6^th March: CMAAO Update COVID-19 - SARS-CoV-2

India: 30 cases so far; Delhi, Noida, Gurugram, Agra, Jaipur, Kerala, Ghaziabad (5 states), 26 active cases, serious none, two clusters (driver + 16 Italians in Jaipur, 1 in Delhi +  6 relatives in Agra),  1 in Ghaziabad, 3 cured, 1 in Gurugram Paytm employee, 1 in Telangana, no community spread

17 Indians abroad infected with coronavirus: 16 cases reported from Japan on the cruise ship and one from the UAE.

Update: 89 countries affected, 98,420 cases, 3385 deaths, 55,622 recovered,  39,413 currently infected patients, 33,413 (84%) in mild condition, 6272 (16%) serious or critical, likely deaths ( 3385  + 6272  x 15 = 940 ) = 4325 with the present trend and available treatment, 10,000 cases outside China

Color Coding: Red infected persons, Yellow close contacts of infected persons, Green non-infected persons.

Red and yellow: Isolation and surgical masks

Green: Universal standard precautions

Near Pandemic: All continents except Antarctica affected,  cases- clusters- community spread; deaths in 15 countries; >15,000 cases outside China, epidemics in China, South Korea, Iran and Italy (81% cases), New cases outside China are 9 times higher than inside the country.

Coronavirus (COVID-19) Mortality Rate

March 5 

1. 3.4% mortality rate estimated by the WHO as of March 3
2. Mortality rate in China as of Feb. 20 estimated as 3.8% nationwide, 5.8% in Wuhan, 0.7% in other areas
3. Mortality rate in China as of Feb. 4 was estimated as 2.1% nationwide, 4.9% in Wuhan, 3.1% in Hubei, and 0.16% in other provinces, as reported by the NHC of China
4. Death rate among patients admitted to hospital (HFR): 15%
5. Comparison: seasonal flu generally kills way lesser than 1% of those infected.

 (https://www.worldometers.info/coronavirus/coronavirus-death-rate/)

Confirmed Cases and Deaths by Country, Territory, or Conveyance

The coronavirus COVID-19 is affecting 89 countries and territories around the world and 1 international conveyance (the Diamond Princess cruise ship harbored in Yokohama, Japan). 

Highlighted in green

= all cases have recovered from the infection

Highlighted in grey

= all cases have had an outcome (there are no active cases)

(https://www.worldometers.info/coronavirus/) 

Formula of ‘C’

• Corona, COVID start with ‘C’
• China Pneumonia was the earliest name
• Containment is feasible
• Chain of transmission needs to be broken
• 3 C’s: 1st Case, 1st Cluster and 1st Community spread whenever a new Case comes
• Avoid COHORT of Contacts
• Close contacts
• Cap price of essential items
• Contact tracing is the most important step
• Care of the elderly - they are at the highest risk
• Convince the patients to wear surgical masks
• Cough not to be ignored, can be corona or TB
• Follow CDC guidelines
• Chaos in Iran, do not let it happen in your country
• Chloroquine can be tried
• Color Coding: Red, yellow and Green is important
• Stay Connected with updates
• Know COUNTRIES not affected
• Critical cases: requiring mechanical ventilation has high mortality
• No CONTACT policy with social distancing
• Check list of hospitals
• Check points (all ports of entry)
• Collective action (government, associations, media) and CONTROLLED measures
• Condom: No evidence that it protects
• Congenital: No evidence of congenital COVID-19
• Clearing of antigen
• Complain: Section 270 of IPC
• Do not criticize if the disease happens
• Remain CALM during illness
• Communication is the key
• Commitment of government
• CAD patients are at highest risk
• Children are less likely to get infected and die
• COLD BLOODED ANIMALS ARE NOT THE SOURCE
• Claim: of insurance should not be cancelled

Main Points

• Isolate patients, avoid cohort (clusters) of contacts. Diamond Princess: 706 cases (23%), 6 deaths, 36 serious
• Ban export of masks, PPE, anti-viral, anti-HIV drugs. India has banned export of 26 drugs and drug ingredients, most of them antibiotics, without explicit government permission.
• Like Tamiflu, three prescriptions required to get masks, PPE
• Increase access to respirators for healthcare personnel
• Involve IMA, HCFI, FOMA
• “Today we will issue new guidance from the CDC that will make it clear that any American can be tested, no restrictions, subject to doctor’s orders,” Vice President Pence says. (NY Times)
• Flu vs. COVID-19: It’s a lung disease, not a stuffy nose disease. About 90% of the patients get a fever, 80% get a dry cough, 30% get shortness of breath and malaise. A runny nose is evident in only 4%, and this may involve people who also happen to have a cold or flu.  Mild case refers to a positive test, fever, shortness of breath, and possibly even pneumonia, but not bad enough to need hospitalization. Once the need for oxygen arises, it is considered as the severe category.
• DO’s: hand washing, avoiding sick people, and not touching the face with unwashed hands
• Insurance to pay

 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 [11^th February]
• Virus: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [11^th 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 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?

• 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.

Why so much fear when the mortality is < 1%?

The population is totally susceptible and in a country like India, with huge population, the deaths in numbers will be very high.

When deaths are less in people with age less than 50 years then why is there anxiety in younger population?

The younger population has more fear of getting quarantines for 14 days or fear of losing their beloved elderly ones with comorbid conditions.

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. On 18^th Feb, the 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 is it 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, a lower rate noted: 1.4%. The death rate may be even lower, if there are many 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 at 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 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 does it effects?

• 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<