144 CMAAO CORONA FACTS and MYTH BUSTER Managing COVID 19 fever
Dr K Aggarwal
966: Minutes of Virtual Meeting of CMAAO NMAs on “Managing fever”
4th July, 2020, Saturday
Dr KK Aggarwal, President CMAAO
Dr Yeh Woei Chong, Singapore Chair CMAAO
Dr Thirunavukarasu Rajoo, Hon. General Secretary, Malaysian Medical Association
Dr Alvin Yee-Shing Chan, Hong Kong
Dr Marie Uzawa Urabe, Japan
Dr Md Jamaluddin Chowdhury, Bangladesh
Dr Qaisar Sajjad, Pakistan
Prof Ashraf Nizami, Pakistan
Dr Prakash Budhathoky, Nepal
Dr Russell D’Souza, UNESCO Chair in Bioethics, Australia
Dr Sanchita Sharma, Editor IJCP Group
Key points from the discussion
Dr KK Aggarwal shared his observations of about 100 patients with loss of taste and/or smell: They did not need hospitalization, none developed pneumonia, recovered in less than 4 weeks, more in men, none needed oxygen, about 50% recovered without treatment. It was the only presentation in many patients. Bitter and sour tastes and sour (lime) smell are retained.
After 9 days, the virus becomes non-replicative; there is no evidence that the virus is culturable after 9 days except for cases who were on ventilator. Antigen can remain positive for up to 40 days. There is also no evidence to date that a culturable virus is positive again.
India is now doing rapid antigen test. If antigen test is negative, do RT PCR. If antigen test is positive, then this is considered positive. Antibody test (Covid-specific IgG) is done after 14 days.
If antigen is positive and Covid-specific IgG antibody is negative, this is resurgence of old infection. If Covid-specific IgG antibodies are present and RT PCR is positive, look for other causes of fever.
The patient who comes after 9 days presents with post-Covid sequelae. These patients have persistent systemic inflammation. The commonest presentation is post-Covid fever (low grade, <100. 4, does not respond to paracetamol, responds to anti-inflamatory drugs like mefenamic acid, naproxen, nimesulide and indomethacin). Other presentations may be post-Covid bronchitis/sore throat/diarrhea/cystitis/exertional tachycardia.
If less than 9 days, critical days are Day 3, 4 and 5; if patient has chest congestion during these days, this is suggestive of pneumonia. A CT scan will show the pneumonia.
If at the onset of pneumonia, patient is given dexamethasone 6 mg x10 days, statin and oral anticoagulant (rivoraxaban) x 40 days and antiviral, mortality may be reduced.
Secondary sudden death (after day 14) may occur even after a month of recovery. Hypercoagulable state can last for up to 40 days.
- Patients have post-Covid problems, but not too much. Patients usually have fever, weakness lasting up to 2-3 weeks, loss of smell/taste x 4-5 days.
- Patients are advised to avoid exertion and take rest, hydration, multivitamins, vitamin D, and balanced diet.
- If post-Covid patients complain of body pain or throat pain, ibuprofen or diclofenac has good response.
- The number of cases are increasing; the number of deaths also increasing.
- Many hospital beds are vacant; this may be due to people taking oxygen at home. So, such cases are probably not coming to the hospital.
- Less than 100 patients in hospital; death rate <1.4%
- All travelers coming into Malaysia are tested (antigen test) at the airport, they are required to download an App on their phones and undergo 14-day home quarantine. On the 13th day, they can go to GP clinic and undergo antibody test. On day 14, they go to district health officer and report.
- No post-Covid fever reported so far.
- Post-Covid fever is rare; there are 2 cases who recovered and were discharged and then presented with fever. They tested positive (RT PCR).
- There are post-Covid fever cases, but the number is not so high.
Hong Kong Update
- There are about 1200 cases, mostly imported cases; local community cases are only a small minority.
- Number of daily tests is around 3000 and trying to increase number of testing.
- Relaxation of regulations of limiting public gatherings
- A judicial inquiry is being held in the state of Victoria (Melbourne) following protocol breach by some of the security looking after international quarantined persons lodged in hotel.
- Rest of Australia is opened up; lockdown (phase 3) only in Victoria. In 10 days, cases have increased to more than 500. Only 5 are in intensive care. Army has been called in.
- Saliva test for coronavirus has been started in Melbourne in hotspots; it is not as specific as nasopharyngeal swab
Various parts of the virus are being used to manufacture the vaccine. Also, there are different ways to produce vaccine: Killed virus, live attenuated virus (India, phase 1 trial), mRNA vaccine (Moderna), spike protein (Oxford), VLP platform, conjugate vaccine, membrane and envelope vaccine. We have no idea which vaccine will succeed. We have to be guardedly optimistic about the vaccine. There are many unanswered questions such as:
- Will the vaccine produce cellular or humoral antibody? Vaccine may produce cellular reaction, but may not prevent cytokine crisis.
- Will they produce antibodies which are safe?
- Will they be able to prevent thromboinflammation?
- Will the effect of the vaccine be long-lasting or not?
- The mRNA can go into every cell of the body; this may be a cause for concern.