COVID-19 Special
Interactions in know each other’s identity before available. If a physical examination
Teleophthalmology the consult. The doctor should verify is critical for consultation then an in-
yy Patient to Doctor and confirm patient’s identity by person consult is more appropriate
yy Caregiver to Doctor name, age, address, email ID, phone which could be examination by another
yy Doctor to Doctor number, registered ID or any other doctor/ Health Worker or an office
yy Health Worker to Doctor identification deemed appropriate. visit. The information required may
The practitioner should be verified by vary from one doctor to another. All
Figure 3: Interactions in Teleophthalmology Council of the area of registration. For patient records including case history,
issuing a prescription the age of the investigation reports, images, etc. are to
Figure 4: Teleophthalmology Type of patient should be expressly asked for be maintained by the practitioner.
Consults and recorded seeking age proof in case
Which Mode to Use and What of doubt. For minors the consultation First Consult and Follow-Up
Precautions to Take? should be conducted after confirming Consult
The professional judgment of the the age in presence of an adult whose Two types of patient consultations first
doctor is the guiding principle for all identity should be ascertained and consult and follow-up consult have
telemedicine consultations. The doctor recorded. It is recommended the been defined.
will decide whether a technology-based doctor should inform the patient his/
consultation is sufficient or an in-person her name and qualifications at the First Consult refers to patient consulting
review is needed. They would decide beginning of the consultation for for the first time or more than 6 months
the appropriate mode/technologies telemedicine. The registration number after previous consultation, or for a
available and their adequacy for from the State Medical Council/MCI different health condition. Follow-
reaching a diagnosis and end the consult should be mentioned prominently Up Consult(s) refers to the patient
with health education or counseling or on prescriptions, website, electronic consulting the same doctor within 6
medication. Every patient/case/medical communication (WhatsApp/ email months of his/her previous in-person
condition is unique and can present in etc.) and receipts etc. given to his/her consultation for continuation of care of
myriad forms. There are limitations patients. All modes Video, Audio or Text the same health condition. However, if
to the technology. The doctor should (chat, images, messaging, email, fax etc.) new symptoms appear or the symptoms
uphold the same standard of care as in can be used. Depending on the situation are not of same health condition then
an in-person consultation within the the doctor is permitted to decide the it will not be considered a follow
constraints imposed by telemedicine. best technology to use to diagnose and up. The doctor can provide Health
The patient and the doctor should treat using his/her best judgment. Education, Counseling and/or prescribe
Medicines. The doctor can give health
A Brief Note on Consent in promotion, disease prevention and
Telemedicine: counseling messages related to diet,
Patient consent can be implied or explicit physical activity, cessation of smoking,
in telemedicine. If the patient initiates contagious infections, immunizations,
the telemedicine consultation then the exercises, hygiene practices, mosquito
consent is implied. If ,however,a Health control , food restrictions, do’s and don’t’s
worker, Doctor or a Caregiver initiates for drugs, proper use of a hearing aid,
a Telemedicine consultation then an home physiotherapy, etc. Prescribing
expressed explicit consent is needed. An medications via telemedicine
explicit consent can be recorded in any consultation is left to professional
form like an email, text or audio/video discretion of the doctor entailing the
message. Patient can state his/her intent same professional accountability as in
on phone/video to the doctor. Never the traditional in-person consult. The
forget to record this in patient records. protocol to diagnose and prescribe for
telemedicine consult remains the same
Teleconsultation versus In- for as for in-person consult and that too
Person Consultation ONLY when doctor is satisfied that he/
If the doctor feels that the information she has gathered adequate and relevant
is inadequate additional information information about the patient’s medical
can be sought in real time or asked condition. Prescribing Medicines
to be shared later through email/ without an appropriate diagnosis/
text. The Consultation process should provisional diagnosis is considered
be resumed once the information is professional misconduct.
www.dosonline.org/dos-times DOS Times - Volume 25, Number 4, January-February 2020 49
COVID-19 Special
50 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
Professional Norms and Medical Learning have not been permitted to o Local Ophthalmological drops
Ethics counsel the patients or prescribe any such as: Ciprofloxacillin for
medicines. Technology Platform is Conjunctivitis, etc
Professional norms for protecting obligated to have a consumer redressal
patient privacy and confidentiality mechanism. In case of violation the o Local Ear Drops such as:
as per IMC Act and the medical ethics technology platform can be blacklisted. Clotrimazole ear drops, drops for
in force shall be binding. IT Act, Data ear wax etc..
protection and privacy laws or any The Medicines That Can be
applicable rules notified from time Prescribed o Follow-up consult for above
to time for protecting patient privacy medications
and confidentiality and regarding the The detailed list is still being drawn up
handling and transfer of such personal but indicative list has been given in the yy Follow-up medications for chronic
information regarding the patient shall guidelines as reproduced below illnesses for ‘re-fill’ (on any mode of
be binding. However, the doctor will consultation) such as medications
not be held responsible for breach of List O counter for
confidentiality if data is compromised yy Common over-the o Hypertension: Enalapril, Atenolol
by a technology breach or by a person etc
other than the doctor. Misuse of patient medications such as o Diabetes: Metformin,
images and data will attract penalties. Glibenclamide etc
Soliciting patients for telemedicine o Antipyretics: Paracetamol o Asthma: Salmetrol inhaler etc
through any advertisements or o Etc
inducements is not permitted. o Cough Supplements: Lozenges,
List B
The doctor needs to maintain the log o Cough/ Common- yy On follow-up, medications
or record of Telemedicine interaction cold medications (such
(e.g. Phone logs, email records, chat/ as combinations of prescribed as ‘Add-on’ to ongoing
text record, video interaction logs Acetylcysteine, Ammonium chronic medications to optimize
etc.),Patient records, reports, documents, Chloride, Guaifensen, management such as for
images, diagnostics, data etc. (Digital or Ambroxol, Bromhexene, hypertension: Eg, add-on of Thiazide
non-Digital), prescription shared with Dextromethorphan) diuretic with Atenolol
the patient o Diabetes: Addition of Sitagliptin
o ORS Packets
Telemedicine consultations should be to Metformin
treated like in-person consultations for o Syrup Zinc o Etc
fees and a receipt/invoice for providing
telemedicine- based consultation o Supplements: Iron & Folic Acid Corresponding Author:
should be issued. tablets, Vitamin D, Calcium
supplements Dr. Jatinder Bali
Technology platforms (mobile apps, MS (Ophth), STT (Pediatric Ophth) PGIMER,
websites etc.) giving telemedicine o Etc WHO Fellow VR, MBA (Operations Research)
services are obligated to ensure that NPC, North Delhi Municipal Corporation, Delhi
consumers and doctors duly registered yy Medications notified by Government
with national medical councils or of India in case from time to time on
respective state medical councils are an Emergency basis
allowed to interlink on the platform.
They should do due diligence before o Such as Chloroquine for Malaria
listing any doctor on the portal with control for a specific endemic
details on the name, qualification region, when notified by
and registration number and contact Government
details. In case of non-compliance the
technology platform will inform the List A
regulator which may take appropriate yy First Consult Medications (Diagnosis
action. Technology platforms based
on Artificial Intelligence/Machine done on video mode of consultation)
such as
o Ointments/Lotion for
skin ailments: Ointments
Clotrimazole, Mupirocin,
Calamine Lotion, Benzyl
Benzoate Lotion etc
www.dosonline.org/dos-times DOS Times - Volume 25, Number 4, January-February 2020 51
COVID-19 Special
The Impact of COVID-19 Pandemic
on Young Ophthalmologists
Diva Kant Misra
MBBS, DO, DNB, MNAMS, FVRS
Consultant Vitreoretina, Eye-Q Super Speciality Eye Hospital, Lucknow
General Secretary, Young Ophthalmologists Society of India - YOSI
Chief Editor, Young Ophthalmologists Times - YO Times
As I write this article, governments and are at high risk of getting infected Though there is no substitute to the
around the world are fighting a themselves and will have to undergo a actual interaction with a patient,
great battle against the pandemic period of isolation as well. examining them and operating on
caused by a highly infectious disease. them, but most of the institutes have
Healthcare workers are right in the There is a huge burden on these switched to e-learning platforms and
center of this crisis, risking their lives young doctors to fight the pandemic regular classes are being conducted
and fighting disease and death. Many and at the same time exercise enough through ZOOM and other similar
ophthalmologists are at the forefront as caution so that they do not spread it platforms. Apart from this,there are
well and are facing a time of great stress, to their patients, colleagues and most many online resources, webinars and
fear and uncertainty. importantly their families. The shortage surgeries available on YouTube and
of Personal Protective Equipments it’s the perfect time to enhance one’s
I conducted an anonymous google (PPE) and incidents of violent attacks on knowledge while sitting at home..
form-based interview amongst young doctors simply compound the problem.
ophthalmologists in different phases of “I had just learnt the basics of PHACO
their training and careers before writing It is extremely important for a young surgery and due to COVID19 surgeries
this article and I realized all of them are ophthalmologist involved in active have stopped. I will be shifting to a new
being affected in a different manner. duty to follow proper guidelines, be safe place in 2 months and had this period to
I have quoted them verbatim in this and keep fighting.
article but their identities have not learn”
been revealed as it was an anonymous Ophthalmologist In Training
interview. “There is No exposure to OPD or OT. The Those who have recently completed
fellowships or small term training
Ophthalmologist at the three-year tenure would end when it’s programs and were planning to join
forefront supposed to, nonetheless.” practice, are concerned that by the
“..posted not only at the eye emergency but time elective surgeries start their newly
One joins an ophthalmic training acquired skill might fade due to this
also later in the rapid response team of program with hopes of learning the discontinuity. They should be reassured
COVID19. Been posted in isolation with fine art of ophthalmic diagnosis and that a couple of months will not impact
friends from other specialities. Feels good to surgery. Bed side clinical teaching and the skill they have acquired and things
serve the nation, I love my nation and am supervised surgical training are pillars will come back to them when they get
ready to serve it till my last breath. Miss of good training. the opportunity.
my family and fiancé who is in isolation
The COVID19 pandemic has forced Ophthalmologist ? Not yet!
ward duty.” the Medical Colleges and Teaching “I was supposed to give my DNB practical
Institutes to suspend active teaching,
We should salute our young warriors defer elective surgeries and routine exam in march and would have been
who are at the frontline and are OPDs. The residents are doing great ready for fellowship interviews from April
usually the first point of contact with service to the nation by being at the onwards. Everything has been stalled and
all the ophthalmic emergencies that forefront. But, this discontinuity from
the hospitals are catering to. Some active learning has impacted their we are left in a limbo.”
are involved in active COVID duty growth as an ophthalmologist.
There is a segment of residents who
have completed their training and are
52 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
awaiting exams, specially the DNB I have a job, but will I lose it? financial burden and find it difficult
residents who had recently cleared “It’s unprecedented and scary. As a young to sustain the practice. There have
their theory exams and were awaiting ophthalmologist employed with a private been some relaxations given by the
allotment of practical centres and government, the banks and there have
dates. With the extended lockdown, centre it makes me quite unsure of the been communications sent by All
restriction of travel, overburdened future and if things would actually resume India Ophthalmic Society to various
examination centres and no clear companies to help out ophthalmologists
directives from the authorities there back to normal post the lockdown?” in private practice. Some are seeking
seems to be a long wait for these financial help from family, friends and
distressed residents to complete the last Ophthalmologists who have recently senior ophthalmologists to help them
lap of their training. joined jobs, have been warned about pay tide through these troubled times.
cuts and they are scared that there might All of us have to stay strong, be safe and
Yes, there is a lot of uncertainty, but be layoffs. One needs to understand utilize the time well. Tough times don’t
this time can be utilized in identifying that these are unprecedented times and last, But tough people do!
and working on one’s shortcomings. the employers are also going through
Exam going residents can form focused a tough time. There will be certain Corresponding Author:
study groups to stay oriented. They can measures that the organizations will
benefit greatly from the various online take to keep things running and viable. Dr. Diva Kant Misra
ophthalmic resources and plenty of Consultant Vitreoretina,
webinars that are happening right now. It is a good time to support your Eye-Q Super Speciality Eye Hospital,
It is really important for them to be organization and make yourself Lucknow
patient and stay focused. indispensable. This can be done by
multitasking and adopting roles beyond
Ophthalmologist, but no job! your core competencies. Make yourself
“The entire hiring process of corporate useful and help the organization to get
hospitals and otherwise has come to a back on its feet. It is also important
standstill. Sitting at home for close to 2 to stay connected and maintain
months without work/salary is quite communication with the key people in
stressful.” the organization. Have realistic growth
expectations, realign your targets with
Those who have recently finished their the uncertainty of the present scenario
training and were searching for jobs are and prepare yourself for the new
in a fix. Indeed, it is a difficult time to normal.
find a job in the present scenario and
this might be the case for some time to Young practitioners
come. But, things will eventually settle “My practice has been affected severely.
down and normalcy will be restored. I had invested all my money in my new
practice and am under huge stress due to
So, It is important to be patient and keep mounting EMIs, Rents and staff salaries.
connecting with potential employers It will be very difficult for me to sustain
so that they can get in touch with
you whenever they resume normal my practice and my family if this continues
functioning. It might also be a good for long”
time to enhance your knowledge while
you wait for the right opportunity. Young ophthalmologists who have
recently invested in a new practice
might find themselves under huge
www.dosonline.org/dos-times DOS Times - Volume 25, Number 4, January-February 2020 53
COVID-19 Special
Medico-legal Advisory on
COVID-19 Pandemic
Mohamed Asif Ibrahime MD, Rohit Saxena MD, Rajesh Sinha MD, DNB, FRCS
474, Dr. R.P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS), New Delhi
In view of covid-19 pandemic, the Union 6. Taking care of oneself is of utmost while treating patients. No suspected
Cabinet Secretary announced on 11th importance. COVID-19 patient should be turned
March 2020 that all the States and Union away from any hospital and the
Territories should invoke Section 2 of 7. It is a legal, ethical and moral admission of any such patient should be
the Epidemic Diseases Act, 1897. This obligation of the hospital that it must notified to NCDC or IDSP immediately.
gave legal backing, a statutory support ensure the safety of its personnels.
to the directions issued by the Union The full advisory is given below:
health ministry, the State governments Duties, Responsibilities and
and the local authorities to contain the Precautions of Professional Indoor facilities: surgeries
corona pandemic which had already bodies, Associations of doctors yy Non-essential elective
been declared as a notifiable disease. and hospitals
Therefore, two laws are applicable to should be postponed.
everyone including the doctors, patients 1. It would be difficult for an individual
and the general public: The Epidemics doctor to be aware about the yy Some beds should be set apart and
Diseases Act, 1897 and The Indian Penal various directives coming from prepared for creating isolation
Code, 1860 (described below). the authorities. Therefore the facilities in every public and private
associations have to be pro-active hospital.
Duties, Responsibilities and to ensure that the doctors are aware
Precautions of Doctors & of these directives. Failure to follow yy All hospitals should mobilize
Hospitals these could result in adverse legal additional resources including
consequences. masks, gloves and personal
1. All doctors must keep themselves protection equipment. Healthcare
aware of the regulations that are 2. The Professional bodies should personnel should be trained for
coming from the State and local disseminate information to all its dealing with any foreseeable
authorities. members so that they would be emergencies.
aware of the regulations or directives
2. Any person who is a suspect must be coming from authorities. yy All doctors, nurses and support staff
managed according to the expertise, in different specialities, including
qualification and the facilities The Ministry of Health and Family pre and para clinical departments,
available with the doctor and the Welfare has issued an advisory for should be mobilized and trained in
hospital. hospitals and medical education infection prevention and control
institutions in view of COVID-19. The practices.
3. Ensure that the referred patients ministry has asked hospitals to postpone
report to the other facility. non-essential elective surgeries. All yy Hospitals must procure sufficient
doctors, nurses, and support staff in numbers of ventilators and high
4. Report to the concern authorities different specialties, including pre flow oxygen masks in preparation
if any patient refuses to follow the and para clinical departments, should for future requirements.
medical advice or acts dangerously. be mobilised and trained in infection
prevention and control practices. Non- yy All hospitals must ensure that they
5. Law is to protect you so don’t fear essential audits of hospitals may be have adequate trained manpower
it. Irrespective of the consequences, postponed. All hospitals must provide and resource pools for ventilator/
anyaction that has been taken in good treatment free of cost to any medical ICU care.
faith is immune from legal action personnel who picks up infection
under section 4 of the Epidemics Act. yy Hospitals may ensure that stable
patients are discharged as early
as possible while further new
54 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
admissions (of stable patients) are to maintain regular communication Doctors are still accountable for the
also restricted. with the students and teachers decisions they make. They’re expected
through electronic means and keep to do their best in extraordinary
yy Number of patients’ attendants them fully informed so that there circumstances to deliver good care and
should be strictly restricted to ‘one’ is no anxiety amongst the students, follow proper guidance. They should
only. teachers and parents. treat with dignity and respect, listen to
the concerns and discuss options with
Information Education yy Institutions are also requested to the patients.
Communication (IEC) Activities: notify help-line numbers/emails
which students can access for their The patients can help by:
yy Patients must be educated about queries.
cough etiquette, Do’s and Dont’s, 1. Following the directions given by
proper use of masks instead of yy All unauthorized/ authorized shops the authorities.
using them indiscriminately and (excluding pharmacies) and eateries
inefficiently, and personal hygiene. in the vicinity of hospitals should be 2. Those who have been advised
Hospitals should put up posters compulsorily shut. isolation or quarantine must strictly
etc. to increase awareness amongst abide to it. Anyone breaching it is
patients on Do’s and Don’ts. yy Leave of all kinds (except under liable to be prosecuted. One must
regarding COVID 19. emergency and unavoidable remember that the legal action can
circumstances) may be cancelled be initiated even after months and
yy Patients must be counselled against immediately. the result could be imprisonment of
attaching any kind of stigma to 2 years.
Corona virus patients or to facilities Outpatient Department (OPD):
where such patients are admitted. yy All patients may be advised not to 3. Being understanding of the pressure
They must be made aware that on doctors and healthcare staff
quick disclosure of symptoms end come for routine visits to the OPD if
undergoing testing if advised is the it can be avoided or postponed. Advice for everyone
surest way of battling COV1D 19. Everyone must stay at home to help
yy OPDs may be organised in such a stop the spread of corona virus. You
Administrative: manner that patients exhibiting should only leave your home for limited
yy Non-essential audits of hospitals by flu like symptoms are attended purposes:
separately from other patients
various regulators and accreditation and spaced out so as to avoid • Shopping for basic necessities like
agencies may be postponed. overcrowding. food and medicine, which must be as
infrequent as possible
yy All hospitals must provide treatment yy Patients suffering from chronic
free of cost to any medical personnel diseases and minor elements may be • Any medical need or to escape risk of
who picks up infection while advised to utilise OPDs in primary/ injury or harm, or to provide care or
treating patients. secondary cam facilities rather than to help a vulnerable person
crowding tertiary care centres.
yy No suspected COVID 19 patient • Travelling for work purposes, but
should be turned away from any yy Pharmacy counters may be increased only where work cannot be done
hospital and the admission of any and queue management systems to from home
such patient should be notified to be followed by engaging Indian Red
NCDC or IDSP immediately. Cross/ NDRP volunteers. Even when doing all these activities,
one should minimise time spent
yy Similarly, all pneumonia patients Duties, Responsibilities and outside home and ensure sticking to
must also be notified to NCDC or Precautions of Patients/Public social distancing.
IDSP so that they can be tested for Doctors, and the whole healthcare team,
COV1D 19. are under intense pressure. The impact Advice for people at most risk
of COVID-19 pandemic means they These people need extra steps to avoid
yy Hospitals to ensure social distancing might need to deliver care in different contracting the virus. This is known as
in their premises. ways. They are trying to do their best for shielding. This includes persons with
all the patients they treat and to protect organ transplant, leukaemia patients,
yy All ongoing examinations may be the health of the public. severe lung condition like cystic
rescheduled. fibrosis or severe COPD, patients on
Much non-urgent care will be delayed, immunosuppressive therapy, pregnant
yy All evaluation work may be while members of the healthcare team females and having serious heart
rescheduled. will likely work in different ways to conditions. These people should:
their usual practice.
yy All Educational Institutions and
Examination Boards are requested
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COVID-19 Special
yy Stay at homes at all times Section 3. Penalty knows of the order which he disobeys,
Any person disobeying any regulation and that his disobedience produces, or
yy Adhere to distancing even with or order made under this Act shall be is likely to produce, harm.
people at home deemed to have committed an offence Section 269. Negligent act likely
punishable under section 188 of the to spread infection of disease
Please note Indian Penal Code (45 of 1860). dangerous to life
Section 188 of the Penal Code prescribes Whoever unlawfully or negligently
punishment of upto 6 months and Section 4. Protection to persons does any act which is, and which he
fine of upto Rupees One Thousand acting under Act knows or has reason to believe to be,
for not following government orders. No suit or other legal proceeding shall likely to spread the infection of any
(discussed below) lie against any person for anything done disease dangerous to life, shall be
or in good faith intended to be done punished with imprisonment of either
There are 2 more provisions of the Indian under this Act. description for a term which may
Penal Code that could be appropriate extend to six months, or with fine, or
for the current scenario. Section 270 The Indian Penal Code, 1860 with both.
and Section 269 - for spreading an Section 270. Malignant act likely
infectious disease either knowingly or Section 188. Disobedience to order to spread infection of disease
unknowingly respectively. The former duly promulgated by public servant dangerous to life
attracts imprisonment for a term which Whoever, knowing that, by an order Whoever malignantly does any act
may extend up to two years, or with promulgated by a public servant which is, and which he knows or has
fine, or with both, the latter attracts lawfully empowered to promulgate reason to believe to be, likely to spread
imprisonment for a term which may such order, he is directed to abstain the infection of any disease dangerous
extend up to six months, or with fine, or from a certain act, or to take certain to life, shall be punished with
with both. (discussed below) order with certain property in his imprisonment of either description for
possession or under his management, a term which may extend to two years,
The Epidemics Diseases Act, 1897 disobeys such direction, shall, if such or with fine, or with both.
Section 2.(1). Power to take special disobedience causes or tends to cause
measures and prescribe regulations obstruction, annoyance or injury, or Corresponding Author:
as to dangerous epidemic disease risk of obstruction, annoyance or injury,
When at any time the State Government to any person lawfully employed, be Mohamed Asif Ibrahime MD
is satisfied that the State or any part punished with simple imprisonment Sr Resident
thereof is visited by, or threatened with, for a term which may extend to one Dr. R.P. Centre for Ophthalmic Sciences,
an outbreak of any dangerous epidemic month or with fine which may extend to AIIMS, New Delhi
disease, the State Government, if it two hundred rupees, or with both; and
thinks that the ordinary provisions of if such disobedience causes or trends
the law for the time being in force are to cause danger to human life, health
insufficient for the purpose, may take, or safety, or causes or tends to cause a
or require or empower any person to riot or affray, shall be punished with
take, such measures and, by public imprisonment of either description for
notice, prescribe such temporary a term which may extend to six months,
regulations to be observed by the public or with fine which may extend to one
or by any person or class of persons as thousand rupees, or with both.
it shall deem necessary to prevent the
outbreak of such disease or the spread Explanation
thereof, and may determine in what It is not necessary that the offender
manner and by whom any expenses should intend to produce harm or
incurred (including compensation if contemplate his disobedience as likely
any) shall be defrayed. to produce harm. It is sufficient, that he
56 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
Post COVID-19 Scenario – Let’s Plan
A New Beginning
Jatinder Singh Bhalla, MS, DNB, MNAMS; Shayana Bhumbla, MS
Department of Ophthalmology, Deen Dayal Upadhyay Hospital, New Delhi
25th March 2020 – the day the nation- what kind of havoc it can wreck – 14 day yy Infrared thermometers to be made
wide lockdown for 21 days in view quarantine of the entire staff, temporary available at the entry.
of the novel coronavirus COVID-19 sealing of the hospital, maybe legal
began. Ever since then the life of every repercussions & unnecessary & Figure 2: Infrared thermometer, N95 mask,
citizen has changed. The lives of all unjustified bad name to the hospital. nitrile gloves
Ophthalmologists have also changed. To regulate the inflow of patients in the yy Encourage hand washing by all
As a lot of us could foresee on 14th April OPD becomes our responsibility since a
the lockdown was further extended lot of our patients are above 60 years of patients after entering or give
till 3rd May. While most are finding it age. sanitizers at the entry.
inconvenient, some are embracing the yy Encourage cashless transactions.
change & turning it into opportunity. How to make a difference in yy Put a linen cover on the consultation
your OPD table and clean it with soap & water
However, the big question when and daily & sundry it.
how can we restart our practice still yy Ask everyone to take prior yy If not a linen cover, clean the glass/
lurks at the back of the mind. Sure, the appointments over the phone plastic/wood surface of the table &
virus is here to stay but someday it’ll chair with sanitizer on a daily basis –
become history & we would’ve come yy Ask them to send pictures of all before starting OPD & after finishing
out of this phase. previous records, so that the number OPD.
of visits can be reduced.
One point of view is that We have Figure 3: Hand Sanitizers
to reopen somehow, someday. We yy Welcome teleconsulting & yy Everyone to wear long aprons &
can’t remain in shutdown mode for teleophthalmology.
indefinite period. If we remain shut wash them & sundry them on a daily
down, we destroy society as we know it. yy Take history of travel, any ILI basis.
If we allow the virus to run willy nilly, (influenza like illness), any positive yy Put a placard “avoid touching your
we will destroy our healthcare system contact in family over the phone face” right where you can see it.
and the economy with it.
yy Provide masks, gloves to all staff at
Let us better become busy trying to plan the very least. N95 if feasible. CDC
our future than to be busy just worrying. recommended the option of reusing
masks “may need to be considered
When the lockdown ends, when when shortages exist”1
we would have flattened the curve,
when herd immunity would have yy Social distancing to be strictly
started developing, we all can expect practiced by staff, patients.
a sudden surge of all the patients who
had been waiting for a visit to the yy Examining ophthalmologist to wear
ophthalmologist all this while. We a face shield.
have to prepare ourselves & our staff
for that stage NOW. If you don’t follow Figure 1:
the precautions religiously during that Face Sheild
period & imagine if even one person
in your entire team becomes positive,
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COVID-19 Special
yy Avoid contact lens use for a little yy Eyecare- amsler grid test app is yy All surgeries must be day care
while. Encourage daily cleaning of available free of cost for all AMD unless the medical conditions or the
spectacles with soap, water. patients to track their presence at Govt of India rules (e.g. for plaque
home. More apps like odysight are brachytherapy) strictly mandate
yy The protective shields everyone put also available.4 admission.6
on their slit lamps during the COVID
era, PLEASE do not take them down Figure 6: “Eyecare- Amsler grid test” app yy Consent discussion with patients
later. Continue using them & clean it yy Consider creating plans, policies, must cover the risk of COVID-19
with 70% alcohol every day. exposure and the potential
and procedures to manage issues consequences.
yy Encourage, educate glaucoma such as staff absenteeism due to
patients about portable visual field- issues with childcare, ill family yy If readily available and practical,
testing options. a free application members, shutdowns of mass transit, surgical patients should be tested
on iPad “VISUAL FIELD EASY” can or personal illness pre-operatively for COVID-19.
be used. A portable, fast (3 min/eye), Despite taking HCQs, all
effective procedure for detecting ophthalmologists should take yy Routine screening Chest X-ray before
moderate and advanced visual field all necessary precautions as the each surgery, if possible or whoever
loss.2 effectivity of HCQs is yet to be can afford
established. treat every patient
Figure 4: “Visual field easy” app as if you’re treating a coved yy Avoid surgeries off-hours or with an
yy Eye Snellen app for iPad can be used positive patient & take all possible incomplete team
precautions.
for visual acuity testing at home.3 How to make a difference in yy Faculty or senior fellows or senior
your OT residents should preferably do the
Figure 5: “Eye snellen” app yy Clean the entire OPD, OT, waiting surgery – quick and safe surgery is
area with warm water, 1% sodium warranted
hypochlorite DAILY every 2 hourly if
possible. Bleaching solution/powder yy Choose the quickest possible surgical
is easily available at all local shops procedure
& economical. Instruct the cleaning
staff how to prepare 1% sodium yy Try to avoid GA unless mandatory
hypochlorite.5
yy Prefer topical anesthesia over local
Figure 7: Sodium hypochlorite solution anesthesia
yy Operating room team members to be
fitted with an N-95 respirator mask
and wear a gown, gloves, and eye
protection.
yy All universal precautions as usual
yy Minimum number of staff in the OT
yy Stop positive ventilation in theatre
during procedure and for at least 20
minutes after the patient has left
theatre
yy Aerosol generating procedures
such as intubation, extubating, bag
masking, electrocautery should be
done by anesthetist and the surgeon
while wearing full personnel
protective equipment
yy Bare minimum staff should be
present when the patients are
intubated and extubated in the OT
yy No two patients should be handled
together. There should be a 20-min
time out between each surgery
yy Protocol based disinfection of the OT
should be done after each surgical
procedure
58 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
yy All HCW coming in direct patient “online lectures” happening all around yy All teachers, professors to pay
contact and ophthalmologists the globe are just a part of training in personal attention to not just
should be encouraged to take a soap ophthalmology. academics post COVID but also the
bath at once they reach home. mental health of these young minds.
The clinics- general ophthalmology
yy All suspected or infected patients & speciality clinics & OT are the most yy Keep online lectures, seminars,
must be managed with the maximum crucial part of ophthalmology training. journal clubs, case presentations (of
attention. OPDs are functioning with minimum old cases) more frequently now.
staff at the moment. With less teachers
yy Transfers must be protected. & less patients the learning of any yy Excellent time to discuss case based
resident in ophthalmology OPD has videos, pictures from a senior’s
yy Infected patients must be moved gone for a toss atleast for 3-4 months, personal archive.
as little as possible through the maybe more who knows.
hospital. yy Time to discuss pictures in retina
Training for ophthalmology OT in itself atlas.
yy Transfer routes must be precisely is very challenging during residency.
planned and be as short as possible. Add to it no OT for 4-6 months, duties Figure 9: Retina atlas
in flu clinics & quarantine facilities yy A lot of home exercises can be advised
yy Disposable material should be & isolation ward & it’ll give you less
preferred. competent ophthalmologists due for practicing sutures, practicing
to lack of surgical exposure & more rhexis on apps
yy Minimal material should be used for stressed, panic striken residents due to yy Whichever institutes have
each intervention. the fear of contracting the coronavirus simulators, should let the residents
while working in flu clinics & isolation use them now.
yy Transport personnel should be ward. yy Cataract Surgery (iPad) and Cataract
the same from transport origin to Mobile (iPhone) are free apps that
destination. Taking care of the future aim to bring the amazing experience
ophthalmologists is the responsibility of cataract surgery to beginners.
yy Once the patient has entered, the OR of the institution. Ofcourse nothing matches doing
doors must be closed. surgery in a human eye but these
yy Making a customized time table for apps can help them get an idea of
yy Operators (i.e., surgeon, anesthetist, all residents NOW is important so how to go about the direction of
nurses, technicians) should enter the that there learning suffers less post instruments.
OR in a timely manner to minimize COVID.
exposure to infected patients.
yy Extra time should be devoted to them
yy Personnel involved in the in the coming year in clinics, OT.
intervention should not leave the OR
during the procedure. yy Eye handbook is a free app for both
testing patients & academic purposes
yy High OR air exchange cycles are for residents.
recommended (>25 exchanges/h).
yy Clinical documentation must
remain outside the OR
yy At the end of each intervention
all disposable materials must be
disposed of and all surfaces and
electromedical devices accurately
cleaned and disinfected.
yy PPE must be removed and disposed
of outside the OR in dedicated
doffing areas ensuring the virus is
not transmitted to the healthcare
worker.
yy OR and surrounding donning/
doffing areas must be sanitized as
soon as possible after each procedure.
Academics Figure 8: “Eye handbook” app Figure 10: “Cataract mobile” app
There are correspondence courses in
a lot of branches but not medicine.
There’s a reason behind that. The
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COVID-19 Special
Figure 11: Cataract surgery simulator taught about disaster management as a 5. Guidelines for disinfection of
yy Open Ophthalmology is a meta- part of their curriculum. quarantine facility (for COVID-19)
https://ncdc.gov.in/WriteReadData/
school in which lecturers from Conclusion l892s/89168637271584172711.pdf
different departments have access For all ophthalmologists it’s important (accessed on 14.04.2020 1900 hrs)
to ophthalmology residents to stay extra cautious since most of our
everywhere. patients are more than 60 years of age. 6. AIOS operational guidelines for
Future Disasters/Pandemics The pandemic, however long it takes, ophthalmic practice during COVID 19
Disasters are as old as human history. will end for sure. preparing ourselves outbreak. https://aios.org/pdf/AIOS-
Knowing that it wouldn’t be completely for the post COVID era now is what any Operational-Guidelines-COVID19.pdf
wrong to say the entire world was visionary would do. (accessed on April 14.04.2020, 1830 hrs)
unprepared for the COVID 19 pandemic
& so were you & I. If anything this yy Don’t underestimate the power of Corresponding Author:
pandemic has taught us we must learn taking care of yourself & your team.
from this mistake & prepare ourselves Dr. Shayana Bhumbla
for both natural & man made disasters yy Give a serious thought to cutting Department of Ophthalmology,
in future. back on expenditures for at least a Deen Dayal Upadhyay Hospital,
year. PRIORITISE. New Delhi
Figure 12: Disaster management cycle
Also MCI, NBE may consider that all yy Preserving financial and human
young ophthalmologists should be resources is crucial & a preventive
approach is mandatory.
While we are in lockdown we need
to make a plan to bounce back &
devise a roadmap to recovery in the
future. To quote the famous saying:
“people don’t remember what you
say but they remember how you
made them feel“. Given the difficult
situation everyone is going through,
you can be sure that your patients
will continue remembering how you
treat them now.
References
1. Decontamination and reuse of filtering
facepiece respirators. https://www.
cdc.gov/coronavirus/2019-ncov/
hcp/ppe-strategy/decontamination-
reuse-respirators.html (accesssed on
14.04.2020, 1830 hrs)
2. Johnson CA, Thapa S, George Kong
YX, Robin al. performance of an ipad
application to detect moderate and
advanced visual field loss in nepal. Am J
Ophthalmol 2017;182:147-154
3. accuracy of snellen apps. https://www.
aao.org/eyenet/article/accuracy-of-
snellen-apps (accessed on 14.04.2020,
1830 hrs)
4. Brucker, J., Bhatia, V., Sahel, J. et al.
Odysight: A Mobile Medical Application
Designed for Remote Monitoring—A
Prospective Study Comparison with
Standard Clinical Eye Tests. Ophthalmol
Ther 8, 461–476 (2019).
60 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
Financial Implications for
Ophthalmologists due to
COVID-19 Outbreak
J.S. Bhalla1 (MS, DNB, MNAMS), Prathama Sarkar1 (MS, DNB), Amit Mehtani1 (MS, DNB),
Col. Aditi Dusaj2 (MS), Pooja Nikas1 (DNB resident)
1Department of Ophthalmology, Deen Dayal Upadhyay Hospital, New Delhi
2Department of Ophthalmology, Sri Balaji Action Medical Institute, New Delhi
The world is undergoing profound The financial aspect for the yy COVID 19 involvement: Category
social, emotional and economic change ophthalmologist in private D in hospital management
as a result of the COVID-19 pandemic. setups (Clinical specialities with limited
How we adapt to the problems that yy Routine surgeries deferred which responsibility for critically sick
we face will have an earnest effect patients)
on society. Ophthalmologists have a entails financial burden on small and
shared responsibility to protect our big centers alike. yy Postgraduate teaching: Stalled
patients, most of whom are elderly, yy The health of the staff: Skeletal staff yy Emergency OT protocols: Only
while making every effort to preserve is deployed keeping in mind the
their vision. However, COVID-19 has social distancing. emergency cases
far fetched implications economically yy Equipping the center: Ensuring
than what is visible now. social distancing norms for the It is very much required to understand
patients. that though, we, ophthalmologists
The burden yy Equipment modifications: The may not be the front-line warriors in
The ongoing lockdown with limited slit lamp shields, avoidance of the fight against COVID-19, but we do
ophthalmological services available ophthalmoscopy and tonometry. belong to the group which is indirectly
(emergency) has implications for the yy Personal protection: More use of N95 taking the brunt of it. We have been
patients and the ophthalmologists alike. masks and PPE requirement classified as Category D in the line of
As has been advised by the government yy Educational up-gradation: Learning management for the COVID patients.
of India to the patients that all non- ophthalmic manifestations of While attending asymptomatic
emergent visits and elective surgeries COVID 19 patients, who may be potential carriers
should be deferred, it entails visual yy Staff salary: Continuation of salary as of the coronavirus, keeps all of us at the
morbidity to the patients and financial before equal stake of getting exposed.
morbidity to the ophthalmologists alike. yy Emergency OT protocols: Only
emergency cases The way forward
The American Academy of Personal and staff protection:
Ophthalmology has laid down The financial aspect for the To carry out the bare minimum
some of the principles of organizing ophthalmologist in government essential services in OPD and OT, the
ophthalmology services during setups physician need to protect themselves,
COVID-19 which include: postponing yy Personal protection: More use of staff members and the patients. To do
all routine ophthalmic surgeries in so, one needs to procure the Personal
private and government centers; N95 masks, gloves, glasses and PPE Protective Equipment (PPE), N-95
making efforts to decompress their requirement masks, time-to-time sanitization of
waiting areas and consider alternatives yy Equipment modifications: The slit the equipments and the concerned
such as encouraging patients to wait in lamp shields, avoidance of direct area. An N-95 mask is not only needed
other locations and shutting down all ophthalmoscopy and to-nometry. for the ophthalmologist, but also
non-essential activities. for the optometrist, staff members,
receptionists and the patients. Hence,
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COVID-19 Special
hospitals/centers with generally thin The OPD and OT protocols: ARMD, Diabetic retinopathy, etc.)
operating margins, have to be front- The challenge not only remains until represent about 60% of the cash flow
loaded with the needed resources for the distribution of the protective kits of the average general ophthalmology
the pandemic, while developing critical to the patient. The main challenge practice. COVID 19 tends to have as
plans to protect their workers. All these begins after that. Everything is needed much as 8 percent mortality rate among
additional requirements are further to be re-sanitized after every single senior citizens on the current trajectory.
digging the hole of financial burden use.1 For ex-ample, the slit lamp is to If 8% of 60% of the business goes away
deeper. be properly wiped with Clorox brand permanently, that is a nearly 5% drop
In today’s scenario, every patient is products (e.g., disinfecting wipes, in cash flow. Since most costs are fixed,
concerned about the sanitization of the multi-surface cleaner + bleach, clean up that translates to a 10% drop in profits.
center and so are the practitioners too. cleaner + bleach), Lysol brand products
The cost price of attending a patient (e.g., professional disinfectant spray, The paradigm shift
incurred by the center has also gone up. clean and fresh multi-surface cleaner, Earlier patients insisted on putting
When a patient comes for the visit, not disinfectant max cover mist) or Purell premium IOLs (Toric lenses, multifocal
only he is provided with the high-end professional surface disinfectant lenses, trifocal lenses, EDOF lenses, etc.),
masks, but also with sanitizers, head wipes, the tonometer if used should but now, due to the financial crunch,
caps and shoe covers. Hence, if we sum it be disinfected with 70% alcohol and patients may be inclined towards the
up, the additional cost is approximately allowed to dry in room air, etc. Hence, regular IOLs. Patients may start opting
Rs. 200 - 300/- per patient borne by the the concerned area is to be properly out of Femto-assisted cataract surgery
doctor for the patient’s safety. disinfected after every patient, which too. To prevent a burning hole in their
consumes a substantial amount of pockets, patients themselves might
Figure 1: n-95 mask time. The total time taken for every start refraining from various surgeries,
patient has now increased by 40-50%. until and unless very much required.
Figure 2: Personal protective equipment Therefore, if earlier 3 patients were The wave of refractive surgeries (LASIK/
attended in 1 hour, it has now become SMILE/ CONTURA) may decrease,
3 patients/1.5 hours. Considering the the cosmetic surgeries (pterygium
same amount of patients to be seen surgeries/ entropion/ ectropion
per day in OPD, the working hour of surgeries, etc.) also may end up taking
the practitioner increases by 4-5 hours/ a back seat. All these will be adding
day. On similar grounds, the duty hours up to the burden on the shoulders
of the staff and other involved people of ophthalmologists to sustain the
also increase. Thus, there is a constant marginal profit at least from the center.
knock on the increment of pay-package
for these staff members, which has to be The entrepreneurs
incurred by the practitioner. According to Rashesh Shah, chairman,
Edelweiss Group, says: “COVID-19 has
Since, patients with refractive errors come at a very bad time — on the back
are avoiding visits, optometrists too of three years of the economic crunch.”
are finding it difficult to make the basic It has also come at the fag end of a
minimum, day by day. The glasses, financial year. “The last quarter is very
frames of the glasses are just piling up crucial for all businesses in India,” he
in the inventory. says. A lot of investments and client and
payment transactions typically happen
As per the laid guidelines, routine in the last quarter. Loan repayment has
surgeries have been deferred become a challenge for most workers
indefinitely. Only the urgent cases are and centers. Many start-up centers are
taken up. This has reduced the number under great stress now-adays. Though
of patients per surgeon per day. Though the time period of paying the interest
the number of patients per OT has has increased, at the same time the
reduced, the cost required to function amount of interest is also increasing.
the OT has remained the same. In short, Without any major source of income,
handling the price per patient incurred it’s only the expenditure which has
by the center has shot up. increased for them.
One2 of the studies has shown that In the United States, recently,
senior citizens (with cataract, glaucoma,
62 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
Coronavirus Aid, Relief and Economic follow-ups, Telemedicine may be the rental costs to your real estate
Security Act (CARES) has been signed practiced. partnership, you can generate some
on March 27, 2020.3 According to this yy Consultation fee for Telemedicine extra savings, bringing down the cost
act, the IRA contribution deadline has consultation may be charged by so it’s only enough to cover your loan
been ex-tended. Employee retention online payment modes like PayPal, payments. One may also request the
credit is been given i.e. employers BHIM, Paytm, UPI. etc. following:
whose operations were fully or partially yy Reduce the stock of office/center yy Rent to be reevaluated on a month-
suspended due to coronavirus related inventory.
shut down order or whose gross receipts yy Reduce staffing at clinics to balance to-month basis.
declined by more than 50% have a the number of patients. yy Rent to be temporarily reduced to
new tax benefit if they continue to yy Remove all automated roles and
pay employees. If NOL (net operating delegate them to an employee (i.e. cover only the debt service of the real
losses), ie. deductions are greater than confirmations of appointment). estate partnership’s loan.
the income generated from operating Support multi-tasking. yy Three to six months of rent deferral,
a business, it may be used to reduce yy Plan to support, utilize and deploy to be repaid over a set period of time.
taxable income in a future tax year. This staff to maintain services and to yy One may appeal for Force Majeure4
slightly relieves the private centers there cover gaps. (under Sections 32 and 56, of the
from the monetary burden. However, in yy Make rotations and contingency Indian Contract Act, 1872), where
India there is no such provision yet. plans with 1st, 2nd, 3rd tier teams to the party can be excused from the
cover as staff go off, including for on- contract on account of COVID-19
Conferences and meetings call. being declared as a pandemic.
yy Think about how non-clinical staff
Many regional, national and can be trained and used to support Consent and declaration
International Ophthalmological outpatient clinical care. One thing which remains the most
conferences which were scheduled yy Stop any accounts payable on important of all is taking the consent
during this period, have been cancelled, invoices where possible. from the patient for the fol-lowing;
with large number of losses being yy Identify any vendor leniency (e.g., to prevent oneself from contracting
incurred by the Organizing committees extended terms, discounts). infection and also to prevent from
& Trading partners. yy Identify repair costs renegotiable getting into legal hassles:
with vendors. yy Self- declaration of no history of any
Infection spares none! yy Place hold on capital purchases.
yy Change the inventory levels for all contact with COVID positive patient
As ophthalmologists work close to clinical supplies and drugs based on or a travel history. (Form 1)
the patient, they have high chances the projected number of patients. yy For the treatment during the period
of getting affected by the aeresols. If yy IOLs inventory to be checked with of COVID-19 pandemic. (Form 2)
the ophthalmologist gets infected the assigned company.
unknowingly, it may spread to the yy Retina practices should consider Conclusion
other co-workers and the family anti-VEGF medication volume and Although COVID-19 poses a major
members too. The practitioner may current inventory and supplies if problem for the global healthcare
need to quarantine himself, there will applicable. Anticipate that many system, practicing physician themselves
be loss of working hours and moreover, injection patients won’t come to the face a particular set of issues. They
the reputation of the centre also gets practice due to comorbidities. need to manage their patients’ urgent
on stake. Similarly, if the patient being yy Retina practices should also monitor needs, while still handling their
treated is infected, these consequences the availability of inventory and employees during a major crisis. We
may happen. All of these circumstances necessary supplies and contact are affected in ophthalmology because
will ultimately add up to the financial local health departments for any most of our patients are geriatric and,
crisis. assistance. sadly, they are the most vulnerable
patients susceptible to virus. The key
The Ophthalmological If you own your practice real estate and to our success is to limit exposure and
modifications and paring the still own your practice, by reducing continue our vigilant action plan to stay
losses abreast of health guidelines as they are
released. At the same time, not to stress
Though damage is there, few too much about the finances. Think of
precautions may be taken which can long term profit margins rather than
curtail the expenses to a bit, even if short term goals.
temporary. These include:
yy To reduce the physical mode of
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COVID-19 Special
References impacts-on-private-practice-a-thought- Corresponding Author:
experiment) (Accessed on 13.04.2020;
1. Lai THT, Tang EWH, Chau SKY, Fung 10:30pm) Dr. Prathama Sarkar
KSC, Li KKW. Stepping up infection Department of Ophthalmology
control measures in ophthalmology 3. CARES Act. https://www.congress.gov/ Deen Dayal Upadhyay Hospital
during the novel coronavirus outbreak: bill/116th-congress/senate-bill/3548/ New Delhi -110064
an experience from Hong Kong. Grae-fes text?q=product+update.) (Accessed on
Arch Clin Exp Ophthalmol. 2020 Mar 3. 13.04.2020; 10:30 pm)
2. Pinto John. Anticipating, mitigating 4. Ghosh Sugata. How coronavirus
coronavirus impacts on private may cause legal wran-gles. (https://
practice: A thought experi-ment. economictimes.indiatimes.com/
Ocular Surgery News U.S. Edition, April news/politics-and-nation/how-
10, 2020. (https://www.healio.com/ coronavirus-may-cause-legal-wrangles/
ophthalmology/practice-management/ articleshow/74815141.cms?from=mdr)
news/print/ocular-surgery-news/ (Accessed on: 13.04.2020; 10:30pm)
anticipating-mitigating-coronavirus-
64 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
Acute Psychological Effects in the
Times of COVID-19 Pandemic
Gagan Hans1, Novy Gupte2, Abdul Faheem3, Dewang Angmo4
1Assistant Professor, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
2Clinical Research Officer (WHO), Department of Paediatrics, VMMC & Safdarjung Hospital, New Delhi
3Junior Resident, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
4Assistant Professor, Department of Ophthalmology, All India Institute of Medical Sciences, New Delhi
Abstract: The emergence of COVID-19 infection caused by coronavirus is one of the worst humanitarian crises in decades which
is going to have wide spread and long-lasting psychological effects. The rapid transmission rates of COVID-19 necessitated
lockdowns as means of social distancing to stop the chain of transmission and preventing overburdening the health care
systems in many countries. The resulting psychological distress experienced by different subgroups of the population are
likely to be different based on their vulnerabilities. Poor socioeconomic status, loss of employment, limited access to essential
supplies, special support needs, duration of lockdown, infection fears, inadequate information, comorbid medical conditions
and advance age could all be possible determinants of these psychological sequelae. The protection of specially vulnerable
groups including health care workers should be a top priority in current situation. Measures like simple and clear information,
minimum necessary period of lockdown, adequate supply of essentials, protection of employment and financial assistance to
the poor will go a long way in minimising these negative psychological effects.
On March 24, 2020 Government of to stop the chain of transmission and and daily wager workers in the private
India ordered a nationwide lockdown of preventing overburdening the health and unorganised sector has led them to
entire 1.3 billion population of India for care system. This situation has the walk hundreds of kilometres to reach
21 days which is unprecedented in the potential to lead to a number of acute their native places and in the process
history both in its scale and magnitude. and chronic psychological effects in jeopardise the quarantine. They are
It is a preventative strategy to stop the the affected populations. However, currently experiencing extreme anxiety
transmission of coronavirus (COVID-19) the current situation is unprecedented and worry about their ability to sustain
pandemic in India. Similar measures and available literature about the themselves during the prolonged period
have been implemented throughout the psychologicalimpactofthequarantineis of lockdown. Financial loss because of
world to contain this deadly pandemic. drawn from small groups of individuals quarantine has been shown to produce
Quarantine is different from isolation under quarantine.2 Thus, extrapolation negative psychological sequelae
in that it implies the separation and of these findings to the current situation that can be long lasting.2 Evidence
restriction of the movement of people is difficult but nevertheless these can suggests that the financial loss during
deemed to have been potentially serve as guiding principles based on quarantine can be a risk factor for
exposed to a contagious disease to find which the preventive strategies can be subsequent development of symptoms
if they develop symptoms or not during planned to tide over current crisis. The of psychological disorders,3 anger and
the period of observation whereas psychological distress experienced by anxiety4 even months after the crisis is
isolation is used in terms of people different subgroups of the population over.
with a diagnosed contagious disease.1 are likely to be different based on
The unfolding of the events leading to their vulnerabilities. It is particularly Preliminary studies have established
complete lockdown was very rapid and relevant in a diverse country like India that the mortality rates of the COVID-19
caught most people off-guard and ill which has a significant percentage infection are disproportionately
prepared to deal with the crisis. of the population living in poor high in the elderly5 and those with
socioeconomic conditions. medical comorbidities. The important
The widespread and rapid transmission Loss of immediate employment during consideration for them is the ability
rates of COVID-19 necessitated lockdown for a large number of migrant to perform daily chores and the
lockdowns as means of social distancing availability of a family member or
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COVID-19 Special
caretaker in case of limited ambulation defined.8,9 If there is lack of clarity about in some of the early cases placed under
or higher dependency needs. In case of the levels of the risk involved from the supervised quarantine.
lack of a family member or caretaker authorities it leads to the participants
this subgroup of individuals is likely fearing the worst outcome.10 If there Health care workers are a highly
to have inadequate basic supplies of are perceived differences in the style, vulnerable group and may experience
food, water and other essentials. Having content and approach of the various high psychological distress during
inadequate supplies of essentials can be public health messages because of pandemic. Health care workers may
a continued source of frustration6 in the poor coordination of the involved have anxiety about their role in
the affected population and has been authorities it leads to widespread the management of suspected and
shown to be persistently associated with confusion among the population.11 In confirmed cases and whether they are
anxiety and anger at 4-6 months after addition, there may be multiple fake adequately trained for the same. Poor
quarantine.4 These individuals are also messages, reports and news articles work conditions without adequate
more likely to experience difficulties about the outbreak whose authenticity safety equipment leads to more chances
in their regular medical care, getting may be difficult to establish adding to of exposure, being placed under
prescriptions and regular supply of the confusion. quarantine and testing positive for the
medications6 compromising them For the individuals who have tested infection. A history of quarantine in
further. Also, the patients who are on positive and put under isolation, those the health workers is most important
medications for psychiatric conditions who have come in contact with a predictor of developing acute stress
run a high risk of relapse because of positive case and quarantined or have disorder, post-traumatic stress disorder,
above mentioned factors. Many people travelled overseas and subsequently low mood, anger, reporting exhaustion,
who are dependent on nicotine, alcohol put under quarantine the amount of anxiety, insomnia, irritability, poor
or other psychoactive symptoms may stress experienced is higher than the concentration, decreased work
experience acute withdrawal states of general population under lockdown. performance, and reluctance to work or
varying intensity depending on the There is a fear of their own health or considering resignation.12,16 Quarantine
substance use pattern. There is some fear of infecting others including family also predicts post-traumatic stress
evidence to suggest that history of members.10,12 They may have excessive disorder and alcohol dependence
psychiatric illness is associated with worry about any physical symptoms in health care workers after a long
persistent anxiety and anger even after potentially related to the infection even duration.16 In addition, the severity
4-6 months post pandemic.4 after the months of the quarantine.4 of the symptoms of post-traumatic
When the lockdown is enforced in Longer durations of quarantine stress disorder may be increased in
pandemic the worries of uncertain are related to poorer mental health the quarantined heath care workers
future are added to the existing fear of outcomes including post-traumatic as compared to the quarantined
contamination. This worry results in stress disorder, avoidance behaviours individuals from general population.
hoarding of the essential supplies and and anger.13,14 Owing to confinement They are also more likely to report
safety equipment. Social isolation is an in a much smaller spaces than those greater stigma, lost income and
identified health risk factor.7 The sense at home, lack of a usual routine and avoidance behaviours in addition to
of having no control over the situation reduced social contact leads to boredom, greater fear, anger, frustration, sadness,
can lead to poor sleep, depressive frustration and a sense of isolation worry, isolation and helplessness post
symptoms and difficulty managing the from the rest of the world.6,8 These quarantine. Health care workers are
emotional states. As people try adjusting symptoms may increase many folds if also likely to be more concerned about
to new routines and ways of life with the quarantine facility lacks adequate spreading infection to other in the
additional household responsibilities sanitation, proper food, comfortable surroundings and family members.17
interpersonal conflicts may escalate. housing and access to internet, or
In the day and age of near universal the participants don’t have access to Stigma resulting from quarantine
access to the social media and news means of connecting to the internet or isolation is another major area of
from varied sources, information like smartphones, tablets, computers concern at the time of the pandemics
processing may become a major source and chargers.4 Some predisposed and often health care workers are at the
of anxiety. It has been shown that poor individuals may also turn suicidal so a receiving end. Literature suggests that
information from the public health careful risk assessment may be needed the individuals or health care workers
authorities becomes a major stressor for before placing the individual under who have to undergo quarantine face
the individuals placed under quarantine supervised quarantine.15 Many of these more stigma as compared to the others.12
if the purpose of the quarantine and factors collectively or in isolation may This may not only be limited to the
actions needed to be taken are not well lead to individuals trying to escape neighbourhood or workplace but even
these quarantine facilities as happened in the household interpersonal tensions
may increase because of the nature of
66 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
work of health care providers.10 numbers should be established will go a long way in minimising these
for people who wish to seek more negative psychological effects.
It can be reasonably anticipated that information. A health care system
the psychological impact of this which can identify individuals who Key Messages
quarantine due to COVID-19 is going are more vulnerable including the yy Simple, clear and effective
to be wide spread, substantial and long elderly, people with high risk comorbid
lasting. However, the impact on various medical conditions and special needs information delivered uniformly
subgroups of the population is going to will help in issuing early warnings to from different sources is essential
be variable with most vulnerable being these people so that they can exercise to allay the fear of the people under
impacted the most. The resilience to the more caution and can be kept under quarantine.
stress may be dependent on a number of increased surveillance. Adequate yy Protection of specially vulnerable
determinants including socioeconomic supplies of essential commodities to groups including health care
condition, age, comorbid medical the quarantined areas with provisions workers should be a top priority in
conditions, pre-existing mental health for supplies in advance helps increase current situation.
conditions, length of the quarantine, confidence in the quarantined yy Adequate supplies of essential
food security, individual coping population that they will be able to commodities to the quarantined
strategies, family support and special overcome the crisis.19 The coordinating areas with provisions for supplies
needs. health agencies should be careful that in advance are necessary to prevent
they are issuing uniform instructions panic.
At an individual level establishing new to the people under quarantine and yy Duration of the quarantine should
work routines, exercising regularly and updating information on a regular be kept as minimum as possible
spending quality time with the family basis.11 Essential legislation may be based on the scientific reasoning of
can go a long way in minimising the mandatory to protect the employment the incubation period.
negative impacts of the quarantine of the workers during quarantine period
period. Judicious use of the social media along with financial assistance. References
with updates on the pandemic only 1. Centers for Disease Control and
from highly reliable sources only can Health care workers should have clarity
prevent the information overload and of their respective role and they should Prevention. Quarantine and isolation.
prevent an individual from becoming be supported by means of protective 2017. https://www.cdc.gov/quarantine/
overwhelmed with anxiety about equipment, special accommodation index.html (accessed March 30, 2020).
future course of events. For individuals near workplace which can allay their 2. Brooks SK, Webster RK, Smith LE, et al.
who are under quarantine or isolation fear of spreading infection to the family The psychological impact of quarantine
in monitored facilities having access members. Legislation may be essential and how to reduce it: rapid review of the
to reasonable amenities including a to protect the health care workers from evidence. Lancet 2020; 395: 912-20.
working internet connection with stigmatising attitudes in the society. 3. Mihashi M, Otsubo Y, Yinjuan X, et
means to access it is a way of keeping in Organisational support has been found al. Predictive factors of psychological
contact with the family members and to be highly protective of mental health disorder development during recovery
significant others which can reduce the during infectious disease outbreak and following SARS outbreak. Health
psychological impact of isolation. staff should be supported in all possible Psychol 2009; 28: 91–100.
ways to keep the morale high.20 4. Jeong H, Yim HW, Song Y-J, et al. Mental
To minimise the psychological impact health status of people isolated due
on the population the duration of the In conclusion, the psychological to Middle East respiratory syndrome.
quarantine should be kept as minimum sequelae of quarantine due to Epidemiol Health 2016; 38: e2016048.
as possible based on the scientific COVID-19 are going to be both acute 5. Liu K, Chen Y, Lin R, et al. Clinical
reasoning of the incubation periods and long term and are likely to pose features of COVID-19 in elderly patients:
of the pathogens as longer durations significant challenge. However, the A comparison with young and middle-
are associated with more negative impact of these psychologically aged patients. Journal of Infection 2020.
psychological consequences.13,17 The sequelae is intricately bound to the 6. Blendon RJ, Benson JM, DesRoches CM,
people should have free access to effective management of the current et al. The public’s response to severe
essential information regarding the crisis both at individual and collective acute respiratory syndrome in Toronto
pandemic by easily accessible means level. Measures like simple and clear and the United States. Clin Infect Dis
so that they can avoid catastrophic information, minimum necessary 2004; 38: 925–31.
appraisals based on limited information period of lockdown, adequate supply 7. Novotney A. Social isolation: it could
and readily understand the purpose of of essentials, protection of employment kill you. Monitor on Psychology.
quarantine.18 Telemedicine facilities and financial assistance to the poor American Psychological Association.
should be encouraged and helpline 2019; 50(5):32.
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8. Braunack-Mayer A, Tooher R, Collins 14. Marjanovic Z, Greenglass ER, Coffey S. 19. Manuell M-E, Cukor J. Mother Nature
JE, et al. Understanding the school The relevance of psychosocial variables versus human nature: public compliance
community’s response to school and working conditions in predicting with evacuation and quarantine.
closures during the H1N1 2009 influenza nurses’ coping strategies during the Disasters 2011; 35: 417–42.
pandemic. BMC Public Health 2013; 13: SARS crisis: an online questionnaire
344. survey. Int J Nurs Stud 2007; 44: 991–98. 20. Brooks SK, Dunn R, Amlôt R, et al. A
systematic, thematic review of social
9. Cava MA, Fay KE, Beanlands HJ, et 15. Barbisch D, Koenig KL, Shih FY. Is there and occupational factors associated with
al. The experience of quarantine for a case for quarantine? Perspectives from psychological outcomes in healthcare
individuals affected by SARS in Toronto. SARS to Ebola. Disaster Med Public employees during an infectious disease
Public Health Nurs 2005; 22: 398–406. Health Prep 2015; 9: 547–53. outbreak. J Occup Environ Med 2018; 60:
248–57.
10. Desclaux A, Badji D, Ndione AG, et 16. Wu P, Fang Y, Guan Z, et al. The
al. Accepted monitoring or endured psychological impact of the SARS Corresponding Author:
quarantine? Ebola contacts’ perceptions epidemic on hospital employees in
in Senegal. Soc Sci Med 2017; 178: 38–45. China: exposure, risk perception, and Dr. Gagan Hans
altruistic acceptance of risk. Can J Assistant Professor, Department of Psychiatry,
11. DiGiovanni C, Conley J, Chiu D, et al. Psychiatry 2009; 54: 302–11. All India Institute of Medical Sciences,
Factors influencing compliance with New Delhi
quarantine in Toronto during the 2003 17. Reynolds DL, Garay JR, Deamond SL,
SARS outbreak. Biosecur Bioterror 2004; et al. Understanding, compliance and
2: 265–72. psychological impact of the SARS
quarantine experience. Epidemiol Infect
12. Bai Y, Lin C-C, Lin C-Y, et al. Survey 2008; 136: 997–1007.
of stress reactions among health care
workers involved with the SARS 18. Rubin GJ, Harper S, Williams PD, et
outbreak. Psychiatr Serv 2004; 55: 1055– al. How to support staff deploying
57. on overseas humanitarian work: a
qualitative analysis of responder views
13. Hawryluck L, Gold WL, Robinson S, et al. about the 2014/15 West African Ebola
SARS control and psychological effects outbreak. Eur J Psychotraumatol 2016; 7:
of quarantine, Toronto, Canada. Emerg 30933.
Infect Dis 2004; 10: 1206–12.
68 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
Artificial Intelligence in Fight
Against COVID-19
Kanika Jain1, Suruchi Bhalla2
1Senior Resident, DDU Hospital, New Delhi
2Masters In Data Science Fellow, Faculty of Science & Technology, Macquarie University, Sydney, NSW, Australia
What is artificial intelligence? 1. Early warnings and alerts For example, China is using robots
Artificial intelligence (AI), also known It can warn of an upcoming epidemic to provide faster diagnostic checks,
as machine intelligence, is intelligence and Hangzhou city ambulances are
demonstrated by machines, in contrast and give us enough time to prepare. assisted by A.I. to speed through
to the natural intelligence displayed For example, BlueDot, a global traffic. China launched an app
by humans and animals. It is the study artificial intelligence database that helps people check if they
of “intelligent agents”: any device that company analyzes information have taken a flight or train with a
perceives its environment and takes from a multitude of sources and confirmed coronavirus patient. At
actions that maximize its chance of track over a hundred infectious the same time, China is using drones
successfully achieving its goals.1 diseases. On December 31st, 2019 to ensure residents are taking the
Blue Dot sent out a warning to its appropriate precautions.
Introduction on Coronavirus- customers to avoid Wuhan, ahead
COVID-19 of both the US Centers for Disease 4. Diagnosis and management of
Coronavirus disease (COVID-19) is Control and Prevention (CDC) and COVID-19
a new strain that was discovered in the World Health Organization
2019 and has not been previously (WHO). They also predicted where AI may provide useful input for fast
identified in humans. On 11th February other Asian city outbreaks could be, and accurate diagnosis of COVID-19,
2020, the WHO formally named the by analyzing traveler itineraries and in particular with an image-based
disease triggered by 2019-nCoV now flight paths. medical diagnosis. INFERVISION
better identified as SARS-CoV-2, as a Beijing-based AI company uses
coronavirus disease 2019 (COVID-19). 2. A.I. Can Speed Up Drug Discovery its algorithm to spot COVID-19 on
On 11th March 2020, WHO declared and Development images of the lung as distinct from
COVID-19 as a pandemic. As of 10th other respiratory infections.
April, 2020 more than 1.71 million A.I. can help us identify, develop, and
confirmed cases of COVID-19 have scale new treatments and vaccines 5. Drones deliver medical supplies,
been reported in over 210 countries and faster than ever before. The key to patrol public spaces, track non-
territories, resulting in approximately developing a vaccine is to be able to compliance to quarantine mandates,
103,000 deaths and 389,000 recoveries.2 rapidly and efficiently recreate the and for thermal imaging
Artificial intelligence (AI) can be useful virus’s genome sequence and build a
to recognize (diagnose), predict, and copy of the virus. 6. Robots sterilize, deliver food and
explain (treat) COVID-19 infections, supplies and perform other tasks
and help manage socio-economic For example- Deargen predicted that
impacts. Since the outbreak of the Atazanavir and Remdesivir are the In China, Pudu Technology deployed
pandemic, there has been a scramble most likely drugs to bind and block a its robots that are typically used in
to use and explore AI, and other data prominent protein on the outside of the catering industry to more than
analytic tools, for these purposes. SARS-CoV-2. Insilico Medicine, SRI 40 hospitals around the country.
Biosciences and Iktos, Benevolent
The ways artificial intelligence (AI) can AI are other AI based companies 7. Data Dashboards
help combat the pandemic are3,4: working in this regard. The tracking and forecasting of
3. A.I. May Help Minimize COVID-19 has caused the emergence
Fatality and Optimize Disease of an industry of data dashboards
Management that visualizes the pandemic. MIT
Technology Review rank the top
www.dosonline.org/dos-times DOS Times - Volume 25, Number 4, January-February 2020 69
COVID-19 Special
dashboards to be those of UpCode, • People flying to Hong Kong airport correct predictions for individuals
NextStrain, the John’s Hopkins’ JHU receive monitoring bracelets that who have COVID-19 (rather than
CSSE, Thebaselab, the BBC, the New alert the authorities if they breach for everyone). It is far worse to
York Times, HealthMap, Microsoft the quarantine by leaving their mistakenly suggest that a person
Bing’s AI tracker. home. with COVID-19 is not sick (which
might allow them to continue
8. Advanced fabrics offer protection • In the United States, AI-enhanced infecting others) than it is to suggest
Israeli startup Sonovia hopes to arm thermal cameras can detect fevers a healthy person has COVID-19.
healthcare systems and others with • In Thailand, border officers at 4. Real-world deployment degrades
face masks made from their anti- airports are piloting a biometric AI performance
pathogen, anti-bacterial fabric that screening system using fever-
relies on metal-oxide nanoparticles. detecting cameras. A drop of 10% accuracy or more
during deployment can occur.
9. AI to identify non-compliance or • AROGYA SETU application
infected individuals launched in India5,6 by the Ministry 5. AI is far better at minute details than
of Electronics & IT that will enable big, rare events
China used facial recognition people to identify and assess their
technology and temperature risk of contracting coronavirus 6. Secondary unintended consequences
detection software from SenseTime infection. The app will calculate Of exceptional concern is the social
to identify people who might have a this based on their interaction with
fever and be more likely to have the others, using cutting edge Bluetooth control technology in China, which
virus. technology, algorithms and artificial uses AI to individually approve
intelligence. The user is asked to or deny access to public space.
10. Chatbots can be used to share answer a number of questions. In case Government action that curtails civil
information and provide online some of the answers suggest Covid liberties during an emergency (and
consultation symptoms, the information will be likely afterwards) is a problem which
sent to a government server. The can lead to long-term undermining
11. Management of resources data will then help the government of privacy.
and developing care as well as take timely steps and initiate the
hospitalization strategies that can isolation procedure, if necessary. 7. AI will be biased
prioritize the riskiest patients. The app alerts are accompanied by Bias in AI models results in skewed
instructions on how to self-isolate
12. Help to identify uninfected and what to do in case you develop estimates across different subgroups,
individuals in the community who symptoms. such as women, racial minorities, or
are at risk for a severe course of people with disabilities leading to
illness. Health care organizations Pitfalls in Application of AI for discriminatory outcomes
can advise these people to exercise COVID-194
complete precautions for self- 1. AI is only helpful when applied Ways to responsibly use AI to
isolation. fight the coronavirus pandemic3,4
judiciously. Deciding what to predict 1. Data anonymization
Instances of AI in use for and how to frame those predictions
COVID-194 is frequently the most challenging 2. Purpose limitation
Enhancing surveillance, monitoring aspect of applying AI. Effectively Personal data that is collected and
and detection capabilities is high on the predicting a badly defined problem
priority list of AI. is worse than doing nothing at all. processed to track the spread of the
• For instance, in China the authorities coronavirus should not be reused for
2. AI needs lots of data another purpose.
relied on facial recognition cameras AI needs tons of prior data with
to track a person who had traveled in 3. Knowledge-sharing and open
an affected area and instructed him known outcomes but there is access data with one another and
to self-quarantine. no database of prior COVID-19 with other key stakeholders in the
• Police in China and Spain have also outbreaks. community, including the public
started to use technology to enforce 3. Don’t trust AI’s accuracy and civil society organizations.
quarantine, with drones being A 96% accuracy, means missing
used to patrol and broadcast audio 4% of the infected people. It is 4. Time limitation
messages to the public, encouraging important to also know the model’s When COVID-19 pandemic does
them to stay at home. “sensitivity,” which is the percent of
come to an end, national authorities
will need to scale back their newly
acquired monitoring capabilities.
70 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
Conclusion 4. https://thenextweb.com/how AI can 9. Becky McCall. Covid 19 and artificial
In a global pandemic such as COVID-19, determine which coronavirus patients intelligence: protecting health care
AI is a widely applicable technology, require hospitalization. workers and curbing the spread. Lancet
but its advantages need to be hedged 2020;2(4):166-7.
in a realistic understanding of its 5. Coronavirus pandemic Arogya setu app
limitations. It is still too early to tell download/Govt launches COVID-19 Corresponding Author:
if, and to what extent, AI will have an tracking app ‘ Arogya setu’ for Android,
impact on the COVID-19 outbreak. IOS users” Techlinics. Retrieved 2020-04- Dr. Kanika Jain
16. Sr Resident (Ophthal)
References DDU Hospital, New Delhi
1. Available from https://en.wikipedia.org/ 6. Govt launches ‘Arogya Setu’ a
coronavirus tracker app. All you need to
wiki/artificial intelligence. know”.livement.2020-04-02. Retrieved
2. Available from: https://en.wikipedia. 2020-04-05.
org/ 2019-20 Coronavirus pandemic. 7. https://www.forbes.com- how artificial
[Last accessed on 2020 April 11]. intelligence can help fight coronavirus-
3. h t t p s : / / t o w a r d s d a t a s c i e n c e . c o m / cognitive world. March 19,2020.
artificial intelligence against COVID-19-
an early review-92a8360edaba. 8. https://www.analyticsinsight.net-top 10
AI powered companies standing against
coronavirus.
www.dosonline.org/dos-times DOS Times - Volume 25, Number 4, January-February 2020 71
COVID-19 Special
COVID–19: Investigational
Anti-Viral Treatments
N.Z. Farooqui MS1, Kiran Bhanot MS, DNB2
1D.D.U. Hospital New Delhi, India
2G.G.S.G. Hospital, New Delhi, India
With the Novel Coronavirus going when there is no clinical trial available, researches claimed to have successfully
from ‘regional crisis’ to ‘pandemic ‘ but if there is, we have to prioritize mapped out a key protein structure in
status, researchers and pharmaceutical enrolment. The FDA has demonstrated virus that causes COVID-19 including
giants are scrambling to find a cure. its willingness to help speed trials and the likeliest target for the antiviral
Investigational drugs like anti-viral facilitate the collection of data. Federal drug remdesivir. It is further claimed
and others with some potential to policy in this area should be driven by that same atomic-scale target, known
combat covid-19 but that have not scientific expertise, not false hope or as nsp12, could be attached by other
yet been approved for any use and short-sighted political demands. Some types of antiviral drugs. “This target…
therefore may not be prescribed off- of the treatments to be tested are drugs could support the development of a
label. These drugs are currently under already being used for other illnesses cocktail of anti-coronovirus treatments
investigation in clinical trials around like HIV and Ebola. that potentially can be used for the
the U.S and the globe. For seriously ill Antiviral drugs administered shortly discovery of broad-specturm antivirals,”
patients, the FDA has a pathway known after symptoms onset can reduce the researchers state in article publised
as “expanded access” (sometimes called infectiousness to others by reducing in Journal Science.
“compassionate use”) by which patients viral shedding in the respiratory
may be dosed with unapproved drugs secretions of patients (SARS-CoV-2 viral Compassionate use of
for treatment use, if they are unable to load in sputum peaks at around 5-6 days Remdesivir for Patients with
enrol in a clinical trial. This eligibility symptoms onset and lasts upto 14 days), Sever COVID-192
restriction is critical because it ensures and targeted prophylactic treatment Remdesivir is a prodrug of a nucleotide
that patients cannot secure access of contacts could reduce their risk of nalogue that is intracellularly
by opting out of the trials designed becoming infected.1 metabolized to an analogue of
to produce the evidence needed to Scientisits Chart Weak Spots adenosine triphosphate that inhibits
confidently assess a product’s safety and in Coronavirus Protein that viral RNA polymerases.3 Remdesivir
efficacy. Antiviral Drugs can Target works by inhibiting an enzyme known
as an RNA-dependent RNA polymerase,
Pragmatism is needed to collect data in Non-Structural protein nsp8 and nsp which many RNA viruses – including
real time, as patients are also in desperate 12 form an active complex2. Chinese corona viruses use to replicate
need of treatment, that’s precisely themselves.4
the approach taken by the World
Health Organization in its mega trial Remdesivir has broad specgtrum
of potential treatments for COVID-19, acitivity against members of severla
with over 70 countries participating. virus families, including filoviruses
The trial is aptly named SOLIDARITY (e.g. Ebola) and coronoviruses [e.g.,
and it is designed to minimize the SARS-CoV and Middle East respiratory
burden to physicians and patients, syndrome cornoaviurs (MERS-CoV)]5-8
while allowing random assignment and and has shown prophylactic and
collection of systematic, anonymous therapeutic efficacy in nonclinical
data. models of these coronaviruses. In
vitro testing has also shown that
Off-label use and expanded access may remdesivir has acitivity against SARS-
be reasonable options for patients CoV-2. Remdesivir appears to have a
72 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
favourable clinical safety profile. This the study were randomly assigned to families including the coronaviruses
study was conducted in a cohort of receive either lopinavir-ritonavir (400 that causes MERS and SARS. In previous
patients hospitalized for sever Covid-19 mg and 100 mg orally;) twice daily phase I studies, Galidesivir was found
who were treated with remdesivir on a or standard care alone for 14 days. to be safe and was well-treated as a
compassionate-use basis. The planned The study concluded that lopinavir- broad-specturm antiviral medicine.
treatment was a 10-day course of ritonavir treatment did not significantly Efficacy measures in the COVID-19
remdesivir, consisting of a loading dose acclerate clinical improvement, reduce study will include the time taken to
of 200 mg intravenously on day 1, plus mortality, or diminish throat viral RNA clinical improvement, time to hospital
100 mg daily for the following 9 days. detectability in patients with serious discharge, time to undetectable levels as
Follow-up was to continue through at Covid-19. More than twenthy trials measured by polymerase chain reaction
least 28 days. The study concluded that around the world are testing the drug as (PCR) in respiratory specimens of SARS-
clinical improvement was observed a covid-19 treatment or post-exposure CoV-2.
in 36 of 53 patients (68%). However, prophylaxi for people with high-risk
the interpretation of the results of this close contact with a confirmed case. Many drugs already approved by
study is limited by the small size of the Initial results are expected as soon as FDA may have promise against
cohort, the relatively short duration of May 2020. COVID-19 writes E.J. Mundell (Health
follow-up, and the lack of randomized Day Reporter, Tuesday, 24 March
control group. Other factors may have Favipiravir For Coronavirus 2020, Health Day News). The results
contributed to differences in outcomes, Infection16 of computer modelling studies on
including the type of supportive Thhis anti viral drug bas previouslyy certain already approved by USFDA,
care and differences in instututional been found to be effective against a to assess their potential in combating
treatemnet protocols and thresholds number of RNA viruses including the coronavirus showed that the most
for hospitalization. The study did not influenza, West Nile virus, foot and promising drugs included several
collect viral load data to confirm the mouth disease and yellow fever. Japan antiviral drugs-including Darunavir
anti viral effects of remdesivir or any approved its manufacture and sale in Nelfinavir, and Saquinavir.
association between baseline viral 2014, for its use only when there is
load and viral suppression, if any and an outbreak of novel or re-emerging Even moderately effective therapies
clinical response. No clear evidence of influenza virus infections in which or combinations could dramatically
nephbhrotoxicity due to remdesivir other influenza antivial drugs are either reduce the crushing demand on
therapy was observed. Measurement not effective or insufficiently effective. hospitals and ICUs, changing the nature
of efficacy will require ongoing China began testing Favipiravir as of the risk the new pathogen represents
randomized, placebocontrolled trials of a potential coronoavirus treatment to populations and healthcare systems.
remdesivir therapy. The initial data for in February and approved its use in New drugs, together with new
the drug remdesivir are from studies of clinical trials for the treatment of diagnostics antibody tests, patient-and
patients with relatively sever COVID-19, COVID-19. China Daily reported that contact-tracing technologies, disease
however, antivirals work best when the drug had shown promising results surveillance and other early-warning
patients are helathier, hence the results in treating coronavirus patients, with tools, mean the anticipated next “wave”
may show limited effectiveness. mild side effects reported. Patients who of the global pandemic does not have to
were given Faipiravir were found to test be nearly as bad the first.
A Trial of Lopinavir-Ritonavir in negative for the virus around four days
Adults Hospitalized with Severe after testing positive for coronvirus, Biblography
COVID-199 compared to 11 days for those who 1. The antiviral compound remdesivir
were not given the drug. 90% patients
Lopinavir, a human immunodeficiency experienced improvements in their potently inhibits RNA-dependent RNA
virus (HIV) type 1 aspartaate protease lung condition following Favipiravir polymerase from Middle East respiratory
inhibitor has been shown to have in drug administration. syndrome coronavirus Calvin J
vitro inhibitory activity against SARS- Gordon, Egor P Tchesnokov1, Joy Y.
CoV, the virus that cuases SARS in Galidesivir for Coronavirus Feng, Danielle P Porter and Matthias
humans.10-12 Ritonavir is combined with Infection17 Gotte, https://www.jbc.org/content/
lopinavir to increase its plasma half-life Galidesivir, is an investigational broad- early/2020/02/24/jbc.AC120.013056
throuhg the hihibition of cytochrome spectrum antiviral drug, currently
P450. Case reports have suggested under trial for yellow fever being 2. The antiviral compound remdesivir
that the combination of lopinavir- conducted in Brazil. It has shown broad- potently inhibits RNA-dependent RNA
ritronavir with ribavirin and interferon spectrum activity in vitro against more fron Middle East respiratory syndrome
alfa resulted in virologic clearance and than 20 RNA viruses in nine different coronavirus. Calvin J Gordon, Egor P
survival.13-15 The eligible patients in Tchesnakav1,Joy Y.Feng, Danielle P
Porterand Matthias Gottte. https://www.
jbc.org/content/early/2020/02/024/jbc.
A120013056
www.dosonline.org/dos-times DOS Times - Volume 25, Number 4, January-February 2020 73
COVID-19 Special
3. Compassionate Use of Remdesivir for coronavirus (2019- nCoV) in vitro. Cell syndrome coronavirus infection case on
Patients with s/ever Covid-19. J. Grein, Res 2020; 30: 269-71. a triple combination antiviral regimen.
N.Ohmaghari, D.Shin et al. The New Int J Antimicrob Agents 2014;44: 528-32.
England Journal of Medicine: April, 2020 9. A Trial of Lopinavir–Ritonavir in Adults 15. Min C-K, Cheon S, Ha N-Y, et al.
NEJM.org; Hospitalized with Severe Covid-19. B. Comparative and kinetic analysis of viral
Cao, Y. Wang, D. Wen, W. Liu, Jingli shedding and immunological responses
4. Welliver R, Monto AS, Carewicz O Wang, et al. The New England Journal of in MERS patients representing a broad
et al. Effectiveness of oseltamivir in Medicine: 18 April 2020. This article was spectrum of disease severity. Sci Rep
preventing influenza in household published on March 18 at NEJM.org. 2016; 6:25359.
contacts: a randomized controlled trial. 16. U.S. to Trial Japenese Anti-Flu Drug
JAMA. 2001; 285: 748-754 10. Chu CM, Cheng VC, Hung IF, et al. Role Avigan For Potential Coronavirus
of lopinavir/ritonavir in the treatment Treatment by Soo Kim on 4/12/20 at 6:21
5. de Wit E, Feldmann F, Cronin J, et al. of SARS: initial virological and clinical am EDT.
Prophylactic and therapeutic remdesivir findings. Thorax 2004; 59: 252-6. 17. BioCryst Begins Study on Galidesivir
(GS-5734) treatment in the rhesus for Coronavirus Infection Zacks Equity
macaque model of MERS-CoV infection. 11. Chen F, Chan KH, Jiang Y, et al. Invitro Research April 13, 2020
Proc Natl Acad Sci U S A 2020; 117: 6771- susceptibility of 10 clinical isolates of
6. SARS coronavirus to selected antiviral Corresponding Author:
compounds. J Clin Virol 2004; 31: 69-75.
6. Sheahan TP, Sims AC, Graham RL, et Dr. N. Z. Farooqui
al. Broad-spectrum antiviral GS-5734 12. Wu C-Y, Jan J-T, Ma S-H, et al. D.D.U. Hospital New Delhi, India
inhibits both epidemic and zoonotic Small molecules targeting severe
coronaviruses. Sci Transl Med 2017; acute respiratory syndrome human
9(396): eaal3653. coronavirus. Proc Natl Acad Sci U S A
2004; 101: 10012-7.
7. Sheahan TP, Sims AC, Leist SR, et al.
Comparative therapeutic efficacy of 13. Kim UJ, Won E-J, Kee S-J, Jung S-I,
remdesivir and combination lopinavir, Jang H-C. Combination therapy with
ritonavir, and interferon beta against lopinavir/ ritonavir, ribavirin and
MERSCoV. Nat Commun 2020; 11: 222. interferon-α for Middle East respiratory
syndrome. Antivir Ther 2016; 21: 455-9.
8. Wang M, Cao R, Zhang L, et al.
Remdesivir and chloroquine effectively 14. Spanakis N, Tsiodras S, Haagmans BL, et
inhibit the recently emerged novel al. Virological and serological analysis
of a recent Middle East respiratory
74 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
Variable Success in Fight Against
COVID-19 Amongst Different
Countries- An Epidemiological and
Scientific Perspective
Jatinder Singh Bhalla, Ashwini Kulkarni, Amit Mehtani
Department of Ophthalmology, DDU Hospital, New Delhi
Background Country Total number of cases Total deaths Case Fatality Rate
On 31 December 2019, the Wuhan China 84149 4642 5.5%
Municipal Health Commission in Spain 182816 19130 10.46%
Wuhan City, Hubei province, China, Italy 168941 22172 13.12%
reported 27 pneumonia of unknown United States
aetiology, with history of contact at of America 632781 28221 4.45%
Wuhan’s Huanan Seafood Wholesale India
Market, a wholesale fish and live animal Australia 13387 437 3.26%
market.1 Global 6468 63 0.97%
The market was shut down on 1 2074529 139378 6.71%
January 2020. According to the Wuhan
Municipal Health Commission, On 30 January 2020, the World Health passengers from China.8 Several
samples from the market tested positive Organization (WHO) declared this first major airlines suspended their flights
for novel coronavirus. Cases showed outbreak of novel coronavirus a ‘public from and to China.9 Several countries
symptoms such as fever, dry cough, sore health emergency of international repatriated citizens living in Wuhan.
throat,dyspnoea; radiological findings concern’.7 During the following On 11 February 2020, WHO announced
showed bilateral lung infiltrates.2 weeks, several countries implemented a name for the new coronavirus disease:
On 9 January 2020, the China CDC entry screening measures for arriving
reported that a novel coronavirus had
been detected as the causative agent
for 15 of the 59 cases of pneumonia.3
On 10 January 2020, the first novel
coronavirus genome sequence was
made publicly available.4
By 20 January 2020, there were reports
of confirmed cases from three countries
outside China: Thailand, Japan and
South Korea.5 All cases had arrived from
China.
On 23 January 2020, Wuhan City was
locked down – with all travel in and out
of Wuhan prohibited – and movement
inside the city was restricted.6
www.dosonline.org/dos-times DOS Times - Volume 25, Number 4, January-February 2020 75
COVID-19 Special
COVID-19. On 11 March 2020, the ii. Direct physical contact with a among those with preexisting comorbid
Director General of the World Health probable or confirmed case; conditions. 14.8% of confirmed cases
Organization declared COVID-19 a among health workers were classified
global pandemic.10 iii. Direct care for a patient with as severe or critical and 5 deaths were
probable or confirmed COVID-19 observed.14
Countries, territories or areas with disease without using proper
reported laboratory-confirmed personal protective equipment; Knowing that specific treatment and
COVID-19 cases and deaths. Data as of prevention options, such as targeted
17th April 2020. iv. Other situations as indicated by antiviral drugs and vaccines, were not
local risk assessments.11 yet available for COVID-19, China
Terms and Definitions focused on traditional public health
1. Suspect case: 4. Quarantine: It refers to separation outbreak response tactics—isolation,
of individuals who are not yet ill quarantine, social distancing, and
(a) A patient with acute respiratory but have been exposed to COVID-19 community containment.15-17
illness (fever and at least one sign/ and therefore have a potential to
symptom of respiratory disease, become ill and spread the disease. Identified case patients with COVID-19
e.g., cough, shortness of breath), quarantined if age is more than 60 were immediately isolated and 2 new
AND a history of travel to or years or severely ill. hospitals were rapidly built to isolate
residence in a location reporting and care for the increasing numbers of
community transmission of 5. Isolation: It refers to separation cases in Wuhan and Hubei. Contacts
COVID-19 disease during the 14 of individuals diagnosed with with COVID-19 cases were asked
days prior to symptom onset. OR COVID-19. Ideally, patients should to quarantine themselves at home.
be isolated in individual isolation Enormous numbers of large gatherings
(b) A patient with any acute rooms or negative pressure rooms were cancelled and traffic was closely
respiratory illness AND having with 12 or more air-changes per monitored. Physical distancing
been in contact with a confirmed hour. measures were most effective as
or probable COVID-19 case (see this reduced the median number of
definition of contact) in the last 6. Containment zone: MOHFW infections by more than 92%.18
14 days prior to symptom onset; defines the containment zone as a
OR specific geographical area where Spain: More than 11 000 cases and
positive cases of coronavirus are 491 deaths by March 17, 2020, had one
(c) A patient with severe acute found. Strict movement restrictions of the highest burdens of coronavirus
respiratory illness (fever and are put in place in such areas to disease 2019 worldwide. Spain declared
at least one sign/symptom of prevent further spread of the virus.12 a 15-day national emergency, starting
respiratory disease, e.g., cough, on March 15. Measures such as social
shortness of breath; AND 7. Hotspot: While a hotspot is distancing, sealing of borders, ban on
requiring hospitalization) AND converted into a containment zone, public gatherings with closure of several
in the absence of an alternative a containment zone need not always public places and even restricting all
diagnosis that fully explains the be a hotspot. The authorities declare movement in some of the most affected
clinical presentation.11 some lanes or neighbourhoods as area.19 The imposition of restrictions on
containment zone even if it has one movement of people except to buy food
2. Confirmed case: A person with case, but it is declared a hotspot and medicines, along with closure of
laboratory confirmation of particularly when more than 6 cases borders was done.
COVID-19 infection, irrespective of appear.12
clinical signs and symptoms.11 Health facilities in the worst affected
Country-wise approach towards regions were struggling, with
3. Contact: COVID management inadequate intensive care capacity and
Acontactisapersonwhoexperienced China: Most case patients were 30 to 79 an insufficient number of ventilators
years of age (87%), 3% were age 80 years in particular. Many reports suggest
any one of the following exposures or older. Most cases were diagnosed that health workers were stretched to
during the 2 days before and the 14 in Hubei Province (75%) and most the point of exhaustion. This situation
days after the onset of symptoms of a reported Wuhan-related exposures.13 in part reflects existing staff shortages,
probable or confirmed case: The overall case-fatality rate (CFR) again following years of austerity with
i. Face-to-face contact with a was 2.3. Cases in those aged 70 to 79 resultant low salaries. The problems
years had an 8.0% CFR. No deaths were being exacerbated by the quarantining
probable or confirmed case reported among mild and severe cases of a growing number of health workers
within 1 meter and for more than and age below 9 years. CFR was elevated
15 minutes;
76 DOS Times - Volume 25, Number 4, January-February 2020 www.dosonline.org/dos-times
COVID-19 Special
exposed to patients who are infected.19 the spread of the virus. U.S. had only strict check on COVID spread.21
A new decree permitted hiring a fraction of the medical supplies it
graduates without specialisation, final needed to combat coronavirus. Phases India: The first case of the 2019–20
year medical and nursing students, of public health efforts for epidemics coronavirus pandemic in India was
and extending contracts of medical and pandemics were implemented reported on 30 January 2020, originating
residents to contain or limit further outbreaks from China. As of 17 April 2020, the
which involved tracing contacts, Ministry of Health and Family Welfare
Italy: On March 10, Italy had been implementing quarantines, and have confirmed a total of 13,835 cases,
quarantined and the government isolating infectious cases. On March 1,767 recoveries and 452 deaths in the
has instituted stronger containment 30, the Institute for Health Metrics and country.5 Experts suggest the number
measures, including strict self-isolation Evaluation estimated a peak in deaths of infections could be much higher
measures. These containment measures per day by April 15, with a total of about as India’s testing rates are among the
and individual citizen responsibility 80,000 deaths in the United States due lowest in the world.8
could slow down virus transmission. to coronavirus by August.
Protective measures were first applied
Italy had 12,462 confirmed cases Australia: First case was detected on in January. India began thermal
according to the Istituto Superiore di 25 January 2020, when a man returning screening of passengers arriving from
Sanità as of March 11, and 827 deaths. On from Wuhan, China, was tested positive China on 21 January. On 3rd March 2020,
March 8, 2020, the Italian Government for COVID. The total number of new the Indian government stopped issuing
implemented extraordinary measures cases initially grew exponentially, of new visas, suspending previously
to limit viral transmission—including levelled out at about 350 per day issued visas. Indians returning from
restricting. The percentage of patients around 22 March, and started falling at COVID-affected countries were asked
in intensive care reported daily in Italy the beginning of April. As of 15 April to be quarantined for 14 days. On 17
between March 1 and March 11, 2020, 2020, 6,523 cases had been reported. March, The Government of India issued
has consistently been between 9% On 1 February 2020, Australia banned an advisory urging to all Indian states
and 11% of patients who are actively the entry of foreign nationals from to take social distancing measures as a
infected. Italy has approximately 5200 mainland China, and ordered its own preventive strategy for implementation
beds in intensive care units and the returning citizens from China to self- till 31 March. On 24 March, the
number of intensive care beds necessary quarantine for 14 days and imposing prime minister ordered a nationwide
to give the maximum number of travel bans on other countries such as lockdown for 21 days. On 14 April, the
patients the chance to be treated will Iraq, South Korea, etc. and started border prime minister extended the ongoing
reach several thousands. Health-care surveillance. On 19 March, Australia nationwide lockdown till 3 May.
professionals have been working day closed its borders and promoted social
and night since February 20, and in distancing along with closing of non- On 23 March, the National Task Force for
doing so around 20% of them have essential services. As of 17 April 2020, COVID19 constituted by Indian Council
become infected, and some have died.20 65 people linked to COVID-19 have died of Medical Research recommended
in Australia. the use of hydroxychloroquine for
USA: The first known case of COVID-19 treatment of COVID19 for high-risk
in the U.S. was confirmed on January Australian Government is expecting cases.
20, 2020. On January 31st, Trump well to cope up with COVID-19 with
administration declared a public health effective social distancing, increasing Within the country itself variable
emergency and announced restrictions healthcare system capacity and isolation results are seen, states with stricter
on travellers arriving from China. of cases and suspects. On 12th March,the containment, ample testing supported
Initially, President had dismissed the Government has delivered a $17.6 by cooperative citizens are controlling
threat posed by COVID-19, making billion economic support package to the COVID spread better than the rest.
optimistic statements and claiming encourage investment and keep people The Oxford Covid-19 Government
the outbreak was under control. By in jobs and $2.4 billion health package. Response Tracker (OxCGRT), in its
early March, the government began to State and territory health authorities report based on data from 73 countries,
heighten its response. By mid-March, are testing people suspected of having reports that the Indian Government has
the U.S. government denied entry to the virus, monitoring close contacts of responded more stringently than other
foreign nationals who had travelled confirmed cases every day, imposing countries in tackling the pandemic
within the past 14 days through China travel restrictions between states with swift action, emergency policy
and other countries and were required and opening fever clinics. Early and making emergency investment in
to undergo a health screening and effective implementation of controlling healthcare, fiscal measures, investment
submit to a 14-day quarantine. Home strategies has helped Australia keep a in vaccine research and active response
quarantines was imposed to stem to the situation.11
www.dosonline.org/dos-times DOS Times - Volume 25, Number 4, January-February 2020 77
COVID-19 Special
Conclusion [updated 22 January 2020]. Stockholm: 11. World Health Organisation,
COVID infection started out as a ECDC; 2020. Available from: https:// Coronavirus disease 2019 (COVID-19)
respiratory infection on December www.ecdc.europa.eu/en/publications- Situation Report – 87. Available from
2019, spreading across whole of China data/risk-assessment-outbrea….
in 30 days. Global spread of the disease https://www.who.int/docs/default-
was seen by late January. Developed source/coronaviruse/situation-
countries with most elite healthcare 3. News X. Experts claim that a new
system were not able to contain the coronavirus is identified in Wuhan reports/20200416-sitrep-87-covid-19.
rapid spread due to delayed imposition 2020 [14 January 2020]. Available from: pdf?sfvrsn=9523115a_2
of controlling measures. Countries with http://www.xinhuanet.com/2020-
prompt decisions, swift screening and 01/09/c_1125438971.htm. 12. Ministry of Health and Family Welfare
stringent restrictions seem to be coping Government of India, Containment
well regardless of the population size or 4. Holmes E. Initial genome release of Plan for Large Outbreaks Novel
efficacy healthcare system. Hence, the novel coronavirus 2020 [14 January Coronavirus Disease 2019 (COVID-19),
need of the hour is stricter measures, 2020]. Available from: http://virological. Available at https://www.mohfw.gov.in/
boosting of testing facilities along org/t/initial-genome-release-of-novel- pdf/3ContainmentPlanforLargeOut
with support and compliance from coronavirus/319. breaksofCOVID19 Final.pdf
the citizens. Though social distancing,
quarantine and isolation are containing 5. World Health Organization. Novel 13. Wu Z, McGoogan JM. Characteristics
spread of disease to a considerable Coronavirus (2019-nCoV) SITUATION of and important lessons from the
extent, Dr. Anthony S. Fauci said that REPORT – 1, 20 January 2020. coronavirus disease 2019 (COVID-19)
a vaccine will still be necessary to end Geneva: WHO; 2020. Available from: outbreak in China: summary of a report
the pandemic at a White House press https://www.who.int/docs/default- of 72 314 cases from the Chinese Center
briefing on April 1 2020.This infection source/coronaviruse/situation- for Disease Control and Prevention.
is not going to disappear. Unless we reports/20200121-sitrep-1-2019-ncov. Jama. 2020 Feb 24.
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20. Remuzzi A, Remuzzi G. COVID-19 and Corresponding Author:
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from https://www.health.gov.au/
news/health-alerts/novel-coronavirus-
2019-ncov-health-alert/government-
response-to-the-covid-19-outbreak
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