CMAAO CORONA FACTS and MYTH BUSTER 102 Super Spreader

CMAAO CORONA FACTS and MYTH BUSTER 102 Super Spreader

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

916: Super-spreader a must for becoming a hot spot of Corona

Without a super spreader the cases in the Country may die out of its own

Superspreader, is a loosely defined term for people who infect a disproportionate large number of others, whether because of genetics, social habits or simply being in the wrong place at the wrong time.

Super-spreader is a feature of nearly every outbreak. Infact the primary case of every epidemic is a super spreader. China cases in Wuhan also might have started with a super spreader.

On average, each person infected with the new coronavirus is passing it on to between two and three other people. But this is only an average; some people will pass it on to nobody while others pass their infection on to far more.

In 2015, a super-spreading event led to 82 people being infected from a single hospital patient with Middle East respiratory syndrome (Mers). And in the Ebola epidemic in West Africa, most cases (61%) came from just a tiny handful of patients (3%).

Some just encounter far more people - either because of their job or where they live - and that means they can spread more of the disease, whether they themselves have symptoms. Others are "super-shedders", who release unusually large amounts of virus (or other bug) from their bodies, so anybody encountering them is more likely to become infected.

Hospitals treating SARS became a major centre of super-spreading because the sickest patients were also the most infectious and they encountered lots of healthcare workers.

It plays a big role at the beginning of any outbreak, when the virus is trying to get established. When it makes the jump into the first patient, the disease might fizzle out before it can cause a large outbreak. But if it can quickly find its way into a super-spreader, then it gives the outbreak a boost. The same rules apply when cases are imported into other countries.

"Typhoid Mary", Irish cook Mary Mallon (1869-1938), unknowingly passed on typhoid fever when she had no symptoms and ended up spending decades in exile and forced quarantine.

HIV person coinfected with STI becomes a super spreader. A heterosexual man co-infected with HIV, hepatitis C virus, and herpes simplex 2 virus has unusually high semen HIV RNA levels.

20/80 rule, a small percentage of individuals within any population control control most transmission events.

A study from Israel has found that so-called super spreaders in Israel have been unusually potent: While, with many viruses, 20 percent of patients are often responsible for 80 percent of cases, the Israeli coronavirus data showed that only five percent of patients were responsible for spreading the disease to 80 percent of those ultimately infected. uper

Example after example have shown the microbe’s affinity for density. The virus has spread easily in nursing homes, prisons, cruise ships and meatpacking plants — places where many people are living or working in proximity. A recent CDC report described how a choir practice in Washington state in March became a super-spreader event when one sick person infected as many as 52 others.

Distinguishing between those who are more infectious and those less infectious could make an enormous difference in the ease and speed with which an outbreak is contained. If the infected person is a super-spreader, contact tracing is especially important. But if the infected person is the opposite of a super-spreader, someone who for whatever reason does not transmit the virus, contact tracing can be a wasted effort.

There has to be a link between people in order to transmit an infection. A link is necessary but not sufficient and the second factor is how infectious a person is.

It can be easy to misattribute multiple infections to an individual — possibly exposing the person to public attack — when the spread has nothing to do with the person’s infectiousness. If you are the first person in a crowded room to get infected and if this is an easily spread disease, you will look like a superspreader. Anyone in that room could have had the same impact. You were just the first in line.

Superspreading events may involve people with symptoms that linger but who are not sick enough to stay home.

Or they could involve infected people who shed an unusual amount of virus — a poorly studied factor that might be due to variations in the amount of virus in the aerosol droplets from a patient’s cough or the amount of infectious virus in feces.

No matter what the cause, public health measures, like avoiding crowds, and cough hygiene, can prevent a superspreading event.

Medical history is replete with stories of superspreading in outbreaks of parasitic disease, tuberculosis, measles and other illness. There is Mary Mallon, a cook better known as Typhoid Mary, who spread typhoid fever to more than 50 people in the early years of the twentieth century. She herself was not ill but was asymptomatic — silently infected with typhoid.

1. China first case looks like was a super spreader

2. The cases in Diamond Princess ship was a case of super spreader focal outbreak

3. The lady in South Korea cult church was a super spreader. There were 28 cases of the coronavirus in South Korea on Feb. 13. Four days had passed without a new confirmed infection. President Moon Jae-in predicted that the outbreak would “disappear before long,” while the prime minister assured people that it was OK not to wear surgical masks outdoors. They probably missed the super spreader possibility. The virus had been rapidly spreading at the time through a large, ​secretive ​church in Daegu, with the presence of a super spreader, where it has since mushroomed into the largest epidemic of the coronavirus outside China, with 1,766 cases, including 13 deaths. Now the president is facing a political backlash over his response as the number of cases continues to climb — 505 new infections on Thursday alone. ​

 4. Iran outbreak is possibly from a super spreader

Possibilities of finding super spreaders

1.     Person with lower respiratory corona illness

2.     Person with coronas pneumonia

3.     Critically ill or terminal corona infected patients

4.     Immunocompromised persons with corona infection

5.     Person who have not suffered from any other corona illness in past with non-virulent strains

6.     Rapidly developing corona illness with very short incubation period

7.     Direct exposure to a super spreader compared to secondary or tertiary cases

8.     Co-infection with another pathogen

9.     Delayed identification and hospital admission of a super spreader

Summary

1.     Low grade transmission: Through a spreader

2.     High grade transmission: through a super spreader, usually will end up with community spread.

Virus ‘does not spread easily’ from contaminated surfaces or animals, revised CDC website states

The coronavirus primarily spreads from person to person and not easily from a contaminated surface.

The revised guidance now states, in headline-size type, “The virus spreads easily between people.” It also notes that the coronavirus, which causes the disease covid-19, “is spreading very easily and sustainably between people.”

The CDC made another key change to its website, clarifying what sources are not major risks. Under the new heading “The virus does not spread easily in other ways,” the agency explains that touching contaminated objects or surfaces does not appear to be a significant mode of transmission. The same is true for exposure to infected animals.

IMA – CMAAO Guidelines for Hospitals, Nursing homes, CLINICS and OFFICES

IMA – CMAAO Guidelines for Hospitals, Nursing homes, CLINICS and OFFICES

Dr Rajan Sharma, Dr RV Asokan, Dr KK Aggarwal

In the unfortunate event if there is a confirmed case of COVID-19 from amongst any employees’ what would be the right step to undertake for the office premise.

• Issue one circular that if anyone or in his or her family is having with fever and cough, he or she should immediately notify the management
• People with cough and fever gets paid leave, work from home
• All with cough and fever should take tele consultation with doctor without delay
• De-contaminate all surfaces of the office in the night with 0.1% bleach as done in any hospitals or washrooms at home
• All persons should enter the office after cleaning the hands with soap and water or 70% alcohol-based sanitiser
• Make sanitisers in your office (70% isopropyl alcohol and 30% PEG or aloe vera gel)
• Wash hands after lunch break, and joining after lunch break, and at signing off
• No biometric attendance
• No touching of papers and currency with oral saliva
• If someone corona infected attends the office, fumigate that room immediately, all persons of that room go for home working
• No international visitors in the office without prior risk assessment
• No leave to be given for people to visit their state and come back
• All employees are directed to inform if they have met anyone with fever and cough visiting from affected countries or Indian states
• If anyone disobeys his services will be terminated and police informed under section 270 IPC)
• Office shut down can only be decided by government under epidemic disease act, if someone is positive
• 50+ people in any organisation with comorbid conditions needs special precautions. People with comorbid conditions should immediately disclose their illnesses to the management
• Follow and greet with only corona namaste, no contact policy, no elbow touch- no shake hands
• Use Tele meetings as much as possible
• Doctors at high risk with comorbid conditions should not see patients with fever and cough or wear N 95 masks
• All should disinfect mobile phones before entering the office
• Disinfects office and personal cars daily
• Eligible people should get flu and pneumonia vaccination done, so that they do not end up with preventable illnesses
• Safai karamcharis should wear gloves and take special precautions
• All persons should give daily undertakings that they are not on cough syrups or anti fever drugs
• No lose tablets to be dispensed
• Surgical masks should be available at the reception desk, entry of labs, imaging centers for anyone who develops fever and or cough
• Separate line in hospital reception, labs, imaging centers for people with cough, Fever. They all should be on surgical masks.
• All visitors should be checked for fever, made to wash hands and undertaking that they do not have fever and or cough
• Even one bought of cough and feverish feeling cannot be ignored
• Enough tissue papers to be made available
• Send circulars of how to wash hands, cough etiquettes and respiratory hygiene
• Doorknobs, handles, toilet seats, to be cleaned after every use
• The employee and his close contacts should follow the clinical protocol to be quarantined/isolated.
• Doctors should always write what physicians should do when examining patients. Like abbreviated physical exam, only necessary ones. Examine heart and chest standing at back etc.

Elderly comorbid people at risk

WHO Mental Health Considerations during COVID-19 Outbreak

WHO Mental Health Considerations during COVID-19 Outbreak

Dr K K Aggarwal, Dr Rajan Sharma and Dr R V Asokan

This time of crisis is generating stress in the population. These mental health considerations were developed by the Mental Health Department of WHO as support for mental and psychological well-being during COVID-19 outbreak.

General population

1. COVID-19 has and is likely to affect people from many countries, in many geographical locations. Don’t attach it to any ethnicity or nationality. Be empathetic to those who got affected, in and from any country, those with the disease have not done anything wrong.

2. Don’t - refer to people with the disease as “COVID-19 cases”, “victims” “COVID-19 families” or the “diseased”. They are “people who have COVID-19”, “people who are being treated for COVID-19”, “people who are recovering from COVID-19” and after recovering from COVID19 their life will go on with their jobs, families and loved ones.

3. Avoid watching, reading or listening to news that cause you to feel anxious or distressed; seek information mainly to take practical steps to prepare your plans and protect yourself and loved ones. Seek information updates at specific times during the day once or twice. The sudden and near-constant stream of news reports about an outbreak can cause anyone to feel worried. Get the facts. Gather information at regular intervals, from WHO website and local health authorities platforms, in order to help you distinguish facts from rumors.

4. Protect yourself and be supportive to others. Assisting others in their time of need can benefit the person receiving support as well as the helper.

5. Find opportunities to amplify the voices, positive stories and positive images of local people who have experienced the new coronavirus (COVID-19) and have recovered or who have supported a loved one through recovery and are willing to share their experience.

6. Honor caretakers and healthcare workers supporting people affected with COVID-19 in your community. Acknowledge the role they play to save lives and keep your loved ones safe. Health care workers

7. For health workers, feeling stressed is an experience that you and many of your health worker colleagues are likely going through; in fact, it is quite normal to be feeling this way in the current situation. Stress and the feelings associated with it are by no means a reflection that you cannot do your job or that you are weak. Managing your stress and psychosocial wellbeing during this time is as important as managing your physical health

 8. Take care of your basic needs and employ helpful coping strategies- ensure rest and respite during work or between shifts, eat sufficient and healthy food, engage in physical activity, and stay in contact with family and friends. Avoid using unhelpful coping strategies such as tobacco, alcohol or other drugs. In the long term, these can worsen your mental and physical wellbeing. This is a unique and unprecedent scenario for many workers, particularly if they have not been involved in similar responses. Even so, using the strategies that you have used in the past to manage times of stress can benefit you now. The strategies to benefit feelings of stress are the same, even if the scenario is different.

9. Some workers may unfortunately experience avoidance by their family or community due to stigma or fear. This can make an already challenging situation far more difficult. If possible, staying connected with your loved ones including through digital methods is one way to maintain contact. Turn to your colleagues, your manager or other trusted persons for social support- your colleagues may be having similar experiences to you.

 10. Use understandable ways to share messages with people with intellectual, cognitive and psychosocial disabilities. Forms of communication that do not rely solely on written information should be utilized If you are a team leader or manager in a health facility. 3 Team leaders or managers in health facility

11. Keeping all staff protected from chronic stress and poor mental health during this response means that they will have a better capacity to fulfil their roles.

12. Ensure good quality communication and accurate information updates are provided to all staff. Rotate workers from high-stress to lower-stress functions. Partner inexperienced workers with their more experiences colleagues. The buddy system helps to provide support, monitor stress and reinforce safety procedures. Ensure that outreach personnel enter the community in pairs. Initiate, encourage and monitor work breaks. Implement flexible schedules for workers who are directly impacted or have a family member impacted by a stressful event.

13. If you are a team leader or manager in a health facility, facilitate access to, and ensure staff are aware of where they can access mental health and psychosocial support services. Managers and team leads are also facing similar stressors as their staff, and potentially additional pressure in the level of responsibility of their role. It is important that the above provisions and strategies are in place for both workers and managers, and that managers are able to role-model self-care strategies to mitigate stress.

14. Orient responders, including nurses, ambulance drivers, volunteers, case identifiers, teachers and community leaders and workers in quarantine sites, on how to provide basic emotional and practical support to affected people using psychological first aid. For caretakers of children

15. Help children find positive ways to express disturbing feelings such as fear and sadness. Every child has his/her own way to express emotions. Sometimes engaging in a creative activity, such as playing, and drawing can facilitate this process. Children feel relieved if they can express and communicate their disturbing feelings in a safe and supportive environment.

16. Keep children close to their parents and family, if considered safe for the child, and avoid separating children and their caregivers as much as possible. If a child needs to be separated from his/her primary caregiver, ensure that appropriate alternative care is and that a social worker, or equivalent, will regularly follow up on the child. Further, ensure that during periods of separation, regular contact with parents and caregivers is maintained, such as twice-daily scheduled phone or video calls or other age-appropriate communication (e.g., social media depending on the age of the child).

17. Maintain familiar routines in daily life as much as possible, especially if children are confined to home. Provide engaging age appropriate activities for children. As much as possible, encourage children to continue to play and socialize with others, even if only within the family when advised to restrict social contract.

18. During times of stress and crisis, it is common for children to seek more attachment and be more demanding on parents Discuss the COVID-19 with your Children in honest and ageappropriate information. If your children have concerns, addressing those together may ease their anxiety. Children will observe adults’ behaviors and emotions for cues on how to manage their own emotions during difficult times. For caretakers of older adults

19. Older adults, especially in isolation and those with cognitive decline/dementia, may become more anxious, angry, stressed, agitated, and withdrawn during the outbreak/while in quarantine. Provide practical and emotional support through informal networks (families) and health professionals.

20. Share simple facts about what is going on and give clear information about how to reduce risk of infection in words older people with/without cognitive impairment can understand. Repeat the information whenever necessary. Instructions need to be communicated in a clear, concise, respectful and patient way. and it may also be helpful for information to be displayed in writing or pictures. Engage their family and other support networks in providing information and helping them practice prevention measures (e.g. handwashing etc.)

21. Encourage older adults with expertise, experiences and strengths to volunteer in community efforts to respond to the COVID-19 outbreak (for example the well/healthy retired older population can provide peer support, neighbor checking, and childcare for medical personnel restricted in hospitals fighting against COVID-19.) People in isolation

22. Stay connected and maintain your social networks. Even in situations of isolations, try as much as possible to keep your personal daily routines. If health authorities have recommended limiting your physical social contact to contain the outbreak, you can stay connected via e-mail, social media, video conference and telephone.

23. During times of stress, pay attention to your own needs and feelings. Engage in healthy activities that you enjoy and find relaxing. Exercise regularly, keep regular sleep routines and eat healthy food. Keep things in perspective. Public health agencies and experts in all countries are working on the outbreak to ensure the availability of the best care to those affected.

24. A near-constant stream of news reports about an outbreak can cause anyone to feel anxious or distressed. Seek information updates and practical guidance at specific times during the day from health professionals and WHO website and avoid listening to or following rumors that make you feel uncomfortable.

Stay informed: Find the latest information from WHO on where COVID-19 is spreading: https://www.who.int/emergencies/diseases/novel-coronavirus-

2019/situation-reports/ Advice and guidance from WHO on COVID-19 https://www.who.int/emergencies/diseases/novel-coronavirus-2019 https://www.epi-win.com/

11th March: CMAAO COVID 19 an Uneven Near Controllable Pandemic Revisited

11^th March: CMAAO COVID 19  an Uneven Near Controllable Pandemic Revisited

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

 As expected wave of 18 cases on 10^th March in India, Kerala under lock down

Indian scenario

On 10 March, confirmed that three more people in Karnataka, including wife and child of the infected Bangalore techie, were diagnosed with the virus.

Kerala reported six fresh cases in Pathanamthitta, all of whom were linked to the five previously confirmed cases from the town.

Three more people in Pune, who had come in contact with the infected couple from the city, tested positive.

Later, both parents of the infected three-year-old child in Ernakulam also tested positive.

 Another case was confirmed in Jammu and Kashmir, with the nation-wide toll reaching 62

62, 12 states  (Delhi 4, Uttar Pradesh 9, Haryana 14, Rajasthan 2, Telangana 1, Kerala 17, Ladakh 2, Tamil Nadu 1, Jammu and Kashmir 1, Punjab 1, Karnataka 4, Maharashtra 5)

High risk areas: UP, Kerala, Delhi, Maharashtra, Haryana, tourists Destinations 

Active: 58

Serious: Zero

Cured: 4

Community spread: zero

Super spreader: Zero

New wave as expected came on 10^th March with 18 new cases, wave to continue on next 2 days; next expected wave around 16^th March

Men more than women

Age group (3-45 years)

Delhi age group: 45, 25,52,25

ICMR: Testing across 52 labs (ICMR-National Institute of Virology, Pune is the apex laboratory for reconfirmation of any positive samples); additionally, 57 other labs to help sample collection

Indians abroad: 17 cases (16 cases reported from Japan on the Diamond Princess Cruise ship and one from the UAE)

Global scenario

Countries 119

Continents all except Antarctica

Cases 119176 cases (5% extra if CT diagnosis is taken)

Deaths 4295 deaths

Recovered: 66617

Currently infected: 48264

Mild: 42217 (87%)

Serious 6047 (13%)

Likely deaths (4295 + 6074 x 15 = 911 ) = 5206

Likely deaths in Italy: 763

Deaths in 26 countries

> 40,000 cases outside China

Epidemics in China, Iran, Italy, South Korea, France, Spain, Germany and USA with >30,000 cases

Public health emergency of international concern declared within a month after the first reported cases, as a result of the signs of human-to-human transmission outside China (30^th January)

Global risk raised to the highest level of alert (28^th February)

10^th March: A near uneven controllable pandemic

COVID Sutras

Disease: Coronavirus disease or COVID-19

Virus: SARS-CoV-2 virus (names used when communicating with the public “the virus responsible for COVID-19” or “the COVID-19 virus”)

Symptoms: fever, tiredness, and dry cough (most common); only cough (pollution), cough and cold (allergy), fever with sore throat in children (streptococcal), fever above 100.4 with cough and cold
(flu), fever with cough and breathlessness (corona like illness), cough > 2 weeks rule out TB

No fever no flu no corona; No breathlessness no seriousness, no breathlessness no oxygen requirement no seriousness

Corona Namaste better than elbow touch

Hygiene: Maintain social distance 1 meter from a person with cough and cold; wash hands (Remember the mnemonic SUMAN K - seedha ulta mutthi anghuta nakhun kalai) with soap and water or 70% alcohol sanitizer, disinfect surfaces, use surgical masks, if infected (symptoms especially coughing or looking after someone who may have COVID-19. 

All doctors: to carry SPO2 monitor to detect early serious cases

Suspect a corona case: Fever or signs/symptoms of lower respiratory illness (cough or shortness of breath) AND any person, including health care workers who has had close contact with a lab confirmed COVID-19 patient within 14 days of symptom onset.

·         Fever and signs/symptoms of a lower respiratory illness (cough or shortness of breath) requiring hospitalization AND a history of travel from affected COVID 19 countries within 14 days of symptom onset

·         Fever with severe acute lower respiratory illness (SARI, pneumonia, ARDS) requiring hospitalization and without alternative explanatory diagnosis (e.g., influenza) AND no source of exposure has been identified.

·         A suspect case for whom testing for 2019-nCoV is inconclusive or for whom testing was positive on a pan-coronavirus assay

Confirmed case: Lab confirmed irrespective of clinical signs and symptoms.

Epidemic cycle: First case, first cluster, first community spread

Epidemic cycle: Contain, Delay, Research and Mitigate

What to do: If you have fever with dry cough with or without breathlessness self- isolate (quarantine yourself at home), wear surgical mask, do frequent hand wash and call your doctor.

Isolate all infected patients. They need to wear surgical mask.   

Isolate (quarantine) at home all close contacts, call them twice daily, counsel them, no testing if no symptoms, test if symptoms develop.

Avoid cohort (clusters) of asymptomatic close contacts without masks (Diamond Princess: 696 in cohort ended with 23% getting the infection and 7 deaths, 32 still serious)

Treatment: Avoid self-medication; start Tamiflu when symptoms appear and stop if COVID 19 is negative.

CDC: Any American can be tested, no restrictions, subject to doctor’s orders

It’s not flu: It’s a lung disease, not a stuffy nose disease. Clinically all have fever, 75% have cough; 50% weakness; 50% breathlessness with low total white count and deranged liver enzymes; runny nose only shows up in 4% cases; 20% need ICU care and 15% of them are fatal. Treatment is symptomatic though anti-viral (remdesivir) and anti-HIV drugs (lopinavir/ritonavir) have shown some efficacy.

Retirees had the highest case fatality rate at 5.1%.

Mild means a positive test, fever, shortness of breath, and possibly even pneumonia, but not so bad that you need to be hospitalized or needs oxygen.

Severe:  Once you need oxygen, then you move into the severe category.        

Color Coding by China: Red code: Remain in quarantine for 14 days; Yellow code: Stay indoors for 7 days; Green code: Free to move about as they please.

Avoid mass gatherings: > 1000 people, in smaller gathering first ask “I hope no one is here with fever and cough, if kindly leave or wear surgical mask”

Travel

• Indian citizens are advised to refrain from travel to China, Iran, Republic of Korea, Italy & Japan and advised to avoid non-essential travel to other COVID-19 affected countries.
• All international passengers entering into India are required to furnish duly filled self-declaration form (including personal particulars i.e. phone no. and address in India) to Health Officials and Immigration officials and undergo Universal Health Screening at the designated health counters at all points of entry.

Dos: hand washing, avoid sick people, avoid touching eyes, nose and mouth with unwashed hands, cover nose and mouth with tissue when coughing or sneezing.

Don’ts: Avoid close contact if cough and fever, do not touch eyes, nose and mouth, avoid spitting in public

       COVID 19

Possibly behaves like SARS, but more contagious and less lethal

Near pandemic, PHEIC

Respiratory virus not a GI virus

56% are males

Deaths rate males 2.8% females 1.7%

Causes mild illness in 82%

Severe illness in 15%

Critical illness in 3%

Death 3.4 % (March 3)

Deaths: 15% serious cases

Deaths 71% with comorbidity

71% deaths are in patients with comorbidity due to cytokine storm. [72,314 Chinese cases, largest patient-based study, JAMA)

CAD patients most at risk [CAD 10.5%, Diabetes 7.3%, COPD 6.3%, HT 6%, Cancer 5.6%, no pre-existing disease (0.9%)

Health care provider infections China 3.8% 0.3% deaths. Singapore Nil

Deaths 10% in Iran (under reporting)

Doing S Korea (0.6%) doing more tests in mild cases

Affects all sexes but predominately males 56%

Age; 87% (30-79), 10% (< 20), 3% (> 80)

Mean time to symptoms 5 days

Mean time to pneumonia 9 days

Mean time to death 14 days

Mean time to CT changes 4 days

3-4 reproductive number R0 (flu 1.2, SARS 2)

Epidemic doubling time 7.5 days

Doubling time in Korea 1 day probably due to super spreader

Tripling time in Korea 3 days

Positivity rate% (UK 0.2, Italy 5, France 2.2, Austria 0.6, USA 3.1)

Origin: Probably from bats (mammal; central hosts), snakes and pangolins (intermediate hosts); possible animal sources of COVID-19 not yet been confirmed

Spread: Large droplets

Spread: Predominately from people having LRTI

Precautions: Standard droplet for the public and close contacts; air borne for healthcare workers dealing with secretions.

Incubation period days 2-14 days

Mean Incubation period: 5.2 days

Recover time Mild cases 2 weeks

Recovery time sever cases 4-6 weeks

Case fatality 80 + 14.8%

Case fatality 70-79 = 8%

Case fatality 60-69 = 3.6%

Case Fatality 50-59 = 1.3%

Case fatality 40-49 – 0.4%

Case fatality 10-39: 0.2%

Case fatality < 9 years: nil

What is the case fatality of other viruses?

MERS 34% (2012, killed 858 people out of the 2,494 infected)

SARS 10% (Nov. 2002 – Jul. 2003, originated from Beijing, spread to 41 countries, with 8,096 people infected and 774 deaths).

Ebola 50%

Smallpox 30-40%

Measles 10-15% developing countries

Polio 2-5% children and 15-30% adults

Diphtheria 5-10%

Whooping cough 4% infants < 1yr, 1% children < 4 years

Swine flu < 0.1-4 %

Seasonal flu 0.01%

Number of flu deaths every year: 290,000 to 650,000 (795 to 1,781 deaths per day)

Spread

·         Person-to-person through respiratory secretions via mucus membrane within a distance of
1 meter

·         Person to person through hand shakes

·         Fabric, carpet, and other soft surfaces: Currently, there’s no evidence.

·         Hard surfaces: doorknob, likely to survive for just a few hours (WHO).

·         Non porous surface 1-2 days and porous surface 8-12 hours

·         Casual exposure: Human to human contact requires prolonged contact (possibly 10 minutes or more) within 3 to 6 feet.

·         Currency notes: The central banking authorities of China are disinfecting cash to stop the spread

·         Biometric attendance: Suspended in India

·         Kissing: Scenes banned in movies in China.  France cut back on “la bise

·         Breath analyser for alcohol: Kerala exempted air crew

·         Public gatherings: Affected countries have banned death ceremonies, people gathering.

·         Uncovered eyes: The transmission is through mucus membrane contamination. One case got infected while using gown, but eyes not covered.

·         Eating meat, fish or chicken: It’s not a food-borne illness but a respiratory illness. It cannot occur by eating any food or meat. However, it is always advised not to touch raw meat, eat raw meat or eat partially cooked meat to prevent meat related food borne illnesses. Eating fish and chicken is safe.

·         Eating snakes or drinking bat soups: Eating wild animals cannot cause it. Handling their secretions can cause it.

·         Handling wild animals or their meat: Yes, if their secretions are handled by the animal handlers.

·         Semen: We do not know yet for the new corona virus (in patients infected with Ebola, the virus may persist for months in the testes or eyes even after recovery and can infect others and keep the epidemic going.

·         Sexual transmission like Ebola and Zika infected cases: No evidence yet.

·         Goods from affected areas: People receiving packages from affected areas are not at risk

·         Pipes: Ventilation systems connect one room to the next. There has been previous concern that the coronavirus can spread through pipes

·         Stress: Stress and anxiety are known to suppress the immune system, making people more susceptible to contracting the virus. 

·         Patients without symptoms: Both SARS-CoV and MERS-CoV infect intrapulmonary epithelial cells more than cells of the upper airways. Consequently, transmission occurs primarily from patients with recognized illness and not from patients with mild, nonspecific signs. Though NEJM has reported a case of COVID 19 infection acquired outside of Asia in which transmission of mild cases appears to have occurred during the incubation period in the index patient but the same has been challenged now.

·         Corona beer: It has nothing to do with coronavirus. It’s a brand of beer.

·         Minimal risk in plane: window seat

·         Airports more at risk: pipes, AC, International travelers, close surface contact, wear gloves when in doubt

·         All TV panelists: wear disposable earphones

      

Travel warning levels

• Level 1 in all countries (Exercise normal standard hygiene precautions)
• Level 2 in all affected countries (Exercise a high degree of caution)
• Level 3 in all countries with secondary cases (Reconsider your need to travel)
• Level 4 in affected parts of China and South Korea, Iran, Italy (Do not travel)

Formula of C: Corona; COVID; CHINA Pneumonia (early name); CONTAINMENT policy; break CHAIN of transmission; 1st Case; 1st Cluster; 1st Community spread; New Case; Avoid COHORT of CLOSE CONTACTS; CAP price of essential items; CONTACT tracing;  CARE of the elderly, CONVINCE patients to wear surgical masks; COUGH not to be ignored, CDC guidelines; CHAOS avoid; CHLOROQUINE can be tried; COLOR CODING (Red, Yellow, Green); Stay CONNECTED with updates; Know COUNTRIES not affected; CRITICAL cases; No CONTACT policy; CHECK list of hospitals; CHECK points ( all port entries); COLLECTIVE action; CONTROLLED measures; CONDOM: No evidence that it protects; CONGENITAL: No evidence of congenital Covid 19; CLEARING of antigen; COMPLAIN:  Section 270 of IPC; Do not CRTICISE; CALM during illness; COMMUNICATION is the key; COMMITMENT of government; CAD patients are highest risk; CHILDREN are less likely to die; COLD blooded animals are not the source; CLAIM of insurance should not be cancelled

                                                      

What is coranxiety?

Anxiety about falling ill and dying; avoiding or not approaching healthcare facilities due to fear of becoming infected during care; fear of losing livelihood; fear of not being able to work during isolation; fear of being dismissed from work if found positive; fear of being socially excluded; fear of getting put into quarantine; fear of being separated from loved ones and caregivers due to quarantine; refusal to take care of unaccompanied or separated minors; refusal to take care of people with disabilities or elderly because of their high-risk nature; feeling of helplessness; feeling of boredom; feeling of depression due to being isolated; stigmatization of being positive infection; possible anger and aggression against government; unnecessary approaching the courts, possible mistrust on information provided by government; relapses of mental illness in already mentally-ill patients; overstress on people to cover work of infected colleagues, quarantined for 14 days and insufficient or incomplete information leading to myths and fake news

If the anxiety is not tackled what will happen?

·         Healthy people will buy masks, get the tests done, get hospitalized and exhaust resources meant for persons who are actually at high risk.

·         The younger population has more fear of getting quarantined for 14 days or fear of losing their beloved elderly ones with comorbid conditions.

Legal

• Despite CDC protest, 14 Americans infected with coronavirus on the Diamond Princess cruise ship shared a plane back to the US with healthy passengers, separated by plastic sheeting. (New York Post)
• A US court temporarily blocked government from sending up to 50 people infected with a new virus from China to a Southern California city for quarantine after local officials argued that the plan lacked details about how the community would be protected from the outbreak.
• Hong Kong police: nabbed a part-time security guard at a shopping mall for allegedly writing on social media that multiple staff members had caught a fever and gone on sick leave. The messages "caused panic" and helped "breed paranoia".
• Singapore: Severe penalties for non-compliance of the quarantine order, including fines or jail time.
• Saudi Arabia will impose a fine of up to 500,000 riyals ($133,000) on people who do not disclose their health-related information and travel details at entry points  
• Italy PM puts citizens on lock down and threatens them with a fine (206 euros; around £178) or jail (3 months) if they leave quarantine zones (Daily Mail UK)
• IPC: Section 270: Malignant act likely to spread infection of disease danger­ous to life.—Whoever malignantly does any act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both.
• Epidemic Disease Act, Essential Commodities Act, NLEM, Municipal corporation acts, state public health acts
• My rights to be tested

Treatments

• Throat swab or LRTI swab in viral VTM media
• CT scan more sensitive than RT-PCR for diagnosis (Feb. 26, Radiology)
• No drug approved in India
  Lopinavir plus Ritonavir promise in lab in SARS.
• Lopinavir plus ritonavir plus recombinant interferon beta-1b in MERS.
• Scientists in Australia have reportedly recreated a lab-grown version of COVID 19.
• Chloroquine had potent antiviral activity against the SARS-CoV, has been shown to have similar activity against HCoV-229E in cultured cells and against HCoV-OC43 both in cultured cells and in a mouse model.
• In Thailand, oseltamivir along with lopinavir and ritonavir (both HIV drugs) has been used successfully.
• DCGI approved the "restricted use" of a combination of drugs (lopinavir and ritonavir)
• Remdesevir trials 6th Feb in China and late February in USA
• Russia and China drug: Arbidol, an antiviral drug used in Russia and China for treating influenza, could be combined with Darunavir, the anti-HIV drug, for treating patients with the coronavirus (COVID 19 shares some similarity to HIV virus also)
• PVP-I mouthwashes and gargles have high potency for viricidal activity against hepatitis A and influenza, MERS and SARS
• In SARS, people were put-on long-term steroids ending with immunosuppression and late complications and death. The current protocol is no or short-term treatment.
• Pneumococcal vaccine and Hib vaccine do not provide protection
• Regularly rinsing the nose with saline can help people recover more quickly from the common cold and dryness can protect one from touching the nose.
• Mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth but cannot kill the virus
• There is no evidence that eating garlic protects people from COVID 19.
• Sesame oil does not kill the new coronavirus.
• Chemical disinfectants that can kill the COVID 19 on surfaces: Bleach/chlorine-based disinfectants or solvents, 70% ethanol, peracetic acid and chloroform.
• Antibiotics do not work against viruses.
• 0.1% bleach is good for surface disinfection
• Take 70 ml of 100% isopropyl alcohol and add 30 ml aloe vera gel or PEG and make sanitizer at home.