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COMMENTARY
Year : 2022  |  Volume : 66  |  Issue : 1  |  Page : 74-76  

COVID-19 Pandemic: An Indian radiologist' perspective


1 Associate Professor, Department of Radio Diagnosis, All India Institute of Medical Sciences, Hyderabad, Telangana, India
2 Additional Professor, Department of Radio Diagnosis, All India Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Submission28-Jun-2021
Date of Acceptance15-Nov-2021
Date of Web Publication5-Apr-2022

Correspondence Address:
Abhishek J Arora
Department of Radio Diagnosis, All India Institute of Medical Sciences, Bibinagar, Hyderabad - 508 126, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1448_21

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   Abstract 


During the COVID-19 pandemic, differences in health-care system and policies among countries worldwide meant that each country had to come up with their own strategies for containment, diagnosis, and treatment of the disease − “no one size fits all.” India being the second populous country in the world with modern and traditional systems of health care has its own challenges to face during the pandemic. Among the increased cacophony of information regarding the COVID-19 disease and controversies surrounding the usage of various radiological modalities for its diagnosis, we are trying to present a sane perspective from an Indian radiologist viewpoint. Knowing the strengths and shortcomings of the Indian health-care system, we have suggested plausible solutions which may be the answers to the issues raised by the Indian media.

Keywords: COVID-19, pandemic, radiologist


How to cite this article:
Srirambhatla A, Arora AJ. COVID-19 Pandemic: An Indian radiologist' perspective. Indian J Public Health 2022;66:74-6

How to cite this URL:
Srirambhatla A, Arora AJ. COVID-19 Pandemic: An Indian radiologist' perspective. Indian J Public Health [serial online] 2022 [cited 2022 Jul 4];66:74-6. Available from: https://www.ijph.in/text.asp?2022/66/1/74/342590



The SARS-CoV 2 infection was declared a pandemic by the WHO on March 11, 2020. In India, the first case of COVID-19 was reported on the January 27, 2020, in the state of Kerala.[1] Since then, India has seen its share of rise and fall in cases as is the expected trend of a pandemic.

Being the second-most populous country in the world with a population of approximately 1.38 billion in 2020,[2] testing, containing and treating the disease posed a gigantic challenge. The Ministry of Health and Family Welfare (MOHFW) and the Indian Council of Medical Research (ICMR) had to garner resources at an unprecedented level to battle the disease. The strategy used by the ICMR was “test-track-treat.”[3]


   Diagnostic Dilemmas and Limitations Top


Recognition of the viral RNA by reverse transcriptase–polymerase chain reaction (RT-PCR) test was considered as the gold standard for the diagnosis of COVID-19.[4] In the early stages of the pandemic (around March 2020), sample collection was available at 57 Virus Research and Diagnostic Laboratories and testing was conducted by only 51 selected national reference laboratories.[5] The test results took an average of 3 days to be declared. The number of laboratories, however, was later sequentially increased by incorporating recognized private laboratories.[3]

With the rising number of cases and limited laboratory resources; the need to recognize, isolate positive cases and identify asymptomatic carriers requiring elective surgeries, the medical fraternity turned to imaging modalities mostly computed tomography (CT) scan as an alternate screening test for the disease. CT chest imaging fits into the mould of a reliable, quick, and readily available screening tool for COVID-19. Moreover, studies conducted in China showed that CT findings suggestive of COVID pneumonia were seen in 60%–93% of initial RT-PCR negative cases.[6] The sensitivity of CT in diagnosing the disease was reported as 97%.[6]

By November 2020, the major CT scan vendors reported a 40% surge in the demand for CT machines with 60% of machines being sold to first-time buyers in India.[7] CT was being used both to assess the severity of disease and diagnosis of suspicious cases with RT-PCR negative test results irrespective of the disease severity.


   Forming Guidelines for Radiological Investigations Top


Meanwhile, consensus statements were issued by the Fleischner Society of Thoracic Imaging[8] refuting the role of CT as a primary diagnostic tool in COVID-19 disease. CT scan was recommended only in cases which showed deterioration in symptoms or with a high probability of disease progression. Its use in the triage area was restricted to places with limited resources and confined to moderate-severe cases. The MOHFW[9] and Indian Radiological and Imaging Association (IRIA)[10] had issued the guidelines for the management of COVID-19 cases in June 2020 which recommended that radiological investigations be used only in severe cases.[9],[10]


   Radiology – In the Eye of the Storm Top


The challenges faced by the government and the medical fraternity in the face of a pandemic depend on the existing health-care system (rural-urban discrepant health-care facilities), organized and efficient use of resources, the ability of the scientific and technological personnel to come up with quick and evidence-based solutions and setting a uniform code of guidelines to be followed across the nation.

With approximately 68% of the Indian population living in the rural areas, shortage of qualified health-care personnel[11] and hospital equipment in the rural areas pose a main hurdle to disease recognition, treatment, and containment.[12] Health-care providers in rural as well as suburban India are diverse ranging from qualified allopathic, AYUSH, and unqualified providers, majority being the last[13] This brings forth a question of the ability to follow a uniform treatment protocol reflecting in the investigations advised and accountability. There was an increase in the number of self-referred CT scans being done by private imaging centers for the detection of COVID-19 pneumonia in lieu of RT-PCR tests.

Soon concerns were being raised regarding the indiscriminate use of CT scan and the potential detrimental effects of radiation exposure it imposed on the patient.[14] The “infodemic” spread as fast as the pandemic through social media posts regarding the treatment and investigations for COVID-19.With heavy workflow and limited resources, concerns were raised regarding regular disinfection of the gantry and personal protection protocols followed by the technicians which spread the fear of CT machines acting as “super spreaders” of infection.[14]

Reacting to the above statements, the IRIA released a press statement citing the negligible radiation dose (0.3–0.55 mSv) incurred by low dose CT indicated for COVID-19 patients.[14]

In a survey conducted by Kalra et al.[15] involving 1633 registrants from 1000 countries, they noted a wide discordance in CT protocols and indications for diagnostic imaging practiced for COVID-19. A balance should be made between the image quality and the radiation exposure to the patient. A foreseeable limitation is ensuring that the guidelines are followed uniformly throughout the country. No estimate is available regarding the number of CT machines in India and their distribution among the public and private sector.


   Plausible Solutions Top


In this setting, the need of the hour is for the radiology fraternity to shoulder the responsibility of spreading awareness about the role of radiological investigations in COVID-19 pneumonia[10] and curtail the indiscriminate use of CT scans.

  • Referring physicians should be guided regarding the appropriateness of the investigation and the self-referred radiological investigations curtailed
  • Scan protocols tailored to the patient habitus and involving radiation doses as low as reasonably achievable should be diligently enforced and followed
  • Educating the radiology technicians regarding the use of personal protection equipment
  • Hospitals and scan centers should be encouraged to organize efficient workflow and reduce the transit and waiting times of suspected cases
  • Hospitals should ensure appropriate sanitization following positive scans.


Advanced technological innovations have made radiological investigations an essential part of diagnosing and treating diseases. With this advancement comes an increase in responsibility. The radiologist needs to be actively involved in not just image interpretation but also in guiding the referring physician and the government in policy decisions. Battling the COVID-19 pandemic requires co-operation and contribution from the government, hospital administration, medical fraternity, and general public.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Andrews MA, Areekal B, Rajesh KR, Krishnan J, Suryakala R, Krishnan B, et al. First confirmed case of COVID-19 infection in India: A case report. Indian J Med Res 2020;151:490-2.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Neil A. Statista; May 05, 2021. Estimated Population of India 2016 to 2026. Available from: https://www.statista.com/statistics/263766/total-population-of-india/. [Last accessed on 2021 May 27].  Back to cited text no. 2
    
3.
Indian Medical Council and Research. Letter to Chief Secretary/Administrator/Advisor to Governor/Advisor to Lt. Governor for Empowering Citizens for Testing of SARS-CoV-2 Virus to Save Precious Lives and Contain the Virus in, July, 2020. Available from: https://www.icmr.gov.in/cteststrat.html. [Last accessed on 2021 May 28].  Back to cited text no. 3
    
4.
Goudouris ES. Laboratory diagnosis of COVID-19. J Pediatr (Rio J) 2021;97:7-12.  Back to cited text no. 4
    
5.
Indian Council of Medical Research. Press Release: Note on COVID-19 Laboratory Preparedness in India. New Delhi: ICMR; 2020. Available from: https://www.icmr.gov.in/pdf/covid/labs/ICMR_PressRelease_COVID_19.pdf. [Last accessed on 2021 May 28].  Back to cited text no. 5
    
6.
Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al. Correlation of chest CT and RT-PCR testing for coronavirus disease 2019 (COVID-19) in China: A report of 1014 cases. Radiology 2020;296:E32-40.  Back to cited text no. 6
    
7.
Das S. Pandemic Pushes up Demand for CT Scanners; Firms Gear up to Meet Surge. Business Standard; November 11, 2020. Available from: https://www.business-standard.com/article/current-affairs/pandemic-pushes-up-demand-for-ct-scanners-firms-gear-up-to-meet-surge-120110301646_1.html. [Last accessed on 2021 May 27].  Back to cited text no. 7
    
8.
Rubin GD, Ryerson CJ, Haramati LB, Sverzellati N, Kanne JP, Raoof S, et al. The role of chest imaging in patient management during the COVID-19 pandemic: A multinational consensus statement from the Fleischner Society. Radiology 2020;296:172-80.  Back to cited text no. 8
    
9.
Ministry of Health and Family Welfare Government of India Clinical Management Protocol for COVID-19 [Revised and Reissued on 27.06.2020] In; July 13, 2020. Available from: https://www.mohfw.gov.in/index.html. [Last retrieved on 2021 Mar 27].  Back to cited text no. 9
    
10.
iria.org.in [homepage] Covid-19-Imaging-Recommendations. In September, 2020. Available from: https://iria.org.in/wp-content/uploads/2020/09/COVID-19-Imaging-Recommendations.pdf. [Last accessed on 2021 May 27].  Back to cited text no. 10
    
11.
Census of India 2011. Rural Urban Distribution of Population. Available from: http://censusindia.gov.in/2011-prov-results/paper2/data_files/india/Rural_Urban_2011.pdf. [Last accessed on 2021 May 27].  Back to cited text no. 11
    
12.
Mitra S. Indian Development Review 2020 March, 25 the Implications of COVID -19 for Rural India. Available from: https://idronline.org/the-implications-of-covid-19-for-rural-india/. [Last accessed on 2021 May 27].  Back to cited text no. 12
    
13.
Chandra S, Bhattacharya S. Unqualified medical practitioners their illegal but indispensable role in primary healthcare. Econ Polit Wkly 2019;54:36-44.  Back to cited text no. 13
    
14.
Mabiyan R. Risk vs. Benefit Analysis of CT Scan in Patients with Mild COVID Economic Times World Health.com; May 08, 2021. Available from: https://health.economictimes.indiatimes.com/news/industry/risk-benefit-analysis-of-ct-scan-in-patients-with-mild-covid-symptoms/82475590. [Last accessed on 2021 Jun 17].  Back to cited text no. 14
    
15.
Kalra MK, Homayounieh F, Arru C, Holmberg O, Vassileva J. Chest CT practice and protocols for COVID-19 from radiation dose management perspective. Eur Radiol 2020;30:6554-60.  Back to cited text no. 15
    




 

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