This guideline is aimed squarely at the current second wave. As there are so many standards and not everyone agrees to the same treatment, physicians should use their own judgement, particularly when recommendations are constantly evolving. Here are the expert consensus guidelines for 2021 COVID-19 management with the Indian context.

COVID management and concerns in 2021

COVID-19 has entered its next calendar year. So far there have been 1,28,01,785 confirmed cases with 8,41,083 active and 1,66,208 deaths detected in India. With reports on increasing positive cases, it seems that COVID has hit the second wave. The surge has been attributed as much to the laxity among people towards compliance with COVID protective protocols as also with the more transmissible variants arising.

Current strains in India

The latest COVID-19 cases may be a mash-up of many strains. Three variants of concern have been recognised by WHO and CDC, the UK variant (B.1.1.7), the Brazilian variant P1, and the South African variant B.1.351, with two more California variants, also catching up.

Besides those previously mentioned, in addition to the previously identified strains, a novel double mutant strain of the SARS-CoV-2 virus has also been found in India. The vaccine roll-out is pitted against the variants of concern and seems to be a static solution to an evolving problem of virus mutation. The Indian health ministry recently released data on the genome - sequencing of 10,787 samples from 18 states of India which showed 771 cases of known variants ( 7.1%). Out of these 736 were the UK variants ( 95.4%), 34 were the South African variants (4.4%) and one was the Brazilian variant. A double mutant strain has been detected in Maharashtra.

Vaccine efficacy remains another challenge and worrisome reports state people getting infected after 14 days of the second dose of vaccination albeit with a less serious disease pattern. Reports that the mRNA vaccines(Pfizer and Moderna) are 4-7 fold less effective against the P1 Brazilian variant and 6-8 fold less effective against the South African B.1.351. AstraZeneca vaccine and the Johnson and Johnson vaccine are also noted to be less effective against the South African variant. However, they were working against the UK variant.

With the risk of vaccination, asymptomatic individuals are also noted to be spreading the virus, where the enemy is largely hidden. The risk multiplies when asymptomatic mobile youngsters may be the super-spreaders in schools, colleges or gatherings.

How variant strain cases vary from those encountered in the first wave

The newly discovered virus strain with two mutations is extremely contagious and has the ability to bypass immunity established by the normal infection or vaccination. As a result, re-infection cases and cases among vaccinated people are not rare. In addition, newer strains contribute to greater vulnerability among the younger population and make it more likely for disease to progress.

COVID 2nd wave: What has changed this time?

1. Shifting age trend: There has been a change in the age category of critically ill patients towards younger age groups. Younger patients are not only affected, but they also need to be admitted to the intensive care unit.
2. Evading RT PCR: Standard RT PCR tests may not efficiently detect COVID cases.
3. Enhanced thrombotic disorders: Thrombotic disorders are becoming more common. In comparison to the cases in 2020, there could be several thrombotic incidents.
4. Despite two doses of vaccine, no one becomes resistant to infection: After two doses of the vaccines, patients are taken to the hospital with symptoms. However, in the vast majority of cases, the disorder is asymptomatic, mild, or moderate, with an elevated CT value on RT PCR indicating a low viral load and transmission capacity.
5. High social class is more profoundly affected: Upper socioeconomic strata are afflicted rather than lower socioeconomic strata (observational opinion).
6. Fatality: Although there would be an absence of comorbid conditions, serious illness and death may occur. It's possible the deterioration will happen quickly. In addition, this strain seems to be more virulent this time around (observation and opinion from a few centres). Admissions to intensive care units (ICUs) and deaths in these units are a reliable measure of mortality.
7. Radiologists are perplexed by CT lesions: The worrying thing is that the percentage of cases with CT lesions is much higher this time, and the CT lesions tend to be more diffuse indicative of the ARDS trend than during the first peak (This is based on observations from a few regions in Maharashtra and Gujarat).

How is the new wave different?

• In 2020, it was speculated that SARS-CoV had a seasonal phenomenon, spreading more in cool, cosy days such as those experienced in Italy. By 2021, though, the virus had proven everybody wrong, displaying no preference for those types of weather.
• Surface virus transmission is no longer a significant concern. Surface disinfection is not being prioritised as much as it can be.
• With most physicians reverting to the use of nebulisers, BIPEP, and other aerosol-generating procedures with due precautions, air transmission remains more of a popular hypothesis.

Is RT-PCR still applicable in these situations?

While an RT PCR test can detect all strains that trigger COVID-19, few newer variants may be missing. Such mutations, such as HV 69/70, have the potential to deflect RT-PCR testing as well, according to WHO, and can go unrecognised in the testing. However, the latest mutation is predicted to have a minor effect on the RT-PCR research that is currently in use around the world. It is recommended that you read the whole RTPCR report because the ORF gene and N gene can still be identifiable but the S gene may not. These cases of S gene drop out may be interpreted as negative by certain laboratories.

How do you know if you have a case like this?

Where clinical suspicion is elevated and RT PCR is negative, clinical manifestations, serum markers, and a chest computerised tomography should be used for diagnosis.

Timing is everything

Identifying the first day of illness, when the patient begins to feel unwell, is critical in the COVID management process.

1. The infection is more contagious one day before and three to four days after the first symptom.
2. The patient is expected to have a high fever for the first 2-3 days due to the virus' higher replication, but at this stage, innate immunity in the form of macrophages, neutrophils, and other cells begins to raise a response against the virus's invasion.
3. The deterioration of symptoms, which is mostly an immune-mediated inflammatory mechanism marked by high-grade fever, increased oxygen requirement, hypoxia, and other symptoms, begins in the second week. Hyperinflammation that spirals out of control can lead to cytokine storm syndrome and multi-organ injury.

As a result, it is important to respond quickly, within 7 to 10 days, with anti-inflammatory drugs. Many modern drugs, such as steroids, Tocilizumab, and plasma, function well when administered at the right time at this stage.

Incubation time

• Symptoms will appear anywhere from two days to two weeks after being exposed to the virus
• The infection can be acquired in 15 minutes
• The incubation time is currently estimated to be between 4 and 5 days
• The virus does not replicate after 9 days
• Fever >101°F, CRP >10 mg/dl with the fast increase, cough on day 3 or a 5% drop in SpO2 on the six-minute walk test are warning signs of pneumonia
• The fifth day is the most crucial during COVID illness (Lancet 2020 Fei Z et al.)
• If the RTPCR test is negative, physical symptoms, serum markers, and a chest CT scan can be used to establish a diagnosis if clinical doubt is substantial
• Consider reinfection if RT-PCR is positive after 3 months or becomes positive after two successive negatives
• From day 3-6, the six-minute walk test (6MWT) is helpful
• If the patient's oxygen saturation drops by 5% while walking, it's a sign of pneumonia necessitating hospital admission