Monday, February 17, 2020

Lockdown not the correct method: 9.6% trapped in the ship acquire COVID 19


Lockdown not the correct method: 9.6% trapped in the ship acquire COVID 19

Dr K K Aggarwal
President CMAAO, HCFI and Past national President IMA

17th Feb: 70 new cases onboard the cruise ship in Japan. Nearly 1 out of 10 passengers and crew (9.6%) have tested positive to the virus so far (355 cases out of 3,711 passengers and crew).  The 952-foot cruise ship also has the highest infection rate of the coronavirus anywhere in the world.
China has imposed unprecedented quarantines across Hubei, locking over 56 million people, in a bid to stop COVID 19 spreading.
Villages in Vietnam with 10,000 people close to the nation's capital are also placed under quarantine on 13th Feb after six cases of the deadly new coronavirus were discovered there. The locking down of the commune of Son Loi, about 40 kilometres from Hanoi, is the first mass quarantine outside of China since the virus emerged from a central Chinese city late last year.

If you lock down COVID 19 infected people with non infected people the transmission are will be around 10%. This will still be insufficient to start the herd immunity chain. The idea of lock down probably was to develop herd immunity in that lock down population but with R 0 value of 3 it looks impossible.

Over last four days the number of new cases in China are declining.  

Limitations
1.     The people on lockdown are kept under a 14-day quarantine. If they are placed together and if anyone is diagnosed during that period, the quarantine will add another 14 days.
2.     In Chinas the lock down has not been lifted so far
3.     The longer you have several thousand people cohoused you will continue to propagate waves of infection.
4.     A better way to quarantine is to break up these people into smaller groups and quarantine them separately.
5.     Why quarantine children < 15 years when the virus is not risky for them.
6.     Why not separate elderly people with comorbid conditions at high risk of deaths and quarantine them separately in one to one or small groups.
7.     Ventilation system connects one room to the next. There has been previous concern that the coronavirus can spread through pipes
8.     Stress and anxiety are known to suppress the immune system, making people more susceptible to contracting the virus. 
9.     Why not quarantine them in open sunlight.


Sunday, February 16, 2020

Experts Opinions on COVID 19


Experts Opinions on COVID 19

Dr KK Aggarwal
President CMAAO, HCFI and Past national President IMA

“I think this virus is probably with us beyond this season, beyond this year, and I think eventually the virus will find a foothold and we'll get community-based transmission and you can start to think about it like seasonal flu. The only difference is we don't understand this virus”
Dr. Robert Redfield
Director, CDC
US Centers for Disease Control and Prevention
Feb. 13, 2020

“What makes this one perhaps harder to control than SARS is that it may be possible to transmit before you are sick. I think we should be prepared for the equivalent of a very, very bad flu season, or maybe the worst-ever flu season in modern times.”
Prof. Marc Lipsitch
Prof. of Epidemiology, Harvard School of Public Health
Head, Harvard Ctr. Communicable Disease Dynamics
Feb. 11, 2020


“I hope this outbreak may be over in something like April’
Prof. Nanshan Zhong
Leading epidemiologist, first to describe SARS coronavirus
Feb. 11, 2020

“It could infect 60% of global population if unchecked”
Prof. Gabriel Leung
Expert on coronavirus epidemics
Chair of Public Health Medicine
Hong Kong University
Feb. 11, 2020

“It’s a new virus. We don’t know much about it, and therefore we’re all concerned to make certain it doesn’t evolve into something even worse”
Prof. W. Ian Lipkin
Epidemiology Director
Columbia University
Feb. 10, 2020

“We are estimating that about 50,000 new infections per day are occurring in China. [...] It will probably peak in its epicentre, Wuhan, in about one-month time; maybe a month or two later in the whole of China. The rest of the world will see epidemics at various times after that.”
Prof. Niall Ferguson
Director, Institute for Disease and Emergency Analytics
Imperial College, London Feb. 6, 2020

“This looks far more like H1N1’s spread than SARS, and I am increasingly alarmed”
Dr. Peter Piot
(Director, The London School of Hygiene and Tropical Medicine)
Feb. 2, 2020


“It sounds and looks as if it’s going to be a very highly transmissible virus [...] This virus may still be learning what it can do, we don’t know its full potential yet.”
Robert Webster
(Infectious disease and avian flu expert at St. Jude Children’s Research Hospital)
Feb. 2, 2020

“Increasingly unlikely that the virus can be contained”
Dr. Thomas R. Frieden
(Former Director of CDC)
Feb. 2, 2020

“It’s very, very transmissible, and it almost certainly is going to be a pandemic. But will it be catastrophic? I don’t know “
Dr. Anthony S. Fauci
(Director, National Inst. Allergy and Infectious Disease)
Feb. 2, 2020

“Until [containment] is impossible, we should keep trying”
Dr. Mike Ryan
(Head of the WHO’s Emergencies Program)
Feb. 1, 2020

“The more we learn about it, the greater the possibility is that transmission will not be able to be controlled with public health measures”
Dr. Allison McGeer
(Director of Infection Control, Mount Sinai Hospital)
Jan. 26, 2020



COVID 19 in China Hospital currency is being disinfected






COVID 19 in China Hospital currency is being disinfected



Dr K K Aggarwal

President CMAAO< HCFI and Past national President IMA



The central banking authorities of China are disinfecting, stashing and reportedly even destroying cash in an effort to stop the spread of the coronavirus.

Fan Yifei, deputy governor of the People’s Bank of China, said that the cash collected by commercial banks must be disinfected before being released back to customers.

Cash collected from hospitals and food markets must be handled separately and disinfected before depositing the notes.



In severely hit regions, the collected cash must undergo ultraviolet or high-temperature disinfection and be stored for 14 days before going back to the market.



In less affected areas, the bank notes must be disinfected and stored for a week before use.





WHO demands to know more about sick doctors, insists group of 12 virus experts will reach Beijing over the weekend?




CMAAO Update 16th February on COVID-19
WHO demands to know more about sick doctors, insists group of 12 virus experts will reach Beijing over the weekend?

Authors: Dr K K Aggarwal, Dr Rajan Sharma, Dr R V Asokan, Dr KK Kalra, Dr Sushil Kumar, Dr Anita Arora, Dr Upasana Arora, Dr SS Srivastava, Dr Shilpi Khanna, Ms Swati, Dr Rahiul Shukla, Dr Arti Verma, Dr Anil Kumar, DSr G S Gyani, Dr Sonal Saxena, DSr CM Bhagat, Dr Vikas Manchanda, Dr Nandani Sharma, Dr Suneela Garg, Dr TK Joshi, Dr Mamta Jajoo, Dr Shariga Qureshi, Dr Manish Kumar, Dr Harmeet Singh, Dr Dr Rai, Dr VK Monga, Dr AP Singh,  Dr Ramesh Datta, Dr Maj Prachi Garg, Dr Anil Kumar,  Dr Rajni, Dr Rajeev Kumar, Dr Harish Grover,  Dr Mini Mehta, Dr Lalan Bharti,  ( More to be added)

Summary

COVID 19 Virus possibly behaves like SARS; causes mild illness in 82%, severe illness in 15%, critical illness in 3% and death in 2% cases ( 15% of admitted serious cases, 71% with comorbidity); affects all ages but predominately males ( 56%) with median age 59 years ( 2-74 years, less in children below 15);  with mean incubation period 5.2 days ( 2-214 days); mean time to symptoms 5 days,  mean time to pneumonia 9 days, mean time to death 14 days,  3-4 reproductive number R0  ( flu 1.2 and SARS 2) , epidemic doubling time 7.5 days, has origin possibly from bats, spreads like large droplets and predominately from people having lower respiratory infections and hence standard droplet precautions the answer for the public and close contacts and air born precautions for the healthcare workers dealing with the secretions.

Clinically all patients have fever, 75% have cough; 50% weakness; 50% breathlessness with low total white count and deranged liver enzymes. 20% need iCU care and 15% of them are fatal.

Close Contacts are defined as Health care associated exposure, including providing direct care for COVID 19 patients, working with health care workers infected with COVID 19, visiting patients or staying in the same close environment of a COVID 19 patient OR working together in close proximity or sharing the same classroom environment with a with COVID 19 patient  OR traveling together with COVID 19 patient in any kind of conveyance OR Living in the same household as a COVID 19 patient OR the epidemiological link may have occurred within a 14-day period before or after the onset of illness in the case under consideration.  
           
New updates
1.     Namaste: Let’s not shake hands
2.     Time for facts, not fear; for rationality, not rumours and for solidarity, not stigma.
3.     Help line India:  +91-11-23978046, ncov2019@gmaildotcom, mohfw.gov.in/node/4904
4.     Total number Includes Lab confirmed plus CT Diagnosed Cases
5.     No reliable evidence to support the possibility of vertical transmission of COVID-19 infection from the mother to the baby. [Lancet Feb 20]
6.     Sudden jump in deaths and new cases on 12th due to inclusion of CT diagnosed cases. The National Health Commission of China, in its 14 Feb report deducted 108 previously reported deaths and 1,043 previously reported cases from the total in Hubei Province due to "repeated statistics."
7.     218 (6%) cases have been confirmed on a ship quarantined in Japan ( three  Indians)
8.     Secondary Cases: Thailand, Taiwan, Germany, Vietnam, Japan, France, US, Korea
9.     Four Deaths outside China: Philippines (Feb 2, 44 Chinese man M, primary, comorbid), Hong Kong (4th feb 39 M, local, comorbid, primary), Japan ( 2 Feb, 18 F, Secondary) , France ( 15 Fe, 80 yr, F, Chinese visitor)
10.   WHO warns epidemic could still ‘go in any direction’ and global expert says outbreak just ‘beginning’ outside China
11.   Coronavirus vaccine could be ready in 18 months (WHO) 
12.  Human to human contact Requires prolonged contact ( possibly ten minutes or more) within three to six feet.
13.  14th Feb: 1,716 medical workers have contracted the virus and six of them have died. Of those people, 1,502 were in Hubei Province, with 1,102 of them in Wuhan. National Health Commission, said the numbers of infected workers represented 3.8 percent of China’s overall confirmed infections as of Feb. 11.
14.  At least two workers who were sent to Wuhan at the end of January to help build one of the new hospitals to treat victims of the coronavirus have been infected with it
15.  The central banking authorities of China are disinfecting, stashing and reportedly even destroying cash in an effort to stop the spread of the coronavirus. Fan Yifei, deputy governor of the People’s Bank of China, that the cash collected by commercial banks must be disinfected before being released back to customers.
16.   



Daily Statistics 15th February, 29  countries

Total cases: 69,198
New cases yesterday: 2008
Deaths: 1,669
Recovered: 9538 (84%)
Currently Infected Patients: 57,991
Mild cases: 46,699 (81%)
Serious or Critical: 11,292 (19%)
Deaths yesterday: 142
Serious or critical mortality 15%
Likely minimum deaths 1490 +1590= 3080 with the present trend and available treatment (plus deaths linked to daily new cases)


Travel Restrictions

Travel advisory:  Level 1 in all countries (Exercise normal standard hygiene precautions), Level 2 in all  affected countries and states including Kerala ( Exercise a high degree of caution), Level 3 in all countries with secondary cases (Reconsider your need to travel) done by India and Level 4 ( Do not travel) done by US. Hong Kong has imposed 14 days quarantine on people arriving from china.

Travel preferable seat: Choosing a window seat and staying lowers the risk

Travel and trade restrictions: WHO says no to countries

Leave china all together: UK, condemned by many countries

Entry to India not allowed: foreigners who went to China on or after January 15

Visas Suspended: All visas issued to Chinese nationals before February 5 (not applicable to aircrew)

Flight suspended: IndiGo and Air India have suspended all of their flights between the two countries. SpiceJet continues to fly on Delhi-Hong Kong route.

Evacuation

Many countries including Tokyo, Japan, India have evacuated their citizens.
Case fatality
COVID 19 2% ; MERS 34% (2012, killed 858 people out of the 2,494 infected); SARS 10% (Nov. 2002 - Jul. 2003, originated from Beijing, spread to 29 countries, with 8,096 people infected and 774 deaths); Ebola 50%; Smallpox 30-40%; Measles 10-15% developing countries; Polio 2-5% children and 15-30% adults; Diphtheria 5-10%; Whooping cough 4% infants < 1yr, 1% children < 4 years; Swine flu < 0.1-4 %; Seasonal flu 0.01%; COVID 19 in Wuhan 4.9%; COVID in Hubei Province 3.1%; COVID 19 in Nationwide 2.1%; COVID 19 in other provinces 0.16%.
Number of flu deaths every year: 290,000 to 650,000 (795 to 1,781 deaths per day)

Public Health Emergency of International Concern 30th Jan 2020
Mandatory to report to WHO each human and animal case.
Prior 5 PHEIC’s: 

26th April 2009 Swine flu: 10 August 2010, WHO announced that the H1N1 influenza virus has moved into the post-pandemic period. However, localized outbreaks of various magnitudes are likely to continue.

May 2014 Polio: resurgence of wild polio. October 2019, continuing cases of wild polio in Pakistan and Afghanistan, in addition to new vaccine-derived cases in Africa and Asia, was reviewed and remains a PHEIC. It was extended on 11 December 2019.

August 2014 Ebola: It was the first PHEIC in a resource-poor setting.

Feb 1 2016 Zika: link with microcephaly and Guillain–BarrĂ© syndrome. This was the first time a PHEIC was declared for a mosquito‐borne disease. This declaration was lifted on 18 November 2016.

2018–20 Kivu Ebola: A review of the PHEIC had been planned at a fifth meeting of the EC on 10 October 2019[44] and as of 18 October 2019, it continues to be a PHEIC.

Kerala: state public health emergency. Three primary cases in North, South and Central. Kasaragod district is in north Kerala, Thrissur in central Kerala and Alappuzha in South Kerala]. Four Karnataka districts bordering Kerala — Kodagu, Mangaluru, Chamarajanagar and Mysuru have been put on high alert.

About the Virus
Single-strand, positive-sense RNA genome ranging from 26 to 32 kilobases in length, Beta corona virus from Corona family.
‘Corona’ means crown or the halo surrounding the sun. Heart is considered crown and hence coronary arteries. In electron microscope, it is round with spikes poking out from its periphery.

Three deadly human respiratory coronaviruses viruses: Severe acute respiratory syndrome coronavirus [SARS-CoV], Middle East respiratory syndrome coronavirus [MERS-CoV]) and COVID 19: The current virus is 75 to 80% identical to the SARS-CoV

Origin: Wuhan, China December 2019. 1st case informed to the world by Dr. Li Wenliang died Feb 6th

Virus is likely to be killed by sunlight, temperature, humidity. SARS stopped around May and June in 2003 due to more sunlight and more humidity.  Alive on surface: possibly 3-12 hours
Link to ACE: COVID 19 might be able to bind to the angiotensin-converting enzyme 2 receptor in humans.

Pathogenesis

High viral load: Detection of COVID 19 RNA in specimens from the upper respiratory tract with low Ct values on day 4 and day 7 of illness is suggestive of high viral loads and potential for transmissibility. [NEJM]

COVID 19 uses the same cellular receptor as SARS-CoV (human angiotensin-converting enzyme 2 [hACE2]), so transmission is expected only after signs of lower respiratory tract disease develop.

SARS is high [unintelligible] kind of inducer. This means that when it infects the lower part of the lung, the body develops a very severe reaction against it and leads to lots of inflammation and scarring. In SARS what we found is that after the first 10 to 15 days it wasn’t the virus killing the patients it was the body’s reaction. Is this virus in the MERS or SARS kind picture or is this the other type of virus which is a milder coronavirus like the NL63 or the 229. It may be the mild (unintelligible) kind inducer. [Dr John Nicholls University of Hong Kong]

COVID 19 grows better in primary human airway epithelial cells than in standard tissue-culture cells, unlike SARS-CoV or MERS-CoV. It is likely that COVID 19 will behave more like SARS-CoV.

Both SARS-CoV and MERS-CoV infect intrapulmonary epithelial cells more than cells of the upper airways. Consequently, transmission occurs primarily from patients with recognized illness and not from patients with mild, nonspecific signs. Though NEJM has reported a case of COVID 19 infection acquired outside of Asia in which transmission appears to have occurred during the incubation period in the index patient but the same has been challenged now.

This new virus attacks the lungs and not just the throat. Patients so far have not presented with a sore throat, the reason being that the COVID 19 launches an attack at the intraepithelial cells of lung tissue.

Transmission

Zoonotic and linked to Huanan Seafood Wholesale Market as 55% with onset before January 1, 2020 were originated there but only  8.6% of the subsequent cases. The Chinese government has banned the wildlife trade until the epidemic passes. 
It is closely related to several bat coronaviruses. Bats are the primary reservoir for the virus. SARS-CoV was transmitted to humans from exotic animals in wet markets, whereas MERS-CoV is transmitted from camels to humans. In both cases, the ancestral hosts were probably bats.
The virus has also been traced to snakes in China. Snakes often hunt for bats in wild. Reports indicate that snakes were sold in the local seafood market in Wuhan, raising the possibility that the COVID 19 might have jumped from the host species - bats - to snakes and then to humans at the beginning of the outbreak. However, it is doubted as to how the virus could adapt to both the cold-blooded and warm-blooded hosts. It can not be transmitted by eating wild animals as it is a respiratory secretions disease.  

It transmits predominantly with  droplets like common flu and not like air born (TB, Measles, Chicken pox).

Kissing scenes have been banned in movies in China. In Kerala air crew are exempted from breath analyser tests and China has banned death ceremonies, people gathering together,

NEJM reported a small cluster of five cases suggested transmission from asymptomatic individuals during the incubation period; all patients in this cluster had mild illness. But the same has been challenged. Another case got infected while using gown, but eyes not covered.

Serious illness in other countries are less as patients with breathlessness are unlikely to board and patients will mild illness or asymptomatic illness are less likely to transmit infections. NEJM reports a taxi driver infected with SARS-CoV-2 in Thailand, potentially from Chinese tourists; the infection appears not to have spread to others.

Legal Implications India: Section 270 in The Indian Penal Code: 270. Malignant act likely to spread infection of disease danger­ous to life.—Whoever malignantly does any act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both.

Quarantine has Limitations
China imposed unprecedented quarantines across Hubei, locking in about 56 million people, in a bid to stop it spreading. Tens of millions of others cities far from the epicentre are also enduring travel restrictions.
In the Quarantined ship in Japan people the total number of infections to 218. With nearly 6% of the 3,711 passengers and crew members now infected, the 952-foot cruise ship also has the highest infection rate of the coronavirus anywhere in the world.

Villages in Vietnam with 10,000 people close to the nation's capital are placed under quarantine on 13th Feb after six cases of the deadly new coronavirus were discovered there. The locking down of the commune of Son Loi, about 40 kilometres from Hanoi, is the first mass quarantine outside of China since the virus emerged from a central Chinese city late last year.
1.     The people on quarantine are kept under a 14-day quarantine. If they are placed together and if anyone is diagnosed during that period, the quarantine will add another 14 days.
  1. The longer you have several thousand people cohoused you will continue to propagate waves of infection.
  2. A better way to quarantine is to break up these people into smaller groups and quarantine them separately.
  3. Why quarantine children < 15 years when the virus is not risky for them.
  4. Why not separate elderly people with comorbid conditions at high risk of deaths and quarantine them separately in one to one or small groups.
  5. Why allow people to celebrate and have cultural programs during quarantine. As was seen in India people dances together with surgical masks during quarantine period,
  6. Ventilation system connects one room to the next. There has been previous concern that the coronavirus can spread through pipes
  7. Stress and anxiety are known to suppress the immune system, making people more susceptible to contracting the virus. 
  8. Quarantine them the way it was done in TB sanitoriums with both sun-balconies and a rooftop terrace where the patients would lie all day either in beds or on specially designed chairs.

Standard Respiratory Droplets Precautions

At triage: Surgical 3 layered mask to the patient; Isolation of atleast 1m distance, Cough etiquette and Hand hygiene
Droplet precautions: Three layer surgical mask by patients, their contacts and health care workers, in an adequately ventilated isolation room, health care workers while caring with the secretions should use eye protection, face shields/goggles. One should limit patient movement, restrict attendants and observe hand hygiene.
Contact precautions: When entering room - gown, mask, goggles, gloves – remove before leaving the room; Dedicated equipment/ disinfection after every use; Care for environment- door knobs, handles, articles, laundry; Avoid patient transport and Hand hygiene
Airborne precautions when handling virus in the lab and while performing aerosol-generating procedures. Room should be with negative pressure with minimum of 12 air changes per hour or at least 160 litres/second/patient in facilities with natural ventilation. There should be restricted movement of other people and all should use gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or equivalent, or higher level of protection)

Public
Strict self-quarantine if sick with flu like illness: 2 weeks
Wash your hands often and  for at least 20 seconds with soap and water or use an alcohol-based hand sanitizer.
Avoid touching:  Eyes, nose, and mouth with unwashed hands.
Avoid close contact:  (3-6 feet) with people who are sick with cough or breathlessness
Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
Clean and disinfect frequently touched objects and surfaces.
Masks
Surgical 3 layered Masks: For patients and close contacts
N 95 Masks: For health care providers when handling respiratory secretions.

Lab tests

1.     There are two ways to detect a virus: through the genetic material DNA or RNA or to detect the protein of the virus. The rapid tests look at the protein. It takes 8-12 weeks to make commercial antibodies. So right now, for the diagnostics tests they are using PCR which give you a turnaround in 1-2 hours.
2.       BOTH the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) AND lower respiratory tract (LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage)
3.     Use PPE in the lab
4.     Use viral swabs (sterile Dacron or rayon, not cotton) and viral transport media
5.      In US January, all testing had to be done in CDC laboratories. However, on February 4, the US FDA issued an emergency-use authorization for the CDC's COVID 19 Real-Time RT-PCR Diagnostic Panel, which allows it to be used at any CDC-qualified laboratory in the United States.
6.     Lab precautions: BSL 2 (3 for viral culture labs)


Treatment

1.     No proven antiviral treatment.
2.     With SARS, in 6 months the virus was gone and it never came back.  Pharmaceutical companies may not spend millions and millions to develop a vaccine for something which may never come back.
3.      Secondary infection, E Coli, are most likely the cause of deaths of the patients in the Philippines and HK.
4.      A combination of lopinavir and ritonavir showed promise in lab in SARS. Combination of lopinavir, ritonavir and recombinant interferon beta-1b was tried in MERS.
6.      Chloroquine had potent antiviral activity against the SARS-CoV, has been shown to have similar activity against HCoV-229E in cultured cells and against HCoV-OC43 both in cultured cells and in a mouse model.
7.      Thailand: Oseltamivir along with lopinavir and ritonavir, both HIV drugs.
8.      Experimental drug: Rrom Gilead Sciences Inc., called remdesevir (started on 6th Feb as a trial)
9.      Russia and China drug: Arbidol, an antiviral drug used in Russia and China for treating influenza, could be combined with Darunavir, the anti-H.I.V. drug, for treating patients with the coronavirus. {the COVID 19 shares some similarity to HIV virus also)
10.   PVP-I mouthwashes and gargles significantly reduce viral load in the oral cavity and the oropharynx. PVP-I has high potency for viricidal activity against hepatitis A and influenza, MERS and SARS
11.   The Drug Controller General of India has approved the "restricted use" of a combination of drugs (Lopinavir and ritonavir) used widely for controlling HIV infection in public health emergency for treating those affected by novel coronavirus.
12.   In SARS, people were put on long term steroids ending with immunosuppression and late complications and death. The current protocol is short term treatment.

Case Definitions

Suspect case
A. Patients with severe acute respiratory infection (fever, cough, and requiring admission to hospital), AND with no other etiology that fully explains the clinical presentation AND at least one of the following:
·       a history of travel to or residence in the city of Wuhan, Hubei Province, China in the 14 days prior to symptom onset, or
·       patient is a health care worker who has been working in an environment where severe acute respiratory infections of unknown etiology are being cared for.
B. Patients with any acute respiratory illness AND at least one of the following:
·       close contact with a confirmed or probable case of COVID 19 in the 14 days prior to illness onset, or
·       visiting or working in a live animal market in Wuhan, Hubei Province, China in the 14 days prior to
·       symptom onset, or
·       worked or attended a health care facility in the 14 days prior to onset of symptoms where patients with hospital-associated COVID 19 infections have been reported.
Probable case
A suspect case for whom testing for COVID 19 is inconclusive or for whom testing was positive on a pan-coronavirus assay.

Confirmed case
A person with laboratory confirmation of COVID 19 infection, irrespective of clinical signs and symptoms.
Severe acute respiratory infection (SARI)
An ARI with history of fever or measured temperature ≥38 C° and cough; onset within the last ~10 days; and requiring hospitalization. Absence of fever does NOT exclude viral infection
SARI in a person, with history of fever and cough requiring admission to hospital, with no other etiology that fully explains the clinical presentation (clinicians should also be alert to the possibility of atypical presentations in patients who are immunocompromised)
AND any of the following:
a)  A history of travel to Wuhan, Hubei Province China in the 14 days prior to symptom onset; or
b)  the disease occurs in a health care worker who has been working in an environment where patients with severe acute respiratory infections are being cared for, without regard to place of residence or history of travel; or
c)  the person develops an unusual or unexpected clinical course, especially sudden deterioration despite appropriate treatment, without regard to place of residence or history of travel, even if another etiology has been identified that fully explains the clinical presentation

OR A person with acute respiratory illness of any degree of severity who, within 14 days before onset of illness, had any of the following exposures:
a)  close physical contact with a confirmed case of COVID 19 infection, while that patient was symptomatic; or
b)  a healthcare facility in a country where hospital-associated COVID 19 infections have been reported

Uncomplicated illness
Patients with uncomplicated upper respiratory tract viral infection, may have non- specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache, muscle pain or malaise. The elderly and immunosuppressed may present with atypical symptoms. These patients do not have any signs of dehydration, sepsis or shortness of breath

Mild pneumonia
Patient with pneumonia and no signs of severe pneumonia. Child with non-severe pneumonia has cough or difficulty breathing + fast breathing: fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40 and no signs of severe pneumonia

Severe pneumonia
Adolescent or adult: fever or suspected respiratory infection, plus one of respiratory rate >30 breaths/min, severe respiratory distress, or SpO2 <90% on room air
Child with cough or difficulty in breathing, plus at least one of the following: central cyanosis or SpO2 <90%; severe respiratory distress (e.g. grunting, very severe chest indrawing); signs of pneumonia with a general danger sign: inability to breastfeed or drink, lethargy or unconsciousness, or convulsions. Other signs of pneumonia may be present: chest indrawing, fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40.
The diagnosis is clinical; chest imaging can exclude complications.
Acute Respiratory Distress Syndrome
Onset: new or worsening respiratory symptoms within one week of known clinical insult.
Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully explained by effusions, lobar or lung collapse, or nodules.
Origin of oedema: respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of oedema if no risk factor present.
Oxygenation (adults):
Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥5 cm H2O, or non-ventilated)
Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP ≥5 cm H2O, or non-ventilated)
Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cmH2O, or non- ventilated)
When PaO2 is not available, SpO2/FiO2 ≤315 suggests ARDS (including in non-ventilated patients)
Oxygenation (children; note OI = Oxygenation Index and OSI = Oxygenation Index using SpO2)
Bilevel NIV or CPAP ≥5 cmH2O via full face mask: PaO2/FiO2 ≤ 300 mmHg
or SpO2/FiO2 ≤264
Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5
Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3

Sever Sepsis

Adults: life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection, with organ dysfunction.
Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia.
Children: suspected or proven infection and ≥2 SIRS criteria, of which one must be abnormal temperature or white blood cell count

Septic shock
Adults: persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65 mmHg and serum lactate level >2 mmol/L
Children: any hypotension (SBP <5th centile or >2 SD below normal for age) or 2-3 of the following: altered mental state; tachycardia or bradycardia (HR <90 bpm or >160 bpm in infants and HR <70 bpm or >150 bpm in children); prolonged capillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea; mottled skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia
e ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3
Common Myths

1.     People receiving packages from China are not at risk of contracting the COVID 19 as the virus does not survive long on objects, such as letters or packages.
2.     There is no evidence that companion animals/pets such as dogs or cats can be infected with COVID 19.
3.     Pneumococcal vaccine and Haemophilus influenza type B (Hib) vaccine, do not provide protection against COVID 19.
4.     Regularly rinsing the nose with saline does not protect people from infection with COVID 19 or respiratory infections although it can help people recover more quickly from the common cold.
5.      There is no evidence that using mouthwash will protect you from infection with COVID 19 although some brands or mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth.
6.     There is no evidence that eating garlic protects people from COVID 19.
7.     Sesame oil does not kill the new coronavirus. Chemical disinfectants that can kill the COVID 19 on surfaces are bleach/chlorine-based disinfectants, either solvents, 75% ethanol, peracetic acid and chloroform.
8.     People of all ages can be infected by COVID 19. Older people, and people with pre-existing medical conditions (such as asthma, diabetes, heart disease) appear to be more vulnerable to becoming severely ill with the virus.
9.     Antibiotics do not work against viruses.
10.  To date, there is no specific medicine recommended to prevent or treat  COVID19.

Trolls and conspiracy theories: Not validated and are fake news

1.     COVID 19 is linked to Donald Trump, and US intelligence agencies or pharmaceutical companies are behind it.
2.     That eating snakes, wild animals or drinking bat soup cases corona
3.     Keep your throat moist, avoid spicy food and load up on vitamin C
4.     Avoiding cold or preserved food and drinks, such as ice cream and milkshakes, for "at least 90 days".
5.     Experts have been aware of the virus for years.
6.     The virus was part of China's "covert biological weapons programme" and may have leaked from the Wuhan Institute of Virology.
7.     Linked to the suspension of a researcher at Canada's National Microbiology Lab.  
8.     China wants to kill 20,000 COVID 19 patients is totally false. The site is linked to a sex website.

Role of CMAAO and other Medical Associations

Get prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread of the virus and to share full data with WHO.   All countries should emphasise on reducing human infection, prevention of secondary transmission and international spread. Intensify IEC activities.

CMAAO IMA FOMA MAMC Recommendations
1.     Prise control of PPE
2.     Acctreditation of private labs for testing
3.     Private insurance should cover the infectyion
4.     IEC and CME activities to be intensified
5.     Allow paid leaves for air born and droplet infections
6.     Allow teleconsultations in flu like diseases
7.     CSR funds for vaccine research
8.     Surgical three layered masks at public places
9.     Start National program on respiratory secretions born illnesses
10.  In India incorporate respiratory infection control under swatch bharat

CMAAO _ Suggestions so far

1.     7th January: CMAAO Alert: WHO to monitor China's mysterious pneumonia of unknown virus outbreak
2.      8th Jan: CMAAO warns Asian citizens travelling China over mystery pneumonia outbreak
3.      10th January: Editorial: COVID 19 strain causing pneumonia in Wuhan, China, It’s a new strain of corona virus in the china pneumonia
4.      13th Jan: China Virus Outbreak Linked to Seafood Market
5.      15th Jan: First Case China Pneumonia Virus Found Outside China in Thailand
6.      17th Jan: WHO issues warning after 'mysterious' Chinese COVID 19 spreads to Japan
7.      17th Jan: India at threat of Corona. CMAAO urges travel advisory on coronavirus: http://www.drugtodayonline.com/medical-news/nation/10379-cmaao-urges-travel-advisory-on-coronavirus.html  (18th Indian govt issues travel advisory as China's mysterious 'Coronavirus' spread in other countries)
9.      18-20 Jan: Three countries CMAAO meet, also discussed COVID 19
10.   22nd Jan: Still not being declared to be a notifiable disease, N 95 to be included in the list of essential drugs and prise capped, Oseltamivir, should also be prise capped, air flights should have available air masks for all passengers, not declaring flu like symptoms while boarding or landing should be a punishable offence (23rd India advisory to airports)
11.   24th: Inter Ministerial Committee needs to be formed on COVID 19 (PMO took a meeting on 24th evening)
12.   25th Jan: Indian government should pay for Indians affected with the virus in China
13.   26 Jan: Need of National droplet Infection Control program, Policy to ban export of face masks, policy to evacuate Indians and neighbouring countries from China affected areas, Time to collaborate on Nosode therapy (Exports of masks banned on 31st January by Indian Government) Action:  [ Feb 1st: Ibrahim Mohamed Solih thanked India for the evacuation of seven Maldivian nationals from the coronavirus-hit Chinese city of Wuhan. India evacuated 647 people] [ on 30th India banned gloves, PEP and masks but on 8th lifted the ban on surgical masks/disposable masks and all gloves except NBR gloves. All other personal protection equipment, including N-95 and equipment accompanying masks and gloves shall remined banned.] 
14.   27th Jan: History of anti-fever drugs at airports should be taken
15.   28th Jan: Do research on Nosodes
16.   29th Jan: Closure of live markets all over the world, India should take a lead
17.   30th Jan: Paid flu leave, surgical mask at public places, N 95 for health care providers
18.   31st Jan: Respiratory hygiene advisory schools, Pan India task force to be made 
19.   1st Feb: Disaster Budget is the need of the hour
20.   3rd Feb: 100 crore budget for COVID 19; Private labs to be recognised; one dedicated COVID 19National help line, MTNL BSNL to have a line of advisory in their bills, isolation wards to be single rooms or two beds separated with six feet distance, national insurance to cover cost of treatment,  Sea ports to have same precautions, prize caps for masks, and gloves, National droplet control program, clarification that import of goods is not risky And suspend AI flights to China and Hong Kong  [Feb 4 Air India on Tuesday suspended flight services to Hong Kong from Friday until March 28. Earlier, Air India had cancelled its flight to Shanghai from January 31 to February 14 and on 5th Feb the Ministry of Defence is setting up 10 new laboratories across the country, primarily to conduct research on viruses] [ 14th Feb: Japan to earmark $140 million to combat coronavirus. The government will earmark 15.3 billion yen (approximately $140 million) for emergency measures, including ones to bolster testing and medical treatment capacity, to double mask production to more than 600 million a month, and credits for small and medium-sized businesses hurt by the outbreak.
21.   4th Feb: Kerala travel advisory needed [The Union Ministry of Health and Family Welfare issued a fresh travel advisory on Monday urging people to refrain from visiting China]
22.   5th Feb: PM should talk about COVID 19in Man Ki Baat or a special address
23.   6th Feb: Time to have makeshift bed policy to tackle deaths in Kota, Muzaffarpur and COVID 19[Uttarakhand to set up two dedicated hospitals to tackle coronavirus : https://www.hindustantimes.com/india-news/uttarakhand-to-set-up-two-dedicated-hospitals-to-tackle-coronavirus/story-NYxBOw6XHTbugznTWa3CXK.html]
24.   7th Feb: IPC 270 should be applicable to COVID 19
25.   8th Feb: teleconsultation should be allowed to flu and COVID 19consultation
26.  9th Feb: Schools should start droplet prevention program
27.  10th Feb: Pharma freebee how to handle
28.  11th Feb: IMR should be classified as  preventable vs non preventable
29.  12th Feb: Swatch Bharat should include COVID 19 prevention
30.  13th Feb: