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Why WHO is not declaring COVID-19 a pandemic?

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Dr KK Aggarwal    02 March 2020

2nd March: CMAAO Update on COVID-19

Breaking News: A 36-year-old Kerala man, who returned from coronavirus-hit Malaysia, died with pneumonia and diabetic ketoacidosis in Ernakulam government hospital in Kochi, a day after he tested negative for the deadly coronavirus.

Why WHO is shying away from declaring Covid-19 a pandemic: 67 countries affected; six of seven continents affected;  community spread; no immunity in public; more cases in South Korea (1062), Italy (566) and Iran (385) than in China (202) yesterday; deaths in 10 countries; 9039 cases outside China

Update: 67 countries affected, 88,583 cases, 3046 deaths, 45089 recovered,  40,462  currently infected patients, 33,109 (82%) in mild condition, 7353 (18%) serious or critical, likely deaths (3043  + 7353 x 15 =1103) = 4146 with the present trend and available treatment.

 COVID-19 SUTRAS

  • COVID-19 virus possibly behaves like SARS; near pandemic in 30 days; causes mild illness in 82%, severe illness in 15%, critical illness in 3% and death in 2.3% cases (15% of admitted serious cases, 71% with comorbidity, 10% in Iran); affects all ages but predominantly males (56%, 87% aged 30-79, 10% aged < 20, 3% aged > 80);  with variable incubation period days (2-14;  mean 3 based on 1,324 cases, 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,  mean time to CT changes 4 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), Tripling time in Korea 3 days,  Positivity rate - UK 0.2%, Italy 5.0%, France 2.2%, Austria 0.6% and USA 3.1%; has origin possibly from bats (mammal), 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.
  • Only 20% will have symptoms and will go for testing, rest may self-quarantine, 15% of serious cases will die.  In Iran, 16 died of 95 tested; this means they are only testing serious patients.

What is COVID-19?

  • Disease: Coronavirus disease or COVID-19 [11th February]
  • Virus: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [11th February]; Earlier name 2019 novel coronavirus. It is closer to SARS in many aspects.
  • Name: Given as per WHO guidelines previously developed with the World Organization for Animal Health (OIE) and the Food and Agriculture Organization of the United Nations (FAO). WHO policy is not linking the name to a person, animal, place or country.
  • WHO also refers to the virus as “the virus responsible for COVID-19” or “the COVID-19 virus” when communicating with the public.

 Is it in a pandemic state?

  • As per WHO and CDC, pandemic declaration is likely.  WHO says outbreak is “getting bigger”, can spread worldwide and is “literally knocking at the doors?”
  • On 21st Feb, CDC said it is a Pandemic Alert and a tremendous Public Health Threat.
  • WHO said that it is concerned about the number of cases with no clear epidemiological link, such as travel history to China or contact with a confirmed case.
  • Community spread: Cases have been detected in Singapore, South Korea, Taiwan, Vietnam, Hong Kong and Japan in community where the source of the infection is not known.
  • 24th Feb: Were in a phase of preparedness for a potential pandemic.
  • 25th Feb: Preparing for community transmission of the COVID-19 coronavirus
  • Feb 29: WHO raises Global Risk for coronavirus to the highest level of alert “We have now increased our assessment of the risk of spread and the risk of impact of COVID-19 to very high at global level,” (UN)
  • WHO: “If we don’t act... that may be a future that we have to experience,” “a lot of the future of this epidemic is in the hands of ourselves?” [
  • 29th Feb: first US death in a patient with a community spread case.

 What is a pandemic?

  • WHO: "the worldwide spread of a new disease" and ability to spread from person to person.
  • CDC: Spreads across "several countries or continents, usually affecting a large number of people.
  • UKs Health and Safety Executive: Virus markedly different from recently circulating strains and humans have little or no immunity to it.

 What is coranxiety?

Anxiety about falling ill and dying; avoiding or not approaching healthcare facilities due to fear of becoming infected during care; fear of losing livelihood; fear of not being able to work during isolation; fear of  being dismissed from work if found positive; fear of being socially excluded; fear of getting put into quarantine; fear of being separated from loved ones and caregivers due to quarantine; refusal to take care of unaccompanied or separated minors; refusal to take care of people with disabilities or elderly because of their high-risk nature; feeling of helplessness; feeling of boredom; feeling of depression due to being isolated; stigmatization of being positive infection; possible anger and aggression against government; unnecessary approaching the courts, possible mistrust on information provided by government; relapses of mental illness in already mentally-ill patients; overstress on people to cover work of infected colleagues, quarantined for 14 days; and insufficient or incomplete information leading to myths and fake news.

If the anxiety is not tackled what will happen?

Normal people will buy masks, get the tests done, get admitted and finish resources meant for high risk persons.

How many countries and continents are affected as on today?

67 countries and all continents except Antarctica.

Does it affect the doctors also?

As on 14th Feb, 1,716 medical workers have contracted the virus and six have died in China; 1,502 belong to Hubei Province, with 1,102 from Wuhan.  The number amounts to 3.8% of China’s overall confirmed infections as of Feb. 11 with 0.3% deaths. On18th Feb, Director of Wuhan Hospital died.  Over 3000 workers have been involved so far. Two workers who were sent to Wuhan in January end to help build new hospital got infected.

What is the seriousness profile?

It causes mild illness in 82%, severe illness in 15%, critical illness in 3% and death in 2.3% cases. About 6% patients admitted in ICU require mechanical ventilation, or died [NEJM].

 How many deaths occur in patients without comorbidity?

No deaths have occurred among those with mild or even severe symptoms.

How much time does it take to recover?

People with mild illness recover in about two weeks; those who are sicker may take three to six weeks to recover. 

In which cases it is riskier?

It caused death in 15% of admitted serious cases.  About 71% deaths are in patients with comorbidity. [72,314 Chinese cases, largest patient-based study, JAMA]

COVID-19 Fatality Rate by COMORBIDITY:

Percentage does not represent the share of deaths by pre-existing condition. It represents, for a patient with a pre-existing condition, the risk of dying if infected by COVID-19.

Pre-existing condition       Death Rate/confirmed cases  Death Rate/ all cases

Cardiovascular disease                                   13.2%                  10.5%

Diabetes                                                          9.2%                  7.3%

Chronic respiratory disease                            8.0%                    6.3%

Hypertension                                                  8.4%                   6.0%

Cancer                                                             7.6%                  5.6%

No pre-existing conditions                                                          0.9%

(Source: https://www.worldometers.info/coronavirus/coronavirus-age-sex-demographics/) 

 

What is the case fatality of COVID-19?

  • 2% overall
  • Wuhan 4.9%
  • Hubei Province 3.1%
  • Nationwide in China 2.1%
  • Other provinces 0.16%.
  • NEJM report - 1,099 cases from China, lower rate found: 1.4%. The death rate may be even lower, if there are several mild or symptom-free cases that have not been detected. The true death rate could  be like that of a severe seasonal flu, below 1%.
  • Case fatality 10% in Iran; probably they are underreporting mild cases.

Why did the first Chines doctor die?

Li Wenliang, 34, while treating patients was possibly exposed to a large blast of the virus. (Denver Post)

 What is the case fatality as per the age?

The percentage   does not represent share of deaths by age group but represents, for a person in a given age group, the risk of dying if infected.

AGE                            Death Rate/ Confirmed cases         Death rate/ all cases

80+                              21.9%                                                              14.8%

70-79                                                                                                   8.0%

60-69                                                                                   3.6%

50-59                                                                                   1.3%

40-49                                                                                   0.4%

30-39                                                                                   0.2%

20-29                                                                                   0.2%

10-19                                                                                   0.2%

0-9                                                                                       no fatalities

(Source: https://www.worldometers.info/coronavirus/coronavirus-age-sex-demographics/) 

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)

 Why elderly people are at risk?

The elderly and the sick may have an immune response that is dangerous. This is referred to as a cytokine storm. There is an overproduction of immune cells that flood into the lungs, causing pneumonia, inflammation and shortness of breath.

People in which occupation are at risk of death?

Patients who reported being retirees appeared to have the highest case fatality rate (5.1%).

 Does it affect all sexes?

Nearly 56% are males. Although men and women have been found to be infected in roughly equal numbers, the death rate among men has been noted to be 2.8%, compared with 1.7% among women.

Does it affect all ages?

87% aged 30-79

10% aged < 20

3% aged > 80

What is the incubation period?

  • Variable, 2-14 days (mean 3 based on 1,324 cases, 5.2 days based on 425 cases, 6.4 days in travellers from Wuhan)
  • An incubation period of 24 days has been observed. WHO said that it could point to a second exposure rather than a long incubation period. Hubei Province local government on Feb. 22 reported a case with an incubation period of 27 days. 

What are the different numbers?

  • 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
  • Reproductive number (R0 or R not): Number of persons infected by one infected person - In COVID-19 it is 3-4
  • R0 of flu: 1.2
  • R0 of SARS: 2
  • Epidemic doubling time: 7.5 days
  • Epidemic doubling time in South Korea: 1 day, probably due to super-spreader
  • Epidemic tripling time in South Korea 3 days; again due to a super-spreader.

 What is the positivity rate in contacts who are tested?

UK 0.2%, Italy 5.0%, France 2.2%, Austria 0.6% and USA 3.1%.

 Which countries one should not travel to?

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 South Korea, Iran, Italy (Do not travel)

 Is it a Zoonotic disease?

It is 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. 

Is it linked to bats?

This new coronavirus has a close relation with bat coronaviruses. Bats are the primary reservoir. While SARS-CoV was transmitted to humans from exotic civet animals in wet markets, MERS-CoV transmitted from camels. The ancestral hosts were probably bats; however. 

Snakes and pangolins have been thought to be the intermediate host. One thing is clear, the origin is from a mammal.

What are different types of transmissions?

  • Droplets, large > 5-micron organisms - flu, coronavirus.
  • Air borne, < 5-micron organisms - TB, chicken pox, measles.
  • Contact on the surface: COVID-19, SARS, Flu [It may be possible to contract COVID-19 by touching a surface or object that has the virus on it and then touching your own mouth, nose, or possibly eyes]

 Which are more important - droplet precautions or contact precautions?

Both. In community spread, contact precautions become more important. In SARS, in Hong Kong, the contact precautions worked more than the droplet precautions.

 Can it transmit from pregnant mother to the baby?

There is no or little evidence to support the possibility of vertical transmission from the mother to the baby. [Lancet Feb 20]

Which part of the respiratory tract is affected?

  • Both upper and lower respiratory tract.
  • URTI causes fever with sore throat and mild cough.
  • LRTI causes fever with cough, and breathlessness.

Which is more contagious LRTI or URTI?

  • COVID-19 uses the same cellular receptor as SARS-CoV (human angiotensin-converting enzyme 2 [hACE2]), so transmission is likely after signs of lower respiratory tract disease develop.
  • COVID-19 thrives 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 SARS-CoV.

Why LRTI is more infectious?

  • 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 that 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]

What is the clinical presentation?

  • Clinically all patients have fever (subjective or evident). No fever no coronavirus.
  • 75% have cough
  • 50% have weakness
  • 50% have breathlessness
  • Low total white count
  • Deranged liver enzymes.
  • It starts with fever, followed by a dry cough. A week later, it can lead to shortness of breath, with about 20% of patients requiring hospital treatment.COVID-19 infection rarely seems to cause a runny nose, sneezing, or sore throat (observed in only about 5% of patients). Sore throat, sneezing, and stuffy nose are most often signs of a cold.

 How many need admission and ICU care?

About 20% need ICU care and 15% of them are fatal.  Cases categorized as critical have the highest fatality rate—at 49.0%.

What is the treatment?

Symptomatic; though chloroquine, anti-viral and anti-HIV drugs have shown some efficacy.

What do you mean by Public Health Emergency of International Concern?

COVID-19 was declared a PHEIC on 30th Jan 2020 which means it is mandatory to report each human and animal case to WHO.

Is it the first time that a PHEIC has been declared?

No, Prior 5 PHEICs are:

  • 26th April 2009 - 10th August 2010 Swine flu
  • May 2014 Polio: resurgence of wild polio
  • August 2014 Ebola: First PHEIC declared in a resource-poor setting
  • Feb 1, 2016 to 18 Nov 2016 Zika
  • 2018–20 Kivu Ebola

 

 

What is Public Health Emergency of a state?

 

  • Kerala declared it when it had three cases and later lifted it on 12th
  • San Francisco declared it even without a case on 26th
  • Washington declared a state emergency on 1st

 

 

Did China delay in reporting of cases?

 

  • While there were 300 cases and 5 deaths with SARS before the Chinese government reported it to the World Health Organization, there were merely 27 cases and no deaths with COVID-19 before it was reported to the agency.

 

  • Chinese authorities imposed lockdown measures on ten cities in an effort to contain the outbreak of coronavirus and built a specialized hospital [Huoshenshan Hospital] in just 10 days as part of its efforts to fight coronavirus. A second facility with 1,500 beds is also being opened. During SARS in 2003, a facility in Beijing for patients was constructed in a week.

 

What are lab-confirmed cases?

Positive throat swab test.

 

What are CT-positive cases?

CT showing pneumonia like changes.

What is total number?

  • Lab-confirmed + CT-diagnosed cases
  • This was the criteria used from 12-19 February in China.
  • Before and after that, only lab-confirmed cases are counted.
  • Sudden jump in deaths and new cases on 12th Feb was due to inclusion of CT-diagnosed cases.

 

What will be the estimated deaths if CT-diagnosed cases were also included?

Around 5% deaths will get added to total deaths.

 

What are the possible modes of spread? Myths and facts

  • Person-to-person: The virus can spread from one person to another, most likely through droplets of saliva or mucus carried in the air for a distance of up to six feet when an infected person coughs or sneezes, or through viral particles that can be transferred on shaking hands or sharing a drink with someone who has the virus.
  • Casual exposure: No, human-to-human contact requires prolonged contact (possibly ten minutes or more) within three to six feet. But with contact transmission, this may not be applicable.
  • Currency notes: 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 banks must be disinfected before being released to customers.
  • Fabric, carpet, and other soft surfaces: Currently, there’s no evidence.
  • Hard surfaces: Virus could be present on frequently-touched surfaces, such as a doorknobs, although early information suggests viral particles would be likely to survive for just a few hours (WHO).
  • Biometric attendance: Maharishi Valmiki Hospital in Delhi stops biometric attendance.
  • Kissing: Kissing scenes have been banned in movies in China.  France has advised to cut back on “la bise,” the custom of giving greetings with kisses, or air kisses, on the cheeks.
  • Breath analyzer for alcohol: Kerala exempted air crew from breath analyzer tests
  • Public gatherings: Affected countries have banned death ceremonies, people gatherings.
  • Uncovered eyes: The transmission is through mucus membrane contamination. One case got infected while using gown, but eyes were not covered.
  • Eating meat, fish or chicken: It’s not a foodborne 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 foodborne illnesses. Eating fish and chicken is safe.
  • Eating snakes or drinking bat soups: No, 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; 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.
  • Sex, like EBOLA and ZIKA: We have no evidence yet.
  • Goods from affected areas: People receiving packages from China or other affected areas are not at risk of contracting the COVID-19 as the virus does not survive for long on objects, such as letters or packages.
  • Pipes: Ventilation system connects one room to the other. There have been concerns that the coronavirus can spread through pipes.
  • Stress: Stress and anxiety suppress the immune system, thus rendering people more vulnerable to contracting the virus. 
  • Patients without symptoms: 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.
  •  

 

What is no contact policy?

 

Greeting people by namaste, bowing or elbow touch. Corona Namaste is a no contact policy in public. Let’s not shake hands; IMA and CMAAO promote the concept of Corona Namaste.

 

Why the cases did not occur in other countries in the initial phase?

Initial serious illness in other countries was less as patients with breathlessness were unlikely to board and patients with mild illness or asymptomatic illness are less likely to transmit infections. For transmission, you require cough secretions or nasal discharge.

 

Should we fear?

 

It’s time for facts, not fear; for rationality, not rumors and for solidarity, not stigma.

 

What is the Help line number?

23978046

 

What is a biphasic infection?

 

Coronavirus follows a biphasic infection wherein the virus persists and causes a different set of symptoms than those noted  in the initial bout. The recovered person can also develop other symptoms, including insomnia and neurological problems, said Angela Rasmussen, a virologist at Columbia University. (NY Times)

What is a spreader and a super-spreader?

Spreader: An infected person with normal infectivity.

Super-spreader

  • An infected person with high infectivity, can infect hundreds of cases in no time. What causes a person to become a super-spreader is not known; HIV person becomes a super-spreader if he or she is coinfected with STI.
  • The examples are the first case in Wuhan, a female in the South Korea Daegu fringe Christian group Shincheonji Church where she infected more than 51.
  • In the church, people shout out amen after every sentence the pastor says, pretty much every few seconds, at the top of their lungs. This sends respiratory droplets flying everywhere.

What can be the cause of a cluster of cases or a hot spot without a super-spreader?

People catching the virus from infected surfaces. We don’t know how long the germs stay on surfaces, but similar viruses can live for a week.

What are the various clusters of corona viruses?

  • The largest cluster was Wuhan itself where over five crore people were locked down ending up with over 2000 deaths.
  • The second largest lockdown was in Japanese Diamond Princess ship where over 3000 patients were locked up and 23% of them developed COVID-19 virus infection.
  • The third example - the cult church in South Korea - where one lady infected with the virus spread it to over 30 people attending the church and she also infected multiple people in a hospital where she was treated and one person later died.
  • Shandong province in China reported of 207 cases of the new coronavirus in Rencheng prison as of Feb. 20. A jail in the Zhejiang province reported 34 infections. All of them were inmates.  A jail will behave like a ship and end up with 21% getting infected.

 

Can the court take ognizance in coronavirus epidemic?

 

  • 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)

 

  • A court temporarily prevented the U.S. government from sending nearly 50 people infected with a new virus from China to a Southern California city for quarantine after local officials argued that the plan lacked details about protection of the community from the outbreak. (Washington Post)
  • Hong Kong police has caught a part-time security guard at a shopping mall for allegedly writing on social media that multiple staff members had caught a fever and gone on sick leave. The messages caused panic and helped create paranoia. (The Print)The government blamed rumour-mongers for fuelling a run on goods at supermarkets .
  • Singapore has announced severe penalties for non-compliance of the quarantine order, including fines or jail time.
  • Prosecutors may investigate the founder and top leaders of Shincheonji Church of Jesus. Its members account for >60% of confirmed cases in the country. They may be probed on murder and other charges for failing to provide an accurate list of church members and by interfering with the government’s efforts to fight the outbreak.
  • IPC: Section 270 in the Indian Penal Code: 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.

 

What do you mean by the word corona?

 

‘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.

 

 

What is the composition of this virus?

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

 

What are other dreaded coronaviruses?

 

  • COVID-19 is 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 virus is 75 to 80% identical to the SARS-CoV

 

Where did it originate?

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

 

Will this virus survive heat?

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.

 

Did it originate from the WUHAN bio terror lab?

 

Unlikely; nobody will procedure bioweapon to be used on themselves or without simultaneously making an anti-weapon or antidote. It’s a myth that the virus was part of Chinas "covert biological weapons programme" and may have leaked from the Wuhan Institute of Virology and was linked to the suspension of a researcher at Canadas National Microbiology Lab. 

 

Is it true that China killed 20,000 COVID-19 patients?

 

It’s a fake news linked to a diversion to a sex site.

 

In initial days does it has 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]

 

Was Diamond Princess ship quarantine a successful model?

 

  • Does not look like as 23% of cases got infected.  705 cases got the virus and 6 deaths and 36 patients are still serious as on 1st This would mean 6 + 36x15 = 1-12 cases will die.  
  • 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.

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  • The longer several thousand people are placed together, waves of infection are propagated.
  • A better way to quarantine is to divide the people into smaller groups and quarantine them separately. Why quarantine children < 15 years of age when the virus is not risky for them and why not separate elderly people with comorbid conditions at high risk of death and quarantine them separately in one to one or small groups.

 

 

How long was the quarantine in the ship?

14 days for the passengers and another 14 days for the crew who took care of the people during the first 14 days.

 

What are different ways to control the infection in the community?

  • Lockdown in China: Unprecedented quarantines across Hubei, locking in about 56 million people, to stop it from spreading. Results 2% deaths.
  • Locking of a village in Vietnam: More than 10,000 people in villages near Vietnams capital placed under quarantine on 13th February after six cases of the new coronavirus were identified there. These cases did not become a hotspot probably; there was no super-spreader in those cases. Only 16 cases so far.
  • Kerala model of containment in India: Hospital one-to-one quarantine of infected patients and individual home quarantine of contacts. They could contain the virus in the state.

 

Was it correct for India to have cultural evenings by quarantined people brought from China?

 

It was risky to allow people to celebrate and have cultural programs during quarantine. As was seen in India, people danced together with surgical masks during quarantine period.

 

Is there a role of quarantine in the sunlight?

Quarantine patients like 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.

 

What should one wear at the triage section of emergency room?

Surgical 3-layered mask for patients; Isolation of two beds with at least three feet distance; Cough etiquette; Hand hygiene for all.

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What are different precautions?

  • 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: When 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) should be used by all.

 

What are the precautions for general public?

  • Strict self-quarantine if sick with flu-like illness: 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: (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.

 

Which masks for which patients?

  • Surgical 3-layered masks: For patients and close contacts
  • N 95 Masks: For healthcare providers when handling respiratory secretions.

 

What are the lab tests?

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