Scientists claimed the XBB.1.16 variant of coronavirus to be responsible for the current surge in cases in India. On March 28, 2023, the Ministry of Health & Family Welfare (MoHFW) recommended an update in the treatment guidelines for managing COVID-19.

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Amid fears of a rapid resurgence of COVID-19 cases in the country, India recorded more than 5,000 cases of coronavirus infection - according to the Union Health Ministry data. With this, the active COVID-19 caseload has risen to >25,000, the Health Ministry data said. The positivity rate for a single day is reported as 3.32%, while the positivity rate for a week is recorded as 2.89%. With 0.06% active cases, the recovery rate currently stands at 98.75%, the data stated.

Possible causes for the increase in COVID cases include:

1. Inadequate booster vaccine coverage: Although immunisation rates in India have significantly increased recently, some people still haven't obtained booster doses. This implies that individuals who haven't had a booster shot might still get the virus rather readily.
2. Evolving variants: The virus is continually evolving and spreading, even among those who have received vaccinations. These mutations might be more contagious or more resistant to current vaccinations, which would increase the number of cases.
3. Loosening of barriers: As COVID-19 cases dropped earlier in the year in India, several states there loosened the COVID-imposed restrictions, allowing for more freedom of movement and social gatherings. This could have led to an increase in instances.
4. Novel infection: Vaccines are not always successful, and some people who have had vaccinations may still get the virus. These so-called "breakthrough infections" are mostly asymptomatic or moderate, yet they may sometimes still result in serious sickness.

While BB.1.16 has certain features with BB.1.5 in terms of its profile, Kerkhove noted that new variations in the spike protein have been found.

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Updated guidance

In light of the recent spike in cases throughout the nation, the Ministry of Health and Family Welfare, the All India Institute of Medical Sciences, the Indian Council of Medical Research, and the Joint Monitoring Group (Dte.GHS) have released updated recommendations for COVID-19.

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Mild disease

• Upper respiratory tract symptoms and/or fever without shortness of breath or hypoxia
• Home isolation & care

Must dos 

• Physical distancing, indoor mask use, hand hygiene
• Symptomatic management (hydration, antipyretics, anti-tussive)
• Monitor temperature and oxygen saturation (by applying a SpO probe to fingers)
• Stay in contact with the treating physician

Seek immediate medical attention if

• Difficulty in breathing or SpO ≤ 93%
• High-grade fever/severe cough, particularly if lasting for >5 days
• Maintain a low threshold for individuals who exhibit any of the high-risk characteristics
• High risk for severe disease or mortality 
• Age > 60 years
• Cardiovascular disease and CAD
• Diabetes mellitus and other
• Immunocompromised states (such as HIV)
• Active tuberculosis
• Chronic lung/ kidney/ liver disease
• Cerebrovascular disease
• Obesity
• Unvaccinated

1. It is not advisable to administer antibiotics unless there are indications of a bacterial infection.
2. In the case of COVID-19, co-occurrence with other commonly prevalent infections should be taken into account.
3. Systemic corticosteroids are not indicated in mild disease.

Do not use in COVID-19

• Lopinavir-ritonavir
• Hydroxychloroquine
• Ivermectin
• Neutralising monoclonal antibody
• Convalescent plasma
• Molnupiravir
• Favipiravir
• Azithromycin
• Doxycycline

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Moderate disease

Any one of the following

• Respiratory rate ≥ 24/min
• Breathlessness
• SpO2: 90% to ≤ 93% on room air
• Admit to the ward 

Oxygen support

Target SpO: 94-96% (88-92% in patients with COPD)

Preferred devices for oxygenation

• Non-rebreathing face mask
• Patients who need extra oxygen therapy are recommended to practice awake proning (sequential position changes every 2 hours)

Anti-inflammatory or immunomodulatory therapy

1. Dexamethasone 6 mg/day or equivalent dose of methylprednisolone (32 mg in 4 divided doses) usually for 5 to 10 days or until discharge, whichever is earlier.
2. If a patient's condition is stable or improving, they may be started or shifted to oral medication.
3. There is no proof of the usefulness of systemic steroids in individuals who do not need oxygen support or after they have been discharged.
4. Anti-inflammatory or immunomodulatory therapy (such as steroids) can have a risk of secondary infection, such as invasive mucormycosis when used at a higher dose or for longer than required.

Anticoagulation

1. A prophylactic dose of unfractionated heparin or low molecular weight.
2. Heparin (weight based, e.g., enoxaparin 0.5mg/kg per day SC)
3. There should be no contraindication or high risk of bleeding.

Monitoring

1. Clinical monitoring: Respiratory rate, hemodynamic instability, change in oxygen requirement.
2. Serial CXR; HRCT chest to be done only if there is worsening.
3. Laboratory tests, including CRP, D-dimer, and blood sugar, should be conducted every 48 to 72 hours, while CBC, KFT, and LFT should be conducted every 24 to 48 hours.
4. After clinical improvement, discharge as per revised discharge criteria.

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Severe disease

Any one of the following

• Respiratory rate >30/min, breathlessness, SpO2 < 90% on room air
• Admit to the HDU/ICU

Respiratory & cardiovascular support

1. Consider the use of NIV (Helmet or face mask interface depending on availability) in patients with increasing oxygen requirements, if work of breathing is low.
2. Consider the use of HFNC in patients with increasing oxygen requirement Intubation should be prioritised in patients with high work of breathing /if NIV is not tolerated.
3. Use institutional protocol for ventilator management when required.
4. Need for vasopressors to be considered based on the clinical situation.

Anti-inflammatory or immunomodulatory therapy

1. Dexamethasone 6 mg/day or equivalent dose of methylprednisolone (32 mg in 4 divided doses) usually for 5 to 10 days or until discharge, whichever is earlier. No evidence of benefit in higher doses.
2. When taken in larger doses or for a longer duration than necessary, anti-inflammatory or immunomodulatory treatments (such as steroids) can increase the likelihood of secondary infections, such as invasive mucormycosis.

Anticoagulation

• A prophylactic dose of unfractionated heparin or low molecular weight
• Heparin (weight based, e.g., enoxaparin 0.5mg/kg per day SC)
• There should be no contraindication or high risk of bleeding

Supportive measures

1. Maintain euvolemia (if available, use dynamic measures for assessing fluid responsiveness)
2. If sepsis/septic shock: manage as per existing protocol and local antibiogram

Monitoring

1. Clinical monitoring: Work of breathing, hemodynamic instability, change in oxygen requirement.
2. Serial CXR; HRCT chest to be done only if there is worsening.
3. Laboratory tests, including CRP, D-dimer, and blood sugar, should be conducted every 48 to 72 hours, while CBC, KFT, and LFT should be conducted every 24 to 48 hours.
4. After clinical improvement, discharge as per revised discharge criteria.

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Additionally in moderate or severe disease at high risk of progression

1. Remdesivir can be considered for a duration of 5 days, with an initial dose of 200 mg IV on the first day, followed by a daily dose of 100 mg IV for the next 4 days.
2. To be started within 10 days of onset of symptoms, in those having moderate to severe disease with a high risk of progression (requiring supplemental oxygen), but who are not on IMV or ECMO.
3. No evidence of benefit for treatment more than 5 days.
4. Not to be used in patients who are not on oxygen support or in-home setting.
5. Monitor for RFT and LFT (Remdesivir not recommended if eGFR <30 ml/min/m2; AST/ALT >5 times UNL) (not an absolute contraindication).

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Additionally in rapidly progressing moderate or severe disease

1. Consider tocilizumab preferably within 24-48 hours of the onset of severe disease/ ICU admission [4 to 6 mg/kg (400 mg in 60 kg adult) in 100 ml NS over 1 hour] if the following conditions are met.
2. Rapidly progressing COVID-19 not responding adequately to steroids and needing oxygen supplementation or IMV.
3. Preferably to be given with steroids.
4. Significantly raised inflammatory markers (CRP and/or IL-6).
5. Rule out active TB, fungal, systemic bacterial infection.
6. Long-term follow-up for secondary infections (such as reactivation of TB, flaring of herpes).

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.