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COVID-19: What India can learn from Sangli's success

April 16, 2020 11:44 IST
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'Have discreet, separate corona and non-corona hospitals for treating these two categories of patients.'
'Concentrate on your non-corona patients as well.'
'Because then your diabetics, your hypertensives, the ones on dialysis, the asthmatics, who, if and when they get corona, are the ones who are going to require more intensive care and are going to be more at risk of death.'

IMAGE: Medical staff wheel a patient at a government hospital in Mumbai, April 11, 2020. Kindly note the image has been posted only for representational reasons. Photograph: Prashant Waydande/Reuters

"Everyday, everybody's learning. We are learning about it and we are working on it. And the administration -- whether it's the health and medical education (departments), the district administration, the police -- everybody is working unitedly in this fight against COVID-19," Dr Pallavi Saple -- dean of the J J Hospital in Mumbai, who led the successful battle against coronavirus in Sangli -- tells Prasanna D Zore/ in the final segment of a must-read interview.


How many more days for the patients to get discharged or go back home?

As per the norms and protocol, all these 25 could have very well gone home and stayed under home quarantine for another 14 days.

The rule is 14-day hospital stay and 14 days's quarantined stay; normally the infectivity is for 14 days. But in very few cases, it can be as long as 28 days.

With abundant caution, the rule is that if you are positive today, then for the next 28 days, you should not be in contact with the world so to say.

Like, they could spread the infection even before knowing they were positive, but then in such cases there is nothing much one can do.

The norm is 28 days's quarantine from the day they test positive. Out of these 28 days, 14 days at a hospital. Then on day 14 and 15 your samples are checked, and if they are negative then you can be discharged for home quarantine.

But what had happened was because these were from one extended family and the whole region was under lockdown, we wouldn't know had they returned home, what repercussions they might have had to face.

So, we, along with the District Civil Surgeon Dr C S Salunkhe, took a collective decision taken to let them stay here in institutional quarantine for some time rather than send them home.

Also, in terms of facilities, as almost the entire family was positive, at home they would have other logistic issues also like who will go out to purchase groceries, vegetables, etc because practically everybody from this family was COVID-19 positive.

Institutional quarantine would be any place outside the hospital like a hotel, lodge, school, or any facility that is identified by the administration for the purpose. There, you don't mix with any outsiders.

Could you tell us about how the district administration and state administration helped this effort?

Normally, the lay public always blames the bureaucracy and government for being slow in responding to emergencies. This is true not only in India; it's universal.

Since I was in JJ (Hospital as its dean) when India recorded its first COVID-19 case in January in Kerala, and even as Maharashtra recorded its first case in March, I can vouch for it that the Maharashtra government began preparing in January.

The airport screening was happening. And then the testing had started.

Unfortunately, since the state's case happened a month-and-a-half later, in the initial phase only people coming from China, Hong Kong and other eight countries that were considered as hotspots (were screened).

Then cases started emerging from Southeast Asia, then Iran and Europe happened. Then all flights were suspended.

At that time, we were screening passengers coming from flights and ships and that was happening since January.

Even testing had started in January, but this (the COVID-19 pandemic) is evolving and teaching each one of us new things.

Remember, the Nipah virus was a huge threat when it started happening in Kerala. In fact, it's a huge killer; out of every hundred people it infects, 90 die. Mortality is that high.

Somehow, it stopped in Kerala. Even if you look at what was known as swine flu or H1N1 it did not affect Mumbai for more than three months.

We were kind of settled into a plateau; even coronavirus could do that; we don't know because we are still learning about it and it is not settling down.

Fortunately, mortality is pretty low if positive patients get good medical care; in Maharashtra for some reason, it's a little on the higher side at 8 to 9 per cent.

China documented one (per cent); certain countries have documented five (per cent), but that also is a reflection of how much medical care you are able to offer.

Like for example, Italy was swamped. They had kind of one ventilator and five patients waiting for it.

So even if you had the best of medical care if you don't have the facility, like a ventilator, then the other four are going to die.

If you have a ventilator, maybe all five could have lived.

Sometimes, mortality is a reflection of unmet health needs. And that is what we are doing right now. Increasing our health facilities so that there is no gap between requirement and supply.

The state health department, the state government are doing their best to provide for as many ventilators, ICUs, PPEs, and all other medical infrastructure that needs to be in place to fight the coronavirus.

You said the general public perception is that bureaucrats and governments act slow during emergencies.
What did you learn while interacting with bureaucrats and the state administration while fighting the COVID-19 pandemic?

Actually, this government pre-empted a lot of things and the bureaucracy was spot on. I can say this because I was part of that system.

When the flights were stopped and visas were suspended or cancelled, people were very surprised. But the way coronavirus is infecting people across India, everybody seems to agree that was the right thing to do.

In fact, we started getting our testing labs in place since January. But then we realised that these testing facilities were not enough.

So now every government and private medical college will be asked to provide a testing lab; there's going to be a little bit of hand holding.

They are going to be decentralised; you won't have to go to Delhi to seek permission for every lab; it will happen at the state level so that we can get started as many labs as possible in quick time.

Everyday, everybody's learning. We are learning about it and we are working on it.

Te administration -- whether it's the health and medical education (department), the district administration, the police -- everybody is working unitedly in this fight against COVID-19.

What are the biggest learnings which you would like to share with other states, other districts in Maharashtra based on your experience of defeating COVID-19 in Sangli district?

One is, if possible, have discreet, separate corona and non-corona hospitals for treating these two categories of patients.

Concentrate on your non-corona patients as well. Because then your diabetics, your hypertensives, the ones on dialysis, the asthmatics, who, if and when they get corona, are the ones who are going to require more intensive care and are going to be more at risk of death.

If you keep your non-corona patients fit now, keep their sugar levels in control, keep their blood pressure under control, they will not come as your complicated corona cases tomorrow.

Because it's so highly infectious, it's going to spread.

The second part is everybody needs to practice social distancing, hand hygiene and cough hygiene.

I don't know how the corona story is going to play out, but if everybody sticks to this hand hygiene and cough hygiene and social distancing, then probably the TB cases will also decrease.

Tuberculosis is one of the many scourges afflicting our country. And not exclusively, but TB, in lots of cases, spreads because of coughing by (TB) patients and close proximity with others.

So, if you are going to practice social distancing, cough and hand hygiene, then probably even TB numbers would go down.

Not probably, I am pretty certain (that TB cases will go down), but first let us fight the corona.

Finally, remember that the healthcare providers are going to be the heroes.

Bolster them emotionally, spiritually and physically. Only then can we win this battle.

Were these 25 COVID-19 positive patients from different age groups? Did they have different symptoms?

The youngest was a two-year-old boy. He was the last one to be declared negative.

And the oldest was the index case, the one who had come from abroad was a 65-year-old male. He was diabetic and hypertensive. He did have co-morbidities, but he did not suffer from any complications.

What was the treatment given to these patients? What medicines helped them defeat COVID-19?

At that time, treatment was evolving and to give you an example, at that time antivirals were recommended.

Today, antivirals are no longer recommended by the government, the (Indian Council of Medical Research) protocol. So at that time, it was new.

And so by protocol, they were given the drugs that ICMR recommends, but I never mention those because hoarding may occur.

Essentially, whatever ICMR recommended at that time and even an antiviral was there. Right now, it's not there; but they got that treatment as per ICMR protocols and guidelines.

None of these 25 patients required a ventilator or an ICU?

Not even an ICU.

They were all kept in the general ward; all of them together because all of them were positive.

And not one of them required any anything more than that, not even oxygen.

Were you, your team, the state administration, the district administration confident that you would be able to treat these patients when you were treating them?

How could a doctor ever be confident of anything?

I mean, I'm a paediatrician by training. I work in the neonatal ICU, paediatric ICU. I've seen patients turn for the better and then suddenly deteriorate.

I've seen patients of whom we almost give up hope, but they fight their way back.

Doctors would never have that kind of arrogance to believe that this is going to happen.

We knew we had to be very systematic. It was a very clinical, a very surgical kind of approach; we knew what we were monitoring; we were monitoring for early signs of pneumonia.

If we found out those, we were pre-empting them and giving them treatment for that.

We were checking their blood pressure and sugar and didn't allow that to go haywire so that that would that wouldn't mess up the whole situation.

We were ensuring that their nutrition was taken care of. We were doing everything to see that they test negative.

But there was no guarantee or confidence.

I mean, medicine doesn't come with guarantees.

All the 25 COVID-19 patients who are right now under institutional quarantine have reported two negative swab tests before they were sent for institutional quarantine.

Yes, the last two consecutive swab tests came out to be negative and hence they were declared negative. 

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