Dr KK Talwar
Former Director, PGIMER
The coronavirus (or Covid-19 virus) evidently originated in Wuhan, China. In retrospect, unfortunately, it does not seem to have been taken seriously enough at the beginning. This led to its spread in the Wuhan region. Surprisingly, the doctor who tried to highlight the issue was ignored, even harassed and framed. Ironically, the noble professional finally himself died of this very disease within six weeks of having publicly documented the issue. The rest, as they say, is history.
The entire world now faces a declared pandemic, and is struggling to come to grips with the problem. So mammoth is the scale of the problem that large parts of the world are at a virtual standstill, with millions of people having to bear the brunt of the strict measures implemented to stem the spread of this malevolent organism.
Covid-19, an acute respiratory syndrome coronavirus-2 (Sar Cov-2), is essentially a protein molecule with a covering layer of fat. It can enter the body through the eyes, nose or mouth mucosa. Once the protective coat is absorbed by the mucosal cells, it changes its genetic code to aggressive cells. The underlying pathogenetic mechanism is caused by the binding of the viral’s surface spike proteins to the human Angiotensin-Converting Enzyme 2 (ACE 2) receptors. ACE 2 is expressed in the lungs and appears to be main portal of entry in the body. ACE 2 is also present in the heart, kidneys and intestines. The virus can affect these organs as well. Cardiac involvement is not uncommon in sick patients, and can affect mortality. As such, ACE 2 has been shown to have protective functions in the cardiovascular system and other organs.
The majority of patients may stay asymptomatic, or mildly symptomatic. About 4 per cent of the infected persons seem to develop serious and acute respiratory issues, requiring ventilator support. As the recent weeks have shown, even developed countries do not appear to be equipped to deal with the attendant medical problems on such a massive scale. Their healthcare infrastructure is stressed, and is struggling to keep pace with the rapid spread of the virus. Cases of patients dying on account of lack of effective and timely medical care have come to light. Medical professionals face the unenviable task of prioritising the available resources, which may be falling short of the huge demand.
It is, thus, imperative to test and identify the vulnerable members of the populace and to make available the necessary healthcare facilities in the early stages so as to prevent the onset, as far as possible, of the ‘critical phase’ in as many patients as possible. Awareness must be generated among the people of the importance of early management of cases, especially among the more vulnerable groups. Empirical data gathered in the last few months shows that some underlying diseases, such as diabetes mellitus, hypertension, coronary artery disease, heart failure, chronic renal disease, chronic lung disease and cancer, render individuals more vulnerable. Persons with these diseases/conditions must religiously follow their treatment schedule, and the preventive measures of social distancing and personal hygiene (including frequent hand-washing) and mouth-protective measures during cough. Many of these patients would already be on ACEI/ARB for the underlying disease. In view of ACE 2 involvement in the pathogenesis of the critical phase of the Covid-19 infection, social media platforms appeared to carry messages which (mistakenly) suggested the discontinuation of these drugs for the present. Fortunately, medical professionals and medical organisations, like the cardiac societies, were quick to dispute these suggestions and support the continued use of these medicines, given that stopping such medications when necessary could worsen the underlying disease.
The use of chloroquine/hydroxychloroquine as prophylaxis is another measure that is being debated, apart from the claims made by alternative medicine systems. At present, one must state, with every bit of emphasis that there is no evidence to conclusively establish the utility of any of these measures. We must avoid creating the impression of the availability of any magical panacea for this problem, and policymakers must be careful and calibrated in their approach and their public statements. It is not surprising that ever since the ICMR issued instructions for the use of hydroxychloroquine as prophylaxis for the healthcare workers involved in the care of Covid-19 patients, there have been reports of panic purchases of the medicine from chemists. This may potentially indicate a significant usage of this medicine by the public on a prophylactic basis. We must not forget that this drug may have serious side effects, such as serious (even fatal) arrhythmias in persons with cardiovascular diseases, and should be used only under medical supervision.
The lockdown and the curfews in some states are necessary and timely measures imposed by the governments. Apart from the other preventive measures rightly being highlighted in the media, the prestigious journal Nature published a pilot study last year emphasising the beneficial role of hypertonic saline nasal irrigation and gargles in regard to the viral flu disease. The hypothesis is that hypertonic saline in the nose and the mouth results in the formation of hypochlorous acid, which has a cleansing property and kills bacteria and viruses. Steam inhalation is another practice commonly prescribed by physicians during flu episodes. The local delivery of heat in the nose and throat may affect the growth of viruses. It has been documented that Covid-19 gets eliminated if exposed to a temperature around 56°C for approximately 15 minutes. Whether these inexpensive and safe practices also have a prophylactic role in regard to the Covid-19 virus deserves further scientific evaluation. I am certain that the experts must be currently evaluating these approaches.
The suffering caused by the Covid-19 virus all over the world is certainly a cause for concern and anxiety. There is a wishful hope that the oncoming summer and the possibility of some existing immunity in our bodies may help save us from this threat. The need of the hour is to stay focused, avoid panic and follow a sensible and science-based approach, based on empirical data and research. In the final analysis, we must all come together to do whatever it takes to defeat this threat to our individual and collective well-being. I am hopeful that humankind will emerge from this crisis wiser and stronger.
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