:Mumbai, May 19, 2020

The Union Ministry of Health & Family Welfare has revised the discharge policy for COVID-19 patients in India. The revised policy which is aligned with the guidelines of the 3-tier COVID management and treatment system and categorization of patients based on clinical severity, says - “Mild/very mild/pre-symptomatic cases admitted to a COVID Care Facility will undergo regular temperature and pulse oximetry monitoring. The patient can be discharged after 10 days of symptom onset and no fever for 3 days. There will be no need for testing prior to discharge”.  Patients with moderate symptoms too need not be tested before discharge, as per the revised policy. Further, it has been said that: At the time of discharge, the patient will be advised to isolate himself at home and self-monitor their health for further 7 days.

Speaking about the basis of revising the discharge guidelines, Dr. Raman R. Gangakhedkar, Chief of Epidemiology and Communicable Diseases at Indian Council of Medical Research (ICMR), said, earlier patients were being discharged only after two Real Time-Polymerase Chain Reaction (RT-PCR) tests came negative within a span of 24 hours. In many cases, it has been noticed that patients who were physically fit to be discharged were being retained in hospitals because RT-PCR tests were coming as positive. Dr Gangakhedkar said: “The SARS-COV2 virus resides in throat muscle cells which have a life span of 3 months. Even if the virus becomes deactivated in those cells, it will remain in those cells from where swabs are collected for testing. RT-PCR being a test to just detect the presence of the virus will always show the result as positive, whether the virus is active or deactivated.”

He added: “Studies have concluded that if a patient does not show symptoms like fever for three days, then the virus can be said to have become deactivated in the infected person’s body. In this connection, it is important to remember that transmission happens only through active viruses”

On the basis of two such studies, ICMR decided to revise the discharge policy, informed Dr. Gangakhedkar. “The sample which is collected in swab test is subjected to microbial culture in laboratory. After three days, if the sample is not found to multiply, then it can be safely assumed to have become deactivated. Such deactivated virus may spread from a person to another, but will not cause the onset of the disease.”

The new policy also recommends 7 days of home isolation for the patients discharged from hospitals. Pointing out the rationale behind this decision, Dr Gangakhedkar stated, the patients come to hospitals a few days after exposure and not on Day 0 when the infection occurs. Hence, calculating the incubation period to be 21 days and hospitalisation period of about 10 days, home isolation period has been revised to 7 days.

Dr. Randeep Guleria, Director, AIIMS, New Delhi opines, as we learn more and more about the virus, we have to change our strategy.  “We have to see as to how we can decrease the load in the hospitals, while protecting the population and patients at the same time. It has been learnt over the last two to three weeks that RT-PCR which was considered a gold standard to conclude that a patient has become negative and hence free of infection, is probably not true. This is because the virus which is dead can still be picked up by the RT-PCR method, but the person becomes non-infectious. Hence, if a patient becomes asymptomatic for 3 days within a time scale of 10 days, then the patient can be discharged from hospital, with an advice to remain in home isolation for 7 more days. On one hand, it will make the patients feel good to return home and at the same time, this will also decrease the load on hospitals.”

We are learning a lot about the disease every day, noted Dr. Guleria. “Even pre-symptomatic patients can spread the infection. The constantly emerging new data about COVID-19 will dictate the strategies on quarantine, home isolation, hospitalization and treatment protocol in future”. 

In the past, several asymptomatic patients have been kept in hospitals for 3-4 weeks just because their RT-PCR test was constantly coming as positive. The present data substantiates that the virus becomes deactivated in the body after 7-8 days. This dead virus has no chance of spreading infection. “ICMR’s analysis of the data collected from 2,000-odd patients, revealed that, the RT-PCR test of all the patients, on an average, turn out to be negative on the 10^th day from onset of symptoms. Patients generally show symptoms after 5-7 days of exposure. The policy change is welcome, since it is in tune with the progress made in research”.

Explaining the 3-tier treatment system, the AIIMS Director added: “80 percent of the patients have mild symptoms requiring hospital care of about 10 days. A few patients show dipping of oxygen saturation level which calls for a little more care. These patients also recover well and are discharged from wards; while a small percentage of patients with comorbidities need ICU care. For the serious and high-risk patients, the policy of conducting a RT-PCR test prior to discharge is still being maintained.”

 
 

Expressing views in support of the new discharge policy, Dr. Yatin Mehta, ICU and Critical Care, Medanta Hospital, opines, everybody wants to stay at home, no one will want to stay in hospitals because there is an additional risk of getting hospital acquired infections and other bacterial infections. Hence, it is safer to be at home if it is clinically fine.

Resounding the same view, Dr. Sanjiv Mishra, Director, AIIMS, Jodhpur said it is a very good step forward and is well-suited for mental health of the patients as well. 

In a word of advice for all the patients who are getting discharged after 10 days of hospital care, the doctors have asked them to follow seven days of home isolation following the associated disciplines like not mixing with the elderly and children, staying apart and so on.

The doctors feel that there is too much panic about this disease. This calls for counselling of the patients before they are discharged. The society also needs to calm down and treat the patients and their families well. Dr. Mehta feels it is good to have some psychological counselling for the patients to help them cope with the stress and depression that comes along with this disease.

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