It probably began in the East and crossed borders and oceans, as it devastated several countries till it reached Rome. The only thing that spread faster than the contagion was the fear and the rumours. People were terror-stricken. Doctors were clueless. Government officials vacillated and losses mounted. Travel was crippled. Festivals, gatherings, sporting events—all cancelled. The economy plunged. Bodies piled up. The world was bewildered.
I am, of course, referring to the Antonine Plague of 165 CE, a global pandemic with a mortality rate of 2-3%. It also began with flu-like symptoms until it escalated and became a catastrophe of unbelievable proportions, in which over 15 million people eventually died.
“Those who do not remember the past are condemned to repeat it” – George Santayana
I was confronted with these words as I walked into the Nazi concentration camp at Auschwitz in 2004 and they have continued to haunt me ever since.
History repeats.
The whole world is in the grip of the coronavirus now. The pandemic started in December 2019 in Wuhan, China and has spread insidiously world over. Coronaviruses have been identified over 60 years ago as one of the agents which cause the annoying common cold. There are 4 types of the beta-coronavirus family which can cause the disease. But, like the influenza virus, it has the uncanny ability to mutate often.
The first such instance of a dangerous mutation was in 2002, the SARS (Severe Acute Respiratory Syndrome) outbreak from Hong Kong, which afflicted over 8,000 people and resulted in around 800 dead (a mortality of 10%). It is believed to have originated in bats, which are, incidentally, asymptomatic and transmitted via civet cats to humans. The second catastrophe was the mutation resulting in MERS (Middle Eastern Respiratory Syndrome), which originated again from bats, and affected humans through an intermediate host, the dromedary camels, in Saudi Arabia. By last counts, there have been around 2,500 cases with over 750 deaths (a mortality of 35%).
The current outbreak is again due to a mutated coronavirus labelled by WHO as SARS-CoV-2, which is believed to have originated from bats in a live animal and sea-food market in Wuhan, and infected man through an intermediary host (? pangolin). The virus has the ability to infect lung cells through a receptor known as ACE-2, leading to complications of pneumonia and respiratory failure. COVID-19, the disease caused by SARS-CoV-2, has affected over 150 countries, 3,00,000 people with over 13,000 deaths. In India, 476 infections have been identified with nine deaths.
How does the virus spread?
The virus spreads through respiratory droplets of an infected person. It could directly spread through inhalation of droplets when you are within a metre of a coughing patient, but more often, it is by touching inanimate objects contaminated by these droplets and taking our hands near our nose and mouth. This essentially means that if we are at least a metre away from anyone, and wash our hands frequently, it is highly unlikely that we would be infected. This is the rationale behind the concept of social / physical distancing. Even though the virus can survive for substantial periods on inanimate objects (a day on cardboard and 2-3 days on plastic and steel, under ideal conditions), it dies on drying.
What are the symptoms?
The symptoms of COVID-19, the common cold, and the flu are akin to each other. The symptoms start with a low grade fever followed by a sore throat and body pain. Nausea and diarrhoea may then occur with worsening throat pain, malaise and joint pains. Severe body pain with nausea, high grade fever and diarrhoea may follow. Breathlessness may occur with severe cough after a week. One needs to consider visiting a hospital only when there is high grade fever and difficulty in breathing.
What are the complications of COVID-19?
Almost 80% of people may not require hospitalization. Around 20% may require admission and oxygen support. About 5% of infected people end up in ICU on a ventilator. The risk of complications is higher in the elderly (over 60yrs of age), diabetics and persons with co-morbidities like uncontrolled hypertension, lung disease, liver or kidney disease and an immune-suppressed status. The case fatality rate is around 2%, but can be as high as 15% in persons over the age of 80. This is because of weakening immunity with age. In some situations, the immune system fights back aggressively, goes berserk and causes more damage. This damaging overreaction is called a ‘cytokine storm’ and can lead to multi-organ failure and death.
Experts, however, believe that the mortality may be lower than 1% in the general population. Surprisingly, the infections have been very mild in young children, but they seem to spread the virus for longer. Pregnant women have also not shown features of severe infection.
Will the coming of summer help in stopping the pandemic?
The concept of seasonality for viral infections, especially the flu, is based on evidence and experience from the west. This has been extrapolated to other viruses which may die when exposed to the heat and humidity. The incidence of flu wanes in the summer in the West because most of transmission in winter occurs indoors, where people stay in close quarters to escape from the cold outside. When summer arrives, they start moving out and lack of proximity causes the flu to die down. In tropical countries, the flu is prevalent throughout the year with outbreaks happening even in the peak of summer. In Chennai, people tend to venture out less in summer and the ambient temperature and humidity indoors can cause the infection to be transmitted, even though it may die more readily outside.
Is there a role of Vitamin C or other food supplements in the prevention and treatment of COVID-19?
At present there is no scientific evidence to recommend Vitamin C or any other food supplements specifically to improve immunity or to protect against COVID-19.
What should every citizen of India do to help control this pandemic?
Since this infection spreads by respiratory droplets, the only way to block transmission is by physical distancing. This means all of us have to avoid crowds and stay at home.
Avoid any kind of travel – international or domestic
Avoid visiting any public spaces like schools, gyms, cultural and social centres, swimming pools, theatres and museums
Avoid restaurants, clubs and bars and pubs
Keep all commercial activity at a distance of one metre between customers. Those that cannot guarantee this distance must close. Places of worship can remain open as long as they can guarantee this distance
Limit hospital visits
Postpone work meetings. Encourage work from home
All sports events and competitions, public or private should be cancelled
Any gathering of over 10 persons should be deferred
What do I do if I have sore throat or fever?
Since most infections are mild, the current recommendations are to stay at home under isolation and take only symptomatic treatment with Paracetamol. Contact your doctor or hospital only if the fever is high or if difficulty in breathing ensues.
How do I quarantine myself at home?
Stay in a well-ventilated single-room preferably with an attached / separate toilet. If another family member needs to stay in the same room, it is advisable to maintain a distance of at least 1 meter between the two.
Stay away from elderly people, pregnant women, children and persons with co-morbidities within the household.
Under no circumstances should one attend any social /religious gathering e.g. wedding, condolences, etc.
Wash hands often with soap and water or with alcohol – based hand rub.
Avoid sharing household items e.g. dishes, drinking glasses, cups, eating utensils, towels, bedding, or other items with other people at home.
Wear a disposable surgical mask at all times, if symptomatic. The mask should be changed every 6-8 hours and disposed of. Disposable masks are never to be reused.
Use disposable gloves and surgical mask when cleaning surfaces or handling soiled linen.
Clean and disinfect frequently touched surfaces in the isolated person’s room (e.g. bed frames, tables etc.) daily with 1% Sodium Hypochlorite solution.
What is the treatment modality?
At present, there are no recommendations for a specific treatment. Therapy is only symptomatic. A cocktail of drugs including Azithromycin, Chloroquine or HCQS (hydroxychloroquine) and Lopinavir may be tried. There is no scientific evidence to start Chloroquine prophylaxis for healthy persons. It may be over a year before a vaccine is available to combat COVID-19.
“Never let a good crisis go to waste” said Churchill.
The risks of doing nothing are greater at this point, which is why we must use this pandemic as an opportunity to learn. We have to act quickly and decisively. We should revisit our practices of yore and re-educate ourselves. Maybe we should begin with not spitting in public places, washing our hands more often, and improving personal hygiene. We need to instil personal and societal responsibility for our actions.
As a doctor, I would strongly encourage people to place their trust in the science of medicine and put to rest the spreading baseless conspiracy theories and rumours. The media should play a responsible role in presenting facts based on scientific evidence. In my opinion, the government should unite with private healthcare providers and global bodies to ensure optimal healthcare delivery during a crisis of this proportion.
