Tuesday, May 26, 2020


Covid in CMAAO countries vs Europe vs USA (Part 2)


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

927: Minutes of Virtual Meeting of CMAAO NMAs

23rd May, 2020, Saturday


Member NMAs

Dr KK Aggarwal, President CMAAO
Dr Yeh Woei Chong, Singapore Chair CMAAO
Dr Kar Chai Koh, Malaysia, Vice Chair of Council
Dr Ravi Naidu, Past President CMAAO, Malaysia
Dr Rajan Sharma, National President IMA
Dr RV Asokan, Secretary General IMA
Dr Thirunavukarasu Rajoo, Hon. General Secretary, Malaysian Medical Association
Dr Alvin Yee-Shing Chan, Hong Kong
Dr Marie Uzawa Urabe, Japan
Dr Sajjad Qaisar, Pakistan
Dr Ashraf Nizami, Pakistan
Dr Deborah Cavalcanti, Brazil
Dr Marthanda Pillai, Member World Medical Council
Dr Md Jamaluddin Chowdhary, Bangladesh
Dr N Gnanabaskaran, President Malaysian Medical Association


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

  • Death rate is much lower in Asian countries compared to that in Europe and US. This low death rate is despite high population density.
  • In the US, death rate is higher in Black population. A reason for this can be that ACEIs do not work in this population. Could the level of ACE receptors be different in people from Asia vs Europe vs North US? We do not know.
  • Vaccine developed from a virus from US or Europe may not work in Asian population.
  • In an update, the CDC has said that person-to-person transmission is the primary and most important mode of transmission for COVID-19. Surface to human transmission is not the main way the virus spreads.
  • A latest study from Israel study says that 5% of population is responsible for the remaining 95% of cases.
  • Super-spreader is must to cause infection; in the absence of a super-spreader the infection will die out. If a super-spreader is present in closed space, the chances of transmission of infection are very high.
  • One reason for low mortality can be good ICU care. Good ICU care makes a difference in mortality by only 0.3-0.5%.
  • Another reason for low mortality is the availability of Airborne Infection Isolation (AII) rooms or negative pressure rooms.
  • Countries like Hong Kong, Singapore, South Korea have more number of AII rooms, which also serve as triage rooms and the patient is shifted to a Covid/non-Covid ward depending on the report, which is available within 3 hours in the triage room itself.
  • In countries like India who do not have AII rooms, the patient should be in a room which has an air purifier with at least 10 exchanges per hour.
  • The difference in clinical manifestations of the virus may influence mortality rates.  
o   It is a viral illness, so it is self-limiting disease in majority; antiviral drugs like remdesivir may work
o   It has bacterial activity as in some patients, high procalcitonin; antibiotics like doxycycline, azithromycin may be effective.
o   It has some HIV like properties, as there is lymphopenia (viruses usually cause lymphocytosis), decrease in CD4 cell count; such patients may respond to anti-HIV drugs.
o   It causes immuno-inflammation: Viral disorders do not cause immunoinflammation. But, increase in ESR, CRP, ferritin (acute phase reactants) is seen in Covid-19. Anti-inflammatory drugs (hydroxychloroquine) may be effective. Immunoinflammation is being seen much more in European countries than in Asian countries.
o   It causes thrombo-inflammation: Increase in d-dimer and fibrinogen; patient requires anticoagulation.
o   Silent hypoxia (walking dead phenomenon): Low oxygen but patient is conscious. Usually, people with hypoxia are drowsy, irritable. This was predominant in Italy. Their mortality improved when they stopped using ventilators.
o   Cytokine storm: ARDS
o   If we know the clinical pattern of patients in different countries, we can find out mortality and also identify a country-specific treatment. In the UK, multisystem immune inflammation is more with increased mortality. This is not seen in Asian countries.
  • Asian countries have lower mortality when compared to Europe and the US, but we do have a reasonable mortality rate and it may increase if we calculate accurately, register all cases and there is better investigation and reporting of cases. It may go up to 2.5-3% in Pakistan.
  • Other reasons can be: Asians already have high immunity; testing is not as aggressive as in Europe, US, the strain of the virus is not aggressive so mostly mild to moderate cases
  • Low mortality in Hong Kong may be attributed to: preventive measures (universal masking, people complying with the directives), local culture (no hugging/kissing), cases are in younger population and are imported, which are mild and lastly, well-prepared investment in ICU facilities and ventilators. Those who died had comorbidity like diabetes.
  • In Singapore, most cases are in migrants, who are young and therefore have mild infection.
  • The lower mortality in Malaysia is because of early interventions, the govt. has been preparing for the worst since March, and all persons who qualify for PUI (person under investigation) are screened and isolated based on the result.
  • Japan has 16,000 positive cases; 800 have died; mortality rate is 5%; Japan has limited PCR tests so this rate compared to the population is very low. Japan is carrying out genome analysis in 500 patients (from asymptomatic to patients with severe symptoms). HLA typing is on the way. High IgM level is related to the severity of disease. Some patients may have early detection of IgG. This may be related to previous infection with other coronavirus. Further research is needed.
  • India: Despite high numbers, the mortality rate is 3%. Experience of the European countries has helped us to lower mortality; also, there is genetic protection from the infection.

Contact time: 10-30 minutes
  • If contact time is less than 10 minutes with precautions, the chances of transmission is very low
  • If a doctor is wearing a N95 mask and the contact time is less than 30 minutes, this is usually not a problem

Protocol of non-Covid clinic in Singapore

A patient who came to the clinic in the morning and tests positive in the evening, answer the following question:

Was the patient wearing a mask? If yes, then ask,

Was the doctor wearing a mask? If yes, then ask,

Was the surface decontaminated in the morning? If yes, then ask,

What was the contact time?

  • If less than 30 min: Monitor
  • If more than 30min: Quarantine

Covid-19 infection in children

  • 13% of children all over the world have Covid-19; mortality is 0.5% in children below 15 years of age.
  • Child to child transmission is rare; but, children can infect the elderly.
  • For children <2 years: no masking
  • For children >2 years: Country-specific guidelines for masking
  • European countries do not recommend masking for children; we do not have a guideline for Asian countries.

Chances of infection are highest when sitting face to face; chances of infection are lower when sitting side to side or face to side.

In schools and colleges, students sit facing front. So chances of infection very low; distance between students should be at least 6 feet. Students should go home immediately after school/college.

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