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| EDITORIAL |
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| Year : 2021 | Volume
: 12
| Issue : 1 | Page : 1-3 |
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Conundrum of COVID-19: The road ahead
Anupam Prakash
Department of Accident and Emergency, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
| Date of Submission | 07-Dec-2020 |
| Date of Acceptance | 07-Dec-2020 |
| Date of Web Publication | 08-Jan-2021 |
Correspondence Address:
Dr. Anupam Prakash
Department of Accident and Emergency, Lady Hardinge Medical College and Associated Hospitals, New Delhi - 110 001
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/injms.injms_160_20
How to cite this article:
Prakash A. Conundrum of COVID-19: The road ahead. Indian J Med Spec 2021;12:1-3 |
The human race on earth was coasting along dealing with its own share of problems, namely., overpopulation, deforestation, global warming, and related environmental concerns. However, despite the recent scares caused by the Nipah, Ebola, and the Zika viruses, probably the stage was set for a virus to take the world by storm, and that is what exactly happened in the fag end of the year 2019. The novel Coronavirus-2019 (nCoV-2019) caused an illness similar to severe acute respiratory syndrome (SARS) witnessed in 2002 caused by an earlier coronavirus (SARS-CoV). The SARS-CoV-2019 virus originated from China but spread in no time across several countries of the world, and was declared a pandemic by the World Health Organization in March 2020. The disease it caused was called coronavirus disease (COVID-2019), having both pulmonary and systemic manifestations. The high infectivity and the initial high mortality rates of 8%–12% in several countries of the world created panic, and to prevent transmission of disease, several countries imposed lockdowns. Quarantine of exposed and suspected persons and isolation of the COVID-positive patients became the norm. Man is a social animal, and coronavirus created havoc by literally jolting the human race to take drastic measures, and tearing the social fabric that human beings had become so used to. It was very hard for human beings, to live away from close ones, with physical social interaction virtually halted. Who would have imagined that the year 2020 would become an impressionable landmark for the human race. With so much of technical and scientific advancement, human beings could not have even dreamt in the wildest of dreams that they would be facing a pandemic caused by a virus, wherein there would not exist any drugs to combat it, and the pace of spread of the disease and the mortality caused would be akin to a fiction novel. In fact, such was the gravity of the situation in the initial few months that leak of a biowarfare agent was also surmised. There could not have been any antiviral agent existing for a novel coronavirus, so drug repurposing was tried with already existing antimicrobials, and emergency use authorizations became the order of the day. In the absence of effective antimicrobial agents, the onus of combating the pandemic rested on “prevention.” The three-pronged preventive strategy of wearing facemask, maintaining social distance, and frequent hand washing has remained the cornerstone in public places, residences, and institutions, including hospitals. This three-pronged preventive strategy aided by national and regional-level lockdowns, travel restrictions, declaration of containment zones, promoting online purchases, meetings, and educational ventures, limited and essential outdoor movements, and screening at entrances of buildings, offices, and shopping establishments, did not halt the pandemic. Moreover, the numbers have been consistently rising, but the peak seems to be now over in most countries, and with lockdowns too lifted, the road ahead is uncharted. There is a possibility of resurgence from pockets such as containment zones or slum clusters. The infection typically has spread from larger metropolises to smaller cities and to rural areas and to the hills. A resurgence may be seen when the people who got first infected now lose their protected status because of the waning of immunity over time, and “rural to urban” reverse infection and infection traveling from the “hills back to the plains,” may then become a distinct possibility.
There are several challenges at hand. As on date, drugs such as remdesivir, tocilizumab, and even convalescent plasma have not shown any survival benefit in moderate-to-severe COVID patients.[1],[2],[3],[4] Oxygen, prone ventilation, noninvasive ventilatory support, steroids, and anticoagulants in selected cases, are the interventions which have shown undoubted benefit in moderate-to-severe COVID-19 patients. There are several drugs which are under trials and the results will be known in coming times.
As we witness more and more cases of COVID-19, atypical and less common manifestations of COVID-19 are being noticed, and an association with GuillainBarre syndrome in a case series by Sud et al.[5] and additionally, posterior reversible encephalopathy syndrome has been reported in this issue.[6] Such manifestations will become more obvious as the pandemic progresses.
At present, for populous countries such as India, easing out restrictions in containment zones, and opening of establishments to boost the economy is a major challenge. Furthermore, opening up colleges and more importantly, schools are going to be tough, since it involves young children and adolescents. Although COVID-19 has not been reported to have significant mortality or severity in children, they can still transmit infections and bring infections to their households, thus endangering the elderly and the “at-risk” populations who have been home confined since the beginning of the pandemic. Besides, any suffering witnessed in children is agonizing. Although not much is known about COVID-19 in children, the haematologic alterations are discussed in a succinct review in this issue.[7]
Although <5%–10% of COVID-19 patients need admission, the post-COVID illnesses[8] have added to the burden of morbidity, although the exact magnitude of the same is yet to be ascertained. The prospect of long COVID has been staring many, especially in India, where pulmonary tuberculosis and posttuberculous fibrotic sequelae are already rampant.[9] Not to forget that co-infection with infections prevailing in the tropics can really contribute to the morbidity and mortality in tropical countries.
The winters pose another challenge to countries such as India, especially observed in the Northern part of India are the high pollution levels and air trapping close to the earth surface. The increased pollution levels and also the flu-season can increase the transmission of coronavirus and lead to a surge in cases.
The acute stress of a pandemic situation is now giving way to a chronic state, and even those with the best of endurances are facing the psychological brunt and finding it difficult to cope. Health care workers and people manning other essential services in the frontline have faced extreme distress,[10] not to forget the mention of the lay public who had to remain indoors, at times away from their relatives and has had to incur the loss of wages/jobs too.
People are looking at “COVID vaccines” with great hope.[11] No doubt vaccines are a very important step to combat any illness, but how effective will the vaccines be, is anybody's guess. Whatever, 95% or 99%, maybe the short-term efficacy with two doses of vaccine, the long-term efficacy of vaccines will need to be observed. It is imperative to monitor long-term efficacy in those who receive the vaccine because the cases of re-infection have started surfacing in persons who had got the natural infection early in the pandemic, i.e., within 6 months. A booster dose may well come out to be a recommendation. Antibodies have also been reportedly disappearing in a matter of 3–4 months, in persons who actually did generate antibodies in response to COVID infection. In this regard, it may be more helpful to boost the cell-mediated immunity against coronavirus, to reduce the chances of infection, and this aspect is also being taken care of by some of the vaccines, and the trial results of Mycobacterium which may throw more light on this aspect. Undoubtedly, short-term protection can definitely be expected from COVID vaccines, and mass vaccination drives can help break the chain of transmission by building a basal level of immunity in an area. Most nations are planning to vaccinate the frontline warriors, the elderly, and the people “at risk” first before planning to vaccinate the masses. Manufacturing vaccines at robotic pace will remain a challenge for several nations, and to maintain the cold chain and transmission channels so that an effective vaccine reaches the person to be vaccinated would test the planning and executing skills of governments. Predictions on “duration of efficacy” and “long-term safety” of vaccines will be too premature at this juncture, and only active surveillance of vaccines will answer this.
Many epidemiologically important communicable and noncommunicable diseases have taken a backseat because of the COVID pandemic and therefore, it is high time to ensure that these sections of the society also re-start their follow-ups and protocols for standardized care. In fact, some of these protocols may need to be modified in view of the continuing corona scare, with social distancing, wearing mask, and frequent hand-washing getting incorporated into these protocols. Furthermore, consultation by telemedicine and incorporation into standard care protocols may be imperative in times to come. One thing that this pandemic forced us to imbibe and may be worthwhile to adopt in the times to come, will be the “work from home” culture. This shall minimize face-to-face interactions in real life and reduce the pressure on transport systems contributing to reduction in pollution levels and conserving time lost in commuting. However, a 24-hour Internet connectivity and electrical connection will remain essential prerequisites. Last but not the least, it is imperative to understand that everyone needs to be prepared for the new normal, wherein COVID-19 has been added to the list of our diseases, and we will always need to be on our vigil against COVID-19 and other microbial attacks in future. These may include the need to wear masks and take other precautions from time to time. We will need to adapt, the faster we do, the better we will be.
The motivational quote by Robert Schuller is apt in the present scenario, “Tough times never last, but tough people do!” Sure enough, we need to be tough to last through this pandemic!
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Beigel JH, Tomashek KM, Dodd LE, Mehta AK, Zingman BS, Kalil AC, et al. Remdesivir for the treatment of COVID-19-final report. N Engl J Med 2020;383:1813-26.  |
| 2. | Stone JH, Frigault MJ, Serling-Boyd NJ, Fernandes AD, Harvey L, Foulkes AS, et al. Efficacy of tocilizumab in patients hospitalized with COVID-19. N Engl J Med 2020; NEJMoa2028836. |
| 3. | Agarwal A, Mukherjee A, Kumar G, Chatterjee P, Bhatnagar T, Malhotra P, et al. Convalescent plasma in the management of moderate COVID-19 in adults in India: Open label phase II multicentre randomised controlled trial (PLACID trial). BMJ 2020;371:m3939. |
| 4. | Simonovich VA, Burgos Pratx LD, Scibona P, Beruto MV, Vallone MG, Vázquez C, et al. A randomized trial of convalescent plasma in COVID-19 severe pneumonia. N Engl J Med 2020;NEJMoa2031304. |
| 5. | Sud R, Verma J, Goswami S, Aggarwal N, Gurtoo A. Post-COVID-19 Guillain-Barre syndrome: a distinct neurological entity. Indian J Med Spec 2020;Current Issue. |
| 6. | Bhowmick M, Chaudhary S, Kumawat A, Singh G. Guillain-Barre syndrome and posterior reversible encephalopathy syndrome associated with COVID-19: Expanding horizon of the novel disease. Indian J Med Spec 2020;Current Issue. |
| 7. | Margekar P, Kumar A, Margekar VG, Margekar SL. Haematological profile in children, whether it matters in COVID-19. Indian J Med Spec 2020;Current Issue. |
| 8. | Prakash A. COVID-19 – An acute infective illness with long-term consequences. JAPI 2020;68:11-2. |
| 9. | Gupta U, Prakash A, Sachdeva S, Pangtey GS, Khosla A, Aggarwal R, et al. COVID-19 and tuberculosis: A Meeting of two pandemics! J Assoc Physicians India 2020;68:69-72. |
| 10. | Parihar J, Grewal K. Unlocking the mental health crisis in health care providers during COVID-19 pandemic. Indian J Med Spec 2020;11:173-4. [Full text] |
| 11. | Sachdeva S, Gupta U, Prakash A, Margekar SL, Sud R. The race to find COVID-19 vaccine: So near, yet so far. Indian J Med Spec 2020;11:175-9. [Full text] |
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