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.

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More from @DrSidMukherjee

25 Apr
1/n Long thread, but of crucial importance. The COVID-19 situation in India is as dire as can be. And it is not just THEIR problem, as long as virus circulates in the world, it becomes EVERYONE'S problem. We live in a global society; viruses don't respect national borders.
2/n This is, or was, a moment of historic importance for the US/ Biden administration to show leadership and solidarity. Recall the legacy of WW2 that established America as a world leader. Compare that to the leadership today.
3/n Now, let's get practical. I've spoken to several people on the ground in India, and here are the immediate needs in terms of priorities. Several field hospitals are being set up, but there are dire infrastructural needs.
Read 7 tweets
12 Jan
1/n Please pay attention, please. I'm afraid that we are falling behind in this COVID race. There are at least 4 variants of concern: variants arising in London, Manaus, Japan and South Africa.
2/n The London variant is more contagious. The Manaus and South African variants may -- MAY -- cause repeat infections.
3/n I cannot see any way forward except: 1. detect the frequency of the variants in the USA and isolate and confine them.
Read 7 tweets
24 Dec 20
Ok let’s start by chopping the mushrooms.
Mix of Crimini, Enoki and Japanese Image
The mix frying in a pan in olive oil Image
Read 17 tweets
22 Dec 20
Ok, cumin, coriander, red chilies ready to roast. You can roast a few garlic cloves if you’d like too Image
Starting in 15 minutes. Get the rice cooking
If you have WHOLE cumin and coriander, then roast them on a pan until the coriander pops (3-5 minutes) and then grind in a spice grinder
Read 31 tweets
21 Dec 20
I'll post all the steps, but it won't be prescriptive. I believe in improvisational cooking. Add, subtract, make it yours. But be honest: $20 to a food bank.
Only requirements: cumin, coriander, turmeric, garam masala, chilies, ORGANIC chicken with skin on, oil (or butter), coconut milk, green cardamom (optional), coriander leaves(optional), $20 to food bank (not optional)
And next week, I'll post at least two veggie recipes. I am not partial to meat...
Read 4 tweets
21 Dec 20
1/2 OK, let's move the challenge. I'm a good cook. Shamelessly good (mostly Asian). If you agree to donate $20 to a local food bank or charity, I'll post our family dinner recipes every night. I'll donate as well until Chistmas (I'm not religious but it's a date)
2/n Tonight I made hotpot. Boiled water, added soy sauce, chillies, SLUG of Miso and Chinese Szechuan Chili Crisp. Cut Tofu, mushrooms, cabbage, carrots, pork slices, scallions, noodles. Everyone had a bowl and had hot pot...
That’s the end of the hotpot Image
Read 6 tweets

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