Tuesday, March 10, 2020

COVID Deaths will cross 5000

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

India: 43 Cases, Delhi, UP (Noida, GBD, Agra),  Gurugram, Jaipur, Kerala,  Ladakh, Telangana, Tamil Nadu,  (8 states), 40 active cases, serious none, 3 cured, no community spread, no super spreader as per doubling time, expected trend likely new wave of cases between 10-15th March  (close contacts of active cases with human to human transmission)

17 Indians abroad infected with coronavirus: 16 cases reported from Japan on the cruise ship and one from the UAE.

Total 61 cases

Round the globe: 113Countries, 114416 cases, 4023 deaths, 46309  recovered,  Currently Infected Patients, 40538 (88%) in Mild Condition, 5771 (12%) Serious or Critical, likely deaths ( 4083  + 5771 x 15 = 866) = 4949 with the present trend and available treatment, 10,000 cases outside China. Likely deaths in Italy 653 (they have the highest elderly population)


Near Pandemic: all continents except Antarctica, cases - clusters- community spread; deaths in 23 countries, > 34,000 cases outside China, epidemics in China, S Korea, Iran, Italy, France, Germany and USA with > 23000 cases.

WHO: Corona weakly infected dog in Hong Kong is asymptomatic. There’s no evidence that animals can transmit the infection.
All 3,533 people aboard a cruise ship idling off San Francisco will be tested for the coronavirus, after 19 crew members and two passengers tested positive.
Hubei, the Chinese province at the center of the coronavirus outbreak, reported that there were no new infections outside its capital, Wuhan.

Colour Coding by China

Red codes: Remain in quarantine for 14 days
Yellow codes: Stay indoors seven days.
Green codes: Free to move about as they please.

Avoid Mass Gatherings: > 1000 people

India: 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.

COVID-19 Mortality Rate: March 5

1.     3.4% Mortality Rate estimate by the WHO as of March 3
2.     Mortality Rate in China as of Feb. 20 (3.8% nationwide, 5.8% in Wuhan, 0.7% other areas)
3.     Mortality Rate in China as of Feb. 4 (2.1% nationwide, 4.9% Wuhan, 3.1% Hubei, and 0.16% other provinces) reported by the NHC of China
4.     Death rate among patients admitted to hospital (HFR): 15%
5.      Comparison, seasonal flu generally kills far fewer than 1% of those infected.”

Formula of C: Corona; COVID; CHINA Pneumonia (early name); CONTAINMENT policy; CHAIN of transmission needs to be broken; 3 C’s: 1st Case, 1st Cluster and 1st Community spread, whenever a new Case comes; Avoid COHORT of CLOSE CONTACTS; CAP prise of essential items; CONTACT tracing is the most important step; CARE of the elderly, they are the highest risk; CONVINCE the patients to wear surgical masks; COUGH not to be ignored, can be corona or TB; Follow CDC guidelines; CHAOS in Iran, do not let it happen in your country; CHLOROQUINE can be tried; COLOUR CODING : Red, yellow and Green is important; Stay CONNECTED with updates; Know COUNTRIES not affected; CRIOTICAL cases: requiring mechanical ventilation has high mortality; No CONTACT policy with social distancing; CHECK list of hospitals; CHECK points ( all port entries)
COLLECTIVE action ( government, associations, media} and 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 if the disease happens; Remain CALM during illness; COMMUNICATION is the key; COMMITMENT of government; CAD patients are highest risk; CHILDREN are less likely to get infected and die; COLD BLOODED ANIMALS ARE NOT THE SOURCE
CLAIM of insurance should not be cancelled
Main Points

·       Isolate patients and avoid cohort (clusters) of contacts. Diamond Princess: 696 cases (23%), 7 deaths, 32 still serious
·       Ban export of masks, PPE, anti-viral, anti HIC drugs. India has banned export of 26 drugs and drug ingredients, most of them antibiotics, without explicit government permission.
·       Like Tamiflu, three prescriptions required to get masks, PPE
·       Increase access to respirators for health care personnel
·       Involve all professional bodies
·       CDC: Any American can be tested, no restrictions, subject to doctor’s orders
·       Flu vs COVID 19: It’s a lung disease, not a stuffy nose disease. 90% get a fever, 80 percent get a dry cough, and then it drops down to 30% getting shortness of breath and malaise — you know, being tired.  A runny nose only shows up in 4 percent, and that may be people who also happen to have a cold or flu, too.  Mild means a positive test, fever, shortness of breath, and possibly even pneumonia, but not so bad that you need to be hospitalized. Once you need oxygen, then you go over into the severe category.
·       DO’s: hand washing, avoiding sick people, and not touching our face with unwashed hands –


·       Possibly behaves like SARS; near pandemic in 30 days. causes mild illness in 82%, severe illness in 15%, critical illness in 3% and death in 3.4 % cases  ( 15% of admitted serious cases, 71% with comorbidity, 10% in Iran); affects all ages but predominately males ( 56%, 87% aged 30-79, 10% aged < 20, 3% aged > 80); with variable incubation period days ( 2-29,  mean 3 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,  mean time to CT changes 4 days,  3-4 reproductive number R0  ( flu 1.2, SARS 2), epidemic doubling time 7.5 days ( Korea 1 day probably due to super spreader), Tripling time in Korea 3 days,  Positivity rate ( UK 0.2%, Italy 5.0%, France 2.2%, Austria 0.6% and USA 3.1% ;  has origin possibly from bats (mammal), 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. Treatment is symptomatic though chloroquine, anti-viral and anti-HIV drugs have shown some efficacy.

·       Only 20% will have symptoms and will go for testing, rest may self-quarantine, 15% of serious will die.  In Iran initially 16 died of 95 tested means they are only testing serious patients.

·       Symptomatic go for testing and asymptomatic self- home quarantine and self-eport.

What is COVID 19?

·       Disease: coronavirus disease or (COVID-19) [11th February]
·       Virus: severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [11th February] Earlier name 2019 novel coronavirus.
·       Name: as per World Organisation for Animal Health (OIE) and the Food and Agriculture Organization of the United Nations (FAO) HO policy is not linking the name to a person, animal, place or country.
·       Other names: “the virus responsible for COVID-19” or “the COVID-19 virus” when communicating with the public.

Is it in a pandemic state?

·       WHO: Outbreak is “getting bigger”, can spread worldwide and is “literally knocking at the doors?”
·       21st Feb CDC: Pandemic Alert and a tremendous Public Health Threat.
·       24th Feb: Phase of preparedness for a potential pandemic.
·       25th Feb: Preparing for community transmission of the COVID-19 coronavirus
·       Feb 29:  WHO raises Global Risk from Coronavirus to the highest level of alert We have now increased our assessment of the risk of spread and the risk of impact of COVID-19 to very high at global level,”
·       WHO: “If we don’t act... that may be a future that we have to experience,” a lot of the future of this epidemic is in the hands of ourselves?” [
·       29th Feb first US death in a patient with a community spread case.

What is a pandemic?

·       WHO: "the worldwide spread of a new disease" and ability to spread from person to person.
·       CDC: Spreads across "several countries or continents, usually affecting a large number of people.
·       UK's Health and Safety Executive: Virus markedly different from recently circulating strains and humans have little or no immunity to it.

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 mental 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?

1.     Normal people will buy masks, get the tests done, get admitted and finish resources meant for high risk persons.
2.      The younger population has more fear of getting quarantines for 14 days or fear of losing their beloved elderly ones with comorbid conditions.

Does it affect the doctors also?

As on 14th Feb, 1,716 medical workers have contracted the virus and six died in China. 1,502 were in Hubei Province, with 1,102 of them in Wuhan.  The number represent 3.8% of China’s overall confirmed infections as of Feb. 11 with 0.3% deaths. (18th Feb: Director of Wuhan Hospital died).  Over 3000 workers involved so far. 2 workers who were sent to Wuhan in January end to help build new hospital got infected.
Hong Kong and Singapore has shown health care workers can be protected 100%.
Does it affect all ages?
87% aged 30-79
10% aged < 30
3% aged > 80

What is the clinical presentation?

·       Clinically all patients have fever (subjective or evident). No fever no corona.
·       75% have cough
·       50% weakness
·       50% breathlessness
·       Low total white count
·       Deranged liver enzymes.
·       It starts with fever, followed by a dry cough. After a week, it can lead to shortness of breath, with about 20% of patients requiring hospital treatment.

Notably, the COVID-19 infection rarely seems to cause a runny nose, sneezing, or sore throat (these symptoms have been observed in only about 5% of patients). Sore throat, sneezing, and stuffy nose are most often signs of a cold.

How many need admission and ICU care?
 20% need ICU care and 15% of them are fatal.  Those cases categorised as critical has the highest fatality rate—at 49.0 per cent.

What is the seriousness profile?
It causes mild illness in 82%, severe illness in 15%, critical illness in 3% and death in 2.3 % cases. About 6% patients admitted in ICU require mechanical ventilation or died [NEJM]. No deaths have occurred among those with mild symptoms.

It causes death in 15% of admitted serious cases.  71% deaths are in patients with comorbidity. [ 72,314 Chinese cases, largest patient-based study, JAMA)

COVID-19 Fatality Rate by COMORBIDITY:

Percentage does NOT represent in any way the share of deaths by pre-existing condition. Rather, it represents, for a patient with a given pre-existing condition, the risk of dying if infected by COVID-19.
Pre-existing condition       Death Rate/confirmed cases  Death Rate/ all cases
Cardiovascular disease                        13.2%                   10.5%
Diabetes                                              9.2%                      7.3%
Chronic respiratory disease                  8.0%                      6.3%
Hypertension                                       8.4%                     6.0%
Cancer                                                 7.6%                      5.6%
no pre-existing conditions                                                 0.9%

What is the case fatality of COVID 19?
·       3.4 % overall
·       Wuhan 4.9%
·       Hubei Province 3.1%
·       Nationwide in China 2.1%
·       Other provinces 0.16%.
·       NEJM:  1,099 cases from China, finds a lower rate: 1.4%. The death rate may be even lower, if there are many mild or symptom-free cases that have not been detected. The true death rate could turn out to be like that of a severe seasonal flu, below 1 percent.
·      Case fatality 10% in Iran, probably they are underreporting mild cases.

What is the case fatality as per the age?
The %  shown do not have to add up to 100%, as they do NOT represent share of deaths by age group but represents, for a person in a given age group, the risk of dying if infected.
AGE                      Death Rate/ Confirmed cases    Death rate/ all cases
80+                        21.9%                                                  14.8%
70-79                                                                                 8.0%
60-69 years old                                                                  3.6%
50-59 years old                                                                  1.3%
40-49 years old                                                                  0.4%
30-39 years old                                                                  0.2%
20-29 years old                                                                  0.2%
10-19 years old                                                                  0.2%
0-9 years old                                                                      No fatalities

Why elderly people are at risk?
The elderly and the sick – may have an immune response that is dangerous. It’s called a “cytokine storm,” when immune cells are overproduced and flood into the lungs, causing pneumonia, inflammation and shortness of breath. Patients who reported being retirees had the highest case fatality rate at 5.1 per cent.

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)

How much time it takes to recover?
People with mild cases recover in about two weeks, while those who are sicker can take anywhere from three to six weeks. 

Does it affect all sexes?

56% are males. Although men and women have been infected in roughly equal numbers, the death rate among men was 2.8 percent, compared with 1.7 percent among women.

What is the incubation period?

·       Variable, 2-14 days (mean 3 based on 1,324 cases, 5.2 days based on 425 cases, 6.4 days in travellers from Wuhan)
·       24 days has been observed. WHO said it could reflect a second exposure rather than a long incubation period. Hubei Province local government on Feb. 22 has reported a case with an incubation period of 27 days. 

What are different numbers?
·       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
·       Reproductive number (R0 or R not): Number of persons infected by one infected person. In COVID 19 it is 3-4
·       R0 of flu: 1.2
·       R0 SARS 2
·       Epidemic doubling time: 7.5 days
·       Epidemic doubling time in S Korea: 1 day, Probably due to super spreader?
·       Epidemic tripling time: S Korea 3 days again due to a super spreader.

What is the positivity rate in contacts who are tested?

UK 0.2%, Italy 5.0%, France 2.2%, Austria 0.6% and USA 3.1%

Which countries one should not travel?
·       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 S Korea, Iran, Italy (Do not travel)

Is it a Zoonotic disease?

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. 

Is it linked to bats?

It is closely related to several bat coronaviruses. Bats are the primary reservoir for the virus. SARS-CoV was transmitted to humans from exotic civet animals in wet markets, whereas MERS-CoV is transmitted from camels to humans. In both cases, the ancestral hosts were probably bats. Snakes and pangolins have been thought to be the intermediate host. One thing is clear the origin is from a mammal.

What are different types of transmissions?

·       Droplets, large > 5-micron organisms, flu, corona.
·       Air borne, < 5-micron organisms, TB, chicken pox, measles.
·       Contact on the surface: COVID 19, SARS, Flu [It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes]

Which are more important droplet precautions or contact precautions?

Both. In community spread contact precautions becomes more important. In SARS in Hong Kong the contact precautions worked more than the droplet precautions.

Can it transmit from pregnant mother to the baby?

No or little evidence to support the possibility of vertical transmission from the mother to the baby. [Lancet Feb 20]

Which part of the respiratory tract it effects?

·      Both upper and lower respiratory tract.
·      URTI causes fever with sore throat and mild cough.
·      LRTI causes fever with cough, and breathlessness.
·       Which is more contagious LRTI or URTI?
·       COVID 19 uses the same cellular receptor as SARS-CoV (human angiotensin-converting enzyme 2 [hACE2]), so transmission is expected more after signs of lower respiratory tract disease develop.
·        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.

Why LRTI is more infectious?

·       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 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]

What is the treatment?

Symptomatic though chloroquine, anti-viral & anti-HIV drugs have shown some efficacy.

What do you mean by Public Health Emergency of International Concern?

COVID 19 was declared as PHEIC on 30th Jan 2020 which means it is mandatory to report to WHO each human and animal case.

Is it the first time that a PHEIC has been declared?

·       No, Prior 5 PHEIC’s ARE
·       26th April 2009 - 10th August 2010 Swine flu
·       May 2014 Polio: resurgence of wild polio
·       August 2014 Ebola: It was the first PHEIC in a resource-poor setting
·       Feb 1, 2016 to 18 Nov 2016 Zika
·       2018–20 Kivu Ebola

What is Public Health Emergency of a state?

·       Kerala declared it when it had three cases and later lifted it on 12th Feb.
·       San Francisco declared it even without a case on 26th February.
·       Washington declared a state emergency on 1st March

Did China delay in reporting of cases?

·       While there were 300 cases and 5 deaths with SARS before the Chinese government reported it to the World Health Organization, there were only 27 cases and no deaths with COVID-19 before it was reported to that agency.

·       Chinese authorities-imposed lockdown measures on ten cities in an unprecedented effort to contain the outbreak of corona virus and built a specialized hospital [Huoshenshan Hospital] in just 10 days as part of China’s intensive efforts to fight corona virus. A second facility with 1,500 beds is also being opened. During SARS in 2003, a facility in Beijing for patients with that viral disease was constructed in a week.

What are lab confirmed Cases?
Positive throat swab test.

What are CT positive cases?
CT showing pneumonia like changes

What is total number?
·       Lab confirmed + CT Diagnosed Cases
·       This was the criteria used from 12-19 February in China.
·       Before and after only lab confirmed cases are counted.
·       Sudden jump in deaths and new cases on 12th is due to inclusion of CT diagnosed cases.

What will be the estimated deaths if CT diagnosed cases were also included?
Around 5% deaths will get added to total deaths.

What are the possible modes of spread? Myths and facts
·       Person-to-person: Yes, the virus can spread from one person to another, most likely through droplets of saliva or mucus carried in the air for up to six feet or so when an infected person coughs or sneezes, or through viral particles transferred when shaking hands or sharing a drink with someone who has the virus.
·       Casual exposure: No, Human to human contact requires prolonged contact (possibly ten minutes or more) within three to six feet. But with contact transmission this may not be applicable.
·       Currency notes: The central banking authorities of China are disinfecting, stashing and reportedly even destroying cash to stop the spread of the coronavirus. People’s Bank of China says that the cash collected by commercial banks must be disinfected before being released back to customers.
·       Fabric, carpet, and other soft surfaces: Currently, there’s no evidence.
·       Hard surfaces: Virus could be on frequently-touched surfaces, such as a doorknob, although early information suggests viral particles would be likely to survive for just a few hours (WHO).
·       Biometric attendance: Maharishi Valmiki hospital in Delhi stops biometric attendance
·      Kissing: Kissing scenes have been banned in movies in China.  France have advised to cut back on “la bise,” the custom in France and elsewhere in Europe of giving greetings with kisses, or air kisses, on the cheeks.
·       Breath analyser for alcohol: Kerala exempted air crew from breath analyser tests
·      Public gatherings: Affected countries have banned death ceremonies, people gathering.
·       Uncovered eyes: The transmission is through mucus membra contamination. One case got infected while using gown, but eyes not covered.
·       Eating meat, fish or Chicken: Its 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: No 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, 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.
·       Sex like EBOLA and ZIKA: We have no evidence yet.
·        Goods for affected areas: People receiving packages from China or other affected areas are not at risk of contracting the COVID 19 as the virus does not survive long on objects, such as letters or packages.
·       Pipes: Ventilation system connects 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.

What is no contact policy?

Greeting people by namaste, bowing or elbow touch. Corona Namaste is a no contact policy in public. Let’s not shake hands, IMA and CMAAO promotes the concept of Corona Namaste.

Why the cases did not occur in other countries in the initial phase?
Initial serious illness in other countries were less as patients with breathlessness were unlikely to board and patients will mild illness or asymptomatic illness are less likely to transmit infections. Foer transmission you require cough secretions or nasal discharge.

What is a biphasic infection?

Coronavirus follows what is known as a biphasic infection: the virus persists and causes a different set of symptoms than observed in the initial bout. The recovered person, too, can develop other symptoms, including insomnia and neurological problems, said Angela Rasmussen, a virologist at Columbia University.

What is a spreader and a super spreader?
Spreader: An infected person with normal infectivity.
Super spreader

·       An infected person with high infectivity, can infect hundreds of cases in no time. What cause a person to become super spreader is not known, HIV person becomes a super spreader if he or she is coinfected with STI.
·       The examples are the first case in Wuhan, a female in the S Korea Daegu fringe Christian group Shincheonji Church where she (61 years) infected more than 51 were infected.
·       In the church people shout out 'amen' after every sentence the pastor utters, pretty much every few seconds. And they do that at the top of their lungs, sending respiratory droplets flying everywhere.

What can be the cause of a cluster of cases or a hot spot without a super spreader?

People catching the virus from infected surfaces. We don’t know how long the germs stay on surfaces, but similar viruses can live for a week.

What are the various clusters of corona viruses?

·       The largest cluster was the Wuhan itself where over five crore people were locked down ending up with over 2000 deaths.
·       The second largest lockdown was in Japanese diamond princess ship where over 3000 patients were locked up and 23% of them developed COVID 19 virus infection.
·       The third example the cult church in South Korea where one lady infected with the virus spread it to over 30 people attending the church and she also infected multiple people in a hospital where she was treated and one person later died.
·       Shandong province in China reported that 207 cases of the new coronavirus were reported in Rencheng prison as of Feb. 20, citing information from the provincial government. A jail in the Zhejiang province has also reported a total of 34 infections. All of them are inmates, according to Chinese media.  A jail will behave like a ship and end up with 21% getting infected.

Can the court take cognigence in corona epidemic?

·       Despite CDC protest, 14 Americans infected with coronavirus on the Diamond. Princess cruise ship shared a plane back to the U.S. with healthy passengers, separated by plastic sheeting. (New York Post)

·      A court temporarily blocked the U.S. 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 this week 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".
·       The government separately blamed "evil" rumour-mongers for fuelling a run on goods at supermarkets such as toilet paper and rice.
·       Singapore has announced severe penalties for non-compliance of the quarantine order, including fines or jail time.
·       Prosecutors may investigate the founder and top leaders of Shincheonji Church of Jesus, whose members account for > 60% of confirmed cases on murder and other charges for failing to provide an accurate list of church members and by interfering with the government’s efforts to fight the outbreak.
·        IPC: 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.

What do you mean by the word corona?

‘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.

What is the composition of this virus?

It is a single-strand, positive-sense RNA genome ranging from 26 to 32 kilobases in length, Beta corona virus from C
orona family.

What are other dreaded corona viruses?

·       COVID 19 is one of the three deadly human respiratory coronaviruses. Others are Severe acute respiratory syndrome coronavirus [SARS-CoV] and Middle East respiratory syndrome coronavirus [MERS-CoV]). 
·       COVID 19 virus is 75 to 80% identical to the SARS-CoV

Where did it originate?
Wuhan, China December 2019. 1st case informed to the world by Dr. Li Wenliang who died on 6th Feb.

Will this virus survive heat?
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.

Did it originate from the WUHAN bio terror lab?

Unlikely, nobody will procedure bioweapon to be used on themselves or without simultaneously making an anti-weapon or antidote. It’s a myth that the virus was part of China's "covert biological weapons programme" and may have leaked from the Wuhan Institute of Virology and was linked to the suspension of a researcher at Canada's National Microbiology Lab. 

Is it true that China killed 20,000 COVID 19 patients?

It’s a fake news linked to a diversion to a sex site.

In initial days does it has 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]

Was Diamond Princess ship quarantine a successful model?

·       Does not look like as 23% of cases got infected.  705 cases got the virus and 6 deaths and 36 still serious as on 1st march. Would mean 6 + 36x15 = 1-12 cases will die. 
·       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.
·       The longer you have several thousand people cohoused you will continue to propagate waves of infection.
·       A better way to quarantine is to break up these people into smaller groups and quarantine them separately. Why quarantine children < 15 years when the virus is not risky for them and why not separate elderly people with comorbid conditions at high risk of deaths and quarantine them separately in one to one or small groups.

How long was the quarantine in the ship?
14 days for the passengers and another 14 days for the crew who took care of the people in  the first 14 days.

What are different ways  to control the infection in the community?
·       Lockdown in China: Unprecedented quarantines across Hubei, locking in about 56 million people, in a bid to stop it spreading. Results 2% deaths,
·       Locking of a village in Vietnam: More than 10,000 people in villages near Vietnam's capital were placed under quarantine on 13th February after six cases of the deadly new coronavirus were discovered there. These cases did not become a hotspot probably there was no super spreader kin those cases. Only 16 cases are so far.
·        Kerala model of containment in India: Hospital one to one quarantine of infected patients and individual home quarantine of contacts. They could contain the virus in the state.

Was it correct for India to have cultural evenings by quarantine people brough from China?

It was risky to allow people to celebrate and have cultural programs during quarantine. As was seen in India people dances together with surgical masks during quarantine period,

Is there a role of quarantine in the sunlight?
Quarantine them like 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.

What should one wear at the triage section of emergency room?
Surgical 3 layered mask to the patient; Isolation of two beds with at least three feet distance, Cough etiquette and Hand hygiene for all.

What are different precautions?
·       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)

What are the precautions for general 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.

Which masks for which patients?
·       Surgical 3 layered Masks: For patients and close contacts
·       N 95 Masks: For health care providers when handling respiratory secretions.

What are the lab tests?

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.

What are false positive and false negative results?
·       PCR tests may detect remnants of the measles virus months after people who had the disease stop shedding infectious virus.
·       Negative test can be if the test is done poorly, or the samples are stored at a temperature at which the virus deteriorates. The throat swab may also simply miss the virus that is hiding elsewhere in the body.
·       A virus test is positive if the virus is there on the swab in sufficient quantities at the time you swabbed the person. A negative test is not a definitive that there is no more virus in that person.

Can you give an analogy of a negative test?

A jam jar with mold on top. Scraping off the surface might give the impression that the jam is now mold-free, but in fact the jar may still contain mold that continues to grow.

What samples to collect?
BOTH the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) AND lower respiratory tract (LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage). Use viral swabs (sterile Dacron or rayon, not cotton) and viral transport media

Can it be done by private labs?
Not yet in India.  In US in 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.

What precautions to take in the lab?
BSL 2 (3 for viral culture labs)

Why pharma companies did not make SARS vaccine?

·       With SARS, in 6 months the virus was gone, and it never came back. Companies may not spend millions to develop a vaccine for something which may never come back.
·       The UN agencies should have initiated the development of vaccine against corona virus, SARS or MERS strain, if that was available, it might have reduced the case fatality of COVID 19.

Can it cause secondary infection?
Secondary infection, E Coli, are most likely the cause of deaths of the patients in the Philippines and HK.

Is there any proven treatment?

Which anti-viral have been tried?

·       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.
·       Scientists in Australia have reportedly recreated a lab-grown version of COVID 19.
·       Is chloroquine effective?
·       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.
·       Is there any role of anti-HIV drugs?
·       In Thailand Oseltamivir along with lopinavir and ritonavir, both HIV drugs have been used successfully.
·       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.
·       What is the role of experimental drug Rrom Gilead Sciences Inc., called remdesevir?
·       On 6th Feb in China and late February in USA trial has started.
·        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)

What are other treatments tried?
·       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
·       In SARS, people were put-on long-term steroids ending with immunosuppression and late complications and death. The current protocol is short term treatment.
·       Pneumococcal vaccine and Hib vaccine do not provide protection against COVID 19.
·       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.
·       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. Keep your throat moist, avoid spicy food and load up on vitamin C can not 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 are bleach/chlorine-based disinfectants, either solvents, 75% ethanol, peracetic acid and chloroform.
·        Antibiotics do not work against viruses.

Can dog/pets  get the COVID 19 virus?
There is no evidence.

Who is more vulnerable?

People with pre-existing medical conditions (such as asthma, diabetes, heart disease) appear to be more vulnerable to becoming severely ill with the virus.

What are various fake news?
·       COVID 19 linked to Donald Trump, US intelligence agencies or pharmaceutical companies.
·        Avoiding cold or preserved food and drinks, such as ice cream and milkshakes, for "at least 90 days can help.
·        Experts have been aware of the virus for years: The virus is not new, its two deadly forma have already caused SERS and MERS in the world. These types of viruses will keep on coming.

What is the 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
Prise control of PPE; accreditation of private labs for testing; private insurance should cover the infection; IEC and CME activities to be intensified; allow paid leaves for air born and droplet infections; allow teleconsultations in flu like diseases; CSR funds for vaccine research; Surgical three-layered masks at public places; Start National program on respiratory secretions born illnesses; in India incorporate respiratory infection control under swatch bharat

How to suspect a corona case?

CDC: PUI (person under investigation) for COVID-19

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 laboratory-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.
What is a Probable case?

A suspect case for whom testing for COVID 19 is inconclusive or for whom testing was positive on a pan-coronavirus assay.

What is a confirmed case?

A person with laboratory confirmation of COVID 19 infection, irrespective of clinical signs and symptoms.

What is 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

What do you mean by close contact?
Close contacts are people providing direct care to patients, working with infected health care workers, visiting infected patients or staying in the same close environment, working together in close proximity or sharing the same classroom environment with an infected patient, traveling together with infected patient in any kind of conveyance, living in the same household as an infected patient. The epidemiological link may have occurred within a 14-day period before or after the onset of illness in the case under consideration.  But once the community spread occurs the definition will no longer be correct.

What is the definition of different cases?
·       Primary case: Who got infected first in Wuhan in China?
·       Secondary case: When the primary cases infected the second person and tertiary when the secondary cases transmitted to another person.
·       Primary case: The first case in the China Wuhan in late December.
·       Index case: The first case in any country or the province.

What is community spread?

Means when the infection spreads without any contactable contact. Once that happens closing borders will not contain the virus. All cases with flu like illness will be presumed to be VOVID 19 AND ONLY patients with breathlessness will be tested.

What are mitigation guidelines?

·       Universal non-pharmaceutical interventions include personal practices, covering coughs and washing hands, as well as community and environmental measures such as surface cleaning.
·       Universal community measures include social distancing, or limiting contact in face-to-face settings, closing schools, telework or tele school for children, and recommending “modify, postpone, or cancel mass gatherings.
·       In healthcare system triaging patients, conducting patient visits via telemedicine, and delaying elective surgeries.
·       Commercial labs need to pitch in for testing.
·       Better to be overprepared than underprepared.
·       The testing criteria may change to testing only symptomatic cases and admitting cases only with breathlessness. (probably Iran is doing this)

What are high risk countries?

China, Macau, Hong Kong, Taiwan, South Korea, Singapore, Italy, Iran, and Japan.  

Will Iran be the next China?

·       With 54 deaths in Iran, looks like that Iran government is hiding the true extent of the outbreak. If the virus kills about 2 percent of known victims, then the number of cases should be 2100. Infact the death rates outside china are 1% and in that case the number will be much higher in Iran.
·       Cases in Iraq, Afghanistan, Bahrain, Kuwait, Oman, Lebanon, United Arab Emirates and Canada have been traced to Iran. Iran borders are crossed each year by millions of religious pilgrims, migrant workers and others, is one of the biggest causes for worry in what threatens to become a global epidemic.

Will afghan be the next source of carrying infection in India?
·       Religious pilgrims, migrant workers, businessmen, soldiers and clerics all flow constantly across Iran’s frontiers, often crossing into countries with few border controls, weak and ineffective governments and fragile health systems.
·       Many Afghanis are coming to India daily on health visa and many of them come via Iran. It is likely many of them would carry the virus to India.

What is the role of 14 days quarantine?

Quarantines and travel restrictions now in place in many counties, including the US, are also intended to help break the chain of transmission. Public health authorities like the CDC may recommend other approaches for people who may have been exposed to the virus, including isolation at home and symptom monitoring for a period of time (usually 14 days), depending on level of risk for exposure.

Should I wear a face mask to protect against coronavirus?
Currently, face masks are not recommended for the general public. Some health facilities require people to wear a mask under certain circumstances, such as if they have travelled from the city of Wuhan, China or surrounding Hubei Province, or other affected countries or have been in contact with people who did or with people who have confirmed coronavirus.
If you have respiratory symptoms like coughing or sneezing, experts recommend wearing a mask to protect others. This may help contain droplets containing any type of virus, including the flu, and protect close contacts (anyone within three to six feet of the infected person).

Should someone who is immunocompromised wear a mask?

Only if you are attending a public function. However, if your healthcare provider advises you to wear a mask when in public areas because you have a particularly vulnerable immune system, follow that advice. But if masking has not been recommended to you to protect against the flu and numerous other respiratory viruses, then it doesn’t make sense to wear a mask to protect against COVID-19.

Should I accept packages from China?
There is no reason to suspect that packages from China harbour COVID-19. Remember, this is a respiratory virus like the flu. We don’t stop receiving packages from China during their flu season. We should follow that same logic for this novel pathogen.

Can I catch the coronavirus by eating food prepared by others?

COVID-19 and other coronaviruses have been detected in the stool of certain patients, so we currently cannot rule out the possibility of occasional transmission from infected food handlers. The virus would likely be killed by cooking the food.

Should I travel on a plane if I have fever?

Of course, if anyone has a fever and respiratory symptoms, that person should not fly if possible, but anyone who has a fever and respiratory symptoms and flies anyway should wear a mask on an airplane.

What should people do if they think they have coronavirus, or their child does? Go to an urgent care clinic? Go to the ER?

Call your doctors instead of rushing to emergency room.

Can people who recover from the coronavirus still be carriers and therefore spread it?

There is no current evidence?

Are we missing infections in India?

We do not know. In Iran the country missed hundreds of cases till two persons died. Infect the first case was the one who died.

Can people who recover from a bout with the new coronavirus become infected again?

·       The Japanese government reported that a woman in Osaka had tested positive for the coronavirus for a second time, weeks after recovering from the infection and being discharged from a hospital. Combined with reports from China of similar cases, the case in Japan has raised some questions. Reinfections are common among people who have recovered from coronaviruses that cause the common cold.

·       Reinfection in a short time is unlikely. Even the mildest of infections should leave at least short-term immunity against the virus in the recovering patient. More likely, the “reinfected” patients still harboured low levels of the virus when they were discharged from the hospital, and testing failed to pick it up.

·       Even if there were occasional cases of reinfection, they do not seem to be occurring in numbers large enough to be a priority at this point in the outbreak.

How long the antibodies last?

Research with MERS has shown that the strength of the immune response depends on the severity of the infection, but that even in those with severe disease — which should produce the strongest immune responses — the immunity seemed to wane within a year.

Why SARS never entered India except a few cases and neighbouring countries?

Either cases were not detected or by the time it reached India there was already a summer.

Are antibodies protective?

On Feb. 13, a Chinese senior health official called on people who had recovered from the new coronavirus to donate blood plasma, because it might contain valuable proteins that could be used to treat sick patients, according to The New York Times

When should I suspect corona cases in India?
H1N1 negative flu like illness.

What is Environmental disinfection?

·       CDC states routine cleaning and disinfection procedures are appropriate for COVID-19 virus. Products approved by the Environmental Protection Agency for emerging viral pathogens should be used.

·       SARS and MERS, have been found to persist on inanimate surfaces, including metal, glass or plastic surfaces, for as long as nine days if that surface had not been disinfected, according to a research published in The Journal of Hospital Infection.

·       Human coronaviruses can be efficiently inactivated by surface disinfection procedures with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite" or bleach within one minute.

·       For SARS coronavirus, the range of persistence on surfaces was less than five minutes to nine days.

·       According to the CDC, the flu virus can live on some surfaces for as long as 48 hours and potentially infect someone if the surface has not been cleaned and disinfected.

In which conditions seasonal flu is more dangerous?
The flu is more dangerous to young children. Children infected with the new coronavirus tend to have mild or no symptoms.  It is also dangerous for pregnant women. Whether the COVID 19 poses as serious a threat to pregnant women is not known.

How many people die of seasonal flu?
As of Feb. 22, in the current season there were at least 32 million cases of flu in the United States, 310,000 hospitalizations and 18,000 flu deaths, according to the C.D.C. 

Can the warm atmosphere kill the virus?

Coronavirus may retreat as weather warms, just as influenza does. Because this is a new virus, there is no information about how the weather might affect it.
Even if the virus were to diminish in the spring, it might rebound later in the fall, as the weather cools. This is a pattern often seen in severe flu seasons.

Can dengue coexist with COVID 19?

In Thailand a 35-year-old man who was diagnosed with dengue and COVID-19 died.  When combined with the emerging infectious disease, it created complications leading to multi-organ failure.

What is the preparedness in India?
The two designated hospitals in Delhi are RML and Safdar Jang, both have an OPD of thousands of people.  Ideally such OPDs should be held at places where there no mix up with other types of patients.

Do we have a China like make-shift hospital like facility in India?
Not so far.

How is the India government coordinating with the IMA?
I am not aware of any such meeting.

How many Indian got Corona in the Diamond Princes ship?

What is the role of army in containment of any epidemic?

In March 2016 there was a biggest military mobilisation in Brazil’s history: 220,000 army, navy and air force personnel were called into action, as well as 315,000 public officials. The enemy was tiny Aedes aegypti mosquito which is believed to be responsible for the spread of the Zika virus.

What can happen if the disease spread in a city?
·       Like Diamond princess ship, quarantine will lead to 23% getting infected
·       Like 1200 who attended church 14% them have exhibited cough and other symptoms
·       China locked down 5 crore people with self-quarantine policy, 80,000 got infected (0.0016% of the community) and 2760 deaths (0.0000552% of the population)
·       647,406 people close contact with infected patients (1:8 patients).

What is the expected number of cases in Delhi in a Wuhan like situation?

·       Total expected positive in 1.67 crore population = 26720
·       Likely contacts: 213760
·       Expected serious cases = 20% = 4008
·       Likely deaths: 926
·       At risk 60+ population In Delhi = 1164147

What will be the preparedness needed then in Delhi?

4000 corona beds (15% of patients); self-quarantine of 17-20000 patients; no admission for patients without breathlessness; paid teleconsultation of mild cases; ICU beds with ventilatory care 3% (801 beds); Listing of hospitals with ECHMO machines; PPE 5 per patient (20,000 per day); Surgical masks usage:  213760 per day; Hand sanitisers: at least 2 lac per day; Health care providers dedicated with corona handling training: 20,000; 250 persons trained in handling dead bodies of infected cases; 500-1000 dedicated mental health councillors to tackled corona anxiety; 20 corona spokesmen to speak the same language; Prize cap of masks, other related diagnostics and PEPs; censoring of myths and fake news on social media and earmarked and segregated areas for Corona triage: suspect but not serious; suspect and serious; confirmed but not serious and confirmed and serious? 

What is the role of CMAAO in COVID 19?

CMAAO alerted
·       26 December 2019: viruses like SARS detected and Chinese scientists alerted the world about it.
·       3 January 2020: Transition from human to human raised concern
·       Despite this, on January 5, the Wuhan administration mentioned that the illness doesn’t seem to unfold from people to people. China lastly formally confirmed on 20 January that the corona was spreading from human to human.
·       7th January: WHO to monitor China's mysterious pneumonia of unknown virus outbreak?
·       8th: CMAAO warns Asian citizens travelling China over mystery pneumonia outbreak
·       10th: It’s a new strain of corona virus in the china pneumonia
·       13th Jan:  China Virus Outbreak Linked to Seafood Market
·       15th Jan: 1st Case China Pneumonia Virus Found in Thailand outside China.
·       21st Jan: New China coronavirus can spread between humans
·       22nd Jan: New China virus now in US, Thailand, Japan, South Korea and Taiwan: Will India or other Asian countries be spared
·       23rd Jan: Corona Virus: will it be declared as International Public Health Emergency by WH
·       11th 24th Jan: Corona virus 1st Death Outside Wuhan Epicentre Is Reported. W.H.O. DECISION: Corona virus is spreading, but the organization says it is not a global emergency
·       25th Jan: 25 Jan Indian Govt should pay for the treatment of India trapped in China with Corona Virus

Since than it has been covering daily.

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