A healthcare worker in PPE collects a swab sample from a man at a weekly market in New Delhi, October 13, 2020. Photo: Reuters/Anushree Fadnavis
With India in the middle of an unprecedented second wave of COVID-19, hundreds of thousands of people have been testing positive every day. Although a positive diagnosis can be demoralising, it is important to be prepared for what comes next.
Encouragingly, even in the context of the newer mutant strains and increased infectivity, most patients will experience only mild symptoms and disease, with mortality rates remaining more or less unchanged over the last six weeks.
With this in mind, let’s look at important questions about home care and when patients may need to seek medical care and post-infection care.
Note: What follows is intended as guidance, not recommendation. Before making any decisions concerning any drugs or treatments, please consult a doctor.
How accurate is RT-PCR for SARS-CoV-2? Could it be a false positive?
The RT-PCR test has a high specificity for SARS-CoV-2, meaning a positive test overwhelmingly indicates that you have the infection. More importantly, the result also means that you are shedding the virus and capable of transmitting it to others.
Could a positive test be caused by vaccination? How can I be positive if I have been vaccinated?
Vaccines can’t directly, by themselves, cause an infection because they carry only part of the virus or the inactivated virus. If you have tested positive after having received both doses of your vaccine, it doesn’t mean that your vaccine didn’t work. The vaccines are designed to protect you from severe infection and mortality, even if they can’t prevent you from contracting the infection.
Even with some of the more infective strains of the novel coronavirus, it is likely that antibodies from vaccination provide at least partial protection from severe disease.
I have tested positive. What happens next?
Unlike the previous waves, where the characteristic symptoms of infection were fever and cough, the second wave has presented with more non-specific symptoms like nausea, abdominal pain and tiredness.
Once you have tested positive, it is important to isolate yourself, monitor your health and determine when you need medical attention. Most importantly, don’t panic – the majority of people will recover with only mild symptoms.
How do I isolate myself and for how long?
With increasing evidence that the virus’s transmission is predominantly airborne, isolating yourself from other people in your household who are COVID-negative in an effective manner is paramount.
For those with enough space, a room with an attached bathroom away from the common areas is best. The aim as far as possible is to create a negative pressure room, so that air moves from your isolation area to the outside of the house, rather than into the rest of the household. Some tips to achieve a system like this are available here.
It is important to keep the room door closed throughout the day, and if you need to use the common area, do distance yourself from other members in the household and wear a mask – because you are likely to be actively shedding the virus early in the illness.
As far as possible, pack everything you need (clothes, linen, bedding, snacks and toiletries) before you begin isolating yourself.
Although viral transmission by surfaces is low, make sure that whoever is handling your disposed waste only handles tied-off garbage bags while wearing gloves and a mask. If you live alone and don’t have a caregiver to help you, or if you can’t isolate yourself from others within your home, you need to be admitted into a COVID-19 care centre.
Elderly patients (>60 years) and/or those with comorbid illnesses like renal failure, heart disease or stroke may also need to be admitted to a care centre for observation.
It is important that you find a way to stay engaged during your isolation: read, listen to music, watch TV shows and speak to family and friends on the phone to help alleviate boredom, stress and anxiety.
You need to isolate yourself for at least 10 days after testing positive. Routine re-testing is not indicated unless you have symptoms that last for longer than this period.
How do I monitor my health?
In most cases, plenty of rest, plenty of fluids, a nutritious diet and supportive care (paracetamol and cough syrup as required) constitute sufficient treatment. For cough and fever persisting beyond five days (but no breathlessness), you can use a budesonide inhaler to treat symptoms. Of course, please consult your doctor before making these decisions. If you can, consult via video.
You will need a thermometer and a pulse oximeter to measure fever and oxygen saturation during the course of your illness. If your saturation is above 94% at rest, you most likely have mild disease and should be able to breathe comfortably.
If you are not sure if your respiration is impeded, you can perform the six-minute walk test: measure the oxygen saturation before and after six minutes of brisk walking. If the saturation falls by more than 5% after walking, it may be a sign of moderate to severe disease.
Do I need any routine blood investigations or chest X-ray for mild disease?
There is no consensus on whether these tests are indicated for patients with mild or no symptoms. In addition, most patients won’t need any tests at all.
Various blood tests like ferritin, D-dimer, CRP and LDH levels have been combined with X-ray or CT scans of chest in these patients, but it is best to leave these decisions to your physician. Please do not order these for yourself from laboratories. They are most often useful if you are suspected to be at risk of moderate to severe disease.
What medications should I start on for COVID-19?
Do not start remdesivir, favipiravir, ivermectin or any other medications unless prescribed by a doctor. None of them are particularly useful except in very specific situations, and can have side effects.
Do not start on antibiotics like erythromycin or ciprofloxacin. They have no benefit.
The most important drugs in the fight against COVID19 are oxygen and steroids (especially dexamethasone) – but only when used judiciously and under the supervision of a medical practitioner.
As a result of hype and panic, many drugs have been black-marketed, even when they are not particularly effective.
Health supplements like vitamins have failed to show benefit unless you are already deficient.
When do I seek medical attention?
A persistent fever over 101º F also suggests moderate to severe disease. Worsening cough, exhaustion, chest tightness or any breathlessness are signs that you require hospital admission and treatment.
Other symptoms that suggest that you need to be evaluated by a doctor are persistent vomiting or diarrhoea leading to dehydration and exhaustion.
Have your caregiver call your local COVID-19 control room to ensure that the healthcare facility you intend to visit is operational. It is helpful to have all the information about the patient available when you speak to them – previous illnesses and medications, current problems and oxygen saturation – as this will help them match you to the most appropriate level of care required.
It may be helpful to monitor social media for help from institutions and good samaritans as well.
What are the treatment options for moderate to severe disease?
Moderate disease refers to the clinical condition when oxygen saturation of room air is 90-94%, the patient has a fever with breathing difficulties and a CT scan of the chest shows 25-50% of each lung involved. Severe disease is associated with even further deterioration – e.g., oxygen saturation below 90%. In these patients, supplementary oxygen is crucial.
In patients who have good respiratory efforts, this is sufficient, whereas those who are unable to effectively breathe, non-invasive ventilation will follow. This is where oxygen is supplied under pressure through an air-tight face mask. If this is also inadequate, the patient will have to be intubated: a tube will be passed into the airway to allow gas exchange directly with the lungs. This happens through the ventilator.
Steroids and anticoagulants (as COVID-19 is associated with a higher risk of forming potentially life-threatening blood clots) have been found to be helpful in managing the patient’s condition in this phase. Other drugs, like the antiviral remdesivir and the monoclonal antibody tocilizumab, may have some benefit in a very specific group of patients – but even in them the response is incremental and not dramatic.
Supportive care like nutrition, prevention of superadded infections and hydration are very important to aid recovery. Among patients who do recover, the process can be prolonged, often taking weeks. It is important to discuss the likelihood of recovery with the treating team to ensure realistic goals and expectations.
What happens if I don’t get a hospital bed?
If you are in a part of the country that is in crisis, you may be unable to get a hospital bed. Try to at least get a video consult with a physician who can guide your treatment. If you need oxygen (i.e. if oxygen saturation is lower than 92% at rest), try to get home oxygen if available, and use a low setting (like 2 litres/min with nasal prongs) to achieve an oxygen saturation level of over 92%.
Oral dexamethasone can be administered orally (6 mg once a day for 10 days), along with paracetamol and oral rehydration solution. Sleeping prone – on your stomach – can ease breathlessness to some extent. If you have greenish or yellow sputum (as a result of a suspected superadded bacterial infection), a course of an antibiotic like augmentin is indicated.
It is crucial to keep monitoring oxygen saturation. If it falls below 85% or your oxygen requirement is more than 4 litres/min, urgent hospitalisation is indicated.
Should I be vaccinated after I contract COVID-19?
It is advisable to be vaccinated even if you have been infected, since vaccination confers a more prolonged and reliable antibody response against the virus than a natural infection might. We know this from a study conducted with infected patients. Almost 9% of them didn’t have antibody responses after recovery.
More recent data shows that vaccination after infection may result in antibody levels up to 10-45-times higher than those after vaccination alone. The US Centres for Disease Control advise people to wait 90 days after infection – while India’s Ministry of Health and Family Welfare advises waiting for 14 days.
Should I donate convalescent plasma?
Unfortunately, convalescent plasma has not shown to be of any benefit against COVID-19 infections.
If you are willing to donate blood, please do so – the COVID-19 crisis may precipitate a national shortage of blood. Blood is vital for those with cancer, blood disorders like thalassaemia and a host of other conditions. You can donate blood one month after recovery.
Dr Narayana Subramaniam is a head and neck surgical oncologist at Sri Shankara Cancer Hospital and Research Centre, Bengaluru.