Contextualising evidence-based recommendations for the second wave of the COVID-19 pandemic in India.

During the second wave of the COVID-19 pandemic in India, which began in March, 2021, demand on the health-care system has far exceeded capacity. Despite crippling shortages, patients are prescribed a battery of ineffective therapeutic interventions. Ivermectin, hydroxychloroquine, and herbal cocktails continue to receive state patronage.2, 3, 4 On May 8, 2021, 2-deoxy-D-glucose was given emergency authorisation, stating that it will “save precious lives” without any published evidence that it impacts mortality. An entrenched culture of polypharmacy and gestalt-driven practice among physicians has resulted in indiscriminate and unwarranted use of remdesivir, favipiravir, azithromycin, doxycycline, plasma therapy, and most recently baricitanib and bevacizumab, regardless of disease severity or drug efficacy. Excessive and inappropriate use of steroids could be contributing to the alarming rise of mucormycosis in patients recovering from COVID-19.

In rural India, where health-care infrastructure is threadbare, and families are poor, patients can ill afford such expensive mistakes. Honing in on the most high yield and affordable interventions, we propose recommendations for testing and management, optimised to India's current resource-constrained context (table ). Every clinical touchpoint should be used to underscore masking, distancing, and vaccination.

Table

Evidence-base interventions for COVID-19 patients not requiring hospitalisation

		Who	Where	How (impact optimisation strategies)
Mild disease*
Treat
	Inhaled budesonide (might help)	Self-administered	Home	Instructional videos
	Antipyretic	Self-initiated	Home	Specific drug name, dose, and frequency
Monitor pulse oximeter and respiratory rate		Self-initiated	Home	Instructional videos
Report test and clinical status		Care coordinator	Home	Community-based, private, or public sector central coordination
Other
	Masking	Self-initiated	Home	Instructional videos
	Ventilate the isolation room, when feasible	Self-initiated	Home	Instructional videos
	Reinforce the importance of completing or initiation vaccination after recovery, including for all family members	All providers	..	Instructional videos
Moderate disease†
Treat
	Oxygenation via concentrator or cylinder (NB: potential risk to inadequately protected care providers); target SpO2 above 92%	Family assisted or trained personnel	Any	Instructional videos on caregiver PPE, correct use, and dosing
	Oxygenation via non-invasive ventilation or high flow nasal cannula (NB: potential risk to inadequately protected care providers); target SpO2above 92%; few will have access to this	Clinician	Any
	Pronation	Self-initiated or assisted	Any	Instructional videos
	Dexamethasone (or other equivalents) only if requiring respiratory support	Clinician	Any	Dosage protocols for clinicians
	Antipyretic	Self-initiated	Any	Specific drug name, dose, and frequency
	Anticoagulation, for patients admitted to care facilities, and only under medical supervision	Trained personnel	Bridge facility or hospital	Instructional videos on administration
Do not use ivermectin and hydroxychloroquine		..	..	..
Test
	Random blood glucose	Trained personnel	Any	Decision support system or telemedicine to higher tier care provider if uncontrolled or new diabetes
	CT not indicated in most cases	..	..	..
Report clinical status		Designated coordinator	..	Standardised daily logs of vital signs and interventions

Disease severity classification as per the Ministry of Health and Family Welfare, Government of India. PPE=personal protective equipment. SpO2=oxygen saturation.

Patients with mild symptoms and SpO2≥94%.

Patients with SpO2<94 and ≥90.

Where RT-PCR test turnaround time is lengthy, or when tests are unavailable, CT scans are being routinely prescribed for diagnosing infection from SARS-CoV-2. Serial scans are prescribed for prognostication; high CT severity scores—regardless of clinical presentation—then inadvertently trigger unwarranted hospitalisations. This practice is neither standard of care nor an option for most patients. In fact, we argue that in the throes of this surge, it would be prudent to initiate treatment for presumed infection if clinically warranted, and have all with mild symptoms isolate for 14 days or until a test result is available. In early May, 2021, national guidelines were finally relaxed to allow such syndrome-based diagnosis, ending a year of delayed or denied hospital admissions due to slow or unavailable testing.

When options for oxygenation or timely transport to higher levels of care are available, oxygen saturation, a reliable predictor of mortality in COVID-19, and measured via cheaply and widely available pulse-oximeters, should suffice for risk stratification. Routinely prescribed expensive laboratory tests such as C-reactive protein, ferritin, interleukin-6, and D-dimer, will have little bearing on clinical outcomes where there are no viable options for basic therapeutic care. Even in urban India, physicians must consider recommending such tests only when there is evidence that interventions are based on their interpretation change outcomes and are actually feasible.

For nearly a year, patients were being advised institutional isolation, regardless of disease severity or ability to isolate at home. For patients with mild disease, home-based care and self-monitoring with a pulse oximeter—as has long been appropriate—has finally gained widespread traction, from sheer necessity. Clear directives (and telemedicine support, where possible) will prevent unwarranted presentations to the hospital. Most patients with hypoxia might only need oxygenation and proning. Current evidence supports the use of steroids such as dexamethasone only among those needing oxygen or invasive respiratory support.8, 9 A few patients might also benefit from prophylactic doses of anticoagulation that can be administered by trained family members. Patients can be taught pronation via effective educational aids. A severe shortage of beds and unreliable power availability threaten other key treatment possibilities in rural India, as oxygen concentrators will need continuous electricity or back-up generators, and oxygen cylinders are expensive to procure and transport. The justified, ad hoc, and self-organised measures to procure and administer oxygen, however, risk inadequate oxygen therapy, rendering these often Herculean efforts clinically futile. A vast number of oxygen concentrators and ventilators have been mobilised internationally. On May 8, 2021, the Supreme Court of India appointed a task force to oversee oxygen allocation. It is imperative that recommendations for distribution be coupled with human-in-the-loop solutions where technical know-how to operate these devices is expanded expeditiously via online adjuncts. The government has also directed India's non-allopathic AYUSH doctors to provide COVID-19 care. It is crucially important that this expanded workforce not amplify missteps from the preceding year.

Hypoxic patients who do not need invasive mechanical ventilation can be cared for at makeshift but monitored, protocolised health-care facilities. Despite the bed shortage, and revised national guidelines, many patients are not being discharged home until their RT-PCR test is negative. There is no evidence that patients need hospitalisation once they are clinically stable for discharge. When isolating at home is unfeasible, they could be sent to recovery centres. Indigenous rural solutions such as isolating patients elsewhere on the farm are not unreasonable, provided family members can provide care.

It is time to double down on effective interventions. The lack of critical care capacity necessitates open discussions about goals of care. We are all practicing physicians and recognise how hard it is to communicate futility to family members, especially in these desperate times. Truth, however, will protect families from crushing debt, and in some cases, financial ruin. Adherence to science, even now, will probably be the least destructive path forward.