Re-Opening Precipitately? Look at India

"I think the problem is that what we are seeing is that this idea of herd immunity is messy."

"Whether we're talking about a single mutant or double mutant or triple mutant, we're seeing quite a few different mutations." 

"The real question for us is figuring out, as quickly as possible, with India, what does this variant mean? Is there a correlation between B.1.617 and the crisis that they're in right now [does it have enhanced properties?} For Canadians, that's the information we need to know."

What does it tell us from our own personal standpoint? It tells us we are still dealing with the same virus.We've got to be vigilant with that stuff if we don't want to see this new variant, or any other variant, transmitting widely through our community. Because once it hits a tipping point, we can't stop it in its tracks."

Jason Kindrachuk, virologist, University of Manitoba

"[Following the first wave in India the numbers started nose-diving early in the New Year], and everybody started celebrating, declaring success, that 'we're out of the woods'."

"And we thought a good proportion of Indians would have gotten naturally infected last year and would have antibodies, and then vaccination started."

"And then the Indian government, in its wisdom, opened up in a hurry. No social distancing [as millions attended religious festivals and super-spreader political rallies], masking went down, public health measures were relaxed and testing went down."

"And then we started to see the number climb again. You've seen the graph, right? It looks like a rocket going up. I've never seen anything like it."

Dr. Madhukar Pai, Canada Research Chair in epidemiology and global health, McGill University

Paramedics wearing protective equipment wheel a patient into the emergency department at Toronto's Mount Sinai Hospital. THE CANADIAN PRESS/Chris Young

 

A directive was issued to hospitals in Ontario in April that non-urgent care in the operating room must cease. Surgeons, nurses and anesthetists should be prepared to redeploy to the COVID wards and the ICU. Triage meetings have become regular events to discuss which of the cases presenting must be sent to the operating room and which patient appears on the brink of permanent or irreparable harm, and that person must then wait -- 'declined'. This is called the reality response to a desperate situation.

India's catastrophic COVID-19 wave has brought with it a dire situation with doctors sending out SOS messages pleading for oxygen. It is where opportunistic variants are now beginning to spread widely in Canada, causing great alarm, but in comparison to the situation in India, a mere ripple as opposed to that nation's riptide of illness. On a number of recent consecutive days India has posted unbelievably huge single daily COVID caseloads such as 332,730 cases and 2,263 deaths. Daily. Mind-boggling.

New Delhi, the nation's capital, is riddled through with COVID cases and they continue to rise. "If we open up everything, give up on public health and not vaccinate rapidly the new variants can be devastating", warned Dr. Madhukar Pai of McGill University. It is as yet unknown whether India's growing caseload owes to new infections or how much reinfection is involved. Studies out of Manaus in Brazil suggest that up to half the population in some of India's largest cities had been infected previously in the first wave, resulting in a fairly high immunity in the population.

Only now has Canada officially closed the air corridor for a month for direct-passenger flights from India and Pakistan to enter Canada. Too late, unfortunately, to prevent a new 'double mutant' from arriving. The B.1.617 variant has already been identified in British Columbia, Quebec and Alberta. "Variants of concern" now account for over half of confirmed COVID-19 infections in Canada, Friday's new modelling confirm.

In the Greater Toronto Area patient transfers are increasing, COVID patients being sent to other, less-crowded hospitals in Ontario to relieve some Toronto hospitals briefly, before even more patients arrive, as anticipated. Pregnant women are now being over-represented in Toronto hospitals with COVID, populating ICUs, requiring emergency C-sections. A new phenomenon has arisen where an average of two people a day die at home, becoming critically ill so suddenly there is no opportunity for them to arrive at a hospital.

 

Despite the Covid-19 surge, crowds have been allowed to gather for Kumbh Mela in Haridwar, India. Photograph: Anushree Fadnavis/Reuters

 

Word of a "triple mutant" virus detected now in India has turned the heads of virologists and infectious disease specialists. There is speculation, but no hard data available, about how these variants behave together, or on the background of other mutations. The variants all carry an alphanumeric soup of mutations, some more threatening than others. B.1.617 is imbued with several mutations shared by other variants shown to have a measure of antigenic escape; in other words the capacity of a virus to evade its host's immune system.

The situation is so grave it is imperative that vaccinations be sped up by all necessary means. Complicated by the reality that vaccines are in short supply, thanks to the incompetence of the federal government that chose early on to do business with China, until that fell through and vaccines had to be sourced elsewhere, late in the game, through more infinitely reliable venues. Masking, distancing and all other infection prevention control measures continue to be in mind of everyone in an effort to control as much as possible, the trajectory of the coronavirus surge.

 

A patient with breathing problems is seen inside a car while waiting to enter a COVID-19 hospital for treatment   Reuters

 

Deaths are known to be under-reported in India, with infections likelier to reflect three million per day, than the official tallies. Space to cremate people is no longer so readily accommodated; there are simply too many to deal with. The vaccination programs are not proceeding as speedily as they should. Vaccine production in India has run into difficulties with the emergence of a scarcity of supplies for which they have turned to the U.S. to expedite the materials needed, held there in greater abundance. India is no longer releasing vaccines outside their interior emergency, and the U.S. is reluctant to release materials they may themselves need. A deadly spiral.

Entire families are becoming ill, the young being infected along with all others in India, and similar reports are beginning to come out of Ontario, with entire families arriving at hospitals with COVID. People in their 30s or 20s in intensive care. Natural acquired immunity may not be adequate in protecting from the new variants, Dr. Pai worries. "But we really need to see this as a global problem. If you have fires raging in India, or Brazil, or somewhere else next month, we will never get out of these pandemic cycles."

A mass cremation of victims who died due to the coronavirus disease (COVID-19), is seen at a crematorium ground in New Delhi   Reuters

Preparing For That Worst-Case Scenario ...

"[Ontario should ensure] liability protection for all those who would be involved in implementing the Proposed Framework ... including an Emergency Order related to any aspect requiring a deviation for the Health Care Consent Act."

"[ICU doctors should regularly reassess people admitted to ICU to consider withdrawal of life support] through a shared decision-making process with SDMs [substitute decision-makers] if a patient does not appear to be improving." 

COVID-19 Bioethics Table, Ontario

Dr.James Downar:  Ottawa Hospital Research Institute/CP

"It's really important to be clear here -- this is not about how long you're likely to live, it's not a lifespan question. It's your probability of being alive 12 months after developing critical illness."

"We're suggesting, out of a principle of fairness, the same approach should apply to people inside the ICU. It would be unfair to treat people differently depending on the timing that they presented."

Nobody likes the idea of ever withdrawing life-support on somebody without their permission, without their consent. But in a triage scenario, we're talking about a scenario where the focus is no longer on the individual himself, but now on our population as a whole, and trying to maximize the number of people who will survive an overwhelming surge [of COVID hospitalizations]."

"We are hopeful that, as part of the state of emergency, should we need it, that there will be an executive order allowing us to withdraw."

Dr.James Downar, head, palliative care, University of Ottawa, member Bioethics Table

"We are going to say, 'By the way, we are taking your family member off the ventilator in lieu of another patient who we feel has a better prognosis, given this pandemic condition. Do you agree'?"

"I think that if we did that we would not get consent. Nobody is going to give us consent."

Dr.Peter Goldberg, head, critical care, McGill University Health Centre

"It's difficult to imagine how troubling that would be, that we would actually have to suspend the consent act."

"[However, should hospitals become unable to handle a rush of people in the ICU who are unable to benefit from critical care, who are likely to die] -- If we don't have the tool to provide equitable access to care, that will create a lot of distress on the system."

Dr.Andrea Frolic, director, Program for Ethics and Care Ecologies, Hamilton Health Sciences

An ICU health-care worker shown inside a negative pressure room cares for a COVID-19 patient on a ventilator at the Humber River Hospital during the COVID-19 pandemic in Toronto  THE CANADIAN PRESS/Nathan Denette

 

In the event that the current situation of burgeoning COVID infections persists and accelerates, the Province of Ontario government has been approached with a request to temporarily suspend the law that requires doctors to obtain consent of patients they are treating or their families prior to withdrawing a ventilator or any other life-sustaining treatment in the case of patients facing a grim end-of-life prognosis, should the feared crushing of hospitals' capability to treat an onrush of patients eventuate.

 

Specifically, Ontario's COVID-19 Bioethics Table, a group of health professionals tasked to forge a method by which the province would be able to handle the epidemic of virus infections most capably, is recommending that the province issue an Executive Order suspending the province's Health Care Consent Act for withdrawal of treatment in the ICU in the possible event of the situation becoming untenable. An enabler to smooth the way for doctors to assess patients' likely outcomes and acting accordingly.

 

The provinces are in the process of protocol preparations determining who should benefit from critical care, and who might be left without, should hospitals become flooded with critically ill COVID patients.As it stands, the Health Care Consent Act requires doctors to obtain prior agreement from patients before they have life-support withdrawn on the advice of attending physicians, any resulting disputes to be resolved by the Consent and Capacity Board, an independent tribunal. 

 COVID-19 vaccine  Carlos Osorio/AFP via Getty Images

An "emergency standard of care" alert was issued this week by the Ontario Critical Care COVID     Command Centre, for hospitals to prepare for the worst-case scenario, somewhat akin to what Italy experienced in its overwhelming demand surge for critical care, when hospitals there were forced by such circumstances to make those wretched life-and-death decisions over who they deemed could be saved by ICU treatment and who would obtain least benefit from it, given the depth of their medical condition.

The document stressed its over-arching objective, to "save the most lives in the most ethical manner possible". Recommending that a critical-care triage be considered as an option of last resort, to be taken only once all other reasonable efforts have been taken to move people to other hospitals where space might be available and appropriate staff present to care for them -- and then only for as long as the surge might go on. Minimizing deaths, minimizing risk of discrimination and "unconscious bias" against people with disabilities, racialized communities and other vulnerable groups, and minimizing "moral injury and burnout", the ultimate stated goal.

Priority, the document made clear, was to be prepared to give patients with the greatest likelihood of surviving any conditions bringing them to hospital, whether it be COVID-19, heart attack, a bleed in the brain, or any other life-threatening illness. Any patients presenting with a steep likelihood of expiring within a year -- from whichever critical condition they present with -- would receive a lower priority rating for an ICU bed.

"This is literally life and death and to not only give doctors that power to operate outside [the act] but to insulate them from any liability whatsoever, that is not something to be taken lightly."

Mariam Shanouda, lawyer, ARCH Disability Law Centre, Toronto