The doctor, who has overseen treatment of Covid-19 patients in Istanbul since the epidemic began, says:
We are past the peak of this epidemic
Recent hospital admissions exhibit milder symptoms
Late curfew announcements seemed to cause further infections
First cases may have been seen in November 2019
Please can you tell us a little about yourself and your professional qualifications?
I am a doctor with over 10 years professional experience, practicing in many parts of Turkey. Internal medicine specialists such as myself treat metabolic diseases such as hypertension, hyperlipidemia and high blood sugar. In addition, I deal with some infectious diseases, kidney diseases, heart diseases, as well as treating elderly and home care patients. I also diagnose patients’ complaints and direct them to appropriate departments that treat their conditions.
How and when did you become aware of Covid’s spread to Turkey?
We learned of Covid-19’s arrival in Turkey via an official circular sent to us by the ministry on March 11th. Immediately after receiving this information, our hospital became one of the first centers in Istanbul specializing in treating the pandemic. Covid-19 Patients began arriving within 1-2 days. I was assigned to be head of the inpatient service, i.e., the internist responsible for the clinic.
Please can you outline how the situation at the hospital where you work has developed – from the first suspected/diagnosed cases, up to today?
Since the disease was new to us, we initially benefited from scientific articles and publications published by the People’s Republic of China in English. Personal protective equipment (PPE) was not available in sufficient quantities at first. To begin with, we just used a few overalls, and entered patients’ rooms sequentially. The entire hospital’s capacity was reserved for Covid-19 patients. Only one patient was allowed per room. From the beginning, great attention was paid to respiratory support and contact isolation.
Before sufficient quantities of PPE came through official channels; overalls, masks, disinfectant and visors were donated to our hospital in large numbers. After the 3rd week, the ministry of health began to give us a new protective mask to be worn and discarded every day.
In the third week, hospital buildings that had been evacuated were reopened due to the large number of patients hospitalized. All equipment was brought into the empty buildings overnight. Nurses, doctors and support personnel were quickly assigned. In the meantime, they assigned me to this newly opened hospital as a clinical coordinator. We were providing all aspects of treatment, including intensive care. At the same time, all kinds of treatment methods [that medical publications suggested offered positive outcomes] were delivered to us quickly. These included drug treatments such as plaquanil, favipiravir, tosiluzumab, high flow oxygen instruments, etc. I think this approach contributed to our success.
How has the virus manifested, in your experience? Is it markedly different from other seasonal viruses you have treated, and how?
I think it’s very difficult to get an idea of how the Covid-19 virus originated, but coronaviruses themselves are not new to us. Other coronavirus outbreaks such as Mers-CoV and Sars-CoV occurred in previous years. However, these past outbreaks ended spontaneously and did not come to our country. In the beginning I was hoping this would be the case for Covid-19. This virus is more contagious than those I have previously treated in Turkey. In tomographies we took to image the lungs, we found that the lower and peripheral parts of the lung were subject to rapid progressive damage, especially in patients who have had tuberculosis in the past, and those with hypertension and diabetes. Those who recovered were left with marks on the lung. Some were hospitalized again with disease exacerbation after initial recovery and discharge.
What symptoms are you seeing? Are you seeing the same Symptoms in all patients?
The most common complaint in patients is fever, dry cough, widespread body and joint pain, headache, sore throat and air hunger. It differs from patient to patient, and not all of them show all symptoms at the same time. The most concerning symptom is air hunger. It can be a warning of respiratory failure.
With hindsight – were you admitting patients with Covid-like symptoms prior to the first officially acknowledged cases in March?
I saw similar cases in November and December – A few of them amongst close friends, colleagues and acquaintances. But since we see viral pneumonia every year, we did not think this was a serious thing at that time. In fact, when I look back, I think that the lung images and blood charts we saw at the end of last year, were very similar to the current coronavirus.
How accurate are the Covid-19 tests and the Antibody tests you have access to? There have been questions in other countries over their reliability – with claims of significant proportions of both false positives and false negatives.
I did not find false positivity. However, I have seen many negative PCR test results in a large number of patients, despite those patients exhibiting clinical and biochemical values compatible with Covid pneumonia. Therefore, I do not find the tests very reliable.
What treatments have been tried by you and your colleagues? What have you found to be the most, and least effective methods of treatment for Covid?
It would be more correct to answer this question in the light of further scientific data, but I think that Favipiravir and Tociluzumab treatment reduced the febrile period and respiratory distress and prevented intensive care. In the early period, I saw that high-flow oxygen treatment greatly relieved the patients. I think that patients with COPD (Chronic obstructive pulmonary disease) and asthma benefit from glucocorticoids and bronchodilator therapy via a nebuliser. The treatment data has been recorded, and the most accurate and precise information will be evaluated by us, using current statistical methods.
What are your thoughts on the plasma treatment being developed/tested by Turkish doctors?
Plasma treatment is a method used in previous epidemics. There are studies indicating that the use of plasma treatment creates a significant decrease in mortality in patients. At the same time, the mechanism for how the healing effect occurs is based on a very logical basis. One of the problems here is that we cannot measure the amount of antibody in the blood collected from the donor for plasma treatment. It is also necessary to be very careful to prevent transmission of diseases. At the same time, allergic reactions to blood products also need to be carefully monitored.
Are you aware of any patients having re-contracted the virus after recovery? Do you think this is possible?
After recovery and discharge, I have seen patients suffer with exacerbation of the disease again. In patients who cannot form antibodies to give an adequate immune response, the disease can flare up again, requiring re-hospitalization.
How would you assess Turkey’s response to the epidemic?
Turkey was not initially efficient in testing for the virus. We conducted studies less and later than countries like South Korea, who have been more successful in minimising the epidemic. However, we are much better than countries such as Italy, USA and England in terms of fatality rates and recovery rates. Our average is very close to Germany. Our recovery rates are very high. Of course, when the data is collected again after the epidemic has ended, it will become clearer how efffective our response actually was.
Why do you think Turkey has opted for an intermittent (i.e., only at weekends and during public holidays) lockdown strategy? Have you seen any effect in the numbers of Covid cases you’re admitting, in relation to the lockdown? Do you think lockdowns/partial lockdowns are an effective strategy for prevention of transmission?
As an economic force on the world stage, Turkey is not in a very strong position at the moment. Therefore, state administrators acted as much as they could to minimize the impact of the epidemic on public health, while trying to mitigate its effect on the economy. One week after the curfew started to be implemented, our case numbers decreased considerably. In fact, some pandemic inpatient services were evacuated and normal patient hospitalizations occurred. So far, there has been no capacity overrun.
When the weekend curfew was first imposed with only two hours notice, it resulted in many people crowding into stores to buy groceries – with some saying that this would increase Covid transmission rates. Did you see any increase in the number of admissions in the days/weeks after the first weekend curfew?
Yes, there was a slight increase in the number of new cases announced by the ministry of health approximately 10 days after that period. We saw two or three days with a little more hospitalization. This might have happened due to stampede in the markets, when the lockdown was first declared.
Turkey has to date reported 126,000 cases and 3,397 deaths. Do you feel these figures are accurate, and why?
Initially only positive test results were included in these data. False negativity was high in the tests. We saw patients exhibiting Covid pneumonia, but testing negative. Later, the ministry of health also put the diagnostic code under the heading ‘possible diagnosis of COVID-19’. As of the 3rd week of March, I think the accuracy of the figures is high and not many cases are being missed.
Which country do you feel has employed the best strategy in dealing with Covid, and why?
I think South Korea has been very successful. It has a population of over 51 million. 81.6% of this population lives in the city. The life expectancy for both sexes is 83.5 years, and the entire population has access to good health care. 15% of the country’s population is over 65 years old. Although this is not as high as European countries, it is still a significant proportion. This country has prior experience, because it previously had an epidemic of MERS (Middle East Respiratory Syndrome). Health information, including travel information of individuals, was effectively recorded. During the epidemic, the government was very transparent and did not hide the real figures from the public. Their program of testing was extensive. They were very quick to isolate patients who tested positive for the virus. Some human rights activists have reacted to perceived intrusions upon privacy because of their contact tracing initiative – the personal data of patients’ contacts, including their movements and credit card transactions, was monitored by authorities. However, in Korea, the epidemic was limited to 10653 cases, and only 232 deaths.
Other countries are reporting that the vast majority of serious cases are found in patients over 70 years old – also often with more than one pre-existing condition (comorbidity) – has that also been the case in your hospital? Please can you detail how, in your hospital, the virus has affected different age / health / wealth demographics?
We see more disease in those who have morbidities such as diabetes, hypertension, tuberculosis and ischemic heart disease. In respect to this, epidemiological and sociodemographic studies are being carried out. Until these are complete, I can’t give any further insight.
A number of epidemiologists globally have calculated Infection Fatality Rates for Covid-19 at 0.1% or 0.2% – (ie, only 1 or 2 in 1000 of those infected will die from the disease – and some are suggesting the figure may even be much lower than this) – a figure close to those seen in severe seasonal flu epidemics. Is it therefore accurate to say that, for the overwhelming majority of the population, there is very little risk of serious illness as a result of Covid-19 infection?
Similarly, I would prefer to reserve my response to this question until the results of epidemiological studies give a clearer picture.
Have you seen any differences in the symptoms Covid sufferers present, over the course of the epidemic?
I observed that patients admitted to our hospital more recently are exhibiting milder respiratory disturbance than those we saw at earlier times in the outbreak. However, I don’t know what the reason for this is. I don’t have an absolute scientific explanation in this regard.
Judging by the cases you are seeing, have we passed the peak of the infection curve?
We are in a phase where we have now passed the peak point of infection and fatality. We are now seeing a plateau in terms of numbers.
Can you please update us on the current situation? Have infections fallen?
The number of patients is the same in the center where I am currently working. However, 2 COVID units were closed in our main building. This shows that the total number of patients has decreased.