We are not at the mercy of the virus COVID 19

11^th March: CMAAO COVID 19

Its official: COVID 19 PANDEMIC but not the time for countries to move to mitigation, Must still try to suppress transmission, continue with containment efforts

Dr KK Aggarwal

President CMAAO, HCFI and Past National President iMA

All Travel from Europe to the United States suspended for 30 Days, Ban will not apply to the UK

INDIA ISOLATES ITSAELF

Total cases 60

Serious: Zero

Community spread: zero

Super spreader: Zero

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)

Countries 124

Continents all except Antarctica

Cases 126273 cases (5% extra if CT diagnosis is taken)

Deaths 4633 deaths

Recovered: 68286

Currently infected: 53354

Mild: 47645 (89%)

Serious 5709 (13%)

Likely deaths (4633 + 5709  x 15 = 856 ) = 5489

Likely deaths in Italy: > 1000

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 (30^th January)

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

10^th 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”

Travel

• 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)

Spread

·         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.

Legal

• 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

Treatments

• 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.

Is it in a pandemic state?

·       WHO: Outbreak is “getting bigger”, can spread worldwide and is “literally knocking at the doors?”

·       21^st Feb CDC: Pandemic Alert and a tremendous Public Health Threat.

·       24^th Feb: Phase of preparedness for a potential pandemic.

·       25^th 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?” [

·       29^th 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 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. 

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 30^th 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

·       26^th April 2009 - 10^th 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 12^th Feb.

·       San Francisco declared it even without a case on 26^th February.

·       Washington declared a state emergency on 1^st 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 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.

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 Corona 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. 1^st case informed to the world by Dr. Li Wenliang who died on 6^th 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 1^st 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 13^th 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?

No

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

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?

16

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.