By Abhishek Bhatia
New Delhi: The recent upswing in COVID-19 infections throughout the country was not seen as a major cause of concern because of the virus’s less severe nature and reportedly minimal hospitalisations. But with the increase in instances of mortality over the past couple of weeks, experts have started calling for intensified countermeasures to stop the virus from spreading further.
Recently, the Prime Minister’s office also stepped in to access COVID-19 preparedness. While there were reportedly 89 deaths in March, that number has increased to 201 as of April 16, 2023, and has been refusing to settle down since then. To get to the bottom of this and perhaps understand potential reasons behind the rising death toll, ETHealthworld spoke with medical specialists who highlighted various aspects of the rising number of mortalities due to the novel coronavirus and also whether it is an alarming situation or not.
Experts also took on the suggestion coming from multiple quarters about a shift in data interpretation and brought in a new approach to interpret it as India is heading towards an endemic stage of the pandemic. With limited testing now, the virologists have been demanding that the focus be more on mortality and hospitalisation than just the daily positivity rate.
Explaining that coinfection was a major contributor to mortalities in the past few weeks along with COVID-19, Dr Jitendra Choudhary, Consultant – Intensive Care and Critical Care, Fortis Hiranandani Hospital Vashi, said, “This is a time when flu cases are also rampant. We are seeing a lot of flu cases, and the number is increasing. COVID patients susceptible to death mostly carry a co infection with them.”
Dr Vikrant Shah, Consulting Physician, Intensivist, and Infection Disease Specialist, Zen Multispeciality Hospital Chembur, suggests that there was a drop in the number of patients coming with classical complaints associated with COVID-19, leading to less emphasis on testing. And, thereafter, H3N2 influenza came with more or less similar symptoms in the form of fever, fatigue, tiredness, runny nose and cough. Dr Shah dubbed the situation “a kind of overlap.” And we didn’t really test each and every patient, he said.
Specialists have deliberated that there could be various reasons behind the rise in deaths due to COVID-19 in the past two weeks, and people putting their guard down have a substantial role to play in it. These could include a surge in new infections, the emergence of more virulent strains of the virus, inadequate healthcare infrastructure or resources, delays in seeking medical attention, or other comorbidities that may make individuals more susceptible to severe illness and death.
Dr Choudhary further elaborated that the major reason could be that people have become a bit complacent about the care and are not following COVID-appropriate behaviour. With this, the chances of spread also get high again, and with the emergence of new variants, infectivity is another threat.
Calling it a sudden rise in COVID deaths is just too dramatic, said Dr Samir Garde, Director of Dept of Pulmonology and Lung Transplant, Global Hospitals, Parel, adding, “If there is a season where there are viral infections, proportionately there will be a number of deaths, and proportionately there will be deaths that will be reported as COVID deaths.”
Dr Garde stated that all the respiratory viruses, be they influenza, para-influenza, or coronaviruses, keep undergoing variations every year. At least 5,200 variations will happen because of genetic changes within the viruses. Coupled with the respiratory viral infection periods taking place almost twice or thrice every year, as per Dr Garde, this time it is some COVID-19 variant causing infection. “Whenever there are viral cases, there will be a certain percentage of people who succumb to that.”
Who is more susceptible to death due to COVID-19? And is COVID the primary cause of death?
Older adults and individuals with underlying health conditions have traditionally been more susceptible to death due to COVID-19. Dr Jayalakshmi T.K., Consultant Pulmonologist, Apollo Hospitals Navi Mumbai, said, “While COVID-19 can be the primary cause of death, it can also cause or exacerbate other complications such as pneumonia, respiratory failure, and sepsis, leading to the recent rise in casualties. Many casualties are those in which COVID is an incidental factor and not the primary cause of death, as in cardiac and renal failures and sepsis cases.”
According to the experts, the vulnerable population with altered immunity, including elderly people, people with uncontrolled diabetes with comorbidities like chronic kidney disease, anyone reliant on chemotherapy for cancer, and individuals undergoing an organ transplant dependent on immunosuppressants, are more prone to mortality.
Once they catch not only any respiratory viral infection, one to two per cent people will also contract a secondary bacterial infection, remarked Dr Garde. He adds: “There is an inflammatory cascade in the body because of which people who already have a heart, lung, or kidney condition or are simply elderly and their immune mechanisms are malfunctioning can succumb to that.”
Are we going to witness more casualties in the coming days?
Several media reports owing to government sources indicate the rising COVID-19 cases are bound to increase over the next week, and thereafter they will start settling down. With the new variant spreading, a lack of COVID-appropriate behaviour will lead to a chain, said Dr Shah, and “that will let this go on and on, out of which the vulnerable population will get affected more. There is a risk of mortality for vulnerable strata of the population due to their secondary complications resulting in worse immune status; they are going to always be vulnerable.”
Dr Choudhary believes that the number of mortalities may go up a bit from this point on, including the proliferation of patients who will require hospitalisation. But translating into mortality on a large scale has a very low probability.
Experts point out that the SARS-CoV-2 pandemic in India is now entering the endemic stage. In other words, bacteria and viruses have become part and parcel of a given geography. The virulence of pathogens infecting human beings in a particular community comes down, and the immunity of an individual is able to fight back.
Good-quality tertiary care may even help people survive properly, said Dr Garde. Agreeing that with the number of cases going up proportionately, deaths are also supposed to rise, Dr Garde added a caveat that, “Since the virus has been circulating for a long time and people have developed immunity, cases may go up, but the deaths may remain the same, or you may also see a decline in the number of deaths.”
Shifting focus from positivity rate to increased surveillance on deaths and hospitalisation?
“As COVID-19 enters the endemic stage in India, the focus should shift towards reducing deaths and hospitalisations rather than just testing positive cases. However, testing remains an essential tool in identifying new outbreaks and implementing appropriate public health measures to control the spread of the virus,” said Dr Jayalakshmi.
Reaffirming this, Dr Garde explained that patients need focused medical care instead of just testing how many people are positive. The PCR/DNA PCR test picks up dead viruses that people are harbouring inside their oropharynx. For instance, one crore people in Mumbai may test COVID-positive if everyone in the city is tested. But that has no meaning unless they are suffering from symptoms like a cold, cough, or breathlessness issues.
If testing is ramped up, it is likely that a greater number of positive COVID-19 cases will be identified, informed Dr Jayalakshmi. She continued, “However, increased testing would also help identify asymptomatic cases and allow for prompt isolation and treatment, reducing the spread of the virus. Additional testing would reveal increased numbers for sure but also raise false alarms due to the asymptomatic cases.”
Despite treatment, if symptoms related to COVID-19 persist, the patient may need to be diagnosed for other infections as well. According to Dr Garde, it is totally unscientific to keep checking only for COVID-19; the time for that has gone long ago. If at all you are doing a test, you should promote a multiplex virus PCR test where you should test for at least six common viruses.
When asked about doing more tests, Dr Shah said that ramping up testing has its own benefits as it will help in finding whether we are really in an endemic stage or are witnessing a kind of just one of those waves that is seen periodically. And testing is a tool to confirm it.
Indian SARS-CoV-2 Genomics Consortium (INSACOG) data recently revealed that 436 cases of the mutated sub-variant XBB1.16.1 have been detected in the country till now. Specialists underscored that there will be multiple strings or mutations of the viruses that will keep happening as the virus spreads and intermingles with other viruses. There is nothing we could have done differently to catch the virus or to prevent the mutation per se from happening. Sticking to COVID-appropriate behaviour will help in preventing and reducing the further mutation of the virus.
The positivity rate doesn’t actually tell the severity of illness, said Dr Choudhary, concluding that “it is not going to be a reflection of the severity of illness, per se, but definitely a mortality rate or rate of hospitalisation will be a more valid marker about the severity of illness.”
Experts highlighted that the counter-strategy to prevent deaths due to COVID-19 would include a combination of measures such as increasing vaccination rates, enforcing preventive measures such as wearing masks and social distancing, improving healthcare infrastructure and capacity, and promoting public awareness and education about the importance of taking preventive measures. Additionally, identifying and addressing underlying health conditions and co-morbidities that increase the risk of severe illness and death would also be crucial. Educating people about respiratory health and hygiene can turn out to be barriers against infectious diseases.
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