200 CMAAO CORONA FACTS and MYTH COVID: Non COVID phase
Dr K Aggarwal
President CMAAO
With input from Dr Monica Vasudev
1071: Minutes of Virtual Meeting of CMAAO NMAs on “Covid-19
Update”
29th
August, 2020, Saturday
9.30am-10.30am
Participants
Member NMAs
Dr
KK Aggarwal, President CMAAO
Dr
Marthanda Pillai, Member World Medical Council
Dr
Alvin Yee-Shing Chan, Hong Kong
Dr
Prakash Budhathoky, Nepal
Invitees
Dr
Russell D’Souza, UNESCO Chair in Bioethics, Australia
Dr
S Sharma, Editor IJCP Group
Key points from the
discussion
- Three acute phase reactants– CRP,
ESR and IL-6. In a resource-limited country, of the three, choose CRP. It
is indicator of intensity of inflammation. CRP cannot rise without
increase in IL-6. Raised CRP, presume that the d-dimer is high.
- We do not know how China which
has a higher population density than India has managed to control the
disease. Mortality is 3 per million; new cases are 9.
- Antigens of various diseases such
as typhoid, malaria, chikungunya, and dengue are false positive in
Covid-19.
- “All overseas players and support staff underwent two COVID-19
RT-PCR tests before flying in to the UAE and could fly only if the tests
are negative. If not, then the same 14-day quarantine period and two
negative tests to be able to fly to the UAE. The players and support staff
will be tested on Day 1, Day 3 and Day 6 of their quarantine in the UAE
and after clearing that, they will be tested every fifth day during the
53-day event.” Instead of three tests, pooled testing of the teams can
be done daily.
- Giving oxygen without
anticoagulation has no significance. You have to give
aspirin/anticoagulation. For cases under home care, rivoraxaban (10 mg prophylaxis)
can be given in place of LMWH; it is cheaper, can be taken by the patient,
onset of action is 10 hours.
- According to TOI report, 87,000
healthcare workers in India are infected with Covid; there have been 573
deaths; 74% cases and over 86% deaths are from six states: Maharashtra, Tamil
Nadu, Delhi, West Bengal, Gujarat and Karnataka. The number projected
seems to be very high and needs to be checked.
- Doctors have high viral load so
have higher chances of developing hypercoagulable state. Should
prophylactic anticoagulation be started on right on Day 1 of the illness
for doctors/HCWs?
- There are three phases of the
illness: Covid (1-9 days, infectious phase), post-Covid (after 9 days,
non-infectious, persistent inflammation) and non-Covid (after 3 months).
After 3 months, the patient should be treated as non-Covid, instead of
post-Covid. This has medicolegal issues
- In Hong Kong, the third wave is
partly controlled. There have been less than 20 cases per day for the last
week or more. One-third of confirmed cases have no known source of origin;
so the chain of spread of infection is not known. Universal community
testing scheme will start from 1st September to find out silent
carriers. The Hong Kong government has agreed to expand to high risk group
tracing and testing even with universal testing. With opening up of
economy, better monitoring of industries so that there will not be a
fourth wave. The third wave began with 9 cases with mutated virus strain
(d614g). At that time, sailors coming to Hong Kong had been exempted from
testing and quarantine; also restrictions of social distancing were
relaxed. This created the third wave.
- Reinfection: A person from Spain
positive in March and became negative reached Hong Kong and tested
positive again in July. This raises a question whether this virus can
re-infect. It was a mutated virus with 24 gene differences. It formed
antibodies quickly, caused no symptoms and not serious and disappeared
early. We need to be vigilant about this. People in post-Covid phase
getting recurrent corona-like illness may be getting re-infection with a
different strain.
- Another case of re-infection
reported in the US; a young person who had severe symptoms and required
oxygen and assisted breathing in the second infection.
- A study from Mumbai has
reconfirmed the US study that antibodies do not last for more than 3
months.
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This is a crucial point to consider during testing. The overlap between antigens of diseases like typhoid, malaria, chikungunya, and dengue can make interpretation of COVID-19 tests more challenging. It's essential to rule out these infections through proper differential diagnosis, especially in endemic regions where these diseases are common.
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China's ability to control COVID-19, despite having a high population density, might stem from stringent early measures, widespread testing, and effective quarantine protocols. While the mortality rates are low, the overall context, including healthcare system differences and governmental policies, needs to be carefully examined before drawing conclusions.
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The importance of anticoagulation in COVID-19 patients cannot be overstated, particularly given the heightened risk of thrombotic events. In high-risk populations such as doctors and healthcare workers, early anticoagulation may be crucial, but individualized risk assessment should guide the use of aspirin or other anticoagulants to prevent complications.
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The reported numbers of healthcare worker infections are alarming, especially in the six high-burden states in India. It’s important to investigate whether the healthcare workers are being adequately protected with personal protective equipment (PPE) and if there are gaps in infection control practices that need addressing. Prophylactic measures like anticoagulation and vaccination should be prioritized for this high-risk group.
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The distinction between post-COVID and non-COVID phases is important for both treatment and medicolegal purposes. It’s essential to continue monitoring patients for long-term effects of COVID-19 beyond the acute phase, while also ensuring that care is adapted for long-haulers, as they may require different management compared to those who have recovered from acute illness. Clear guidelines are needed to prevent any confusion, especially in the legal context.
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