'Containment best way to stop coronavirus': AIIMS' Dr Prasun Chatterjee on elder care, hygiene practices, boosting immune system

As a locked down India watches the uptick in coronavirus cases with a growing sense of anxiety, the elderly have cause for concern. The statistics are disturbing: more than 80 percent of deaths due to COVID-19 — 14 out of 17 (till the time of filing the copy) — are elderly. This is roughly in line with global numbers.

According to statistics provided by the Imperial College London, while the average rate of death due to novel coronavirus infection is 0.5 percent to 1 percent, the rate for people above the age of 60 is significantly higher at 2.5 percent to 10 percent.

Globally, the elderly make up 45 percent of hospitalisations due to COVID-19.  Fifty-three percent of these need to be shifted to the intensive care units (ICU), and 80 percent of them in the ICU do not survive. Experts say the senior citizens' best shot at surviving COVID-19 is avoiding infection.

The shockingly large number of deaths in Italy  — the highest in the world and having crossed 10,000— is being attributed to the country’s aging population, the second oldest in the world.

The most disturbing news to emerge from the worst-affected regions of Italy is not just the large number of fatalities, but how the older people infected with COVID-19 are being left to die as a result of the healthcare system being overwhelmed. Doctors are being forced to invoke triage — where in a doctor chooses whom to extend medical aid to when the number of patients exceeds the capacity of a hospital to provide treatment, invariably choosing the young who have a better shot at survival.

As the infections grow in India at a higher rate, it's time to take utmost care of the older members of our families. We may be one of the younger nations of the world — with 63.6 percent of our population between the age of 15 and 64 and only 5.3 percent above 65 — but the sheer numbers of the elderly are overwhelming.

This underscores the urgency of the situation India. Dr Prasun Chatterjee, associate professor, Department of Geriatric medicine, AIIMS Delhi and consultant, WHO SEARO, also a founder president of Healthy Aging India, TEDx speaker and an author, speaks to Firstpost on various aspects of COVID-19 with a special emphasis on the elderly.

Edited excerpts follow:

The elderly seem to be most vulnerable to COVID-19. What are the main symptoms people should be on lookout for?

The older people, especially who are above 80, not vaccinated against flu or pneumonia, who are residing in old age homes or long-term care facilities are at high risk of getting COVID-19.

Main symptoms for COVID-19 are fever, cough (dry and persistent) and shortness of breath, not due to a known chronic disease like COPD (Chronic Obstructive Pulmonary Disease), bronchial asthma or heart failure. The other atypical symptoms could be headache, sore throat, nausea, diarrhea, muscle pain or joint pain, nausea or vomiting, nasal congestion, haemoptysis conjunctival congestion. Approximately, 90 percent of patients have more than one symptom, and 15% of patients have fever, cough, and dyspnoea.

The most important consideration is detailed contact history with someone who has travelled to countries where COVID-19 has already been a pandemic. However, anyone who is 65 or above with disproportionate respiratory symptoms should contact a doctor.

Which groups are in most danger?

Elderly 80-plus are the most vulnerable, followed by 60-plus with diabetes, lung problems or kidney disease. Next are the patients of any age group with TB, cancer or HIV. A patient with other respiratory diseases needs admission.

Why the higher mortality rate among elderly?

Possible explanations for the observed higher morbidity and mortality rates among older patients due to COVID-19 include the following:

a. Low physiological reserves due to the biologic changes that accompany aging

b. Frequent presence of multi-morbidity (presence of more than two chronic diseases)

c. Fading immune system. The number of white blood cells that find and help eliminate infections can decline. When there is a challenge by the virus, an older person’s immune system faces a higher chance of an overreaction known as Cytokine Storm. Cytokines are proteins that serve as signals to the body to mount its infection-fighting machinery.

The two main reasons for death due to the SARS-CoV2 virus are respiratory failure and septicemia due to the Cytokine Storm.

This is also flu season. Should older people go for testing for COVID-19 if they have fever, cold and cough? If they can’t get tested, what are the options?

Initially, if an elderly person is suffering from any of symptoms such as fever, dry cough and throat congestion without any contact history, they should only take rest, stay home, maintain cough etiquette (coughing and sneezing into tissues), sanitise their hands frequently with a sanitiser containing 60 percent alcohol, and call the helpline provided by the government. Don't panic.

However, if they have any alarming signs related to organ failure, shortness of breath, decrease in urine, chest discomfort, diarrhea with fever they should immediately visit a hospital. The elderly shouldn’t visit a hospital for routine follow-up for chronic, non-communicable diseases such as hypertension, coronary artery disease, knee pain.

What is the impact of COVID-19 on their mental health?

Social distancing will puts older adults at greater risk of depression and anxiety. Besides films and TV programmes, online technologies can be harnessed to provide social support networks and a sense of belonging.

More frequent telephone contact with close family and friends, voluntary organisations, or health-care professionals may be a solution.

What are the best practices that the senior citizens should follow? How best to take care of them?

Some precautions include disallowing any visitors to long-term care centres or old age homes as only visitors would carry infections inside. As most inhabitants of old age homes are frail and cognitively impaired with multiple diseases, they are at a high risk of contracting this fatal disease.

Old-age homes should be well ventilated and physical distance of more than one metre should be maintained. In addition, they should follow routine hygiene protocol meant for other age groups.

What is the best way to prevent this pandemic from growing larger?

Prevent the entry of virus in your body and prevent the spread of virus to others in your community. More than 80 percent of infected persons are asymptomatic or with minimum symptoms as per the previous studies, so in a crowded place, it’s very difficult to know who is infected. Of course, a detailed epidemiological history of travel and contacts is the best way to screen but sometimes it’s not possible to trace them.

Why is it spreading so rapidly?

In epidemiology, there is a term called ‘Reproduction Number’ (Ro). Ro of coronavirus is 2.2, which means a person who is diseased or is a carrier can infect 2 to 2.5 persons on an average. Someone who is diseased or carrying SARS-CoV2 virus and is without protection, can infect 2 to 3 persons who in turn can transmit to a further 2 to 3 persons each. The chain will go on without interruption if most of them are asymptomatic (no symptoms).

However, we need not panic as the mortality rate is not that high (2 percent to 3 percent) as per data from various countries who have already suffered from this disease.

Why should we quarantine for 14 days?

As per previous data, 97 to 98 percent people who develop symptoms do so within 12 days of being infected. According to various studies, the incubation period varies from two to 14 days, which means someone who has had a contact with an infected/diseased person may develop florid or mild symptoms up to 14 days. Therefore, a 14-day quarantine is necessary to confirm if a person is infected.

What’s the difference between isolation and quarantine?

Isolation is for someone suffering from the disease. The patient can be isolated at home, or in a hospital room as per the symptoms and the discretion of the treating doctors.

Quarantine is meant for someone who has not been diagnosed with the disease but may be exposed to the cases.

It is one of the best preventive methods to contain the infection, especially when there is a threat of an impending epidemic.

For example, X is exposed to a case, knowingly or unknowingly. If he is quarantined at home for 14 days, there are two possibilities: first, if he develops significant symptoms like dry cough, fever and specially breathlessness, then he must contact a doctor and check if he is suffering from COVID-19.

Second, if he is asymptomatic for a total of 14 days, it means he is neither infected nor suffering from the disease. So, the best way is self-quarantine for at least two weeks.

One more point that needs to be highlighted is that you need not presume you are suffering from the disease until there are significant symptoms or contact history. So, you should not go to the pharmacy and ask for medicines.

Some people are going for antibiotics and Hydroxychloroquine tablets...

I have learnt that some people are buying antibiotic and anti-viral drugs. This should be stopped as these drugs are not appropriate for this disease. In fact, they will do more harm. Let's allow the doctor to take the call. No prophylactic role for presumptive cases.

How can the elderly boost their immune system?

Any infection can weaken your immune system and make your body prone to catching viral infections. To keep your immune system in robust shape, take plenty of fresh fruits, vegetables, and foods containing Vitamin C. Even though there is not enough evidence, all these foods will definitely strengthen your immune system to deal with infections. This is applicable for people of all age groups.

Besides, while we continue to face the threat, it’s advisable for people to workout at home, yoga, meditation and do cognitive stimulation (playing Sudoku, solving crossword puzzles). And while the lockdown continues, socialise through digital platforms.

How is this new coronavirus different from earlier coronaviruses that spread SARS or MERS?

It's more contagious due to high reproduction number, but mortality rate is lower than SARS or MERS. However, fewer people were infected in the case of SARS and MERS.

How effective is a good hygiene in slowing down the spread of coronavirus?

The virus stays on hand but infects humans only when they touch the mouth, nose and ears. The virus can penetrate mucus, but not skin.

So good hand hygiene, especially cleaning your hand before you touch these areas can prevent transmission. Second is cough etiquette (coughing and sneezing). It’s also advisable to wash vegetables, fruit, meat, poultry and eggs properly after getting them home from market and before consumption.

How does the infection progress?

It affects our respiratory system. Through the respiratory pipe it goes inside to reach the terminal area of lungs called alveoli, where the exchange of air takes places.

It stimulates various cytokines which precipitate acute inflammation and fluid retention across the long parenchyma, and as a result there is significant reduction of air exchange.

It decreases lung surface area to oxygenate the blood, which then circulates to the entire body. Medically, this condition is called acute respiratory distress syndrome (ARDS).

It is a condition that causes fluid to build up in your lungs so that oxygen can't get to your organs. Fluid leaks from small blood vessels and collects in tiny air sacs (alveoli) in your lungs so they can't be filled with enough air. ARDS is a ‘very very fatal’ disease with high mortality (35 to 55 percent).

At what point should one approach a doctor?

If you have a history of travel abroad and returning here in the past month; if you had a contact with someone who travelled abroad recently; if you have serious symptoms of cough, fever and breathlessness.

However, if you only have running nose, you need not to worry at all as this is seasonal flu, which will subside on its own.

What about all kinds of new cures and treatments we get to hear about on the internet?

Nothing can stop the entry of the virus into your body except keeping enough distance from the infected. But even if you get it, remember that 80 percent of people are asymptomatic. Only 10 to 15 percent need hospital care. Survival depends upon the health care facilities, your age, previous co-morbidities and immune system.

How effective is the 21-day national lockdown?

This is the only step he could have taken to prevent transmission. Partial paralysis of system will not work as inherently we are not law-abiding people. The best way to stop any epidemic is containment.

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Debobrat Ghose