Pulse oximeters more useful than symptom-based screening for COVID-19 in older adults

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Pulse oximeters are more useful screening methods for COVID-19 in older adults compared to temperature measurement.

Fever is considered a classic presentation of COVID-19. However, a new research from the College of Nursing, Washington State University, suggests that since older adults have a lower core body temperature (less than 98.6°F or even as low as 94°F), the standard definition of fever (≥100.4°F) may be a less useful indicator of infection in this population group. The study says, “Lower baseline temperatures may result in overlooking fevers. In fact, upwards of 30% of older adults with serious infections show a mild or no fever.”

In addition, COVID-19 symptoms such as fatigue, body ache, weakness, increasing loss of taste and smell may well be attributed to aging. Atypical symptoms are more often seen in older adults, which could be in the form of change in cognitive status or mobility. There is a delay in fever and respiratory symptoms.

The study cautions healthcare providers to look out for any fall in SpO2 (3–5%) after mild activity/ambulation, room air, and the presence of hypoxemia without tachypnea. This can be done in homes using a small, portable and an economical device, the pulse oximeter.

The authors recommend that pulse oximeters should be considered to screen for asymptomatic hypoxia in older adults, given their potential efficacy for detecting changes in SpO2.

Since the absence of fever does not always rule out the presence of an infection, screening for “silent hypoxia” with pulse oximeters could help identify older adults with COVID-19 pneumonia.

(Source: Frontiers in Medicine, April 14, 2021)

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

Most hospitalized vaccinated patients likely acquired COVID-19 infection before development of immunity

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Most people who had taken the vaccine and were hospitalized for COVID-19 likely had developed the infection just before or about the time of the vaccination, as per a BMJ report.

Hospitalized vaccinated patients during the second wave of the UK were evaluated by the International Severe Acute Respiratory Infection Consortium Clinical Characterisation Protocol (ISARIC4C) using data available up to April 10, 2021. Of the 99,445 hospitalized patients enrolled in the study, 3842 (7.3%) had received the vaccine. Time to onset of symptoms and also mortality were analyzed for the vaccinated patients.

729 (40%) symptomatic patients developed COVID-19 symptoms 0-7 days after the vaccination
352 (19%) developed symptoms 8-14 days post-vaccination
211 (12%) patients developed symptoms 15-21 days after vaccination
526 (29%) developed symptoms more than 21 days after vaccination
Since the median incubation period for SARS-CoV-2 is approximately 5 days, these observations suggest that the majority of patients had been infected before they developed full immunity as this is not enough time (0-7 days) for the immunity to develop. And those who developed symptoms 8-14 days after the vaccine were infected before the immunity had fully developed. These infections are unlikely to be vaccine failures.

However, there is a possibility that those who developed symptoms 15-21 days or >21 days post-vaccine were cases of vaccine failure. But, this is along expected lines as vaccines were not 100% effective.

ISARIC4C report states that the “elderly and vulnerable people who had been shielding, may have inadvertently been exposed and infected either through the end-to-end process of vaccination, or shortly after vaccination through behavioural changes where they wrongly assume they are immune.”

Among those who developed symptoms ≥21 days after the vaccination, 28% (113/400) died with COVID-19. Of these, 82 were in the “frail elderly” group. The report said, “Mortality appears to remain high for people in high risk vaccination tiers who are admitted to hospital with SARS-CoV-2 infection despite vaccination 21 day or more previously.”

These findings reiterate the importance of maintaining social distancing, even after vaccination, to minimize the risk of infection as most infections had occurred within 14 days of vaccination before immunity fully develops.

Deborah Dunn-Walters, chair of the COVID-19 taskforce at the British Society for Immunology and professor of immunology at the University of Surrey, said, “A very small number of people were hospitalized 21 days post-vaccination, and it’s these people that we need to examine in more detail to understand why the vaccine did not afford them full protection.”

(Source: BMJ 2021;373:n1127, published 30 April 2021)

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

Covid-19 Crisis: India gasps for oxygen

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Reproduced from: India Legal,  https://www.indialegallive.com/column-news/covid-19-crisis-india-oxygen-hospital-beds-medicine-spo2//Published April 30, 2021

Images of breathless people scrambling to hospitals have shocked the nation. As the macabre dance of death continues, what is obvious is the lack of planning in every sphere by our bumbling governments.

Citizens of Delhi are going through a hellish existence in the wake of Covid-19. Many are dying due to deficient oxygen supply and insufficient number of medicines, hospital beds and medical devices like SPO2 monitor. People are not able to get even a basic medicine like paracetamol. What can be worse for human life than having to purchase oxygen just to breathe?

The pandemic is now raging with greater intensity than in 2020. The number of Covid-19 positive patients has exceeded 25,000 in the National Capital Territory of Delhi. As of April 2, 2021, the country reported an all-time high of 3,38,611 lakh cases, with the current doubling rate being prevalent in the last two weeks.

It is observed that the test positivity rates (TPR) are rising continually, with around 1/3rd of all districts in the country having a positivity rate of more than 35 percent. TPR was more than 13 percent on April 15, 2021. According to medical estimates, around 15-20 percent of these patients could require hospital admissions, with a quarter of them needing specialised ICU care. This translates to a requirement of roughly 50,000 beds daily in the country. It is evident that the healthcare infrastructure is on the verge of an imminent collapse.

DEFICIENT OXYGEN SUPPLY

In almost all hospitals, the availability of oxygen has dropped dramatically. This has led to oxygen pressure being reduced in order to keep it going longer. But this has resulted in serious patients having a drastic fall in their oxygen levels, leading to many fatalities.

In an order on April 2, the Delhi High Court in Rakesh Malhotra versus GNCT of Delhi, held: “9. We hope and expect that State of Rajasthan to honour the orders passed by the Central Government, as well as orders passed by this Court. Any intervention by anyone in the plan put in place by the Central Government for the supply of medical oxygen in the country, at this stage, would tantamount to endangering hundreds of human lives, if not more.

“10. It serves no purpose for anyone to cause any obstruction in the smooth flow of much needed Medical Oxygen. Stoppage of tankers by one State would have snowballing effect, and would eventually adversely impact the concerned State as well. Since the Central Government is mindful of the needs of all the States and Union Territories, and the distribution plan has been worked out by taking into account the needs of all the States and Union Territories, if any concerns arise before any State, they should be addressed to the Central Government, for which the Central Government has already created a Virtual Central Control Room on which the Nodal Officers of all the States are represented….

“14. One other aspect that we would like to deal with today itself is with regard to the non-availability and consequent black marketing of Oxygen cylinders which is taking place rampantly in the NCT of Delhi.”

The Court said that any intervention by anyone in the plan put in place by the central government for the supply of medical oxygen would be tantamount to endangering hundreds of lives, if not more.

India’s oxygen crisis isn’t just about a growing demand-supply gap. Even if the government diverts all oxygen production in the country to medical uses and coronavirus cases don’t rise in the coming weeks, it will still face a massive logistical challenge to transport and store the oxygen.

VACCINE WASTAGE

Another issue is vaccine wastage. Since January 2021, Covishield and Covaxin vaccines were being used in India for inoculating people. However, it is quite astonishing and depressing that the country’s biggest vaccination drive is experiencing huge wastage. This is at a big cost to the country’s scarce resources.

In its ongoing vaccination drive, Delhi recorded a wastage rate of 4.1 percent for Covishield and 17.5 percent for Covaxin, said a senior Delhi government official, citing a report prepared by the Health Department on April 19, 2021. The Delhi High Court in an order dated April 19, 2021, in Rakesh Malhotra versus GNCTD and Others, expressed serious concern about the wastage and stressed on the need to vaccinate more and more people.

Citing news reports, the bench of Justices Vipin Sanghi and Rekha Palli said: “The number of vaccines has been wasted is 44 lakhs out of 10 crore vaccine. The vials have to be consumed once it has to be opened. Now the ones which are not used are being wasted. Why are we wasting even one shot, why can’t we deal with it?” The Court suggested creating a mobile application with a list of people who can be vaccinated. “Give it to people willing to take it. Those drops which can save the lives, are being wasted.”

Talking about the dip in vaccination numbers, the Court said: “If we wait for 10 days, the problem may persist. We are losing on valuable and young lives. The pandemic does not discriminate. Whomsoever needs vaccines, give them. Everyone needs vaccination.”

WHAT THE CONSTITUTION SAYS

Various Articles in our Statute relate to the health of citizens and the need to take care of it.

Article 38 of the Constitution states: “The State shall strive to promote the welfare of the people by securing and protecting as effectively as it may a social order in which justice, social, economic and political, shall inform all the institutions of the national life.”

Article 39(e) states: “(e) that the health and strength of workers, men and women, and the tender age of children are not abused and that citizens are not forced by economic necessity to enter avocations unsuited to their age or strength.”

Article 41 goes on to impose a duty on the State to give public assistance, basically for those who are sick and disable. Article 42 makes a provision to protect the health of infants and mothers by maternity benefits.

The Directive Principles of State Policy under the Article 47 says that it is the duty of the “State to raise the level of nutrition and the standard of living and to improve public health, The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties and, in particular, the State shall en­deavour to bring about prohibition of the consumption except for medicinal purposes of intoxicating drinks and of drugs which are injurious to health…”

The right to health is the fundamental right of a citizen, as per the Constitution. However, this has been blatantly violated by both central and state governments in every which way. Besides not being able to provide oxygen to its citizens, there is little by way of succour. The long line of bodies at various cremation grounds is a staggering testimony to the way all governments have abdicated their responsibility and left citizens to fend for themselves.

FOREIGN COUNTRIES

India has been at the forefront of exporting vaccines to other countries. By March 24, it had dispatched 60 million vaccines to 76 countries, and administered only 52 million doses to Indians. Only a small portion was donations to friendly nations; most of the exports were under commercial agreements made by the Pune-based Serum Institute of India, the world’s largest vaccine manufacturer.

While exporting vaccines is a strategy to enhance the prime minister’s image, it is shocking that the country did not plan to vaccinate its own citizens first. There are reports of India facing a vaccine shortage even as vaccination for those over 18 years started from May 1.

Most other countries have done much better planning than India. The UK has already vaccinated a quarter of its population. But when a group of charities urged PM Boris Johnson to “swiftly clarify” how many Covid-19 vaccine doses the UK was prepared to donate to poorer countries, Culture Secretary Oliver Dowden said the UK does not currently have a surplus of vaccines. But the fact is that the UK had ordered 400 million doses, and reports say it will have many left over.

Meanwhile, the US, which has surplus AstraZeneca vaccines, said it would send them to India. This was after it faced a backlash over its growing stockpile and tardy response. The US has around 30 million doses of AstraZeneca vaccine that are not approved for use there. So if other countries could plan ahead, why couldn’t India?

The present scenario reveals that our governments have failed miserably to abide by the Constitution and left their citizens to die alone.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

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