Saturday, March 28, 2020

28th March COVID 19 Update Deaths will cross 30,000 in 199 countries, Minimum 27052


28th March  COVID 19 Update Deaths will cross  30,000 in 199 countries, Minimum 27052
1st one lac in 67 days, 2nd in 11 days, 3rd in 4 days, 4th in 3 day, 5th lac  in 2.5 Days, 6 lac in 2 days

0.1% population of Italy Infected, Italy and Spain more deaths than China
5909 new cases and 919 new deaths in Italy. Highest number of new deaths since the beginning of the epidemic in Italy [source] [video]. 46 doctors have died to date (with 4 additional deaths today). 6414 health workers have tested positive [source

Dr KK Aggarwal
President Confederation of Medical Associations of Asia and Oceania

India: 727 cases as per world meter, 20 deaths ( 16, MOH)
To watch
1.     Reduction in cases starting today / 30th March in view of a Nationwide Restriction of movement on 22 and Lock on 24th Night.
2.     Reduction in pollution levels

Countries 199
Cases 596723 (5% extra if CT diagnosis is taken)
Deaths 27352
Recovered: 133355
Currently infected: 436016   
Mild: 412016 (95 %)
Serious 23523 (%%)
Likely minimum deaths (23523 + 23523  x 15 = 3529) =  27052  

Friday, March 27, 2020

Caring for TB patients in the time of Corona


Caring for TB patients in the time of Corona

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

India continues to have the highest burden of both TB and drug-resistant TB in the world. India launched a TB Free India Campaign on March 13, 2018 at the Delhi End TB Summit and has set 2025 as the deadline of eliminating TB from the country.

Today, with much of the global focus, including resources, being shifted towards Covid-19, other diseases such as TB run the danger of being relegated to the background.

But, can we afford to do so? Not, if we are to meet the deadline, which is five years before the global target of 2030.

There are lessons to be learnt from Covid-19. Covid-19 has in a way shown us the path to control the TB burden in the country. Prevention is the key and this is what will bring us closer to our goal of making India TB-free.

Both Covid-19 and TB can have similar symptoms such as cough, fever and difficulty breathing. Do not ignore any patient with cough. The WHO recommends that tests for both conditions should be made available for individuals with respiratory symptoms.

TB is an airborne infection which spreads via droplet nuclei (< 5 µ in size) released into the air when the infected person coughs, sneezes, sings or even talks. Covid-19, though not yet known to be air-borne, spreads by large droplets (< 5 µ in size).

Open TB cases are infectious and just being within close proximity of an infected person may expose a person to the risk of acquiring the infection. The risk of disease transmission is particularly high in overcrowded conditions. Anybody could be harboring the infection and therefore could be the source of infection, which could also be Covid-19.

Measures must be put in place to limit disease transmission; protective measures such as basic infection prevention and control, hand hygiene, cough etiquette are common to both.

All household and close contacts of patients with infectious TB should be traced and tested and treated with a full course of ATT if found positive for TB. This also includes people living with HIV and other people at risk with lowered immunity or living in crowded settings. These groups are also at high risk of Covid-19. And if infected, they are at risk of developing severe disease.

Contact tracing interrupts the chain of transmission of the disease by early diagnosis of cases as well as timely and complete treatment.

All TB patients, especially active and drug-resistant cases, should be isolated or self-quarantined for 14 days.

The CDC has defined the “minimum period of isolation of the patient – pulmonary tuberculosis (also includes mediastinal, laryngeal, pleural, or miliary). Until bacteriologically negative based on three appropriately collected and processed sputum smears that are collected in eight – 24 hour intervals (one of which should be an early morning specimen), and/or until 14 days after the initiation of appropriate effective chemotherapy, provided therapy is continued as prescribed, and there is demonstration of clinical improvement (i.e., decreasing cough, reduced fever, resolving lung infiltrates, or AFB smears showing decreasing numbers of organisms.” (Available at: https://www.cdc.gov/tb/programs/laws/menu/isolation.htm)

Every case of TB should be notified and diligently followed up during the course of its treatment. Public awareness at grass root level must be created to the scale similar to Covid-19.

Social distancing, adopted as preventive measure for Covid-19 may interrupt treatment of TB. The government must act to ensure availability of anti-tuberculosis treatment.

TB is a treatable condition. But, any disruption in treatment can result in drug-resistant TB.

The WHO has published an information note to assist national TB programs and health personnel to urgently maintain continuity of essential services (prevention, diagnosis, treatment and care) for people affected with TB during the COVID-19 pandemic. It has cautioned that during the Covid-19 pandemic, adequate stocks of TB medicines should be provided to all patients to take home to ensure treatment completion without having to visit treatment centers unnecessarily to collect medicines.

Following this call from the WHO, the government has said that it has enough drugs to last until March 2021 and India’s TB patients will not be affected. Drugs will be issued for a month in advance so that patients have enough medicines with them even case of a lockdown (https://www.indiaspend.com/covid19-could-disrupt-tb-drug-supply-hitting-those-most-vulnerable-to-the-virus/, March 24, 2020).

The government has now allowed doorstep delivery of essential medicines during the 21-day national lockdown vide a notification dated 26th March, “…in exercise of the powers conferred by Section 26B of the Drugs and Cosmetics Act, 1940 (23 of 1940), the Central Government hereby directs that in case any person holding a license in Form-20 or Form-21 under the Drugs and Cosmetics Rules, 1945 to sell, stock or exhibit or offer for sale, or distribute drugs by retail, intends to sell any drug including the drugs specified in Schedule H except narcotics, psychotropics and controlled substances as defined in the Narcotic Drugs and Psychotropic Substances Act, 1985 (61 of 1985) and the drugs as specified in Schedule H1 & Schedule X to the said rules, by retail with doorstep delivery of the drug, the licensee can sell such drugs subject to the condition that any such sale of a drug specified in Schedule H shall be based on receipt of prescription physically or through e-mail…” (https://www.mohfw.gov.in/pdf/Doorstepdelivery26B.pdf )



COVID has given the answer for winter life threatening pollution: Lock Down

COVID has given the answer for winter life threatening pollution: Lock Down

Dr K K Aggarwal, President and Dr Anil Kumar Director Environment, Heart Care Foundation of India

COVID 19 pandemic has shown scary picture in number of countries and as a preventive measure entire India has been lock down for 21 days starting from 25-03-2020.

In Delhi, lock down is from 22-03-2020 (the day of Janta Curfew) and almost no movement of people and vehicles on roads in last 5 days. This has resulted in improved air quality in Delhi. In Delhi, prominent pollutants are PM10 and PM2.5. As per Central Control Room for Air quality Management – Delhi NCR, the average values of PM10 and PM2.5 in Delhi- NCR from 21-03-2020 to 26-03-2020 are as follows:

Date: 21-03-2020 (the day before Janta curfew):
Time
PM10 (Standard – 100 microgram per metre cube )
PM2.5 (Standard – 60 microgram per metre cube )
6:00 AM
203.4
87.0
12 Noon
188.4
79.0
6:00 PM
187.4
79.5
11: 00 PM
184.0
80.4

Date: 22-03-2020 (the day of Janta curfew):

Time
PM10 (Standard – 100 microgram per metre cube )
PM2.5 (Standard – 60 microgram per metre cube )
6:00 AM
182.9
86.8
12 Noon
177.3
88.8
6:00 PM
159.6
82.7
11: 00 PM
129.6
72.6

Date: 23-03-2020 (starting day of Lock down):

Time
PM10 (Standard – 100 microgram per metre cube )
PM2.5 (Standard – 60 microgram per metre cube )
6:00 AM
104.8
58.9
12 Noon
98.5
54.2
6:00 PM
96.7
51.7
11: 00 PM
105.1
52.7


Date: 24-03-2020 (Lock down continued):

Time
PM10 (Standard – 100 microgram per metre cube )
PM2.5 (Standard – 60 microgram per metre cube )
6:00 AM
115.9
58.5
12 Noon
118.1
58.6
6:00 PM
127.7
62.1
11: 00 PM
109.5
55.1


Date: 25-03-2020 (Lock down continued):

Time
PM10 (Standard – 100 microgram per metre cube )
PM2.5 (Standard – 60 microgram per metre cube )
6:00 AM
94.6
45.5
12 Noon
81.2
39.4
6:00 PM
67.8
34.7
11: 00 PM
72.5
37.3

Date: 26-03-2020 (Lock down continued):

Time
PM10 (Standard – 100 microgram per metre cube )
PM2.5 (Standard – 60 microgram per metre cube )
6:00 AM
75.8
40.9
12 Noon
75.0
39.5
2:00 PM
75.0
39.4





These levels of PM10 and PM 2.5 indicate significant declined trend in values of PM10 and PM2.5 due to restriction of movement of people and vehicles on roads as well as of stoppage of all other activities causing air pollution. During complete Lock down, the air quality in Delhi-NCR is within the standards.

Further, the Air quality Index (AQI) of various Continuous Ambient Air Quality Monitoring Stations (CAAQMS), maintained by DPCC, CPCB and IMD in Delhi, on 26-03-2020 at 3:00 PM is in the range of 51 to 137 which is in the satisfactory/ moderate range.

There are six AQI categories, namely Good, Satisfactory, Moderate, Poor, Very Poor, and Severe. Each of these categories is decided based on ambient concentration values of air pollutants and their likely health impacts (known as health breakpoints). AQ sub-index and health breakpoints are evolved for eight pollutants (PM10, PM2.5, NO2, SO2, CO, O3, NH3, and Pb) for which short-term (up to 24-hours) National Ambient Air Quality Standards are prescribed.

These results indicate that such measures can be taken to control Severe condition (smog condition) of air pollution in Delhi-NCR, which is happening every year in the month of November.




New telemedicine guidelines released: Urgent need of the hour


New telemedicine guidelines released: Urgent need of the hour

Dr KK Aggarwal


The government has released new telemedicine guidelines. These guidelines were much needed and have come at an opportune time.

A doctor at a mohalla clinic in Delhi has tested positive for Covid-19. His wife and daughter of the doctor have also tested positive for the virus. Following this, over 800 people who recently visited the clinic have been put under home quarantine and asked to contact the control room if they develop any symptoms. The clinic has been closed and sanitized (Business Today). It has been reported that the doctor developed the infection after contact with an infected woman who returned from Saudi Arabia (TOI).

Modalities like telemedicine are now absolutely essential if we are to prevent many more such scenarios. The number of positive Covid-19 cases is increasing every day in India. The entire country is under a lockdown with the intent to break the chain of transmission.

Teleconsultations will help to prevent cross infection of flu or corona-like illnesses among the large number of patients waiting to see the doctor.

We have been asking the government to permit teleconsultations, especially for cases of respiratory infections, for precisely this reason. We had written to the PMO in this regard as early as on 7th February (PMOPG/E/2020/0066034, dated Feb 7, 2020), when the PMO has cancelled Holi celebration events.

Teleconsultations are useful for routine checkups and follow-up. In cases of flu it is easy to identify patients who need hospitalization as they will be breathless. 

The guidelines have been developed by the Board of Governors in partnership with Niti Aayog.

All Registered Medical Practitioners can provide telemedicine consultation to patients from any part of the country. But they are bound by the same professional standards and ethical regulations as they apply to the regular consultations in the clinic.

Four types of telemedicine consults have been identified according to:

·        Mode of communication (video, audio, text-based
·        Timing of the information transmitted (real time or asynchronous – accessed as per need or convenience)
·        Purpose of the consultation (Non-Emergency or emergency) and
·        Interaction between the individuals involved (RMP-to-patient / caregiver, or RMP to RMP).

Five scenarios have been defined:

1.    Patient to Registered Medical Practitioner
2.    Caregiver to Registered Medical Practitioner
3.    Health Worker to Registered Medical Practitioner
4.    Registered Medical Practitioner to Registered Medical Practitioner
5.    Emergency Situations

Both the patient and the doctor need to know each other’s identity. Patient consent is necessary for telemedicine. If the patient initiates the telemedicine consultation, then the consent is implied.

The complete guidelines are available at the Health Ministry’s website.

Here are some safe practice guidelines for doctors:

·        Provide as many paid tele consultations as possible at least for the duration of the lockdown.
·        Doctors aged more than 65 years with uncontrolled diabetes, immunocompromised, who have six minutes’ walk distance< 200 meters, are unvaccinated for flu and pneumonia (with common secondary or co-infections) should completely stop OPDs and only give tele consultations.
·        Inform all patients that if they or any close contact has and fever they should call first and not visit the clinic/hospital without tele consultation.
·        Always wear surgical masks; if doing any procedure where aerosols may be produced, use N95 masks.
·        Doctor with cough and fever should go for self-quarantine and Covid-19 assessment, In a WHO study from Italy, it has been shown that 90% of doctors attending patients were asymptomatic when they were tested COVID-19 positive.
·        Install air purifiers with 10 air exchanges per hour rate at the clinic
·        When you come back home from you clinic, wash feet first, then hands, face, change cloths (keep them in separate box for washing), decontaminate all surfaces you have touched including your car, wash hands again with soap and water.
·        Stay away from elderly people in your home if possible.