T&T is now experiencing the ‘second wave’ of this COVID-19 pandemic and while in the month of August, we witnessed numbers increasing exponentially, we were being told that this definite upward trajectory of the virus was in keeping with the so-called ‘Log phase’ of the virus. The concern then was how high and how long this steep part of the curve will exist. The major thrust of breaking the transmission of this virus was placed squarely on the responsibility of the public to adhere to all safety protocols.
I had previously stated in an article of 1/6/20 in this newspaper that the MOH had done a satisfactory job in handling the pandemic. I write in an attempt to review my own statement.
One of the most striking findings coming out of the collected data so far is the rise in numbers in the younger age groups. This was the group that dominated the mingling, the partying and the flouting of the regulations, particularly the non-wearing of masks. The most alarming finding is that there are almost daily deaths, with a total of 75 at this time, highest in the elderly and in those with co-morbidities. Question is, how did these elderly patients contract the virus? Were they also mingling in public spaces or did the young ones take it home to them? Herein lies a point I was labouring amongst those I knew—that the young ones will contract the virus, become asymptomatic carriers, take it to their older folks, and the latter will be the ones to succumb.
There was a thinking by the partying folks that the virus was gone and that they were safe to mingle, to party both in their own homes and elsewhere, beaches in particular. The rationale employed was that they all knew each other, were family and they were all safe.
We must have failed in reaching the good sense of these delinquents. The message seemed to have been lost somewhere. My own observation is that the MOH slipped. I make reference to my article of the 1/6/20 in this newspaper where I wrote, “My fear that the public will start to let down their guard as they misinterpret and misunderstand that the apparent reduction in the number of new cases indicates we are safer now. This false sense of safety can cost us dearly. Now is the time for the MOH to intensify their mass education programmes, emphasising it’s not the majority doing the right thing who will win but that it takes only one person to do the wrong thing”.
I stated then that the population needed to be bombarded by educational videos demonstrating the simple correct techniques of wearing the masks and washing the hands. Again, we had the time.
But, in this quiet phase, how much pre-planning was being done? Just how pro-active were we? We never heard about not “if” but “when” the second phase comes. The talk was feverish and about elections. We were so bombarded by the campaign ads, ad nauseum.
Prime time news hour was hijacked by the politics while Rome was going to go on fire! For sure, much went astray during the elections, whether some want to admit it or not. Caution was thrown to the winds even by those who should be exemplars! Thankfully, there were many of us guided by good sense. This ‘quiet’ period should have been for us to step up with our public health education ads and ramp up our community testing.
Of the lack of adequate testing at that phase, we have no information on what existed in the community. Public health education programmes are few and inadequate as it relates to COVID-19. They need to be improved in frequency, graphics and content and the public needs to be bombarded by mass education programmes. There should be more colourful flyers and posters and while some are funding bill boards with political propaganda meant for a few, it would be more nationalistic if these billboards bore messages to the effect of ‘Mask Up!’.
This method has changed many trends in the morbidity and mortality of chronic diseases in developed countries in earlier years. I am shocked at how little our young people understand about this condition. The MOH has a challenge to reach this group.
The MOH has to be commended for legislating the use of masks. It sent the signal that the MOH was serious in its fight against this virus.
Our culture at times seem to border on indiscipline and lawlessness. As such, many need the heavy hand of the law, and it is very unfortunate that mandatory wearing of masks was not legalised prior to the elections in anticipating the culture of some here. But, we all know well, the heavy politicising of the pandemic pre-elections could in no way extend to common support for such a measure.
Similarly, announcing the closure of beaches and bars on a Saturday to take effect on a Monday morning, shows we do not understand the culture here. Clearly, the virus was at bay and would have been released on Monday! Hikes in gas prices take immediate effect on budget day. Future decisions must factor in this aspect. The danger is with the delinquent few.
HOTBED OF UNCERTAINTY
Since mid-August, we have not been provided with an accurate daily figure for number of cases reported on that specific day. Instead, the figure given to the public can include cases that go as far back as days to over a week. However, the MOH Epidemiologist seems to have this daily figure and rightly so, yet, we are not privy to it. Indeed, this raises a hot bed of uncertainty and doubt in the concerned public’s mind. Is there something we are not supposed to know or only know it when timely? Effective dissemination of information to the public is important and indeed, it is our right to know.
The MOH decision to have home care of those asymptomatic to mild cases and further, deliver pulse oximeters to them and have cases involved in monitor ing the course of their own condition is also very commendable.
In early years, when nebulisers were being prescribed for asthmatics at home, this was associated with an increase in mortality for the simple reason that patients over relied on their nebulizer and presented at a delayed time to the A&E.
The major pitfall that comes with home care of COVID-19 cases is relying on their symptoms, especially the absence of dyspnoea or a feeling of difficulty in breathing. I wish to emphasise a clinical point raised on the media update. There exists a discrepancy or a marked disconnect between low levels of oxygen in the blood (hypoxemia) and relatively absent or mild symptoms of SOB. This so called ‘Happy or Silent Hypoxemia’ phenomenon can result in rapid deterioration of a patient and death. Therefore, patients need to be vigilant in this regard and in those patients at home equipped with pulse oximeters, relying on symptoms alone is not best practice. Patients are hopefully being given a flyer explaining this phenomenon when being given the oximeter. In fact, a major sign to note is any increase in the respiratory rate (Tachypnoea ) that can be an invaluable signal of impending compromised lung function.
While the parallel health system seems to now have satisfactory capacity with the new discharging guidelines, screening at the community level is poor and no one can be satisfied with our TESTING capabilities at this time.
TESTING MUST BE A PRIORITY
Without rapid antigen testing in the community, we can never know the burden of our spread and to say numbers are dropping, will leave uncertainty and doubt while propelling some delinquents. Finally, after weeks of lengthy delays, there seems to be some progress in handling the backlog of cases waiting on reporting. We are told the problem is not in testing but in reporting.
How does that help? The trend was always that the so called 2nd wave rebounds harder. Now, is the real test. The numbers were always known to be going to rise. We created new beds. We added extra staff. But, did we anticipate that with added numbers meant increased samples for testing and therefore, increase staff at the TPHL?
Long before the minister stated repeatedly the hitch was not at CARPHA, the latter had already put out a statement that they had no outstanding samples to test. The usual very confident minister had to openly apologise to patients for lengthy delays in them acquiring their test result. Samples from Tobago had to be sent to Trinidad and samples from SWRHA were being sent to as far as Sangre Grande and Port-of-Spain.
The decentralizing of testing services, setting up new testing sites and machines were being told to us since March. As much as there must be a process such as acquiring the appropriate testing kits, (demand-supply chain), validating machines, training staff etc, it does seem an unusually lengthy period of time getting this aspect of the system going. The interval of swabbing a suspect case and accessing that report is a critical period. The Minister of Health should focus more on providing updates on procurement details, staff recruitment and deployment, and plans to avoid a 3rd and 4th wave, and indeed, nitpicking those businesses that can in fact function rather than presenting clinical details or other social ills. We are happy Tobago and SWRHA are now seemingly coming on stream with their own testing capabilities.
DEATHS AND CO-MOPRBIDITIES
The numbers of deaths are being presented and this is a critical part of public information.
But, to qualify it by referencing the figure to the global projected figure gives us no comfort.
It sounds too clinical and almost harsh and justifiable.
Any death in this small community of ours is a most distressing and heartbreaking occurrence and no one will like to feel their dear one’s passing was acceptable as we are still below the global trend. This calls for much sensitivity in presentation. Personally, I find the number of deaths very concerning, of ones dying at home and some en route to the hospital.
I was shocking to hear of patients dying because they pulled off their oxygen masks. Hypoxic patients are confused but it is hoped that they are being properly cared for medically. We need to know how many have required ventilators, and of those, how many died.
I make reference to my previous article again, where I stated the concept of Medical Confidentiality needed to be revisited. As a medical professional myself of over 40 years standing, am very much conscious of this term. By repeatedly stating ‘2 were elderly men with co-morbidities ‘ etc, tells little of worth.
By stating the co-morbidity, eg the patient was Diabetic or Hypertensive can serve as a message to those Diabetics and Hypertensives in the public domain, to tighten their control of these conditions, further limit their whereabouts and increase their safety protocols. A Diabetic or Hypertensive who controls their condition more tightly will be better able to survive the infection.
It is being suggested that apart from presenting the Global, and Local Epidemiology, we must include the Regional. We must involve ourselves in the Regional COVID-19 epidemiological findings as this can only be a further learning exercise.
The intention here is not to point fingers at loop holes but to support good initiatives as laid out by the MOH while expressing some concerns. COVID-19 is everyone’s business.
DR C SINANAN-MAHABIR,
Former Senior Chest Consultant/TB Personnel,