158 CMAAO CORONA FACTS and MYTH COVID Asia Update
Dr K Aggarwal
With inputs from Dr Monica Vasudev
993: Minutes of Virtual Meeting of CMAAO NMAs on “Covid Asia Update”
18th July, 2020, Saturday, 9.30am-10.30am
Participants, Member NMAs
Dr KK Aggarwal, President CMAAO
Dr Yeh Woei Chong, Singapore Chair CMAAO
Prof Ashraf Nizami, Pakistan First Vice President CMAAO
Dr Alvin Yee-Shing Chan, Hong Kong, Treasurer CMAAO
Dr Ravi Naidu, Past President CMAAO, Malaysia
Dr Marthanda Pillai, Member World Medical Council
Dr N Gnanabaskaran, President Malaysian Medical Association
Dr Md Jamaluddin Chowdhury, Bangladesh
Dr Qaisar Sajjad, Pakistan
Dr Prakash Budhathoky, Nepal
Dr Russell D’Souza, UNESCO Chair in Bioethics, Australia
Dr Sanchita Sharma, Editor IJCP Group
Dr Yeh Woei Chong elaborated on “Lessons learnt in Singapore during the pandemic” and Dr KK Aggarwal spoke on his personal observations of patients with Covid in the last 3-4 months in his talk on “Covid symptoms – India Experience”. Here are key points from each presentation.
Lessons learnt in Singapore during the pandemic
Dr Yeh Woei Chong
- Total number of cases 47126; cases in migrant workers (44404) constitute the bulk of these cases, while community cases are only 2095. As of today, ICU deaths stand at zero; there have been total 627 deaths.
- Because of the SARS experience, Singapore initiated early action and intervention. First case was detected on 23rd January; Disease Outbreak Response System Condition (DORSCON) yellow was activated. Singapore started closing its borders from 28th January onwards to Hubei province, mainland China, South Korea, Italy, Iran, Europe, Japan and Asean countries including Malaysia. Complete closure of the country on 20th March.
- 7th Feb: Dorscon Orange activated. Doctors are confined to one hospital; only infectious disease specialists and anesthetists can move between few hospitals. Hospitals restricted visitors, workplace restrictions were put into place. Temperature checks were carried out twice daily in schools and workplace. All mass events were cancelled. Contact tracing (4000 daily by 20 teams at the peak).
- Lessons learnt: There was a returning wave in March; around 60,000 citizens and permanent residents returned to Singapore. People flouted stay home notices as required by law. From 25th March, people returning back were sent directly to hotel rooms for 14-day quarantine.
- Around 200,000 migrant workers live in 43 large dormitories; some housing up to 20,000 workers. The vulnerable group (older than 40 years, those with chronic diseases) was removed; medical posts were established with security; the migrant workers were paid salaries in time; three meals daily ensured; access to WiFi/Sim cards to stay in touch with their families.
- Resources: Singapore has 1100 ICU beds and 1000 isolation rooms. A new National Centre for Infectious Diseases, which opened last year, is handling around 60% of all Covid cases in Singapore. There is a N95 factory in Singapore (lesson learnt from SARS). Although testing has been increased (currently 13000 daily), bottlenecks remain such as shortage of transport media, swab sticks, reagent for RNA extraction and surgical masks.
- Public health measures: Initially masks were meant only for the ill (as there were not enough masks at that time), but were made mandatory (cloth masks issued by the government) for all from 3rd April. Singapore had lockdown from 7th April to 2nd June as community cases were increasing. At one point of time, all employers were sending their migrant workers to emergency units for swab testing. They had to be stopped as emergency units were being overwhelmed. So, the Ministry of Manpower initiated punitive measures against these employers. In retrospect, punitive measures are not good in public health in crisis situations. Singapore had the first cluster of 5 cases in migrant workers in early February; this should have been an early warning signal as there was a massive outbreak in the dormitories subsequently in April.
- Indicators of performance: Detection and breaking transmission chains, healthcare system reduces morbidity and mortality, protection of HCWs, protect and support the neglected group, do not allow healthcare system to be overwhelmed and financial support for health care needs.
- The NCID has flexible and scalable design with 64 cohort beds, 100 isolation beds, 124 negative pressure beds, 38 ICU beds. The scalable design allows increasing the number of beds to more than 500; outside areas, which can be converted into extended screening areas.
- Analysis of the first 1500 cases in Singapore showed that in patients ≤30 years, only half percent needed oxygen and no patient needed intensive care. Oxygen and ICU requirement needs increase with age.
- Assessment of clinical course of Covid-19 showed that the most critical period was between Day 5 and Day 7.
Covid symptoms – India experience
Dr KK Aggarwal
- India is at the top among the Asian countries with more than one million confirmed cases. Mortality is 2.5-3%. India is far ahead of China even though the population density is similar.
- Children (0-12 years) are not the first one in a family to get the infection. If all family members are infected, the child will be the last to get the infection. Common symptoms are rash, diarrhea, fever, and cough. The mean duration of symptoms is 3 days. They cannot spread to other children or adults.
- Common symptoms observed: Hypothyroidism (4%), rash (3%), headache (persistent, first onset 2%), shortness of breath (exertional with no fall of SpO2 10%), diarrhea (10%), loss of smell and taste (20%); two had hemoptysis with negative CT scan. Other symptoms are fatigue or tiredness, pain below the knee, cystitis, redness in left eye, right iliac fossa pain, nose block, throat pain or feeling of obstruction in throat.
- Covid patients can be grouped into two: those presenting before 9 days and those presenting after 9 days (post-Covid).
- Post-Covid symptoms: Throat irritation (30%), bronchitis (15%), exertional tachycardia (10%), episodic tiredness, fever (low grade, exertional, evening rise – 10%), chest pain, costochondritis. These symptoms may last for several weeks. These patients should go to a non-Covid facility.
- About 7% of non-ventilated, non-hospitalized, non-immunocompromised people had positive RT PCR on 14th day (generally, PCR should become negative by the 14th day) (mean 20 days)
- Loss of smell and taste (data of 100 patients): Three had mild pneumonia, nobody required oxygen or ventilator; zero deaths; 14 had fever, 7 were children (>12 years), ear involvement in 70%, loss of taste and smell in 88% (7 had only loss of taste, 5 had only loss of smell), two lost sour taste – most recovered in 3 weeks.
- Post-Covid fever: Fever lasting for more than 2 weeks is either due to dysregulation of the body’s thermostat or due to persistent inflammation. Fever >50 days (2%), >40 days (2%), >28 days (2%), >21 days (1%) and 7% had fever lasting for more than 14 days.
- Higher IgG levels seen in adults and in those who have pneumonia; low levels in children and elderly, those who have loss of smell/taste, low fever (<100); still present in those who are antigen positive (dead virus)
- Screening of patients in OPD for Covid: Instead of screening just for temperature, we recommend 5 parameters – temperature (low grade, does not respond to paracetamol), SpO2 (happy hypoxia), loss of smell, loss of taste (give jaggery – first taste to go is sweet taste) and hand grip strength.
- Wave 1 is ending in Delhi, Mumbai, Chennai and Ahmedabad; it is now appearing in Pune, Bangalore, and Hyderabad. In India, the first wave is related to joint families and closed colonies.
- Instead of complete lockdown, personal lockdown is the answer.
- Seroprevalence in Delhi and Mumbai is 18-20%.
- Mortality in Delhi and Mumbai has reduced by 50% in the last one month. Early diagnosis and standard protocols are reducing mortality.
- Day 3-6 are critical. Look for exertional tachycardia/hypoxia/difficulty in talking/cough, this means pneumonia. If you give steroid/ LMWH/antiviral on Day 3, mortality should be an exception and not a rule.
- India still has no AII rooms; labs do not give Ct value in RT PCR test (low Ct value means high viral load, doctors and other HCWs need to be very careful in such cases).
- Most people who have died of covid are usually cases of delayed reporting; they come to the hospital around Day 7/8 or later.
- Transmission: In areas with very high population density, recommend 0.3 micron mask; toilets are becoming covid chambers as are closed poorly ventilated rooms. In Covid chambers, contact time of 5 minutes for transmission, in non-Covid chambers, contact time of 10 minutes.