By Dr Edward Nazareth
Sep 15: Nearly 70 members of an elite club met in Mangaluru for a celebration followed by dinner recently. Of these, more than 25 people turned out to be positive for COVID-19 infection within a few days; one senior member succumbed to the infection and six of them are still in the hospital. It is now believed that one of the members who had fever and given the sample for testing on the same day had attended the celebrations; his report came positive on the next day. The members of this club are well educated and well informed.
A group of Catholic priests were tested positive a few weeks ago. They all had gathered for the birthday celebration at a parish house. It was later known that one of them had attended an engagement ceremony a few days ago where many guests were present. Fortunately all the priests recovered without complications.
When lockdown was announced in India by our Prime Minister on March 24 this year, there were only five positive cases in the Dakshina Kannada district and Udupi had one. The first death due to COVID-19 infection in Dakshina Kannada was reported on April 19 - a lady aged 50 years from Kasaba, Bantwal died at Government Wenlock Hospital.
Once the lockdown was announced, though there were a few positive cases the people were extremely alert. Everyone was wearing mask and people used to chase away anyone without mask. Social distancing was strictly followed - it was a common scene, people waiting even in the hot sun in front of the super markets maintaining strict social distancing by standing at the previously marked places. There were no celebrations, no parties - people were extremely vigilant. Almost everyone was carrying hand sanitizers. The public transports were not used, even if it was available, people were scared to travel in auto-rickshaws.
As I prepare this write up in the second week of September, we have more than 400 positive cases reported in Dakshina Kannada almost every day and total deaths due to COVID-19 related complications are nearing to 430. In Karnataka total positive cases have crossed 4,40,000 and deaths have crossed 7,000.
The number of positive cases and the number of deaths are increasing in almost every city of the country. Though through statistics we are trying to give low death rate compared to many other countries, we have to accept that we are not able to contain the deadly virus. We are almost reaching the mark of one lakh positive cases per day in the country, which were barely 500 total cases with 10 deaths in the entire country when the lockdown was announced on 24th March 2020. Our total tally of positive cases now is nearing to 50 lakhs with deaths reaching to 80 thousands.
But the common people seem to be least bothered. Once the lockdown was relaxed in phases, people were feeling the importance of freedom-freedom from banned travelling, freedom from restricted shopping, freedom for public gatherings etc. Though the authorities are warning frequently, most of the people seem to be care free. It appears, people wear masks in public as if it is a statutory requirement. Masks are most often seen on the chin than covering the nostrils and mouth. Social distancing is hardly seen, people are crowding everywhere. The public transport like city buses are overcrowded during peak hours. It appears that the common people have reached the threshold of behavioural fatigue; they do not want to follow the restrictions any more. Wearing the masks, maintaining social distancing and hand washing- which are not difficult to follow, but cannot become part of our natural human behaviour. This seems to be the main reason for increase in the number of positive cases; though we give the excuse that our testing rate is far more superior to many other countries.
Why everyone has to take care?
When the pandemic started, people were cautioned about the infection through all possible means. News papers, television and all the social media were used to educate the people. This in turn created phobia among the people and people were so scared, even the dead bodies of COVID19 victims were not allowed decent funeral in the burial grounds.
To alleviate the fear, the campaign started that the virus was not deadly. Elderly and people with co-morbidities only may get the complications. This campaign has resulted in false confidence in common people. Now most of the people believe that the COVID19 virus won’t affect them as they are healthy. Some people quote some elderly politician who had no problems even if infected. Many of the politicians and celebrities have survived the infection and are perfectly healthy. But, unfortunately it is not true in every one.
A young doctor in Mangaluru who had started his postgraduation about ten days prior to the fateful night died suddenly. He developed chest pain and collapsed in the intensive care unit. He was tested positive and was on treatment. He is not the only one. It is now reported that of the total deaths in India, about 15% are below the age of 45 years. In Karnataka more than a quarter of COVID 19 related victims are younger than 50 years and without any known co-morbidities. It is believed that these people develop either acute myocardial infarction due to clotting of the blood or acute myocarditis. Heart related complications seem to be the main cause of death in young population without known co-morbidities.
Many healthy young individuals who had severe illness due to COVID19 infection have survived and are suffering from breathing difficulties, which is attributed to post-covid lung damage. The after effects of the infection are not fully known and it is not known whether they will ever recover from it.
At the beginning of the pandemic and even now the complications of COVID19 are more common in people with co-morbidities. It doesn’t mean that the virus won’t infect the young and healthy. Many of these remain asymptomatic and pass on the infection to the vulnerable in their families or in the neighbourhood, but a few get the illness and develop complications.
As believed at the beginning of the pandemic, the virus is spread mainly by asymptomatic and the people in the pre-symptomatic stage. It is now almost impossible to trace the source of infection in many people. Asymptomatic carriers of the virus are everywhere. It was initially thought, only young individuals are asymptomatic. Now it is clear that asymptomatic people can be at any age. ICMR had suspected (not yet approved) that more than 15% people in the hot spots had contacted the virus, but many did not have the disease-they were asymptomatic. More than 80% adults and 95% children are asymptomatic when infected. Of the remaining more than 10% to 15% of adults and 2% to 3% children have mild symptoms; many of them may not go for testing. It means that for every positive symptomatic case, there may be 8 asymptomatic infected people. These asymptomatic people are there everywhere in the community. They can spread infection like any other person having the symptoms.
Infection and re-infection
It was initially thought, the people who get infected would develop immunity for re-infection. Recently four junior doctors working in COVID wards in Mumbai are tested positive due to re-infection. The reports of re-infection are also coming from different parts of the world. It was earlier reported that the antibodies developed after an infection by COVID19 virus disappear in many people within three months. This has disappointed many who trusted an effective vaccine to protect from infection. More details are awaited and we are not sure whether we will get an effective vaccine and if we get how frequently we may have to take it to remain protected.
We have not conquered the virus, it is around us. The possibilities of infection are quite high. We have to take care, we have to be vigilant. To protect from infection we have to inculcate the ‘Covid Behaviour’ as a part of our daily life. There are three important parts in this, wearing the mask and wearing it properly, maintaining social distance and hand hygiene.
Though these are at times irritating, these are now essential to save our life from the deadly virus and life of others who come to our vicinity.
Wear the mask, wear properly
When we are in a group we have to remember that we may be surrounded by people who may be able to spread the virus to us. Therefore, it is important for everyone to wear the mask and wear it properly.
If one is not working as a health care professional or not in the hospital for whatever reason, ordinary cloth mask may be enough. The advantages of the cloth masks are that they can be washed and re-used. The surgical masks are better than the cloth masks, but a surgical mask has to be disposed off after a single use or using continuously for 6 hours. N 95 masks, which are expensive, are especially needed for health care workers who work with COVID19 positive or suspected individuals.
It is proved that the masks slow the spread of COVID 19 virus by reducing the infected people spraying the virus into the environment around them when they cough, sneeze or talk. If you are close to a person wearing the mask who is having the virus(with or without symptoms), the chances that person transmitting viruses on to you are far less. Therefore it is important for you to insist all the people closer to you to wear the mask, wear it properly irrespective of whether they are sick or not.
When you wear a mask – even a cloth mask – you typically are exposed to a lower dose of COVID19 virus than if you do not. If the virus load is less, even if you are infected you may not become sick or may have mild symptoms. It is now clearly known that the COVID19 virus enter human body through nose and mouth and rarely through eyes. Therefore wearing the mask and spectacles (plain glasses also) can protect you substantially from infection.
The viruses are normally spread on the common surfaces like tables, chairs, door knobs, lift buttons, railings of the steps that we touch. The viruses are transmitted to our hands from these surfaces. We frequently take the hands (involuntarily) near the nose or mouth, from where viruses get entry into our body. If we wear the mask continuously and do not touch the nose or mouth, transmission of the virus is avoided.
No mask is perfect, and wearing one might not prevent from getting infected totally. But the mask definitely reduces the risk and even if infected, reduces the viral load (the amount of viruses). The mask can reduce the intensity of infection - a person who would have gone to the ventilator if infected without a mask, may get mild infection with a mask and may not even perceive it, may remain asymptomatic.
Maintain social distance
COVID-19 virus spreads mainly among people who are in close contact (within about two meters or 6 feet) for a prolonged period. The possibility of contacting the virus by a healthy person from an infected person depends on two factors- the distance between the two and the duration of exposure.
The virus spreads when an infected person coughs, sneezes, or talks, and droplets from their mouth or nose are launched into the air. These may land in the mouths or noses of people nearby. This is more so in closed rooms like cabins, chambers with air conditioners. The studies have shown that the viruses can thrive in the air in closed rooms for several minutes and spread to others and the droplets can be inhaled into the lungs from the air. This must be the main reason why many guests in the celebrations and parties are infected from one or two infected person(s).
The time duration a healthy person spends in the vicinity of an infected person is also an important factor in spreading the virus. Using the ‘exposure to virus x time’ formula, the studies have shown that anyone who spends more than 10 minutes with in a face-to-face situation is potentially infected. Anyone who shares the space with an infected person (for example, an office) for an extended period is potentially infected.
Coughing and sneezing release hundreds of millions of viruses that travel at a great speed (80-320 kmph) and have high chances of infecting the people. A healthy person can get infected just by exposure for a few minutes to the infected person who has been coughing or sneezing.
• When going out in public, it is important to stay at least 2 meters (6 feet) away from other people. It is very important to follow this in public places like public transport, offices, banks, places of worship etc.
• Whenever possible, avoid using public places. Most of the shopping may be done online or go to the market places when they are less crowded. Only visit stores selling household essentials in person when you absolutely need to, and stay at least 6 feet away from others who are not from your household while shopping. Please insist politely to the people around you to wear the mask and wear it properly, when you also wear the mask properly. Finish the shopping at the earliest and move out from the place.
• If possible avoid public transport, use your own vehicle. Faster mode of transport is better- if you can travel by air, it is better than using a bus or train. Consider social distancing options to travel safely when running errands or commuting to and from work, whether walking, bicycling or using public transit, rideshares, or taxis. When using public transport, try to keep at least 6 feet from other passengers or transport operators – for example, when you are waiting at a bus station or selecting seats on a bus or train. When using rideshares or taxis, avoid pooled rides where multiple passengers are picked up.
• It is safest to avoid crowded places and gatherings where it may be difficult to stay at least 6 feet away from others who are not from your household. If you are in a crowded space, try to keep 6 feet of space between yourself and others at all times, and always use mask and use it properly. Masks are also important in times when physical distancing is difficult.
• When you go for a walk or exercises out in the park consider how many other people might be there and choose a location where it will be possible to keep at least 6 feet of space between yourself and other people who are not from your household.
The hands have a crucial role in the transmission of COVID-19 virus. The COVID-19 virus primarily spreads through droplet and contact transmission. Contact transmission means by touching infected people and/or contaminated objects or surfaces, the hands get infected. These hands can spread virus to other surfaces and/or to the mouth, nose or eyes if the person touches them.
The hand hygiene is one of the most effective actions that can be taken to reduce the spread of pathogens and prevent infections, and is considered as the No. 1 tip for preventing the spread of COVID-19 virus. It is common sense and it works. However, it must be done properly and with soap and water. It is recommended that copious amount of soap has to be applied and hands should be rubbed together for at least 20 seconds and washed with running water. They may be dried using fresh tissues or personal hand kerchief. The hand dryers, commonly found in public bathrooms are also effective.
• Using clean, running water is important. Never wash the hands by submerging them in a basin or bowl of standing water. This water could contain germs that continue to live there. Avoid touching doorknobs, toilet flush handles, and faucets after washing the hands.
• When soap and water are not available, the next best option is to use an alcohol-based hand sanitizer. The sanitizer should have at least 60% alcohol.
• Alcohol-based hand sanitizer (containing at least 60% alcohol) is helpful in protecting against the spread COVID 19 viruses. However, hand washing with soap and water is still the best. The hand sanitizers can be an alternative when soap and water is not available. This includes when taking public transportation and when it is difficult to get to a bathroom (airplane, train, bus). Carrying a travel size bottle of hand sanitizer makes it easy to disinfect the hands in these situations. Some people use it when they sit down to eat at a restaurant. Others use it when they are in the presence of crowds (games, church service, school meetings).It is important to apply generous amount of hand sanitizer to the palm of the hand and rub it across both hands, front and back, and fingertips till it evaporates.
• The hand sanitizers should not be used at homes and offices where soap water is available.
Let us not get tired
A few weeks ago, the head of the World Health Organization, Tedros Adhanom Ghebreyesus said, he hoped the COVID 19 pandemic would be over in less than two years, especially if we could pool our efforts. He probably was hoping to get an effective vaccine.
Now a few researchers are keeping the fingers crossed as there are multiple reports of re-infection. It supports earlier studies that the antibodies developed in infected people would disappear within three months. It means that the conventional vaccines would be of no use.
If vaccines do not work and if the people do not develop lasting immunity, then how this pandemic will end?
Till we get an answer, it is prudent to learn to live with the virus. We have to live with it and have to take care that it doesn’t infect us. We have to change our behavior and should not get tired of it.
The deer and tiger live in the forests. The deer always remains alert about the tiger attacking it. If at all it is chased by the tiger, it runs and runs because it knows that if it gets tired and stops that would be its end.
That is how we have to live with COVID 19 virus at least for now.
Editor's Note: Readers may post their questions on COVID-19 to Dr Edward Nazareth on 'Ask Your Doctor' column. Your questions will be answered by Dr Nazareth.
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