— By Dr KK Aggarwal

17^th March: CMAAO COVID 19 PANDEMIC

India

States: 14,

Total cases 11 4 (MOH), 129 World Meters

Serious: Zero, Death: 2, Community spread: zero; Super spreader: Zero; Men more than women.

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

Countries 162 , Continents all except Antarctica

Cases 175982 Cases (5% extra if CT diagnosis is taken)

Deaths 6717

Recovered: 77871

Currently infected:91394

Mild: 85416 (93%)

Serious 5978 (7%)

Likely deaths (6717 + 5978 x 15 = 888 ) = 7613      

Likely deaths in Italy: > 2060

Deaths in over 46 Countries

More than 50% of cases outside China

 COVID Sutras

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

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 othersand 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

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.