118 CMAAO CORONA FACTS and MYTH BUSTER: Home Management Guidelines

118 CMAAO CORONA FACTS and MYTH BUSTER: Home Management Guidelines

Dr K K Aggarwal

President CMAAO

942: Minutes of Virtual Meeting of CMAAO NMAs on “Home Management Guidelines”

6^th 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 N Gnanabaskaran, President Malaysian Medical Association

Dr Thirunavukarasu Rajoo, Hon. General Secretary, Malaysian Medical Association

Dr Alvin Yee-Shing Chan, Hong Kong

Dr Marie Uzawa Urabe, Japan

Dr Sajjad Qaisar, Pakistan

Dr Deborah Cavalcanti, Brazil

Dr Marthanda Pillai, Member World Medical Council

Dr Md Jamaluddin Chowdhary, Bangladesh

Dr Prakash Budhathoky, Nepal

Dr Subramaniam Muniandy, Malaysia

Invitees

Dr Russell D’Souza, UNESCO Chair in Bioethics, Australia

Dr KK Kalra, Former CEO NABH

Dr Sanchita Sharma, Editor IJCP Group

KEY DISCUSSION POINTS

1. Should doctors have the right to know their Covid status? When should they get themselves tested? Is there a policy in CMAAO countries in this regard?

·        India: There are four epicenters including Mumbai, Delhi. Doctors are not allowed to be tested, even if exposed to Covid positive patients, unless they are symptomatic. In Kerala, work for one week and then one week quarantine.

·        Bangladesh: Earlier, 14 days quarantine (with 6 days at home) after 10 days of duty. Now, 7 days of duty followed by 7 days quarantine (in hotel); during this time, if they test negative or Covid, then they are allowed to go home and can resume work after 7 days.

·        Malaysia: In the public sector, those who are directly involved in testing are tested; the occupational health dept. stringently monitors all those who do not have PPE and are directly involved in sampling and also treating patients. As a result, Covid hospitals have no cases o infection among healthcare workers (HCW). Clinics have to adhere to all SOPs issued by the govt. to prevent spread of infection.

25000 tests per day are being done; focused group testing. New cases are coming down; more cases in detention centers (illegal immigrants). Social distancing is being observed even by Malaysians. More than one million people use the App launched by the Govt. last month. Disease Prevention Act 1998 is being used to enforce screening. More businesses have opened up; companies have been strictly ordered to shut down for 2 weeks if they find a cluster of cases; if no RT PCR screening, then construction industry cannot open

·        Pakistan: 7 days of duty followed by 14 days quarantine; if they develop symptoms, then they are tested. If no symptoms, then they come back to work. After quarantine, if somebody wants to go home, they are allowed to do so for 5-7 days, with duty covered by another doctor for this duration.

·        Australia: Everyone who comes in contact with a positive patient even if asymptomatic or those working in hospitals are tested

·        Singapore: Criteria driven policy in this regard; doctors can get tested if they have been exposed to a patient and feel the need to be tested. If they have symptoms like fever, they will be tested. All doctors should be tested as healthcare resources should be protected.

·        Hong Kong: A new cluster of 4 confirmed cases in one day has been found in a resurgence of infection as there had been no cases for almost a month. There is apprehension of a second wave. Utensils for eating may be carriers. Exhaust fans may be the portal of infection. More testing is needed; currently it is 2000/day, which is far from adequate. Doctors are urged to get tested if they think they have symptoms. But, the fear of stigmatization is why many are reluctant to get tested. But, they use level 3 face masks and PPE even in cases of flu, allergies. Doctors in ICU or infectious diseases use N95 masks. So far, no infection among medical personnel in hospital or clinic setting has been reported.

2. What is that parameter or trigger, which is indicative of “point of no return” in Covid-19 patients? What has been the experience of CMAAO countries?

Hypothesis: The triggering factor in Covid-19 patients is silent hypoxia. So, do not neglect patients after fever resolves. Monitor SpO2 levels regularly.

If oxygen saturation falls, when walking/talking, this is the earliest sign of oxygen fall.

If level falls to ≤90, oxygen therapy will prevent or reduce mortality. Till a hospital bed is available, use an oxygen concentrator and monitor oxygen. Give one shot of LMWH.

·        Bangladesh: High flow nasal cannula is used to avoid ventilator, which are a scarce resource in the country

·        Singapore: Portable pulse oximeters have been issued to migrant workers in dormitories with directive to monitor oxygen twice daily; if oxygen falls below 93%, then shift to hospital

·        Hong Kong: No cases of deaths due to hypoxia; people in quarantine have been given pulse oximeters to monitor oxygen.

·        Pakistan: There are cases of hypoxia, which need oxygen therapy. There are isolation centers, where cases are managed only symptomatically and oxygen therapy, if needed. No ICU/ high-dependency unit (HDU) at these centers.

·        Nepal: 98% positive cases are asymptomatic and have been discharged without any intervention; few have symptoms like malaise, fever, dry cough; only symptomatic treatment. No experience with hypoxia, but will now impose in govt. guidelines

·        Japan: Very few reported cases of hypoxia. Asymptomatic and mildly ill patients are monitoring oxygen with oximeter thrice or four times daily. If oxygen is low, then ICU care.

3. Hydroxychloroquine+Azithromycin

·        Lancet has withdrawn its article on hydroxychloroquine, which said that HCQ had no benefit and was associated with increased risk of death.

·        Japan has treated 30 patients with hydroxychloroquine + azithromycin and the results have been very good.

·        This combination is used routinely in India. Some may use doxycycline instead of azithromycin. Doctors are taking HCQ as prophylaxis against coronavirus. The govt. has recommended the prophylactic use of HCQ.

4. Vaccines

mRNA and Adenovirus (Oxford) vaccines are doing well in phase I human trials.

5. Proposed strike in Hong Kong

Young doctors in Hong Kong are planning a strike against the new law. But this is a difficult time for all; hence, a strike at this time is the not the best thing to do.

CMAAO CORONA FACTS and MYTH BUSTER 106 Lessons Learned So far from COVID

CMAAO CORONA FACTS and MYTH BUSTER 106 Lessons Learned So far from COVID

Dr K K Aggarwal

President Confederation of Medical Associations of Asia and Oceania, HCFI, Past National President IMA, Chief Editor Medtalks

Round Table Expert Zoom Meeting on Lessons learnt from Covid-19

23^rd May, 2020

11am-12pm

Participants

Dr KK Aggarwal

Dr Alok Roy

Dr AK Agarwal

Dr Narottam Puri

Dr Suneela Garg

Dr Girdhar Gyani

Dr Atul Pandey

Dr Ashok Gupta

Dr Jayakrishnan Alapet

Dr Alex Thomas

Dr K Kalra

Dr Major Prachi Garg

Ms Ira Gupta

Dr Sanchita Sharma

·        Do not miss the first case in the country or your state. A first case of a new disease is a potential epidemic.

·        We should have permanent Arogya Setu App for all notifiable communicable diseases, specifically MDR TB and other highly infectious diseases. Personal privacy does not apply in cases of notifiable diseases. The concept of “broader good” comes into play here.

·        Elderly are at risk. We must have a national program for the protection of health of the elderly. There is a need to set up separate geriatric medicine departments in all medical colleges. It is also important to establish a group of doctors aged ≥65years. Their rich experience can be tapped into in times of crisis.

·        Contact time: we must know the contact time for every disease. For TB, the contact time is 8 hours. For Covid-19, the contact time is between 10 and 30 minutes. A casual contact time of less than 10 minutes has low risk of transmission (monitoring). If the contact time is more than 30 minutes, the risk of transmission is high (quarantine).

·        A virus may have several different types of presentations/manifestations in different countries or population groups and the treatment will be according to the presentation. Identify the presentation in different communities. Covid-10 has so far shown the following 7 characteristics.

1.    It is a viral illness, so it is self-limiting disease; antiviral drugs like remdesivir may work

2.    It has bacterial activity as in some cases, procalcitonin is high, neutrophilia is also seen; antibiotics like doxycycline, azithromycin may work.

3.    It has some HIV like properties, as there is lymphopenia (viruses usually cause lymphocytosis), decrease in CD4 cell count; anti-HIV drugs may be effective.

4.    It causes immuno-inflammation: Viruses do not cause immunoinflammation. But, increase in ESR (>100), CRP, ferritin (acute phase reactants) is seen in Covid-19. Hydroxychloroquine may be effective. Immunoinflammation is being seen much more in European countries than in Asian countries.

5.    It causes thrombo-inflammation: Increase in d-dimer and fibrinogen (usually if d-dimer is high, fibrinogen is low); anticoagulation may be important.

6.    Silent hypoxia (walking dead phenomenon): Patients have low oxygen but are conscious. Usually, people with hypoxia are drowsy, irritable.

7.    Cytokine storm: ARDS

·        We have learnt three terms: Home isolation, home quarantine and monitoring.

·        The pandemic has focused on different populations e.g. migrants, factory workers, private sector

·        The problem of migrants should be anticipated timely and planned properly. Positivity rate in India is 3.5-7%

·        Random testing rate of people reaching Bihar is 8% and for those reaching UP is 5%.

·        Living with fear: Manage fear by being well-prepared.

·        Treat the patient, not the report. About 30% of tests may be false-negative.

·        There should be a worldwide ban on wet markets.

·        Vaccine may or may not come. We may be over-relying on a vaccine.

·        Health infrastructure will change. Now, new hospitals will be airy, roomier, more ventilated; there will be no central AC, no attached bathroom with every room.

·        Standard precautions: We did not learn social distancing from the 2009 H1N1 flu. Face to face meeting is more risky than side to side meeting.

·        Never ignore nature.

·        Never ignore essential health services.

·        Super spreader: A latest study from Israel says that 5% people are responsible for the remaining 95% of transmission. This is similar to the 80/20 rule, which has been the standard teaching in PSM, where approximately 20% of infected individuals are responsible for 80% of transmissions. The first known super spreader was in South Korea (patient #31) and then there have been super spreaders in different countries.

·        We have learnt how to sustain the improved pollution. If pollution levels are very high, then a lockdown of 1-2 days may help.

·        Terms like R0 (R naught; reproduction number), herd immunity have been revisited.

·        Create more awareness in the society.

·        Transparent communication and dissemination of accurate information to promote community engagement is important to allay the fears, stigma. We need to be consistent in data projections.

·        “Be a realist rather than being an optimist when presenting data”

·        This pandemic has highlighted the inadequacy in testing and testing facilities, the importance of investment in health and more focus on research and indigenous health technologies.

·        We must keep a watch on every situation happening in the world. Be prepared in advance.

·        The disease has focused on the need of Epidemic Intelligence services, which can forecast epidemics. A training program can be started on pilot basis in few medical colleges.

·        Learn to live with Corona is the new buzzword.

·        A change in lifestyle with new norms is key “self-disciplined”; practice social distancing, personal hygiene.

·        This is an opportunity to be self-sufficient, self-reliant and promote “Make in India”. The pandemic started with virtually no PPE but there are now over 600 manufacturers.

·        We have to devise ways to keep the economy running as the pandemic has greatly affected the jobs leading to a negative GDP.

·        This is an opportunity to decongest slums.

·        We need to have a White Paper on national health security.

 Histopathology

Seven lungs from patients who died of confirmed COVID-19 and seven lungs obtained during autopsy from patients who died from H1n1 ARDS in 2009, showed three distinctive features of COVID-19:

·        Severe endothelial injury associated with intracellular SARS-CoV-2 virus and disrupted endothelial cell membranes

·        Widespread vascular thrombosis with microangiopathy and occlusion of alveolar capillaries

·        Significant new vessel growth through intussusceptive angiogenesis.

This is a respiratory virus that causes a vascular disease, and the damage to the blood vessels

May 21 in the New England Journal of Medicine.

Although lungs from influenza sufferers also showed diffuse alveolar damage, in the COVID-19 lungs, there were 9-fold as many segments occluded by microthrombi (P < .001).

Although tissue hypoxia was probably a common feature in the lungs from both these groups of patients, the greater degree of endothelialitis and thrombosis in the lungs from patients with COVID-19 may contribute to the relative frequency of sprouting and intussusceptive angiogenesis observed in these patients

The amount of angiogenesis seen was unexpected, and about 2.7-fold higher than that seen in lungs from patients with influenza (P < .001).

Wuhan Update
In two weeks, the Chinese health authorities managed to administer 6.5 million tests for the coronavirus in Wuhan, the city where the pandemic began and where six new infections detected two weeks ago raised fears of a second wave of contagion.  200 cases were found, mostly people who showed no symptoms.

CMAAO IMA CORONA FACTS and MYTH BUSTER 97: CORONA SERIOUSNESS

CMAAO IMA CORONA FACTS and MYTH BUSTER 97:  CORONA SERIOUSNESS

           

Dr K K Aggarwal

President Confederation of Medical Associations of Asia and Oceania, HCFI, Past National President IMA, Chief Editor Medtalks

With inputs from Dr Monica Vasudev

868: Even serious can recover: A WUHAN study found that survivors recovered after a host of complications: 42% had sepsis, 36% had respiratory failure, 12% had heart failure, and 7% had blood clotting problems.

869: Which doctors are at risk: A survey data show that of all resident physicians who worked within the greater New York City area between March and April, anesthesiology, emergency medicine, and ophthalmology residents were at greatest risk of contracting COVID-19.

870:  Children recover more from serious illnesses:  North American case series of children with COVID-19 suggests the clinical course is typically less severe and the hospital outcomes better in critically ill children than in adults. Overall ICU mortality at the end of our follow-up period of less than 5% compared with published mortalities of 50% to 62% in adults admitted to the ICU," Dr. Lara Shekerdemian of Texas Children's Hospital, in Houston, and colleagues write in JAMA Pediatrics.

871: Preventing sudden deaths in athletes: prevent cardiac injury, athletes should rest for at least 2 weeks after symptoms resolve, then undergo cardiac testing before returning high-level competitive sports, reported lead author Dermot Phelan, MD, PhD, of Atrium Health in Charlotte, N.C., and colleagues in JAMA Cardiology

870: 

872: Time of serious illness: Severe illness usually begins approximately 1 week after the onset of symptoms. Dyspnea is the most common symptom of severe disease and is often accompanied by hypoxemia.

873: A striking feature of Covid-19 is the rapid progression of respiratory failure soon after the onset of dyspnea and hypoxemia. Patients with severe Covid-19 commonly meet the criteria for the acute respiratory distress syndrome (ARDS), which is defined as the acute onset of bilateral infiltrates, severe hypoxemia, and lung edema that is not fully explained by cardiac failure or fluid overload.

874: Blood markers: The majority of patients with severe Covid-19 have lymphopenia,5 and some have disorders of the central or peripheral nervous system.

875: Severe Covid-19 may also lead to acute cardiac, kidney, and liver injury, in addition to cardiac arrhythmias, rhabdomyolysis, coagulopathy, and shock. These organ failures may be associated with a cytokine release syndrome characterized by high fevers, thrombocytopenia, hyperferritinemia, and elevation of other inflammatory markers.

876: Preliminary data from a randomized, placebo-controlled trial involving patients with severe Covid-19 suggest that the investigational antiviral remdesivir shortens time to recovery.

877: Definition: Severe Covid-19 in adults is defined as dyspnea, a respiratory rate of 30 or more breaths per minute, a blood oxygen saturation of 93% or less, a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2:FIO2) of less than 300 mm Hg, or infiltrates in more than 50% of the lung field within 24 to 48 hours from the onset of symptoms.

878: Occurrence: In a large cohort of patients with Covid-19, 81% had mild disease, 14% had severe disease, and 5% became critically ill with organ failure; the mortality in the critically ill group was 49%. The majority of critically ill patients with Covid-19 receive prolonged mechanical ventilation.

879: Who suffers more: People with chronic health conditions such as cardiovascular disease, diabetes mellitus, and obesity are more likely to become critically ill from Covid-19. The incidence of critical illness is also higher among men than among women and higher among persons older than 65 years of age than among younger persons

880: hall mark: A hallmark of the Covid-19 pandemic is the sudden appearance of an unprecedented number of critically ill patients in a small geographic area.

881: Consent: At the earliest opportunity, clinicians should partner with patients by reviewing advanced directives, identifying surrogate medical decision makers, and establishing appropriate goals of care. Because infection-control measures during the pandemic may prevent families from visiting seriously ill patients, care teams should develop plans to communicate with patients’ families and surrogate decision makers.

882: Risk factors for severe illness — Severe illness can occur in otherwise healthy individuals of any age, but it predominantly occurs in adults with advanced age or underlying medical comorbidities.

Comorbidities and other conditions that have been associated with severe illness and mortality

●Cardiovascular disease

●Diabetes mellitus

●Hypertension

●Chronic lung disease

●Cancer (in particular hematologic malignancies, lung cancer, and metastatic disease) [95]

●Chronic kidney disease

●Obesity

●Smoking

The United States Centers for Disease Control and Prevention (CDC) also includes immunocompromising conditions and liver disease as potential risk factors for severe illness.

883: In a subset of 355 patients who died with COVID-19 in Italy, the mean number of pre-existing comorbidities was 2.7, and only 3 patients had no underlying condition.

884: Age: Among patients with advanced age and medical comorbidities, COVID-19 is frequently severe. For example, in a SARS-CoV-2 outbreak across several long-term care facilities in Washington State, the median age of the 101 facility residents affected was 83 years, and 94 percent had a chronic underlying condition; the hospitalization and preliminary case fatality rates were 55 and 34 percent, respectively.

885: Males have comprised a disproportionately high number of deaths in cohorts from China, Italy, and the United States.

886: Particular laboratory features have also been associated with worse outcomes

●Lymphopenia

●Elevated liver enzymes

●Elevated lactate dehydrogenase (LDH)

●Elevated inflammatory markers (eg, C-reactive protein [CRP], ferritin)

●Elevated D-dimer (>1 mcg/mL)

●Elevated prothrombin time (PT)

●Elevated troponin

●Elevated creatine phosphokinase (CPK)

●Acute kidney injury

Progressive decline in the lymphocyte count and rise in the D-dimer over time were observed in nonsurvivors compared with more stable levels in survivors

886: Viral load:  Patients with severe disease have also been reported to have higher viral RNA levels in respiratory specimens than those with milder disease

CMAAO IMA CORONA FACTS and MYTH BUSTER 96: IDSA Guidelines Diagnosis

CMAAO IMA CORONA FACTS and MYTH BUSTER 96: IDSA Guidelines Diagnosis

Dr K K Aggarwal

President Confederation of Medical Associations of Asia and Oceania, HCFI, Past National President IMA, Chief Editor Medtalks

With inputs from Dr Monica Vasudev

867:  Summary of the IDSA guidelines on the diagnosis of COVID-19 [Infectious Diseases Society of America]

Recommendation 1

SARS-CoV-2 nucleic acid amplification test in symptomatic individuals in the community suspected of having COVID-19, even when the clinical suspicion is low (strong recommendation, very low certainty of evidence).

The panel placed a high value on accurate assessment of COVID-19 with the intent of minimizing overdiagnosis of COVID-19 using clinical diagnosis alone.

Without testing, the rate of overdiagnosis ranges from 62% to 98%. If patients are misdiagnosed as having COVID-19, they may spend unnecessary time in quarantine and then may stop taking appropriate safety precautions to protect themselves from infection.

Recommendation 2

The IDSA panel suggests collecting nasopharyngeal, or mid-turbinate or nasal swabs, rather than oropharyngeal swabs or saliva alone for SARS-CoV-2 RNA testing in symptomatic individuals with upper respiratory tract infection or influenza-like illness suspected of having COVID-19 (conditional recommendation, very low certainty of evidence).

The rationale for this recommendation is that comparative data showed a much lower sensitivity for oral sampling, compared with nasopharyngeal, mid-turbinate, or nasal sampling.

The average sensitivity of oral swabs is 56%, compared with nasopharyngeal at 97%, mid-turbinate at 100%, and nasal sampling at 95%. Given these test characteristics, there are far less false-negative tests with nasopharyngeal, mid-turbinate, and nasal swabs.

Fewer false negatives means fewer instances of incorrectly telling COVID-19–positive patients that they do not have the illness. An exciting new area of testing that is being evaluated is saliva, which appears to have a sensitivity of 85%.

Recommendation 3

The IDSA panel suggests that nasal and mid-turbinate swab specimens may be collected for SARS-CoV-2 RNA testing by either patients or health care providers in symptomatic individuals with upper respiratory tract infection or influenza-like illness suspected of having COVID-19 (conditional recommendation, low certainty of evidence).

This recommendation is particularly exciting because patient self-collection provides the potential for health care personnel to avoid exposure to infection, as can occur when health care personnel are swabbing a patient; this is ow testing has been done at most testing centers.

While the data are limited, it appears that patient self-collection of nasal or mid-turbinate swabs results in similar detection rates as occurs with health care personnel–collected nasopharyngeal swabs.

Recommendation 4:

The IDSA panel suggests a strategy of initially obtaining an upper respiratory tract sample (e.g., nasopharyngeal swab) rather than a lower respiratory sample for SARS-CoV-2 RNA testing in hospitalized patients with suspected COVID-19 lower respiratory tract infection. If the initial upper respiratory sample result is negative, and the suspicion for disease remains high, the IDSA panel suggests collecting a lower respiratory tract sample (e.g., sputum, bronchoalveolar lavage fluid, tracheal aspirate) rather than collecting another upper respiratory sample (conditional recommendations, very low certainty of evidence). Remark: • The panel considered timeliness of SARS-CoV-2 NAAT results essential to impact individual care and isolation decisions. In the hospital setting, results within 24 hours of collection is preferable.

Recommendation 5:

The IDSA panel suggests performing a single viral RNA test and not repeating testing in symptomatic individuals with a low clinical suspicion of COVID-19 (conditional recommendation, low certainty of evidence). Remarks: • A low clinical suspicion should be informed by epidemiological information available for the region coupled with clinical judgment. • The panel considered symptomatic patients to have at least one of the most common symptoms compatible with COVID-19

Recommendation 6

The IDSA panel suggests repeating viral RNA testing when the initial test is negative (versus performing a single test) in symptomatic individuals with an intermediate or high clinical suspicion of COVID-19 (conditional recommendation, low certainty of evidence).

Since none of the tests are perfect and any can have false negatives, the panel places a high value on detecting infection when present. If there is a low clinical likelihood of disease, the panel recommends not retesting. When the clinical likelihood of COVID-19 is moderate to high, in the event that the initial test is negative, the panel recommends retesting for COVID-19 1-2 days after the initial test.

Recommendation 7:

The IDSA panel makes no recommendations for or against using rapid (i.e., test time ≤ 1hour) versus standard RNA testing in symptomatic individuals suspected of having COVID-19 (knowledge gap).

Recommendation 8

The IDSA panel suggests SARS-CoV-2 RNA testing in asymptomatic individuals who are either known or suspected to have been exposed to COVID-19 (conditional recommendation, very low certainty of evidence).

For this recommendation, a known contact is defined as someone who has had direct contact with a confirmed case.

A suspected exposure occurs when someone is working or living in a congregate setting such as long-term care, a correctional facility, or a cruise ship in which there is an outbreak. The time frame during which to do post-exposure testing is five to seven days after the exposure.

Recommendation 9:

The IDSA panel suggests against SARS-CoV-2 RNA testing in asymptomatic individuals with no known contact with COVID-19 who are being hospitalized in areas with a low prevalence of COVID-19 in the community (conditional recommendation, very low certainty of evidence). Remarks: • Asymptomatic individuals are defined as those with no symptoms or signs of COVID-19. • A low prevalence of COVID-19 in the community was considered communities with a prevalence of

Recommendation 10

The IDSA panel recommends direct SARS-CoV-2 RNA testing in asymptomatic individuals with no known contact with COVID-19 who are being hospitalized in areas with a high prevalence of COVID-19 in the community (conditional recommendation, very low certainty of evidence).

The idea is to do rapid testing to identify individuals entering the hospital either for other illnesses or for procedures, in order to be able to institute appropriate precautions and decrease the likelihood of nosocomial transmission and/or transmission to health care personnel. It is worth noting that the recommendations do not address testing in areas with a low or intermediate prevalence of COVID-19. In the absence of an official guideline-based-recommendation, the decision about testing needs to made by the local hospital system.

Recommendations 11, 12, and 13

The IDSA panel recommends SARS-CoV-2 RNA testing in immunocompromised asymptomatic individuals who are being admitted to the hospital and in asymptomatic individuals prior to receiving immunosuppressive therapy regardless of exposure to COVID-19. It is also recommended to test asymptomatic individuals planning to undergo major surgery.

The rationale for this recommendation is that patients who are to receive chemotherapy, other immunosuppressive procedures, or surgery are at high risk if they have COVID-19 and may be better off delaying the procedure.

Some additional issues were addressed, though not in the form of additional recommendations. It was clarified that some individuals remain nucleic acid positive after their symptoms resolve, and sometimes even after seroconversion. It is not clear if those individuals remain infectious to others. The recommendations did not address serologic testing for public health surveillance.

Recommendation 14:

The IDSA panel suggests against SARS-CoV-2 RNA testing in asymptomatic individuals without a known exposure to COVID-19 who are undergoing a time-sensitive aerosol generating procedure (e.g., bronchoscopy) when PPE is available (conditional recommendation, very low certainty of evidence). Last updated May 6, 2020 and posted online at www.idsociety.org/COVID19guidelines/dx. Please check website for most updated version of these guidelines. Supplementary materials are available here. Version 1.0.1 Remarks: • The panel defined time-sensitive procedures as medically necessary procedures that need to be done within three months

Recommendation 15:

The IDSA panel suggests SARS-CoV-2 RNA testing in asymptomatic individuals without a known exposure to COVID-19 who are undergoing a time-sensitive aerosol generating procedure (e.g., bronchoscopy) when PPE is limited, and testing is available (conditional recommendation, very low certainty of evidence).

Remark:

• The panel defined time-sensitive procedures as medically necessary procedures that need to be done within three months.

• Testing should be performed as close to the planned procedure as possible (e.g. within 48- 72 hours).

• Decisions about PPE will be dependent on test results because of limited availability of PPE. However, there is a risk for false negative test results, so caution should be exercised for those who will be in close contact with/exposed to the patient’s airways.

The decision to test asymptomatic patients will be dependent on the availability of testing resources.

This recommendation does not address the need for repeat testing if patients are required to undergo multiple procedures over time.

CMAAO IMA CORONA FACTS and MYTH BUSTER 94

CMAAO IMA CORONA FACTS and MYTH BUSTER 94

Dr K K Aggarwal

President Confederation of Medical Associations of Asia and Oceania, HCFI, Past National President IMA, Chief Editor Medtalks

With inputs from Dr Monica Vasudev

New facts

842: Most children hospitalized for COVID-19 had pre-existing conditions, with nearly 40% who required invasive mechanical ventilation [U.S. and Canadian PICU]

843:  Gastrointestinal symptoms affected 26% of hospital employees hospitalized with presumptive COVID-19 infection, according to the results of a study from Wuhan, China. Most commonly included diarrhea (18%), nausea (8%), vomiting (6%), and abdominal pain (2%), the researchers reported. [ Zhou Z et al. Gastroenterology. 2020 Mar 18.]

844: The successful treatment of a patient with pulmonary arterial hypertension who contracted COVID-19 with self-administered inhaled nitrous oxide from a tankless device at home has caught the imagination of researchers investigating treatments for other patients.

845: While initial research suggested that children are not as susceptible to severe Covid-19 as adults and those with co-morbidities, further studies indicated that children may be hit harder by Covid-19 than initially thought. Because of guidelines telling us to look out for mainly three symptoms (a dry cough, fever and breathlessness), we might be missing Covid-19 in children, according to a new study published in Frontiers in Pediatric

846: Digestive symptoms in children can be a sign of coronavirus: GI symptoms such as diarrhoea and an upset stomach might be the first hints of coronavirus infection. As per Dr Wenbin Li from the Department of Pediatrics at the Tongji Hospital in Wuhan, China, ACE2 receptor, which can be found in certain cells in the lungs as well as the intestines.

847: One study, published in the European Heart Journal, found higher plasma levels of the ACE2 receptor/enzyme in men vs women in two large samples of patients with heart failure.

848: NEJM: With reports of transmission of SARS-CoV-2 from humans to domestic cats and to tigers and lions at the Bronx Zoo, coupled with our data showing the ease of transmission between domestic cats, there is a public health need to recognize and further investigate the potential chain of human–cat–human transmission. This is of particular importance given the potential for SARS-CoV-2 transmission between family members in households with cats while living under “shelter-in-place” orders. In 2016, an H7N2 influenza outbreak in New York City cat shelters5 highlighted the public health implications of cat-to-human transmission to workers in animal shelters. Moreover, cats may be a silent intermediate host of SARS-CoV-2, because infected cats may not show any appreciable symptoms that might be recognized by their owners.

849: COVID-19 Supertreaters in the ICU (physicians who treat 20+ COVID-19 patients)

850:  Among Supertreaters in the ICU, 50% believe severe COVID-19 is more of a “respiratory failure disease” resulting in ARDS and necessitating ventilation support; 50% believe it is more of an “oxygen failure” disease necessitating oxygen therapy with ventilation as a last resort (n=118).  

CMAAO CORONA FACTS and MYTH BUSTER 90

CMAAO CORONA FACTS and MYTH BUSTER 90

Dr K K Aggarwal

President Confederation of Medical Associations of Asia and Oceania, HCFI, Past National President IMA, Chief Editor Medtalks

With inputs from Dr Monica Vasudev

830: Three drugs better

Patients hospitalized with COVID-19 who received a combination therapy with three antivirals -- protease inhibitor lopinavir-ritonavir (Kaletra), nucleoside analogue ribavirin, and injectable interferon beta-1b (Betaseron, Extavia) -- showed significantly shorter median time to a negative SARS-CoV-2 test versus controls, a small phase II trial found. Median number of days from start of study treatment to a negative test result, the trial's primary endpoint, was 7 days compared with 12 days in a control group that only received lopinavir-ritonavir, reported Kwok-Yung Yuen, MD, of the University of Hong Kong, and colleagues writing in The Lancet.

831: COVID formulas revisited
Documented PCR-positive COVID-19 cases are just the tip of the iceberg.

1.      In US 5.7% of people in that tip have died.

2.       How much iceberg is under the water:

Steamroller COVID: There were roughly two undocumented cases of COVID-19 for each documented case. It means that a ton of people are still susceptible to the disease. No herd immunity is developing, the mortality rate is high, and we're going to be stuck inside for a long time.

But recently, using antibody tests, researchers are starting to sample asymptomatic people to figure out who had the disease. In early April, German researchers published this study, which found that 70 out of 500 people tested in a hard-hit area had coronavirus antibodies. That's 14%. Translating that to the entire population put the ratio of undocumented to documented COVID-19 at about 5 to 1.

A much criticized California seroprevalence study of 3300 individuals found that 50 were positive — just 1.5% — but in an area that hadn't seen many symptomatic cases, putting the undocumented-to-documented ratio at 85 to 1.

Windstorm COVID : Governor Andrew Cuomo reported that sampling of New York City grocery store shoppers (perhaps not the most random sample) has a seroprevalence rate of around 20%. That implies an undocumented-to-documented ratio of 10 to 1. This is the COVID that allows us to open up more quickly, assuming that antibodies are protective.

So which COVID is it?

Antibody tests: No test is perfect. The false positives are particularly high. Imagine you have an antibody test that is 98% specific. Only 2 out of 100 people will have a false positive. You'll estimate that 2% of the population has had the disease. If you did that in a random sample of America, you'd estimate that there have been 6 million coronavirus infections, compared with the roughly 1 million we've detected, allowing you to comfortably cut the death rate down by a factor of 6 — making us all feel a bit better.

But, of course, that result was just due to random chance. A 95% specific test would lead to a conclusion that at least 15      million Americans have already been exposed, allowing you to take the observed death rate of 5.7% and cut it right down to a much more comfortable 0.3%.

           

832:  Mutation: Scientists have warned that a mutation called D614G in the Spike protein region of the SARS-CoV-2 virus — which causes Covid-19 — “is of urgent concern,” as it makes the virus more contagious.

CMAAO CORONA FACTS and MYTH BUSTER 89 Living with Corona 1.0 is the answer

CMAAO CORONA FACTS and MYTH BUSTER 89 Living with Corona 1.0 is the answer

Dr K K Aggarwal

President Confederation of Medical Associations of Asia and Oceania, HCFI, Past National President IMA, Chief Editor Medtalks

With inputs from Dr Viraj Suvarna

829: Extending Lockdown not the answer: Living with Corona 1.0 is the answer

How long can we continue lockdown? 54 days are enough to learn and get prepared. We all know that prevention with physical distancing and hand hygiene is the only vaccine.

At some point people we will have to get out. The time we get out asymptomatic cases will spread the infection to others and some of them will become symptomatic. They will be tested and if positive, isolated while their close contacts will also be tested and home quarantined. The answer is only timely and mandatory contact tracing of all symptomatic cases and act on them. 

A peak will be reached and then it will decline. The earlier a state achieves the peak the better it will be for their economy. Remember most young people, unless you deploy army or strict discipline will not observe the lockdown.

For them getting 14 days of isolation when become positive is better than 54 days of lockdown with still a chance of ending up with another 14 days of isolation when they actually get the disease.

The monsoon and then the winter, both with high humidity, will bring its own share of problems. Today we have near 60,000 cases they will double over-time and so on. One can only postpone or delay the inevitable by a few days. Doubling rate of the whole world is around 11 days. You can delay it by a few days only.

Lockdown success depends on the density of the population. In an HCFI study we found that states with average population density of more than 1000 / sq. km (1185) had 2048 average number of cases. While states with population density of < 1000/ sq. km (909) had only 56. When Chandigarh and Pondicherry with high population density were taken out from these states the average density fell to 217/ sq. km and the average numbers to only 35.

Density is linked to the migrant population. Many metros in India including Mumbai have so much migrant population that it is impossible for any administration or healthcare system to force physical distancing of six feet effectively. This is also evident from that in India only 7 states with highest density/ sq. km population are the most affected.

We must follow living with “corona 1.0” and start doing our own work and not depend so heavily on people from outside. The population density is such that physical distancing of six feet may not be possible. Maid servants from high density areas and such slums routinely come and work in flats of high-rise buildings.

Let us reopen the country the way the US is reopening. They are not bothered even if more than a lakh Americans die.  We too will have to learn to live with the virus and learn how not to die from the virus.

The young, fit and healthy will get mild infections, recover, be protected with neutralizing antibodies and they can then go to work and mingle in the community and contribute to natural herd immunity and even provide plasma for treatment of serious COVID-19 patients.

The elderly, with co-morbidity, and immunocompromised can stay at home protected by physical distancing, masks, goggles, sanitisers, disinfectants, etc. The vaccine will take time though ChadOx1 will come by September?

More the people get infected, more will the one who have recovered and more will be the plasm donors available to the community. At that time, we may even think of considering early plasma therapy of high-risk cases.

Finally, according to me with must make Corona our friends and listen to him what he wants. Why can’t we agree with his (CORONA’s) conditions and let him live

Corona just wants a friendship with you and says just follow my following advises

1.     If you do not want me to attack you than do not allow my competitors to come and stay in your body. Wash your hands regularly and get rid of my competitors like typhoid bacteria, food poisoning and diarrhoea organisms, viral hepatitis and A and E viruses etc. Clean your surfaces and all products with 0.1% bleach and other sanitisers. If you do not allow them, I also will not enter your body. I hate my competitors.

2.     Similarly eradicate TB bacilli from entering your body. “agar main nahi to vo bhi nahi: If I am not there then I do not want him also to be not there.  For this just follow six feet social distancing, respiratory hygiene, cough etiquette and proper sputum disposal.

3.     Respect the elderly and make them sit at a high place. Do not talk to them face to face, do not allow them to do the public meetings, instead make them advisors.

4.     Respect all visitors ‘athithis’. I like to come with them. Respect them by washing their feet, hands and mouth and then give them also a place to sit higher than your sitting place.

5.     I also like AC places and want to rest there. Let me rest there in peace and do not disturb me and just maintain a distance of six feet from each other and keep your hands covered with gloves.

6.     Remember meri ‘2-3 din ki jindagi hei, mujhe bhi jine do” I am here in this universe to live only for few hours or few days. Let me enjoy the life and do not disturb me. I only like to be left alone.

7.     By any chance if you can-not maintain an adequate six feet distance mask yourself and do not allow me to enter your mucus membrane of the nose, mouth and eyes. I hate people who try to unmask their nose when they try to talk. I also hate people who coughs and sneezes as they are forcing me to enter your nose. It is better to stay masked if you want me to live outside your body.

8.     I do not want to live long and suffer. For me living in the body is a curse. Do not force me to stay in your infected body for weeks. Why can’t you people keep your BP, blood sugar and heart failure under control. In that situation I will get liberated in less than 2 weeks only. Why can.t you build up your immunity, practice deep breathing exercises and prone sleeping so that I do not have to suffer for weeks inside your body

9.     Even if you force me (my not following my advice) to enter your body and spend two weeks in your body, just give that two weeks to me. I like isolation and do not want people to listen to our talks. During that period Just let me interact with you and silently teach you your purpose of life. I will still allow you to meet people virtually. I will teach you about good and simple lifestyle. Once you have learnt that I will go away, get liberated and will not come back again.

10. So just enjoy your life, live with me, let me also enjoy my few moments of life. Be friendly with me and do not allow me to become your enemy.