CMAAO Update 18th February on COVID-19
Coronavirus: China announces drop in new cases for fifth straight
day
19 cases in ship in
serious condition, 3642 likely deaths
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 2-14 days (3 days based on 1,324 cases); 5.2 days (based on
425 cases), 6,4 days in travellers from Wuhan); 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.
Daily Statistics 15th February, 29 countries
Total cases: 73,333
New cases yesterday: 2008
Deaths: 1,873
Recovered: 12,712 (87%)
Currently Infected Patients: 58748
Mild cases: 46,953 (80%)
Serious or Critical: 11,795 (20)
Deaths yesterday: 98
Serious or critical mortality 15%
Likely minimum deaths 1873 +1769 = 3642 with the present trend and
available treatment (plus deaths linked to daily new cases)
New updates
1.
Namaste: Let’s not shake hands
2.
Time for
facts, not fear; for rationality, not rumours and for solidarity, not stigma.
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.
Secondary Cases:
Thailand, Taiwan, Germany,
Vietnam, Japan, France, US, Korea
8.
Five 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), Taiwan
9.
WHO
warns epidemic could still ‘go in any direction’ and global expert says
outbreak just ‘beginning’ outside China
10. Coronavirus vaccine could be ready in 18 months (WHO)
11.
Human to human
contact Requires
prolonged contact ( possibly ten minutes or more) within three to six feet.
12. 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.
13. 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
14.
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.
15. Maharishi Valmeki hospital in Delhi stops
biometric attendance
16.
China has more than 80 running or pending clinical trials on
potential treatments for COVID-19.
17. WHO demands to know more about sick doctors, insists group of
12 virus experts will reach Beijing over the weekend?
18. Bangkok: A health worker was
found to have been infected by coronavirus on Friday, bringing the total number
of infections in the country to 34 since January.
February 17
- 79 new cases and 5 new deaths occurred
outside of Hubei province in China on February 17, as reported by the
National Health Commission (NHC) of China.
- Report from Hubei province
for February 17:
- 1,807 new cases
- 93 new deaths
- 59,989 cumulative
total cases
- 7,862 cumulative
total hospital discharges
- 41,957 currently
hospitalized, of which:
- 30,987 (73.9%) in mild condition
- 9,117 (21.7%) serious
- 1,853 (4.4%) critical - 1,223 new
hospital discharges
- 2 new cases in Taiwan:
- woman in her 80s.
- man in his 30s who had fever and coughing symptoms from Jan. 28 to Feb. 6. - 1 new case in Japan: a man in his 60s in the Owari district
of Aichi Prefecture who is an acquaintance of a case confirmed on Feb. 16.
- 2
new cases in Hong Kong.
- 2
new cases in Singapore.
5 new discharges. New cases:
- a 1 year-old male Singaporean, part of the group evacuated from Wuhan on Feb. 9.
- a 35 year-old male Singaporean with no recent travel history to China but a contact of a previously confirmed case. - 1
new case in Hong Kong.
- 4 new cases in Japan (Wakayama Prefecture).
- 1 new case in Thailand: a 60-year old Chinese woman whose family
members earlier contracted the virus.
- 2 new cases in Japan:
- a hospital staff who was nursing a patient.
- a 50-year-old male government employee who was engaged in quarantine-related operations on the cruise ship Diamond Princess. - 1
new case in South Korea:
the 68-year-old wife of a previously confirmed case.
- 115 new cases and 5 new deaths occurred
outside of Hubei province in China on February 16, as reported by the
National Health Commission (NHC) of China
85 new cases onboard
the Diamond Princess cruise ship in Japan. Nearly 1 out of 8 passengers and
crew (12.23%) have tested positive to the virus so far (454 cases out of 3,711
passengers and crew). 19 are in a
serious condition. The
952-foot cruise ship also has the highest infection rate of the coronavirus
anywhere in the world.
- 14 new cases from
the Diamond Princess cruise ship in Japan: a group of US citizens whose results for
COVID-19 tests (done 2-3 days earlier) arrived while en-route from the
cruise ship to the airport for a flight back to the United States.
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–Barré 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.ship
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.
2.
The longer you have several
thousand people cohoused you will continue to propagate waves of infection.
3.
A better way to quarantine is to
break up these people into smaller groups and quarantine them separately.
4.
Why quarantine children < 15
years when the virus is not risky for them.
5.
Why not separate elderly people
with comorbid conditions at high risk of deaths and quarantine them separately
in one to one or small groups.
6.
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,
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.
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 at least 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.
Experts Opinions on COVID 19
“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
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
Search:
|
Country,
Other |
Total Cases |
New
Cases |
Total
Deaths |
New
Deaths |
Total
Recovered |
Serious,
Critical |
|
China
|
72,436
|
+1,888
|
1,868
|
+98
|
12,552
|
11,741
|
|
Diamond Princess
|
454
|
17
|
19
|
|||
|
Singapore
|
77
|
24
|
4
|
|||
|
Japan
|
66
|
1
|
18
|
19
|
||
|
Hong Kong
|
60
|
1
|
2
|
7
|
||
|
Thailand
|
35
|
15
|
2
|
|||
|
S. Korea
|
31
|
+1
|
10
|
|||
|
Taiwan
|
22
|
1
|
2
|
|||
|
Malaysia
|
22
|
9
|
||||
|
Germany
|
16
|
7
|
||||
|
Vietnam
|
16
|
7
|
||||
|
Australia
|
15
|
10
|
||||
|
USA
|
15
|
3
|
||||
|
France
|
12
|
1
|
5
|
|||
|
Macao
|
10
|
5
|
||||
|
U.A.E.
|
9
|
3
|
1
|
|||
|
U.K.
|
9
|
8
|
||||
|
Canada
|
8
|
1
|
||||
|
Philippines
|
3
|
1
|
2
|
|||
|
Italy
|
3
|
2
|
||||
|
India
|
3
|
3
|
||||
|
Russia
|
2
|
2
|
||||
|
Spain
|
2
|
2
|
||||
|
Egypt
|
1
|
|||||
|
Cambodia
|
1
|
1
|
||||
|
Sweden
|
1
|
|||||
|
Nepal
|
1
|
1
|
||||
|
Belgium
|
1
|
1
|
||||
|
Sri Lanka
|
1
|
1
|
||||
|
Finland
|
1
|
1
|
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)
8. 18th Jan: WHO issues warning after
mysterious Chinese Coronavirus spreads to Japan [http://blogs.kkaggarwal.com/tag/who/]
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
3
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