Indian Transplant Newsletter. Vol.20 Issue No.62. March 2021 - June 2021
Impact of COVID-19 Pandemic on Transplantation- Evolution of patient care 2020-2021
Dr. Shruti Tapiawala
MD ( Int. Med), DNB ( Nephrology), FICN ( Canada)
Senior Consultant & Renal Transplant Physician
Gleneagles Global Hospitals, Mumbai
Sir HN Reliance Foundation Hospital & Research Center Mumbai
Secretary- India Society of Nephrology - West Zone Chapter
Hospital Education Committee - ZTCC Mumbai
Director ATDI Lab Pvt Ltd - Precision Transplant Diagnostics
The world was starting to wake up to the COVID-19 viral pandemic in March 2020. A time when the World Health Organisation, Centre of Disease Control were trying to study the virus, its mechanisms of spread, its pathogenic effect and more importantly a way to treat it and prevent it. The world was experiencing the horrifying effects of the virus which was overwhelming the hospitals and cemeteries all around the world. Even the most developed nations found themselves unprepared to handle the sheer number of people who were getting infected, requiring hospitalisations and critical care. The virus was proving itself more than a flu.
India fared no differently. India saw one of the earliest and strictest lockdowns to control the spread. Today I will share our journey with our patients through the pandemic. Early March 2020, we started making protocols and educating our dialysis staff and hospital staff to screen patients in terms of symptoms, travel history or contact with an infected person. We could see the fear in their eyes as well as patients’ eyes. PPEs were deployed for all staff- we could see the staff trying to live with it. We could even see the paramedical staff being not allowed in their own apartments and families asking their near and dear ones to leave the job in wake of the pandemic putting them at risk at their workplaces. We were getting phone calls from our society management about whether we were working in COVID set-ups, as if wanting to indirectly understand if we were a threat to them. One would dread that we would also be told not to come back home.
Let me start with the story of patients on dialysis. A shocking situation awaited us in March 2020, when hospitals were told to stop inpatient and out-patient services due to 90 per cent staff getting infected and patients started calling us that they did not have a place for dialysis as their units had shut down and would we be able to accommodate them. We were witnessing deaths due to patients not getting dialysis for weeks together as they were denied dialysis at their own centres. Another group was the patients who tested positive and were treated as a stigma. They were told not to come for dialysis at their parent units as they could not dialyse COVD patients. These patients did not receive dialysis as they did not know what to do and would either succumb to complications related to not receiving dialysis or require ICU admission for the same. As nephrologists we are a cohesive group in Mumbai. Few members of the Mumbai Nephrology group namely Dr. Vishwanath Billa and ShrirangBichu along with IIT Mumbai came up with Project Victory- a software which would help centralise the dialysis bed allocation and ensure dialysis availability to one and all. This was an online portal which would help a patient get a dialysis bed within 24 hours of being added online with a positive status. All hospitals could nominate an administrator (nephrologist) who was in charge of updating the number of COVID dialysis beds available at their centre to accept / accommodate a patient and add their own patients and request dialysis slots if required. This way by April 2020 we were on track and our dialysis patients could be taken care of. It was indeed a feeling of fulfilment to be able to work as a BIG team – everyone working with everyone for every patient!
In May 2020 we were fairly confident regarding the quarantine periods, eligibility for hospital admission, treatment (at least we were learning how to diagnose, grade the severity and treat with whatever evidence was available- although feeble and changing by the day). In May 2020, when we had come around handling ourselves, our families and our patients with the COVID pandemic, we realised that there were so many patients whose transplants were held back due to the fear of contracting the virus in a post-transplant situation and these patients were actually being exposed to contracting the infection as they had to come to their dialysis units every other day. We were now attending and participating in virtual webinars where we could discuss and exchange notes nationally and internationally. We realised we could safely plan to take transplants through and this will actually help patients stay healthier as it would help them get transplanted which was a healthier option for end-stage kidney disease and it would help them stay and home and avoid being exposed to getting COVID infection. The hospital outpatient departments were slowly starting in a hybrid manner - partial virtual consultations and few physical appointments were initiated. Next hurdle in restarting the transplant programme was that the patients were very scared and they were refusing living or deceased donor transplants. Deceased donor organs were being refused by patients and precious organs were being wasted. Patients who had living donors were getting unwell as time passed by making them unfit despite having living donors in the family.
Our team believes in educating the masses and shedding the ignorance which will show patients the path to health. It has been our tradition for decades (since early 1990s) to do a weekly education program for our patients. It would help patients meet their peers, learn about their disease and coping strategies. Our weekly education activity had stopped since March 2020 due to the restrictions of the pandemic and the need to avoid a gathering of people, let alone patients. We decided to restart education. We started our weekly education sessions online. Initially patients found it difficult as not everyone was technologically comfortable. We had our coordinators handhold them through the technological issues and slowly the numbers of attending patients and their family members picked up. We could reach out and discuss COVID prevention, care on dialysis, chronic kidney disease care and the ease of transplant and safety. We could help patients far and wide, thanks to technology. The transplant programme which had been at a standstill from March 2020 picked up from June. In August our institute was offered limbs from a deceased donor. We bravely went ahead with the transplant. The young girl today has functional upper limbs!
Second wave started in March 2021 after 2-3 months of respite. This time the virus was different and we realised that the strategies to treat patients had to change. This time the lung damage was severe and people also had clotting abnormalities leading to cardiac and cerebral events. Vaccinations were ongoing but this time the country was looking at a severe lack of facilities including oxygen supplies, intensive care beds for COVID infected patients. In many communities, an informal network of providers including rural medical practitioners, frontline health workers, non-governmental organisations, and community self-help groups came together to meet with the chronic care needs of the people, including arranging medications and teleconsultations. We were seeing much younger patients and mortality was high despite best of the services. There were horrifying reports from other cities and states in the country where people were dying as they did not get oxygen, bodies had no place to be buried or cremated. In Mumbai we did not see a lack of facilities as we were a first-tier city of India with reasonably good health care network. In Mumbai the Project Victory was revived to allocate patients if required, but the crisis was not as much as we saw last year, as we now had a system which was already in place.
This time, unlike last year, we lost many of our patients (chronic kidney disease, dialysis and transplant) to the COVID-19 infection, some with all the care and some who could not get facilities being in smaller cities. As a country we rose again and with strict guidelines, preventive measures and aggressive vaccination drives the wave is somewhat controlled and there has been a sharp drop in the cases.
My take home message to all
As we cross every day, our only weapon remains prevention strategies and education of the masses to mask up, maintain distance and ensure that we encourage people to vaccinate themselves and their acquaintances.
The human race shall overcome all the adversities and prove themselves to be a superior being.
Take care and be safe - make others safe!