163 CMAAO CORONA FACTS and MYTH COVID Cardiac Markers

163 CMAAO CORONA FACTS and MYTH  COVID Cardiac Markers

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

1007:  Redefine cardiac injury marker cut-offs to predict 28 days mortality in COVID-19 inpatients

The abnormal cardiac biomarker pattern seen in patients with COVID-19 is significantly associated with a higher risk of death, and the cut-offs of those markers for effective prognosis of 28-day mortality of COVID-19 appear to be much lower than for regular heart disease, at 49% of currently recommended thresholds, according to a study in Hypertension.

The biomarkers are high-sensitivity cardiac troponin I (hs-cTnI), creatine kinase-MB (CK-MB), NT-proB-type natriuretic peptide (NT-proBNP), creatine phosphokinase (CK) and myoglobin (MYO).

Their retrospective cohort study enrolled patients diagnosed as COVID-19 and admitted to 9 hospitals in Hubei Province, China, from December 31, 2019, to March 4, 2020. The study included 3219 patients with myocardial biomarker measurement, and 2814 without. The primary endpoint was 28-day all-cause mortality.

Compared to patients without cardiac injury biomarker measurement, patients with biomarker values were older (median age at 57) and had higher percentages of pre-existing comorbidities and more severe symptoms.

All five myocardial biomarkers were significantly associated with 28-day all-cause death of COVID-19. 

After adjusting for age, gender and comorbidities such as hypertension, diabetes, coronary heart disease and cerebrovascular disease, the 28-day mortality hazard ratio for hs-cTnI was 7.12, NT-proBNP was 5.11, CK-MB was 4.86, MYO was 4.50, and CK, a much less specific cardiac biomarker, was 3.56.

In patients showing heart injury during the entire hospitalization, neutrophil percentage and CRP were rapidly and simultaneously increased after disease onset, immediately followed by the increases of CK-MB, MYO, and hs-cTnI.

The significant elevation of IL-6 occurred only after the increases of these myocardial markers and was highly elevated mainly in patients with evidence of cardiac injury.

162 CMAAO CORONA FACTS and MYTH COVID Drugs Update

162 CMAAO CORONA FACTS and MYTH  COVID Drugs Update

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

1003:  Pfizer will get $1.95 billion from the U.S. government to produce 100 million doses of their COVID-19 vaccine candidate. (Reuters)

1004: More data suggested humoral immunity faded quickly in people with mild COVID-19 illness. (New England Journal of Medicine)

1005: Small study suggests rapid decay of anti–SARS-CoV-2 antibodies in persons with mild COVID-19
DG Alert: Findings from a study published in The New England Journal of Medicine “raise concern” that humoral immunity against SARS-CoV-2 may not be long lasting in persons with mild illness. Javier Ibarrondo, David Geffen School of Medicine at University of California, Los Angeles, California, and colleagues evaluated 34 persons (20 females and 14 males; mean age: 43 years, [range, 21 to 68]). Of these, 30 participants had their infection confirmed by PCR, while the other 4 participants had CLI.  Most of the participants had mild illness.
A total of 31 of the 34 participants had two serial measurements of IgG levels, while the remaining 3 participants had three serial measurements. The first measurement was obtained at a mean of 37 days after the onset of symptoms (range, 18 to 65), and the last measurement was obtained at a mean of 86 days after the onset of symptoms (range, 44 to 119).
The initial mean IgG level was 3.48 log10 ng per milliliter (range, 2.52 to 4.41). On the basis of a linear regression model that included the participants’ age and sex, the days from symptom onset to the first measurement, and the first log10 antibody level, the estimated mean change (slope) was reported to be −0.0083 log10 ng per milliliter per day (range, −0.0352 to 0.0062). The authors noted that this corresponds to a half-life of approximately 73 days over the observation period. Further, they reported that the 95% confidence interval for the slope was −0.0115 to −0.0050 log10 ng per milliliter per day (half-life, 52 to 120 days).
The protective role of antibodies against SARS-CoV-2 is unknown, but these antibodies are usually a reasonable correlate of antiviral immunity, and anti–receptor-binding domain antibody levels correspond to plasma viral neutralizing activity. Given that early antibody decay after acute viral antigenic exposure is approximately exponential, we found antibody loss that was quicker than that reported for SARS-CoV-1.
Reference: https://www.nejm.org/doi/10.1056/NEJMc2025179

1006: Treatment of AMI and acute stroke will be  Tenecteplase

The COVID-19 pandemic could hasten the switch to tenecteplase for stroke and AMI treatment because it is given as a single, 5-second IV bolus that takes about 2 minutes to mix, prepare, and administer rather than the more than 1 hour for weight-based bolus and subsequent infusion of alteplase.

161 CMAAO CORONA FACTS and MYTH COVID Drugs Update

161 CMAAO CORONA FACTS and MYTH  COVID Drugs Update

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

1002: Medscape Excerpts:

Remdesivir

Much-anticipated results from the National Institute of Allergy and Infectious Diseases' clinical trial of remdesivir, published in May, confirmed preliminary results suggesting that the drug shortens the disease course for hospitalized COVID-19 patients. That earlier report resulted in the US Food and Drug Administration (FDA) issuing an emergency use authorization for the drug. Drugmaker Gilead subsequently released results from the sponsored, randomized phase 3 SIMPLE trial, which found that a 5-day course of the drug improved outcomes among patients hospitalized with COVID-19 who did not need ventilation.

The National Institutes of Health said that the most benefit was in patients on oxygen who did not require ventilation.

Dutch investigators have cautioned that it can be associated with rare but severe liver complications.

Take home message: Remdesivir is administered intravenously, limiting its use to hospitalized patients. However, phase 1 trials of an inhaled nebulized version were initiated in late June 2020 to determine whether remdesivir can be used on an outpatient basis and at earlier stages of disease.

The FDA has warned against use of remdesivir in combination with hydroxychloroquine (HCQ) .

Dexamethasone

British researchers that the RECOVERY trial involving over 6000 patients had been halted early due to positive results. The investigators reported that dexamethasone reduced death rates by about a third among severely ill hospitalized COVID-19 patients. Initial reaction in the United States was mixed.

While a number of clinicians indicated that the results confirmed their own experience, others were wary of embracing the study results prior to peer review.

Infectious Diseases Society of America (IDSA) announced that the drug will now be incorporated into COVID-19 treatment guidelines. Dexamethasone, or an equivalent steroid such as methylprednisolone or prednisone, is recommended for hospitalized patients who require supplemental oxygen, mechanical ventilation, or extracorporeal mechanical oxygenation.

Take home message: Corticosteroids are not generally recommended for treatment of COVID-19 or any viral pneumonia, the UK RECOVERY trial changed that. IDSA guidelines include low-dose dexamethasone (6 mg orally or intravenously daily for 10 days) in patients requiring respiratory support. At present, the World Health Organization has cautioned clinicians to reserve use for severely ill patients.

Hydroxychloroquine

Initial data suggested that HCQ and chloroquine, sometimes in combination with azithromycin, had some degree of efficacy in treating COVID-19. But those studies were rapidly followed by newer data from observational trials, suggesting that the drugs were not only without benefit but also could be dangerous in some patients. After 2 months of controversy, the FDA revoked the emergency use authorization it had previously granted for use of these agents in inpatient settings.

The matter seemed to be put to bed until early July when the Henry Ford Hospital released results of a retrospective, observational trial of HCQ with azithromycin that concluded that the combination, if given within the first 2 days of hospital admission, reduced COVID-19 mortality.

Trials of HCQ as preventive therapy are ongoing, though a randomized trial published in early June found that the drug was ineffective as prevention and that side effects were common.

Take home message: While some continue to tout its benefit, particularly if given early in the course of infection, there is little evidence at this time to support its use at any stage of illness.

Other Antimicrobials

Azithromycin. While some initial trials of azithromycin in combination with HCQ were promising, later results have not held up and major cardiology organizations now warn against the combination. There are no recommendations for use of this antimicrobial.

Antiviral agents. The UK-based RECOVERY trial examined other drugs in addition to dexamethasone, concluding that the combination of lopinavir and ritonavir had no benefit in hospitalized patients. A Japanese trial of favipiravir, determined that patients given the drug early in the trial showed more improvement than those who received delayed doses, but the results did not reach statistical significance.

Convalescent plasma. While a very small Chinese pilot study of convalescent plasma reported in April that its use in severely ill COVID-19 patients raised antibody titers, reduced viral load, and led to symptom improvement, other studies have not yet shown it to be effective. The FDA has approved its use in patients with serious or immediately life-threatening infection.

Colchicine. An open-label, randomized trial currently underway in Greece has reported that hospital course was slightly shorter and the time to clinical deterioration improved in patients treated with colchicine, although there were no significant differences between treated and untreated groups in cardiac and inflammatory biomarkers.

Nitric oxide. Inhaled nitric oxide was studied as a supportive measure for patients with SARS-CoV-1 infection in 2004. It was found to reverse pulmonary hypertension, improve severe hypoxia, and shorten the length of ventilatory support. A phase 2 study is underway in patients with COVID-19, with the goal of preventing disease progression in those with severe acute respiratory distress syndrome.

Zinc. Initial trials of HCQ often studied it in combination with azithromycin and zinc. While some studies have suggested that zinc may be somewhat effective in treatment of upper respiratory infections, some of which are caused by coronaviruses, the National Academies of Sciences, Engineering, and Medicine cautions that there is no evidence to suggest that the supplement has a role in the treatment or prevention of COVID-19.

Monoclonal antibodies. The use of human antibodies is being investigated by a number of teams around the world. Eli Lilly has reported positive interim results of its trials of monoclonal antibodies, and anticipates FDA review and possible approval by September. European trials of another antibody could begin as early as this summer. And trials of a third agent are planning to start in August in Singapore.

160 CMAAO CORONA FACTS and MYTH COVID Update

160 CMAAO CORONA FACTS and MYTH  COVID Update

Dr K Aggarwal
President CMAAO
With inputs from Dr Monica Vasudev


994:   When the prevalence of COVID-19 is high, even atypical imaging features are more likely to be COVID-19.

995: Typical chest CT findings in COVID-19 pneumonia include bilateral, peripheral and basal-predominant ground-glass opacities (GGOs) and/or consolidation, followed later by a mixed pattern of crazy paving, architectural distortion and perilobular abnormalities superimposed on GGOs that slowly resolve.

996: Upper lobe or peribronchovascular distribution of GGOs, cavitation, lymphadenopathy, and pleural thickening are found atypically

997: Other viral pneumonias can be more challenging to distinguish from COVID-19. For example, GGOs can be seen in up to 75% of adenovirus cases, more than 75% of cytomegalovirus and herpes simplex virus cases, and up to 25% of measles and human meta-pneumovirus cases. GGOs can be widespread in pneumocystis pneumonia, but, unlike in COVID-19, they tend to predominate in the upper lobes.

998: GGOs can also be common in hypersensitivity pneumonitis, lung injury from use of electronic cigarettes or vaping products, pulmonary edema, diffuse alveolar hemorrhage, pulmonary alveolar proteinosis, and eosinophilic pneumonia. But clinical features and GGO patterns are generally useful for differentiating these conditions from COVID-19.

999: Singapore scientists have uncovered T cell immunity specific to SARS-CoV-2 in recovered Covid-19 & SARS patients, and also in uninfected individuals. The study is published in Nature. T cells, along with antibodies, are part of the human immune response against viral infections. The T cells directly target and kill infected cells. In the study, the specific T cells were found in all subjects who recovered from SARS 17 years ago, and in over 50% of both SARS-CoV-1 and SARS-CoV-2 uninfected individuals tested. This suggests that a level of pre-existing SARS-CoV-2 immunity is present in the general population. They inferred that infection and exposure to coronaviruses induces long-lasting memory T cells, which could help in the management of the current pandemic. This could be due to cross-reactive immunity obtained from exposure to other coronaviruses, such as those causing the common cold. The researchers said it is important to understand if this could explain why some individuals are able to better control the infection. Source: Duke-NUS Medical School

1000: The incidence of stillbirth has increased since the COVID-19 pandemic began, according to a comparative study of pregnancy outcomes in a London hospital. This may have resulted from indirect effects such as reluctance to attend hospital when needed (e.g., with reduced fetal movements), fear of contracting infection, or not wanting to add to the National Health Service burden as reported by Dr Asma Khalil of St George's University of London in JAMA.


1001: A phase I/II trial of a vaccine against SARS-CoV-2 being developed by the University of Oxford has found that the vaccine is safe, causes few side effects, and induces strong immune responses. The early stage results, published in The Lancet, found that the candidate vaccine provoked a T-cell response peaking 14 days after vaccination, and an antibody response within 28 days. The trial, which has so far involved 1077 healthy adults, caused minor side effects when compared with a control group given a meningitis vaccine. Fatigue and headache were the most commonly reported reactions. However, there were no serious adverse events from the vaccine. The chimpanzee adenovirus viral vector vaccine (ChAdOx1) against the COVID-19 coronavirus is developed at Oxford University.

Phase II data on a competing vaccine from China, also using an adenovirus vector to deliver a gene encoding SARS-CoV-2 antigen, also indicated the product could be effective.
Phase I results on Moderna's mRNA vaccine published last week, all suggest that a vaccine -- and perhaps more than one -- to ameliorate the COVID-19 pandemic may soon be in reach.

159 CMAAO CORONA FACTS and MYTH COVID Dermatology Update

159 CMAAO CORONA FACTS and MYTH  COVID Dermatology Update

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

994: Update on Covid-19

IMA-CMAAO Webinar on “Dermatology Update and Covid-19”

18^th June, 2020

4-5pm

Participants

Dr KK Aggarwal, President CMAAO

Dr RV Asokan, Hony Secretary General IMA

Dr Ramesh K Datta, Hony Finance Secretary IMA

Dr Jayakrishnan Alapet

Dr Sanchita Sharma

Faculty

Dr Anil Ganjoo

Senior Dermatologist

Gujranwala, Delhi

·        The coronavirus has an affinity for the bronchial mucosal and the immune system. But the infection can also involve the cardiovascular system, liver and kidney.

·        Skin involvement may either be a direct manifestation of the disease such as skin rashes (primary cutaneous manifestations) or indirect manifestation due to the many processes associated with the disease (secondary cutaneous manifestations).

·        Skin rashes can be nonspecific and can be seen in any viral infection. But, during the pandemic, the dermatologist must keep in mind the likelihood of Covid presenting with skin manifestation, which can be the first symptom. Different types of skin lesions have been reported. It is important to be aware of the kind of rashes associated with Covid for timely diagnosis.

·        In a study from Italy, skin manifestations were seen in about one-fifth of patients with Covid-19. Eighteen of 88 patients (20.5%) had skin lesions: maculopapular rash (14), urticaria (3), chickenpox-like vesicles (1). Eight had skin rash at the onset of their illness, while the rest developed during their hospitalization (J Eur Acad Dermatol Venereol. March 26, 2020)

·        A patient presented with typical features of dengue fever in a hospital in Bangkok with skin rash, petechiae and thrombocytopenia. Covoid-19 was diagnosed only when this patient developed respiratory symptoms and subsequently tested positive for Covid-19.

·        A 67-year-old patient presented with symptoms of common cold, but no difficulty in breathing and developed a livedoid vascular rash (non pruritus, blanching) on right anterior thigh and hematuria. The rash and hematuria cleared up in 24 hours, but the patient tested positive for Covid-19.

·        Fatal Kawasaki-like disease has been reported in children; Covid toes have also been observed due to thromboembolic phenomenon (peripheral gangrene in digits or chill blain like lesions).

·        Patients with dermatological diseases might be at greater risk of developing the infection. 

·        Management of patients with diseases such as psoriasis, atopic dermatitis, lupus, scleroderma, which require immunosuppressants, is a concern. Stopping immunosuppressant or immunomodulator therapy is an easy decision in naïve patients, but is difficult as sudden withdrawal could make the disease more precarious and exaggerate response of cytokine storm. Tocilizumab is being used in Covid patients to reduce the host immune response and prevent severe lung damage.

·        Patients on immunosuppression therapy are vulnerable to severe Covid infection. Hence, they should be advised appropriate preventive measures.

·        The AAD (American Academy of Dermatology) and IADVL (Indian Association of Dermatologists, Venereologists and Leprologists) have give guidelines for the use of immunosuppressants and biologics during Covid-19.

·        IADVL guidelines: Decision to continue or start immunosuppressant in a patient with severe disease has to be made on cases to case basis. These patients are at an increased risk of severe coronavirus disease. Hence, patients on immunosuppressants including steroids, chemotherapy and biologics should be advised effective preventive strategies.

·        The International Psoriasis Council recommends stopping biologics in patients with Covid 19. Reduce steroids and other immunosuppressants to the lowest clinically effective dose for asymptomatic patients and who have not tested positive.

·        If the patient has been on long-term oral prednisolone, the target dose should be 7.5-10 mg/day to avoid manifest adrenal insufficienty.

·        The AAD recommends that patients should not stop biologics without consulting their doctors.

·        Hand eczema is quite common as a secondary cutaneous manifestation of Covid-19. It may occur due to too frequent handwashing, use of harsh detergents or prolonged use of latex gloves.

·        Use of N95 masks can cause contact irritant dermatitis of the nasal bridge, frictional dermatitis and postinflammatory hyperpigmentation.

·        PPEs can cause miliarial rash due to excessive sweating; they can also increase risk of developing fungal infections.

·        In a recent study from Wuhan of 700 healthcare workers, 526 reported skin problems. The most commonly affected areas were hands, nasal bridge, cheeks and forehead. Wearing protective equipment for longer than 6 hours resulted in greater degree of skin manifestations.

·        The general population can also develop skin problems during the pandemic. Excessive handwashing, as is advised for all, can cause xerosis and hand eczema. Wearing masks can cause facial rashes, contact allergies, pigmentation, frictional dermatitis; acne and seborrheic dermatitis can be aggravated.

·        Use of emollients, barrier creams, moisturizers can prevent such skin problems.

158 CMAAO CORONA FACTS and MYTH COVID Asia Update

158 CMAAO CORONA FACTS and MYTH  COVID Asia Update

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

993: Minutes of Virtual Meeting of CMAAO NMAs on “Covid Asia Update”

18^th July, 2020, Saturday, 9.30am-10.30am

Participants, Member NMAs

Dr KK Aggarwal, President CMAAO

Dr Yeh Woei Chong, Singapore Chair CMAAO

Prof Ashraf Nizami, Pakistan First Vice President CMAAO

Dr Alvin Yee-Shing Chan, Hong Kong, Treasurer CMAAO

Dr Ravi Naidu, Past President CMAAO, Malaysia

Dr Marthanda Pillai, Member World Medical Council

Dr N Gnanabaskaran, President Malaysian Medical Association

Dr Md Jamaluddin Chowdhury, Bangladesh

Dr Qaisar Sajjad, Pakistan

Dr Prakash Budhathoky, Nepal

Invitees

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

Dr Sanchita Sharma, Editor IJCP Group

Dr Yeh Woei Chong elaborated on “Lessons learnt in Singapore during the pandemic” and Dr KK Aggarwal spoke on his personal observations of patients with Covid in the last 3-4 months in his talk on “Covid symptoms – India Experience”. Here are key points from each presentation.

Lessons learnt in Singapore during the pandemic

Dr Yeh Woei Chong

• Total number of cases 47126; cases in migrant workers (44404) constitute the bulk of these cases, while community cases are only 2095. As of today, ICU deaths stand at zero; there have been total 627 deaths.

• Because of the SARS experience, Singapore initiated early action and intervention. First case was detected on 23^rd January; Disease Outbreak Response System Condition (DORSCON) yellow was activated. Singapore started closing its borders from 28^th January onwards to Hubei province, mainland China, South Korea, Italy, Iran, Europe, Japan and Asean countries including Malaysia. Complete closure of the country on 20^th March.

• 7^th Feb: Dorscon Orange activated. Doctors are confined to one hospital; only infectious disease specialists and anesthetists can move between few hospitals. Hospitals restricted visitors, workplace restrictions were put into place. Temperature checks were carried out twice daily in schools and workplace. All mass events were cancelled. Contact tracing (4000 daily by 20 teams at the peak).

• Lessons learnt: There was a returning wave in March; around 60,000 citizens and permanent residents returned to Singapore. People flouted stay home notices as required by law. From 25^th March, people returning back were sent directly to hotel rooms for 14-day quarantine.
• Around 200,000 migrant workers live in 43 large dormitories; some housing up to 20,000 workers. The vulnerable group (older than 40 years, those with chronic diseases) was removed; medical posts were established with security; the migrant workers were paid salaries in time; three meals daily ensured; access to WiFi/Sim cards to stay in touch with their families.

• Resources: Singapore has 1100 ICU beds and 1000 isolation rooms. A new National Centre for Infectious Diseases, which opened last year, is handling around 60% of all Covid cases in Singapore. There is a N95 factory in Singapore (lesson learnt from SARS). Although testing has been increased (currently 13000 daily), bottlenecks remain such as shortage of transport media, swab sticks, reagent for RNA extraction and surgical masks.

• Public health measures: Initially masks were meant only for the ill (as there were not enough masks at that time), but were made mandatory (cloth masks issued by the government) for all from 3^rd April. Singapore had lockdown from 7^th April to 2^nd June as community cases were increasing. At one point of time, all employers were sending their migrant workers to emergency units for swab testing. They had to be stopped as emergency units were being overwhelmed. So, the Ministry of Manpower initiated punitive measures against these employers. In retrospect, punitive measures are not good in public health in crisis situations. Singapore had the first cluster of 5 cases in migrant workers in early February; this should have been an early warning signal as there was a massive outbreak in the dormitories subsequently in April.

• Indicators of performance: Detection and breaking transmission chains, healthcare system reduces morbidity and mortality, protection of HCWs, protect and support the neglected group, do not allow healthcare system to be overwhelmed and financial support for health care needs.

• The NCID has flexible and scalable design with 64 cohort beds, 100 isolation beds, 124 negative pressure beds, 38 ICU beds. The scalable design allows increasing the number of beds to more than 500; outside areas, which can be converted into extended screening areas.

• Analysis of the first 1500 cases in Singapore showed that in patients ≤30 years, only half percent needed oxygen and no patient needed intensive care. Oxygen and ICU requirement needs increase with age.

• Assessment of clinical course of Covid-19 showed that the most critical period was between Day 5 and Day 7.

Covid symptoms – India experience

Dr KK Aggarwal

• India is at the top among the Asian countries with more than one million confirmed cases. Mortality is 2.5-3%. India is far ahead of China even though the population density is similar.

• Children (0-12 years) are not the first one in a family to get the infection. If all family members are infected, the child will be the last to get the infection.  Common symptoms are rash, diarrhea, fever, and cough. The mean duration of symptoms is 3 days. They cannot spread to other children or adults.

• Common symptoms observed: Hypothyroidism (4%), rash (3%), headache (persistent, first onset 2%), shortness of breath (exertional with no fall of SpO2 10%), diarrhea (10%), loss of smell and taste (20%); two had hemoptysis with negative CT scan. Other symptoms are fatigue or tiredness, pain below the knee, cystitis, redness in left eye, right iliac fossa pain, nose block, throat pain or feeling of obstruction in throat.

• Covid patients can be grouped into two: those presenting before 9 days and those presenting after 9 days (post-Covid).

• Post-Covid symptoms: Throat irritation (30%), bronchitis (15%), exertional tachycardia (10%), episodic tiredness, fever (low grade, exertional, evening rise – 10%), chest pain, costochondritis. These symptoms may last for several weeks. These patients should go to a non-Covid facility.

• About 7% of non-ventilated, non-hospitalized, non-immunocompromised people had positive RT PCR on 14^th day (generally, PCR should become negative by the 14^th day) (mean 20 days)

• Loss of smell and taste (data of 100 patients): Three had mild pneumonia, nobody required oxygen or ventilator; zero deaths; 14 had fever, 7 were children (>12 years), ear involvement in 70%, loss of taste and smell in 88% (7 had only loss of taste, 5 had only loss of smell), two lost sour taste – most recovered in 3 weeks.

• Post-Covid fever: Fever lasting for more than 2 weeks is either due to dysregulation of the body’s thermostat or due to persistent inflammation. Fever >50 days (2%), >40 days (2%), >28 days (2%), >21 days (1%) and 7% had fever lasting for more than 14 days.

• Higher IgG levels seen in adults and in those who have pneumonia; low levels in children and elderly, those who have loss of smell/taste, low fever (<100); still present in those who are antigen positive (dead virus)

• Screening of patients in OPD for Covid: Instead of screening just for temperature, we recommend 5 parameters – temperature (low grade, does not respond to paracetamol), SpO2 (happy hypoxia), loss of smell, loss of taste (give jaggery – first taste to go is sweet taste) and hand grip strength.

• Wave 1 is ending in Delhi, Mumbai, Chennai and Ahmedabad; it is now appearing in Pune, Bangalore, and Hyderabad. In India, the first wave is related to joint families and closed colonies.

• Instead of complete lockdown, personal lockdown is the answer.

• Seroprevalence in Delhi and Mumbai is 18-20%.

• Mortality in Delhi and Mumbai has reduced by 50% in the last one month. Early diagnosis and standard protocols are reducing mortality.  

• Day 3-6 are critical. Look for exertional tachycardia/hypoxia/difficulty in talking/cough, this means pneumonia. If you give steroid/ LMWH/antiviral on Day 3, mortality should be an exception and not a rule.

• India still has no AII rooms; labs do not give Ct value in RT PCR test (low Ct value means high viral load, doctors and other HCWs need to be very careful in such cases).

• Most people who have died of covid are usually cases of delayed reporting; they come to the hospital around Day 7/8 or later.

• Transmission: In areas with very high population density, recommend 0.3 micron mask; toilets are becoming covid chambers as are closed poorly ventilated rooms. In Covid chambers, contact time of 5 minutes for transmission, in non-Covid chambers, contact time of 10 minutes.

157 CMAAO CORONA FACTS and MYTH Viral Load

157  CMAAO CORONA FACTS and MYTH Viral Load

Dr K Aggarwal

President CMAAO

With inputs from Dr Monica Vasudev

992: DG alert: A study published in The American Journal of Pathology showed that non-hospitalised patients with COVID-19, with less severe symptoms, have a higher SARS-CoV-2 viral load (VL) than hospitalised patients with more severe symptoms.

In a cohort of 205 patients treated at a tertiary care centre in New York City who were tested using both qualitative RT-PCR and quantitative RT-PCR to obtain diagnostic SARS-CoV-2 VL at initial presentation, Kimon V. Argyropoulos, New York University Langone Health, New York, New York, and colleagues found that diagnostic viral load (VL) was significantly lower in hospitalised patients than in patients not hospitalised after adjusting for age, sex, race, body mass index, and comorbidities.

Higher VL was associated with shorter duration of symptoms in all patients (P< .001). Among hospitalised patients only, higher VL was also associated with shorter duration of symptoms (P = .002) and with shorter hospital stay (P = .013). No significant association was noted between VL, admission to intensive care unit, length of oxygen support, and overall survival.

Non-hospitalised patients were overall younger (median age, 45 vs 60 years; P< .001). The median duration of symptoms from symptom onset to nasopharyngeal swab collection in the hospitalised group was 5 days compared with 3 days in the non-hospitalised group (P = .017).

In the hospital triage setting, the information from the viral load can be utilised to determine which patient would receive a negative pressure room.

In the outpatient setting, clinicians can utilise viral load as a quantitative metric to reinforce the importance of self-isolation and face coverings to reduce the risk spreading the infection.

Comments: The virus becomes non replicative by 9 days. In hospitalised patients the viral load in this study was done later in the disease course and hence coulc have been lower.

https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.049252 SOURCE: Circulation and The American Journal of Pathology