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Good news from India’s Covid battle — fatality rate is down 50% since May

Experts say the fall in India’s Covid fatality rate can be credited to wider testing in the country and a better understanding about how the disease needs to be dealt with. 

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New Delhi: The relief about India’s dipping daily Covid-19 case tally is palpable but there is another metric that charts India’s coronavirus trajectory better — the case fatality rate (CFR). 

The CFR is a measure for the share of Covid-19 patients who succumb to the disease. In the last six months, India’s CFR has fallen by more than 50 per cent — to 1.49 per cent on 1 November from 3.28 per cent on 1 May. 

Source: Union Health Ministry data
Source: Union Health Ministry data

This is a result, experts say, of wider testing in the country and a better understanding about how the disease needs to be dealt with. 

The medical fraternity’s experience with the disease has led them to prioritise oxygen administration over invasive ventilators when a patient’s oxygen saturation dips below 94 per cent, and the testing regimen has been eased to offer a wider testing bouquet and on-demand testing in most states. 

The panic of the early days has been replaced by better awareness, not just among doctors and health policymakers but even the general public, who now understand the importance of keeping a pulse oximeter at home and the need to rush to a hospital if readings dip, experts say.


Also Read: India’s Covid data like counting potholes under streetlights. There are far more in the dark


Lesson learnt

Dr Vinod Paul, member (health) in the government think-tank Niti Ayog and one of the key architects of the central government’s Covid strategy, said there are two aspects to India’s falling CFR. 

“Firstly, over time, we understood the pathophysiology of the disease better and realised what works, what does not. We realised the importance of early use of high-flow oxygen, use of non-invasive ventilation, early use of anticoagulants, timely use of dexamethasone (anti-inflammatory steroid) and the importance of overall supportive care, especially for those with comorbidities,” he added. 

“The second part is that the system understood the importance of early mobilisation of patients, especially when there is a fall in oxygen saturation levels. The importance of reducing delays at home, delays waiting for an ambulance, and third delay (delay that happens after a patient reaches the hospital),” he said, pointing out that “people also got conscious and pulse oximeters became a household item”. 

Most importantly, he added, “the state and central governments and professional medical bodies mounted a lot of effort to educate each other about the disease”.

He cited Delhi as an example, saying the realisation that 70 per cent of the deaths were happening in the first 72 hours spurred a massive effort to prepare the system to minimise casualties, and awareness campaigns to ensure people did not take too long to shift to a hospital. 

“We realised that, while intubating a patient and putting him on a ventilator is a complex and dangerous process, high-flow oxygen is very effective too. The focus shifted on early care and simple modalities,” Paul said. 


Also Read: India has bent the Covid graph but one large state is surprisingly the worst-performer


‘The denominator has changed’

Another important thing that has happened since the beginning of the pandemic is that India is testing much more and the testing protocol has been relaxed to allow on-demand testing, said Dr K. Srinath Reddy, president of the Public Health Foundation of India (PHFI) and member of the government’s Covid-19 task force.  

In the early days, even though the WHO directive was “test test test”, concerns about resource availability had led India to largely restrict testing to symptomatic people and to people who were first-degree contacts of Covid patients. 

Since June, in steps, the testing regimen has been relaxed and rapid antigen tests introduced as an alternative to RT-PCR for quicker, cheaper tests in containment zones and hospital settings. Many states have since incorporated the rapid antigen tests in areas outside these limits too.

“The denominator (number of total cases) is much bigger now. Earlier, we were testing only symptomatic (people) and contacts, but with more liberal testing, we are now catching a lot of asymptomatic and mild cases, too, that would earlier have escaped the net,” said Reddy. 

“These people will also have better outcomes, so the numerator (number of deaths) does not increase as much. Thus, the CFR has gone down. The patient management has improved, too, but there is a need to examine these two factors separately.” 

According to Reddy, to understand the contribution of better patient management, “there is a need to look at the outcomes only in hospitalised patients”. 

Talking about the shift in treatment approach since the initial days of the pandemic, he said, “The big changes have been oxygen steroids and home isolation that took the pressure off the system and spared the beds for patients more in need of hospitalisation.” 

Dr Gagandeep Kang, a professor in the Department of Gastrointestinal Sciences at Christian Medical College, Vellore, and a former member of a government Covid-19 vaccine research panel (disbanded in April), agreed. 

“We started, in the early days of the epidemic, to use what we had learnt from other severe respiratory distress management protocols. Since then, we have changed practice as we learn more and more. We recognised that we should delay invasive ventilation as much as possible, we should start patients on supplemental oxygen as soon as saturation decreases below 94 per cent, we should put patients in the prone position to breathe more easily, we have learnt whom to give anticoagulants, when to start steroids, etc etc,” she said.

“Each of these changes helps us improve outcomes and save more lives.”


Also Read: Best for India to vaccinate health staff first to beat Covid, health expert Devi Sridhar says


Overcoming staff shortage

Dr Anjan Trikha, professor of anaesthesiology, pain and critical care at AIIMS, offered the same assessment. “We started in the early days of the epidemic with limited knowledge about the disease. We tried to treat patients with our experience from managing other forms of viral pneumonia — H1N1, SARS, MERS etc. Since then, we have changed our treatment practices,” he said. 

“Now, we have learnt when and how much of anticoagulants, steroids, remdesivir are to be given. Further, we have realised when and which few patients may show improvement with modalities like plasma. Each of these changes helps us improve outcomes and save more lives,” he added.

Over the past few months, hospitals have also learnt to deal with staff crunch to better optimise the abilities of the employees available. 

“I am talking not just about doctors but also healthcare workers. I have been saying from the beginning that this is the real issue. In March, all of us were novices, we did not know too much. Even now, we do not know how the patient will be a year later because we have not seen it. We are wiser, testing more, picking up early. But what is all that without manpower? It is like buying Rafale jets without having fighter pilots to fly them,” Trikha said.

Hospitals, he added, retrained people to deal with the shortages to some extent. “Gadgets are fine but people are needed to operate them. We did some handholding of the staff. Healthcare workers were shifted from non-critical areas to somewhat change the situation.”


Also Read: India’s Covid R value steady at 0.88, but many states see rise in infection rates


 

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