Coping with COVID Crisis

Abstract

Emergence of the deadly corona virus infection took place in Wuhan in China in December last year. It soon spread to all countries and became a pandemic. India’s first case of COVID 19 was confirmed in Kerala’s Thrissur district on 30 January 2020. Ever since, our lives have changed and we are facing numerous difficulties. This editorial will take you through these difficulties faced by us at practice and in life in general. It presents a brief account of the impact of COVID 19 on functioning of this journal. We have compiled quality articles on COVID in a special section of this issue. This editorial also presents the highlights of these articles along with editorial comments. It contains lessons learned from original research on 141 covid positive pregnant women. It also covers issues faced by obstetricians like taking informed consent, lactation management, and safety of computed tomography imaging in pregnancy and newly introduced rapid testing strategies. It delves into the most sensitive issue of mental health of health care workers, economic crisis and takes a look at the way forward. We sincerely hope that this editorial is useful to our readers in their practice to cope up with this unforeseen crisis situation.

Introduction

We have been in the grip of the public health emergency, the COVID-19 (Coronavirus disease 2019), which has created a havoc in the world ever since it was declared as a pandemic by WHO [1].

This has led to an unprecedented crisis across the globe, sparing neither any community nor any country. World has witnessed a huge setback on all fronts, and India is no exception. We in India are performing rather well when compared to many other countries because of the strategies adopted by national and local authorities in prevention of spread of this dreadful virus. After implementation of early complete lockdown, government had to announce the extension of lockdown three times, and now we are walking through the process of lockdown exit! All these steps have led to different challenges and difficulties.

It is amply clear to us now that we have to face this crisis with great courage, wait for the vaccine to become available and learn to live with this “new normal.”

This editorial will take you through various issues faced by most of us in our daily practice and our lives, also the difficulties faced by this journal in these COVID times. We have compiled good articles on COVID dealing with these concerns in a special section in this issue. In this editorial, I present highlights of these articles. These interesting papers will be useful to our readers to cope up with this unforeseen crisis situation.

Impact of Covid 19 on Journal

The online portal of this journal witnessed an infodemic of articles over last few months! This unprecedented inflow of the manuscripts has put the entire editorial team and publishers under great pressure of processing these articles. Because of the need of the hour, journal then geared up for this new requirement as we were astonished with the quality of articles that were being submitted by our members. It is worthwhile to note that this year from 1st Jan to 25th June, a total of 550 articles have been submitted on the system!!!!! When compared with the number of submissions over exactly the same period last year, to my surprise they were only 302 submissions from 1st Jan 2019 to 30th June 2019. It has indeed been a tough job to cope up with this voluminous workload.

However, we took up this challenge. We kept a special tab on COVID 19 special articles, we fast-tracked them and processed them with great speed. The editors, reviewers, the office staff and Springer team were charged with this mission. We had multiple rounds of discussion after we received comments from reviewers, thereafter followed a proactive interaction with the concerned authors. We chose the best quality papers submitted on COVID 19 and included in special section on COVID 19 of this issue.

I appreciate the cooperation extended by the authors and the whole editorial team. To cope up with the crisis, we introduced first-ever “e-journal issue” for March this year. Despite all the difficulties, we managed to release e-journal of March–April, May–June, and July–August issues on time! Because of suspended posting and printing work, the release of the print versions of these three issues is uncertain.

This ecofriendly e-journal has been a boon in disguise, as it is more economical than print issue.

Obstetrician’s Predicament

It is very difficult to plan management of pregnant women on the background of very little or no original published data to be confident of your management. This issue of JOGI has included an article “Editor’s pick”, perhaps largest single center experience on “Impact of Coronavirus Infection in Pregnancy—a preliminary study of more than 141 patients.” Nayak et al. have presented a case control study of 141 COVID 19 positive patients. It is good to learn that there was no significant adverse impact on pregnancy outcome. They report three maternal deaths in COVID 19 group. Pregnancy is an immunosuppressive and pro thrombotic state; hence, theoretically pregnant women are more prone for Covid 19 infection and its thrombosis-related complications. However, there is no supporting data available yet. Likewise vertical transmission of SARS-CoV-2 is possible. Nayak et al. in this study report that almost all the babies tested negative for COVID 19. Only three neonates tested positive who tested negative after 1 week! Therefore, we need to wait for more such data to draw any significant conclusion. The ICMR has given clear guidelines and testing strategies for the pregnant woman in COVID 19 [2, 3]. It also advises hydroxychloroquine (HCQ) prophylaxis for all frontline workers [4].

Informed Consent

In this pandemic, when a patient gets admitted, she has to go through triage before admission. But because of fear, and lack of enough knowledge, her sense of right or wrong gets blunted. Relatives also get confused about the procedure to be followed so it is very important that we counsel the patient and offer complete information on what is being done for her. A special informed consent must be taken that is specific and relevant to suspected or positive COVID 19 cases to avoid future medicolegal issues. Possibility of asymptomatic carriers infecting their contacts must be discussed and included in the form. Each healthcare facility must have such directives about ideal informed consent and keep one such format ready. In COVID section of this issue, Tripathi and Mohapatra present a consent form to be used in emergency obstetric services in COVID times. Readers may find this suitable for use in their respective facility.

Lactation Management and Care of Newborn

Breast milk is not considered a source of transmission of SARS-CoV-2, so we should support breast-feeding in post-partum phase and recommend it as the best choice for infant feeding even after discharge. If mother chooses rooming in practice, breast-feeding could be allowed directly under strict prescribed safety precautions. If the neonate is isolated, breast milk can be expressed with a sterile pump and may be fed by health care worker or a non-infected family member observing strict hand and respiratory hygiene. There is a possible but yet unproven risk of transmission of the virus to the neonate through breast feeding. It also involves additional risk of transmission of the antiviral drugs that mother might be consuming. Safety of these drugs is not yet proven in the neonates. Literature is divided on the issue of breast feeding in COVID 19 positive patients. So it is important that we counsel and educate the mothers and the family members regarding best breast-feeding practices. A thorough discussion of various views and reviews on breast-feeding have been included in a mini-review by Hethyshi in COVID 19 special section of this issue.

Diagnostic Tests

All pregnant women residing in cluster or containment areas are advised to do naso-pharyngeal swab testing for antigen even if they are asymptomatic, when they are expected to deliver in next 5 days [3] as advised by ICMR. The antigen testing is advised in all symptomatic pregnant women. Nayak et al. in their study report doing the swab test for 977 pregnant women on admission out of which 141 women tested COVID positive. This 14.7% positivity is of interest and in a way, alarming as it may point to more widespread community infection than was believed at that stage.

As per guidance released on 23-6-2020 [5], ICMR recommends new Rapid Point-of-Care (PoC) Antigen Detection Test (Standard Q COVID-19 Ag kit) for quick diagnosis along with RT-PCR in the field setting.

A positive rapid PoC test should be considered as a true positive, whereas all symptomatic individuals testing negative through the rapid antigen test (PoC) should be confirmed with a real-time PCR test. This is particularly essential as the newer rapid antigen PoC test is not highly sensitive. This could be useful for screening of pregnant women.

“Test, track and treat” is the strategy recommended by ICMR to prevent spread of infection and saving lives. HCQ treatment was given to all covid positive pregnant women in the study by Nayak et al. IgG ELISA test is used to study seroprevalence in health care workers and not useful for diagnosis.

Early computerized tomography (CT) scan in symptomatic patients will help diagnose pulmonary changes early to save lives. One should not hesitate doing CT scan of chest with abdominal shielding in symptomatic pregnant women when clinically indicated as saving life is more important than the concern about exposure of fetus to radiation. CT scan exposes fetus to a radiation dose of only 0.01–0.66 milli Gray (mGy). It should be remembered that minimum dose that can cause developmental delay is > 610 mGy.

These issues have been dealt well by Francis et al. in a short commentary included in COVID 19 section in this issue.

Pandemic of Guidelines

Many organizations have come forward and published their guidelines or good clinical practice recommendations. ICMR guidelines have also been in place, with updated versions published subsequently. It is very difficult for common practitioner to choose and follow guidance as by the time they adopt a guidance, a new version is published which sometimes is contrary to the previous one. We are facing information fatigue. We present a review article by Khoiwal et al. on “Management of Pregnant Women In Times of COVID-19: A Review of Current Literature.” a fairly balanced compilation of various guidelines from FOGSI, ICMR, ACOG, RCOG, etc. I sincerely hope this helps our readers.

Mental Health of Health Care Providers

Healthcare providers really are going through a trying time, as it is difficult to continue to offer selfless services knowing fully well that their life is at stake.

The factors such as physical stress, shortage of staff, disturbing media reports, lack of timely treatment, colleagues developing respiratory symptoms, fear about transmission of infection to family members, death of a close friend or a relative are extremely stressful conditions. Many face apathy of administrators; some face violence at work.

Obstetric practice is mostly dealing with emergency patients, at such times health care workers may not get enough time and may have to deliver patients without adequate personal protection. Even if they get time to wear personal protection kits, managing patients with same efficiency without food and water for hours at work is also stressful. There is tremendous workload on COVID 19 hospitals. Hence, even a small mistake or lapse may expose them to infection with this deadly virus. HCQ prophylaxis in frontline workers is advised by ICMR, but it must be stated here that it should not give them a false sense of security, and they must follow precautions strictly irrespective of chemoprophylaxis [4].

Above all, they are expected to be flawless in their work and compassionate toward patients so it is not surprising that they often face compassion fatigue, depression and other psychological problems in addition to physical fatigue. Administrators should identify local problems and find suitable solutions, regularly conduct counseling sessions and provide psychological support in addition to other needs of personal protection and treat them with empathy.

Telemedicine: A Boon in COVID 19 Times

We are fully aware that remote consultations are difficult in obstetrics and gynecology practice, but with telemedicine we can certainly limit the number of visits to the hospitals and plan the management more efficiently with minimum hazard of infection which would otherwise occur by physical visit to health care facility. After lockdown, Medical Council of India has brought guidance regarding teleconsultation and is available on their site since 25-3-2020, readers can access and follow these guidelines [6].

We enclose a short commentary on experience and recommendations after 375 teleconsultations by Vimee Bindra in obstetrics and gynecology, which will be useful to practitioners. Telemedicine will help economic revival of many practitioners who are experiencing financial crunch.

Economic Crisis

World faced a huge health and wealth wise setback a hundred years ago in 1918–1919 because of a spanish flu pandemic! This crisis lasted for almost one and half years as the then government took long to understand the right steps to recover from the crisis. Despite this, recession was followed by a heavy boom in industrial sector and overall economy for next decade. Then came the Great Depression of 1929 and again economists and governments at that time did not have a clue how to handle it. With that experience and history, governments today are better equipped to cope up with current Great Recession [7]. Also in this era of much advanced technology and economics knowledge, recovery from economic and health crisis may be faster than last century. Experts predict that this may happen in 4–6 months.

There is always a silver line on the dark clouds; we may witness a golden decade for medical profession in future. If not golden decade, medical profession will certainly thrive due to deeper penetration of medical insurance schemes. Markets have started picking up from 40% fall to now 20% only and may improve even more in next 6–12 months. It may be noted that taking loan for buying a new clinic, equipment or hospital will be more comfortable and feasible as interest rates on loan have crashed to all time low! Even patients who are avoiding doctors for other ailments will come rushing back once pandemic settles down.

At individual level, financial crunch of no or a very low income may resolve in few months, as there are always newer options like teleconsultation opening up. Senior practitioners who have had many years of successful practice are looking at retiring early and stopping work due to COVID 19 crisis situation.

We have witnessed the pandemic of webinars during this lockdown! This has attracted a lot of criticism but has also been acknowledged by many. I do appreciate these webinars and feel that webinars and virtual conferences are the most economical way of knowledge exchange with national as well as international experts of repute. We need to change with the world by using technology and need to go digital whenever possible to combat economic crisis.

Summary

These changing-challenging times are indeed difficult to cope with! The first and foremost challenge is of one’s own survival! Other one is the commitment as obstetrician to help our women bring new life on this earth. We ought to continue to offer emergency obstetric services as this cannot be postponed or managed remotely.

We also have responsibility toward our families and society at large. We need to support family members financially, medically, mentally and demand the same support in return from them. We need to manage issues of the health care workers compassionately and take responsibilities of domestic workers. Frontline Health care workers are truly the corona warriors as they offer their ongoing dedicated services at the cost of their lives. On one hand, their services are being honored by government; on the other hand, they face challenges of violence at work.

We sincerely hope that readers benefit from the special section in this issue containing articles touching upon all aspects of these challenges faced by us in COVID times.

Remember the most progressive race in this universe is human race, and they will evolve and change for better and bigger than ever before as always.

Never lose hope! You never know what tomorrow may bring …. Have patience for better tomorrow!