Tuesday, June 30, 2020

139 CMAAO CORONA FACTS and MYTH BUSTER Unusual CNS Manifestations



139 CMAAO CORONA FACTS and MYTH BUSTER Unusual CNS Manifestations

Dr K Aggarwal
President CMAAO

961:  Update on Covid-19

IMA-CMAAO Webinar on “Neurological complications in Covid-19 – Part 2”

27th June, 2020
4-5pm

Participants

Dr KK Aggarwal, President CMAAO
Dr RV Asokan, Hony Secretary General IMA
Dr Ramesh K Datta, Hony Finance Secretary IMA
Dr Sanchita Sharma

Faculty

Dr MV Padma Shrivastava
Prof & Head, Dept of Neurology
AIIMS, New Delhi

Key points from the discussion

  • Covid-19 is very similar to SARS coronavirus of 2003 as it shares the same ACE2 receptor. The initial clinical manifestations are fever, cough, dyspnea and fatigue. The most important lab parameter is lymphopenia. In severe cases, viral pneumonia may lead to severe acute respiratory syndrome, which may be fatal.
  • Diagnosis: rapid antigen test, Nucleic Acid Amplification Test (NAAT), which gives results in 2 hours and RT PCR test (nasopharyngeal swab), which gives results in 8-12 hours.
  • ACE2 receptors are present in nervous system and skeletal muscles.
  • Coronaviruses go beyond the respiratory tract and may invade the CNS resulting in neurological complications (CNS, PNS and skeletal muscle injury). Although the exact route by which the virus enters the nervous system is not known.
  • A missed diagnosis of patient presenting with neurological manifestations increases the chances of spread of infection to HCWs.
  • The Covid-19 virus may enter the CNS through the hematogenous or retrograde neuronal route (evident by the symptom of anosmia).
  • Patients with severe disease have greater likelihood of developing neurological symptoms compared to patients who have mild or moderate disease.
  • It has been shown that intranasal administration of SARS CoV and MERS CoV led to rapid invasion of the virus into the brain, the likely route being through the olfactory bulb via trans-synaptic route.
  • Neurological damage that follows invasion of the Covid-19 virus in the CNS is partially responsible for the acute respiratory failure seen in these patients.
  • Neurological complications seen include HCoV related meningitis, encephalitis, acute flaccid paralysis, early onset olfactory and gustatory dysfunction and changes in smell and taste perception. Anosmia, hyposmia and dysgeusia have been added in flu screen now.
  • The first observational case series from Wuhan was published in April this year in JAMA Neurology, where around 40% of hospitalized patients had some neurological complaints. The CNS manifestations were dizziness, headache, impaired consciousness, stroke, ataxia and seizures were found in patients, while the peripheral nervous system manifestations included aguesia, anosmia, vision impairment, neuropathies, GBS. There were skeletal muscular injury manifestations.
  • Red flags in lab parameters, which increase the chances of neurological complications, are lymphopenia, decreased platelet count and high BUN.
  • Older Covid-19 patients with risk factors are more at risk of developing new onset cerebrovascular accident during hospitalization (did not present with stroke), which is an important negative prognostic factor. Most of strokes were ischemic stroke (Lancet).
  • Older patients and those with diseases like HT, DM, CVD, and malignancy are more susceptible to Covid-19 and are also more likely to develop serious infection.
  • Nervous system manifestations, which include acute ischemic stroke, intracerebral hemorrhage, encephalopathy, skeletal muscle injury, seizures are more common in patients with severe infections.
  • Patients with severe infection had raised TLC, increased neutrophils, lymphopenia and high CRP; they also had high d-dimer levels (JAMA).
  • Lymphopenia is indicative of immunosuppression in hospitalized patients; high d-dimer levels suggest a consumptive coagulopathy.
  • Another paper published in last week of March has summarized the spectrum of neurological presentations in Covid-19 patients: Headache, malaise, fatigue, imbalance, anosmia/ageusia, cerebral hemorrhage, acute neuropathies, encephalitis, and seizures.
  • Neurological presentations could be a manifestation of hypoxia, metabolic/respiratory acidosis, multiorgan dysfunction and sepsis, and certain medications.
  • Inflammation could potentially be related to stroke occurrence (directly/indirectly) or could follow an acute stroke. Atherosclerosis is an inflammatory process; plaque destabilization and rupture may contribute to stroke.
  • Covid-19 is also a prothrombotic state as high levels of d-dimer have been observed in these patients.
  • Measures of protection for health professionals while managing neurological emergencies like stroke in the time of Covid-19 include PPE (level 2) for all team members, team member role designation, green corridor for stroke; CT scan machines need to be sanitized.
  • Contact and droplet precautions: aerosol generating procedures such as oropharyngeal/nasal suctioning, bag valve mask ventilation, intubation, chest compression, NIPPV, nebulization and CPR are minimized; early extubation is not recommended; avoid CPAP, BiPAP and nasal high flow therapy due to the risk of aerosol formation.









Monday, June 29, 2020

138 CMAAO CORONA FACTS and MYTH BUSTER Unusual Manifestations



138 CMAAO CORONA FACTS and MYTH BUSTER Unusual Manifestations

Dr K Aggarwal
President CMAAO

960: Round Table Expert Zoom Meeting on “Unusual manifestations of Covid-19”

27th June, 2020
11am-12pm

Participants

Dr KK Aggarwal
Dr AK Agarwal
Dr Shashank Joshi
Dr Ashok Gupta
Dr Suneela Garg
Dr JA Jayalal
Dr Jayakrishnan Alapet
Dr Atul Pandya
Dr TS Jain
Mrs Upasana Arora
Dr K Kalra
Ms Ira Gupta
Dr Sanchita Sharma

Key points from the discussion

  • Many unusual symptoms of Covid-19 have been observed. These may differ even in different members of the same family.

  • The CDC has recently added 3 new symptoms to its list of symptoms of Coronavirus: Congestion or runny nose, nausea or vomiting and diarrhea

  • Isolated sudden loss of taste and/or smell is Covid, unless proved otherwise. However, bitter and sour tastes are retained. This symptom may be intermittent and may last for up to 2 months. It occurs more commonly in females. Such patients have not become serious.

  • Isolated diarrhea may occur; the affected person may be a superspreader and may be the first person to be infected; more common in women. This is small intestine Covid. Such patients have not become serious.

  • Constipation has been observed.

  • Covid cystitis: low grade persistent fever or no fever, increased frequency of urination, urinalysis may show 50-60 pus cells, but culture is negative and total leukocyte count may be normal. No antibiotics are needed as it resolves spontaneously.

  • If the patient comes before 9 days, this is acute viral response. If the patient comes after 9 days and is not hospitalized, this is post-Covid syndrome, which may manifest as low grade exertional afternoon rise of temperature or chills without rigors x 6 weeks. Give high doses of Vitamin C, D and zinc x 3 days OR give colchicine or hydroxychloroquine (HCQ) twice daily. This fever is because the virus causes some thermostat dysregulation.

  • Neurological complications like encephalitis, meningoencephalitis have been observed in ICU patients. Prognosis is not good.

  • Skin lesions may occur – small blister/s, scratch-like lesion, bruise; more in females

  • Eye involvement: Conjunctivitis may occur.

  • Covid toes, presenting as gout-like symptoms. Such patients may test negative in the beginning, but may test positive late

  • Covid may present as calf pain (muscle pain - myositis), which responds only to mefenamic acid, naproxen, nimesulide or indomethacin.

  • Leukocyte count <1000 signifies serious illness; high monocyte count is a new observation - may be indicative of prolonged inflammatory response

  • SLE-like manifestations may be seen (high ESR, low CRP)

  • If CRP >100, such patients invariably have pneumonia; get a CT chest done for these patients.

  • Backache, which responds to naproxen; ISA (inflammatory spondyloarthropathy) like or Behcet’s like or Ritter-like phenomenon

  • Other symptoms such as tinnitus, persistent sore throat, nausea and vomiting, exertional tachycardia, urinary pain, menstrual pain have also been seen.

  • A new phenomenon of delayed hypoxia has been observed by Day 15-17 with sudden deterioration; all high risk patients must be given anti-thrombotic treatment, DVT prophylaxis to prevent delayed hypoxia.

  • In Tamil Nadu, almost all deaths have been occurring early morning; hence, absolute bed rest for all patients. Most patients have sympathetic overactivity - hypoxia, exertional tachycardia, which can precipitate early morning acute myocardial infarction. Ivabradine may be considered in patients with exertional tachycardia.

  • ENT manifestations: herpes zoster oticus, Ramsay Hunt syndrome, anosmia, acute peritonsillitis.

  • Covid-19 spares joints and larynx.

  • Coinfections of dengue, chikungunya, TB may occur. This may be a dangerous combination.

  • Covid positive patients have false positive Typhidot due to cross reaction.

  • If a Covid-positive patient has symptoms like joint pain, retro-orbital headache, laryngitis, exertional tachycardia, look for coinfections or underlying disease. E.g., if retro-orbital headache look for co-existing dengue; if exertional tachycardia, look for underlying coronary artery disease; if persistent shortness of breath, look for small airway obstruction.

  • Do not ignore isolated skin manifestations, even small rashes. These should be investigated as first sign of Covid infection.

  • RT PCR test may be positive for up to 50 days; but the patient becomes non-contagious after
    9 days as the virus becomes non-replicating.

  • Covid-19 causes lymphopenia, low CD4 count (HIV-like symptoms). A question was raised that could diarrhea, aseptic cystitis, ear manifestations, secondary viral manifestations be a presentation of low CD4 count? If yes, there may be an upsurge of lymphoma cases. Patients with low CD4 count should be given combination of lopinavir and ritonavir.




Sunday, June 28, 2020

137 CMAAO CORONA FACTS and MYTH BUSTER Treatment Protocols



137 CMAAO CORONA FACTS and MYTH BUSTER Treatment Protocols

Dr K Aggarwal
President CMAAO

959:  Minutes of Virtual Meeting of CMAAO NMAs on “Covid-19 treatment experiences in CMAAO countries”

27th June, 2020, Saturday; 9.30am-10.30am

Participants

Member NMAs

Dr KK Aggarwal, President CMAAO
Dr Yeh Woei Chong, Singapore Chair CMAAO
Dr Ravi Naidu, Past President CMAAO, Malaysia
Dr Marthanda Pillai, Member World Medical Council
Dr Marie Uzawa Urabe, Japan
Dr Md Jamaluddin Chowdhary, Bangladesh
Dr Sajjad Qaisar, Pakistan
Dr Deborah Cavalcanti, Brazil
Dr Prakash, Nepal

Invitees

Dr Russell D’Souza, UNESCO Chair in Bioethics, Australia
Dr Sanchita Sharma, Editor IJCP Group

·        If the patient comes after 9 days of symptoms or 9 days of Covid positive test, he/she is presenting with Covid sequelae and not Covid per se. Treatment of post-Covid sequelae is as per their standard treatment guidelines or protocols.

·        The virus becomes non-replicating from 9th day onwards in mild cases; RTPCR test may remain positive for up to 48 days. In non-hospitalized patients, isolation may be stopped after 9th day, followed by 4 days of quarantine and then monitoring (with precautions like masking).

·        Loss (partial) of smell and taste usually means mild illness; it may be intermittent and may last up to 3 months. Bitter and sour tastes and sour (lime) smell are retained. In women, it may be associated with single episode of diarrhea or skin rash.

·        If the patient has fever (<100.40F), evidence of hyper immune inflammatory response (high ESR, CRP or ferritin), treat with hydoxychloroquine (HCQ) and colchicines.

·        If patient comes within first 4 days of symptoms, give antibiotics with anti-viral response (doxycycline or azithromycin x 5 days). Antibiotics may have no role if patient presents after 9 days.

·        Anti-parasitic drug ivermectin 12 mg single dose as prophylaxis to whole family

·        If patient develops exertional hypoxia or pneumonia (very high d-dimer and ferritin levels) (day 4-7), give IL-6 pathway inhibitor (tocilizumab IV 8 mg/kg as a single dose or IV remdesivir or methyl prednisolone alone or in combination.

·        In high risk case (HT, DM), give Favipiravir x 7 days (in India, given for 14 days) in the first three days of onset of symptoms; it probably has no action after 72 hours. Remdesivir acts best when given at the time of hypoxia. Tocilizumab is given when CRP is >100.

·        If cytokine response is very high, the two options are tocilizumab and prednisolone.

·        In all high risk patients, if they develop hypoxia (day 4), give LMWH.

·        Give prednisolone 1 mg per kg stat in case of sudden development of hypoxia (exertional or rest), as an alternative to remdesivir or tocilizumab.

·        Advise patients to sleep prone; oxygen concentrator at home or in hospital @ 5 liters/min

·        Give elemental zinc 75 mg daily; vitamin D 60,000 units x 3 days and then 2000 units per day; vitamin C 1000 mg x 3 days and then 500 mg daily

·        Ranitidine 150 mg twice daily to reduce acidity; mefenamic acid, naproxen, indomethacin for fever

·        Regularly monitor SpO2 and pulse, especially between days 4 and 7.

·        Inform if temperature >1030F or lasts >14 days or breathlessness, SpO2 falls by >4 after six minutes walking, persistent chest pain

·        Sudden loss of smell and taste is not a serious sign, may persist for some time, may come and go, may come before fever

·        Conjunctivitis may occur in one eye and is not a serious sign

·        Rash may occur on any part of body (more in women) and is not a serious sign

·        Pus cells may be present in urine, indicating viral cystitis and not secondary infection (low TLC)

·        High monocytes indicate high viral response; if CRP > 100, this means very high inflammatory response

·        If diarrhea (more common in women), this means a superspreader; it may be intermittent.

·        Povidone iodine gargles twice daily

·        Do CBC with ESR, CRP, LDH on day 1 and day 5 onwards every 3rd day.

·        If lymphocyte count is < 1000, give ritonavir + lopinovir combination






Treatment experience in CMAAO countries

·        Singapore: The pandemic is slowing down; there are very few patients in ICU.

·        Pakistan: Antiviral drugs are being used; tocilizumab and dexamethasone are also being used.

·        Bangladesh: Stopped using HCQ as not recommended by WHO. Favipiravir and remdesivir are being used. Ivermectin is not officially recommended though it is being used by some; there is a difference of opinion about this drug.

·        Nepal: Antiviral and/or HCQ are not used; if critical patients, then physicians can use

·        Malaysia: Cases are now in single digits; infection is mostly coming from overseas and migrant workers. All Covid patients are referred to designated government hospitals and not treated in private sector.

·        Japan: Around 100 people diagnosed positive a day, mostly young and no serious cases. 3000 patients have been given favipiravir; but no RCT because of lack of number.

·        Brazil: Cases are increasing, more than one million diagnosed cases; ivermectin is being used as prophylaxis

·        Australia: Melbourne has some amount of community transmission; 6 suburbs have been identified as hotspots and everyone will be tested.

·        Kerala, India: The number of cases is decreasing. Less than 6% need ICU care; mortality is around 1%. Azithromycin is preferred; treatment covers monsoon fevers like dengue. HCQ is not used as patients have lot of comorbidities and renal and liver functions have to be strictly monitored. Strict titration of medication and monitoring of patients has to be done. Also, selective use of medicine has helped to reduce mortality.


Saturday, June 27, 2020

136 CMAAO CORONA FACTS and MYTH BUSTER Mortality Reduction in CMAAO countries Drug Protocol for Treating Doctors


136 CMAAO CORONA FACTS and MYTH BUSTER Mortality Reduction in CMAAO countries Drug Protocol for Treating Doctors

Dr K Aggarwal
President CMAAO



1.      Evidence of fever, hyper immune inflammatory response (High ESR, CRP or ferritin): Tab HCQS (hydroxychloroquine) 400mg 1 tab twice on first day, 400mg 1 tab once a day based on acute phase reactants response

2.      Tab Doxycycline (DOXT) 200 mg first day and 100 mg from day 2 to 7 Or Azithromycin 500 mg daily for five days. (Antibiotic with anti-viral response)

3.       Anti-parasitic Tab Ivermectin 12 mg I tablet once only (by all family)

4.      If severe hypoxia or pneumonia with very high D Dimer and Ferritin give IL-6 pathway inhibitors (Actrmra 400 mg 50K) IV: 8 mg/kg as a single dose (NIH 2020b; NIH 2020e).


5.       In high risk cases in first three days of onset: Favipiravir or Fabiflu 1600 mg twice daily on day 1, followed by 600 mg twice daily for a total duration of 7 to 14 days (Cai 2020; NIH 2020a).


6.      Inj Clexane 0.6 Ml OD or BID in all above age 58, heart patients, hypertension, diabetes, heart failure, asthma, COPD, post cancer, on Oxygen, sudden drop of oxygen on rest or exertion

7.      Prednisolone 1 mg per kg stat if sudden development of hypoxia on exertion or rest (3-7 days)

8.      Ing Remdesivir (Cipla) 200 mg day 1 and 100 mg day 2-5 at the development of oxygen requirement

9.      Sleep prone on your abdomen

10.   Prone oxygen by oxygen concentrator, minimum rate to get 92-96% oxygen levels

11.  Vitamin D Cap D-Rise 2000 IU once a day for three months

12.   Elemental Zinc 75 mg daily

13.  Vitamin C 500 mg twice daily for three days and then 500 mg daily

14.  Tab Ranitidine 150 mg twice daily till the duration of illness

15.   Tab Meftal 200 mg or Naprosyn 500 mg or Indomethacin 25 mg or Nice 100.

16.  SpO2 and Pulse monitoring regularly, especially day 4-7 three times daily.

17.   Inform your local authorities, if COVID positive.

18.   Inform if Temp >1030F or lasts >14 days or Breathlessness, SpO2 falls by >4 after six minutes walking, persistent chest pain

19.   Sudden loss of smell and taste is not a serious sign, may persist for some time, may come and go, may come before fever

20.  Conjunctivitis may occur in one eye and is not a serious sign

21.  Rash may occur on any part of body (more in women) and is not a serious sign

22.  Pus cells may be present in urine, indicate cystitis and not secondary infection (TLC will remain low)

23.   Monocytes presence indicates high viral response

24.  High CRP > 100 means very high inflammatory response

25.  Loose motions (70% women) means super spreader and often a mild sign. May come and go. Take ORS.

26.   Whole family may get COVID or COVID like illness, all may have different symptoms, atleast one will get loose motions

27.  All should do betadine povidone iodine gargles twice daily and povidone iodine nasal wash

28.   Get CBC with ESR, CRP, LDH on day 1 and day 5 onwards every third day

29.   If Lymphocyte count is low ( < 1000) LOPIMUNE one twice day for two weeks ( Ritinovir and Lopinovir)


30.   Review with reports at hcfimedicalreports@gmail.com

31.   9th day onwards you have non replicative virus and cannot pass on the infection to others

32.   RTPCR test may remain positive for up to 48 days

33.   Those who are 65 plus or have underlying diabetes or heart disease should wear three layered fabric mass

34.   Join daily zoom session at 8am (ID drkkaggarwal)



Friday, June 26, 2020

135 CMAAO CORONA FACTS and MYTH BUSTER Mortality Reduction in CMAAO countries



135 CMAAO CORONA FACTS and MYTH BUSTER Mortality Reduction in CMAAO countries


Dr K K Aggarwal
President CMAAO

With inputs from Dr Monica Vasudev

957: Minutes of Virtual Meeting of CMAAO NMAs on “Can mortality in Covid-19 patients be reduced?”

20th June, 2020, Saturday
9.30am-10.30am

Participants

Member NMAs

Dr KK Aggarwal, President CMAAO
Dr Yeh Woei Chong, Singapore Chair CMAAO
Dr Ravi Naidu, Past President CMAAO, Malaysia
Dr Rajan Sharma, National President, IMA
Dr N Gnanabaskaran, President Malaysian Medical Association
Dr Marthanda Pillai, Member World Medical Council
Dr Marie Uzawa Urabe, Japan
Dr Md Jamaluddin Chowdhary, Bangladesh
Dr Sajjad Qaisar, Pakistan

Invitees

Dr Russell D’Souza, UNESCO Chair in Bioethics, Australia
Dr Sanchita Sharma, Editor IJCP Group

  • In high density population, transmission rate is high (40%); if low density, then chances of transmission are low (<5%).
  • Mortality in most Asian countries is not as high as in Europe, US.
  • Doctors should work on reducing mortality, while the government should work on prevention of infection.
  • Mortality should be an exception and not the rule (exceptions are patients with fulminant disease – severe AMI, stroke, encephalitis).
  • Mortality is high, if signals are missed.

India Update

  • Deaths are 9 per million population
  • Situation differs from state to state; Delhi, Mumbai are epicenters
  • Delhi has abolished home quarantine; as per new policy, all positive cases will be placed in mandatory institutional quarantine for at least 5 days. Patients will only be allowed to leave the quarantine centre if there are no symptoms.
  • Cost of Covid-19 testing in Delhi has been reduced to Rs 2400 from Rs 4500.
  • Cost of Covid-19 treatment in private hospitals has been capped for 60% of isolation beds and ICU beds.
  • To create more beds, two railway stations in Delhi have been totally converted to Covid facilities.
  • Testing has been increased; this will help detect asymptomatic carriers and potential superspreaders
  • In Kerala, only the very sick patients are hospitalized in tertiary centers; other positive cases are in peripheral hospitals/hotels; home quarantine is practiced with HCW visit/teleconsultation. People participation, better health infrastructure, more testing have contributed to low mortality (≤1%)
  • Observations from Delhi & Mumbai, India

  • About 20% of people have loss of taste and smell; recovery is a rule in these patients.
  • If patient has diarrhea, the virus is more contagious and the patient may be a superspreader.
  • Fever may last as long as 3 weeks and does not respond to paracetamol. It responds to indomethacin, naproxen, mefenamic acid and nimesulide.
  • People with persistent respiratory symptoms respond immediately to inhaled corticosteroids (ICS).
  • If low lymphocyte count, there is better response to ritonavir + lopinavir combination.
  • Mortality can be reduced, if LMWH is given on the day hypoxia is detected (continued till recovered), short course of steroids (3 doses of IV/oral prednisolone/dexamethasone), remdesivir if available, continuing aspirin and statin for 3 months after discharge.
  • Patients who develop cytokine storm may not recover.

Bangladesh Update

  • There is alarming spread of infection.
  • Till now home quarantine is allowed but this is increasing chances of infection.
  • Death rate is less; deaths are 8 per million population.

Pakistan Update

  • 15 deaths per million population
  • Total cases: 748 per million population
  • Total tests: 4581 per million population
  • Around 50,000 patients are in isolation
  • Many people are not following precautionary measures (social distancing, masks; they do not consult a doctors, if they develop symptoms)

Australia & New Zealand Update

  • The state of Victoria has had fresh new cases every day for 5-6 days with opening of schools, restaurants etc.  There is high alert for a second wave. Testing has increased.
  • Other states have had virtually no new cases in the last two days.
  • Borders have not been opened except in the states of Victoria and New South Wales.
  • New Zealand had few cases last week after 2-3 weeks of no new cases.

Malaysia update

  • There are 8530 cases and 121 deaths; 807 have been discharged
  • The movement control order (MCO) has been reduced; industries have started opening up,      though cinemas, pubs, swimming pools are still closed.
  • Clusters are starting in foreign workers
  • There is a concern that the general population may start to relax as Malaysia is doing well.



Singapore Update

  • There have been 26 deaths; 40,000 cases (of these only 1800 are community cases, rest are in migrant workers living in the dormitories) and only 26 in ICU
  • Most patients are young and fit; statistics show that below 30 years of age, only 0.5% need oxygen and zero percent need ICU care. 
  • The system was not allowed to be overwhelmed at any time.
  • Social distancing, masking, lockdown, contact tracing, lessons learnt from SARS have helped to reduce mortality.


Thursday, June 25, 2020

134 CMAAO CORONA FACTS and MYTH BUSTER Mortality Reduction


134 CMAAO CORONA FACTS and MYTH BUSTER Mortality Reduction

Dr K K Aggarwal
President CMAAO

With inputs from Dr Monica Vasudev

956: Round Table Expert Zoom Meeting on “Mortality reduction in Covid-19”

20th June, 2020
11am-12pm

Participants

Dr KK Aggarwal
Dr Ashok Gupta
Dr Suneela Garg
Dr Alex Thomas
Dr DR Rai
Dr JA Jayalal
Dr Jayakrishnan Alapet
Dr PN Arora
Mrs Upasana Arora
Ms Meenakshi Datta Ghosh
Dr K Kalra
Ms Ira Gupta
Dr Sanchita Sharma

Key points from the discussion

  • Mortality due to Covid-19 differs in different countries, although there are no answers as to why. The answer may lie in different clinical presentation.
  • Careful treatment and educated patients may reduce mortality to less than 0.2%.
  • We must learn from our experiences. Lessons learnt over the course of the pandemic may reduce mortality.
  • Presentation may vary in different patients; hypoxia (silent) for 4-6 hours increases mortality. We must learn to recognize the symptoms.
  • Day 1 symptom is not fever, cough or shortness of breath; nonspecific symptoms such as headache, muscle pain, diarrhea, nausea, pain in the legs below knees may be seen on Day 1, which may be missed.
  • Patients who have loss of taste and smell usually recover.
  • A person who has diarrhea may be a superspreader.
  • Fever may last as long as 3 weeks and does not respond to paracetamol. It responds to naproxen, indomethacin, mefenamic acid and nimesulide.
  • LMWH on Day 1 in all patients who have comorbid conditions; this may reduce mortality due to thrombosis.
  • Use of steroid (injectable) may reduce hypoxia.
  • Every ER should have an Airborne Infections Isolation (AII) room; this should be a part of SOP. If no AII room, then every ER should have air purifier with at least 10 exchanges per hour.
  • Many patients come late to the hospital when the disease has become severe; patients do not know at what stage they should reach the hospital.
  • The new order of Delhi Government, which abolished home quarantine, is a retrograde step. This will overburden the hospitals.
  • Capacity building in healthcare workers is not optimal.
  • SOPs should be displayed prominently in every hospital, restaurants etc.
  • Alternatives to central oxygen supply in hospitals such as oxygen cylinders, ambu bag should be in place in case the central oxygen pressure falls.
  • Data of all Covid patients in the country - clinical presentation, treatment - should be analyzed and made available for learning.
  • Pulse oximeters, oxygen concentrators should be accessible to communities (primary care, residential societies).
  • There is a lack of awareness about proper home quarantine. Putting patients in home quarantine without monitoring may be detrimental and may increase mortality.
  • Tamil Nadu follows the PALM regime (Prone position, Absolute bed rest, Low molecular weight heparin, Methyl prednisolone 1 mg/kg in moderate to severe cases).
  • Health is the right of the patient. There is no clarity about advisories. Patients should know how to proceed.
  • Various videos circulating in the media have created fear. People may hide their illness because of fear and stigma.