Received from Prof Seshadri today vital advice on surgical patients.

‘COVID 19: Current scenario and suggested steps for coping

Professor M.S.Seshadri MD, PhD, FRCP

Former Professor of Medicine & Endocrinology Department of Endocrinology Diabetes & Metabolism Christian Medical College & Hospital, Vellore Consultant Physician & Endocrinologist

Honorary Medical Director

Thirumalai Mission Hospital, Vanapadi Road, Ranipet Vellore 632404 &

Professor T Jacob John FRCP (Paediatrics), PhD (Virology), Former Professor&Head,

Department of Clinical Virology,

Christian Medical College & Hospital, Vellore632004

We have learned that recently in 2 hospitals in the country, where emergency surgical procedures were performed on patients and healthcare personnel got infected with SARS- CoV-2. These surgical patients developed COVID-19 pneumonia in the postoperative period, and succumbed. In these hospitals, a large number of health care professionals got infected. This had led to a lock down and containment situation of these hospitals. These incidents have many important lessons for the medical profession, other health care workers , administrators and health ministries.

The message is loud and clear. If asymptomatic (for COVID-19) individuals,who are actually in incubation period, develop COVID- 19 in the postoperative period, there are only 2 possibilities. 1. Their infection was nosocomial; 2. They came in infected, in which case community level spread is already occurring. Actually, nosocomial infection is also

indicative of community transmission, highlighting silent infection in medical staff or other admitted patients.

Italian doctors, after their heart-rending experiences with COVID-19, made a plea in NEJM Catalyst; their article carries the following messages for the rest of the world in the approach to COVID pandemic.

1. The virus is exploiting centralized health care systems of the current era in a large number of countries

2. Once you keep admitting very sick patients with high viral load, the hospital becomes the reservoir of the virus. Health care personnel acquire infection and unwittingly become vectors, whospread the infection to their patients and this leads on to further community spread. So hospitals become hot-beds of SARS-CoV-2 infection.

3. A good number of health care professionals contract and some succumb to the infection they contracted in the hospital

4. The way to deal with this epidemic is to consider the population as the individual patient and do your level best to keep the population healthy, even at the expense of some loss of lives

5. If you do not do this, the human toll becomes huge as in Italy, Spain and the US.

6. They recommend home based care as far as possible (level 1 and level 2 disease) with home oxygen if needed

7. There is a place for a fully isolated, well-equipped COVID centre with all tertiary facilities manned by a committed team to take care of those who needpositive pressure ventilation.

There is an old saying ‘Physician, heal thyself! ‘ In the current COVID 19 context, this can be rephrased as ‘Health-care worker, protect thyself’. If health-care professionals are depleted because of COVID-19 or if the health-care force is demoralised because of personal risk and fear, the situation can become extremely difficult to handle.

How can we handle a catastrophe of this magnitude? How would a humane,caring person approach this problem?

1. Shut down regular OPDs for chronic illness. These are vulnerable people who should not be coming to hospital – for their own safety, to reduce hospital crowd and avoidable workload of an already stressed group of healthcare staff

2. Mobile telephone/telemedicine based counselling for patients with chronic illness through their usual caregiver with the understanding that if there is a medical emergency they will have to access a safe hospital not frequented by COVID-19 patients

3. Home delivery of medications to avoid elderly coming out of their homes. They should be cocooned (reverse quarantined). When necessary, physicians wearing protective paraphernalia should make home visits — instead of patients coming to hospitals when their illness is of low/moderate severity and not life-threatening. For example acute exacerbation of asthma can be managed at home

4. Multiple hot-linesshould be manned round the clock by appropriate personnel including medical professionals both for medical advice and for counselling for emotional and moral support . Tertiary level and medical college hospitals must serve as resource centres for practitioners in order to guide them in caring for

complex problems. [examples complicated Diabetes/hypertension/community acquired infections etc]

5. Samples for lab tests should be collected at home , transported to the lab and the results of tests communicated to concerned doctors/practitioners .

6. Use a syndromic approach* to diagnose COVID-19 and treat such subjects and prevent spread to their family members using appropriate home isolation and other prophylactic measures.

7. PCR or Rapid tests only forconfirming diagnosis when essential for care, or for well- designed and ethical studies, so that resources saved can be put to better use

8. Dedicated ambulance services with adequately protected personnel to carry sick infected subjects to a dedicated COVID centre

9. Have separate emergency facility for patients with acute respiratory problems.Adedicated respiratoryteam should handle this, adopting very effective respiratory and universal precautions. Those needing admission for respiratory failure to have a separate ICU facility for COVID-19

10. Major hospitals in either private or public sector to take on the management of the town and surrounding villages and to set up a model system of referral and management

11. At the same time continue to manageemergencies in non-COVID patients, who needhospitalbased care in a separate facility manned by a different set of healthcare personnel.

12. Every patient coming to hospital for any emergency should be considered to be potentially infected with SARS-CoV- 2and suitable precautions (respiratory and universal) taken by all the staff.

13. Surgicalprocedures must be reserved for emergencies. Each patient going for surgery to have a screening PCR on a nasopharyngeal swab and Ig M antibody and, lab report to be seen before taking up for surgery, similar to the present system in place for hepatitis B , C and HIV. As even this will miss out a proportion (~10 %) of SARS- CoV-2 infected patients, respiratory and universal precautions will be mandatory for every surgical patient and procedure.

14. While we write about the scenario in India, we feel that the above suggestions are equally applicable to all the middle and low income countries which are trying to cope with this pandemic

The natural history of the pandemic will be the eventual waning of the transmission. This will occur after at least about 50-60, possibly 70 % of the population have gone through the epidemic and developed immunity to the infection. This may take a few to several months.Till such time the priorities should be cocooning (reverse quarantine) the elderly and vulnerable subjects, restoring the confidence of health workers by demonstrating that they have acquired immunity and getting immune subjects from the population quickly back to work so as to resuscitate the economy, save livelihoods and lives.

We make these suggestions based on scientific evidence and in the hope of bringing about a change in the approach to this pandemic.

*Details available on request

To a query on whether virus is found in stools, Prof Seshadri responded,

-“Virus clearly demonstrated in stool. In fact Chinese say a patient is cured only when throat swab and stool are PCR negative and next gen sequencing is also negative”

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