168 CMAAO CORONA FACTS and MYTH COVID Paradigm shifts in COVID 19

168 CMAAO CORONA FACTS and MYTH COVID  Paradigm shifts in COVID 19

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

1029:  Update on Covid-19

IMA-CMAAO Webinar on “Paradigm shifts in COVID-19”

25^th July, 2020

4-5pm

Participants

Dr RV Asokan, Hony Secretary General IMA

Dr Ramesh K Datta, Hony Finance Secretary IMA

Dr Jayakrishnan Alapet

Dr Brijendra Prakash

Dr Sanchita Sharma

Faculty

Dr KK Aggarwal

Padma Shri Awardee

President CMAAO & HCFI

Dr KK Aggarwal elaborated on the paradigm shifts in the management of Covid-19 from the month of March to July, based on his experiences of patients with Covid-19.

Key points from the discussion

• Covid-19 was first considered to be a viral pneumonia, but now it is known as a mysterious virus, which is predictable unpredictable.
• It spares joints and larynx, so no joint involvement or hoarseness of voice; also, no lymph nodes involvement.
• Covid-19 was earlier believed to be non-inflammatory, but we now know that it is predominantly an inflammatory disease.
• Earlier, it was thought that the patient could become critical on any day of the illness; now we know that Days 3-6 are the days to watch.
• Social distancing has changed to physical distancing.
• From macrodroplets (surface to human transmission) earlier, we now talk of microdroplets (crowded ill ventilated rooms) today.
• Surface to human transmission was the most important route of transmission; now it has become less important (heat and humidity)
• The shift from no masking to mandatory masking in public has become the norm.
• From simple masks, we have moved to N95 masks for all high risk patients (COPD, asthmatics)
• Masking only when going out, now adds masking also at home.
• Distancing of 3 feet has changed to 6 feet; with microdroplets, this distance is now 9 feet.
• We started the pandemic with very high mortality (10%); now mortality is around 0.3%.
• Institutional care has shifted to home care
• In the early days, no treatments were available; but individualized treatment is now available. If inflammatory parameters are raised, then give steroids, if d-dimers are high, give anticoagulant, if early presentation, give antiviral etc.
• From mandatory ventilation, the concept has changed to noninvasive ventilation.

• Children to grandparents; now children are no risk for transmission to adults or other children.
• Menstruation reduces severity of illness.
• We have shifted to no steroids to early low dose steroids.
• Hydroxychloroquine (HCQ) for all to no HCQ for mild cases.
• Late discharge – earlier patients were kept for 30-40 days; now patients are discharged early (Day 6) if no complications, to home quarantine
• Thinking of death to thinking recovery
• No pooled test to pooled test
• We have now understood that after 9 days of illness, the virus is non-culturable and the person is non-infectious, the presentation is post-Covid sequelae due to persistent inflammation, or hypercoagulable state. Before 9 days, it is covid.
• No Ct value to Ct value of RTPCR to find out if cohort isolation can be done; low Ct value means high viral load.
• Testing has moved from antigen RTPCR to rapid antigen and now antibodies testing (total vs IgG)
• Isolation to cohort isolation (multiple infected persons in a family can stay together)
• Isolation and now isolation/quarantine/monitoring
• From no oxygen at home to oxygen at home
• Closed camps/OPDs to open sunlight camps – microdroplets are killed in sunlight
• Earlier testing was done only for symptomatic persons, but now liberal testing
• A mandatory government prescription has now become non-mandatory
• When it first began in Wuhan, China, it was pulmonary COVID and CT diagnosis was a must; but now it is also recognized as non-pulmonary COVID, involving GIT, CNS.
• Typically, fever at the time of presentation; now no fever presentation
• Asymptomatic persons are really not asymptomatic; they may have some atypical symptoms such as diarrhea, sore throat etc.
• High grade fever, which is classically associated with viral illness to low grade (100^oF) exertional persistent fever, due to persistent inflammatory process
• The six minute walk test (6MWT) was meant for only COPD, heart failure patients, but it is now mandatory from Day 3-6. If the patient desaturates by 5% on walking, this is indicative of pneumonia with thrombosis. This is an emergency.
• Transmission from joint families to nuclear families
• No toilet transmission, now toilets are recognized as a covid chamber
• Contact time from 30/10 minutes to 15/5 minutes in closed areas
• Testing till Ag negative to no testing to confirm when Ag will become negative
• Fear to no or less fear
• Mortality is two times that of the government figures reported
• For every 1 tested people, there are 20 untested; for every 20 Covid patients, there are 80 patients with corona-like illness.
• Stigma to less stigma
• Low mortality to high mortality amongst doctors
• Ignorance to knowledge
• Engineering (AII rooms) to social engineering (test for 5 parameters when screening - – 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)
• New loss of smell and taste has been seen in 20-30% of patients; the disease is mild in nature.
• We now know that plasma therapy is effective if given early.