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
11am-12pm
Participants
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.
Histopathology
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 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.
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