Wearing face masks is just a part of an inclusive strategy for preventing and controlling the spread of viral infectious diseases, including COVID-19. Masks can be worn by healthy persons (for self-protection while accidentally coming in contact with an infected patient) or by an already infected patient for preventing further spread of the infection (source control). But, solely using a mask cannot provide optimum protection or source control. The WHO advises people to wear masks when unable to maintain social distancing. Compliance to other infection prevention and control (IPC) measures, such as maintaining social distancing and practicing hand hygiene are imperative to prevent human transmission of the viral disease.

Guideline for using masks in the health care settings

A) Use of medical masks (surgical or procedure masks) and respirators (N95 masks) for caring suspected or confirmed COVID-19 patients

It is recommended that health workers who directly provide care or come in direct contact with COVID-19 patients, should wear a medical mask (along with other PPE components that are a part of aerosol and contact precautions), in the absence of aerosol-generating procedures (AGPs).

In areas where AGPs are being performed, it is recommended to health care personnel that they should wear a N95 or FFP2 or FFP3 or equivalent standard respirator.

B) Targeted continuous use of medical mask by health workers in locations of known or suspected COVID-19 community transmission.

In the context of areas, where community spread of COVID-19 is suspected or an intense COVID-19 outbreak exists, following recommendations are provided:

Health workers practicing in clinical area should always wear a medical mask during their routine activities throughout the entire shift; apart from the duration when they are having their meals and changing their medical mask after caring for a patient who requires droplet/contact precautions for other reasons

It is particularly vital to adopt the strategy of continuous use of masks in areas with a potentially higher risk of transmission such as triage, waiting lounges of family physicians or OPDs, designated COVID-19 hospitals, cancer units, transplant units etc.

While continuously using medical masks, it is also vital to:

• Change the mask if it gets wet, soiled or damaged.
• Not touch the mask to adjust it.
• If you have touched it, safely remove it, perform the hand hygiene procedure and use a fresh mask.
• Discard the mask and the PPE and use a new set after coming in contact with a patient for contact or droplet precautions.
• Personnel not working in clinical areas need not wear a medical mask during routine activities.
• PPEs including masks should not be shared between workers and be suitably disposed after use and not to be re-used.
• In addition to above recommendations, precautions of social distancing and hand hygiene practices should not be avoided as they are equally important.

Considerations for using non-medical masks

The utility of medical masks by the non-affected population may lead to a shortage of this extremely important supply to the health workers, who need them the most. In settings where medical masks are in short supply, medical masks should be reserved for use by only health workers and at-risk population when need arises.

Non-medical or fabric masks are prepared from varied woven and non-woven fabrics like polypropylene. Non-medical masks may be composed from differing fabric compositions, sequences or layers and shapes. However, a non-medical mask is neither a medical or surgical device nor a PPE.

Usage Considerations

The use of non-medical masks, prepared from woven fabrics such as cloth, and/or non-woven fabrics, should only be considered for used by infected persons in unrestricted settings and not for prevention. They can be used temporarily for activities such as travelling on public transport when social distancing cannot be maintained, and their use should without fail go with frequent hand hygiene and physical distancing.

Elastic materials are not preferred to prepare masks as they get stretched after each use, causing increased pore size and lower effectiveness of the mask to filter droplets.

Layers

A minimum of three layers is needed for a non-medical mask, as per the used fabric. However, cotton handkerchief masks should consist of a minimum of 4 layers. Cotton gauze is found to be very porous with a filtration efficiency of only 3%.

The ideal material combination for non-medical masks should include three layers as follows: 1) an innermost layer of a material which absorbs water (e.g. cotton or cotton blends); 2) an outermost layer made of non-water absorbing material (e.g., polypropylene, polyester, or their blends) which may restrict external impurity from penetration through to the wearer’s nose and mouth; 3) a middle non-water absorbing layer of synthetic non-woven material such as polyproplylene or a cotton layer which may enhance filtration or retain droplets.

Shape

Shape of the non-medical mask should be flat-fold, fitting closely over the nose, cheeks and chin of the wearer. If the mask’s edges are not close to the face and shift, during activities like  speaking, air penetrates through the mask’s edges rather than getting filtered through the fabric. The mask should be equipped to be held in place by the use of elastic bands or ties.

Coating

Coating the mask with materials like wax may raise the barrier and make the mask liquid-resistant, but too much coating may cause difficulty in breathing through the mask due to complete blocking of pores.

Maintenance

• Mask should be used only by a single person and not shared by multiple individuals
• All masks should be changed immediately, if they get wet or are visibly soiled
• When required, masks should be removed without touching the front portion of the mask and after mask removal, do not touch the eyes and mouth
• Discard the mask, if you wish or keep it in a sealable bag until you wash it. After washing, immediately perform hand hygiene
• Cloth masks should be frequently washed as per the cloth’s recommended washing temperatures
• Wash in warm hot water, 60°C, with soap or laundry detergent.
• Non-woven polypropylene (PP) may be washed at high temperatures, up to 125°C.
• Natural fibres may resist high temperature washes and ironing.
• Wash the mask delicately (without too much friction, stretching or wringing) if non-woven materials are used.
• The combination of non-woven PP and cotton can tolerate high temperatures; masks made of these combinations may be steamed or boiled.
• Where hot water is not available, wash mask with soap/detergent at room temperature water, followed by either i) boiling mask for one minute OR ii) soak mask in 0.1% chlorine for one minute then thoroughly rinse mask with room temperature water, to avoid any toxic residual of chlorine.

Wearing a face mask is not a substitute for physical distancing and basic hand hygiene but in some situations where you can’t follow social distancing and other preventive measures, wearing a mask can give you some layer of protection. It is important to follow the Government’s latest guidance on safeguarding yourself during the coronavirus pandemic, including travel advice within and outside the country.

Patients who get completely recovered from the fatal COVID-19 disease possess chemicals (antibodies) in their blood plasma that their bodies have produced to counter the infection in their blood and get cured of the infection. The blood of recovered COVID-19 patients is termed as Convalescent Plasma. In easier terms, plasma is the yellowish liquid part of the whole blood in which the blood cells (RBC, WBC and platelets) stay suspended. It is believed that this convalescent plasma of recovered patients can be transfused into severely ill COVID-19 patients, for boosting their immunity and enabling them to fight off their infection.

Certain blood cells function as “memory cells”, remembering the pathogen against whom they have produced antibiotics. When such blood plasma possessing the antibodies against COVID-19 is isolated from the recovered patient and transfused in the existing patient, the donor’s plasma immediately recognizes the COVID-19 viral pathogen and again produces the antibiotics to fight off the organism in the transfused patient’s body to improve their condition. This therapy is known as “Convalescent Plasma Therapy” (CPT) or simply, “Plasma Therapy”. Experts believe that this therapy can also prevent moderately ill COVID-19 patients from experiencing severe symptoms and complications related to the infection. Development of passive immunity is the basis of this therapy.

Where is this therapy used?

CPT is believed to aid COVID-19 patients who do not respond expectedly to other experimental drug therapies. Such patients may develop a severe lung complication called “Acute Respiratory Distress Syndrome”, necessitating mechanical ventilation to breathe, or else their organs begin to fail.

CPT may also help patients having chronic co-morbid conditions such as diabetes or cardiovascular diseases, whose immunity is already impaired and are COVID-19 infected of becoming severely ill.

CPT might also be considered for family members of COVID-19 patients or medical staff, who get exposed to potential patients, for preventing them from getting the infection.

Probable Risks of CPT:

Blood and plasma transfusions have been used to treat multiple diseases with exceptional safety. However, CPT does carry a risk of complications such as:

• Allergies
• Damage to the lungs and impaired breathing
• Infections from the donor’s plasma such as hepatitis or HIV

Although the risk of above-mentioned problems is very low, they can occur. Also, the therapy is still in the experimental phase and its effectiveness is not well-established in large clinical trials.

Who all can donate plasma?

• People between the age of 18 to 60 years.
• You weigh above 50 kgs.
• You are not suffering from any transmissible or chronic diseased condition.
• Your heart rate should be normal.
• Your hemoglobin level is ≥ 12.5 g/dl.
• Your blood pressure is normal.
• You should not have got any piercing done in the last 6 months.
• Above all, you should be completely free of COVID-19.

What is the procedure for donating plasma?

The procedure of donating plasma differs from that of donating blood. Though the initial process of blood collection is the same i.e. through the IV route, the whole blood collected from your arm for plasma donation has to pass through a dedicated machine for separating plasma and the blood components. Then, just the plasma is stored and the remaining portions are transfused back to the body with some saline. Hence, the procedure of plasma donation takes more time (approx. 90 minutes) than blood donation (which is 30 minutes).

In preliminary treatment, numerous individuals have benefited from CPT. Researchers keep on assessing the outcomes of individuals who got the treatment done. By considering the consequences of this treatment for COVID-19, specialists are drawing nearer to finding a treatment. Likewise, getting familiar with the utilization of CPT currently will assist healthcare workers to be better prepared to provide optimal patient care.

As the COVID-19 cases continue to mount and with no availability of immediate potential treatment or vaccine, it is absolutely necessary to train ourselves for living with COVID-19. In order to save the global economy, countries are now considering having certain relaxations during the lockdown in their respective countries, including India. In such circumstances, we have to prepare ourselves for living with the new “normal” by ways of introducing certain behavioral changes in our routine and implement social distancing, in order to combat the pandemic and save ourselves.

2) Be prepared for the possibility of getting ill:

• Take due care of family members who are deemed to be at higher risk of getting infected, such as elderly members or those who suffer from co-morbidities.
• Keep in mind which room you will select to use as a “quarantine” area if any of your family members get the infection and needed to be isolated.

3) Strictly follow the preventive steps:

• Frequently wash your hands with soap and water
• Avoid frequently touching your eyes, nose and mouth
• Stay in your room if you are sick
• While sneezing or coughing, cover your nose and mouth with a cloth or tissue and dispose of in a covered bin after use
• Clean and disinfect the surfaces in your home, which are frequently touched
• Be prepared for creating ample room for every family member, in case the children and/or other members have to stay at home due to shutdown

4) Be alert in case of witnessing any symptoms:

• Stay at home and consult your doctor, if any family member, including yourself, develop symptoms such as   fever, cough or difficulty in breathing
• Other family members should stay away from the symptomatic patient

5) If any family member gets sick:

• Continue the following hand hygiene
• Isolate the sick member
• While caring for the sick family member, follow all recommended protocols (PPE kits and face mask) and be aware of your own health
• Keep the surfaces disinfected
• Take care of the emotional well-being of all your family members

6) Care of children and co-morbid family members:

• Remain at home and avoid venturing into crowded places
• Pileup the stocks of the medicines, you require in case you need to stay home
• Strictly follow hand hygiene practices
• If at all you need to go out, maintain at least 6 feet distance with others
• If any child in your family gets infected, notify the school authorities so that they can alert others

7) Take care while going to buy supplies:

• Family members who are not sick and are at least risk of getting infected should run the necessary errands.
• Always wear a face mask, avoid gatherings and follow social distancing norms while going out
• Don’t go for public transportation or shared cab services
• If at all you need to go through public transport, maintain social distancing and avoid touching handrails and frequently wash your hands with a hand sanitizer.
• Once you return home, immediately wash your hands with soap and water and then perform any tasks.

8) Coping with stress:

• Avoid watching, reading or listening to news related to the pandemic for a prolonged period.
• Take deep breaths and meditate to cope with the stress
• Eat nutritious meals
• Regularly engage yourself in exercises
• Avoid alcohol, tobacco or consumption of drugs
• Talk with your friends through telephone, regarding any bothersome issues.
• Consult your psychiatrist, if you are feeling too anxious
• Take care of the elderly and co-morbid patients, as they are more prone to get extra stress due to COVID-19
• Keep a watch on children and teenagers as they may get excessively stressful due to being confined at home
• Avoid the spread of false news and stigmatizing healthcare workers working with COVID-19 patients

The ongoing pandemic is exerting the whole world both physically and mentally but there’s no doubt that this pandemic will come to an end one day. Sooner or later there are going to be vaccines and treatment that will bail us out. However, what’s also for sure is that, life after this pandemic is going be significantly different than before and full of precautionary measures. So, if you want to get back your previous lives then a lot will depend on our actions and only then we will experience a normal world after the COVID-19 pandemic. 

Condition of COVID 19 pandemic in the USA

When the dreadful novel coronavirus reached the USA, it granted the USA an exclusive luxury of “perception after the fact”. The virus’s biological character and course were already revealed in China, and its genome had also been charted. It was already established that it was a novel virus corona without known treatment or prophylactic means. It was known that only non-drug-based interventions like quarantine, isolation, and social distancing could aid in containing its spread.

Still, the USA turned out to be the epicenter of the COVID-19 pandemic and as of now, suffers the highest death toll. As of April 10th, it possessed 30% of confirmed cases and 18% of COVID-19 deaths in the world.

As the USA is a superpower, there was even no lack of commitment, skill or financial means to counter the pandemic. The first confirmed case of COVID-19 in the USA was detected on January 21st.

Condition of India as compared to  the USA amid global COVID 19 crisis

India is still a lower-middle-income country. It witnessed her first case on January 30^th, 2020. India with almost 430% of the US population and just 14% of US GDP has seen far fewer infections and deaths due to COVID 19. There are several learning here related to India’s success story.

1. Strong Leadership: Prime minister of India understood the magnitude of the situation early and was swift to seek faith of the countrymen on the need for compulsory strict measures needed to preserve lives. Early lockdown implementation at the national level prevented the pandemic to spread without control. Currently, India stands unified regardless of political affiliations at state levels.
2. Effective Policy Implementation at Grass-root Levels: Reflecting the urgency at the capital level, district and rural bodies, also understood the seriousness of the problem at hand and contributed to an already motivated bureaucracy in curbing the pandemic. Its outcomes can be witnessed in the significantly lesser numbers of COVID 19 cases seen in the rural and semi-urban areas of India.
3. Disaster preparedness: India’s frequent encounter with natural disasters has facilitated the countrymen to develop a seamless response system where hundreds of workers are organized rapidly. These acts and rules of disaster management are traditionally verified, effective, and devoid of political interference. Such freedom to take spot assessments and act peculiarly to unique ground situations is the strength of the Indian system of governance.
4. Full Supply of Empirical HCQ: Due to the inherent Indian policy of helping its partners, India was generous in supplying Hydroxychloroquine tablets to countries including the USA and the entire world, which bore good outcomes in terms of exchanging ideas, apart from saving lives at home.

However, there is a caution to this analysis. The USA consists of significantly higher air traffic than India and containment would have always been comparatively tough in the USA.

The COVID-19 pandemic continues challenging healthcare systems globally. As per an estimate, we are yet to experience the complete impact of the outbreak, despite practicing social distancing. Surgeons also require to aid in policy implementation for helping to tackle the potential rise in COVID-19 patients at their respective hospitals. Regarding this fact, it is recommended that surgeons and hospitals cut down the number of “elective” surgical procedures to reduce patient traffic. However, owing to the uncertainties in defining the surgeries, elective surgeries can realistically be classified into essential or non-essential procedures, which means that there is an elevated risk of adverse results by delaying the “essential” elective surgery compared to a non-essential elective procedure, which is purely not time-sensitive as far as medical emergencies are concerned.

Why are elective surgeries on hold?

Surgical patient’s stratification will help in accurate decision-making and reduce patient-burden in each hospital and also aid in proper resource allocation. As per this stratification, essential elective procedures bear an urgency of carrying out the surgery in 1 to 3 months and include cancer surgeries, cardiac valve surgeries, hernia repair, hysterectomy, reconstructive surgeries, etc. Contrary to the above procedures, discretionary elective procedures can be delayed by 3 months or more, such as cosmetic, bariatric, joint replacement surgeries, or others. Elective surgeries should preferably be postponed before it seems necessary. Postponing surgeries will cut needless patient movement in the hospital and lessen the likelihood and the spread of disease between symptomatic and asymptomatic patients and hospital staff. Also, the reduction in surgeries saves healthcare assets including hospital beds, personal protective equipment, along with maintaining the health of surgical staff.

3. Operating rooms require ventilators that may be needed to support COVID-19 patients rather than being utilized for elective surgeries.

If your “elective” surgery is delayed, you need to follow certain precautions until your surgery is rescheduled:

1. Change your activities to avoid positions that may cause pain and discomfort
2. In some extreme cases, injection of a heavy dose painkiller may be given by your doctor
3. Use NSAID to control your pain or swelling
4. Apply ice or heat pads to the affected area, depending on your comfort levels
5. Try restricting your movement levels and avoid lifting heavy loads
6. Try conservative treatments such as physical therapy if you have been a patient of arthritis
7. Immediately consult your doctor if your condition becomes unbearable and you need an emergency operation