What is COVID-19?

It is a type of infectious corona virus with high contagiousness and low mortality. The name China pneumonia was changed to COVID-19 as per WHO policy of not linking the name to a person, place or country.

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 21^st 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.
• 24^th Feb: Were in a phase of preparedness for a potential pandemic.
• 25^th 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?” [
• 29^th Feb: first US death in a patient with a community spread case.

What is a pandemic?

The WHO defines a pandemic as "the worldwide spread of a new disease."  Its also defined by a lack of available treatment, a lack of human immunity, and an ability to spread from person to person.

A pandemic disease spreads across "several countries or continents, usually affecting a large number of people," according to the US Centers for Disease Control and Prevention (CDC).

 Virus outbreaks can be characterized as a pandemic if the disease is "markedly different from recently circulating strains" and if "humans have little or no immunity" to it, according to the UKs Health and Safety Executive.

A disease becomes a pandemic when it can infect many humans over a large area, be transferred from person to person, and cause clinical illness.

 The term epidemic, by contrast, refers to a more localized or regional outbreak, rather than a global one.   The CDC says an epidemic is an "increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area."  Similarly, the WHO defines an epidemic as the "occurrence in a community or region of cases of an illness, specific health-related behaviour, or other health-related events clearly in excess of normal expectancy."

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.

How many countries are affected as on today?

64 countries

How many continents have been infected?

All except Antarctica.

How many cases have occurred as on today?

86,989 cases with 2977 deaths.

42,326 has recovered, 42,326 are currently infected

34,117 (82%) in Mild Condition and 7569 (18%) Serious or Critical condition

What are the likely deaths?

Current deaths (2977) + likely deaths (critical patients 7569 x15 =1135) = 4112 with the present trend and available treatment

Does it affect the doctors also?

As on 14^th 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. On18^th 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.

Does it behave like SARS or MERS?

It possibly behaves like SARS

 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 it takes 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.

71% deaths are in patients with comorbidity.

An analysis of 72,314 Chinese cases, largest patient-based study of the illnesses from the new virus, published JAMA, for people who are otherwise healthy, fewer than 1 percent died.  The death rate jumped to 5.6 percent for those with cancer, 6 percent for hypertension, 6.3 percent for chronic respiratory disease, 7.3 percent for diabetes and 10.5 percent for people with cardiovascular disease. The overall death rate was 2.3 percent. That likely an overestimate because people with mild cases may not have sought medical help, so weren’t included. 

Children under the age of 9 didn’t die.  But for patients between the ages of 70 and 79, the death rate was 8 percent. For those over the age of 80, it was 14.8 percent.

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.

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 the case fatality is 10% in Iran?Probably they are underreporting mild cases.

Why did the first Chines doctor died?

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

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.

 Which occupation person are at risk of death?

By occupation, 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?

Yes.

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 is the mean time to symptoms?

5 days

What is the mean time to pneumonia?

 9 days.

What is the mean time to death?

14 days

What is the mean time to CT changes?

 4 days

What is the reproductive number (R0 or R not)?

Number of persons infected by one infected person. In COVID 19 it is 3-4

What is the reproductive number of flu and SARS?

Flu 1.2

SARS 2

What is the epidemic doubling time?

7.5 days

Why the epidemic doubled time in S Korea was 1 day?

Probably due to super spreader?

What is epidemic tripling time?

In Kores it was 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 30^th 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:

• 26^th April 2009 - 10^th 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 12^th
• San Francisco declared it even without a case on 26^th
• Washington declared a state emergency on 1^st

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 12^th 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.

Can a person get the infection with a casual exposure?

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.

Can it spread through 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.

Can it spread by fabric, carpet, and other soft surfaces?

Presently, there’s no evidence that COVID-19, the new coronavirus, can be transmitted from soft surfaces like fabric or carpet to humans.

Can it spread by hard surfaces?

It’s possible that the 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).

 This also assumes that someone who is sick with the virus has touched a surface after sneezing or coughing into their hand or rubbing their eye. That’s why personal preventive steps like frequently washing hands with soap and water or an alcohol-based hand sanitizer, and wiping down often-touched surfaces with disinfectants or a household cleaning spray, are a good idea.

Can it transmit via biometric attendance?

Maharishi Valmiki hospital in Delhi stops biometric attendance

Can it spread by 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

Can it spread by breath analyser for alcohol?

Kerala exempted air crew from breath analyzer tests

Should be stop attending public gatherings?

Affected countries have banned death ceremonies, people gatherings.

Can patients without symptoms transmit the infection?

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.

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.

Can it get transmitted through uncovered eyes?

The transmission is through mucus membrane contamination. One case got infected while using gown, but eyes were not covered.

 Can it spread by eating meat?

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.

Can it spread by handling wild animals and wild animal meat?

Yes, if their secretions are handled by the animal handlers.

What is Corona Namaste?

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.

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)

Can corona be seen in the 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 others and keep the epidemic going

Can it spread by sex like EBOLA and ZIKA?

We have no evidence yet.

What is a spreader?

An infected person with normal infectivity.

What is a 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 cognigence in corona 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.

Does IPC cover spread of infection?

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.

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. 1^st case informed to the world by Dr. Li Wenliang who died on 6^th 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 1^st 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.

.

• 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.

Was the lockdown in China successful?

Unprecedented quarantines across Hubei, locking in about 56 million people, to stop it from spreading. Results 2% deaths.

What about locking of a village in Vietnam?

More than 10,000 people in villages near Vietnams capital placed under quarantine on 13^th 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.

What is the 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.

Can corona spread through pipes?

Ventilation system connects one room to the other. There have been concerns that the coronavirus can spread through pipes.

Can stress increase the chances of infection?

Stress and anxiety suppress the immune system, thus rendering people more vulnerable to contracting the virus. 

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.

What are 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.

What are 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.

What are airborne precautions when handling virus in the lab and while performing aerosol-generating procedures?

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?

There are two ways to detect a virus: through the genetic material DNA or RNA or 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.

What is the sensitivity of PCR test?

PCR tests may detect remnants of the measles virus months after people who had the disease stop shedding the virus.

What are the causes of false negative results?

• Negative test can come if the test is done poorly, or the samples are stored at a temperature at which the virus deteriorates. A throat swab may miss the virus that is present elsewhere in the body.
• A test is positive if the virus is present on the swab in sufficient quantities at the time of swabbing the person. A negative test is not a confirmation that there is no more virus in that person.

Can you give an analogy of a negative test?

A jam jar with mold on top. Clearing the surface might suggest that the jam is now mold-free, but the jar may still contain mold that continues to grow.

What samples to collect?

Both the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) and lower respiratory tract (LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage). Use viral swabs (sterile dacron or rayon, not cotton) and viral transport media

Can it be done by private labs?

Not yet in India.  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.

What precautions to take in the lab?

BSL 2 (3 for viral culture labs)

Is there any proven treatment?

No

Why pharma companies did not make SARS vaccine?

• With SARS, in 6 months the virus was gone, and it never came back. Companies may not spend millions to develop a vaccine for something which may never come back.

Can it cause secondary infection?

Secondary infection, such as E. coli, is most likely the cause of death of the patients in the Philippines and Hong Kong.

Which anti-viral have been tried?

• 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.

Have we been able to recreate lab grown version of the virus?

• Scientists in Australia have reportedly recreated a lab-grown version of COVID-19.

Is chloroquine effective?

• 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.

Is there any role of anti-HIV drugs?

• In Thailand, oseltamivir along with lopinavir and ritonavir, both HIV drugs, have been used successfully.
• 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.
• 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.

What is the role of experimental drug from Gilead Sciences Inc., called remdesevir?

On 6^th Feb in China and late February in USA trial has started.

How are they treating in China?

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. {the COVID 19 shares some similarity to HIV virus also)

Is there a role of PVPI?

PVP-I mouthwashes and gargles significantly 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

Is there a role of steroids?

• In SARS, people were put on long-term steroids ending with immunosuppression and late complications and death. The current protocol is short-term treatment.

Is one at risk of getting infection from goods for 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 long on objects, such as letters or packages.

Can dog get the virus?

There is no evidence that pet animals such as dogs or cats can be infected with COVID 19.

Is there a role of flu vaccine?

Pneumococcal vaccine and Hib vaccine does not provide any protection against COVID 19.

Is there a role of nasal saline droops?

Regularly rinsing the nose with saline does not protect people from infection with COVID 19 or respiratory infections although it can help people recover more quickly from the common cold.

Is there a role of mouthwash?

There is no evidence that using mouthwash will protect you from infection with COVID 19 although some brands or mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth. Keep your throat moist, avoid spicy food and load up on vitamin C can not kill the virus.

Is there a role of garlic?

There is no evidence that eating garlic protects people from COVID 19.

Is there a role of sesame oil?

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.

Who is more vulnerable?

People with pre-existing medical conditions (such as asthma, diabetes, heart disease) are more vulnerable to become severely ill with the virus.

Is there a role of antibiotics?

 Antibiotics do not work against viruses.

Is COVID 19 linked to Donald Trump?

 It’s a fake news that the virus is linked to Trump, US intelligence agencies or pharmaceutical companies.

Can avoiding cold or preserved food and drinks, such as ice cream and milkshakes, for "at least 90 days can help?

It has no scientific basis

Is it true that experts have been aware of the virus for years?

The virus is not new, its two deadly forma have already caused SERS and MERS in the world. These types of viruses will keep on coming.

What is the role of CMAAO and other Medical Associations?

Get prepared for containment measures, including active surveillance, early detection, isolation and case management, contact tracing 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

Price control of PPE; accreditation of private labs for testing; private insurance should cover the infection; IEC and CME activities to be intensified; allow paid leaves for airborne and droplet infections; allow teleconsultations in flu-like diseases; CSR funds for vaccine research; Surgical three-layered masks at public places; Start National program on respiratory secretions borne illnesses; in India, incorporate respiratory infection control under Swachh Bharat.

How to suspect a corona case?

 CDC has already revised it Criteria to Guide Evaluation of PUI (person under investigation) for COVID-19

• Fever or signs/symptoms of lower respiratory illness (cough or shortness of breath)            AND Any person, including health care workers who had close contact with a laboratory-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 history of travel from affected areas (China, Iran, Italy, Japan, South Korea) within 14 days of symptom onset
• Fever with severe acute lower respiratory illness (pneumonia, ARDS) requiring hospitalization and no alternative explanatory diagnosis (e.g., influenza) AND No source of exposure has been identified. (CDC)

What is a Probable case?

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

What is a confirmed case?

A person with laboratory confirmation of COVID-19 infection, regardless of clinical signs and symptoms.

What is 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. The elderly and immunosuppressed may have atypical symptoms. These patients have any no of dehydration, sepsis or shortness of breath.

What do you mean by close contact?

Close contacts are people providing direct care to patients, working with infected healthcare 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, living in the same household as an infected patient. The epidemiological link may have occurred within a 14-day period prior to or after the onset of.  But once the community spread occurs, the definition will no longer be correct.

What are primary cases?

Who got infected first in Wuhan in China.

What are secondary cases?

When the primary cases infected the second person and tertiary when the secondary cases transmitted to another person.

What is the primary case?

The first case in the China Wuhan in late December.

What is an index case?

The first case in any country or the province.

What is community spread?

Community spread means when the infection spreads without any contactable contact. Once that happens, closing borders will not contain the virus. All cases with flu-like illness will be presumed to be COVID-19 and only those  with breathlessness will be tested.

What are mitigation guidelines?

       Universal non-pharmaceutical interventions include personal practices, covering coughs and washing hands, as well as community and environmental measures such as surface cleaning.

• Universal community measures include social distancing, or limiting contact in face-to-face settings, closing schools, telework or tele school for children, and recommending modify, postpone, or cancel mass gatherings.
• In healthcare system triaging patients, conducting patient visits via telemedicine, and delaying elective surgeries.
• Commercial labs need to pitch in for testing.
• Better to be overprepared than underprepared.
• The testing criteria may change to testing only symptomatic cases and admitting cases only with breathlessness. (Probably Iran is doing this)

What are high risk countries?

China, Macau, Hong Kong, Taiwan, South Korea, Singapore, Italy, Iran, and Japan.  

Will Iran be the next China?

• With 54 deaths in Iran, looks like that Iran government is hiding the true extent of the outbreak. If the virus kills about 2 percent of known victims, then the number of cases should be 2100. In fact the death rates outside china are 1% and in that case the number will be much higher in Iran.
• Cases in Iraq, Afghanistan, Bahrain, Kuwait, Oman, Lebanon, United Arab Emirates and Canada have been linked to Iran. Millions of religious pilgrims, migrant workers and others cross the borders of Iran. each year - This is one of the biggest causes for worry in what threatens to become a global epidemic.

Will Afghan be the next source of carrying infection in India?

• Religious pilgrims, migrant workers, businessmen, soldiers etc. move constantly across Iran’s frontiers, often moving into countries with few border controls, weak and ineffective governments and fragile health systems.
• Many Afghanis are coming to India on a daily basis on health visa and many of them come via Iran. It is likely many of them would carry the virus to India.

Does the coronavirus spread person-to-person?

Yes, the virus can spread from one person to another, most likely through droplets of saliva or mucus carried in the air for up to six feet or so when an infected person coughs or sneezes, or through viral particles transferred when shaking hands or sharing a drink with someone who has the virus.

What is the role of 14 days quarantine?

Quarantines and travel restrictions currently in place in many counties intend to break the chain of transmission. Public health authorities may recommend other approaches for people who may have been exposed to the virus, including isolation at home and symptom monitoring