COVID-19 India



COVID-19: India Report, May 23, 2020, Mumbai

Basant Misra
1st Vice President, WFNS
Head, Departments of Surgery, Neurosurgery & Gamma Knife Radiosurgery Hinduja National Hospital, Mumbai

COVID-19 Global Pandemic
Since the discovery of the first case of COVID-19 in Wuhan, China, on 17th November 2019 in a 55-year-old gentleman, there have been unprecedented changes in the entire world in a matter of six months. The World Health Organization (WHO) declared COVID-19 a pandemic on 11th March 2020. Since then the COVID-19 pandemic has disrupted all aspects of society globally and Neurosurgery is no exception.

COVID-19 India
India is the largest democracy in the world with an estimated population of 1.4 billion (https://countrymeters.info/en/India). The first case of COVID-19 was reported in India on 30th January 2020 and the count as of 23rd May was 125,101 cases with 3,720 deaths and 51,784 cured (https://www.worldometers.info/coronavirus/). The state of Maharashtra had the most cases and deaths, 45,582 and 1,517 respectively (https://www.mygov.in/covid-19). Mumbai has been the worst hit city, with more than 27,251 cases. The total number of cases in India is probably much higher as testing is limited. However, it is significant to note that this death rate is much less compared to some European and USA cities. The Prime Minister (PM) of India announced a nationwide lockdown on 22nd March which ended on 17th May - barring a few states like Maharashtra where it was extended until 31st May owing to a large number of cases in these provinces. India was one of the first countries that air-lifted its stranded citizens from Wuhan, Maldives, Iran and Italy in the first half of this pandemic, following which all commercial air travel was suspended and remains suspended until the time of this report.

In support of the global pandemic, India sent 15 tons of masks, gloves and other emergency medical equipment to China. On 13th March, the PM allocated ₹74 crores (US $10 millions) of funds classified as COVID-19 Emergency Fund for the South Asian Association for Regional Cooperation (SAARC) countries. Indian government exported consignments of hydroxychloroquine tablets to USA, Brazil, Spain, France, UK, Germany, Australia, the Gulf countries and the SAARC neighbors.

On a technological front, ‘Aarogya Setu’ mobile app was developed and launched by the government to help contact tracing and contain the spread – each and every citizen was urged to install the app on his/her device. This app allowed easier tracing of patients. It also gave latest updates on the number of cases in the adjoining neighborhood and enabled Bluetooth beeps when a COVID-19-positive patient with an installed app on his/her phone is nearby. For administrative purposes and implementation of law and order, the entire nation was divided into three zones, i.e. red, orange and green based on the highest number of cases, a few cases and no reported cases within the last 21 days, respectively.

National Healthcare Strategy
The healthcare system has been under significant challenge to accommodate the rising cases of COVID-19. We at Hinduja National Hospital, Mumbai, were among the first in the country to formulate protocols for COVID-19 admissions and their management. A dedicated COVID-19 ICU, isolation ward and suspect wards were set up in a separate building – the COVID-19 facility. Holding wards and holding ICUs were earmarked for all patients getting admitted to the main hospital (non-COVID-19 facility) pending the swab report. A policy was made and a protocol followed on how to admit patients, their testing and further management. Meanwhile, all elective surgeries were stopped and only emergency surgeries and COVID-19 patients were catered to. Three major public tertiary care centres in Mumbai were converted to dedicated COVID-19 hospitals. In addition to hospitals which were primarily reserved for sicker patients with COVID-19, the government set up multiple centres for the admission of COVID patients with mild symptoms (fever and respiratory complaints). Many public schools, public halls, railway carriages, hotels and lodges were converted to isolation facilities. Additionally, major facilities have been erected on open grounds, comprising 1000 beds with an expansion capacity to 5000 beds for COVID-19 admissions (Figure 1). A mobile testing unit was initiated to do mass screening in overcrowded areas (Figure 2). All medical health professionals age < 55 years were urged to join COVID-19 duties in dedicated COVID-19 facilities.

COVID-19 & Neurosurgery Care
COVID-19 has not spared Neurosurgery, resulting in significant changes in the management of cases. The author on 7th April 2020 formulated guidelines for surgical procedures suspending all elective surgeries in all surgical sections. Prioritization of procedures was done with essential life-saving procedures. Surgery to arrest progression of disease was allowed to be undertaken after careful consideration of risk to benefit ratio. Surgeries that were associated with prolonged morbidity, poor prognosis and requiring prolonged ICU care and would further strain the available facilities and block beds for COVID-19 cases were deferred if possible. Wherever possible, day care was advised. The allocation of staff was as follows: clinical rounds on rotation by consultants, on call neurosurgery resident as per schedule for clinical work and emergency or, one senior and one junior resident for a scheduled surgery (Figure 3).

All patients undergoing surgery underwent an infectious disease risk stratification for COVID-19 by eliciting a detailed history (Figure 4). A fixed protocol was followed before the patient could be deemed fit for surgery (Figure 5). Based on the time frame, surgeries were classified as Emergency, Urgency and Priority. Emergency surgeries comprised those to be operated within 6 hours of admission (through ER). The patient was treated as a suspect case of COVID-19, i.e. admission to isolation ward/ICU, operation in dedicated COVID-19 OR with full personal protective equipment (PPE) and post-operatively in the isolation until test results were available. Preoperatively swab as well as chest CT was done. Urgent surgeries comprise those that can be postponed a maximum of 7-10 days. These patients underwent COVID-19 screening and were further subclassified into (1) low risk (score less than 6) with the surgery performed under universal precautions, (2) high risk (score more than 6) which necessitated an ID consultation and the patient being admitted in isolation and steps followed as per Figure 5. Priority cases comprise those that cannot be postponed beyond 4 weeks.

Surgery-specific guidelines that were adapted were as follows:

  1. Routine cranial and spinal neurosurgical procedures were deemed to be safe with routine face (N95 mask) and eye protection.
  2. Cranial and spinal drilling to include adequate irrigation of drills to prevent aerosol formation.
  3. Utmost care to be taken with anterior skull base procedures which might breach an air sinus - full PPE was recommended.
  4. Endonasal procedures carry significant risk: Use of debriders/drills within the nasal cavity produce a droplet aerosol which is highly dangerous. In those patients with sellar, suprasellar tumors/pathologies where surgery cannot be deferred, an alternate modality like microscope-based trans-sphenoidal surgery using non-drill techniques. PPE should be employed by all theatre staff and care taken with nasal secretions. Microscopic endonasal instead of endoscopic endonasal may be preferred.

Training & Teaching During COVID 19
Clinical work-load and surgical exposure has reduced dramatically with the significant reduction of non-emergency cases, greatly affecting resident training. A puzzling statistic has been the reduction in emergency admissions and surgery across all specialties as experienced by many colleagues across the continents. To continue academic activity and teaching, we have a weekly schedule to review 10 subjects. All residents write on these subjects and the papers are evaluated by the Faculty. We also have periodic webinars on a variety of subjects (complimentary registration to all) that have been very popular. I am grateful for the contributions by many faculty both national and international (including Prof Franco Servadei, WFNS President). We hope to continue this initiative after the COVID-19 pandemic has resolved.

Final Thoughts
None of us has seen a catastrophe of such magnitude in our lifetime. Many have known or lost somebody to this virus. It is a humbling experience to realize how insignificant we are in the scheme of things of this universe. The COVID-19 pandemic has taught me to treasure and value the time I have and thank the almighty for the free air I breathe and marvel at the beauty of nature which I did not have time to cherish!
I am optimistic that this will also pass and I will back to 12 hours a day routine soon!

Figure 1: A train compartment converted for COVID-19 care.

 

Figure 2: Mobile testing unit for COVID-19.

 

Figure 3: Neurosurgery resident assignments during COVID-19.

 

Figure 4: Infectious disease risk stratification for COVID-19.

 

Figure 5: Protocol for COVID-19.

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