Thread by @DrSidMukherjee

1/n The anecdotal stories about the number of people in India getting COVID after AZ or Covaxin need to be addressed.

2/n Either it’s a question of the denominator. Even with 90 percent effectiveness, 10 percent breakthrough in a country of 1.3 billion is a HUGE number. So maybe the anecdotes are that 10 percent

3/n Or the true effectiveness of the vaccines in the field are substantially lower. In which case, we need to measure that... it’s crucial to drive policy

4/n Such a study should be relatively easy to launch — I’d be happy to contribute thoughts on study design @AskDrShashank or others.

5/n Also crucial to know if vaccines reduce hospitalization or severity. Is there an inoculum dose response ? And is there a critical time post vaccine that full immunity kicks in ?

6/n Last two questions from the virological point of view. In vitro evidence suggests that the B117 and B1617 strains (dominant in India) can be neutralized with the vaccines.

7/n In Israel, a SMALL study suggests that the Pfizer vaccine protects against B 1617. We KNOW it protects against B117. But what about AZ and Covaxin ? Do they protect ?

8/n And what do we know about the virulence of B1617. B117 (UK variant) is clearly more pathogenic— although protected by vaccination. One would expect B1617 to also be more infectious and virulent. Any real (human) data ?

9/n Turning away from virology, where does one get an assessment of the oxygen situation in the worst affected States ?

10/n The GOI keeps telling us it’s under control. But the testimonies of people tell us a completely opposite story. Can one get the real data ? Where ? Is there a plan ? Who is making the plan, and under what situation?

11/n Are there field hospitals being set up ? If so, would people be comfortable with the army corps being deployed to manage them ? The requirements for mild/moderate Covid are simple ...

12/n 1. If Oxygen sat above 92 percent, stay home, use fever medicines, lie prone, drink water and use Budesonide inhalers (small study).
2. Do NOT crowd hospitals.

13/n If oxygen saturation falls below that, go to hospital in
an ambulance that has a working oxygen tank. Prone position. Fluids. Oxygen. Dexamethasone. Remdesivir and Toci only under medical supervision (does not reduce deaths in severe Covid).

14/n So overall suggestions
1. Release data or appoint from a clinical body to assess the reality of viral breakthrough after vaccination

2. Release data about oxygen supply chain problem and appoint a commission to solve it ASAP.

3. Transport oxygen by airlift or train if possible. Start refitting industrial plants for medical oxygen.

4. Rely on other countries to stopgap while the supplies are low. Release customs barriers ASAP.

5. Create field hospitals where oxygen sats can be checked and lower level Covid care (as above can be administered). Remember how during the Spanish flu pandemic, field hospitals were set up outside.

6. Open green lanes for ambulances to bring people to the hospital that need more acute and urgent care.

7. Waive the requirement for “ prior Covid test” to admit critically ill patients. Bayesian statistics would argue that these people have covid.

16/n The three pillars of response (oxygen supply chain /hospital logistics and vaccine virology and distribution) should be meeting EVERY OTHER DAY to provide live and realistic data outputs so that we can understand the evolving nature of the pandemic

17/n STAY AT HOME; wear a mask. Isolate. Do not attend crowded places (rallies or melas) with poor ventilation.

18/n If the situation worsens (how can it worsen?), contemplate a 2 week nationwide lockdown AS A LAST RESORT. Plan in that case to provide human services to migrants PROSPECTIVELY, again by appointing a commission NOW, not after

19/n I know it’s easy to opine from far away, but I’ve taken care of Covid patients. Follow @PSampathkumarMD and @Atul_Gawande who give good clear advice.