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Buddha :

You look sad today…

Me :

Shouldn’t I be? The Covid-19 second wave is raging like a wild fire in India. So much suffering and gloom all around with no immediate end in sight. I fear the worst for myself and my dear ones too.

Buddha :

I agree. One is bound to get affected. But you still need to keep your calm. Fear does more harm than good.

Me :

But this virus is fearful stuff…

Buddha :

Well, to be frank, nearly 98 to 99% of those infected are recovering while 1 to 2% are unfortunate to succumb. It is the sheer number of positive cases and the resultant overwhelming of the health infrastructure which is inducing panic. Even the commonly encountered dengue fever has a mortality rate of nearly 1%, infact more, if it is severe.

Me :

So all this panic for hospital beds, oxygen is unwarranted..??!!

Buddha :

No, I never meant that. The Government and National Covid Task Force have given clear guidelines about the cases which need hospitalization and those which can be treated with home isolation. But in a panic situation, many from the latter category also seek hospital beds thereby putting additional burden on the health system. Also, many of the best health infrastructures around the world have collapsed in this Covid tsunami. Caution is must, but panic needs to be avoided. Though I agree, it is easier said than done.

Me :

And what about the mad rush for injections like Remdesivir, the convalescent plasma..?

Buddha :

Again, the protocol for administration of such injections are defined. These help only to some extent in the early stages of the disease and in few. Scientific trials have not shown them to be effective in decreasing the death rates. Oxygen, steroids, blood thinners, and prone ventilation are the mainstay of the treatment but it is the core human emotion of survival which makes one clutch on to any hope available. Fear is clouding the rationale and judgement of all involved. Like you, I too wish for sanity to prevail.

Me :

Okay I get it. Fear is harmful since it causes panic among people.

Buddha :

Yes, but not only that. On an individual level, the emotion of fear is a subconscious acceptance of sorts and the law of attraction then works the other way around. Just like one can achieve good things by positive thoughts, one can end up getting bad ones by constant fear and negative thoughts. Not to mention, fear causes release of stress hormones thereby affecting the natural healing mechanisms of body. So, cheer up!

Me :

Let aside being cheerful. At times, I find it difficult to focus on even simple tasks.

Buddha :

Well, you can. But you need to have a plan in place to deal with all this.

Me :

How can one plan for something which has left the entire world clueless? There are talks of a third wave and maybe more. Contradictory news, doomsday forecasts keep pouring in on social media. Emotional turmoil, financial losses and uncertainty about future – this pandemic seems to be unrelenting.

Buddha :

It may well be. But remember, this is a natural calamity and like all others it will settle. Just like the good times, bad times too don’t last. It is the Universe’s law. You just need to ensure that you remain calm and mentally strong to weather this storm.

Me :

And how do I do it..?

Buddha :

Well for starters, tell yourself that the pandemic will be around atleast for another year or so. The World Health Organization (WHO) had mentioned at the start of pandemic in 2020, that it will last for atleast 2 years and that was when no one had any idea of the way ahead. Our scientists have done an incredible job of developing the vaccines in less than an year. With increasing percentage of population getting vaccinated and the virus eventually running out of bodies to infect (it needs to stay in human body to mutate), the pandemic will lose it’s sting. We are already witnessing this in Israel, Europe, UK and USA. The virus may not disappear altogether but it will exist only in mild form (endemic). What goes up, will surely come down.

Me :

It does sound logical and promising but in a distant future. What about the present when the going is really tough..?

Buddha :

Well, now that you seem to be filled with some hope for the future, I can suggest few practical things to deal with the present difficulties –

1) Be proactive about the evolving pandemic –

Read about the new treatment protocols from official Government/Health authorities websites at regular intervals – Ministry of Health and Family Welfare (MoHFW), Indian Council of Medical Research (ICMR), World Health Organization (WHO), Centers for Disease Control and Prevention (CDC) are few such. In an evolving pandemic, such changes are expected and keeping oneself updated helps deal the problems better when we actually face them. In case of doubts, get them clarified from a qualified, experienced doctor rather than a non-medico friend who is equally clueless.

Keep abreast with the work of scientists and researchers from reliable print/digital news sources. A new vaccine or a new treatment (the latest news about Pfizer’s oral anti-viral pill to cure Covid-19) raise our hopes about the future.  Remember, the vaccines being used currently were developed in the last one year and are already instrumental in halting the pandemic in many countries around the globe. Science, not antiscience and fake news, is the way ahead.

Most importantly, do not let your guard down after the second wave. Face mask, social distancing and hand sanitation measures will remain the golden rules, for some more time  till majority of the population is vaccinated and the pandemic starts receding slowly.

2) Be careful but not fearful –

Fear, as I said earlier, will create more trouble. An important thing which can be done in this regards is to avoid reading/watching sensational news on social/print media consciously. Neither do they educate nor create awareness but merely feed negativity. निरक्षीर विवेक (wisdom to distinguish between right and wrong) was probably never needed to such an extent before.

News about untimely deaths of healthy young/middle aged adults, especially those known to us, are extremely disturbing. Still, keep your emotions in check. Remember, all of us travel from point B (birth) to point D (death), with a station C (choice) in between. And we can choose not to live in fear, for it will only make us more miserable. Infact, many are already suffering from anxiety, depression and psychosomatic problems due to excessive fear.

3) Be organised –

In these depressing times when all days seem alike, many tend to procrastinate and end up spending way too much time on cellphone/ social media. So, make a schedule of your day (weekday and weekends separately) and try sticking to it as much possible.

4) Be health conscious –

Few things which can be done in this regard are :

• Allot minimum 30 minutes daily for physical exercise (there are few which can be easily done in the safe confines of home).

• Be conscious about your meals – let them be timely and nutritious.

• Take your daily dose of multi-vitamins especially Vitamin C, D and Zinc (do this after consulting your doctor).

• Ensure a good 6 to 7 hours of sleep at night.

All this will surely help improve your immunity levels. Also, a healthy mind resides in a healthy body!

5) Be adaptive –

You may be facing loss of job or business. But use this time to upgrade your skills, knowledge about your field. Explore ways which will help you navigate the changing times and work conditions better. Remember, evolution suggests that it is not the strongest but those willing to adapt who survive and progress. To give an example, Shakespeare wrote some of his greatest works including “Romeo and Juliet”, “King Lear” and “Macbeth”, during outbreaks of the horrifying bubonic plague waves which wiped out nearly a fifth of London in the 1600s.

6) Be cheerful –

There are many ways to do this :

• Spare some time to read a novel of your interest.

• Watch a funny/ inspiring/ classic movie or a television show.

• Call up (not chat with) your friends/ relatives and enquire about their well being. However, the ones obsessed with talking only about the horrors of Covid-19 are better avoided.

• If you have young kids, ensure a playtime with them. Children, with their energy and cheerfulness, are sometimes the best antidote for anxiety and depression.

7) Be Helpful –

You may be feeling helpless when you see known persons/ friends desperately seeking a hospital bed/ injection etc. Guide them if possible. Even if you can’t help physically, just reassure them. Kind words can be helpful in such times.

There are many who are doing exemplary acts of kindness in these desperate times despite their limitations.

Source – The Times of India

Source – The Times of India

Source – The Times of India

Let these noble acts serve as inspiration to do your bit. Remember, like the virus, humanity too comes in many variants of kindness and will eventually fight it off.

8) Be thankful –

You may have had financial losses. You may have lost a loved one. You may be mentally stressed due to umpteen reasons. Yet, make a diary and note down the smallest good thing(s) which happened to you in the entire day. Be thankful for them. Simultaneously, pray for the less fortunate ones for there are many who may be fighting a much harder battle out there. No matter how philosophical this may sound, gratitude and prayer have great healing powers.

Me :

Do you really believe that such ridiculously simple things are a solution to the chaos all around and the harrowing plight of people?

Buddha :

No, they are not. But as an individual, we do not have much control over the external happenings and are bound to feel helpless. However, we can always check our emotions which will help us respond to the situation in an appropriate manner. Also, no matter how clichéd this may sound, but a larger change in society is always preceded by individual transformation.

Me :

Honestly, I have been reading about all this self improvement stuff time and again but I keep faltering. It is difficult to implement.

Buddha :

You are a Surgeon, right?

Me :

Yes..??

Buddha :

When you started your training, were you  infallible right from the beginning? That is to say, did you not commit any mistakes?

Me :

Infact, I am not one (infallible) even now. I did many but I was corrected and guided by my teachers. I studied and practiced. I learnt from my mistakes and keep learning even now.

Buddha :

Well, there you go. This is true of almost everyone and eventually, it all comes down to how badly we want to succeed. Once we realize it, the excuses cease to exist.

Me :

All this does help at a philosophical level. But you hardly gave any substantial information regarding the disease and related stuff. It does not have much clinical utility.

Buddha (smilingly) :

Ohh, I never meant to do that. All I wish is to help you attain some peace of mind, which in turn can help you muster wisdom and courage, for, it is your battle to be fought. I will be around though, provided you have the right insight.

Once again I invoke Hamlet in my blog title. But the famous words do aptly convey the dilemma faced by many amongst us regarding the COVID-19 vaccination. After the start of its COVID vaccination drive in January ’21, India has so far (till April 20th) managed to fully vaccinate nearly 1.74 crore people (two doses) and nearly 10.96 crores have received the first dose. It is important to realize that unless a majority of the population has immunity against the virus (herd immunity), either by natural infection or by vaccination (the latter will help it achieve faster and safer), the pandemic is never going to end. Though there is no magic number to achieve this herd immunity, it is being projected that at least 70% population needs to be vaccinated to halt the pandemic. With a current population of nearly 138 crores, we sure have an enormous task at hand and the vaccine hesitancy/dilemma will only add to our woes. I am not into active management of COVID-19 patients but being a doctor, I come across many queries related to COVID-19 vaccination. Here’s my bit to simplify a few.

“I hear about different types of COVID-19 vaccines – Covishield, Covaxin, Pfizer, Moderna, Johnson, and Johnson. I am confused..?”

To understand this, one has to know about the different technologies used presently to develop COVID-19 vaccines –

(1) Whole virus-based vaccine

(a) Using a dead virus

Here, the coronavirus is completely inactivated/killed using certain technology, an adjuvant is added to it to increase the immune response and then injected into the human body. This is a traditional way to prepare vaccines and is believed to be the safest. However, the immune response generated by such a vaccine is unpredictable and can be weak. Two such vaccines being used currently in clinical practice are –

• Covaxin (Bharat Biotech, India)
• BBIBP-CorV (Sinopharm, China)

(b) Using a live attenuated virus

Here, the virus is made less potent (but not killed) using certain technology and then injected into the human body. Such a vaccine can generate a good immune response. But, the SARS-COV2 is an mRNA virus and can mutate if it comes in contact with another strain. Hence, safety is a major concern with this type of vaccine. There is no such vaccine available currently. Few are being attempted but are in the pre-clinical stage of trials.

(2) Recombinant viral vector-based vaccine

Here, a modified, harmless version of a different virus is used as a “vector” or “carrier”, to deliver immunity instructions to cells in the human body. The viral vector delivers a coded message which causes human body cells to produce the copies of the coronavirus spike proteins. This, in turn, triggers an immune response in human body leading to production of neutralizing antibodies which help fight off the COVID-19 infection. Three such vaccines are available for clinical use presently –

(a) Oxford – Astrazeneca vaccine – It uses chimpanzee adenovirus (ChAdOx1) as the viral vector. It is sold under the brand name Covishield in India and is manufactured by the Serum Institute of India. In Europe and elsewhere, it is available under the brand name Vaxzevria.

(b) Sputnik V (Russia) – It has been developed by the Gamaleya National Research Institute of Epidemiology and Microbiology, which has also been involved in developing vaccines for Ebola and MERS. It uses 2 viral vectors – both human adenoviruses (common cold virus) – Ad26 and Ad5. Ad26 based vaccine is given on Day 1 and Ad5 based one is administered on Day 21. A single-dose version Sputnik-Light is being introduced soon.

(c) Johnson and Johnson – It uses human adenovirus (Ad26) as the viral vector and is available under the brand name Janssen COVID-19 vaccine.

Hyderabad-based Biological E. Ltd has tied up with the Janssen Pharmaceutical Companies to manufacture the above-mentioned vaccine under the brand name Bio E vax in India – it has received the nod for phase 3 trials in India.

The immune response to all such viral vector vaccines is good and the efficacy is more than 70%. However, there are rare instances of blood clotting in the case of AstraZeneca and the J&J vaccine (will discuss this point in a subsequent question).

It is worthwhile mentioning here that Bharat Biotech is working on an intra-nasal vaccine based on such adenovirus vector technology. If successful, it is believed to be a potential game-changer since it will produce immune responses at the site of infection (in the nasal mucosa) thereby blocking both infection and transmission of COVID-19.

(3) Nucleic acid-based vaccine

Here, an encoded messenger RNA (mRNA) or DNA is delivered to the human body after they are combined with lipid nanoparticles. This mRNA instructs human body cells to make copies of coronavirus spike proteins, which in turn leads to the production of neutralizing antibodies. These vaccines are safe (non-infectious), highly effective (more than 90%), can be produced rapidly and administered multiple times. Two such vaccines are available in clinical use presently –

• Pfizer – BioNTech vaccine
• Moderna vaccine

(4) Protein subunit vaccine

This vaccine contains full-length coronavirus (CoV-2) S protein or portions of it with the goal of inducing neutralizing antibodies. However, they are poorly immunogenic and generally require repeated administration. Novovax Covid-19 vaccine is one such and is undergoing trials in India in collaboration with Serum Institute of India under the brand name Covovax.

(5) Virus-like particles (VLP)

VLPs are spontaneously forming particles composed of several structural viral proteins. Currently, none such is available for clinical use.

“I know few people who got COVID infection after first dose/second dose of vaccination. Then why should I get vaccinated?”

The maximum immunity post-vaccination is attained 2 to 4 weeks after the second dose. So the person known to you who developed COVID infection may not have taken both doses of the vaccine.

If the person has developed COVID infection following both doses, then he/she is amongst the rare instances of “vaccine breakthrough cases”. It is possible that this person was infected just before or just after the second dose and got sick, since (as mentioned earlier) it typically takes a minimum of 2 weeks for the body to build protection after the second dose.

There is also a possibility of a “new variant” causing this infection. But the good news is that all vaccines offer some degree of protection against the new variants too, thereby ensuring that such “breakthrough case” is a “mild” one and will not need hospitalization.

The Centres for Disease Control and Prevention (CDC) has so far reported approximately 5,800 so-called “breakthrough infections”, out of the nearly 77 million (7.7 crores) individuals in the United States who have been fully vaccinated.

In India, the following image gives an idea regarding such breakthrough cases – these are indeed very less and mostly “mild”.

Source – Ministry of Health and Family Welfare

“I know a few people in whom the RT-PCR turned out to be positive due to vaccination. I am not keen to get vaccinated.”

As described earlier, none of the vaccine types can cause COVID infection and thereby a positive RT-PCR. Such a person has probably contracted the virus just before or after vaccination and developed infection before the vaccine immunity could set in. So do not worry on this count at all.

It would be worthwhile mentioning here that some of the vaccination centres are indoors/crowded. Make sure that you follow the golden rule of face mask and social distancing, else, you might end up catching infection at vaccination centre.

“I am worried I will get fever, bodyache after the vaccination.”

No pain, no gain. Few side effects such as minimal pain at injection site, low grade fever, bodyache etc may be experienced by some. However, these are mild, self limiting and respond to a single dose of oral paracetamol. So relax. Infact, such mild symptoms are a welcome sign that your body is producing an immune response (this, however, doesn’t mean that the immune response would be any less in those not having side effects).

“I have allergy to certain medicine/food/dust etc. I cannot take the vaccine.”

If you have had a severe allergic reaction to any medicine or food item in the past, you need to consult your doctor prior to vaccination; if it is something of a mild/ routine thing, you need not worry (you can refer to the Ministry of Health and Family Welfare guidelines link shared at the end of this article for more clarity in this context).

“I need to stop my blood thinners before vaccination.”

Many elderly patients or those who suffer from heart disease/ hypertension/ brain diseases are on blood thinners. As per the official guidelines, there is no need to stop these before or after vaccination. Despite this, at many centres, patients are asked to withhold them for 3 days prior to vaccination. This can cause more harm than good in someone. If doubt still persists, one can always consult the regular physician in this matter before complying blindly with the instructions given at local vaccination centre.

“If I have/had COVID-19 infection, should I take the vaccine and when?”

If someone is having active COVID-19 symptoms, the person needs to wait for 4 to 8 weeks (I would go with 8 weeks) after recovery and then get vaccinated. A person with a history of past infection should also get vaccinated since this will help strengthen the immune response. Also because, there is still no clarity regarding how long the immunity lasts after the natural infection.

“If I get COVID-19 infection after 1st dose of vaccine, should I take the 2nd dose and when?”

The answer is same as above – wait for 4 to 8 weeks after recovering from the infection and then take the 2nd dose.

“If I am unable to take the 2nd dose on time due to vaccine shortage, how long can I delay it? Will I need to take both doses again?”

As we know, in India two COVID-19 vaccines are available – Covishield and Covaxin. Following the recent directives by the Central government, in Maharastra the second dose of Covishield vaccine is now being given between 6 – 8 weeks after the first (initially it was at 4 weeks). For Covaxin, the second dose is being given 28 days after the first dose, as was being done earlier. There is currently limited information on the effectiveness of receiving the second shot earlier or later than recommended. Presently, if you do receive your second shot of COVID-19 vaccine earlier or later than recommended, you do not have to restart the vaccine series. This guidance might be updated as more information becomes available.

“Can I drink alcohol after vaccination?”

According to experts, alcohol does not decrease the effectiveness of vaccines. And how soon can one start? Well, it is advisable to wait for a minimum of 2 to 3 days, since you wouldn’t want to celebrate too soon and get up with a hangover which cannot be differentiated from the vaccine side effects.

“Should I get my neutralizing antibody titres checked after vaccination?”

There has been a trend to check the neutralizing antibody titres in blood post-vaccination. There is no official recommendation/guideline regarding this. It doesn’t make much sense though, since the vaccine effectiveness is not merely due to the antibodies. The helper T cells/other immune mechanisms also play a role and these aren’t being evaluated. Ditch this one.

“I have heard/read about deaths after vaccination. I am worried about the blood clotting side effect of some vaccines.”

This, according to me, is the Achilles heel of the COVID-19 vaccination drive. Yes, there have been instances of blood clotting, especially in the brain veins (cerebral venous sinus thrombosis), following Astrazeneca vaccine (sold under brand name Covishield in India). However, these have been found to be rare and the vaccine is still under use since the benefits outweigh the risk. I will try to put forth the present scenario related to this in some parts around the globe –

(1) Europe

The EU (European Union) regulatory body was the first to red flag this complication. The European Medicines Agency (EMA) has asked those receiving the Astrazeneca vaccine to remain aware of the possibility of very rare cases of blood clots combined with low levels of blood platelets occurring within 2 weeks of vaccination. These clots occur mostly in brain veins (cerebral venous sinus thrombosis) and abdomen (splanchnic vein thrombosis). So far, most of the cases reported have occurred in women under 60 years of age within 2 weeks of vaccination.

Based on the currently available evidence, specific risk factors have not been confirmed. The EMA has hence advised that patients should seek medical assistance immediately if they have the following symptoms after vaccination –

• shortness of breath
• chest pain
• swelling in your leg
• persistent abdominal (belly) pain
• neurological symptoms, including severe and persistent headaches or blurred vision
• tiny blood spots under the skin beyond the site of injection

Following occurences of such rare blood clots, a recent study conducted at Oxford University (yet to be peer reviewed) has observed that the chances of blood clotting in brain veins after the 1st dose of Astrazeneca vaccine is 5 in a million whereas in COVID-19 patients it is 39 in a million (nearly 8 times more) vaccine. For mRNA vaccines (Pfizer/Moderna), the risk is 4 in a million.

Since the chances of blood clotting after COVID-19 infection is way more than the extremely rare ones after vaccination, it is presently concluded that the overall benefits of the vaccine in preventing COVID-19 outweigh the risks of side effects. As a result, the Astrazeneca vaccine is still under use in Europe, albeit, in those above 60 years of age.

(2) United Kingdom

Britain’s medicines regulator has revealed that here have been 168 major blood clots following the 1st dose of Astrazeneca vaccine. This amounts to 7.9 clots per million dose. There have been 21.2 million first doses of AstraZeneca’s shot given in Britain’s rollout, with all except one of the side effect case reports coming after a first dose. The total number of deaths, so far, have been 32. Officials have emphasised the side effect is “vanishingly” rare and advised that most people still get the shots. However, the under-30s have been advised to receive an alternative to the AstraZeneca-Oxford vaccine. This is due to that age group’s low risk from COVID-19, combined with Britain’s low prevalence of infection.

Source : NHS, UK

(3)United States of America

The Astrazeneca vaccine is not yet rolled out in USA. However, blood clotting problem has been observed in the J&J vaccine being used there. As of April 12 2021, out of nearly 6.8 million people in US who received the J&J vaccine, 6 cases of blood clotting in brain were reported. In this case, however, a review is underway and use of the said vaccine is presently paused in US.

Regarding the Pfizer and Moderna mRNA vaccines – whether they cause such blood clotting – in the US, where more than 180 million doses have been administered, the Centers for Disease Control and Prevention (CDC) says there have been zero cases reported. The European Medicines Agency (EMA) has however reported 25 cases with Pfizer and 5 with Moderna.

(4) India

Now the all important question – what are Indian statistics for such complication in Astrazeneca vaccine (used under the brand name Covishield)?

A presentation made to the National AEFI (adverse event following immunisation) Committee on March 31 2021 recorded that there had been 180 deaths till that time and three-fourths of the deaths happened within three days of the shot. Even as AEFI deaths are reported daily, causality assessment by the National AEFI Committee appears to be lagging.

Many of the AEFIs and deaths reported in India bear striking similarities to those recorded in the European Union and the UK. Public health activists who have been tracking adverse events following immunisation (AEFI) in the ongoing covid vaccination effort have repeatedly sought greater transparency in AEFI investigations and more rapid causality assessments to help inform vaccination policy. Since Covishield is the same vaccine as the AstraZeneca one, warnings related to the rare conditions flagged by Europe and UK, information for vaccine recipients and the public about when to seek medical attention, and information for health providers about how to identify and treat such occurrences needs to be done for Covishield too at the earliest (I have already mentioned these in point 1 above).

Some of you may find the above discussion and statistics adding to the confusion rather than solving it. On a personal note, I too was a victim of the same. But when I realized that such side effects are extremely rare and the chances of contracting COVID-19 infection and it’s complications are way higher, I went ahead with my vaccination.

Also, there is a concept of “availability heuristic”, also known as “availability bias” in the way humans think. It is a mental shortcut that relies on immediate examples that come to a given person’s mind when evaluating a specific topic. It operates on the notion that if something can be recalled, it must be important and people tend to heavily weigh their judgments toward more recent information, making new opinions biased toward that latest news. The same thing is happening with us as far as the blood clotting side effect of COVID-19 vaccines is concerned. It is essential to take the larger picture and actual statistics in account and realize that these vaccines are indeed effective in our fight against COVID-19 – their benefits are much more than their extremely rare side effects.

“I have to wear mask and follow social distancing even after vaccination. Then why should I get vaccinated?”

Well, as has been mentioned earlier, the pandemic will only cease once a large section of the population acquires immunity. Until such time, we need to follow the norms of face mask, social distancing and hand sanitation. The reason to get vaccinated is that it will help you prevent from getting infected and even if one gets the infection (rare instances), it will be a mild disease in all probability.

“There is no assurance on how long will the immunity last following vaccination. Will a booster dose be required?”

Presently, there is no confirmed data regarding the duration for which immunity will last following Covid vaccination. Pfizer has claimed it’s vaccine remains 91% effective after 6 months. But it’s CEO Albert Bourla recently said that a booster shot may be needed between 6 months – 1 year. Apart from the immunity decreasing, this will also depend on emergence of new variants.

“The efficacy rates of various vaccines are different. Pfizer/Moderna is supposed to be very good. I will wait for the best one.”

“Vaccine efficacy” measures a vaccine’s protection against a disease/pathogen in a vaccine trial. If a vaccine has, for example, 70% efficacy, it means a person vaccinated in a clinical trial is around two-thirds less likely to develop the disease than someone in the trial who didn’t get the vaccine. When you give a vaccine outside a clinical trial, we then refer to “vaccine effectiveness”. Compared with efficacy, effectiveness takes into account all the complexities of the real world, outside of a controlled clinical trial setting. So far all the COVID-19 vaccines being used seem to be highly effective in real-world settings.

However, we still need to assess the full consequences for each vaccine’s effectiveness against newly identified variants that cause COVID-19. The data so far shows that all COVID vaccines are better at protecting against severe disease, hospitalization and death which is our aim at present. All leading health regulatory bodies (WHO, Europe, USA) have stated that any vaccine with 50% efficacy is good enough to offer protection in clinical setting. So, do not fret over non-availability of a particular brand of vaccine. Take the one readily available and make yourself safe.

“The vaccines are developed in a haste. We don’t know the long term side effects. I will prefer to wait some more time before I get vaccinated.”

Many of us are skeptical about the long term effects of these Covid-19 vaccines since they are newly developed with no long term data available. But even though these vaccines are new, the technology used in their production has been around for quite some time to help allay our fears.

(1) mRNA vaccine (eg.Pfizer, Moderna)

mRNA vaccines against HIV, rabies, Zika and flu have been tested in phase 1 and phase 2 trials in people. The technology has also been used in clinical trials as a way to treat some cancers. Even though these products have not been licensed for use in people, these efforts provided important information about mRNA technology and its safety.

(2) Adenovirus based vaccine (eg.Astrazeneca, J&J)

This type of vaccine has been studied in people before, and another adenovirus-based vaccine was approved for use in Europe in those 1 year of age and older starting in the summer of 2020. That vaccine is one of two doses of an Ebola vaccine, and it uses the same type of adenovirus as the Johnson & Johnson vaccine.

(3) Inactivated virus based vaccine (eg.Covaxin)

As mentioned at the beginning, this is a time tested technology of vaccine production. Some other examples of such vaccines which have been safely used over years are the vaccines used against polio, rabies and Hepatitis A.

While concerns about long-term effects of vaccines are legitimate, it is important to be aware that the organized anti-vaccine industry has targeted this issue as a way to sow doubt and confusion about COVID-19 vaccines. In some cases, individuals in these groups do not believe the science, and in other cases, they are seeking to profit from the vaccine hesitancy by encouraging the use of other products to “protect” against COVID-19.

Vaccines – the Endgame for COVID-19?

Israel is presently the world leader in vaccinating its population against COVID-19. As of March 15, 50 percent of Israel’s population had been fully vaccinated, and 60 percent had its first dose. The rate of new infections has plummeted – from a peak of almost 10,000 a day to about 140 and the number of serious coronavirus cases in many hospitals is down to single digits. The same is being observed in the UK and USA, as the percentage of the fully vaccinated population is increasing.

In India, the vaccination drive was initiated on January 16th, 2021, and yet now, in April ’21, we are finding ourselves amidst a raging second wave. Incidentally, in Israel, during the early weeks of the vaccination campaign, the number of cases and hospitalized patients rapidly increased, along with the local emergence of the B1.1.7 variant, leading the government to impose a third lockdown on 8 January 2021 which was gradually eased a month later. UK too had a more or less similar scenario. It started the vaccination drive on December 8th ’20 amidst the second wave, underwent a lockdown and now the curbs are being eased nearly 4 months later after vaccinating a significant chunk of its population. I am not an expert on public health policies, but this does seem to be the best way ahead for us too.

Vaccines will definitely help reduce the infection rates, number of hospitalizations and deaths. But the Governments/Health authorities will have to watch out for the emergence of new variants and change their vaccine policy accordingly. And we, the people, will have to do our bit simultaneously by watching out for fake, unscientific news related to COVID-19 and vaccines. This is one battle where we seem to be in for a long haul (unless there is a miracle/cure), but proactive planning with proper execution, discipline and hope should see us through…

“Success is failure turned inside out

And you can never tell how close you are

It may be near when it seems so far.

So stick to the fight when you’re hardest hit

It’s when things seem worst that you must not quit.”

– Edgar A. Guest

Few links for authentic information on COVID-19 vaccines

https://www.mohfw.gov.in/covid_vaccination/vaccination/faqs.html#what-to-expect-after-vaccination

https://vaccine.icmr.org.in/covid-19-vaccine

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.htm

Pardon my slightly poetic and Shakespearean inspiration in the title but I am pretty much sure if Hamlet were to be real and alive today, he would have uttered pretty much the same words. A lot has been written, said, heard, and experienced about the Covid-19 pandemic which hit us nearly a year ago and is now hitting us harder the second time around in April 2021. It is a deja-vu of sorts, in fact, scarier, with the same mistakes being repeated by many of us. At the risk of sounding alarmist and pessimistic, I will say that unless we learn and improve, Covid will not stop teaching us the lesson, making sure we suffer more such waves in the future. I am a General and Laparoscopic Surgeon with a special interest in Laser treatments of Varicose Veins and wouldn’t call myself an expert on this topic. Despite that, I still thought of sharing my perspective which is shaped by my medical and surgical training, and an experience of nearly 18 years in clinical practice. To some extent, it has also been compelled by the frantic, harrowing queries from my patients and friends amidst the raging second wave that we are presently suffering. I will discuss a few of the common questions and practical situations which many of us are facing.

(1)”I had a mild fever/common cold-like symptoms for only 2 days, took Paracetamol tablet and now I feel better except for some weakness. I don’t think there is any reason to worry.”

Honestly, there is every bit of reason to worry. During these pandemic times, any fever should be considered as Covid unless proven otherwise. By now, we know that majority of those who get Covid infection will get a mild disease and recover. But these ‘mild cases’ can spread the virus in the first 8 to 10 days. So, it is necessary to get tested for Covid and isolate oneself for minimum of 10 days from the day symptoms start (please, please keep a track of the first day when the symptoms start). Remember that your ‘mild’ disease can spread the infection to an elderly person in your family or a friend with diabetes/ hypertension/ heart disease and be the reason for their ‘severe’ disease and in unfortunate circumstances, even their death.

Also, one has to remember that Covid causes the ‘cytokine storm’ in the second week of its infection. The virus multiplies in the human body in the first week and it is in the second week that it causes the person’s immune system to go haywire (one can compare it to an ‘electrical short circuit’ of sorts), which leads to blood clotting in various organs. Depending on the organ where this blood clotting occurs, patients then present with serious problems such as – breathlessness and low oxygen levels (clotting in lungs), chest pain (clotting in the blood vessels of the heart leading to a heart attack), severe abdominal pain (pancreas getting affected), sudden swelling of the leg (blood clotting in leg veins) – to name a few. Hence, it is important to get tested and start treatment in the first week of symptoms.

Some of the symptoms which can indicate the disease taking a turn for the worse are :

– Fever which is not subsiding

– Continual dry cough

– Feeling breathless and oxygen saturation on pulse oximeter below 94% at rest

– Severe weakness (these patients are unable to walk even a few steps)

This may sound basic and repetitive but it is important to remember that in the first week Covid can cause any one or more of the following symptoms :

– Fever (it may be mild, lasting for only a day or two)

– Nasal blockage or Runny nose

– Throat pain

– Loss of appetite

– Bodyache

– Severe weakness

– Abdominal pain/Vomiting/Diarrhoea

– Redness of eyes (conjunctivitis)

– Loss of smell, taste (these patients generally end up getting a ‘mild’ disease)

(2)”My Covid test is negative. I need not worry.”

In my practice, I come across many patients who tend to consider blood and other medical investigation reports as infallible. For some, everything mentioned in the report is the only truth. Then again, it would be wrong to expect the patients or relatives to know the pitfalls of investigations. The point I am trying to make is that – all medical investigation reports need to be correlated with the patient’s clinical condition.

In case of Covid-19, a negative Rapid Antigen Test which is done at many Government centres (since it is cheap and gives report in a short time), does not rule out infection. It has to be confirmed with a RT-PCR test which is the gold standard. Then again, there are cases when even the RT-PCR test is negative and the patient may still have Covid infection – the reasons may vary from poor swab collection, testing done too early (on Day 1 or 2 of symptoms) or a mutant strain of coronavirus (it is being said that RT-PCR test may fail to pick up the new variants; however, this is a mere speculation presently and not yet confirmed). If such a patient with negative RT-PCR report has clinical symptoms, it is better to repeat the test or get a CT scan of the Chest done. The doctor treating you is the best judge for this.

(3)”I will do a CT scan of Chest instead of RT-PCR to diagnose if I have Covid infection.”

Over the last year and even now, I have come across many patients who prefer to get a CT scan of Chest done to diagnose their suspected Covid infection. Avoiding social stigma and government institutional quarantine are some of the common reasons. Amidst the spiralling second wave, the non-availability of RT-PCR testing facility due to excessive load on the laboratories is another reason. But then, just like with the RT-PCR test, a patient may have a normal CT scan report and yet be Covid positive. Hence, it is ideal to get an RT-PCR test done first and a CT scan of the Chest only if deemed necessary by your treating doctor. It is important to remember that in some cases, the CT scan may reveal Covid changes only in the second week with rapid progression in a few.

(4)”My Ct value in the RT-PCR test is low. I need to get hospitalized.”

The cycle threshold (Ct) value in the RT-PCR test is merely indicative of disease infectivity or viral load in the patient. Lower the Ct value, the higher the viral load in the patient, and the higher the chance of spreading the infection to others. However, many patients correlate Ct value on RT-PCR test with disease severity. They panic if this value is low and seek unnecessary hospitalization.

It would be worthwhile remembering that alongside Ct value of RT-PCR test and CT scan of Chest, clinical evaluation by your doctor and in some cases, assessment of blood investigations such as CBC, CRP, LDH, Ferritin, D-dimer, and Interleukin-6 levels are also very much important before one decides the severity of Covid infection. These blood investigations give a better idea of the patient’s disease is worsening and heading towards a cytokine storm.

(5)”My RT-PCR test is positive/CT shows Covid changes. I have to get admitted.”

The Government and Covid Task Force have given clear guidelines regarding home isolation, institutional quarantine, and hospitalization. Following are some of the clinical criteria for getting hospitalized :

– All symptomatic patients above 60 years

– All symptomatic patients with comorbidities such as diabetes, hypertension, obesity, cancer, asthma, kidney disease, liver disease

– Fever not subsiding for 5 days or more despite initial treatment with oral medications

– Feeling breathless and oxygen saturation on pulse oxymeter below 94% at rest

– Severe weakness (these patients are unable to walk even a few steps)

– CT Scan Chest : Score of 18 or more (after assessment by your doctor)

– Grossly abnormal blood investigation reports (after assessment by your doctor)

But there are all sorts of patients and many times the protocols are breached. On one hand, those with utter disregard tend to neglect their symptoms and fail to get hospitalized on time leading to disastrous results. Then there are those with mild disease who can be treated with home isolation but prefer to remain hospitalized out of sheer panic. Unless, the Government officials and private healthcare providers work in unison, and unless the people themselves act wisely, the “bed availability” issue will always remain the Achilles heel of our Covid management, especially amidst such a resurgent wave.

(6)”I need Remdesivir injections urgently for my hospitalized patient. I need blood plasma from a recovered patient to treat mine.”

It has been extremely distressing to see relatives run from pillar to post for procuring Remdesivir injections and at obnoxious costs in this hour of crisis. I am not an authority to comment on the administrative aspect of this issue but patients and relatives need to remember that Remdesivir is just one aspect of the Covid treatment. The medicine only works to reduce the viral load in the initial replication phase of 8 to 10 days. Also, the scientific data so far has not proven that Remdesivir decreases the chances of mortality; it only helps to decrease the hospital stay in some cases. Steroids and medications to prevent blood clotting, which is freely available and given to all moderately ill hospitalized patients, are the more important aspects of treatment to help prevent the cytokine storm. So, do not worry excessively if you fail to procure Remdesivir – your patient still has a good enough chance of survival. The same is true for convalescent plasma therapy (blood plasma from a person who has recovered from Covid recently). Plasma therapy is no longer recommended by the Covid Task Force in moderate/ severe disease since it does not help in reducing mortality.

(7)”I am not sure if I should take the Covid vaccine and which one?”

Covid-19 vaccines are a topic of discussion on their’s own and the technicalities are beyond the scope of this blog. Yes, there are lot many doubts about their efficacy, the rare complications associated with some vaccines, the chance of infection despite vaccination (the chances are very less and even if this does happen, the disease will be a mild one), the possibility of taking booster shots and many others. However, it is important to understand that the last pandemic which probably matches Covid-19 in its scale is the Spanish Flu of 1918 which ended only after infecting one-third of the world population and causing millions of deaths. Any such pandemic will only decline once the majority develop immunity to the virus. Vaccination will help us achieve this earlier and with far lesser deaths. Time and again, scientists and medical researchers have saved humanity from dreadful diseases with novel medicines and vaccines (polio, smallpox are some shining examples). We need to keep faith in their efforts and get vaccinated at the earliest opportunity with the one readily available.

(8)”I was infected with Covid. I am now protected. I need not take Covid vaccine.”

Again, this is a misconception. There are doubts regarding the duration of immunity after Covid-19 infection. The same has been confirmed with many getting reinfected in the second wave. Hence, it is advisable to get vaccinated even if one has had Covid infection in the past. Currently, there is no recommended duration of interval for vaccination after recovering from Covid infection. But the natural immunity from infection decreases over time. Considering this, one may get vaccinated anywhere between 8 to 12 weeks after recovery.

(9)”Should I take Ayurvedic kaadha/inhale steam or a variety of natural ingredients/ consume Homeopathy medicines/follow home remedies such as drinking turmeric milk, applying coconut oil in the nose, etc to protect myself from Covid?”

The efficacy of all such home remedies cannot be proven scientifically. But in my opinion, there is no harm in following them as long as one observes the 3 golden rules :

– Use of Face Mask once outside the home.

– Maintain social distancing and avoided crowded places as much as possible.

– Meticulous hand sanitation at regular intervals.

(10)”When will this pandemic end..?”

This is a question haunting us all. Again, one can only speculate about it. The pandemic will cease when the majority of the world population (at least 50% and above) develops immunity to the virus. As mentioned earlier, vaccination will help achieve it faster and with far lesser deaths. At the present rate of vaccination and if they deliver efficacy as expected, we can hope that by the end of 2022 the world starts getting back some semblance of the pre-Covid ‘normalcy’. The end of the pandemic, though, will not be a big bang moment. It will be a gradual process – one individual, one country at a time given the enormous physical and emotional toll it has taken. Also, the end of a pandemic will not mean the disappearance of the virus. The SARS-CoV2 will merely become endemic (like influenza and other coronaviruses) and may cause seasonal/sporadic outbursts. It will be necessary to track new infections, do the genomic sequencing to keep a track of new variants if any, and adapt our policies accordingly. To quote Margaret Thatcher – “You may have to fight a battle more than once to win it.”

(11)”The Covid pandemic is an organized plan unleashed with an ulterior motive (and umpteen such unverified or disturbing news about Covid on social media).”

Undoubtedly, the relentless pandemic has taken a great deal of physical, financial, and mental toll on humanity. However, the human mind is relentless in its pursuit of reasons for a particular occurrence, especially of such magnitude. Blaming an external source for our suffering, rather than introspection, is easier and kind of soothing. Only time will bring forth the real reasons for the pandemic but on a philosophical note, I feel that the Covid-19 pandemic is merely the Universe holding a mirror in front of us. Humanity was never so divided in the recent past along the lines of race, religion, and nationalism. Covid has reflected the distanced and fractured human race with its now hallmark “social distancing”. It is in fact making us humans ache to get back together. Such irony!

World Press Photo of 2020 by Danish photographer Mads Nissen

The incessant social and electronic media coverage of Covid-19, on many occasions, adds to our frayed nerves. I suggest few things which can be done to negotiate through these testing times (honestly, I too struggle and keep trying) :

– Consciously avoid reading and watching negatively toned news. Allot a set, limited time each day to catch up on current developments. Print media and reliable digital news apps are sufficient in this regard. Take a break from WhatsApp, Facebook, and Twitter universities.

– Make sure you eat right and healthy. Keep your weight in check.

– No matter how busy you are with “work from home” or how unmotivated you are feeling, make sure you indulge in physical exercise at least 30 minutes daily. Let this be a sacrosanct habit. Many are developing various physical ailments due to the forced sedentary lifestyle in the pandemic.

– Do not binge-watch television or overindulge in your cellphone. Spare some time for your hobby, be it reading/ music/ playtime with kids, etc.

– Maintain a regular sleep schedule at night where you get at least 6 to 7 hours of sound sleep.

– The constant fear of contracting Covid, the lack of socializing and vacations, and the overall sense of ‘losing freedom’ are all taking a toll on us. If possible, spend few minutes every day in silence with your God. Realize that there is always someone who is suffering more and is fighting a harder battle. Pray for the less fortunate and be thankful for everything you have. Know that, like every other natural calamity, this too shall pass. The real question, however, is – whether all this immense suffering will leave humanity wiser or instead make it self-indulgent than ever before leading to the same mistakes over and over again. Guess, only time will answer that one.