Sunday, May 31, 2020

CMAAO CORONA FACTS and MYTH BUSTER 110: Wear face mask at home, patients with diarrhea ? super spreader

CMAAO CORONA FACTS and MYTH BUSTER 110: Wear face mask at home, patients with diarrhea ? super spreader

Dr K K Aggarwal
President CMAAO

With inputs from Dr Monica Vasudev

934: Wear Face Masks at Home if you deal with public AND are people with diarrhea super spreaders
I have been saying about this and now a study has proven the same. During lock down wear mask when you go to buy essentials but after lockdown wear mask when you go for work involving meeting with [public or colleagues.
Now a new study conducted in China says wearing face masks at home greatly reduces a person’s risk of catching the coronavirus -- a major escalation from the most common advice on the cloth coverings, which is that they should be worn in public when social distancing can’t be practiced.
Researchers interviewed 335 people from 124 families in Beijing between late February and late March about their households during the pandemic. Each family had one confirmed case of coronavirus. The average family had four people, and most families had three generations.
Most person-to-person transmission occurred within households. Wearing face masks in the same house was 79% effective at curbing transmission, but only before symptoms emerge. Wearing masks really wasn’t protective after the symptoms started.
The daily use of chlorine or ethanol-based disinfectant was 77% effective at curbing transmission in the household.
This study confirms the highest risk of household transmission being prior to symptom onset, but that precautionary [non-pharmaceutical interventions], such as mask use, disinfection and social distancing in households can prevent COVID-19 transmission during the pandemic
BMJ Global health, the medical journal published the study. If the first person to become infected had diarrhea, the risk of passing the virus quadrupled.
Having close daily contact with the first person infected, such as eating meals or watching television together, had an 18-fold increased risk.
Overall, the study supports “universal face mask use, not just in public spaces, but also at home.

Saturday, May 30, 2020



Dr K K Aggarwal
President CMAAO

With inputs from Dr Monica Vasudev

931: How long does it take to get sick?
The “incubation period” is the time between being exposed to the virus and the onset of symptoms. For COVID-19, the incubation period ranges from 1 to 14 days. But most people who develop COVID-19 symptoms do so 4 to 6 days after exposure.

932: How long are you infectious?

The “infectious period” means the time you’re able to spread the virus to someone else. For COVID-19, there is emerging evidence to suggest the infectious period may start 1 to 3 days before you develop symptoms. The most infectious period is thought to be 1 to 3 days before symptoms start, and in the first 7 days after symptoms begin. But some people may remain infectious for longer.

Commonly reported symptoms for COVID-19 – such as fever, cough and fatigue – usually last around 9 to 10 days but this can be longer.

Typically with viruses, the higher the viral load (the more virus circulating in the body), the higher the risk of transmission through known transmission pathways.

A study conducted in Hong Kong looking at viral load in 23 patients diagnosed with COVID-19 found higher viral loads in the first week of illness.

Another study from China looking at 76 hospitalized patients found that by 10 days after symptom onset, mild cases had cleared the virus. That is, no virus was detectable through testing. However, severe cases have much higher viral loads and many continue to test positive beyond the 10 days after symptoms start.

So the more severe the illness and the higher the viral load, the longer you continue to shed the virus and are infectious.

933: When are you no longer infectious?

If someone has been symptom-free for 3 days and they developed their first symptoms more than 10 days prior, they are no longer considered to be infectious. But we’re not sure whether people are infectious when they have recovered but the virus can still be detected in their bodies.

One study from Hong Kong found the virus could be detected for 20 days or longer after the initial onset of symptoms in one-third of patients tested. Another study from China found found the virus in a patients’ faecal samples five weeks after the first onset of symptoms. But the detection of the virus doesn’t necessarily mean the person is infectious. We need more studies with larger sample sizes to get to the bottom of this question.

Should you get tested again before going back into the community?

People who have been self-quarantining, because they had contact with a confirmed case of COVID-19 and have completed their 14-day quarantine period without developing symptoms, can return to the community. There is no requirement to be tested prior to returning to the community. It is, however, recommended they continue to practise social distancing and good hygiene as a precaution.

At present, re-testing people who have experienced mild illness, and have recovered from COVID-19 is not recommended. A person is considered safe to return to the community and discontinue self-isolation if they are no longer infectious. This means they developed their first symptoms more than 10 days prior and have not experienced any symptoms for at least 3 days (72 hours).

For people who have been hospitalized with more severe illness, the testing requirements before discharge are different. They will have two swabs taken 24 hours apart to check if they have cleared the virus. If the swabs are both negative, they can be discharged and don’t require further self-isolation.

If one or both tests are positive but the person is well enough to go home, they must continue to self-isolate for at least 10 days since they were discharged from hospital and they have not experienced any symptoms for at least 3 days.

There are also different testing requirements for people working or living in high-risk settings. If you work or live in a high-risk setting you should consult with your health care provider on re-testing requirements.


What was earlier criteria for discharging COVID-19 patients

The earlier criteria for discharging RT-PCR positive were (a) chest radiograph has cleared and (b) two consecutive negative test results on RT-PCR.

What is the new discharge policy for COVID-19 patients?

For mild/very mild/pre-symptomatic cases

Patient can be discharged after 10 days of symptom onset and no fever for 3 days

No need for testing prior to discharge

Patient will be advised to isolate himself/herself at home & self-monitor his/her health for further 7 days

Such patients should at all times use triple layer medical mask. Patient must stay in the identified room and away from other people in home, especially elderlies and those with co-morbid conditions like hypertension, cardiovascular disease, renal disease etc. They should maintain strict personal hygiene and self-monitor his/her health with daily temperature monitoring and report promptly if develops any deterioration of symptom.

For moderate cases

Patient can be discharged (a) if asymptomatic for 3 days and (b) after 10 days of symptom onset

No need for testing prior to discharge

Patient will be advised to isolate himself/herself at home & self-monitor his/her health for further 7 days

For severe cases

Clinical recovery

Patient tested negative once by RT-PCR (after resolution of symptoms)

Friday, May 29, 2020

CMAAO CORONA FACTS and MYTH BUSTER 108 Thrombo-inflammation

CMAAO CORONA FACTS and MYTH BUSTER 108 Thrombo-inflammation

Dr K K Aggarwal
President CMAAO

With inputs from Dr Monica Vasudev

930: Complete Fibrinolysis Shutdown in Severe COVID-19
COVID-19 causes not only hypercoagulability, but also "fibrinolysis shutdown," which is associated with venous thromboembolism (VTE), stroke, and renal failure.

Complete lack of clot lysis at 30 minutes on a thromboelastogram (TEG) assay, coupled with a D-dimer value above 2600 ng/mL, identifies high-risk individuals who will potentially require more aggressive anticoagulation.

Patients with COVID-19 are at high risk of blood clots, both in small and large blood vessels.

The study was published online May 7 in the Journal of the American College of Surgeons.

Wright and colleagues did a retrospective study of 44 COVID-19 patients (28 male; median age, 54 years).

The primary study outcomes were VTE events and new-onset renal failure requiring dialysis. Forty-one (93%) patients required mechanical ventilation, 16 (36%) had acute renal failure requiring dialysis, 11 (25%) had a VTE, and six (14%) had a thrombotic stroke.

Derangements in coagulation laboratory values included an elevated D-dimer level and elevated fibrinogen, with normal platelet counts in the majority of patients and mildly elevated prothrombin time (PT) and partial thromboplastin time (PTT), with median values at or slightly above the upper limits of normal.

The median International Society on Thrombosis and Haemostasis (ISTH) disseminated intravascular coagulation (DIC) score was 0, with no patient having a score higher than 4. TEG variables were consistent with a hypercoagulable state with an elevated maximum amplitude and low lysis at 30 minutes.

On TEG testing, more than half of patients (57%) had a complete lack of clot lysis at 30 minutes (LY30), and this was a significant predictor of VTE, with an area under the receiver operating characteristic curve (AUROC) of 0.742 (= .021).

A D-dimer cutoff of 2600 ng/mL was a significant predictor of need for dialysis, with an AUROC of 0.779 (= .005).

Overall, patients with no clot lysis at 30 minutes on TEG assay and a D-dimer value above 2600 ng/mL had a rate of VTE of 50%, compared with 0% for patients with neither risk factor (P = .008). The time to VTE was also significantly shorter in patients with fibrinolysishutdown.

The hemodialysis rate was 80% with these two coagulation risk factors, compared with 14% without (P = .004).

This cohort of critically ill COVID-19 patients was clearly hypercoagulable, despite high normal or frankly elevated PT and PTT levels, demonstrating the importance of using whole blood coagulation assays (which more closely approximate in vivo conditions including the presence of cells and platelets) such as the TEG for improved risk stratification."

1.     Coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state associated with acute inflammatory changes and laboratory findings that are distinct from acute disseminated intravascular coagulation (DIC), save for those with very severe disease.
2.     Fibrinogen and D-dimer are increased, with typically only modest prolongation of the prothrombin time (PT) and activated partial thromboplastin time (aPTT) and mild thrombocytosis or thrombocytopenia.
3.     The presence of a lupus anticoagulant (LA) is common in individuals with a prolonged aPTT.
4.     The risk for venous thromboembolism (VTE) is markedly increased, especially in patients in the intensive care unit (ICU), with case series reporting prevalences of 25 to 43 percent in ICU patients, often despite prophylactic-dose anticoagulation.
5.      The risk for other thrombotic events (stroke, microvascular thrombosis) is less clear.
6.     All patients admitted to the hospital for COVID-19 should have a baseline complete blood count (CBC) with platelet count, PT, aPTT, fibrinogen, and D-dimer. Repeat testing is done according to the patient's clinical status.
7.      Outpatients do not require coagulation testing.
8.     All inpatients should receive thromboprophylaxis unless contraindicated. Low molecular weight (LMW) heparin is preferred, but unfractionated heparin can be used if LMW heparin is unavailable or if kidney function is severely impaired. Some institutional protocols include more aggressive anticoagulation with intermediate-dose or even therapeutic-dose anticoagulation for thromboprophylaxis.
9.     Therapeutic-dose (full-dose) anticoagulation is appropriate to treat deep vein thrombosis (DVT) or pulmonary embolism (PE), unless contraindicated.
10.  Bleeding is unusual but can occur. If it occurs, treatment is similar to non-COVID-19 patients and may include transfusions, anticoagulant reversal or discontinuation, or specific products for underlying bleeding disorders.

What’s new

COVID-19 hypercoagulable state (May 2020): Many reports have described a hypercoagulable state associated with COVID-19. The prevalence of venous thromboembolism (VTE) is increased, especially in critically ill individuals, often despite prophylactic anticoagulation. Arterial thrombosis has also been reported but the prevalence is not known. Some individuals have markedly elevated D-dimer, which correlates with worse prognosis. Unlike disseminated intravascular coagulation (DIC), the fibrinogen is often elevated, and clotting times and platelet counts are typically normal.

Causes of death from COVID-19 (May 2020)
Two new autopsy studies, together including a total of 33 individuals who died of COVID-19, have revealed common causes of death to be pneumonia and pulmonary embolism.

Lung histology also showed diffuse alveolar damage consistent with early acute respiratory distress syndrome, and inflammatory infiltrates consistent with viral or bacterial pneumonitis. In both studies, the average age was in the mid-70s, most were men, and most had preexisting conditions, especially heart disease, hypertension, diabetes, and obesity. While both studies were small, they emphasize the contributions of lung inflammation and hypercoagulability to fatal illness in this disease.  [uptodate]

RV dilatation

Respiratory distress and myocarditis common in patients hospitalized with COVID-19 have an impact on the right ventricle (RV), but the acute effects and whether they create longer-lasting damage is less well understood as per a pair of recent reports in JACC: Cardiovascular Imaging.

In the retrospective study, 31% of more than 100 such patients with a clinical indication for echocardiography were found to have RV dilation, a feature that didn't track with myocardial inflammation or injury or with pulmonary embolism (PE). But it did independently predict more than a fourfold increase in in-hospital mortality.

The RV dilation wasn't continuous, typically. These changes were  dynamic. We saw patients moving in either direction, going from normal ventricle to enlarged and going from enlarged to normalized.

All of the people who had RV enlargement underwent CT angiography to look for pulmonary embolisms, and only 50% of them had PE

The echocardiography study, was published May 15.

The other report included findings on postdischarge MRI in 26 consecutive patients from one center in Wuhan, China, who had recovered from COVID-19 but later experienced cardiac symptoms, such as chest pain or palpitations; none had a pre-COVID-19 history of myocarditis or other heart disease.

Fifteen of the cohort, or 58%, showed MRI signatures for diffuse myocardial edema and for fibrosis by late-gadolinium enhancement (LGE), or for both along with impaired RV cardiac index and ejection fraction, despite preserved LV function.

That was compared with 20 recent historical control subjects without documented cardiovascular or inflammatory disease who underwent the same MRI examinations.

The presence of myocardial tissue abnormalities in otherwise healthy subjects suggests cardiac involvement as a lasting consequence of SARS-CoV-2 infection

Lu Huang, MD, PhD, Tongji Medical College and Huazhong University of Science and Technology, Wuhan, in their report published May 11.

Thursday, May 28, 2020

CMAAO CORONA FACTS and MYTH BUSTER 107 Strategic Lessons

CMAAO CORONA FACTS and MYTH BUSTER 107 Strategic Lessons

929:  Lessons learnt from coronavirus strategies
Dr K K Aggarwal
President CMAAO

With inputs from Dr Monica Vasudev

1.     Italy reached nearly 100,000 Covid-19 cases and more than 10,000 deaths by March 29, becoming the deadliest epicentre in the pandemic. They were slow to implement strict social distancing measures and, even once officials began to institute social distancing as Covid-19 cases began to spike, the public did not seem to respond to government directives with urgency. Italy suffered from “a systematic failure to absorb and act upon existing information rapidly and effectively rather than a complete lack of knowledge of what ought to be done.”

2.     In early days it was common to see officials sceptical of the Covid-19 threat pointing to low fatality numbers and asking why there was panic, given how many people die of the seasonal flu every year. But the coronavirus spreads stealthily, with those who contract it not showing symptoms for days, and the full gravity of their illness not becoming clear until a week or two after infection.

Most political leaders of the world who have not faced the taste of SARS and MERS earlier did not act pre-emptively despite evidence suggesting such delays could increase the number of cases. State-of-emergency declarations were shrugged off by the public and political leaders.

3.     Threats such as pandemics that evolve in a non-linear fashion (they start small but exponentially intensify) are especially tricky to confront because of the challenges of rapidly interpreting what is happening in real time. The most effective time to take strong action is extremely early, when the threat appears to be small — or even before there are any cases. But if the intervention actually works, it will appear in retrospect as if the strong actions were an overreaction. This is a game many politicians don’t want to play. The first step to a better pandemic response is acknowledging the current situation.

When three cases appeared in Kerala India between 31st January and 2nd February, even India did not close the International boarders thinking it to be a Kerala local [problem. They only acted on 22nd March.

4.     Ignoring and not anticipating the problem of migrants: Italy started small with its coronavirus containment and only expanded it as the scale of the problem revealed itself. The country started with a targeted strategy: Certain areas with a lot of infections were designated as “red zones.” Within the red zones, there were progressive lockdowns depending on the severity of the outbreak in the area. The restrictions were only broadened to the whole country when these measures did not stop the virus’s spread.

In fact, these limited lockdowns made it worse. Because the coronavirus transmits so silently, the “facts on the ground” (number of cases, deaths, etc.) didn’t actually capture the full scale of the problem. Once partial lockdowns went into effect, people fled to less restricted parts of the country — and they may have unwittingly taken the virus with them.

The selective approach might have inadvertently facilitated the spread of the virus. Consider the decision to initially lock down some regions but not others. When the decree announcing the closing of northern Italy became public, it touched off a massive exodus to southern Italy, undoubtedly spreading the virus to regions where it had not been present.

Even in India after the 3rd lock down was partially lifted the migrants caused a surge in the cases.  Between 3.5 to 7% of them became positive and carried the infection to other states.

5.     There will be a surge after the lockdown is lifted: The disease will continue to spread with no lockdown, social distancing, or other intervention with no change in transmission rate. R0= 2.66

If there is moderate lockdown, it will reduce transmission to R0 of 2 during lockdown period, then transmission will resume at R0 of 2.4.

In Hard Lockdown, there will be reduced to R0 of 1.5 during lockdown period, then transmission will resume at R0 of 2.4.

And with Hard Lockdown and Continued Social Distancing/Isolating Cases there will be reduced transmission to R0 of 1.5 during lockdown period, then, through social distancing regulations and isolation of symptomatic individuals will resume at R0 of 2.

6.     Uniform national policy vs state policies: Both India and USA did not declare a public health national emergency and had asked states to take care of the problem. Trump did issue his recommendation that people stay home for 15 days to stop the Covid-19 spread, but he did not renew the call. States took different approaches: some, like New York, California, and Washington locked down completely. Others, like Florida, were reluctant to take the same step.

7.     Lockdown will only postpone the worse: Italy’s experience indicates that truncated social distancing periods and a mishmash of social distancing policies across different interlocked areas only prolonged and deepened the problem.

8.     Public ignorance: The message that personal social distancing and masking will never be lifted for the next few years has not been understood by the masses as yet.

9.     Having two strategies in the same country: The experiences of Lombardy and Veneto, two neighbouring Italian regions that took two different strategies for their coronavirus response and saw two different results, are instructive. Lombardy has 10 million people, and it has endured 35,000 Covid-19 cases and about 5,000 deaths; Veneto is home to 5 million people, but it has seen just 7,000 cases and fewer than 300 deaths. Its outbreak is a fraction the size of its neighbour’s.

This is what Veneto did to successfully control the outbreak:
Extensive testing: People with symptoms and people who were asymptomatic were tested whenever possible.

Proactive tracing: If somebody tested positive, everybody they live with was tested or, if tests weren’t available, they were required to self-quarantine.
Emphasis on home diagnosis and care: Health care providers would actually go to the homes of people with suspected Covid-19 cases to collect samples so they could be tested, keeping them from being exposed or exposing other people by visiting a hospital or doctor’s office.

Monitoring of medical personnel and other vulnerable workers: Doctors, nurses, caregivers at nursing homes, and even grocery store cashiers and pharmacists were monitored closely for possible infection and given ample protective gear to limit exposure.

Lombardy, on the other hand, was much less aggressive on all of those fronts: testing, proactive tracing, home care, and monitoring workers. Hospitals there were overwhelmed, while Veneto’s have been comparatively spared. And yet it took weeks upon weeks for Lombardy to adopt the same strategies that were already working next door in Veneto:

10.  Not reporting the proper data or underreporting the data for political gains: Importance of good data — the raw numbers themselves — which were lacking in the early days of Italy’s outbreak. These figures should focus on the important metrics like tests conducted and hospitalizations. The data is often downplayed by most countries. Every one wants gto show that they have the best results. .

Wuhan Update: In two weeks, the Chinese health authorities managed to administer 6.5 million tests for the coronavirus in Wuhan, the city where the pandemic began and where six new infections detected two weeks ago raised fears of a second wave of contagion.  200 cases were found, mostly people who showed no symptoms. This study demonstrates that for every, one symptomatic case there are 33 asymptomatic cases.

Actual Cases (1.7 million: 10 times the number of confirmed cases)
New York State conducted an antibody testing study
12.3% of the population COVID-19 antibodies as of May 1, 2020.
The survey developed a baseline infection rate by testing 15,103 people at grocery stores and community centers across the state over the preceding two weeks. The study provides a breakdown by county, race (White 7%, Asian 11.1%, multi/none/other 14.4%, Black 17.4%, Latino/Hispanic 25.4%), and age, among other variables. 
19.9% of the population of New York City had COVID-19 antibodies.
With a population of 8,398,748 people in NYC, this percentage would indicate that 1,671,351 people had been infected with SARS-CoV-2 and had recovered as of May 1 in New York City. The number of confirmed cases reported as of May 1 by New York City was 166,883, more than 10 times less.

11. Actual deaths are twice the number of reported deaths

As of May 1, New York City reported 13,156 confirmed deaths and 5,126 probable deaths (deaths with COVID-19 on the death certificate but no laboratory test performed), for a total of 18,282 deaths

The CDC on May 11 released its "Preliminary Estimate of Excess Mortality During the COVID-19 Outbreak — New York City, March 11–May 2, 2020" in which it calculated an estimate of actual COVID-19 deaths in NYC by analyzing the "excess deaths" (defined as "the number of deaths above expected seasonal baseline levels, regardless of the reported cause of death") and found that, in addition to the confirmed and probable deaths reported by the city, there were an estimated 5,293 more deaths to be attributed. After adjusting for the previous day (May 1), we get 5,148 additional deaths, for a total of actual deaths of 13,156 confirmed + 5,126 probable + 5,148 additional excess deaths calculated by CDC = 23,430 actual COVID-19 deaths as of May 1, 2020 in New York City.

Mortality Rate (23k / 8.4M = 0.28% CMR to date) and Probability of Dying

As of May 1, 23,430 people are estimated to have died out of a total population of 8,398,748 in New York City. This corresponds to a 0.28% crude mortality rate to date, or 279 deaths per 100,000 population, or 1 death every 358 people.

Infection Fatality Rate (23k / 1.7M = 1.4% IFR)

Actual Cases with an outcome as of May 1 = estimated actual recovered (1,671,351) + estimated actual deaths (23,430) = 1,694,781.
Infection Fatality Rate (IFR) = Deaths / Cases = 23,430 / 1,694,781 = 1.4% (1.4% of people infected with SARS-CoV-2 have a fatal outcome, while 98.6% recover).

12.  Admitting covid patients in non covid hospitals instead of managing them at home: Home admissions: Coronavirus can hit "like a tsunami". In one hospital in Italy more than 100 out of 120 people admitted with the virus developed pneumonia. Doctors became  patients. Opening separate COVID-19 blocks to admit and treat the infected patients made the hospital hot spots. Delhi is doing the same mistake that Italy made.

Do not allow hospitals becoming “the main” source of Covid-19 transmission. The related coronavirus illness MERS also has high transmission rates within hospitals, as did SARS during its 2003 epidemic.
Major hospitals in Italy such as Bergamo’s themselves became sources of [coronavirus] infection with Covid-19 patients indirectly transmitting infections to non-Covid-19 patients. Ambulances and infected personnel, especially those without symptoms, carry the contagion both to other patients and back into the community.

Covid-19 patients started arriving and the rate of infection in other patients soared. That is one thing that probably led to the disaster in Italy.
Western health care systems have been built around the concept of patient-cantered care. But a pandemic requires “community-cantered care.”. Broader good overrules over the individual good.

Wednesday, May 27, 2020

CMAAO CORONA FACTS and MYTH BUSTER 106 Lessons Learned So far from COVID

CMAAO CORONA FACTS and MYTH BUSTER 106 Lessons Learned So far from COVID

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

Round Table Expert Zoom Meeting on Lessons learnt from Covid-19

23rd May, 2020


Dr KK Aggarwal
Dr Alok Roy
Dr AK Agarwal
Dr Narottam Puri
Dr Suneela Garg
Dr Girdhar Gyani
Dr Atul Pandey
Dr Ashok Gupta
Dr Jayakrishnan Alapet
Dr Alex Thomas
Dr K Kalra
Dr Major Prachi Garg
Ms Ira Gupta
Dr Sanchita Sharma

·        Do not miss the first case in the country or your state. A first case of a new disease is a potential epidemic.
·        We should have permanent Arogya Setu App for all notifiable communicable diseases, specifically MDR TB and other highly infectious diseases. Personal privacy does not apply in cases of notifiable diseases. The concept of “broader good” comes into play here.
·        Elderly are at risk. We must have a national program for the protection of health of the elderly. There is a need to set up separate geriatric medicine departments in all medical colleges. It is also important to establish a group of doctors aged ≥65years. Their rich experience can be tapped into in times of crisis.
·        Contact time: we must know the contact time for every disease. For TB, the contact time is 8 hours. For Covid-19, the contact time is between 10 and 30 minutes. A casual contact time of less than 10 minutes has low risk of transmission (monitoring). If the contact time is more than 30 minutes, the risk of transmission is high (quarantine).
·        A virus may have several different types of presentations/manifestations in different countries or population groups and the treatment will be according to the presentation. Identify the presentation in different communities. Covid-10 has so far shown the following 7 characteristics.
1.    It is a viral illness, so it is self-limiting disease; antiviral drugs like remdesivir may work
2.    It has bacterial activity as in some cases, procalcitonin is high, neutrophilia is also seen; antibiotics like doxycycline, azithromycin may work.
3.    It has some HIV like properties, as there is lymphopenia (viruses usually cause lymphocytosis), decrease in CD4 cell count; anti-HIV drugs may be effective.
4.    It causes immuno-inflammation: Viruses do not cause immunoinflammation. But, increase in ESR (>100), CRP, ferritin (acute phase reactants) is seen in Covid-19. Hydroxychloroquine may be effective. Immunoinflammation is being seen much more in European countries than in Asian countries.
5.    It causes thrombo-inflammation: Increase in d-dimer and fibrinogen (usually if d-dimer is high, fibrinogen is low); anticoagulation may be important.
6.    Silent hypoxia (walking dead phenomenon): Patients have low oxygen but are conscious. Usually, people with hypoxia are drowsy, irritable.
7.    Cytokine storm: ARDS
·        We have learnt three terms: Home isolation, home quarantine and monitoring.
·        The pandemic has focused on different populations e.g. migrants, factory workers, private sector
·        The problem of migrants should be anticipated timely and planned properly. Positivity rate in India is 3.5-7%
·        Random testing rate of people reaching Bihar is 8% and for those reaching UP is 5%.
·        Living with fear: Manage fear by being well-prepared.
·        Treat the patient, not the report. About 30% of tests may be false-negative.
·        There should be a worldwide ban on wet markets.
·        Vaccine may or may not come. We may be over-relying on a vaccine.
·        Health infrastructure will change. Now, new hospitals will be airy, roomier, more ventilated; there will be no central AC, no attached bathroom with every room.
·        Standard precautions: We did not learn social distancing from the 2009 H1N1 flu. Face to face meeting is more risky than side to side meeting.
·        Never ignore nature.
·        Never ignore essential health services.
·        Super spreader: A latest study from Israel says that 5% people are responsible for the remaining 95% of transmission. This is similar to the 80/20 rule, which has been the standard teaching in PSM, where approximately 20% of infected individuals are responsible for 80% of transmissions. The first known super spreader was in South Korea (patient #31) and then there have been super spreaders in different countries.
·        We have learnt how to sustain the improved pollution. If pollution levels are very high, then a lockdown of 1-2 days may help.
·        Terms like R0 (R naught; reproduction number), herd immunity have been revisited.
·        Create more awareness in the society.
·        Transparent communication and dissemination of accurate information to promote community engagement is important to allay the fears, stigma. We need to be consistent in data projections.
·        Be a realist rather than being an optimist when presenting data”
·        This pandemic has highlighted the inadequacy in testing and testing facilities, the importance of investment in health and more focus on research and indigenous health technologies.
·        We must keep a watch on every situation happening in the world. Be prepared in advance.
·        The disease has focused on the need of Epidemic Intelligence services, which can forecast epidemics. A training program can be started on pilot basis in few medical colleges.
·        Learn to live with Corona is the new buzzword.
·        A change in lifestyle with new norms is key “self-disciplined”; practice social distancing, personal hygiene.
·        This is an opportunity to be self-sufficient, self-reliant and promote “Make in India”. The pandemic started with virtually no PPE but there are now over 600 manufacturers.
·        We have to devise ways to keep the economy running as the pandemic has greatly affected the jobs leading to a negative GDP.
·        This is an opportunity to decongest slums.
·        We need to have a White Paper on national health security.


Seven lungs from patients who died of confirmed COVID-19 and seven lungs obtained during autopsy from patients who died from H1n1 ARDS in 2009, showed three distinctive features of COVID-19:

·        Severe endothelial injury associated with intracellular SARS-CoV-2 virus and disrupted endothelial cell membranes
·        Widespread vascular thrombosis with microangiopathy and occlusion of alveolar capillaries
·        Significant new vessel growth through intussusceptive angiogenesis.

This is a respiratory virus that causes a vascular disease, and the damage to the blood vessels

May 21 in the New England Journal of Medicine.

Although lungs from influenza sufferers also showed diffuse alveolar damage, in the COVID-19 lungs, there were 9-fold as many segments occluded by microthrombi (P < .001).

Although tissue hypoxia was probably a common feature in the lungs from both these groups of patients, the greater degree of endothelialitis and thrombosis in the lungs from patients with COVID-19 may contribute to the relative frequency of sprouting and intussusceptive angiogenesis observed in these patients

The amount of angiogenesis seen was unexpected, and about 2.7-fold higher than that seen in lungs from patients with influenza (P < .001).

Wuhan Update
In two weeks, the Chinese health authorities managed to administer 6.5 million tests for the coronavirus in Wuhan, the city where the pandemic began and where six new infections detected two weeks ago raised fears of a second wave of contagion.  200 cases were found, mostly people who showed no symptoms.