CMAAO Update 24^th February on COVID-19

Inputs: Dr Rajan Sharma, Dr R V Asokan, Dr KK Kalra, Dr Sushil Kumar, Dr Anita Arora, Dr Upasana Arora, Dr SS Srivastava, Dr Shilpi Khanna, Ms Swati, Dr Rahiul Shukla, Dr Arti Verma, Dr Anil Kumar, Dr G S Gyani, Dr Sonal Saxena, Dr CM Bhagat, Dr Vikas Manchanda, Dr Nandani Sharma, Dr Suneela Garg, Dr TK Joshi, Dr Mamta Jajoo, Dr Shariga Qureshi, Dr Manish Kumar, Dr Harmeet Singh, Dr Dr Rai, Dr VK Monga, Dr AP Singh,  Dr Ramesh Datta, Dr Maj Prachi Garg, Dr Anil Kumar,  Dr Ragini Agrawal, Dr Rajeev Kumar, Dr Harish Grover,  Dr Mini Mehta, Dr Lalan Bharti,  Dr Rajeev Sood, Dr N V Kamat, Dr Atin Kumar, Dr RN Tandon, Dr Kaushik Sinha Deb, Dr Tarun Mittal, Dr Dinesh Sahay, Dr SK Poddar

COVID-19 SUTRA

COVID-19 virus possibly behaves like SARS; causes mild illness in 82%, severe illness in 15%, critical illness in 3% and death in 2% cases (15% of admitted serious cases, 71% with comorbidity); affects all ages but predominantly males (56%) with median age 59 years (2-74 years, less in children below 15);  with variable incubation period days (2-14;  mean 3 based on 1,324 cases, 5.2 days based on 425 cases,  6.4 days in travellers from Wuhan);  mean time to symptoms 5 days,  mean time to pneumonia 9 days, mean time to death 14 days,  3-4 reproductive number R0  (flu 1.2 and SARS 2), epidemic doubling time 7.5 days (Korea 1 day probably due to super spreader), has origin possibly from bats, spreads via large droplets and predominantly from people having lower respiratory infections and hence, standard droplet precautions are the answer for the public and close contacts and airborne precautions for the healthcare workers dealing with the secretions.

Clinically all patients have fever, 75% have cough; 50% have weakness; 50% have breathlessness with low total white count and deranged liver enzymes. About 20% need ICU care and 15% of them are fatal. 

Treatment is symptomatic though chloroquine, anti-viral and anti-HIV drugs have shown some efficacy.

Pandemic Alert 21^st February

US CDC: Tremendous Public Health Threat.

WHO: "… we are concerned about the number of cases with no clear epidemiological link, such as travel history to China or contact with a confirmed case"

Public Health Emergency of International Concern 30^th Jan 2020: It is mandatory to report each human and animal case to the WHO.

Prior 5 PHEICs:  

1. 26^th April 2009 - 10^th August 2010: Swine flu
2. May 2014 Polio: Resurgence of wild polio.
3. August 2014: Ebola; It was the first PHEIC in a resource-poor setting.
4. Feb 1 2016 - 18 Nov 2016: Zika
5. 2018–20: Kivu Ebola

Public Health Emergency of State Concern: Kerala - lifted on 12^th Feb.

Community spread: Cases are detected in Singapore, South Korea, Taiwan, Vietnam, Hong Kong and Japan in communities where it is not known what the source of the infection was.

Close Contacts of COVID-19 patients: Providing direct care to patients, working with infected health care workers, visiting infected patients or staying in the same close environment, working together in close proximity or sharing the same classroom environment with an infected patient, traveling together with infected patient in any kind of conveyance, living in the same household as an infected patient. The epidemiological link may have occurred within a 14-day period before or after the onset of illness. 

Daily Statistics

Total cases: 78,999

Deaths: 2,470

Recovered: 23,577

Currently Infected Patients: 52,952

Mild cases: 41,283 (78%)

Serious or Critical cases: 11,569 (22%)

Deaths yesterday: 100 (97+1+2)

Serious or critical mortality 15%

Likely minimum deaths 2470 + 1735 (11,569 x15) =4205 with the present trend and available treatment (plus deaths linked to daily new cases)

23^rd Feb Update

ITALY OUTBREAK (Feb. 23 Updates):

• Mayor of one of the towns in lockdown stated that theyve run out of coronavirus testing kits.
• ECDC: "As the situation is rapidly evolving, more cases are expected in Italy [...] Extraordinary measures in northern Italy are essential to limit the outbreak and may need to be replicated in other communities in the coming days." [ECDC]
• 78 new cases and 1 new death (a woman being treated for cancer in Crema), including 4 new cases near Bergamo, 2 new cases in Venice, a 17-year-old male in Valtellina, and a couple in Turin who visited their child at the Regina Margherita Hospital.
• Current total cases in Italy:

- 114 cases in Lombardy (including 2 deaths)

- 25 cases in Veneto (including 1 death)

-   9 in Emilia Romagna (all in Piacenza)

-   3 in Trentino Alto Adige (tourists from Lombardy)

-   3 in Piedmont (3 previously confirmed cases were later retracted)

-   3 in Rome (including 1 person who had been repatriated).

• At least 26 patients (17 in Lombardy) are in critical condition in intensive care.
• 11 towns, 50,000 people, placed in lockdown.
• Armed forces and police have been mobilized to form a "health belt" around contagion areas. Roadblock violators may be subjected to up to a 3 months prison sentence.
• Schools closed in Lombardy, Veneto, Friuli Venezia Giulia, Emilia Romagna, Liguria, and in Trentino Alto Adige regions. Universities closed in Piedmont.
• Carnival in Venice and all sport and public events in Veneto cancelled.
• All public and private events, including sport, cultural, and religious events in Lombardy cancelled; Movie theatres closed.
• More than 40 football matches, including at least 4 Serie A games, postponed.
• Armani cancels his fashion show in Milan.
• Teatro alla Scala in Milan suspends all performances.

 "I think these three cases that have no contact with a primary carrier show how this virus is now ubiquitous so, as with flu symptoms, you get it and dont know who you got it from" said Veneto governor Luca Zaia, who, in a separate comment, said "we are worried, drastic measures are needed."

"Serious mistake was made not to quarantine people who arrived in Italy from China" said Walter Ricciardi of the WHO. "…..within two weeks we will know if we are facing an epidemic" and advised that for the next two weeks, people "should avoid crowded places: metro, buses, trains, schools, discos, and gyms."

[Source: https://www.worldometers.info/coronavirus/] 

South Korea Outbreak (Feb. 23 Updates):

• 166 new cases and 4 new deaths.
• President Moon Jae-in raised alert level to maximum (Level 4: Serious) – empowering lock down of cities and restrict travel. “The coming few days will be a critical time for us” he said in a meeting.
• Progression of total cases over last few days:
• 23: 602 cases (day still in progress)
• 22: 436 cases
• 21: 209 cases
• 20: 111 cases
• 19:  58 cases
• 18:   31 cases

1 new case in Canada (Toronto) - a woman who arrived from China on Feb. 21.

1 new case in Israel - former passenger of the Diamond Princess cruise ship.

4 new cases in the UK - former passengers of the Diamond Princess cruise ship.

1 new death in Hubei province, China - a 42-year-old doctor.

57 new cases - 55 crew members, 2 passengers (of these 52 asymptomatic) - and 1 new death (a man in his 80s) from the Diamond Princess cruise ship in Japan.

2 new deaths and 14 new cases in Iran.

2 new cases in Taiwan: father and son, in their late 80s and 50s.

The older man is a kidney dialysis patient with chronic diseases - hypertension and diabetes - had symptoms of cough and runny nose on Feb. 6; developed fever and was diagnosed with pneumonia on Feb. 9; and had shortness of breath on Feb. 16, when he was transferred to the intensive care unit.

The son, whose brother had returned from China on Feb. 2, had symptoms two days prior, on Jan 31. He had fever, runny nose and sore throat on Jan. 31, approached a clinic on Feb. 4 and, due to continuous fever, went to the emergency room on Feb. 8; he was diagnosed with pneumonia. He returned home for independent health management, but went back to the hospital on Feb. 11 and Feb. 18 and was isolated on Feb. 21.

12 new cases in Japan.

1 new case in Australia from the Diamond Princess cruise ship.

18 new cases and 1 new death outside of Hubei province in China on February 22 [National Health Commission (NHC) of China]

630 new cases and 96 new deaths reported by Hubei province for Feb. 22.

[Source: https://www.worldometers.info/coronavirus/] 

Summary Points

1. Corona Namaste: Let’s not shake hands
2. Time for facts, not fear; for rationality, not rumors and for solidarity, not stigma.
3. Help line: 23978046
4. Total number = Lab-confirmed + CT-diagnosed cases (12-19 February) and before and after that, only lab-confirmed cases
5. No or little evidence to support the possibility of vertical transmission from the mother to the baby. [Lancet Feb 20]
6. Sudden jump in deaths and new cases on 12^th due to inclusion of CT-diagnosed cases.
7. WHO: Epidemic could still ‘go in any direction’ and outbreak is just ‘beginning’ outside China, say experts
8. Coronavirus vaccine could be ready in 18 months (WHO) 
9.  Human to human contact requires prolonged contact (possibly ten minutes or more) within three to six feet.
10. 14^th Feb: 1,716 medical workers have contracted the virus and six of them have died; 1,502 belong to Hubei Province, with 1,102 from Wuhan. The numbers of infected workers amount to 3.8% of China’s overall confirmed infections as of Feb. 11. (18^th Feb: Director of Wuhan Hospital died).
11. Two workers who were sent to Wuhan in January end to help build new hospital have been infected
12. The central banking authorities of China are disinfecting, stashing and even destroying cash in a bid to stop the spread of the coronavirus. People’s Bank of China says that the cash collected by commercial banks must be disinfected before being released back to customers.
13.  Maharishi Valmiki Hospital in Delhi stops biometric attendance
14.  China has more than 80 running or pending clinical trials on potential treatments for COVID-19.
15.  634 infected people have been found among 3,011 passengers and crew members tested (21% infection rate) out of 3,711 total people on the ship; 2 Deaths, 27 serious
16. Growing number of clusters of coronavirus cases: a party in a boat in Japan with 90 guests where one case spread infection to more than a dozen, or a church where 43 were infected. This can be explained in 2 possible ways: a “super-spreader,” or person who can spread more germs than others; or people catching the virus from infected surfaces. It is not yet known as to how long the germs stay on surfaces, but similar viruses can live for as long as a week.
17. Chinese researchers have published the largest analysis of coronavirus cases till date. While men and women have been found to be infected in roughly equal numbers, the death rate among men was 2.8% compared with 1.7% among women.
18. Despite CDC protest, 14 Americans infected with coronaviruson the Diamond Princess cruise ship shared a plane back to the U.S. with healthy passengers, separated by plastic sheeting. (New York Post)
19. An outlier of a 24 days incubation periodhas been observed. The WHO said that it could indicate a second exposure rather than a long incubation period, and stated that it wasnt going to change its recommendations. Hubei Province local government on Feb. 22 reported of a case with an incubation period of 27 days. 
20. A court temporarily blocked the U.S. government from sending nearly 50 people infected with the new virus from China to a Southern California city for quarantine as local officials argued that the plan lacked details about protection of the community from the outbreak. (Washington Post)

Travel Restrictions

Travel advisory

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 need to travel)

Level 4 in affected parts of China and Korea (Do not travel)

Case fatality

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 33 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%; COVID-19 in Wuhan 4.9%; COVID-19 in Hubei Province 3.1%; COVID-19 Nationwide 2.1%; COVID-19 in other provinces 0.16%.

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

About the Virus

‘Corona’ means crown or the halo around the sun. Heart is considered a crown. Therefore, the arteries that supply oxygen to the heart are also called coronary arteries. Under an electron microscope, the virus appears round with spikes poking out from its periphery.

Single-strand, positive-sense RNA genome that ranges from 26 to 32 kilobases in length; A beta coronavirus from Corona family.

One of the three deadly human respiratory coronaviruses. Others are Severe acute respiratory syndrome coronavirus [SARS-CoV] and Middle East respiratory syndrome coronavirus [MERS-CoV]). COVID-19 is 75 to 80% identical to the SARS-CoV.

Origin: Wuhan, China, December 2019. 1^st case informed to the world by Dr. Li Wenliang; died on 6^th Feb.

The virus is likely to be killed by sunlight, temperature, and humidity. SARS was reported to have stopped around May-June, 2003 owing to more sunlight and more humidity.

Pathogenesis

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. When it infects the lower part of the lung, a very severe reaction occurs against it which leads to inflammation and scarring. In SARS, after the first 10 to 15 days, it wasn’t the virus but the body’s reaction was what was killing patients. Is this new virus in the MERS or SARS kind picture or is this some other type of virus - 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]

COVID-19 thrives better in primary human airway epithelial cells as compared to the standard tissue-culture cells, unlike SARS-CoV or MERS-CoV. COVID-19 will likely behave more like SARS-CoV.

Both SARS-CoV and MERS-CoV affect the intrapulmonary epithelial cells more than the upper airway cells. Transmission thus occurs principally from patients with known illness and not from patients with mild, nonspecific signs. However, NEJM has reported a case of COVID-19 infection acquired outside of Asia in which transmission appears to have occurred during the incubation period in the index patient, but the same has been challenged now.

Transmission

Zoonotic and linked to Huanan Seafood Wholesale Market as 55% with onset before January 1, 2020 originated there vs. only 8.6% of the subsequent cases. The Chinese government has put a ban on wildlife trade until the epidemic passes. 

This new coronavirus has a close relation with 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. 

It transmits predominantly via droplets, like common flu and not like airborne illnesses (TB, Measles, Chicken pox). Kissing scenes have been banned in movies in China. In Kerala, air crew are exempted from breath analyser tests and China has banned death ceremonies, and people gathering together.

NEJM has reported a small cluster of five cases suggesting transmission from asymptomatic individuals during the incubation period; all patients in this cluster had mild illness. But the same has been challenged. Another patient got infected while using gown, but eyes were not covered.

Initial serious illness in other countries have been less as patients with breathlessness are unlikely to board and patients will mild illness or asymptomatic illness are less likely to transmit infections.

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.

Quarantine has Limitations

China imposed quarantines across Hubei province, thus locking in about 56 million people, in order to stop COVID-19 from spreading.

Vietnam villages with 10,000 people near the nations capital have been placed under quarantine after cases of the new coronavirus were identified there.

1. 21% quarantined on Diamond Princess cruise ship got infected.
2. The people on quarantine are subjected to a 14-day quarantine. While placed together, if anyone is diagnosed with the infection during that period, the quarantine will add another 14 days.
3. The longer several thousand people are place together, waves of infection are propagated.
4. A better way is to divide the people into smaller groups and quarantine them separately.
5. Why quarantine children <15 years of age when the virus is not risky for them.
6. Why not separate elderly people with comorbid conditions at high risk of death and quarantine them separately in one to one or small groups.
7. What is the need to allow people to celebrate and have cultural programs during quarantine, as was seen in India, when people danced together with surgical masks during quarantine period.
8. Ventilation system can connect one room to the other. There have been concerns that coronavirus can spread through pipes.
9. Stress and anxiety suppress the immune system, thus rendering people more vulnerable to contracting the virus.
10. Quarantine the people the way it was done in TB sanatoriums with both sun-balconies and a rooftop terrace where the patients would lie all day either in beds or on specially designed chairs.

Standard Respiratory Droplets Precautions

At triage: Surgical 3-layered mask for patients; Isolation of at least three feet distance; Cough etiquette; Hand hygiene.

Droplet precautions: Surgical 3-layered mask for patients, their contacts and healthcare workers, in an adequately ventilated isolation room; healthcare workers caring with secretions should use eye protection, face shields/goggles. Limit patient movement, restrict attendants and observe hand hygiene.

Contact precautions: Entering room – use 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 and practice hand hygiene.

Airborne precautions when handling virus in the lab and while performing aerosol-generating procedures. Room should be with negative pressure with minimum of 12 air changes per hour or at least 160 litres/second/patient in facilities with natural ventilation. There should be restricted movement of other people and gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or equivalent, or higher level of protection) to be used by all.

Public

Strict self-quarantine if sick with flu-like illness for 2 weeks

Wash hands often and for at least 20 seconds with soap and water or use an alcohol-based hand sanitizer.

Avoid touching eyes, nose, and mouth with unwashed hands.

Avoid close contact (within 3-6 feet) with people 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.

Masks

Surgical 3-layered masks: For patients and close contacts

N 95 Masks: For healthcare providers when handling respiratory secretions.

Lab tests

1. 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, PCR is being used which gives a turnaround in 1-2 hours.
2. BOTH the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) AND lower respiratory tract (LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage)
3. Use PPE in the lab
4. Use viral swabs (sterile Dacron or rayon, not cotton) and viral transport media
5. 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 its use at any CDC-qualified laboratory in the United States.  
6. Lab precautions: BSL 2 (3 for viral culture labs)

Treatment

1. No proven antiviral treatment.
2. With SARS, in 6 months the virus was gone and it never came back.  Pharmaceutical companies may not be willing to spend millions to develop a vaccine for something which may never come back.
3. Secondary infection is the most likely cause of death of the patients in the Philippines and Hong Kong.
4. A combination of lopinavir and ritonavir showed promise in lab in SARS. Combination of lopinavir, ritonavir and recombinant interferon beta-1b was tested in case of MERS.
5. Scientists in Australia have reportedly recreated a lab-grown version of COVID-19.
6. 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.  
7. Thailand: Oseltamivir along with lopinavir and ritonavir, both HIV drugs.
8.  Experimental drug: From Gilead Sciences Inc., called remdesevir (started on 6^th Feb as a trial)
9.  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. (The COVID-19 shares some similarity to HIV virus also)
10. PVP-I mouthwashes and gargles reduce viral load in the oral cavity and the oropharynx. PVP-I has potent viricidal activity against hepatitis A and influenza, MERS and SARS.
11. 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.
12. In SARS, people were put on long-term steroids ending with immunosuppression and late complications and death. The current protocol is short-term treatment.

Common Facts

1. 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.
2. There is no evidence that animals/pets such as dogs or cats can get infected with COVID-19.
3. Pneumococcal vaccine and Hib vaccine do not provide protection against COVID-19.
4. Regularly rinsing the nose with saline does not protect against infection with COVID-19 or respiratory infections although it may hasten recovery from the common cold.
5. There is no evidence to suggest that using mouthwash protects from infection with COVID-19 although some brands of mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth.
6. There is no evidence that eating garlic protects people from COVID-19.
7. 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.
8. People of all ages can be infected by COVID-19. Older people, and people with pre-existing medical conditions are at increased odds of becoming severely ill with the virus.
9. Antibiotics do not work against viruses.
10. There is no specific medicine recommended to prevent or treat COVID-19. 

 Trolls and conspiracy theories: Not validated and are fake news

1. COVID-19 is linked to Donald Trump,and US intelligence agencies or pharmaceutical companies are behind it.
2. Eating snakes, wild animals or drinking bat soup causes coronavirus infection.
3. Keep your throat moist, avoid spicy food and load up on vitamin C.
4. Avoiding cold or preserved food and drinks, such as ice cream and milkshakes, for at least 90 days.
5. Experts have been aware of the virus for years.
6. The virus was part of Chinas "covert biological weapons programme" and may have leaked from the Wuhan Institute of Virology.
7. Linked to the suspension of a researcher at Canadas National Microbiology Lab. 
8. China wants to kill 20,000 COVID-19 patients is totally false. The site is linked to a sex website.

Case Definitions

 Suspect case

1. Severe acute respiratory infection (fever, cough, need hospital admission), with no other cause that can explain the clinical presentation PLUS at least one of the following:

• a history of travel to or residence Wuhan, Hubei Province, China in the 14 days before symptom onset, or
• patient is a healthcare worker who has worked in an environment where severe acute respiratory infections of unknown etiology are being cared for.

1. Any acute respiratory illness PLUS 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 having worked 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 symptom onset where patients with hospital-associated COVID-19 have been reported.

Probable case

A suspect case with inconclusive COVID-19 testing or testing was positive on a pan-coronavirus assay.

Confirmed case

Laboratory confirmation of COVID-19 infection, regardless of clinical signs and symptoms.

Severe acute respiratory infection (SARI)

ARI with history of fever or temperature ≥38°C and cough; onset within the last 10 days; need for hospital admission. Absence of fever does NOT exclude viral infection.

SARI in a person, with history of fever and cough requiring hospital admission, with no other cause to explain the clinical presentation (clinicians should be alert to the possibility of atypical presentations in immunocompromised patients)

AND any of the following:

1. a)  A history of travel to Wuhan, Hubei Province, China in the 14 days before symptom onset; or
2. b)  the disease in a healthcare worker 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
3. c)  development of an unusual or unexpected clinical course, especially sudden deterioration despite appropriate treatment, irrespective of place of residence or history of travel, even if another etiology has been identified that can explain the clinical presentation

 OR

A person with acute respiratory illness of any severity who, within 14 days before illness onset, had any of the following exposures:

1. a)  close physical contact with a confirmed case of COVID-19 infection, while the patient was symptomatic: or
2. b)  a healthcare facility where hospital-associated COVID-19 infections have been reported.

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 have atypical symptoms. These patients have no signs of dehydration, sepsis or shortness of breath

Mild pneumonia

Pneumonia and no signs of severe pneumonia. Child has 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 rule out complications.

Acute Respiratory Distress Syndrome

Onset: new or worsening respiratory symptoms within one 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.

Oxygenation (adults):

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

Sepsis

 Adults: life-threatening organ dysfunction due to a dysregulated host response to suspected or proven infection, with organ dysfunction.

Signs of organ dysfunction: 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 in spite of volume resuscitation, need for 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

(Source: https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf)

Confirmed cases and deaths

• Highlighted in green = all cases have recovered from the infection.
• Highlighted in grey = all cases have had an outcome (there are no active cases).

Role of CMAAO and other Medical Associations

Get prepared for containment measures, 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.

CMAAO IMA FOMA MAMC Recommendations

1. Price control of PPE
2. Accreditation of private labs for testing
3. Private insurance should cover the infection
4. IEC and CME activities to be intensified
5. Allow paid leaves for airborne and droplet infections
6. Allow teleconsultations in flu-like diseases
7. CSR funds for vaccine research
8. Surgical three-layered masks at public places
9. Start National program on respiratory secretions borne<