As expected, a wave of 18 cases on 10^th March in India, Kerala under lock down

Indian scenario

On 10th March, it was confirmed that three more people in Karnataka, including wife and child of the infected Bangalore techie, were diagnosed with the virus.

Kerala reported six new cases in Pathanamthitta, all of whom were linked to the five previously confirmed cases from the town.

Three more people in Pune, who had come in contact with the infected couple from the city, tested positive.

Both parents of the infected three-year-old child in Ernakulam have also tested positive.

Another case was confirmed in Jammu and Kashmir, with the nation-wide toll reaching 62.

Current scenario: 62 cases, 12 states  (Delhi 4, Uttar Pradesh 9, Haryana 14, Rajasthan 2, Telangana 1, Kerala 17, Ladakh 2, Tamil Nadu 1, Jammu and Kashmir 1, Punjab 1, Karnataka 4, Maharashtra 5)

High risk areas: UP, Kerala, Delhi, Maharashtra, Haryana, tourists destinations

Active: 58

Serious: Zero

Cured: 4

Community spread: zero

Super-spreader: Zero

New wave as expected came on 10^th March with 18 new cases; wave to continue on next 2 days; next expected wave around 16^th March

Men are affected more than women

Age group (3-45 years)                      

Delhi age group: 45, 25, 52, 25

ICMR: Testing across 52 labs (ICMR-National Institute of Virology, Pune is the apex laboratory for reconfirmation of any positive samples); additionally, 57 other labs to help with sample collection

Indians abroad: 17 cases (16 cases reported from Japan on the Diamond Princess cruise ship and one from the UAE)

 Global scenario

• Countries affected: 119
• Continents affected: all, except Antarctica
• Cases: 119176 cases (5% extra if CT diagnosis is taken)
• Deaths: 4295 deaths
• Recovered: 66617
• Currently infected: 48264
• Mild: 42217 (87%)
• Serious: 6047 (13%)
• Likely deaths (4295 + 6074 x 15 = 911 ) = 5206
• Likely deaths in Italy: 763
• Deaths in 26 countries
• 40,000 cases outside China
• Epidemics in China, Iran, Italy, South Korea, France, Spain, Germany and USA with >30,000 cases
• Public health emergency of international concern declared within a month after the first reported cases, as a result of the signs of human-to-human transmission outside China (30^th January)
• Global risk raised to the highest level of alert (28^th February)
• 10^th March: A near uneven controllable pandemic

COVID-19 Sutras

Disease: Coronavirus disease or COVID-19

Virus: SARS-CoV-2 virus (names used when communicating with the public “the virus responsible for COVID-19” or “the COVID-19 virus”)

Symptoms: fever, tiredness, and dry cough (most common); only cough (pollution), cough and cold (allergy), fever with sore throat in children (streptococcal), fever above 100.4 with cough and cold (flu), fever with cough and breathlessness (coronavirus-like illness), cough > 2 weeks - rule out TB

No fever no flu no coronavirus: No breathlessness no seriousness, no breathlessness no oxygen requirement no seriousness

Corona Namaste is better than elbow touch

Hygiene: Maintain a social distance of 1 meter from a person with cough and cold; wash hands (Remember the mnemonic SUMAN K - seedha ulta mutthi anghuta nakhun kalai) with soap and water or 70% alcohol based sanitizer, disinfect surfaces, use surgical masks, if infected (symptoms especially coughing or looking after someone who may have COVID-19).

 All doctors: to carry SPO₂ monitor to detect early serious cases

Suspect a coronavirus case: Fever or signs/symptoms of lower respiratory illness (cough or shortness of breath) AND any person, including health care workers who has had close contact with a lab 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 a history of travel from affected COVID-19 countries within 14 days of symptom onset; Fever with severe acute lower respiratory illness (SARI, pneumonia, ARDS) requiring hospitalization and without alternative explanatory diagnosis (e.g., influenza) AND no source of exposure has been identified.

Probable case: A suspect case with inconclusive testing for 2019-nCoV or testing was positive on a pan-coronavirus assay

Confirmed case: Lab confirmed irrespective of clinical signs and symptoms.

Epidemic cycle: First case, first cluster, first community spread

Epidemic cycle: Contain, Delay, Research and Mitigate

What to do: If you have fever with dry cough with or without breathlessness, self-isolate (quarantine yourself at home), wear surgical mask, do frequent hand wash and call your doctor.

Isolate all infected patients. They need to wear surgical mask.  

Isolate (quarantine) at home all close contacts, call them twice daily, counsel them; no testing required if there are no symptoms, test if symptoms develop.

Avoid cohort (clusters) of asymptomatic close contacts without masks (Diamond Princess: 696 in cohort ended with 23% getting the infection and 7 deaths, 32 still serious)

Treatment: Avoid self-medication; Btart Tamiflu when symptoms appear and stop if COVID-19 is negative.

CDC: Any American can be tested, no restrictions, subject to doctor’s orders

It’s not flu: It’s a lung disease, not a stuffy nose disease. Clinically all patients have fever, 75% have cough; 50% have weakness; 50% have breathlessness with low total white count and deranged liver enzymes; runny nose is seen only in 4% cases; 20% need ICU care and 15% of them are fatal. Treatment is symptomatic though anti-viral (remdesivir) and anti-HIV drugs (lopinavir/ritonavir) have shown some efficacy.

Retirees had the highest case fatality rate at 5.1%.

Mild case means a positive test, fever, shortness of breath, and possibly even pneumonia, but not bad enough to need hospitalization or oxygen.

Severe case:  Once the need oxygen arises, it is said to be severe category.       

Color Coding by China: Red code: Remain in quarantine for 14 days; Yellow code: Stay indoors for 7 days; Green code: Free to move about as they please.

Avoid mass gatherings: > 1000 people, in smaller gathering - first ask “I hope no one is here with fever and cough, if yes, kindly leave or wear surgical mask”

 Travel

• Indian citizens have been advised to abstain all travel to China, Iran, Republic of Korea, Italy and Japan and are advised to avoid non-essential travel to other COVID-19 affected countries.
• All international passengers entering into India need to furnish duly filled self-declaration form (including personal particulars i.e. phone no. and address in India) to Health Officials and Immigration officials and undergo Universal Health Screening at the designated health counters at all points of entry.

 (MoHFW)

Dos: hand washing, avoid sick people, avoid touching eyes, nose and mouth with unwashed hands, cover nose and mouth with tissue when coughing or sneezing.

Don’ts: Avoid close contact if cough and fever, do not touch eyes, nose and mouth, avoid spitting in public.

COVID-19 – All you need to know

• Possibly behaves like SARS, but more contagious and less lethal
• Near pandemic, PHEIC
• Respiratory virus, not a GI virus
• Affects all sexes but predominately males (56%)
• Death rate - males 2.8%, females 1.7%
• Causes mild illness in 82%; Severe illness in 15%; Critical illness in 3%
• Death 3.4 % (as on March 3)
• Deaths: 15% serious cases; 71% with comorbidity. About 71% deaths are in patients with comorbidity due to cytokine storm. [72,314 Chinese cases, largest patient-based study, JAMA]
• CAD patients most at risk [CAD 10.5%, Diabetes 7.3%, COPD 6.3%, HT 6%, Cancer 5.6%, no pre-existing disease (0.9%)]
• Healthcare provider infections: China 3.8%, 0.3% deaths; Singapore Nil
• Deaths 10% in Iran (under reporting)
• South Korea (0.6%) doing more tests in mild cases
• Age affected: 87% (30-79), 10% (< 20), 3% (> 80)
• 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, SARS 2)
• Epidemic doubling time 7.5 days; Doubling time in Korea 1 day, probably due to super-spreader; Tripling time in Korea 3 days
• Positivity rate% - UK 0.2, Italy 5, France 2.2, Austria 0.6, USA 3.1
• Origin: Probably from bats (mammal; central hosts), snakes and pangolins (intermediate hosts); possible animal sources of COVID-19 not yet confirmed
• Spread: Large droplets
• Spread: Predominately from people having LRTI
• Precautions: Standard droplet precautions for the public and close contacts; airborne precautions for healthcare workers dealing with secretions.
• Incubation period 2-14 days; Mean incubation period: 5.2 days
• Recovery time: Mild cases 2 weeks, Severe cases 4-6 weeks
• Case fatality in different age groups: 80 + = 14.8%; 70-79 = 8%; 60-69 = 3.6%; 50-59 = 1.3%; 40-49 – 0.4%; 10-39: 0.2%; < 9 years: nil

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)

Spread

• Person-to-person spread through respiratory secretions via mucus membrane within a distance of 1 meter
• Person-to-person spread through hand shakes
• Fabric, carpet, and other soft surfaces: Currently there’s no evidence.
• Hard surfaces: doorknobs etc. - likely to survive for just a few hours (WHO).
• Non-porous surface: 1-2 days and porous surface: 8-12 hours
• Casual exposure: Human-to-human contact requires prolonged contact (possibly 10 minutes or more) within 3 to 6 feet.
• Currency notes: The central banking authorities of China are disinfecting cash to stop the spread
• Biometric attendance: Suspended in India
• Kissing: Kissing scenes banned in movies in China; France cuts back on “la bise
• Breath analyser for alcohol: Kerala exempted air crew
• Public gatherings: Affected countries have banned death ceremonies, public gatherings.
• Uncovered eyes: The transmission is through mucus membrane contamination. One case got infected while using gown, but eyes 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. But it is in your best interest 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: Eating wild animals cannot cause it. Handling their secretions can cause it.
• Handling wild animals or their meat: Yes, if their secretions are handled.
• Semen: We do not know yet for the new coronavirus (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).
• Sexual transmission like Ebola and Zika infected cases: No evidence yet.
• Goods from affected areas: People receiving packages from affected areas are not at risk
• Pipes: Ventilation systems connect one room to the other. There has been concern 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 infect intrapulmonary epithelial cells more than cells of the upper airways. 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.
• Corona beer: It has nothing to do with coronavirus. It’s a brand of beer.
• Minimal risk in plane: window seat
• Airports more at risk: pipes, AC, international travelers, close surface contact; wear gloves when in doubt
• All TV panelists: wear disposable earphones

Travel warning levels

• 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)

Formula of C: Corona; COVID; CHINA Pneumonia (early name); CONTAINMENT policy; break CHAIN of transmission; 1st Case; 1st Cluster; 1st Community spread; New Case; Avoid COHORT of CLOSE CONTACTS; CAP price of essential items; CONTACT tracing;  CARE of the elderly, CONVINCE patients to wear surgical masks; COUGH not to be ignored, CDC guidelines; CHAOS to be avoided; CHLOROQUINE can be tried; COLOR CODING (Red, Yellow, Green); Stay CONNECTED with updates; Know COUNTRIES not affected; CRITICAL cases; No CONTACT policy; CHECK list of hospitals; CHECK points (all ports of entry); COLLECTIVE action; 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 CRTICIZE; CALM during illness; COMMUNICATION is the key; COMMITMENT of government; CAD patients are at highest risk; CHILDREN are less likely to die; COLD blooded animals are not the source; CLAIM of insurance should not be cancelled.

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?

• Healthy people will buy masks, get the tests done, get hospitalized and exhaust resources meant for persons who are actually at high risk.
• The younger population has more fear of getting quarantined for 14 days or fear of losing their beloved elderly ones with comorbid conditions.

 Legal aspect

• Despite CDC protest, 14 Americans infected with coronavirus on the Diamond Princess cruise ship shared a plane back to the US with healthy passengers, separated by plastic sheeting. (New York Post)
• A US court temporarily blocked 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 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.
• Singapore: Severe penalties for non-compliance of the quarantine order, including fines or jail time.
• Saudi Arabia is set to impose a fine of up to 500,000 riyals ($133,000) on people who do not disclose their health-related information and travel details at entry points (US News)
• Italy PM puts citizens on lock down and threatens them with a fine (206 euros; around £178) or jail (3 months) if they leave quarantine zones (Daily Mail UK)
• IPC: Section 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.
• Epidemic Disease Act, Essential Commodities Act, NLEM, Municipal corporation acts, state public health acts
• My rights to be tested

Treatments

• Throat swab or LRTI swab in viral VTM media
• CT scan more sensitive than RT-PCR for diagnosis (Feb. 26, Radiology)
• No drug approved in India
• Lopinavir plus ritonavir promising in lab in SARS.
• Lopinavir plus ritonavir plus recombinant interferon beta-1b in MERS.
• Scientists in Australia have reportedly recreated a lab-grown version of COVID-19.
• Chloroquine had potent antiviral activity against the SARS-CoV, has been shown to have similar activity against HCoV-229E in cultured cells and against HCoV-OC43 both in cultured cells and in a mouse model.
• In Thailand, oseltamivir along with lopinavir and ritonavir (both HIV drugs) has been used successfully.
• DCGI approved the "restricted use" of a combination of drugs (lopinavir and ritonavir)
• Remdesevir trials started on 6th Feb in China and late February in USA
• 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 (COVID-19 shares some similarity to HIV virus also)
• PVP-I mouthwashes and gargles have high potency for viricidal activity against hepatitis A and influenza, MERS and SARS
• In SARS, people were put on long-term steroids ending with immunosuppression and late complications and death. The current protocol is no or short-term treatment.
• Pneumococcal vaccine and Hib vaccine do not provide protection
• Regularly rinsing the nose with saline can hasten recovery from the common cold and dryness and can protect one from touching the nose.
• Mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth but cannot kill the virus
• There is no evidence that eating garlic protects people from COVID-19.
• Sesame oil does not kill the new coronavirus.
• Chemical disinfectants that can kill the COVID-19 on surfaces: Bleach/chlorine-based disinfectants or solvents, 70% ethanol, peracetic acid and chloroform.
• Antibiotics do not work against viruses.
• 1% bleach is good for surface disinfection
• Take 70 ml of 100% isopropyl alcohol and add 30 ml aloe vera gel or PEG and make sanitizer at home.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA