Covid in CMAAO
countries vs Europe vs USA (Part 2)
CMAAO CORONA FACTS and
MYTH BUSTER 105
Dr K K Aggarwal
President
Confederation of Medical Associations of Asia and Oceania, HCFI, Past National
President IMA, Chief Editor Medtalks
927: Minutes of
Virtual Meeting of CMAAO NMAs
23rd
May, 2020, Saturday
9.30am-10.30am
Participants
Member
NMAs
Dr
KK Aggarwal, President CMAAO
Dr
Yeh Woei Chong, Singapore Chair CMAAO
Dr
Kar Chai Koh, Malaysia, Vice Chair of Council
Dr
Ravi Naidu, Past President CMAAO, Malaysia
Dr
Rajan Sharma, National President IMA
Dr
RV Asokan, Secretary General IMA
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
Ashraf Nizami, Pakistan
Dr Deborah
Cavalcanti, Brazil
Dr
Marthanda Pillai, Member World Medical Council
Dr
Md Jamaluddin Chowdhary, Bangladesh
Dr
N Gnanabaskaran, President Malaysian Medical Association
Invitees
Dr
Russell D’Souza, UNESCO Chair in Bioethics, Australia
Dr
KK Kalra, Former CEO NABH
Dr
Sanchita Sharma, Editor IJCP Group
- Death rate is
much lower in Asian countries compared to that in Europe and US. This low
death rate is despite high population density.
- In the US, death
rate is higher in Black population. A reason for this can be that ACEIs do
not work in this population. Could the level of ACE receptors be different
in people from Asia vs Europe vs North US? We do not know.
- Vaccine
developed from a virus from US or Europe may not work in Asian population.
- In an update,
the CDC has said that person-to-person transmission is the primary and
most important mode of transmission for COVID-19. Surface to human
transmission is not the main way the virus spreads.
- A latest study
from Israel study says that 5% of population is responsible for the
remaining 95% of cases.
- Super-spreader
is must to cause infection; in the absence of a super-spreader the
infection will die out. If a super-spreader is present in closed space,
the chances of transmission of infection are very high.
- One reason for
low mortality can be good ICU care. Good ICU care makes a difference in
mortality by only 0.3-0.5%.
- Another reason
for low mortality is the availability of Airborne Infection Isolation
(AII) rooms or negative pressure rooms.
- Countries like
Hong Kong, Singapore, South Korea have more number of AII rooms,
which also serve as triage rooms and the patient is shifted to a
Covid/non-Covid ward depending on the report, which is available within 3
hours in the triage room itself.
- In countries
like India who do not have AII rooms, the patient should be in a room
which has an air purifier with at least 10 exchanges per hour.
- The difference
in clinical manifestations of the virus may influence mortality rates.
o
It is a viral illness, so it is self-limiting
disease in majority; antiviral drugs like remdesivir may work
o
It has bacterial activity as in some
patients, high procalcitonin; antibiotics like doxycycline, azithromycin may be
effective.
o
It has some HIV like properties, as there is
lymphopenia (viruses usually cause lymphocytosis), decrease in CD4 cell count; such
patients may respond to anti-HIV drugs.
o
It causes immuno-inflammation: Viral
disorders do not cause immunoinflammation. But, increase in ESR, CRP, ferritin
(acute phase reactants) is seen in Covid-19. Anti-inflammatory drugs (hydroxychloroquine)
may be effective. Immunoinflammation is being seen much more in European
countries than in Asian countries.
o
It causes thrombo-inflammation: Increase in
d-dimer and fibrinogen; patient requires anticoagulation.
o
Silent hypoxia (walking dead phenomenon): Low
oxygen but patient is conscious. Usually, people with hypoxia are drowsy,
irritable. This was predominant in Italy. Their mortality improved when they
stopped using ventilators.
o
Cytokine storm: ARDS
o
If we know the clinical pattern of patients
in different countries, we can find out mortality and also identify a
country-specific treatment. In the UK, multisystem immune inflammation is more
with increased mortality. This is not seen in Asian countries.
- Asian countries
have lower mortality when compared to Europe and the US, but we do have a
reasonable mortality rate and it may increase if we calculate accurately,
register all cases and there is better investigation and reporting of
cases. It may go up to 2.5-3% in Pakistan.
- Other reasons
can be: Asians already have high immunity; testing is not as aggressive as
in Europe, US, the strain of the virus is not aggressive so mostly mild to
moderate cases
- Low mortality in
Hong Kong may be attributed to:
preventive measures (universal masking, people complying with the
directives), local culture (no hugging/kissing), cases are in younger
population and are imported, which are mild and lastly, well-prepared
investment in ICU facilities and ventilators. Those who died had
comorbidity like diabetes.
- In Singapore, most cases are in
migrants, who are young and therefore have mild infection.
- The lower
mortality in Malaysia is because
of early interventions, the govt. has been preparing for the worst since
March, and all persons who qualify for PUI (person under investigation)
are screened and isolated based on the result.
- Japan has
16,000 positive cases; 800 have died; mortality rate is 5%; Japan has
limited PCR tests so this rate compared to the population is very low.
Japan is carrying out genome analysis in 500 patients (from asymptomatic
to patients with severe symptoms). HLA typing is on the way. High IgM
level is related to the severity of disease. Some patients may have early
detection of IgG. This may be related to previous infection with other
coronavirus. Further research is needed.
- India:
Despite high numbers, the mortality rate is 3%. Experience of the European
countries has helped us to lower mortality; also, there is genetic
protection from the infection.
Contact time: 10-30
minutes
- If contact time
is less than 10 minutes with precautions, the chances of transmission is
very low
- If a doctor is
wearing a N95 mask and the contact time is less than 30 minutes, this is
usually not a problem
Protocol of non-Covid
clinic in Singapore
A
patient who came to the clinic in the morning and tests positive in the
evening, answer the following question:
Was
the patient wearing a mask? If yes, then ask,
Was
the doctor wearing a mask? If yes, then ask,
Was
the surface decontaminated in the morning? If yes, then ask,
What
was the contact time?
- If less than 30
min: Monitor
- If more than
30min: Quarantine
Covid-19 infection in
children
- 13% of children
all over the world have Covid-19; mortality is 0.5% in children below 15
years of age.
- Child to child
transmission is rare; but, children can infect the elderly.
- For children
<2 years: no masking
- For children
>2 years: Country-specific guidelines for masking
- European
countries do not recommend masking for children; we do not have a
guideline for Asian countries.
Chances
of infection are highest when sitting face to face; chances of infection are
lower when sitting side to side or face to side.
In
schools and colleges, students sit facing front. So chances of infection very
low; distance between students should be at least 6 feet. Students should go
home immediately after school/college.
