps from the preceding year.

Hypoxic patients who do not need invasive mechanical ventilation can be cared for at makeshift but monitored, protocolised health-care facilities. Despite the bed shortage, and revised national guidelines, many patients are not being discharged home until their RT-PCR test is negative. There is no evidence that patients need hospitalisation once they are clinically stable for discharge. When isolating at home is unfeasible, they could be sent to recovery centres. Indigenous rural solutions such as isolating patients elsewhere on the farm are not unreasonable, provided family members can provide care.

It is time to double down on effective interventions. The lack of critical care capacity necessitates open discussions about goals of care. We are all practicing physicians and recognise how hard it is to communicate futility to family members, especially in these desperate times. Truth, however, will protect families from crushing debt, and in some cases, financial ruin. Adherence to science, even now, will probably be the least destructive path forward.

ZU serves on the Maharashtra Covid Task Force and National Task Force constituted by the Supreme Court of India; and has received honoraria or grants from AstraZeneca and Glenmark. AG has received grants from Cipla, Glenmark, Pfizer, Sanofi, Astellas, Mylan, Natco, Biomerioux, Bharath Serum, and GlaxoSmithKline. All other authors declare no competing interests.

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