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Contextualising evidence-based recommendations for the second wave of the COVID-19 pandemic in India

15 Jun, 2021
During the second wave of the COVID-19 pandemic in India, which began in March, 2021, demand on the health-care system has far exceeded capacity. Despite crippling shortages, patients are prescribed a battery of ineffective therapeutic interventions. Ivermectin, hydroxychloroquine, and herbal cocktails continue to receive state patronage. On May 8, 2021, 2-deoxyD-glucose was given emergency authorisation, stating that it will “save precious lives” without any published evidence that it impacts mortality.5 An entrenched culture of polypharmacy and gestalt-driven practice among physicians has resulted in indiscriminate and unwarranted use of remdesivir, favipiravir, azithromycin, doxycycline, plasma therapy, and most recently baricitanib and bevacizumab, regardless of disease severity or drug efficacy. Excessive and inappropriate use of steroids could be contributing to the alarming rise of mucormycosis in patients recovering from COVID-19. In rural India, where health-care infrastructure is threadbare, and families are poor, patients can ill afford such expensive mistakes. Honing in on the most high yield and affordable interventions, we propose recommendations for testing and management, optimised to India’s current resource-constrained context (table). Every clinical touchpoint should be used to underscore masking, distancing, and vaccination. Where RT-PCR test turnaround time is lengthy, or when tests are unavailable, CT scans are being routinely prescribed for diagnosing infection from SARS-CoV-2. Serial scans are prescribed for prognostication; high CT severity scores—regardless of clinical presentation— then inadvertently trigger unwarranted hospitalisations. This practice is neither standard of care nor an option for most patients. In fact, we argue that in the throes of this surge, it would be prudent to initiate treatment for presumed infection if clinically warranted, and have all with mild symptoms isolate for 14 days or until a test result is available. In early May, 2021, national guidelines were finally relaxed to allow such syndrome-based diagnosis, ending a year of delayed or denied hospital admissions due to slow or unavailable testing.

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