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CMAAO Update 13th February
Based on WHO guidelines set in 2015 that ensure the name does not refer to a geographical location, an animal, an individual or group of people, while still being pronounceable and related to the disease.
Round Table - Experts from HCFI and MAMC Draft Document
Namaste: Let’s not shake hands
Sudden jump in deaths and new cases on 12th due to inclusion of clinically diagnosed cases
Confirmed cases: 60,280; Countries 28; Deaths 1367
Active cases: 52950 (currently infected), 44707 (84%) mild cases; 8243 (16%) serious cases. 12 serious cases outside China
Closed cases: 7330 (with outcome), 5963 Recovered or discharged (81%)
Pattern: 82% mild, 15% severe, 3% critical, 2% deaths
Deaths yesterday: 252
Serious or critical mortality: 15%
More than 136 cases have been confirmed on a ship quarantined in Japan
Secondary cases: Thailand, Taiwan, Germany, Vietnam, Japan, France, US
Deaths outside China: Philippines on Feb 2 (44-year-old Chinese man) and 2nd in Hong Kong (39 M, local) on February 4; both had co-morbid conditions. Both acquired infection from Wuhan.
Likely deaths 1236+1367= 2603 with the present trend and available treatment
WHO warns that the epidemic could still go in any direction, while global experts say that the outbreak is just beginning outside of China
Coronavirus vaccine could be ready in 18 months, says WHO
The virus possibly behaves like SARS with <2 % case fatality (15% of admitted serious cases), mean time to death 14 days, mean time to pneumonia 9 days, mean time to symptoms 5 days, 3-4 reproductive number R0, incubation period 2-14 days, mean 5.5 days, has origin possibly from bats, spreads through large droplets and predominantly from people having lower respiratory infections and hence, standard droplet precautions are the answer for the public and airborne precautions for the healthcare workers. [So: RT Experts meet HCFI and MAMC]
New COVID-19 Cases Rise by Ten-fold or Nearly 15,000 in Chinas Hubei Province After Change in Classification System: The province has started including “clinically diagnosed” cases in its figures and 13,332 of the new cases fall under that classification.
- Patients with severe acute respiratory infection (fever, cough, need admission to hospital), with no other etiology that can explain the clinical presentation, AND at least one of the following:
- a history of travel to or residence in the city of Wuhan, Hubei Province, China in the 14 days before symptom onset, or
- patient is a healthcare worker who has been working in an environment where severe acute respiratory infections of unknown etiology are being cared for.
- Patients with any acute respiratory illness AND at least one of the following:
- close contact with a confirmed or probable case of COVID 19 in the 14 days before illness onset, or
- visit to or working in a live animal market in Wuhan, Hubei Province, China in the 14 days before symptom onset, or
- worked or attended a healthcare facility in the 14 days before dymptom onset where patients with hospital-associated COVID 19 infections have been reported.
A suspect case for whom testing for COVID 19 is inconclusive or for whom testing was positive on a pan-coronavirus assay.
A person with laboratory confirmation of COVID 19 infection, irrespective of clinical signs and symptoms.
Severe acute respiratory infection (SARI) in a person, with history of fever and cough requiring hospital admission, with no other etiology that can fully explain the clinical presentation (clinicians should also be alert to the possibility of atypical presentations in immunocompromised patients )
AND any of the following:
- a) history of travel to Wuhan, Hubei Province China in the 14 days before symptom onset; or
- b) disease occurs in a healthcare worker who has been working in an environment where patients with severe acute respiratory infections are being cared for, irrespective of place of residence or history of travel; or
- c) person develops an unusual or unexpected clinical course, especially sudden deterioration despite appropriate treatment, irrespective of residence or history of travel, even if another etiology has been identified that fully explains the clinical presentation
A person with acute respiratory illness of any severity who, within 14 days before onset of illness, had any of the following exposures:
- a) close physical contact with a confirmed case of COVID 19 infection, while that patient was symptomatic; or
- b) a healthcare facility in a country where hospital-associated COVID 19 infections have been reported
- An ARI with history of fever or temperature ≥38 C° and cough; onset within the last 10 days; and requiring hospitalization
- Absence of fever does NOT exclude viral infection
- Healthcare associated exposure, which includes providing direct care for COVID 19 patients, working with healthcare workers infected with COVID 19, visiting patients or staying in the same close environment of a COVID 19 patient
- Working together in close proximity or sharing same classroom environment with a COVID 19 patient
- Traveling together with COVID 19 patient
- Living in the same household as a COVID 19 patient
The epidemiological link may have occurred within a 14-day period before or after the onset of illness in the case under consideration.
Public Health Emergency of International Concern - 30th January, 2020
Mandatory to report to WHO each human and animal case.
Prior 5 PHEICs:
26th April 2009 Swine flu: 10 August 2010, WHO announced that the H1N1 influenza virus has moved into the post-pandemic period. However, localized outbreaks of various magnitudes are likely to continue.
May 2014 Polio: resurgence of wild polio. October 2019, continuing cases of wild polio in Pakistan and Afghanistan, in addition to new vaccine-derived cases in Africa and Asia; the status was reviewed and it remains a PHEIC. It was extended on 11 December, 2019.
August 2014 Ebola: It was the first PHEIC in a resource-poor setting.
Feb 1, 2016 Zika: link with microcephaly and Guillain–Barré syndrome. This was the first time a PHEIC was declared for a mosquito‐borne disease. This declaration was lifted on 18 November, 2016.
2018–20 Kivu Ebola: A review of the PHEIC had been planned at the fifth meeting of the EC on 10 October, 2019and as of 18 October, 2019, it continues to be a PHEIC.
Kerala: State public health emergency. Three primary cases identified in North, South and Central - Kasaragod district in north Kerala, Thrissur in central Kerala and Alappuzha in South Kerala. Four Karnataka districts bordering Kerala — Kodagu, Mangaluru, Chamarajanagar and Mysuru - have been put on high alert.
Single-strand, positive-sense RNA genome ranging from 26 to 32 kilobases in length, Beta corona virus from Corona family.
‘Corona’ means crown or the halo surrounding the sun. Heart is considered crown and hence the arteries that supply oxygen to the heart are also called coronary arteries. Under an electron microscope, is the virus appears round with spikes poking out from its periphery.
Origin: Wuhan, China December 2019. First case informed to the world by Dr. Li Wenliang; died on Feb 6
The virus is likely killed by sunlight, temperature, humidity. The virus can remain intact at 4 degrees or 10 degrees for a longer time. At 30 degrees; however, there is inactivation. SARS stopped around May and June in 2003 probably due to more sunlight and more humidity. Alive on surface: 3-12 hours
Link to ACE: COVID 19 might be able to bind to the angiotensin-converting enzyme 2 receptor in humans.
Three deadly human respiratory coronaviruses: Severe acute respiratory syndrome coronavirus [SARS-CoV], Middle East respiratory syndrome coronavirus [MERS-CoV]), and COVID 19: The current virus is 75-80% identical to the SARS-CoV.
High viral load: Detection of COVID 19 RNA in specimens from the upper respiratory tract with low Ct values on day 4 and day 7 of illness suggests high viral loads and potential for transmissibility. [NEJM]
COVID 19 uses the same cellular receptor as SARS-CoV (human angiotensin-converting enzyme 2 [hACE2]), so transmission is expected only after signs of lower respiratory tract disease develop.
SARS is high [unintelligible] kind of inducer. This means that when it infects the lower part of the lung, the body develops a very severe reaction against it and leads to lots of inflammation and scarring. In SARS, after the first 10 to 15 days, it wasn’t the virus killing the patients it was the body’s reaction. Is this virus in the MERS or SARS kind picture or is this the other type of virus which is a milder coronavirus like the NL63 or the 229? It may be the mild (unintelligible) kind of inducer. [Dr John Nicholls, University of Hong Kong]
Infectiousness to humans: COVID 19 seems to thrive better in primary human airway epithelial cells as compared to standard tissue-culture cells, unlike SARS-CoV or MERS-CoV. COVID 19 will likely behave more like the SARS-CoV.
SARS-CoV and MERS-CoV affect the intrapulmonary epithelial cells more than the upper airway cells. Transmission thus occurs primarily from patients with recognized illness and not from patients with mild, nonspecific signs. However, NEJM has reported a case of COVID 19 infection acquired outside of Asia wherein transmission seems to have taken place during the incubation period in the index patient but the same has been challenged now.
No sore throat: This new virus attacks the lungs as well, and not just the throat. Patients so far have not presented with a sore throat, because COVID 19 attacks the intraepithelial cells of lung tissue.
Types: Droplet (droplet, contact, fomites) Corona; aerosol, nuclei or airborne, e.g. TB
Kissing scenes banned in movies in China
Air crew exempted from breath analyser tests: Kerala
Burial: China has banned death ceremonies, people gathering together Lockdown: 50 million people in China
Asymptomatic transmission: A report of a small cluster of five cases indicated transmission from asymptomatic individuals during the incubation period; all patients in this cluster had mild illness. Another person got infected while using gown, but the eyes were not covered. NEJM reported a transmission from asymptomatic case but the same has been challenged.
Link to Huanan Seafood Wholesale Market: 55% with onset before January 1, 2020 and 8.6% of the subsequent cases. The Chinese government has banned wildlife trade until the epidemic passes.
Zoonotic but unlikely to spread through seafood: This new coronavirus is closely related to bat coronaviruses. Bats are the primary reservoir. While SARS-CoV was transmitted to humans from exotic animals in wet markets, MERS-CoV transmitted from camels. The ancestral hosts were probably bats; however.
The virus has been traced to snakes in China. Snakes often hunt for bats. According to reports, snakes were sold in the local seafood market in Wuhan, thus raising the likelihood that COVID 19 might have moved from the host species, i.e., bats, to snakes and then to humans. It is still not understood as to how the virus could adapt to both the cold-blooded and warm-blooded hosts.
Risk to other Asian countries: It is less likely to have serious illness in other countries, as patients with breathlessness are unlikely to board and patients will mild illness or asymptomatic illness are less likely to transmit infections.
NEJM reports of a taxi driver infected with SARS-CoV-2 in Thailand, potentially from Chinese tourists; the infection appears not to have spread to others.
Legal Implications India: Section 270 in the Indian Penal Code: 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.
Clinical Features (Current trend)
- Uncomplicated illness
Patients with uncomplicated upper respiratory tract viral infection, may have non- specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache, muscle pain or malaise.
The elderly and immunosuppressed may present with atypical symptoms.
No signs of dehydration, sepsis or shortness of breath
- Mild pneumonia
Patient with pneumonia and no signs of severe pneumonia
Child:; cough or difficulty breathing + fast breathing:
fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40 and no signs of severe pneumonia
- Severe pneumonia
Adolescent or adult: fever or suspected respiratory infection, AND one of respiratory rate >30 breaths/min, severe respiratory distress, or SpO2 <90% on room air
Child: cough or difficulty in breathing, AND at least one of the following: central cyanosis or SpO2 <90%; severe respiratory distress (e.g. grunting, very severe chest indrawing); signs of pneumonia with a general danger sign: inability to breastfeed or drink, lethargy or unconsciousness, or convulsions.
Other signs of pneumonia may be seen: chest indrawing, fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40.
Diagnosis is clinical; chest imaging can help exclude complications.
- Acute Respiratory Distress Syndrome
Onset: new or worsening respiratory symptoms within a week of known clinical insult.
Chest imaging: bilateral opacities, not fully explained by effusions, lobar or lung collapse, or nodules.
Origin of edema: respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of edema if no risk factor present.
- Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥5 cm H2O, or non-ventilated)
- Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP ≥5 cm H2O, or non-ventilated)
- Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cmH2O, or non- ventilated)
- PaO2 not available: SpO2/FiO2 ≤315 suggests ARDS (including in non-ventilated patients)
Oxygenation (children; OI = Oxygenation Index and OSI = Oxygenation Index using SpO2)
- Bilevel NIV or CPAP ≥5 cmH2O via full face mask: PaO2/FiO2 ≤ 300 mmHg
or SpO2/FiO2 ≤264
- Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5
- Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3
- Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3
Adults: life-threatening organ dysfunction due to a dysregulated host response to suspected or proven infection, with organ dysfunction.
Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia.
Children: suspected or proven infection and ≥2 SIRS criteria; of these one must be abnormal temperature or white blood cell count
- Septic shock
Adults: persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65 mmHg and serum lactate level >2 mmol/L
Children: any hypotension (SBP <5th centile or >2 SD below normal for age) or 2-3 of the following: altered mental state; tachycardia or bradycardia (HR <90 bpm or >160 bpm in infants and HR <70 bpm or >150 bpm in children); prolonged capillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea; mottled skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia
Median age: 59 years (2-74 years); Male to female ratio: 56% male
Mean incubation period: 5.2 days (95% confidence interval [CI], 4.1 to 7.0), with the 95th percentile of the distribution at 12.5 days.
Epidemic doubling time: In its early stages, every 7.4 days, with a mean serial interval of 7.5 days (95% CI, 5.3 to 19)
Contagiousness or Basic reproductive number: 2.2 (95% CI, 1.4 to 3.9). The reproduction number, referred to as R0 or “r naught” is the number of additional people that an infected person can infect. An outbreak with a reproductive number of below 1 will gradually disappear. The R0 for the common flu is 1.3 and for SARS it was 2.0.
Comorbid conditions: 71%, deaths in comorbid cases; SARS affected people in their 30 or 50 years. MERS affected people with co-morbidity. The China data indicate that it’s those with the co-morbidity that are most at risk like seasonal influenza.
0-15 years age: Just like SARS, it mostly does not affect children 15 years of age or less
ICU need: 20% need ICU care, with 15% mortality
Fever: In all (no fever, no COVID 19)
Cough: 75% cases
Weakness or muscle ache: 50%
Shortness of breath: 50%
Liver transaminase levels: raised
Case fatality: 2% [Dr John Nicholls, University of Hong Kong] China is only reporting those who come for test, there are stricter guidelines for a case to be considered positive, actual mortality may be 0.8%-1% like outside China
Researchers are reporting two new case-series studies from China and a review of case-finding information in the United States. The largest case series published till today highlights the risk for hospital staff in the early part of the outbreak, with nearly one third of cases noted in healthcare professionals. (Medscape)
Lab precautions: BSL 2 (3 for viral culture labs)
Human to human contact period: Requires prolonged contact (possibly ten minutes or more) within three to six feet
Travel preferable seat: Choosing a window seat and staying there lowers the risk
Travel advisory: Level 1 in all countries (Exercise normal standard hygiene precautions), Level 2 in all affected countries and states including Kerala (Exercise a high degree of caution), Level 3 in all countries with secondary cases (Reconsider your need to travel), done by India, and Level 4 ( Do not travel), done by US. Hong Kong has imposed 14 days quarantine on people arriving from China. The Karnataka government has ordered that anybody arriving from the 23 COVID 19 affected countries must stay in isolation at home for 28 days. The home isolation requirement is irrespective of the virus symptoms. To date, 72 countries have implemented travel restrictions.
Travel and trade restrictions: WHO says no to countries
Leave china all together: UK, condemned by many countries
Entry to India not allowed: foreigners who went to China on or after January 15
Visas Suspended: All visas issued to Chinese nationals before February 5 (not applicable to aircrew)
Flight suspended: IndiGo and Air India have suspended all of their flights between the two countries. SpiceJet continues to fly on Delhi-Hong Kong route.
Mass Quarantine May Spark Irrational Fear, Anxiety, Stigma
Many countries including US, Japan, India have evacuated their citizens.
COVID 19 2%
MERS 34% (2012, killed 858 people out of the 2,494 infected)
SARS 10% (Nov. 2002 - Jul. 2003, originated from Beijing, spread to 29 countries, with 8,096 people infected and 774 deaths)
Measles 10-15% developing countries
Polio 2-5% children and 15-30% adults
Whooping cough 4% infants < 1yr, 1% children < 4 years
Swine flu < 0.1-4 %
Seasonal flu 0.01%.
Current virus in Wuhan 4.9%.
Current virus in Hubei Province 3.1%.
Current virus in Nationwide 2.1%.
Current virus in other provinces 0.16%.
Number of flu deaths every year: 290,000 to 650,000 (795 to 1,781 deaths per day)
There are two ways to detect a virus: through the genetic material DNA or RNA and to detect the protein of the virus. The rapid tests look at the protein. It takes 8-12 weeks to make commercial antibodies. Currently, for the diagnostic tests, PCR is being used which gives a turnaround in 1-2 hours.
BOTH the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) AND lower respiratory tract (LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage)
- Use PPE
- Use viral swabs (sterile Dacron or rayon, not cotton) and viral transport media
In US, in January, all testing had to be done in CDC laboratories. However, on February 4, the US FDA issued an emergency-use authorization for the CDCs COVID 19 Real-Time RT-PCR Diagnostic Panel, allowing it to be used at any CDC-qualified laboratory in the United States.
No proven antiviral treatment.
With SARS, in 6 months the virus was gone and it never came back.
Pharmaceutical companies may not spend millions to develop a vaccine for something which may never come back.
Secondary infection, E. coli, is most likely the cause of deaths in the Philippines and Hong Kong.
A combination of lopinavir and ritonavir showed promise in lab in SARS
Combination of lopinavir, ritonavir and recombinant interferon beta-1b was tried 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.
Thailand: Oseltamivir along with lopinavir and ritonavir, both HIV drugs.
Experimental drug: From Gilead Sciences Inc., called remdesevir (started on 6th Feb as a trial)
Russia and China drug: Arbidol, an antiviral drug used in Russia and China for treating influenza, could be combined with Darunavir, the anti-H.I.V. drug, for treating patients with the coronavirus. ( COVID 19 shares some similarity to HIV virus also)
PVP-I mouthwashes and gargles are known to reduce viral load in the oral cavity and the oropharynx. PVP-I has high potency for viricidal activity against hepatitis A and influenza, MERS and SARS
The Drug Controller General of India has approved the "restricted use" of a combination of drugs (Lopinavir and ritonavir) used widely for controlling HIV infection in public health emergency for treating those affected by novel coronavirus.
In SARS, people were put on long-term steroids ending with immunosuppression and late complications and death. The current protocol is short-term treatment.
Standard Respiratory droplets precautions
- At triage
Surgical 3 layered mask to the patient
At least 1m distance
- Droplet precautions
While caring - eye protection- face shields/goggles
Limit patient movement
Restrict attendants – w/ face mask
- Contact precautions
When entering room - gown, mask, goggles, gloves – remove before leaving the room
Dedicated equipment/ disinfection after every use
Care for environment- door knobs, handles, articles, laundry
Avoid patient transport
- Airborne precautions When performing aerosol-generating procedures
- Adequately ventilated
- Negative pressure rooms with minimum of 12 air changes per hour or at least 160 litres/second/patient in facilities with natural ventilation
- Restricted movement of other people
- gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or equivalent, or higher level of protection)
Self-quarantine if sick with flu-like illness: 2 weeks
Soap and water: Wash your hands often and for at least 20 seconds.
Alcohol-based hand sanitizer: if soap and water are not available
Avoid touching: Eyes, nose, and mouth with unwashed hands.
Avoid close contact: (3-6 feet) with people who are sick with cough or breathlessness
Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
Clean and disinfect frequently touched objects and surfaces.
Surgical 3 layered Masks: For patients
N 95 Masks: For health care providers and close contacts
- People receiving packages from China are not at risk of contracting the COVID 19 as the virus does not survive long on objects, such as letters or packages.
- There is no evidence that animals/pets such as dogs or cats can be infected with COVID 19. However, it is always in your best interests to wash your hands with soap and water after contact with petsto prevent transmission of common bacteria such as E. coli and Salmonella.
- Pneumococcal vaccine and Haemophilus influenza type B (Hib) vaccine, provide no protection against COVID 19.
- Regularly rinsing the nose with saline does not protect people from infection with COVID 19 or respiratory infections although it can hasten recovery from the common cold.
- There is no evidence that using mouthwash protects you from infection with COVID 19 although some brands of mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth.
- Garlic may have some antimicrobial properties, however, 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 are bleach/chlorine-based disinfectants, either solvents, 75% ethanol, peracetic acid and chloroform. However, they have little to no effect on the virus if you put them on the skin or under your nose. It can even be dangerous to put these chemicals on your skin.
- People of all ages can be infected by COVID 19. Older people, and people with pre-existing medical conditions (such as asthma, diabetes, heart disease) have increased odds of becoming severely ill with the virus. People of all ages are advised to protect themselves from the virus, for example by following good hand hygiene and good respiratory hygiene.
- Antibiotics do not work against viruses. Hence, antibiotics should not be used to prevent or treat COVID 19 unless bacterial co-infection is suspected.
- To date, there is no specific medicine recommended to prevent or treat COVID19.
Trolls and conspiracy theories: Not validated and are fake news
- COVID 19 is linked to Donald Trump,and US intelligence agencies or pharmaceutical companies are behind it.
- That eating snakes, wild animals or drinking bat soup cases corona
- Keep your throat moist, avoid spicy food and load up on vitamin C
- Avoiding cold or preserved food and drinks, such as ice cream and milkshakes, for "at least 90 days".
- Experts have been aware of the virus for years.
- The virus was part of Chinas "covert biological weapons programme" and may have leaked from the Wuhan Institute of Virology.
- Linked to the suspension of a researcher at Canadas National Microbiology Laboratory.
- China wants to kill 20,000 COVID 19 patients is totally false. The site is linked to a sex website.
Role of CMAAO and other Medical Associations
Get prepared for containment, including active surveillance, early detection, isolation and case management, tracking contacts and prevention of spread of the virus and to share full data with WHO. All countries should emphasize on reducing human infection, prevention of secondary transmission and international spread. Intensify IEC activities.
Confirmed Cases and Deaths
Total Deaths of Novel Coronavirus (COVID 19)
Change inTotal (%)