Wednesday, March 11, 2020

11th March: CMAAO COVID 19 an Uneven Near Controllable Pandemic Revisited

11th March: CMAAO COVID 19  an Uneven Near Controllable Pandemic Revisited

Dr KK Aggarwal
President CMAAO, HCFI and Past National President IMA
 As expected wave of 18 cases on 10th March in India, Kerala under lock down
Indian scenario
On 10 March, confirmed that three more people in Karnataka, including wife and child of the infected Bangalore techie, were diagnosed with the virus.
Kerala reported six fresh cases in Pathanamthitta, all of whom were linked to the five previously confirmed cases from the town.
Three more people in Pune, who had come in contact with the infected couple from the city, tested positive.
Later, both parents of the infected three-year-old child in Ernakulam also tested positive.
 Another case was confirmed in Jammu and Kashmir, with the nation-wide toll reaching 62

62, 12 states  (Delhi 4, Uttar Pradesh 9, Haryana 14, Rajasthan 2, Telangana 1, Kerala 17, Ladakh 2, Tamil Nadu 1, Jammu and Kashmir 1, Punjab 1, Karnataka 4, Maharashtra 5)
High risk areas: UP, Kerala, Delhi, Maharashtra, Haryana, tourists Destinations 

Active: 58
Serious: Zero
Cured: 4
Community spread: zero
Super spreader: Zero
New wave as expected came on 10th March with 18 new cases, wave to continue on next 2 days; next expected wave around 16th March
Men more than women
Age group (3-45 years)
Delhi age group: 45, 25,52,25
ICMR: Testing across 52 labs (ICMR-National Institute of Virology, Pune is the apex laboratory for reconfirmation of any positive samples); additionally, 57 other labs to help sample collection

Indians abroad: 17 cases (16 cases reported from Japan on the Diamond Princess Cruise ship and one from the UAE)

Global scenario

Countries 119
Continents all except Antarctica
Cases 119176 cases (5% extra if CT diagnosis is taken)
Deaths 4295 deaths
Recovered: 66617
Currently infected: 48264
Mild: 42217 (87%)
Serious 6047 (13%)
Likely deaths (4295 + 6074 x 15 = 911 ) = 5206
Likely deaths in Italy: 763
Deaths in 26 countries
> 40,000 cases outside China
Epidemics in China, Iran, Italy, South Korea, France, Spain, Germany and USA with >30,000 cases

Public health emergency of international concern declared within a month after the first reported cases, as a result of the signs of human-to-human transmission outside China (30th January)

Global risk raised to the highest level of alert (28th February)

10th March: A near uneven controllable pandemic

COVID Sutras

Disease: Coronavirus disease or COVID-19

Virus: SARS-CoV-2 virus (names used when communicating with the public “the virus responsible for COVID-19” or “the COVID-19 virus”)
Symptoms: fever, tiredness, and dry cough (most common); only cough (pollution), cough and cold (allergy), fever with sore throat in children (streptococcal), fever above 100.4 with cough and cold
(flu), fever with cough and breathlessness (corona like illness), cough > 2 weeks rule out TB

No fever no flu no corona; No breathlessness no seriousness, no breathlessness no oxygen requirement no seriousness

Corona Namaste better than elbow touch

Hygiene: Maintain social distance 1 meter from a person with cough and cold; wash hands (Remember the mnemonic SUMAN K - seedha ulta mutthi anghuta nakhun kalai) with soap and water or 70% alcohol sanitizer, disinfect surfaces, use surgical masks, if infected (symptoms especially coughing or looking after someone who may have COVID-19. 

All doctors: to carry SPO2 monitor to detect early serious cases

Suspect a corona case: Fever or signs/symptoms of lower respiratory illness (cough or shortness of breath) AND any person, including health care workers who has had close contact with a lab confirmed COVID-19 patient within 14 days of symptom onset.

·         Fever and signs/symptoms of a lower respiratory illness (cough or shortness of breath) requiring hospitalization AND a history of travel from affected COVID 19 countries within 14 days of symptom onset

·         Fever with severe acute lower respiratory illness (SARI, pneumonia, ARDS) requiring hospitalization and without alternative explanatory diagnosis (e.g., influenza) AND no source of exposure has been identified.

·         A suspect case for whom testing for 2019-nCoV is inconclusive or for whom testing was positive on a pan-coronavirus assay

Confirmed case: Lab confirmed irrespective of clinical signs and symptoms.

Epidemic cycle: First case, first cluster, first community spread

Epidemic cycle: Contain, Delay, Research and Mitigate

What to do: If you have fever with dry cough with or without breathlessness self- isolate (quarantine yourself at home), wear surgical mask, do frequent hand wash and call your doctor.

Isolate all infected patients. They need to wear surgical mask.   

Isolate (quarantine) at home all close contacts, call them twice daily, counsel them, no testing if no symptoms, test if symptoms develop.

Avoid cohort (clusters) of asymptomatic close contacts without masks (Diamond Princess: 696 in cohort ended with 23% getting the infection and 7 deaths, 32 still serious)

Treatment: Avoid self-medication; start Tamiflu when symptoms appear and stop if COVID 19 is negative.

CDC: Any American can be tested, no restrictions, subject to doctor’s orders

It’s not flu: It’s a lung disease, not a stuffy nose disease. Clinically all have fever, 75% have cough; 50% weakness; 50% breathlessness with low total white count and deranged liver enzymes; runny nose only shows up in 4% cases; 20% need ICU care and 15% of them are fatal. Treatment is symptomatic though anti-viral (remdesivir) and anti-HIV drugs (lopinavir/ritonavir) have shown some efficacy.

Retirees had the highest case fatality rate at 5.1%.
Mild means a positive test, fever, shortness of breath, and possibly even pneumonia, but not so bad that you need to be hospitalized or needs oxygen.
Severe:  Once you need oxygen, then you move into the severe category.        
Color Coding by China: Red code: Remain in quarantine for 14 days; Yellow code: Stay indoors for 7 days; Green code: Free to move about as they please.

Avoid mass gatherings: > 1000 people, in smaller gathering first ask “I hope no one is here with fever and cough, if kindly leave or wear surgical mask”

  • Indian citizens are advised to refrain from travel to China, Iran, Republic of Korea, Italy & Japan and advised to avoid non-essential travel to other COVID-19 affected countries.
  • All international passengers entering into India are required to furnish duly filled self-declaration form (including personal particulars i.e. phone no. and address in India) to Health Officials and Immigration officials and undergo Universal Health Screening at the designated health counters at all points of entry.

Dos: hand washing, avoid sick people, avoid touching eyes, nose and mouth with unwashed hands, cover nose and mouth with tissue when coughing or sneezing.
Don’ts: Avoid close contact if cough and fever, do not touch eyes, nose and mouth, avoid spitting in public

       COVID 19
Possibly behaves like SARS, but more contagious and less lethal
Near pandemic, PHEIC
Respiratory virus not a GI virus
56% are males
Deaths rate males 2.8% females 1.7%
Causes mild illness in 82%
Severe illness in 15%
Critical illness in 3%
Death 3.4 % (March 3)
Deaths: 15% serious cases
Deaths 71% with comorbidity
71% deaths are in patients with comorbidity due to cytokine storm. [72,314 Chinese cases, largest patient-based study, JAMA)
CAD patients most at risk [CAD 10.5%, Diabetes 7.3%, COPD 6.3%, HT 6%, Cancer 5.6%, no pre-existing disease (0.9%)
Health care provider infections China 3.8% 0.3% deaths. Singapore Nil
Deaths 10% in Iran (under reporting)
Doing S Korea (0.6%) doing more tests in mild cases
Affects all sexes but predominately males 56%
Age; 87% (30-79), 10% (< 20), 3% (> 80)
Mean time to symptoms 5 days
Mean time to pneumonia 9 days
Mean time to death 14 days
Mean time to CT changes 4 days
3-4 reproductive number R0 (flu 1.2, SARS 2)
Epidemic doubling time 7.5 days
Doubling time in Korea 1 day probably due to super spreader
Tripling time in Korea 3 days
Positivity rate% (UK 0.2, Italy 5, France 2.2, Austria 0.6, USA 3.1)
Origin: Probably from bats (mammal; central hosts), snakes and pangolins (intermediate hosts); possible animal sources of COVID-19 not yet been confirmed
Spread: Large droplets
Spread: Predominately from people having LRTI
Precautions: Standard droplet for the public and close contacts; air borne for healthcare workers dealing with secretions.
Incubation period days 2-14 days
Mean Incubation period: 5.2 days
Recover time Mild cases 2 weeks
Recovery time sever cases 4-6 weeks
Case fatality 80 + 14.8%
Case fatality 70-79 = 8%
Case fatality 60-69 = 3.6%
Case Fatality 50-59 = 1.3%
Case fatality 40-49 – 0.4%
Case fatality 10-39: 0.2%
Case fatality < 9 years: nil

What is the case fatality of other viruses?
MERS 34% (2012, killed 858 people out of the 2,494 infected)
SARS 10% (Nov. 2002 – Jul. 2003, originated from Beijing, spread to 41 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%
Number of flu deaths every year: 290,000 to 650,000 (795 to 1,781 deaths per day)

·         Person-to-person through respiratory secretions via mucus membrane within a distance of
1 meter
·         Person to person through hand shakes
·         Fabric, carpet, and other soft surfaces: Currently, there’s no evidence.
·         Hard surfaces: doorknob, likely to survive for just a few hours (WHO).
·         Non porous surface 1-2 days and porous surface 8-12 hours
·         Casual exposure: Human to human contact requires prolonged contact (possibly 10 minutes or more) within 3 to 6 feet.
·         Currency notes: The central banking authorities of China are disinfecting cash to stop the spread
·         Biometric attendance: Suspended in India
·         Kissing: Scenes banned in movies in China.  France cut back on “la bise
·         Breath analyser for alcohol: Kerala exempted air crew
·         Public gatherings: Affected countries have banned death ceremonies, people gathering.
·         Uncovered eyes: The transmission is through mucus membrane contamination. One case got infected while using gown, but eyes not covered.
·         Eating meat, fish or chicken: It’s not a food-borne illness but a respiratory illness. It cannot occur by eating any food or meat. However, it is always advised not to touch raw meat, eat raw meat or eat partially cooked meat to prevent meat related food borne illnesses. Eating fish and chicken is safe.
·         Eating snakes or drinking bat soups: Eating wild animals cannot cause it. Handling their secretions can cause it.
·         Handling wild animals or their meat: Yes, if their secretions are handled by the animal handlers.
·         Semen: We do not know yet for the new corona virus (in patients infected with Ebola, the virus may persist for months in the testes or eyes even after recovery and can infect others and keep the epidemic going.
·         Sexual transmission like Ebola and Zika infected cases: No evidence yet.
·         Goods from affected areas: People receiving packages from affected areas are not at risk
·         Pipes: Ventilation systems connect one room to the next. There has been previous concern that the coronavirus can spread through pipes
·         Stress: Stress and anxiety are known to suppress the immune system, making people more susceptible to contracting the virus. 
·         Patients without symptoms: 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 of mild cases appears to have occurred during the incubation period in the index patient but the same has been challenged now.
·         Corona beer: It has nothing to do with coronavirus. It’s a brand of beer.
·         Minimal risk in plane: window seat
·         Airports more at risk: pipes, AC, International travelers, close surface contact, wear gloves when in doubt
·         All TV panelists: wear disposable earphones
Travel warning levels

  • Level 1 in all countries (Exercise normal standard hygiene precautions)
  • Level 2 in all affected countries (Exercise a high degree of caution)
  • Level 3 in all countries with secondary cases (Reconsider your need to travel)
  • Level 4 in affected parts of China and South Korea, Iran, Italy (Do not travel)

Formula of C: Corona; COVID; CHINA Pneumonia (early name); CONTAINMENT policy; break CHAIN of transmission; 1st Case; 1st Cluster; 1st Community spread; New Case; Avoid COHORT of CLOSE CONTACTS; CAP price of essential items; CONTACT tracing;  CARE of the elderly, CONVINCE patients to wear surgical masks; COUGH not to be ignored, CDC guidelines; CHAOS avoid; CHLOROQUINE can be tried; COLOR CODING (Red, Yellow, Green); Stay CONNECTED with updates; Know COUNTRIES not affected; CRITICAL cases; No CONTACT policy; CHECK list of hospitals; CHECK points ( all port entries); COLLECTIVE action; CONTROLLED measures; CONDOM: No evidence that it protects; CONGENITAL: No evidence of congenital Covid 19; CLEARING of antigen; COMPLAIN:  Section 270 of IPC; Do not CRTICISE; CALM during illness; COMMUNICATION is the key; COMMITMENT of government; CAD patients are highest risk; CHILDREN are less likely to die; COLD blooded animals are not the source; CLAIM of insurance should not be cancelled
What is coranxiety?

Anxiety about falling ill and dying; avoiding or not approaching healthcare facilities due to fear of becoming infected during care; fear of losing livelihood; fear of not being able to work during isolation; fear of being dismissed from work if found positive; fear of being socially excluded; fear of getting put into quarantine; fear of being separated from loved ones and caregivers due to quarantine; refusal to take care of unaccompanied or separated minors; refusal to take care of people with disabilities or elderly because of their high-risk nature; feeling of helplessness; feeling of boredom; feeling of depression due to being isolated; stigmatization of being positive infection; possible anger and aggression against government; unnecessary approaching the courts, possible mistrust on information provided by government; relapses of mental illness in already mentally-ill patients; overstress on people to cover work of infected colleagues, quarantined for 14 days and insufficient or incomplete information leading to myths and fake news

If the anxiety is not tackled what will happen?

·         Healthy people will buy masks, get the tests done, get hospitalized and exhaust resources meant for persons who are actually at high risk.

·         The younger population has more fear of getting quarantined for 14 days or fear of losing their beloved elderly ones with comorbid conditions.


  • Despite CDC protest, 14 Americans infected with coronavirus on the Diamond Princess cruise ship shared a plane back to the US with healthy passengers, separated by plastic sheeting. (New York Post)
  • A US court temporarily blocked government from sending up to 50 people infected with a new virus from China to a Southern California city for quarantine after local officials argued that the plan lacked details about how the community would be protected from the outbreak.
  • Hong Kong police: nabbed a part-time security guard at a shopping mall for allegedly writing on social media that multiple staff members had caught a fever and gone on sick leave. The messages "caused panic" and helped "breed paranoia".
  • Singapore: Severe penalties for non-compliance of the quarantine order, including fines or jail time.
  • Saudi Arabia will impose a fine of up to 500,000 riyals ($133,000) on people who do not disclose their health-related information and travel details at entry points  
  • Italy PM puts citizens on lock down and threatens them with a fine (206 euros; around £178) or jail (3 months) if they leave quarantine zones (Daily Mail UK)
  • IPC: Section 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.
  • Epidemic Disease Act, Essential Commodities Act, NLEM, Municipal corporation acts, state public health acts
  • My rights to be tested


  • Throat swab or LRTI swab in viral VTM media
  • CT scan more sensitive than RT-PCR for diagnosis (Feb. 26, Radiology)
  • No drug approved in India
    Lopinavir plus Ritonavir promise in lab in SARS.
  • Lopinavir plus ritonavir plus recombinant interferon beta-1b in MERS.
  • Scientists in Australia have reportedly recreated a lab-grown version of COVID 19.
  • 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.
  • In Thailand, oseltamivir along with lopinavir and ritonavir (both HIV drugs) has been used successfully.
  • DCGI approved the "restricted use" of a combination of drugs (lopinavir and ritonavir)
  • Remdesevir trials 6th Feb in China and late February in USA
  • Russia and China drug: Arbidol, an antiviral drug used in Russia and China for treating influenza, could be combined with Darunavir, the anti-HIV drug, for treating patients with the coronavirus (COVID 19 shares some similarity to HIV virus also)
  • PVP-I mouthwashes and gargles have high potency for viricidal activity against hepatitis A and influenza, MERS and SARS
  • In SARS, people were put-on long-term steroids ending with immunosuppression and late complications and death. The current protocol is no or short-term treatment.
  • Pneumococcal vaccine and Hib vaccine do not provide protection
  • Regularly rinsing the nose with saline can help people recover more quickly from the common cold and dryness can protect one from touching the nose.
  • Mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth but cannot kill the virus
  • There is no evidence that eating garlic protects people from COVID 19.
  • Sesame oil does not kill the new coronavirus.
  • Chemical disinfectants that can kill the COVID 19 on surfaces: Bleach/chlorine-based disinfectants or solvents, 70% ethanol, peracetic acid and chloroform.
  • Antibiotics do not work against viruses.
  • 0.1% bleach is good for surface disinfection
  • Take 70 ml of 100% isopropyl alcohol and add 30 ml aloe vera gel or PEG and make sanitizer at home.

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