CMAAO consensus on COVID 19

From the desk of Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

Minutes of Virtual Meeting CMAAO NMAs

18^th April 2020, Saturday; 9.30am-10.30am

Participants

Member NMAs

Dr KK Aggarwal, President CMAAO

Dr Yeh Woei Chong, Singapore Chair CMAAO

Dr Rajan Sharma, National President IMA

Dr R V Asokan HSG IMA

Dr Ravi Naidu, Past President CMAAO, Malaysia

Dr N Ganabaskaran, President Malaysian Medical Association

Dr Yee Shing Chan, Treasurer CMAAO

Dr Alvin Yee-Shing Chan, Hong Kong

Dr Marie Uzawa Urabe, Japan

Dr Marthanda Pillai council member WMA

Invitees

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:

• We must have a clear post-lockdown plan for all healthcare facilities.
• There is a shortage of supply of PPE kits to protect healthcare workers from Covid-19; many small clinics have shut down because of lack of appropriate PPE. This shortage is expected to persist because Covid-19 is not going away for another 2 years; there is, therefore, the need to be prepared. We do not know how the situation will unfold.
• In this scenario, PPEs will become a norm, which will necessitate a continuous supply of PPEs. Wearing of gloves, shoes, cap, and goggles will become mandatory.
• We need to resume working. So, we need to have feasible alternatives to them now, especially for small clinics. One way to address the shortage is to know how we can safely and effectively recycle them. For instance, you can use rubber bands to make the surgical mask more seal-proof or wear double surgical masks if no N95 masks available. One can wear a surgical mask or a cloth mask over a N95 mask to prolong its life. Simple motorcycle visors can be a very useful and economical alternative. A simple surgical mask can be used under this. It can be easily sanitized.
• Another major challenge is violence against doctors. There has been a surge of incidents of violence against doctors in India.
• There are different viewpoints on accepting PPEs as gift from any source. In our last meeting, the consensus was that if doctors are seeking PPEs in the form of donation from any source, it should not be considered unethical under respective councils in the time of a public health crisis.
• Patient autonomy along with their privacy and confidentiality can be curtailed during this crisis for the greater good.

Indian Medical Association Update

• India too is facing a shortage of PPE kits.
• Use of motorcycle visors, as an alternative to the PPE shortage, has been implemented in the state of Haryana. You can wear it with a simple surgical mask. It will protect from droplets.
• The government has approved 50 fabric factories to produce PPEs (impervious to water and blood) as per specifications (thickness etc.) as laid down by the Government and Defence Research and Development Organisation (DRDO) and after following all protocols.
• Guidelines and norms need to be defined about the use of PPEs i.e. which to be used where.
• IMA has shortlisted all the vendors and will soon share the list. The entire PPE kit will be available to private OPDs; costs have come down (Rs 350-450/-) and will be delivered at doorstep. They are found to be safe for routine use. These kits are not the same as HazMat suits. For the seriously ill Covid patients and in ICUs, the original PPE kits are to be used.
• Now there are sanitizers (like fumigators) available for single or two doctors’ clinics
• Lockdown must be lifted in a phased manner, depending on the local environment.
• Fear must be overcome and resume work.
• We must have a clear post-lockdown plan. Preparedness, regular use of PPE, personal hygiene including hand hygiene, behavioral changes and full cooperation of the public will be instrumental to defeat Covid-19.
• Protect our limited resources.
• There will be a surge in psychiatric problems; financial health of every healthcare establishment is very important.
• Violence against doctors must be stopped. It is demoralizing.

Hong Kong Medical Association

In HK, for the past week there have been only one to four daily new confirmed cases of Covid19, almost all were imported, as students returned from UK and other citizens returned from USA and Europe. The total number of confirmed cases remains just about one thousand. And no one got infected in the hospital setting but one elderly patient. We had no cases due to contact with people from mainland China with the border theoretically closed. We do not have massive outbreaks as all local or foreign residents in HK are all used to universal masking, frequent hand washing and use of alcohol sanitizers now, with awareness of social distancing.

Stay home advice had been there with closed schools and nurseries, close down of many businesses involving personal interaction like beauty Centers (except Doctor-run medical beauty clinics) sports Centers, bars, and gyms, etc. But hairdressings, shops, cinemas and restaurants are still open. Rules limit social gathering in public to less than 4. Penalty Tickets had been issued, only occasionally. The hospital manpower and beds are stressed but occupation is basically for isolation, convalescence and not so many are in ICU. High demand for quarantine is persistent though hopefully shrinking if drop of new case confirmation continues. Elective surgeries or services have reduced. No outbreaks so far in expatriate community, domestic helpers staying with the employer families.

Singapore Medical Association

• Singapore had 5050 cases yesterday, mostly in foreign migrant workers (3500). They are housed in 43 dormitories; some have around 20,000 people in them. We are trying to separate them and finding them alternate accommodation. These migrant workers are fairly asymptomatic and so are not consuming much resources.
• Community cases have reduced to 20 to 30 in a day. The ICUs are not overwhelmed; there are 22 critically ill patients.
• Singapore did well till mid-March; the number of cases rose as people returned home.
• We are stepping up testing. Now we are doing more than 3000 tests per day.
• Singapore does have some community spread discovered through our routine Flu Surveillance network.

Japan Medical Association (JMA)

• The government has been asked to produce more PPE to address their shortage.
• Many doctors are reusing the N95 masks very carefully.
• University of Osaka is using 3D printer technology to produce face screens for the protection of healthcare workers.
• Clinics are using gowns made from garbage bags, if they cannot get PPE.
• Japan is using an App to identify and contain the clusters.

Malaysia Medical Association

• Malaysia is doing well with total of 5255 cases; there have been 86 deaths; 2900 have recovered; 601 foreigners have tested positive. There were 69 new cases yesterday.
• The movement control order (MCO) will end on April 28th.
• We must be prepared for the next two years and assess the availability of PPE kits for the future.
• There is a shortage of PPE for healthcare workers, especially in the private sector. GPs, particularly those older than 50, have closed down their clinics.
• Initially there was lot of shortage. But now, the shortage is being eased down.
• The MMA is trying to source materials or whatever we need for the protection of GPs, through a cooperative under MMA. GPs pick up the supplies as and when they come in.
• Doctors are using the 3-ply surgical mask; N95 not available. Sanitizers are in short supply. But gloves are available. Face shields and gowns are available. But shoe covers and head covers are not so easily available.
• Many industries have been allowed to open. All workers returning to work are being tested (using the coronavirus antibody rapid test) before they enter.

Minutes Round Table 2 on Lockdown Exit Policy

18th April 2020, Saturday, 11am-12pm

Participants

Dr KK Aggarwal, President CMAAO

Dr Rajan Sharma, National President IMA

Dr AK Agarwal, Ex Dean MAMC

Dr Mahesh Verma, VC IP University, Ex Director MAIDS Govt of Delhi

Dr Suneela Garg Dir Prof MAMC, National President-Elect IAPSM

Dr Alok Roy, West Bengal

Dr TS Jain, Consultant Pediatrician, Max Smart City Hospital, Ex MS

Mr Bejon Misra, Founder Patient safety and Access, Consumer online Foundation

Mrs Upasana Arora, Director, Yashoda Hospital

Dr K Kalra, Ex CEO NABH, Director HCFI

Dr Sanchita Sharma, Editor IJCP

The following points emerged after the discussion:

• We must look at the overall scenario before the lockdown is opened completely.
• A small crisp exit plan is needed: First preparedness on the medical front and then general preparedness.
• Prepare healthcare facilities to function again; they should open with all precautions.
• Fear should reduce among healthcare workers and medical professionals.
• On priority, start with private practitioners, stand-alone clinics and peripheral health facilities first to decongest load on hospitals.
• Follow the 10 commandments: Decision alert, Design (social distancing), Drill, Disinfect, Drape (PPE), Disposal (biomedical waste), Dos & Don’ts, Display best practice, Dilate/Distend/Ventilate and Danger dynamics would change.
• Guidelines on different kinds of PPE available; which to be used in which setting; N95 mask and gloves should be a must in non-Covid OPDs also.
• Physicians, not just in hospitals, but also in stand-alone clinics, should start wearing surgical scrubs.
• A good surface cleaning (disinfection) with floor washing is enough. Fumigation may be done twice or thrice in a week during the Covid outbreak.
• Air purifiers (with HEPA filter) can be used in OPDs.
• Start gearing up for admissions and investigate the ability to test every patient for Covid at will.
• Put all lessons learnt at one place.
• We should assume that every patient is a potential Covid case and plan our strategy around this. Follow the guidelines even if there is no case in the last 14 days in hotspots. Continue this for at least 2 years and then change according to the scenario.
• Multiple organizations have released multiple guidelines, which are often discordant with each other; this has led to confusion about policies and directives. A uniform policy is required for doctors and hospitals on how to manage Covid patients.
• Start voluntary certification scheme stating that “my clinic/hospital follows these protocols and will continue to follow them after the lockdown”. Develop a mechanism to build trust in the delivery system.
• It is important to get subclinical immunity because of as of today there is no vaccine for Covid-19.
• Since summer is approaching, we need to focus on three vaccines – Rota, measles and polio. We also need to look at adult vaccination.
• Doctors are the softest target in incidents of violence. Such incidents cannot be tolerated. A strong deterrent action (non-bailable) must be taken by state Governments against those who commit violence.  If people are not punished for carrying out acts of violence against doctors, it is going to be difficult for healthcare services to function and deliver effective services to the public.
• Army discipline is necessary, but this is not the right time to involve the military in the war against Covid. The Army may be required when the lockdown is lifted, when overcrowding will increase, and practices will change. Then would be the right time probably for Army to step in or this can be done by vigilant policing.
• Our personal lockdown must continue even after the government lockdown is opened.