What is Covid?
Corona virus (single stranded RNA belonging to Coronaviridae family) named in view of its characteristic appearance (halo of sun)has assumed the highest popularity in the human history with 18,41,00,00,000citations on google. It started with unidentified after exposure to wet marketsin Wuhan, China in December 2109. Overthe past two decades two other similar and highly pathogenic novel zoonoticCorona virus disorders namely Severe Acute Respiratory Syndrome (SARS-CO-1) inNov 2002 and Middle East Respiratory syndrome (MERS-COV-1) in June2012 werereported.
Being a novel disease little is known about pathophysiology,modes of transmission, preventive and treatment strategies. What is known isthat COVID 19 binds to the ACE 2 receptor (mainly found in lower respiratorytract, heart, kidneys and brain) and enters in to human cells where the virusreplicates by taking control of the host cell. The relation to ACE 2 receptorad relation to pulmonary vasculature (lung blood vessels) is hypothesized tocause acute respiratory distress in the Covid Pneumonia. The disorder has spectrum of clinical manifestationsis mild in 80% and moderate to severe (around 5% critical). in the restdepending on AGE (>65 years) or existing disease conditions such as Diabetesor Hypertension (high BP) or Heart/Lung disease.
What is global burden and why the alarm?
Covid 19 kept on spreading since December across continentsand was WHO in February 2020 declared it ”Pandemic ” and 6th Public Health emergency of internationalconcern. Covid 19 is highly transmissible especially through asymptomaticcarriers (super spreaders). Whilewriting this piece 488,289 active cases (81,285 China, 74, 386 Italy and 68,594USA) are reported worldwide with 22,069deaths. Italy is leading in the deathtoll (7503) followed Spain (4089) and China (3287). India has 716 cases with 14deaths out of which 20 cases are from J& K. Kashmir reported its firstdeath of 65 year old male who had diabetes and hypertension.
How does covid 19 present?
There is plethora of information available on symtomologyand precautions to be observed for Covid prevention. We should laud the effortsof health sector and the media who are playing a significant role in thisregard. Briefly saying majority of subjects have no symptoms or have mildsymptoms that can easily be confused with common flu. Among those who havesymptoms high grade fever, running nose, cough associated with respiratorydistress, chest discomfort, fatigue, myalgias, abdominal pain, diarrhea. Thecommonality of symptom reported from Wuhan or S Korea are fever (91.7%), cough(75%), fatigue (75%) and gut symptoms (39.6%) being reported in the COVIDpositive patients.
What are its modes of spread?
The most common mode of transmission is person to person viadroplets. It stays in air for 3 hours, on steel and plastics for days and oncopper for just 1 hour. Community transmission of the virus is very high, so inorder to prevent the infection from the infected persons social gatheringsshould be avoided, social distancing ,frequent washing if hands with soap for at least 20 seconds, proper sanitizationis very important to break the chain of spread. All the people who have travel history from the infected country shouldbe quarantined for 14 days, as per the recent ICMR guidelines all the closecontacts of the person should be quarantined and checked to prevent thetransmission of the virus and to contain it, and if any of the COVID-19 positive contacts develop fever orany other associated symptoms related to infection should be tested.
What is Diabetes mellitus ?
Diabetes mellitus or (high blood sugar) is a widespread andrapidly increasing condition where glucose levels (normal feul for day to dayenergy) cross its upper limit (126 mg/dl in fasting state) of normal. This highglucose level ends up damaging most of the body tissues mainly blood vessels inheart, kidneys, eyes, feet. This leadsto very high morbidity (handicaps) and mortality (death) among populations ifnot taken care.
What is the burden of Diabetes in the community?
According to 2020 IDF (International Federation of Diabetes)ATLAS 1 in 11 adults has diabetes (455 million) and 12% ofglobal health expenditure is spent on diabetes Three quarters of peoplewith diabetes live in low and middle income countries. In India 79,203 millionof people are supposed to be affected and the disease is galloping crossing theinitial projections as per latest studies including ICMR-INDIAB Study.
How does COVID -19 affect Diabetics?
Diabetes is considered as an immuno-supressed state and eventhough scientific proof is lacking they may be more susceptible. InternationalDiabetes Federation (IDF) recommends that people with diabetes plan ahead oftime what to do before they get ill. This includes having the contactinformation of their treating doctor at hand and making sure to have an adequatestock of medications and supplies for monitoring blood glucose at home, so thatthey do not need to leave the house if they become ill. In case of infectionwith Covid 19 diabetics may see their glycaemic control deteriorating and theyshould follow the “Sick day rules” generally recommended for any stressfulsituation. They should not panic but should contact their health care providerfor advice on how to monitor their blood glucose, get adequate refills formedications (especially insulin) and what adjustments they may need to do intheir medication or diet.
- Sick day rules for people with diabetes
- Keep themselves well hydrated (take adequate water)
- Monitor blood glucose regularly
- Monitor body temperature
- If type 1 diabetes on insulin, may check urine ketones
Why is Covid 19 relevant to Diabetics?
Although there is more risk of mortality in elderly,pregnant and immune-compromised subjects but data from countries who haverecently undergone spikes of infection showed severe disease among subjectswith preexisting diabetes or hypertension. In a retrospective study done inWuhan in the patients who had contracted the virus and were admitted in thehospital , it was found that 48% of the deaths were associated withhypertension as a comorbidities, followed by diabetes which was 19% and CVD 8%followed by lung diseases, cancers etc. ACE 2 gene polymorphism that has beenlinked to diabetes and hypertension in Asian population creates a possibilitythat patients with these comorbid diseases are at a higher risk of COVID 19, ascompared with the healthy population.
How can you harmonise care of people with diabetes?
In response to government administered lockdown in thecountry to curb the community spread of COVID-19 pandemic, diabetic subjectshave restricted movement and are likely to missed routine exercise protocol.Since regular physical activity is of great benefit to the general populationand even more for people living with diabetes. This unprecedented lockdownalong with scary statistics in news is going to add to the already existingburden of psychiatric comorbidities. Hence there has to be tailor madeprogramme of exercise schedule according to home environments while maintainhygiene and social distancing. Building their morale with frequent telephonicconversations, showing optimism, avoiding panic and even discussion with apsychotherapist may go a long way in avoiding problems. NGO or self help groupsshould play their role in the hour of need.
How does COVID 19 affect patients with high blood pressure?
Because of the weakened immunity in the patients withDiabetes, they are at a higher risk as compared to non diabetics. Diabeticsshould pay attention to there blood sugars, as diabetics are more prone toDiabetic ketoacidosis with COVID 19. Arecent study on 2000 admitted patients in hospital it was found that Bloodgroup A are more susceptible to COVID-19. A recent debate on as COVID-19 gets attached to ACE-2 receptors safetyof ACE inhibitors/ ARBs in patients who are already on these drugs wasspeculated, but AHA (American Heart a Association) recommended to continue themedications of patients with hypertension /cardiovascular disease (CVD) andheart failure. Hypertensionis the most common comorbidity in Covid19 patients and may have higher risk of complications. These subjects need to continue antihypertensive medications andhealthy life practices (dailywalk 30 minutes in your courtyard and low salt diet). In case of anybreathlessness, you may contact your treating doctor. You should remain understringent vigilance of healthcare workers especially by telephone. Panicrushing to hospital should be avoided. Self ambulatory blood pressuremonitoring if possible, can be very useful.
How does COVID -19 affect Elderly?
With epidemiological trends in the country there issignificant proportion of population of elderly in India and the valley. WorldHealth Organization (WHO) have identified elderly people as especiallyvulnerable to Covid-19 as lessons from the Chinese outbreaks have shown more fatal cases among elderly people. Thisis attributed to existing health problems such as those of lungs, heart, kidneyor diabetes or cancer. Fortunately in our valley as in most parts of thecountry most of elderly live in joint families paving a way for their care andavoiding isolation during lockdown. But the downside of living in jointfamilies is that elderly may get infected through an asymptomatic family memberlike a child. Thus, you need to keep them in separate rooms even in the houseand when you visit elderly people, maintain a two-metre distance. Also do notforget to wash your hands with a soap or use of alcohol-based hand sanitiserbefore you touch them or their fomites. The Care-Givers have to be vigilant forany minutest symptoms as elderly are known to show less symptoms till in thedisease process in general.
Is there any vaccine available for Covid?
Since Covid is a novel (first time seen affecting humans)virus no vaccine is available unlike other flu virus disorders. First vaccine (mRNA-1273)has been given to 45 volunteers aged 18-55, results of which are much waited bythe whole world. However, attempts by researchers are underway for the same. Atthis moment best vaccine is prevention of contact from other fellow humans.
Are there any drugs available for COVID-19 prevention or treatment ?
For prevention The National Taskforce for COVID-19 by ICMRrecently recommended the use ofhydroxy-chloroquine (HCQS) for prophylaxis in : asymptomatic healthcare workerscaring Covid cases or asymptomatic household contacts of laboratory confirmedcases. It may be noted that HCQS is already in Indian market as add-on therapyfor type 2 diabetes. HCQs 400 mg twice aday on Day 1, followed by 400 mg once weekly for next 3 weeks; to be taken withmeals Exclusion/contraindications. The drug is not recommended for prophylaxisin children under 15 years of age, cases of retinopathy, known hypersensitivityto hydroxychloroquine, 4-aminoquinoline compounds. It has to be prescribed by aregistered medical practitioner.
According to the World Health Organization (WHO), theCenters for Disease Control and Prevention (CDC), and the U.S. Food and DrugAdministration (FDA), there are currently no medications or vaccines proven tobe effective for the treatment or prevention of the 2019 severe acuterespiratory syndrome coronavirus 2. China International Exchange and PromotiveAssociation for Medical and Health Care (CPAM) recommends use of lopinavir;ritonavir [2 capsule (dose undefined) by mouth twice daily] in combination withnebulized alfa-interferon (5 million units in Sterile Water for Injectioninhaled twice daily). Sofosbuvir in combination with ribavirin is alsopotential agent. WHO is going to start aintervention trial (SOLIDARITY Trial) at multiple center by this weekendwhereby antiviral drugs like Remdesivir combination of Lopinavir and Ritonavir with or with Inf-Gamma and Hydroxychloroquine (HCQS).
Prof Mohammad Ashraf Ganie, Endocrinology and MetabolismSKIMS Srinagar