New therapies can help handle the third wave better. But they must be used smartly.
As we battle the third wave of the pandemic in India, it is important to acknowledge that we have learned a lot during the past two years. We now have better tools. If we can avoid the past errors, and use the newer tools smartly, we should handle this crisis better.
Since the Omicron variant is exceptionally transmissible and can cause infections among vaccinated people and people who have had Covid-19 previously, we can anticipate a big spike in cases during the first few weeks of the new year. Whether this surge overwhelms our healthcare system will depend largely on how well we control the spread, and how stringent we are with selecting individuals for hospitalisation.
The principles for limiting spread remain the same as the last wave: Masking (surgical masks are better than cloth masks, but the ideal masks would be KN95 or N95), ventilation, double vaccination (with boosters for approved groups), sanitising and avoiding the 3 Cs — closed spaces, crowded spaces and close contact with others.
Those who are completely unvaccinated should be strongly nudged to get themselves vaccinated. That is the most important action at the individual level. Many people have taken their first dose but failed to take the second. It’s critical to complete the vaccination schedule, especially with Omicron becoming the dominant variant of the virus. For the detection of Covid-19, including its Omicron variant, a rapid antigen test, and RT-PCR are both useful. Blood tests and CT scans of the chest have no role for either the routine diagnosis or treatment of Covid.
With Omicron, most individuals who are doubly vaccinated will need no more than symptom-based treatment at home, such as paracetamol for fever, along with the monitoring of oxygen levels with a pulse oximeter. There is no need to rush to hospitals or go seeking oxygen. We cannot afford to have hospital beds occupied for social reasons (lack of isolation facilities at home), fear (what if I don’t get a bed when I need one?), isolation of mildly symptomatic or asymptomatic travellers or people with clout. Covid patients should only be hospitalised if they have low oxygen levels (less than 94 per cent oxygen saturation on pulse oximetry) or have comorbidities that are serious enough to warrant hospitalisation.
During the second wave, there was a lot of confusion among doctors, which resulted in over investigation, over medication and irrational treatments. For this wave, we must avoid useless and dangerous therapies. The following drugs should be avoided: Favipiravir, Ivermectin, Azithromycin, Doxycycline, Hydroxychloroquine, convalescent plasma, Vitamin C and D, Zinc, Colchicine, Itolizumab, Bevacizumab, Lopinavir-ritonavir, Interferon alpha-2b, Coronil and other herbal medications.
Corticosteroids continue to be the drugs with the greatest life-saving role in Covid, but this is true only when they are used with the caveats. Corticosteroids (oral or intravenous) are useful in select patients with low oxygen levels. But if used too soon, for too long, and in high doses, they can cause a rapid deterioration in individuals and increase the risk of mucormycosis (black fungus) that we saw after the second wave. Corticosteroids should only be prescribed when oxygen levels fall below a threshold of 92 per cent, for a limited duration (5-10 days for most individuals) and in doses that do not exceed 6mg Dexamethasone or its equivalent (40 mg Prednisolone or 32mg Methylprednisolone) per day. Inhaled, not oral, corticosteroids (such as Budesonide) may have a role, especially in individuals with underlying diseases such as asthma and COPD who have lower respiratory symptoms such as a cough.
Since the second wave, three new treatments have emerged and are available in India: Monoclonal antibodies, Molnupiravir and Fluvoxamine. Another anti-viral drug, Paxlovid, developed by Pfizer, has not been approved in India yet.
Monoclonal antibodies may have a role in high-risk individuals once they have been detected with the infection. However, the only products approved in India are cocktails of either Casirivimab and Imdevimab or Bamlanivimab and Etesevimab. This therapy is expensive and requires IV infusion in a healthcare facility. These cocktails are known to be effective against the Delta variant, but not so against the Omicron variant. So, they have been discontinued in many countries that are facing an Omicron-driven surge. If the present surge in India is largely due to Omicron, our guidelines must recommend discontinuing the use of these antibody cocktails or using them selectively in patients infected with the Delta variant.
Molnupiravir, an antiviral that was recently given an Emergency Use Authorisation for treating adult patients, has shown limited efficacy when tested in unvaccinated individuals with risk factors. Whether it will offer any benefit to vaccinated individuals is not known. The drug did not work in those with diabetes and those with high viral loads. The fact that the rampant use of antivirals can lead to resistance, especially to new mutants, should make one very cautious about the widespread use of the drug. Presently, one should limit the scope of prescribing Molnupiravir to early use (within five days of onset of the symptoms) among symptomatic, unvaccinated individuals with one or more risk factors (more than 60 years, active cancer, chronic kidney disease, chronic obstructive pulmonary disease, obesity, serious heart conditions). Indiscriminate use that’s quite likely in the Indian setting, given how aggressively pharmaceutical companies are advertising the drug, needs to be prevented.
Fluvoxamine, a drug already used for depression, is an inexpensive and widely available drug. One trial showed that treatment with fluvoxamine (100 mg twice daily for 10 days) among high-risk outpatients who were diagnosed early reduced the need for hospitalisation. While it may be premature to routinely use this drug, it has shown enough promise to merit more studies, especially in the Indian context.
Since most Indians have some protection, either from past infection or vaccination, the third wave should cause less severe disease and fewer deaths. However, with Omicron, we know that such protection may not prevent infection. So, a spike in cases is expected. While we brace ourselves for a huge surge, we must not forget lessons from the last wave and smartly use the tools and knowledge we have.