Thursday, April 30, 2020



Dr K K Aggarwal
President Confederation of Medical Associations of Asia and Oceania, HCFI and Past National President IMA

With regular inputs from Dr Monica Vasudev

781:  Pot lockdown surveillance

A far-reaching surveillance initiative was implemented in Shenzhen, China, to isolate and contact trace people suspected of having the COVID-19 coronavirus. This initiative led to faster confirmation of new cases and reduced the window of time during which people were infectious in the community. This potentially reduced the number of new infections that arose from each case, according to a study of patients and contacts over 4 weeks (Lancet Infect Dis. 2020 Apr 27. doi: 10.1016/S1473-3099[20]30287-5).

782: Cases of large-vessel stroke in young patients with COVID-19

According to a study published in The New England Journal of Medicine, large-vessel stroke may be another complication of COVID-19. Over a 2-week period from March 23 to April 7, 2020, a total of 5 patients who were younger than 50 years of age presented with new-onset symptoms of large-vessel ischaemic stroke, wrote Thomas J. Oxley, MD, Mount Sinai Health System, New York, New York. All 5 patients tested positive for COVID-19. By comparison, every 2 weeks over the previous 12 months, our service has treated, on average, 0.73 patients younger than 50 years of age with large-vessel stroke.

All patients presented with signs and symptoms of stroke, including reduced level of consciousness, hemiplegia, and dysarthria. Patients 1, 4, and 5 had COVID-19 symptoms, including cough, fever, and lethargy. Two patients in our series delayed calling an ambulance because they were concerned about going to a hospital during the pandemic.

783: A study, published in Clinical Infectious Diseases, showed that the majority of patients with SARS-CoV-2 developed robust antibody responses between 17 and 23 days after illness onset, with delayed but stronger antibody responses in critical patients.

Jiuxin Qu, MD, Third People’s Hospital of Shenzhen, Shenzhen, China, and colleagues analysed data from 41 patients with confirmed SARS-CoV-2 (two back-to-back tests). Patients with mild, moderate, and severe disease were included. IgG and IgM antibodies against SARS-CoV-2 were measured using the iFlash-SARSCoV-2 IgG/IgM chemiluminescent immunoassay kit. According to the instructions, the sensitivity and specificity of the kits was 90% and 95% for IgG, and 80% and 95% for IgM. Combined nucleocapsid protein and spike glycoprotein were used as coated antigens to increase the sensitivity. 

Of the 41 patients, 40 (97.6%) of patients (40/41) were positive with IgG and 36 (87.8%) were positive with IgM. The median time of seroconversion after disease onset was 11 days for IgG and 14 days for IgM. The level of IgG antibody reached the highest concentration on day 30, while the highest concentration of IgM antibody appeared on day 18, but then began to decline.

Although the IgG level of those in the mild and moderate group was still rising on day 28, the IgG response of the critical group was significantly stronger than that of non-critical groups within 4 weeks after illness onset (P = 0.0001). For IgM, the fitting curve of the critical group rose above the cut-off value on day 10, peaked on day 23, and then began to decline. However, the IgM levels of non-critical groups rose above the cut-off value as early as day 5, peaked on day 16, and then decreased.

In the majority of the patients, there were antibody responses to SARS-CoV-2 during the first 3 weeks of the disease. The seroconversion time of IgG antibody was earlier than that of IgM antibody. The kinetics of anti-SARS-CoV-2 antibodies should be helpful in epidemiologic surveys, and especially in clinical diagnoses since the immunoassays can efficiently compensate the false negative limitations of nucleic acid testing. SOURCE: The New England Journal of Medicine and Clinical Infectious Diseases

783: Viral Shedding Continues Up to 6 Weeks After Coronavirus Symptom Onset

Patients may continue to shed the SARS-CoV-2 virus for up to six weeks after symptoms emerge, a small study of recovered COVID-19 patients suggests. In the convalescence period, a trace of virus may still be detected however, similar to other virus infections, this is not indicative of the transmission ability of the infected individual.

As reported in Clinical Infectious Diseases, 299 RT-PCR assays were performed (about five tests per patient). The longest duration between symptom onset and an RT-PCR test was 42 days, whereas the median duration was 24 days. In the first three weeks after symptom onset, the majority of RT-PCR results were positive for SARS-CoV-2. From week three onward, negative results increased. All tests were negative at week six after symptom onset. The rate of positive results was highest at week one (100%), followed by 89.3%, 66.1%, 32.1%, 5.4% and 0% at weeks two, three, four, five and six, respectively.

784: What is prolonged shedding
Is nucleic acid conversion time more than 24 days

785: What is the risk factor for prolonged shedding
Patients with longer viral shedding tended to be older and were more likely to have comorbidities such as diabetes and hypertension.
From a public health perspective, he added, "I need to emphasize that the public should not be scared by those seemingly 'prolonged' positive cases. It is way harder to prove 'no transmission ability' than 'potentially transmissible.'"

786: What does 14 days isolation means
 People need to realize that a 14-day isolation is appropriate for seeing whether one will develop symptoms after a known exposure to an infected person. Fourteen days is not a sufficient amount of time to be infected, recover and then be virus free.

787: What is the HCW return policy
Dr. Robert Quigley, Senior Vice President and Regional Medical Director of International SOS, noted in an email to Reuters Health, "The question that remains is how great does the viral load need to be to infect another person if in fact the viral load actually decreases over time. Regardless, until this virologic feature is defined, it is clear that infected healthcare professionals (HCPs) should have two consecutive negative tests before returning to the healthcare arena where they could potentially infect a fragile patient."

788: When should non-HCPs return to the workplace after testing positive for COVID-19
The absence of symptoms may not eliminate the risk of transmission to co-workers for up to 42 days post the onset of symptoms. Such conclusions could clearly impact our present practices of quarantine and isolation. [SOURCE: Clinical Infectious Diseases, online April 19, 2020.Deaths]

789: Confirmation of COVID-19 in Two Pet Cats in New York

U.S. Centers for Disease Control and Prevention (CDC) and the United States Department of Agriculture’s (USDA) National Veterinary Services Laboratories (NVSL) announced the first confirmed cases of SARS-CoV-2 (the virus that causes COVID-19) infection in two pet cats. These are the first pets in the United States to test positive for SARS-CoV-2.

The cats live in two separate areas of New York state. Both had mild respiratory illness and are expected to make a full recovery. SARS-CoV-2 infections have been reported in very few animals worldwide, mostly in those that had close contact with a person with COVID-19.

At this time, routine testing of animals is not recommended. Should other animals be confirmed positive for SARS-CoV-2 in the United States, USDA will post the findings. State animal health and public health officials will take the lead in making determinations about whether animals should be tested for SARS-CoV-2.

·         In the NY cases announced today, a veterinarian tested the first cat after it showed mild respiratory signs. No individuals in the household were confirmed to be ill with COVID-19. The virus may have been transmitted to this cat by mildly ill or asymptomatic household members or through contact with an infected person outside its home.
·         Samples from the second cat were taken after it showed signs of respiratory illness. The owner of the cat tested positive for COVID-19 prior to the cat showing signs. Another cat in the household has shown no signs of illness.

Both cats tested presumptive positive for SARS-CoV-2 at a private veterinary laboratory, which then reported the results to state and federal officials. The confirmatory testing was conducted at NVSL and included collection of additional samples.

The World Organisation for Animal Health (OIE) considers SARS-CoV-2 an emerging disease, and therefore USDA must report confirmed U.S. animal infections to the OIE.

Public health officials are still learning about SARS-CoV-2, but there is no evidence that pets play a role in spreading the virus in the United States. Therefore, there is no justification in taking measures against companion animals that may compromise their welfare. Further studies are needed to understand if and how different animals, including pets, could be affected.

Until we know more, CDC recommends the following:

·         Do not let pets interact with people or other animals outside the household.
·         Keep cats indoors when possible to prevent them from interacting with other animals or people.
·         Walk dogs on a leash, maintaining at least 6 feet from other people and animals.
·         Avoid dog parks or public places where a large number of people and dogs gather.

If you are sick with COVID-19 (either suspected or confirmed by a test), restrict contact with your pets and other animals, just like you would around other people.

·         When possible, have another member of your household care for your pets while you are sick.
·         Avoid contact with your pet, including petting, snuggling, being kissed or licked, and sharing food or bedding.
·         If you must care for your pet or be around animals while you are sick, wear a cloth face covering and wash your hands before and after you interact with them.

Wednesday, April 29, 2020



Dr K K Aggarwal
President Confederation of Medical Associations of Asia and Oceania, HCFI and Past National President IMA

With regular inputs from Dr Monica Vasudev

775: Evidence on spironolactone safety, COVID-19 reassuring for acne patients

Concerns about potential risks about the use of spironolactone for acne during the COVID-19 pandemic were raised on social media last month, but spironolactone and other androgen blockers might actually protect against the virus, according to a report in the Journal of the American Academy of Dermatology.

The virus needs androgens to infect cells, and uses androgen-dependent transmembrane protease serine 2 to prime viral protein spikes to anchor onto ACE2 receptors. Without that step, the virus can’t enter cells. Androgens are the only known activator in humans, so androgen blockers like spironolactone probably short-circuit the process, said the report’s lead author Carlos Wambier, MD, PhD, of the department of dermatology at Brown University, Providence, R.I (J Am Acad Dermatol. 2020 Apr 10. doi: 10.1016/j.jaad.2020.04.032).

The lack of androgens could be a possible explanation as to why mortality is so rare among children and why fatalities among men are higher than among women. At least one study is underway to see if spironolactone is beneficial: 100 mg twice a day for 5 days is being pitted against placebo in Turkey among people hospitalized with acute respiratory distress. The study will evaluate the effect of spironolactone on oxygenation.

 776: Buy a pulse oximeter

1.      Some COVID-19 patients have dangerously low levels of oxygen, but appear completely comfortable. This is being called “silent hypoxia.”

2.      COVID-19 patients monitor their oxygen levels at home with a pulse oximeter.

3.      A normal oxygen level measured by a pulse oximeter is around 97%, unless you have other underlying health problems like COPD. Start to worry when this level drops under 90% because this can affect the amount of oxygen going to your brain and other vital organs. People can experience confusion and lethargy at low levels. Levels below 80% are considered dangerous and increase the risk of organ damage.

4.      Normally, when parts of the lung are damaged, blood vessels constrict (or get smaller) to force blood to go to areas of the lung that are not damaged, keeping up the oxygen levels. With COVID-19, this response may not be working, so blood flow continues even to areas with damaged lung, where oxygen can’t make it across to the blood stream.

5.      There’s also the newer finding of “microthrombi” or tiny blood clots that can block oxygen flow into the blood vessels in the lungs which may be causing the drop in oxygen levels.

6.      Checking oxygen levels at home is beneficial mostly for those who have diagnosed COVID-19 or symptoms that are highly suggestive of infection. Monitoring your oxygen levels can provide reassurance as symptoms of shortness of breath ebb and flow during the course of the illness. If you notice your levels dropping, it can also help you know when to reach out to your doctor for help.

7.      Along with the risk of device malfunction, small things like wearing dark nail polish, false nails, and having cold hands can all throw off the reading, and the readings can change a little depending on your position. So, it’s important to track the trend in your levels, not to react to a single reading.

8.      If you do notice your oxygen levels dropping, contact your doctor for advice.

9.      Many people are being given oxygen through nasal tubes or facemasks and are also being placed in what’s called “prone positioning.” This is basically where you are put on your stomach or side to help open up air sacs at the bottom and back of your lungs to allow for more oxygen exchange into the blood stream.

10.  The key to taking care of yourself at home with COVID-19 is to monitor your symptoms. If you choose to use a pulse oximeter, do not rely on it to measure your condition. Keep a close eye on all your symptoms and be sure to contact your doctor if you experience worsening symptoms like weakness, confusion, chest pain, shortness of breath, regardless of your oxygen levels.

777: Learn to strengthen your lungs

1.      Learn to sleep prone or on the side

Belly breathing. Sit with one hand on your chest and the other on your belly. Take a deep breath in through your nose and feel your belly move out, not your chest. Then slowly breathe out through pursed lips as if you are whistling. Feel your belly move back in. Repeat this a few times slowly, take your time and stay comfortable. This has the added bonus of relieving stress because it is relaxing.

Incentive spirometer. This is a device used by people after surgery or after a lung illness like pneumonia to take deep breaths that expand the lungs. It has a mouthpiece with tubing that connects with an air chamber that has an indicator inside it. As you inhale, the indicator rises to a goal marked on the spirometer and lets you know you’ve achieved the appropriate deep breath.

778: European Doctors Warn Rare Kids' Syndrome May Have Virus Tie

Doctors in Britain, Italy, and Spain have been warned to look out for a rare inflammatory condition in children that is possibly linked to the new coronavirus. A multi-system inflammatory state requiring intensive care with features of toxic shock syndrome or Kawasaki disease. School-age children suffering from “an unusual picture of abdominal pain, accompanied by gastrointestinal symptoms” that could lead within hours to shock, low blood pressure and heart problems.

 779: Diabetes risk

In Diabetes the risk for death from COVID-19 is up to 50% higher in people with diabetes than those without. Evidence also suggests risks associated with COVID-19 are greater with suboptimal glycemic control, and that the virus appears to be associated with an increased risk for diabetic ketoacidosis and new-onset diabetes.

 780: COVID-19 is not ARDS

 PEEP be set to zero, inspiratory time to 1.4 seconds, pCO2 to less than 35 mmHg, and that tidal volume be increased to at least 800 mL. The regimen runs in direct contrast with widely held ventilation strategies and current guidance on COVID-19 treatment. [MESscape]

Tuesday, April 28, 2020


Dr K K Aggarwal
President Confederation of Medical Associations of Asia and Oceania, HCFI and Past National President IMA

With regular inputs from Dr Monica Vasudev

772:  Asymptomatic transmission has made controlling the spread of the disease all the more difficult.
Controlling the disease requires testing of even asymptomatic cases in different population settings such as prisons, enclosed mental health facilities, homeless shelters, hospitalised inpatients and other congregate living situations, the researchers argued in an editorial published in the The New England Journal of Medicine (NEJM) on April 24.
These factors support the case for the general public to use face masks when in crowded outdoor or indoor spaces. The only strategy for a resource limited country is symptom-based case detection and subsequent testing to guide isolation and quarantine.
773: In an editorial at NEJM, the researchers from University of California, San Francisco pointed out that there are differences in transmission and spread of SARS-CoV-1 and SARSCoV-2.
SARS was controlled within 8 months after SARS-CoV-1 had infected about 8100 persons in limited geographic areas. In contrast, SARS-CoV-2 has infected much more people within five months and it is spreading around the world even now very rapidly.
A key factor in the transmissibility of Covid-19 is the high level of SARS-CoV-2 shedding in the upper respiratory tract, even among presymptomatic patients, which distinguishes it from SARS-CoV-1, where replication occurs mainly in the lower respiratory tract.
Viral loads with SARS-CoV-1, which are associated with symptom onset, peak a median of 5 days later than viral loads with SARS-CoV-2, which makes symptom-based detection of infection more effective in the case of SARS CoV-1.
774; NHS warns of rise in children with new illness that may be linked to coronavirus
Sent By Dr Reddy Telangana: NHS have written to doctors alerting them that children are falling ill with a new and potentially fatal combination of symptoms apparently linked to Covid-19, including a sore stomach and heart problems. The children affected appear to have been struck by a form of toxic shock syndrome.

In a letter to GPs in north London, reported by the Health Service Journal , NHS bosses said: “It has been reported that over the last three weeks there has been an apparent rise in the number of children of all ages presenting with a multi-system inflammatory state requiring intensive care across London and also in other regions of the UK.

“The cases have in common overlapping feature of toxic shock syndrome and atypical Kawasaki disease with blood parameters consistent with severe Covid-19 in children.

“There is a growing concern that a Sars-CoV-2-related inflammatory syndrome is emerging in children in the UK, or that there may be another, as yet unidentified, infectious pathogen associated with these cases.”
The NHS letter continues: “Abdominal pain and gastrointestinal symptoms have been a common feature, as has cardiac inflammation. This has been observed in children with confirmed PCR positive Sars-CoV-2 infection as well as children who are PCR negative. Serological evidence of possible preceding Sars-CoV-2 infection have also been observed.”

Draft Minutes of Virtual Meeting held on 25th April 12-1.00 PM to discuss Future Pandemic Friendly Infrastructure

IJCP May Issue

Draft Minutes of Virtual Meeting held on 25th April 12-1.00 PM to discuss Future Pandemic Friendly Infrastructure

List of Participants

Dr KK Aggarwal, President CMAAO & President HCFI
Dr AK Agarwal, Ex Dean MAMC, Advisor Apollo Hospital, Delhi
Dr Mahesh Verma, VC IP University, Ex Director MAIDS Govt of Delhi
Dr Suneela Garg Dir Prof MAMC,  National President Elect IAPSM
Dr Atul M Kochar, CEO NABH
Dr T S Jain, Consultant Pediatrician, Max Smart City Hospital, Ex MS
Dr Bejon Misra, Founder Patient safety and Access, Consumer online Foundation
Mrs Upasana Arora, Director, Yashoda Hospital
Dr K K Kalra, Ex CEO NABH, Director HCFI
Dr Sanchita, Editor IJCP

Subject Experts

Mr Sarvagya  Srivastava, Engineer in Chief (Rtd), CPWD, Advisor IP University  
Dr R Chandrashekhar, Chairman IGBC Green Healthcare Rating,  Consultant World Bank, Consultant IUIH ( Indo UK Institute of Health ), Vice President RFHHA, Vice President IBIMA (India BIM Association), Visiting Prof. London South Bank University, UK;  Former Chief Architect, Ministry of Health &FW, Govt. of India
 Mrs Maninder Kaur, Architect Yashoda Hospital
 Mr Suresh DN, Project Manager, Max health care
 Mr Ashish Rakheja, Managing Partner AEON Integrated Building Design Consultant, Past President ISHRAE and Ashrae India Chapter, Chairman Technical Committee Indian Green Building Council Specialization Thermal Engineering


1.      Past pandemics and especially present Covid -19 infection around the globe and in our country, have given us opportunity to think about future protection from similar attacks and built systems which are safer, resilient and adaptable.

2.       A s Covid -19 infection is going to persist for some time may be 2 years or so, even after the lockdown is lifted in phased manner, we need to start afresh with new way of working in our workplace, hospitals or homes to maintain social distance and hygiene measures for personal protection as well of ours neighbors.

3.      Discussion points: How to maintain social distance in lifts, clinics, hospitals, factories, public transport systems, airports  etc.; Appropriate ventilation systems at homes, workplace and hospitals, high risk areas which are necessary to stop transmission of microorganisms including viruses and consumer friendly.; Impact of NO TOUCH technology and its utility in cost effective way; Use of infection resistant materials like wall paints, door knobs, handles etc. and Decontamination ease

Following infrastructure related concerns were highlighted by the experts after deliberations 

1.      Most importantly, after an episode is over, complacency sets in at all stakeholder’s levels and learnings are forgotten to safeguard future calamities.

2.      Ventliation is double edges sword, if not appropriate is rather counterproductive and is den for colonization and enhance transmission of disease agent. 

3.      Space management

4.      Non utilization of technology and poor design of the building like green building concepts, natural ventilation and lighting

5.      High cost of establishment and operative costs

Broad Solutions suggested are

1.      Building designs should be Evidence based designs (EBD) and meticulous planning to incorporate Green concepts, use of nature resources like lighting and ventilation, resilient and adoptable for expansion and contraction of services in time of crisis (need based) as makeshift arrangement.

To cut down cost, in place of single rooms, Nightingale wards having large windows for lighting and ventilation, maintaining distance between beds minimum 1 meter and curtains for privacy. Common hygienic toilets.

For this purpose, provision to be made in parking areas, lobbies and other space within or near premise to raise modular structures in minimum time.

Use of auditoriums, conventions halls, sports auditoriums etc.  to turn them into temporary isolation/quarantine/ triage facilities/primary care/monitoring areas like Wuhan erected 13 temporary hospitals in such places in hours to a weeks’ time creating 18000 beds with zoning and ventilation. Minimum standards for quality and safety were implemented in these makeshift arrangements also.

2.      To reduce over crowing in OPDs
Provision for large area in OPD to maintain physical distance
Appointment system
Teleconsultation/video consultation room

3.      Triage /screening area for prioritization of patients, less than 3 minutes for screening to minimize chances of contact transmission.

4.       Separate walkway for movement / transfer of infected patients from non -infected patients

5.      2-4 patients per lift and separate corridor and lift for Healthcare workers

6.       To reduced transmission by contact:  use of sensors for doors, washbasin taps, flush systems in toilets/urinals.

7.      Use of copper alloy (minimum 63%) cu as bacterial resistance material in doorknobs/handles/railings etc.

8.      Sufficient facilities for hand wash /sanitizers in clinical areas

9.      Sufficient AIIR rooms (isolation rooms) with negative pressure [CDC suggest 1.7 rooms per 10,000 population in mild epidemic; 6.56 rooms per 10,000 population in moderate epidemic severity and  61.5 rooms per 10,000 population in severe   epidemic        

Ventilation: involves 4 steps

1.      Pressurization

2.      Air changes per hours

3.      Filtration

4.      Purification of exhaust air

Ventilation systems should follow standards laid down by ASHRAE or other recognized national standards for installation and operations and maintenance. First 3 processes result in trapping and colonization with microorganisms, purification of these is most essential and generally this step is not taken care of adequately resulting in transmission of infection through HVAC system.

Proper Temperature and Relative Humidity as per need of clinical area is important for comfort of staff /patient and well as deterrent for infecting agents

Various methods for purification like HIPPA filtration, UVGI or ionization can be used in combination

Direction of air flow is also concern

Provision for switching of type of pressure from positive to negative in rooms or ICU on need base can be made

Preventive and regular maintenance as per guidelines

In any type of setting varying from a single room clinic to N Homes to tertiary hospitals, system of adequate ventilation and safe disposal of exhaust air is must and is feasible by using various technologies. The additional cost of installation is going to add cost to establishment but is vital for safety of staff and patients and communities.

Public Transport

Decongestion at airports, stations and bus stops is need of hour.

Sitting norms in airplanes, trains or buses shall change

Bicycle or two wheelers use to be encouraged

Minimum Quality standards should be made mandatory for all types of health facilities
Standards to include social distancing norms and infection prevention & control measures

Meeting ended with vote of thanks to chair and participants. It was decided to hold 2-3 more sessions to discuss technical details.

Copy of guidelines issued by CPWD for ventilation and by IDA for Dental facilities are attached

Monday, April 27, 2020


Dr K K Aggarwal
President Confederation of Medical Associations of Asia and Oceania, HCFI and Past National President IMA

Dr Anil Kumar
Director Herat Care Foundation of India

With regular inputs from Dr Monica Vasudev

771: Safe handling and disposal of PPEs, Home Masks etc.
The requirement of PPEs:
To safeguard health workers from the COVID-19, it is required to have suitable Personal Protective Equipment (PPE), which include goggles, face-shield, mask, gloves, coverall/gowns (with or without aprons), headcover and shoe cover. Coverall/gowns are designed to protect the torso of healthcare providers from exposure to the virus.
The coverall should be impermeable to blood, body fluids etc. India needs a huge quantity of such overalls.
As per the guidelines of the WHO Disease Commodity Package (Version 4.0), the fabric that clears/passes ‘Synthetic Blood Penetration Resistance Test’ (ISO 16603) and the coverall that passes ‘Resistance to penetration by biologically contaminated solid particles (ISO 22612:2005), maybe considered as the benchmark specification to manufacture coveralls. ASTM F 1670/F-1670M-08(2014) may be used to test synthetic blood penetration.
Disposal of PPEs, Masks etc:

In India, safe handling and disposal of PPEs, Masks etc. are covered under Bio-medical Waste Management Rules, 2016.  

In exercise of the powers conferred by Section 6, 8 and 25 of the Environment (Protection) Act, 1986 (29 of 1986), and in supersession of the Bio-Medical Waste (Management and Handling) Rules, 1998 and further amendments made thereof, the Central Government vide G.S.R. 343(E) dated 28th March 2016 published the Bio-medical Waste Management Rules, 2016. These rules apply to all persons who generate, collect, receive, store, transport, treat, dispose, or handle bio- medical waste in any form including hospitals, nursing homes, clinics, dispensaries, veterinary institutions, animal houses, pathological laboratories, blood banks, Ayush hospitals, clinical establishments, research or educational institutions, health camps, medical or surgical camps, vaccination camps, blood donation camps, first aid rooms of schools, forensic laboratories and research labs.

The prescribed authority for enforcement of the provisions of these rules in respect of all the health care facilities located in any State/Union Territory is the respective State Pollution Control Board (SPCB)/ Pollution Control Committee (PCC) and in case of health care establishments of the Armed Forces under the Ministry of Defence shall be the Director-General, Armed Forces Medical Services (DGAFMS). These rules stipulate duties of the Occupier or Operator of a Common Bio-medical Waste Treatment Facility as well as the identified Authorities. According to these rules, every occupier or operator handling bio-medical waste, irrespective of the quantity is required to obtain authorization from the respective prescribed authority i.e. State Pollution Control Board and Pollution Control Committee, as the case may be. These rules consist of four schedules and five forms. These Rules were further amended in the year 2018 and 2019.

As per Guidelines for Handling, Treatment and Disposal of Waste Generated during Treatment/Diagnosis/ Quarantine of COVID-19 Patients – Revision 2 dated 18/04/2020 issued by CPCB, with regard to COVID-19 Isolation wards: (isolation wards are those where COVID-19 positive patients are being kept for treatment/diagnosis), the following steps are needed to ensure safe handling and disposal of PPEs, used masks, head cover/cap, shoe-cover, disposable linen Gown, non-plastic or semi-plastic coverall,:

·        Collect used PPEs such as goggles, face-shield, splash-proof apron, Plastic Coverall, Hazmat suit, nitrile gloves into Red bag;   

·        Collect used masks (including triple-layer mask, N95 mask, etc.), head cover/cap, shoe-cover, disposable linen Gown, non-plastic or semi-plastic coverall in Yellow bags.

These Red bags and Yellow bags are needed to be treated and disposed of as per Part 1 of Schedule I of Bio-medical Waste Management Rules, 2016 as amended to date.

However, as per CPCB Guidelines-Revision 2 dated 18/04/2020, used masks and gloves generated from home quarantine or other households should be kept in a paper bag for a minimum of 72 hours prior to disposal of the same as general waste. It is advisable to cut the masks prior to disposal to prevent reuse.

Sunday, April 26, 2020

Minutes of Virtual Meeting CMAAO NMAs

Minutes of Virtual Meeting CMAAO NMAs

25th April, 2020, Saturday



Member NMAs

Dr KK Aggarwal, President CMAAO
Dr Yeh Woei Chong, Singapore Chair CMAAO
Dr Rajan Sharma, National President IMA
Dr RV Asokan, Honorary Secretary General IMA
Dr Marthanda Pillai, Member World Medical Council
Dr Ravi Naidu, Past President CMAAO, Malaysia
Dr N Ganabaskaran, President Malaysian Medical Association
Dr Thirunavukarasu Rajoo, Hon. General Secretary, Malaysian Medical Association
Dr Alvin Yee-Shing Chan, Hong Kong
Dr Marie Uzawa Urabe, Japan
Dr M Namazi Ibrahim, Malaysia


Dr Russell D’Souza, UNESCO Chair in Bioethics, Australia
Dr KK Kalra, Former CEO NABH
Dr Sanchita Sharma, Editor IJCP Group

The following points emerged from the discussion today:

  • Many Asian countries are coping well and are in a better position than the western countries like the US, UK and European countries.
  • Some countries like Malaysia, Singapore are facing some outburst of cases due to foreign workers.
  • CMAAO countries are working very hard to contain the spread of Covid-19. The mortality is lower in Asian countries.
  • Lockdown seems to be a common phenomenon among the CMAAO countries.
  • All countries are in different stages of Covid infection.
  • It is still not clear what will be the course of the pandemic in the next 2-3 months.
  • The situation is evolving very rapidly.
  • The virus is here to stay; it will come back in waves. We must prepare for post-lockdown situation.
  • Precautions (personal lockdown) should continue for at least 2 years.
  • Pre-operative testing, which also includes Covid-19 in addition to HIV, Hepatitis B & C, will become a norm.
  • AII rooms must be introduced in hospitals; if not possible, then rooms must have air purifiers with HEPA filters and exchange rate of 12 per hour.
  • Social distancing will be the new norm, even for doctors. Plan for social distancing in offices.
  • Airlines will not be fully operational for at least 2 years; may resume travel to lowest risk areas, and monitor it further.

Malaysia Update

  • Malaysia had 88 cases yesterday; total active cases are 1932; 363 (64%) patients have been treated and discharged. At presented total cases reported are 5691.
  • The 3rd phase of the MCO has been extended.
  • Launched an app “MySejahtera” meaning “My Wellbeing” has been launched; details about your health can be put in the app and there is a symptom checker, which will give results and tell you if you are at risk. We can also check the area we are in (Red, yellow or Green zone) based on our location.
  • The government is rolling out a return to work policy. It is planning to roll out RTPCR test for the first 100,000 workers in the next couple of days followed by antibody testing for surveillance of those returning to work.
  • The exit strategy for MCO will be rolled out slowly.
  • Malaysia has a sizeable migrant worker population, which is an area of concern. There might be clusters.

Singapore Update

  • There has been an explosion of cases in migrant workers, but we still have a very low death rate. One of the reasons for this is that migrants are mostly under 30 years of age. Our local data shows that if you are under 30, only half (0.5%) will need oxygen; the remaining 99.5% are just lying in bed, we test them, if they are negative then they go home. So, fortunately the disease is very mild in our migrant population.
  • Migrant population have been moved out of their dormitories and put in temporary isolation centers. Only about 10% rooms are infected i.e. there are clusters within the dorms (the whole dorm is not affected).
  • The lockdown has been extended to the 1st of June.
  • The lockdown has started to some effects; there are less and less community cases.
  • In future, the pandemic will come back in waves.
  • Singapore is facing both 2nd and 3rd waves together. 2nd wave due to people returning back, especially from the UK; the 3rd wave is the migrant population.
  • Run your own local tests. We used antibody tests that came from China, which had 90-99% sensitivity and specificity, but our local tests showed that it was only 30%.

India Update

  • We are more or less keeping the rate of growth of infection under control. The doubling time has improved to 6.5 days from 3.5 days.
  • The increase is only linear; there is no exponential increase in the number of cases.
  • Because of shortage of PPE kits, we have started manufacturing (good standard) them locally.
  • The situation varies from state to state. Every district has been divided into 3 zones - red, yellow and green depending upon the number of Covid-positive cases.
  • Antiviral drugs are being tried as treatment; convalescent plasma therapy has been successful in at least one patient.
  • Vaccine trials are going on at ICMR level and the National Institute of Virology (NIV), Pune.
  • The lockdown is complete; we are slowly trying to release the lockdown for economic and social reasons.
  • Pre-operative test for Covid-19 should be routine for all surgeries, even elective procedures. This has medicolegal and safety concerns.
  • Decontamination of clinics is a viable option.
  • The quality of kits is very important. Kits from China have also failed in India.
  • The govt. of India has brought in an ordinance to amend the Epidemic Diseases Act, 1897 incorporating stringent provisions against people who commit violence against doctors, nurses and paramedical workers. Attacks on doctors, paramedic staff have been made non-bailable offences punishable with up to 7 years imprisonment. We hope that the govt. will extend this law even when there is no epidemic and we will have this as a regular law.
  • All surgeries

Australia Update

  • There are very good reports from Australia.
  • Australia is in the midst of stage 3 lockdown. New Zealand is in stage 4 lockdown.
  • The lockdown in Australia could be lifted in three weeks, in a gradual manner. Schools will restart.

Japan Update

  • We are now improving but it is still not controlled since there are few patients with serious illness.
  • We have tried to prepare ICU into a full negative pressure room to reduce the use of PPE.

Hong Kong Update

  • The number of confirmed cases has been less than 10 each day. This number has been nil for the last 2 days now.
  • We have practiced absolute quarantine for those coming back to Hong Kong; moving them to hotels designated for quarantine. There is no contact between people coming back from overseas and the local people.
  • People have been using face masks voluntarily. We have advised them to not touch face even though wearing a mask; this is a loophole for getting the infection.
  • We have kept our confirmed cases to 1036, but this is not the time to be complacent. Next month, there is a possibility that the border between Hong Kong and mainland China may reopen. We are on our guard.
  • Schools are still closed; university entrance examinations started yesterday. Few students had high fever and left the examination room. This has introduced loopholes in the disease transmission.