First reported Case: 10th January

Total cases and numbers are based on RT PCR test which has only 67% sensitivity (no false positive). Total number likely to be higher (5-33%)

GOOD NEWS: No new cases in South Korea or Hong Kong: Following months of imposing social distancing,. They are not the only ones on that path —Australia and New Zealand are also close. Beijing’s major tourist sites will reopen just in time for China’s extended holiday weekend.

Bad News:  After UK Prime Minister Boris Johnson, now Russia’s Prime Minister, Mikhail V. Mishustin, said that he was sick with COVID-19. Senior Trump administration officials have pushed U.S. spy agencies to look for evidence to support an unsubstantiated theory that the coronavirus outbreak started in a lab in Wuhan, China.

Situation Around the Globe

Likely minimum deaths (239588 + 51355 x 15 = 7703) = 247261   

Coronavirus Cases: 3,400,767

Deaths: 239,588

Recovered: 1,081,598

ACTIVE CASES: 2,079,581

Currently Infected Patients

2,028,226 (98%): in Mild Condition

51,355 (2%): Serious or Critical

CLOSED CASES: 1,321,186

1,081,598 (82%): Recovered / Discharged

239,588 (18%): Deaths

436 cases per million population (India 19)

30.7 deaths per million population (India 0.6)

India

India Cases 2^nd May 37257

Cases on 21^st 20080

Doubling time: 11 days

Expected Number: To cross 50,000 in one week

India Death Rate: 3.28%

World Death rate: 7.04 %

Death Rates: others on 1^st May

Europe 9.84 %

North America: 5.86 %

Asia 3.58

South America: 4.92

Africa: 4.12

Oceania 1.33%

Asia Mortality 5.7% (11 countries average 0.44; 10 countries average 1.6; 11 countries average 3.9; 3 countries average 9.6 and 3 countries (Isreal, turkey, Iran) average 41.3)

Europe: 131 Deaths per million population

North America: 42.88 Deaths per million population

USA: 186 Deaths per million population

India: 0.8 Deaths per million population

India, Pakistan, Nepal, Sri Lanka, Bangladesh: (0.8 + 1+ 0+0.3 + 0.9 = 0.60)

Others

1. Chinese scientists reported capturing tiny droplets containing its genetic markersin two hospitals in Wuhan, where the outbreak started. Scientists don’t know if it was capable of transmitting the virus. [Journal nature] Those are going to stay in the air floating around for at least two hours
2. Europe, face masks became mandatory on public transport and in most shops across Germany.
3. Health care workers, stigmatized as vectors of contagion because of their work, have been assaulted and abusedin several countries. In the Philippines, attackers doused a nurse with bleach, blinding him.
4. CDC has now added six moreconditions that may come with the disease: chills, repeated shaking with chills, muscle pain, headache, sore throat and new loss of taste or smell.
5. In India in states with average population density of 1185 /sk km, average number of cases were 2048. These when compared to states with population density of 909/ sk km the number of cases were 34.6. In these two sates (Chandigarh and Pondicherry) with high population density were taken out the Average Density of other states were 217 and the average number of cases were 35 [HCFI]

Revised COVID Sutras

It’s a COVID-19 Pandemic due to SARS 2 Beta Corona Viruses (different from SARS 1 where spread was only in serious cases); with three virus sequences floating (one similar to Wuhan, second similar to Iran and the third strain similar to USA – UK); has affected upto . 10%  (5.7 %  S Korea) of the population; Causes Mild or Asymptomatic Illness in 82%, Moderate to Severe Illness in 15%, Critical Illness in 3% and Death in 2.3% cases (15% of admitted serious cases, 71% with comorbidity< Male > Females); 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 5.2 days);  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 1.5 to 3  (Flu 1.2 and SARS 2), Epidemic Doubling Time 7.5 days; Origin Possibly from Bats (Mammal); Spreads via Human to Human Transmission via Large and Small Droplets and Surface to Human Transmission via Viruses on Surfaces for up to three days. Enters through MM of eyes, nose or mouth and the spike protein gets attached to the ACE2 receptors.  ACE2 receptors make a great target because they are found in organs throughout our bodies ( heart muscle, CNS, kidneys, blood vessels, liver) Once the virus enters, it turns the cell into a factory, making millions and millions of copies of itself — which can then be breathed or coughed out to infect others.

Prevalence: New York: 13.9%; New York City at 21.2%, S Korea 5.7%, world 5%

Fatality to infection rate: 0.5%

Ohio prison: 73% of inmates had virus

Town of Vo, Italy: 43% of people who tested positive showed no symptoms.

New York: 5700 patients hospitalized, 21% mortality rate, April 22 in JAMA.

Autopsy and biopsy reports: viral particles seen in tears, stool, kidneys, liver, pancreas, heart and CSF.

Thrombosis play a major role in lethal COVID-19 with clots everywhere: large-vessel clots, DVT, pulmonary emboli; clots in arteries, strokes; and small clots in tiny blood vessels in organs throughout the body.

Early autopsy: widely scattered clots in multiple organs. As per University of Pennsylvania s clots are happening at high rates even when patients are on blood thinners for clot prevention. In Netherlands study, 31% of patients hospitalized with COVID-19 got clots while on blood thinners.

Like Pandemic Influenza the SARS-CoV-2 virus is likely to enter long-term circulation alongside the other human beta-coronaviruses (which has immunity lasting only for one year with no IMMUNITY PASSPORT).

Recurrent wintertime outbreaks will probably occur. In absence of other innovations and interventions, the key successes will be prolonged or intermittent social distancing (till 2022-24) along with building up critical care capacities and surveillance till 2024 or more. 70% persons need to be immune for no outbreak to occur.

Longitudinal serological studies are needed to determine the extent and duration of immunity to the virus.  Consistent long-term immunity if detected will lead to effective elimination of the virus and lower overall incidence of infection BUT low levels of cross immunity from the other beta-coronaviruses against SARS-CoV-2 could make SARS-CoV-2 appear to die out, only to resurge after a few years. Therefore, even in the event of apparent elimination, SARS-CoV-2 surveillance should be maintained since a resurgence in contagion could be possible as late as 2024.

During the peak most important is to trace and treat the patients and after the peak most important is to trace and treat the close contacts (close physical contacts starting 2 days before the symptoms and contact time of more than 10 minutes).

Increased spread: close environment, crowded place with close physical contacts with no ventilation (singing choirs; sporting non ventilating complexes)    

Four phases are: No case; sporadic cases; cluster of cases and community cases. Aim is the shift to the left in any situation. Each one has a different containment strategy.

Containment: from community mitigation to individual containment; broader good over individual autonomy; perfect cannot be the enemy of the good; pandemics are fought on the grounds and not the hospitals.

Like other coronaviruses, most recovered people should develop at least a short-term immunity for a year. Virus may persist as a latent infection, like chickenpox, lying dormant in the body, only to re-emerge periodically as shingles does, or become a chronic infection, like hepatitis B, living within the body for a sustained period of time, causing long-term damage.

We must learn to live with corona now: Simple living. No show sha,  walk ro cycle shorter distances, prefer stairs than lifts, do not allow to smoke cigarette – bidi- of hooka in front of you; Wear long sleeve shirt; Carry hand sanitiser; do not shake hands or touch anyone; carry currency and coins in a plastic pouch; handle tickets in metro with care; wear gloves; maintain 3 feet social distance and do not meet strangers for more than  3 minutes.

HCW: Direct patient meeting time < 5 minutes; single surgeon direct OT surgical time < 30 minutes; 7 days work and 7 days holidays for front line staff, In Italy mortality reduced when they were short of ventilators.

Hospital at HOME: Patients who can be treated safely at home are those with congestive heart failure, pneumonia, exacerbations of asthma and COPD, cellulitis, and urinary tract infections.

COVID 19 clinically may present with

Classical symptoms (fever in all, cough 75% and breathlessness 50%); 26^th April: Fever, Cough, Shortness of breath or difficulty breathing, Chills, Repeated shaking with chills, Muscle pain, Headache, Sore throat, New loss of taste or smell.

Great Imitator (protean manifestation)

Brain: Encephalitis; Guillain Barry Syndrome (6 cases), seizures, confusion, meningitis, large vessel stroke (5 cases)

GI: Nausea, Diarrhoea, abdominal pain, small intestinal obstruction, loss of appetite,

ENT: Loss of smell and loss of taste (mild to moderate cases, may last for over a month), running nose,

Kidney: AKI (5%, tremendously catabolic with hyperkalaemia, hyperphosphatemia, and profound metabolic acidosis to a degree not seen in typical kidney failure patients)

Liver: Hepatopathy; Deranged liver enzymes

Musculo skeletal: Muscle aches, fatigue

Eye: Conjunctivitis, pink eye

Endocrine: Diabetes and hyperglycaemia without prior diabetes

Haematology: Thrombocytopenia (20.7%), Toxic Shock Syndrome in Children

Lab: Low total white count; low lymphocyte count (< 800 serious, < 1000 common)

Immuno-inflammation: High ESR, high CRP and high ferritin

Heart: Cardiac involvement in 10% (myocarditis, heart attack, heart failure with high Pro BNP, LDH, Troponin test)

Thrombi- inflammatory: Microvascular thrombosis (high D Dimer)

High Altitude: Severe hypoxemia with normal respiratory compliance (need oxygen not pressure)

Skin: Rash can be general rash consistent with viral exanthema, or consistent with superficial clotting in blood vessels close to the skin called “COVID toes," or pernio (small clots in toes and fingers, especially in children.)

Elderly: They may sleep more than usual or stop eating. They may seem unusually apathetic or confused, losing orientation to their surroundings. They may become dizzy and fall. Sometimes, seniors stop speaking or simply collapse.

Autopsy and biopsy reports, show that viral particles can be found not only in the nasal passages and throat, but also in tears, stool, vaginal fluids, the kidneys, liver, pancreas, and heart. One case report found evidence of viral particles in CSF in a patient with meningitis.

Insignificant Symptoms: Confused with ALI and Allergy

Pre symptomatic (20% of asymptomatic developing symptoms in 2-3 days.

Asymptomatic (6-70%)

Treat the patient and not the test report

1. Tests are based on molecular test (NAAT) and RT PCR for detecting the RNA

2. Antigen test to detect the viral fragments (currently active)

3. RT PCR is 67% sensitive in nasal swab only with no false positive.

4. Antibodies: IgM, IgG and IgA (positive only after 7 days) via ELIESA or RDT.

5. Antibodies are only for sero-surveillance and only for research purposes. They have no role for active diagnosis.

6. For active diagnosis the test is molecular tests (positive on day1).

7. IgM if positive needs confirmation with RTPCR (RDT IgM can be false positive in pregnancy, immunological diseases)

8. Pooled tests (< five persons) if the seroprevalence is < 5% (preferable < 2%. Reliability depends on no contamination, no mixing of samples, number of samples pooled. It is linked to success story of pooling in blood banks

9. 2 PCR required (if low viral load situations)

10. PCR can remain positive for 8 weeks (active RNA or inactive detectable virus RNA as reported by S Korea)

11. Samples which can be tested are: Respiratory material (upper and lower); stool, blood

12. Point of care molecular test if reliable is the need

No test is 100% sensitive or specific. In view of only 67% positivity of RT PCR test on nasal sample and unreliable rapid blood antibodies tests IgG and IgM and both with false negative and false positive known results, we cannot rely on the test report for the treatment.  

Like Acute flaccid paralysis is treated as Polio unless tested negative all cases of SARI (serious acute respiratory illness) and ALI should be notified and treated as Covid like illness even if detected negative or ends up with complications.

Clinical diagnosis should be backed by early treatment to reduce the viral load and prevent cytokine storm using off label use of drugs like hydroxy chloroquine with azithromycin; ivermectin, remdesivir; Tocilizumab interleukin (IL)-6 receptor inhibitor; convalescent plasma therapy ( given early; bridge compassionate therapy, donor 14 days symptoms free, single donation can help 4 patients), Lopinavir-ritonavir and Favipiravir).

Hypoxic patients should be treated with low flow oxygen < 6l/mt) up titrated to high flow oxygen using non breathing mask, Venti mask, HFNC and helmet CPAP, NAV in supine or prone position. Early intubation with prone ventilation only if progressive.

Hypoxia (walking dead) have capillary problem and not alveoli. Do not allow normal lung to hyperventilate di to loss of vasoconstriction protective mechanism.

Lung-protective ventilation:  Earlier on the patient is able to take deeper breaths without excessive lung stretch and may feel more comfortable in doing so; use a ventilator setting with a larger tidal volume but lower positive end expiratory pressure, or PEEP [5].

Future will be decided by vaccines like BCG (ICMR); Anti-Leprosy Vaccine called Mw Mycobacterium w or mycobacterium indicus pranii (CSIR and Cadila), Novavax (antigens derived from the Coronavirus spike (S) protein vaccine JV with Cadila), m RNA vaccines.

Unanswered questions: How long plasma antibodies will last in the recipient. 

Home COVID Equipments: Thermal Scanner; SPO2 Monitor; Oxygen concentrator.

Exercises to do: Start sleeping prone

Updates

• Tablighi Jamaat has contributed a large number in India, Malaysia and Shincheonji Church in S Koreacases.

• Singapore’s coronavirus surge is in the crowded dormitories where migrant laborers live.

• In Delhi all the 186 novel coronavirus cases found positive in the capital on 18th April were asymptomatic.

• In New York City in a universal testing of pregnancy trial they found 13.7 % were COVID infection (87.9% were asymptomatic and 12.1% were pre symptomatic)

• In India it is also affecting younger people (< 50 years) with mild symptoms

• All healthcare worker and on HCQS prophylaxis should fill the form https://www.surveymonkey.com/r/6KPW8CR

• Do not ignore polio, measles, rota virus, routine immunisation and TB notification. Isolate all MDR and TB positive cases till sputum negative

• Consider every surface and every asymptomatic person as virus carrier

• Post @ https://mobile.twitter.com/ChestImaging?s=08: Post COVID positive X rays, CT images.

• Collateral benefits: Reduction in air pollution, Clear Ganges, reduction in overall deaths (low pollution, less stress, more hygiene, no traffic accident deaths).

• ZIKA Brazil Model: Army used for the crisis. Keep Army at standby.

• Convalescent plasm therapy: start early to reduces viral load. One COVID recovered patient (2 weeks after antigen negative) can give it to four patients at a time (500Ml) and ten patients over time.

• Significant exposure to Covid-19: face-to-face contact within 6 feet with a patient with symptomatic Covid-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching Covid-19 from a passing interaction in a public space is minimal.

• Mask Policy

Health Care Workers: Tight sealed N 95, Polypropylene OR 3 ply (outer layer hydrophobic polypropylene, middle filter and inner layer hydrophilic) surgical mask

Or double protection surgical over N 95 or triple protection surgical- N95 and Surgical.

Revision 2 dated 18/04/2020 issued by CPCB: Isolation wards: (isolation wards)

Used PPEs:    Goggles, face-shield, splash proof apron, Plastic Coverall, Hazmet suit, nitrile gloves into Red bag  

Used masks:  3 layers mask, N95 mask, head cover/cap, shoe-cover, disposable linen Gown, non-plastic or semi-plastic coverall in Yellow bags.

General public: 2 layers cotton cloth mask with or without additional middle carbon layer mask when on the roads or bandana or a scarf.  Washable- dry-iron.  OR CPCB Guidelines-Revision 2 dated 18/04/2020: Used masks and gloves generated form home quarantine or other households should be kept in paper bag for a minimum of 72 hours prior to disposal of the same as general waste. It is advisable to cut the masks prior to disposal to prevent reuse.

Reuse: Limited availability. CDC has made a spreadsheet available that facilities can use to calculate their "burn rate," or average daily usage rate for PPE, using the change in inventory.

Optimizing the supply of PPE 

• Canceling non-urgent procedures or visits that would warrant use of PPE and favoring home care rather than hospitalization when appropriate.

• Limiting movement outside the patients room, prioritizing the use of certain PPE for the highest risk situations (eg, aerosol-generating procedures), and designating entire units within a facility to care for known or suspected patients with COVID-19 (ie, cohorting).

• Minimizing face-to-face encounters with the patient, which can be done by excluding nonessential personnel and visitors, limiting the number of people who examine the patient, using medications with extended intervals to reduce nursing encounters, and allowing some providers to perform telephone interviews with hospitalized patients. In some facilities, patients can convey needs to providers using tablets or other electronic interfaces, further reducing some in-person interactions.

• Utilizing alternatives to N95s, such as elastomeric half-mask and full-facepiece air-purifying respirators as well as PAPRs.

In a crisis situation, cautious extended or limited reuse of PPE may be reasonable. As an example, the same medical mask can be used for repeated close contact encounters with several different patients (assuming it is not visibly damaged or soiled). When this strategy is used, the provider should not touch or remove the mask between patient encounters, since the outside surface is presumably contaminated. If the provider does touch the mask, they must immediately perform hand hygiene. The CDC suggests that masks can be used for 8 to 12 hours whereas the WHO states medical masks can be used for up to six hours when caring for a cohort of patients with COVID-19.

Decontamination of PPE for reuse: N95 respirators and face shields

Ultraviolet light: Dose needed to inactivate the virus on a respirator surface is unknown. Nebraska Medicine has implemented a protocol for UV irradiation.

Hydrogen peroxide vapor – Duke University Health System is using hydrogen peroxide vapor. US FDA granted an emergency use authorization for use of low-temperature vaporous hydrogen peroxide sterilizers, used for medical instruments, to decontaminate N95 respirators.

Moist heat: Moist heat is applied by preparing a container with 1 L of tap water in the bottom and a dry horizontal rack above the water; the container was sealed and warmed in an oven to 65°C/150°F for at least three hours; it was then opened, the respirator placed on the rack, and the container resealed and placed back in the oven for an additional 30 minutes. No residual H1N1 infectivity was found. Several studies observed inactivation of SARS-CoV after 30 to 60 minutes at 60°C/140°F

Ethylene oxide: Off-gassing from ethylene oxide-treated PPE could be harmful to the wearer but some facilities have taken steps to verify safe concentrations prior to deploying this method.

If decontamination of PPE is done, staff should be cautioned to not wear makeup, use lotions or beard oils, or write on masks, as they make decontamination difficult or impossible.

Environmental disinfection: CDC states routine cleaning and disinfection procedures are appropriate for SARS-CoV-2.

Adjunctive disinfection methods, such as UV light and hydrogen peroxide vapor, are used in some facilities to disinfect the rooms that have housed or been used for aerosol-generating procedures on patients with COVID-19.

Environmental services workers who are cleaning areas potentially contaminated with SARS-CoV-2 should be trained to conduct the cleaning in appropriate PPE.  Workers should be fit tested and trained to wear N95 respirators and face shields (or PAPRs) when cleaning patient rooms that are or have been occupied by persons with known or suspected COVID-19 or have been used for aerosol-generating procedures on patients with COVID-19. Environmental services workers can use droplet and contact precautions, plus eye protection (surgical mask, face shield or goggles, gown, and gloves) when cleaning areas used by health care workers who are caring for COVID-19 patients.

The importance of environmental disinfection was illustrated in a study from Singapore, in which viral RNA was detected on nearly all surfaces tested (handles, light switches, bed and handrails, interior doors and windows, toilet bowl, sink basin) in the airborne infection isolation room of a patient with symptomatic mild COVID-19 prior to routine cleaning [41]. Viral RNA was not detected on similar surfaces in the rooms of two other symptomatic patients following routine cleaning (with sodium dichloroisocyanurate). Of note, viral RNA detection does not necessarily indicate the presence of infectious virus.

 Cloth mask – Wash, disinfect, dried and reused.

 Surgical mask – If it’s dry and the layers and shape are intact, put it in a zip lock pouch with a desiccated gel. The gel absorbs moisture and keeps the mask dry. If the mask is intact and not torn, it can be reused for 3 days. If it’s worn by an infected person, it should never be reused or shared.

 N95 respirator – When you are not using it, store it in a closed plastic container and dispose of and regularly clean the storage containers. When reusing the N95 respirator, leave a used mask in the dry atmosphere for 3-4 days to dry it out. Polypropylene in N95 is hydrophobic and contains zero moisture. 

COVID-19 needs a host to survive – it can survive on a metal surface for up to 48 hours, on plastic for 72 hours and on cardboard for 72 hours.

If the respirator is dry for 3-4 hours, the virus would not have survived. Best is to use four N95 masks and number them 1-4. On day 1 use mask 1, then let it dry for 3-4 days. On day 2 use mask 2 and then let it dry for 3-4 days. Same for Day 3 and Day 4.

Another method is to sterilize the N95 mask by hanging it in the oven (without contacting metal) at 70 degrees C for 30 min. Or use a wooden clip to hang the respirator in the kitchen oven.

N95 masks are degraded by UV light so keep them away from UV light or sunlight. Label the string of the mask with your name so that no one else uses it. Follow the guidelines provided by the manufacturer or use it maximum up to 5 times.

Extended use of N95 respirators

 Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters. Extended use may be implemented when multiple patients are infected with the same respiratory pathogen and patients are placed together in dedicated waiting rooms or hospital wards. Studies have shown that respirators can function within their design specifications for 8 hours of continuous or intermittent use.

When to discard the N95 respirator: Following use during aerosol-generating procedures; Contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients; Following close contact with any patient co-infected with an infectious disease requiring contact precautions; Consider the use of a cleanable face shield over N95 when feasible to reduce surface contamination of the respirator; Use a pair of clean gloves when donning a used N95 respirator and performing a user seal check. Discard the gloves after use properly.

• The cost of API used in hydroxychloroquine touched Rs 70,000 per kg, from Rs 6,500 per kg in February and of azithromycin has doubled to Rs 16,000 a kg. China is a major supplier of APIs.
• A six-day delay by China: On January 14, top Chinese officials sensed a pandemic. The head of Chinas National Health Commission, Ma Xiaowei, in a confidential teleconference with provincial health officials, said: "The epidemic situation is still severe and complex, the most severe challenge since SARS in 2003, and is likely to develop into a major public health event." Yet in the six days that followed, Wuhan hosted a banquet attended by thousands and millions of Chinese migrated within the country for the Lunar New Year celebrations. On January 20, President Xi Jinping warned the public, saying the outbreak "must be taken seriously". The same day, a leading Chinese epidemiologist, Zhong Nanshan, announced for the first time that the virus was transmissible from person to person on national television. But by then, more than 3,000 people had been infected.
• 12 days of silence added to the fuel: From Jan. 5 to Jan. 17, Chinas CDC did not register any case of pneumonia-like disease from local officials. Yet during that time, hundreds of patients were appearing in hospitals not just in Wuhan but across the country. On January 2, local officials of the Chinese Communist Party punished eight doctors for "rumour mongering" for warning friends on social media about the emerging SARS-like threat. One of the doctors, Dr. Li Wenliang, later died on Feb. 7.
• Two Chinese companies sold UK 2 M home test kits for $20 million on upfront payment on take it or leave it terms. The simple pregnancy test like option was a potential game changer but the tests did not work.
• More doubt on coronaviruss Wuhan origin: in a paper published earlier this month, geneticists said it may have started spreading as early as mid-September, and from elsewhere in China. (PNAS, Newsweek)
• US Secretary of State Mike Pompeo on Wednesday pressed China to allow inspectors into sensitive laboratories. Pompeo has refused to rule out that the deadly virus leaked out of a laboratory in the Chinese metropolis of Wuhan, a scenario strenuously denied by Beijing.
• As per a Lancet study, more than 232,000 people may have been infected in the first wave of Covid-19 in mainland China, four times the official figures, according to a study by Hong Kong researchers.
• The coronavirus crisis has killed more than 7,000 people at nursing homes across the country in USA
• To speed up, US FDA made a move to allow a free-for-all for developers to begin marketing antibody tests that had not gone through the agencys usual evaluation and validation process.  The result was a flood of more than 90 unapproved tests "that have, frankly, dubious quality. The FDA, has moved quickly into damage control, conducting evaluations of the tests in an effort to distinguish the potentially useful from the useless. So far, they have succeeded in issuing emergency use authorizations (EUAs) to only four tests, those marketed by Cellex, Ortho Clinical Diagnostics, Chembio Diagnostic Systems, and the Mount Sinai Laboratory.
• Beware of isopropyl alcohol, bleaching powder, disinfectants, IV Alcohol, IV disinfectants, bleach with ammonia (chloramine gas); bleach with IPA (form chloroform), bleach with vinegar or window cleaner ( chest pain) fatal poisoning.

  Quarantine models

 India: Early lock down for forty days

 Wuhan: Selective sealing of epicentre, isolate, contact monitor, elderly lockdown, bye time for infra structure,

 Vietnam: Sealing of a village with most cases

 Bhilwara CLUSTER: Seal 2 km all around, fumigate each house, house to house survey for ALI and SARI, isolate infected cases, test all close contacts

 Bird flu model: April 20, 2016, the Lebanonese Ministry of Agriculture found H5N1 in 2 poultry farms in the border of Lebanon with Syria. 20,000 domestic birds died. The ministry culled all (60K) domestic birds within a 3-km radius. All farms were disinfected, and organic remains were disposed safely.

 Germany, Sweden and Japan model: Selective isolation of elderly and high-risk comorbid patients

 S Korea: Intensify testing amongst all or high-risk group

 Italy: Deploy younger health care workers and women as front-line fighters (2 hospitals posted young doctors < 40 years, 60% women on duties with no mortality in healthcare workers)

 Singapore: Make available surgical masks at reception to be worn by all patients entering the hospital. Give N 95 masks to all health care providers and use AII rooms for all procedures on infected cases

 Germany:  Random testing for antibodies is key in Germanys strategy. (New York Times)

 AII rooms: Aerosol-generating procedures should take place in an airborne infection isolation room (AII) only. These are single-patient rooms at negative pressure relative to the surrounding areas, and with a minimum of six air changes per hour (12 air changes per hour are recommended for new construction or renovation). When an AII room is not available, a portable high-efficiency particulate air (HEPA) unit can be placed in the room, although it does not compensate for the absence of negative air flow. If avoiding aerosol-generating procedures or use of a nebulizer is not possible, appropriate PPE for health care workers includes use of N95, eye protection, gloves, and a gown.

 Aerosol-generating procedures/treatments [Bronchoscopy (including mini bronchoalveolar lavage); CPR; Colonoscopy; Filter changes on the ventilator; High-flow oxygen; Manual ventilation before intubation; Nasal endoscopy; Noninvasive ventilation; Open suctioning of airways; Tracheal intubation and extubation; Tracheotomy; Upper endoscopy (including transoesophageal echocardiogram); Swallowing evaluation, Nebulisation

 Numbers

1. Case fatality rate:Number of Deaths / Number of Cases: Current 6.91%
2. Corrected CFR = Deaths on Day X / Cases on Day X -T(T = average time from case confirmation to death. Which is 14 days)
3. Deaths in symptomatic cases= 1-2%

Number of deaths X 100= expected number of symptomatic cases

4. Symptomatic casesx 50 = number of asymptomatic cases
5. Expected Number of cases after seven days: Number of cases today x 2 (doubling time 7 days)
6. Number of cases expected in the community:Number of deaths occurring in a five-day period and estimate the number of infections required to generate these deaths based on a 6.91% case fatality rate.

Compare that to the number of new cases actually detected in the five-day period. This can then give us an estimate of the total number of cases, confirmed and unconfirmed.

7. Lock down effect = Reduction in cases after average incubation period (5 days)

8. Lock down effect in reduction in deaths: On day 14 (time to death)
9. Requirements of ventilators on day 9:Three percent 3% of number of new cases detected
10. Requirement of future oxygen on day seven: 15% of total cases detected today
11. Number of people which can be managed at home care: 80% of number of cases today
12. Requirements of ventilators: 3% of Number of cases today
13. Requirement of oxygen beds today: 15% of total cases today
14. RT- PCR false negative 33%.

Ø  20000 cases