Mumbai’s Covid-19 death rate or case fatality rate, while showing marginal decline, remains firmly above the state and national death rates. On October 1, the city’s case fatality rate stood at 4.1%, even as the rate for the state was at 2.64% and the national figure was 1.53%. Among the reasons cited for the high death rate are late hospitalisation and a reluctance to get tested even though testing norms were eased in July to allow anybody to get tested without prescription.
To address this, Mumbai’s civic body, the Municipal Corporation of Greater Mumbai, on the advice of the state Covid task force, has begun door to door screening of all residents for fever, oxygen levels and co-morbidities.
Scroll.in asked Dr Sanjay Oak, chief of the Maharashtra Covid task force what he thought were the reasons for the high mortality rate and how the state has adapted new data and information while formulating treatment plans and non-medical interventions.
What have been the reasons for Mumbai’s high death rate?
Mumbai’s death rate is coming down as you can ascertain by the latest figures.
Even so, the death rate in Mumbai continues to be higher than the death rate at the national level. What is the analysis of the task force?
The reasons for the high death rate in Mumbai are:
1 Too many occupants in too small places. [Mumbai is the second-most densely populated city in the world, with 31,700 people per square kilometre. Within Mumbai, there are pockets of very high density clusters.]
2 Failure of social distancing
3 People are still not wearing masks.
4 There is a tendency to avoid getting tested, medical consultation and getting admitted in hospital.
5 Ineffective lockdowns.
In hindsight, was it a mistake to include smaller hospitals/ nursing homes as Covid facilities? After all these places lack the ability to provide critical care. Most don’t have intensivists, even ICUs.
No. Small hospitals with more than 50 beds, having five-plus ICU beds and at least two consultants with two ventilators must be included .
It has been three month since the administration launched Mission Save Lives aimed at bringing the death rate down below 3%. What specific intervention appears to have worked, in your analysis.
Door-to-door analysis, Sp02 [oxygen saturation] monitoring, identifying high-risk cases, taking vulnerable people to CCUs [Covid Care Units], admissions in field hospitals, timely intervention of Remedesvir and HFNCs [high-flow nasal cannula oxygen noninvasive ventilation].
Looking back, what would you identify as mistakes?
The Task Force did not make any mistakes. Its executions were suboptimal. We should do more testing, tracking, tracing and treating.
Could you elaborate? What do you mean by suboptimal execution?
There were delays in setting up and equipping field units. There were delays in implementing lockdowns in districts. There was a massive movement of the labour force.
What about contact tracing [originally a key non-medical tool in containing the pandemic]? Has it been happening as scrupulously as it should ?
One should trace and track down 1:18 contacts. We did far less.
Are you unhappy with the levels of testing in Maharashtra ? What is the ideal and why is the state testing less than states like Tamil Nadu?
We should be very aggressive in testing.
We know more about the virus today than we did yesterday, so the treatment protocol should also be constantly evolving. Give us a sense of how the task force sets the treatment protocol. What is the data you use, what are the inputs that you seek from physicians treating patients for Covid-19?
Inputs are obtained from world literature and trials that get published. All the task force members are virtually connected to journals 24 hours a day, 365 days a year. We also talk to ICU intensivists from hospitals inland as well as overseas. We connect with all districts through zoom link and get their perspectives . The data is updated and evolving as always.
Why then, despite evidence to the contrary, drugs such as Hydroxychloroquine, Ivermectin, Azithromycin, Doxycycline, Favipiravir, Itolizumab [a monoclonal antibody] and convalescent plasma continue to be endorsed by the task force? There is either no evidence or lack of proven benefits.
The task force is well aware of evidence coming from both ends about the drugs that you mentioned. However clinical observation reveals that these drugs are useful in a case-to-case manner. They have inconspicuous side effects if chosen for the right age group. Therefore HCQs is recommended for people under 55 who do not have cardiac issues whereas other drugs are to be chosen on a case-to-case basis.
How does the task force arrive at recommendations? How does it grade the published evidence and use it in the recommendations.
Review and peer discussions on articles from Lancet, NEJM [New England Journal of Medicine], Science, BMJ [British Medical Journal] etc, confirming its applicability to our society and its usefulness. Only those things which are evidence based , useful and less harmful are suggested as guidelines.
But at least half a dozen papers published in highly reputed journals – the New England Journal of Medicine, Annals of Internal Medicine and JAMA [Journal of the American Medical Association] – have shown that Hydroxychloroquine does not reduce the risk of healthcare providers of acquiring infections, nor does it have a role in mild, moderate or severe Covid. Why then has the task force failed to take it off from its recommendations?
The Task Force has left the choice to individual health workers. It is very difficult to deprive people and especially in case of HCWs [health care workers] if there are even fringe benefits of the drugs. The task force, right in its early advisories, had expressed limitations of its usefulness.
The committee auditing Covid-19 deaths in Maharashtra had reportedly cautioned that the use of HCQ [hydroxychloroquine] in combination with the antibiotic azithromycin for confirmed Covid-19 patients could likely cause cardiac toxicity. As recently as last week cardiologists and critical care experts have spoken of how HCQ by itself or given in combination with azithromycin, may cause irregular heartbeats.
Heartbeats are lowered .i.e. bradycardia is noted but cardiac arrhythmias are not reported. No deaths have been reported due to HCQ. And the task force has already pointed out this side effect.
Now that the randomised controlled trial conducted by ICMR [Indian Council for Medical Research] has shown that plasma does not work in Covid , where does the Task force place plasma in Covid-19 management? Shouldn’t the task force categorically say that plasma has no proven benefits and de-emphasise the wide publicity conferred to plasma by politicians, media etc.
The Task Force is of the opinion that plasma definitely works when instituted in the early phase of the disease. It has a special place for those patients who have hepatic derangements and hence can not receive Remedesvir. These are clinical observations.
Why does the Task Force only have specialists from Mumbai.? Particularly now, with Covid-19 cases surging in rural Maharashtra, wouldn’t it have served the cause better to also have had specialists working in the rural areas?
The Task Force has consultants from various super-specialities, which eventually work in Covid ICU care. They represent public as well as private sector hospitals. They are authorities in the respective field and have representations at National and World Fora. The task force regularly talks with all respected consultants and teachers from Pune, Nagpur, Aurangabad , Jalna and various other places. Therefore please understand that the Task Force is more a meeting of analytical minds rather than regional representations by rule.
How does the task force carry out its own audit of whether hospitals are following the task force recommendations?
The Task Force talks to hospitals and doctors at even district and subdistrict places in Maharashtra. Task force is basically an advisory body and doctors are expected to follow prudent advice.