Managing COVID-19 in India: Breaking through the myths and caring at home
Authors: Nidhi Rohatgi, MD and Aruna Subramanian, MD
Dr. Nidhi Rohatgi practices General Medicine at Stanford University in California, United States and Dr. Aruna Subramanian is an Infectious Disease Specialist at Stanford University.
India is going through an unprecedented wave of COVID-19 pandemic. The health infrastructure seems to be collapsing under the explosive demand. Medical supplies including oxygen and medications, hospital beds are all in extremely short supply. Health care professionals are struggling to keep up with the volume of patients.
As families try to figure out how to best care for themselves, there is a plethora of well-meaning health advice floating around that may not be supported by scientific studies and taking away resources from those who need it the most. Monitoring of clinical signs and symptoms carefully is the most important. Blood testing or CT scans of chest or vitamin supplementation is needed only in a handful of patients.
With this article, we hope to provide helpful information and break through some of the myths around self-care of COVID-19. This is meant to be a set of general considerations but ultimately, your care should be guided by your local doctors and nurses.
1) What are the symptoms and signs of COVID-19?
COVID-19 can present with a wide variety of symptoms and signs:
2) What is the typical course of COVID-19?
a. Many patients may have no symptoms but can infect others.
b. Some patients may have symptoms. More common are loss of appetite, fatigue (that may persist for 4–8 weeks or more), cough, shortness of breath with exertion, and sore throat (that may linger for weeks), fevers (may last 3–10 days or more), gastrointestinal symptoms (may last <1 week or more).
c. Severe disease occurs in <15% of the patients. These are the patients who definitely need in-hospital care. Most of the other patients can be managed carefully at home under the supervision of outpatient doctors and home care nurses.
d. Patients with pre-existing significant heart or lung problems, uncontrolled diabetes, obesity (BMI >35), or immunocompromising conditions can be more severely affected by COVID-19.
e. Sometimes patients can start feeling better at first and then get worse again in the next few weeks — this may be the same infection having a fluctuating course or a bacterial infection in addition to COVID-19. Contact your local doctor if this is occurring.
3) Are the variants and mutants causing more severe disease in India? Are these patients more contagious?
It appears that some of the new variants are more readily transmissible from person to person and therefore precautions to prevent this transmission are important.
4) Is it necessary to get the vaccine for COVID-19?
a. Getting a vaccine for COVID-19 is protective against severe disease and decreases the chances of death from COVID-19. All available vaccines have been equally effective for this
b. Getting a vaccine does not completely protect us from getting COVID-19.
c. It may take 2–3 weeks after you get the vaccine for immunity to develop.
d. Get the first available vaccine that is approved by your local doctors.
e. Even if you have had COVID-19 before, getting the vaccine provides additional protection from the disease in future.
f. If you are currently infected with COVID-19, then you can take the vaccine after your symptoms have resolved and you are cleared from being in quarantine.
If you received any medications in the hospital for COVID-19 (e.g., monoclonal antibodies, convalescent plasma), then discuss the timing of vaccine with your local doctor as you will likely have to wait for 90 days from the last dose of that medication.
5) What if you get COVID-19 after getting the vaccine?
The vaccine can still protect you from getting severe illness or death even if you get COVID-19 after getting the vaccine.
i. If you only received the first dose of vaccine, then you should try take the second dose as follows:
1. You do not need any blood tests or a test for COVID-19 (RT-PCR or rapid test) prior to getting the second dose of vaccine.
2. Covaxin: 4–6 weeks after the first dose
3. Covishield: 4–8 weeks after the first dose. There is preliminary data that up to 12 weeks is okay.
4. You should get both doses using the same vaccine.
ii. So far, data shows that both Covaxin and Covishield are effective against variants.
6) When should you get tested for COVID-19?
a. Get tested for COVID-19 if you have symptoms and signs of disease or have a known exposure to someone with COVID-19
b. If you cannot get tested but have close exposure to a patient with COVID-19, then isolation, masking, hand hygiene should continue
c. If you cannot get tested but have symptoms that could be suggestive of COVID-19, then take all the precautions (isolation, masking, hand hygiene) and monitor closely for any worsening of symptoms.
7) What test should you get to confirm if a person has SARS-CoV-2 infection or not? Rapid or RT-PCR?
Either rapid test, RT-PCR from nasal, oropharyngeal, or nasopharyngeal, or saliva test from a reliable laboratory are acceptable.
8) Who requires hospitalization?
Only 10–15% of the patients may have severe disease and require hospitalization. It is important to maximize care at home as much as feasible, take measures to prevent further spread, and use the resources judiciously.
· If you are breathing too fast, having difficulty breathing, or oxygen levels are steadily declining from baseline to less than 94%, then call your local doctor or emergency room hotline to get advice on the next steps.
· If you are having chest pain, excessive dehydration, stroke-like symptoms, unable to maintain nutrition for days, multiple other severe medical conditions, then consult your local doctor or emergency room hotline to get advice on the next steps.
9) What is CT value on RT-PCR? Is it accurate? How does it define management?
a. CT stands for cycle threshold and can help shed light on the amount of virus present in the nasal passages. The higher the CT value, the lower the amount of virus present. The threshold cutoff cycle CT is defined by individual laboratory. As an example, if the threshold cutoff cycle CT is 36, then a patient with a CT value of 23 may have lower amount of virus compared to a patient with a CT value of 13.
b. A lower CT value (higher amount of virus) may still not mean that the patient will have severe disease.
c. It can be a helpful indicator of how infectious a person is, meaning that if someone has a low CT, they should be extra careful in masking and social distancing to avoid further spread.
10) What initial blood tests should be done?
a. Most patients don’t need any additional blood testing. Testing can be catered to the constellation of symptoms the patient is experiencing. For example, if a patient has loss of appetite for days, severe vomiting or diarrhea, then a kidney panel may be considered.
b. Many of the tests can be done outside the hospital setting, if clinically indicated.
c. The following tests are helpful mostly in patients with severe illness as determined by the signs and symptoms: Complete blood count, ferritin, D-dimer, C-reactive protein, lactate dehydrogenase, procalcitonin, liver and kidney profile. Interleukin-6 is not an essential test even in those with severe illness.
d. The results of these tests should not determine if the patient needs hospitalization or escalation of care. The clinical signs and symptoms should determine the need for hospitalization.
e. If these test results are done outside a hospital and any of them are abnormal, then do not panic. Consult with your local clinicians.
11) Who needs a computed tomography (CT) scan of the chest?
a. CT of the chest is very infrequently indicated in COVID-19. A CT chest should invariably be done in sicker patients who continue to have high oxygen needs.
b. Patients who have tested positive for COVID-19 but do not have any oxygen requirement do not need CT scan of the chest.
c. CT chest severity score should not be used in general to determine who needs hospitalization. The clinical symptoms and signs should determine the need for hospitalization.
12) Who needs an electrocardiogram (ECG)?
Patients with symptoms such as chest pain or palpitations who have risk factors for heart disease (e.g., advanced age, hypertension, diabetes, obesity) should have an ECG.
13) Should you wear a mask if you and your entire family has COVID-19?
Yes, everyone should continue to wear a mask, distance, and isolate as practically possible to reduce ongoing transmission between family members since people may be at different stages of the illness.
14) What medications and supplies are needed to keep at home if a patient has COVID-19?
It is most important to stay calm and not panic. Continue isolation, social distancing (>6 feet distance from another masked human being), and masking. Do not eat meals together. Do not have social gatherings. Only a very few patients get severe illness and require hospitalization. Take turns to get rest, so family members can take care of each other.
Adequate nutrition: There can be loss of appetite, intense fatigue, and loss of taste with COVID-19. Many patients can have poor nutritional status and dehydration, especially if not intervened sooner.
If patients can eat adequately, then no additional vitamin supplementation (e.g., multivitamin, zinc, vitamin D, vitamin C) is needed.
Adequate fluids: Oral rehydration solution (ORS), homemade electrolyte solutions (sugar, salt, lemon), water, juices, milk, soups, gatorade, are all good, whatever can be tolerated by patients.
· A few patients may require intravenous fluids at home to supplement and a home care nurse as locally available may be able to help with your local doctor.
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