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Dealing With COVID-19

Fulbright-Nehru Fellow Dr. Ashish Goel shares how underlying conditions, like diabetes and hypertension, might put people at greater risk during outbreaks like COVID-19, and what people can do to protect themselves.


The COVID-19 pandemic is one of the biggest global health crises of our time. Countries across the world are trying to slow the spread of the virus through measures like testing and treating patients, carrying out contact tracing, restricting travel, quarantining citizens and canceling large gatherings. Certain groups of people, however, are considered particularly vulnerable. These include people with underlying health conditions like hypertension, diabetes and cardiovascular diseases.

This has, thus, become a key focus area in the health sector. Dr. Ashish Goel, clinical associate professor at University College of Medical Sciences and Guru Teg Bahadur (GTB) Hospital, New Delhi, is among those at the forefront in India’s fight against COVID-19. Dr. Goel attended the Johns Hopkins Bloomberg School of Public Health in Maryland as a Fulbright-Nehru Fellow in 2017 to pursue a master’s degree in public health.

Excerpts from an interview.

Could you please tell us briefly about your academic and professional background?

I completed my master’s degree in medicine from the first rural medical college in India at Sevagram, Maharashtra, in 2003 and pursued a senior residency program at the All India Institute of Medical Sciences in New Delhi. I joined as a teaching faculty at the University College of Medical Sciences and affiliated GTB Hospital in 2009. I further completed a master’s in public health from the Johns Hopkins Bloomberg School of Public Health, under a Fulbright-Nehru Fellowship in 2017. Over the years, I have worked in several medical schools and trained in geriatric and emergency medicine, ethics, epidemiology and biostatistics. 

What are some of the underlying health conditions that put people more at risk of COVID-19?

It has been found that older individuals with comorbid illnesses, such as diabetes, hypertension, cardiovascular disease, chronic obstructive airway disease (COPD), malignancy and chronic kidney disease, are at a greater risk of developing serious illness requiring hospitalization after exposure to the COVID-19 virus infection. (Emami et al., 2020)

In what ways does the virus affect these groups of people?

Without going into too much technical detail, I would briefly say that the novel coronavirus affects the Renin-Angiotensin-Aldosterone axis and depends on Angiotensin-converting Enzyme receptors to gain entry into human cells. The precise mechanism is still under exploration and analysis. 

The verdict on the use of anti-hypertension drugs is still under consideration and there is no evidence to guide the use of ACE-inhibitor drugs or Angiotensin receptor blocker drugs. (Cheng et al., 2020; Danser et al., 2020; Meng et al., 2020) The COVID-19 infection also affects the glucose metabolism. Strict control of blood sugars is an important consideration during management in previously diabetic patients. (Zhou et al., 2020a)

What are some of the precautions that people with underlying health conditions can take to minimize the risk?

Social, rather physical, distancing and good hygiene, in addition to handwashing, are very important to reduce an individual’s risk of exposure. In addition, the role of wearing a mask at all times when interacting with people cannot be over-emphasized. While the role of N95 masks has been emphasized in different forms of media, it has been seen that using any kind of mask will be protective as compared to not using masks. (Zhou et al., 2020b). It is also important to stay indoors as much as possible and to move out as briefly as possible, only when it is essential, to contain the disease spread and prevent the health care system from collapsing. 

There are reports that claim certain medications like ACE inhibitors, commonly taken by diabetes and hypertension patients, might increase susceptibility to coronavirus. How true are these claims?

The final verdict on the use of ACE inhibitors and Angiotensin Receptor Blockers (ARBs) is not out yet. While the role of ACE receptors has been studied in the pathogenesis of COVID-19 viral infection at the cellular level, arguments on both sides have been put forward. (Danser et al., 2020; Liu et al., 2020; Meng et al., 2020; Sparks et al., 2020; Talreja et al., 2020) 

At the present time, there is no evidence favoring discontinuation of ACE inhibitors or ARB among patients with hypertension. The protective effects of these drugs outweigh the potential speculated harm. In fact, I am continuing with Olmesartan, an ARB, for myself.

How soon can we hope to find a cure or vaccine for COVID-19?

Vaccine development is a slow process and needs to be executed with meticulous planning. There has been considerable focus on the development of a possible vaccine in recent times. Social media is rife with reports of a new vaccine every day. 

But, it would be impractical to expect a vaccine to help us fight the current first wave of the epidemic. (Amanat and Krammer, 2020) To understand the practical timeframe, let me draw a comparison to the H1N1 epidemic in 2009. During the epidemic in 2009, vaccine production was immediately geared to produce a monovalent pandemic vaccine instead of making the usual trivalent seasonal influenza vaccine. Although this was a minor change of strategy to target the new strain, the new vaccine became ready for use only after a period of six months. 

Notwithstanding the progress in vaccine development over the last decade, the safety, efficacy and sustained antibody response of a new vaccine for COVID-19, an entirely new virus that has just emerged in humans, first needs to be established in animal models before it can be made available for use in human subjects. 

What measures do you think can help us strengthen our immune systems?

The novel coronavirus appears to affect lymphocytes in the body, as evidenced from recent data. (Qin et al., 2020) Among the different approaches that are being explored to challenge the virus, the role of immunomodulatory therapy with harvested antibodies from recovering patients as well as established chemotherapy is under the lens. (Jawhara, 2020; Russell et al., 2020)

There have been reports emphasizing the role of Vitamin D (McCartney and Byrne, 2020) and several mechanisms have been proposed in alternative and traditional medicine approaches. But there is no evidence that either of these will make a definitive impact in the human body’s response against the virus. Anosmia, or the loss of olfaction/smell sensation, and ageusia, or the loss of taste sensation, have been reported in association of COVID-19 infection. (Lechien et al., 2020) Intuitively, this may, in turn, reduce appetite and affect diet even in mild cases.

The only advice that may be valid is that one should take a healthy nutritious balanced diet, sleep adequately, reduce stress, exercise regularly and maintain a daily schedule. While social (read physical) distancing is important to reduce infection, social contact and uninterrupted communication (read camaraderie) are essential to maintain mental balance. (Kim and Su, 2020)

Could you please tell us about the cooperation between the United States and India to help prevent the further spread of COVID-19?

There is the highest degree of cooperation and mutual collaborative work being done at the highest administrative levels in both countries. Indeed, it is heartening to see the camaraderie between President Donald Trump and Prime Minister Narendra Modi in this difficult time.

It may be difficult for the two countries, or any other country, to share or export physical devices, personnel or technology, such as personal protective equipment, drugs and ventilators, because every country is struggling with inadequately prepared health care systems in the face of the pandemic.

However, in my opinion, the one thing that we urgently need is transparent sharing of real-time data. There are several researchers and experts who can interrogate a dataset and explore its diverse aspects in different ways. If there was a universally accessible real-time database of clinical and demographic details on outcome of patients, freely available on the cloud, maintained by participant countries, it would be the most valuable resource we could create. Several independent experts, trained in epidemiology and biostatistics around the world, who are not directly involved in the pandemic response, could then analyze this data to understand how the pandemic is behaving in different countries. This may not only provide guidance to countries lagging on the epidemic curve, but will also open the door to several thousands of brilliant minds around the world. 

While this may be easy in health care systems already maintaining electronic medical records, it becomes difficult for clinical epidemiologists like myself to understand what is happening at the local level, despite my training and expertise to do so. A timely international collaborative undertaking, led by the United States in this direction, could provide the necessary impetus to preserve the existing world order.


References:

Amanat, F. and Krammer, F. (2020). SARS-CoV-2 Vaccines: Status Report. Immunity.
Cheng, H., Wang, Y. and Wang, G. Q. (2020). Organ-protective effect of angiotensin-converting enzyme 2 and its effect on the prognosis of COVID-19. J Med Virol.
Danser, A. H. J., Epstein, M. and Batlle, D. (2020). Renin-Angiotensin System Blockers and the COVID-19 Pandemic: At Present There Is No Evidence to Abandon Renin-Angiotensin System Blockers. Hypertension, Hypertensionaha12015082.
Emami, A., Javanmardi, F., Pirbonyeh, N. and Akbari, A. (2020). Prevalence of Underlying Diseases in Hospitalized Patients with COVID-19: a Systematic Review and Meta-Analysis. Arch Acad Emerg Med, 8, e35.
Jawhara, S. (2020). Could Intravenous Immunoglobulin Collected from Recovered Coronavirus Patients Protect against COVID-19 and Strengthen the Immune System of New Patients? Int J Mol Sci, 21.
Kim, S. W. and Su, K. P. (2020). Using psychoneuroimmunity against COVID-19. Brain Behav Immun.
Lechien, J. R., et al. (2020). Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study. Eur Arch Otorhinolaryngol.
Liu, Y., et al. (2020). Clinical and biochemical indexes from 2019-nCoV infected patients linked to viral loads and lung injury. Sci China Life Sci, 63, 364-374.
McCartney, D. M. and Byrne, D. G. (2020). Optimisation of Vitamin D Status for Enhanced Immuno-protection Against Covid-19. Ir Med J, 113, 58.
Meng, J., et al. (2020). Renin-angiotensin system inhibitors improve the clinical outcomes of COVID-19 patients with hypertension. Emerg Microbes Infect, 9, 757-760.
Qin, C., et al. (2020). Dysregulation of immune response in patients with COVID-19 in Wuhan, China. Clin Infect Dis.
Russell, B., et al. (2020). Associations between immune-suppressive and stimulating drugs and novel COVID-19-a systematic review of current evidence. Ecancermedicalscience, 14, 1022.
Sparks, M. A., et al. (2020). Sound Science before Quick Judgement Regarding RAS Blockade in COVID-19. Clin J Am Soc Nephrol.
Talreja, H., et al. (2020). A consensus statement on the use of angiotensin receptor blockers and angiotensin converting enzyme inhibitors in relation to COVID-19 (coronavirus disease 2019). N Z Med J, 133, 85-87.
Zhou, F., et al. (2020a). Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet, 395, 1054-1062.
Zhou, Z. G., Yue, D. S., Mu, C. L. and Zhang, L. (2020b). Mask is the possible key for self-isolation in COVID-19 pandemic. J Med Virol.