Caring for respiratory disease in India in the COVID era

KEYWORDS:

• COVID-19
• India
• interstitial lung disease
• post-COVID pulmonary fibrosis
• tuberculosis

1. Introduction

Nothing in the last hundred years has impacted the practice of medicine as adversely as the COVID-19 pandemic [1]. The effects have been particularly severe in India, struggling with problems of a large population, homeless migrant workers, limited resources, and poor access to health services. Marked slowing down of economic activity due to prolonged lockdowns and restricted mobility had put the health services on the back foot. Resurgence of the pandemic during the current year has further worsened the situation at a time when recovery from the first wave in 2020 had just begun to be seen. The overstretched health-care infrastructure and reassignment of health-care personnel to COVID duties have affected, in particular the care of non-COVID patients and health personnel [2,3]. There had been an extreme shortage to almost complete absence of general medical facilities for several months. Activities related to medical teaching, training and research were not even talked about. Patients with non‑COVID infections and non-communicable diseases could not be managed as effectively as needed [3]. Sharing of epidemiological information (and misinformation) through the digital platforms such as the television, social media and the internet have only worsened the situation.

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Patients with respiratory diseases which clinically mimicked COVID-19 suffered the most. They were often shunted from one facility to the other. Patients with even previously diagnosed respiratory diseases found it difficult to continue maintenance treatment and receive emergency care. Sputum examination, spirometry, nebulization and bronchoscopic procedures were almost abandoned. Tuberculosis (TB) management has been severely affected causing a major set-back to control of tuberculosis [4].

The Revised National TB Control Program (RNTCP) in India introduced in 1993 had achieved such significant results that the Prime Minister of India in 2017 envisaged to achieve elimination of TB by 2025 and therefore the government modified RNTCP to National TB Elimination Program – NTEP [5]. Besides the direct supervision of administration of anti-tubercular therapy (Directly Observed Therapy or DOTS), the NTEP incorporated case-detection and other strategies [6]. Nationally, the number of newly registered TB patients during 2020 showed a monthly fall of 21%, 63%, 47%, 25%, 38%, and 45%, respectively, for the months of March to August, compared to the same period of the previous year [7]. Similarly, there was a sharp decline in TB case notification in a public–private partnership (PPP) model under the Mission TB Free Haryana during the lockdown period of March–May 2020 [8]. Patients on DOTS have missed their treatment doses for several weeks. An assistance of INR 500 per month was provided for nutrition support for each notified TB patient during the period of treatment under the ‘Niskay Poshan Yojna’ (National Nutritional Support Scheme). None of these strategies could be successfully implemented during this period. According to a recent news report, none of the 45,000 patients enrolled under the control program in Punjab alone could receive this assistance [9]. There is prediction of a surge in TB cases and deaths in the post-COVID period in different modeling exercises [10]. Telemedicine was not an alternative solution for diagnosis of sputum examination and ‘directly observed therapy’ – essential for NTEP. The final data on the outcomes of treatment are not yet finally available, but the damage is already done. Achieving ‘TB elimination’ by 2025 seems highly ambitious in the current scenario.

Patients with chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) constituted other major group who suffered due the obvious focus of attention on COVID-19 [3,11]. We do not have documented national data but overall clinic attendance and admissions had fallen from nil to less than a quarter of the pre-COVID period [3,12]. An overall reduction in the levels of air-pollution due to lack of human activity and adoption of public hygienic practices including the routine use of face-masks were partly responsible for a decrease in the incidence of upper respiratory tract infections as well as allergic catarrh. In the absence of physical visits, there was an expansion of tele-services for consultations employing various electronic media such as the telephone and WhatsApp. There was also an increase in the appropriately structured telemedicine platforms but the number of non-COVID respiratory disease patients seeking consultation was less than half of that reporting previously.

The absence of investigations greatly hampered the diagnostic and management capabilities of physicians even for diseases such as flu, allergic catarrh, asthma, COPD and pneumonia, which mimicked clinical picture of one or the other form of COVID-19. It was a big challenge to make a specific diagnosis and treatment was therefore most symptomatic. Moreover, a large number of patients of lower socio-economic groups could not use these resources for one or the other reason. Administration of appropriate treatment and/or hospitalization got frequently delayed for 48–72 hours pending the availability of COVID-19 tests for patients with high fevers, pneumonias and acute respiratory distress syndrome (ARDS). There was almost complete absence of facilities for intensive care and assisted ventilation for all non-COVID respiratory failure. Besides the problem of differential diagnosis from non-COVID acute respiratory illnesses (infections and allergies), COVID-19 was frequently responsible for precipitating an acute exacerbation of a chronic respiratory disease often with concomitant comorbid conditions (hypertension, cardiac or renal disease, diabetes, malignancy, and other chronic diseases). The problem was particularly severe in such patients with septic shock and/or multiple organ failure.

Not just the nebulization therapy, there was a general skepticism on use of inhalers and inhaled corticosteroids for the fear of aggravation of COVID-19. Such fears were fueled by ill informed social media reports among the gullible patients. Absence of direct patient to physician contact and regular follow-up visits did not help to alleviate the misconceptions. There had been a significant increase in such cases landing with acute worsening of stable condition. It was worse that there was a general lack of facilities to treat such emergencies.

A significant number of patients who suffer from ‘long COVID’ or ‘post-COVID syndromes’ continue to complain of general systemic and respiratory symptoms following recovery from acute infection [13]. The symptoms were largely attributable to stress, anxiety and depression following the period of quarantine. Panic created by falsehood, rumors and misinformation significantly contributed to social, behavioral, and mental deprivation. Further, the patients posed problems of psychological assessment and management. Such patients, often on advice of ill-informed friends and doctors frequently resorted to repeated blood tests for inflammatory markers and chest radiography rather than opting for professional psychological help. Around 10% of patients who suffered from severe illness and ARDS developed post-COVID pulmonary fibrosis and presented with breathlessness, de-oxygenation, chest interstitial infiltrates, and/or honey-combing [14]. In the absence of a well-tested algorithm for the diagnosis, it was difficult to identify an underlying interstitial lung disease on history alone. As a result, many of these patients received a cocktail of therapy consisting of corticosteroids, other immunosuppressive agents and anti-fibrotic drugs. General ‘on-the-counter’ availability of drugs worsened the situation. The subject of post-COVID pulmonary fibrosis in fact has increased now even after the significant containment of the pandemic in India. It seems highly likely that post-COVID pulmonary fibrosis will continue to constitute an important cause of interstitial lung disease. Similarly, the use of anti-fibrotic drugs such as nintedanib and pirfenidone in its management remain a subject of intense interest [14,15]. Whether the condition is also a likely risk factor for lung cancer remains conjectural and an issue of follow-up research for the present.

After a relative quiet period, the COVID situation has again flared up. The earlier control was attributed to early and effective anti-pandemic steps, strict lockdown conditions, and adoption of public-health measures. The second wave has hit like an earthquake threatening the entire infrastructure even more than the first wave. The task of managing non-COVID respiratory illnesses in the presence of COVID-19 illness is both enormous and onerous. Besides the general strain on health personnel and scarcity of resources faced by all physicians, the pulmonologists and intensivists confront additional problems related to both the diagnostic and treatment approaches which pose a potential threat of dissemination of infection. One hopes that different strategies to control the pandemic are also effective to handle other medical problems. The health-care providers at the community level as well as in the hospitals need to maintain and strengthen the existing health care in patients with non-COVID lung diseases.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.