Deaths Of ‘Non High-Risk’ Patients Raise Concerns

Mumbai: On April 7, 2020, a 25-year-old man was brought to the Rajawadi Hospital in Mumbai, a 596-bedded secondary care facility in the city’s eastern suburbs. The young patient had no additional health conditions such as chronic kidney disease, diabetes or hypertension, called ‘comorbidities’, that would put him in the high-risk category for COVID-19. He did not make it through the day, becoming one of 121 COVID-19 fatalities that Mumbai has recorded from COVID-19.

At 6%, the death rate from COVID-19 in India’s financial capital is higher compared to the 3.3% nationwide.

Mumbai city’s confirmed COVID-19 cases, at 2,120, are more than the number in several states such as Kerala (395) and Delhi (1,640). 

On April 7, 2020, the same day that the 25-year-old patient was brought to hospital, another 45-year-old man was admitted to the Sion Hospital. Officially the Lokmanya Tilak Medical College and General Hospital (LTMCGH), this is a 1,900-bed tertiary care centre. This patient, too, neither fell in the elderly category (60 years and above) nor did he have any comorbidities. Yet, the next day, he succumbed to the contagious virus that has so far killed 147,337 globally and 452 in India.

As India’s COVID-19 tally rises, the curious case of otherwise healthy individuals succumbing to the virus has begun to emerge. This trend was earlier reported in China, where experts pointed out that it was not clear why the virus turned fatal for some of the youngest patients and only led to mild symptoms in others.

“We now have to ask why are these people getting infected and having bad outcomes,” said Om Srivastava, an infectious disease expert based in Mumbai and a member of the task force set up to devise a treatment protocol for COVID-19. So far, doctors have been relying on generic guidelines and feedback from their peers, as IndiaSpend reported earlier.

The task force has specialist doctors including experts in infectious diseases, tuberculosis (TB) and public health. “In terms of the pattern of infection, it [Mumbai] is following the standard kind of graph that it has followed all over the world,” he said.

The ages of the patients range from those a few months old to those above 90. 

Watch this interview for how Mumbai and Delhi are dealing with the pandemic: 

Delhi is admitting all #COVID19 cases, while Mumbai is admitting only the symptomatic ones. How are the two cities managing the pandemic? @govindethiraj speaks to @DrJeenam & @drrajeshchawla on the frontlines. pic.twitter.com/qKZpUzBP91

— IndiaSpend (@IndiaSpend) April 16, 2020

Deaths among the young make things fuzzier, as those the government believes are high-risk might not be the only ones. This would mean we need to expand testing further. 

No clear answers

Instead of ramping up testing, as experts have advised, Mumbai officials have decided they simply cannot afford to test all the patients, and only those with symptoms will now be tested, even though evidence is clear: Around 80% of COVID-19 patients have either mild symptoms or remain asymptomatic, and can infect many others.  

In keeping with the experience around the world, 87% of patients who have succumbed to COVID-19 so far in Mumbai have had comorbidities and 7-8% have had age-related risk factors, according to data released by the city’s civic officials on April 13, 2020. The remaining have been healthy, young people.

Only ramping up testing significantly, as recommended repeatedly by the World Health Organization (WHO), will give us an idea of the number of young people affected with COVID-19 in a community.

“Should it draw the attention of policy makers, yes it should, because it [younger patients] was information that was not there previously,” said Srivastava. “It is important for all this information to come your way before you can say, look, this is what we have learnt from this experience.” 

Why are healthy individuals, who are otherwise not at risk for COVID-19, dying? 

“When you have got somebody who has succumbed on the first day of the infection as against somebody who has succumbed on the eighth or the ninth day of the infection, you probably have to look at not just at the virus, social distancing [physical distancing] or comorbidity--you have to look at what are the immune parameters of these patients,” said Srivastava. 

To understand why the young are succumbing to the virus, it is important to investigate what the trigger to their immune system was that caused the cases to turn critical, he said. 

At the moment, our knowledge of the virus, of the ones most at risk, and of how it affects different demographics, is both patchy and constantly evolving. Some COVID-19 patients experience what is referred to as a “cytokine storm”, when the patient’s own body releases immense amounts of proteins (cytokine) that cause more inflammation. 

Many other factors come into play, such as the patient’s overall health before the infection.

“If someone is chronically malnourished then they are not necessarily in the best of health,” said Vineeta Bal, an immunologist and researcher at the Indian Institution of Science, Education & Research (IISER), Pune. Bal said it would matter whether these young individuals were undernourished migrants, for instance.

The gap between when someone was infected and the treatment could also be important, as well as the ‘viral load’ (number of viral particles in the blood), Bal said. She added that the tests in India currently only give a yes or no answer to COVID-19 infection, and are not at a point to tell the viral load.

Those familiar with the city believe the officials are handling it to the best of their capacity. “If you want to respond to it [COVID-19], then you need to have city-level planning and capacity,” said Milind Mhaske, director of Mumbai-based Praja Foundation that works to increase accountability in governance. “BMC [Mumbai’s civic body] is one of the places responding very well. In Mumbai, we are testing crazily. There is a lot of coordination with the city and the state.” 

The decision to limit testing could undo those gains. 

“Ideally I would have liked to see most of the population have access to testing, like [in] South Korea,” Bal said. “Our country has systematically underfunded the public health system over the years and now [in the middle of a pandemic] nothing can be done about it.”

(Shetty is a reporting fellow with IndiaSpend.)

Update: The story has been updated to remove a comparison with cases in New York.

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