Let us end the social pandemic before the medical pandemic. Let’s live with it.

212 Countries affected, Crosses 4.17M, Nearly 80,000 cases per day, Minimum Likely Deaths 290900, Deaths to Cross 300,000 this Week

World: Cases: 1M: April 2, 2 M: April 15, 3 M: April 27, 4 M: May 8

1^st Case: 10th January.  Total cases are based on RT PCR which has only 67% sensitivity. Does not include clinical cases.

GOOD NEWS:  Nearly controlled in China, South Korea, Hong Kong, Australia & New Zealand. Remdesivir approved in US for emergency compassionate use.

Learn to live with Corona. Restructure (Reaction, adjustment and liking) your life and economics with Social Distancing and Cleanliness.

Patients with prostate cancer being treated with androgen deprivation therapy (ADT) have lower odds of becoming infected with COVID-19 and dying from the disease compared to other groups, including other patients with cancer. [May 7 in Annals of Oncology]

Pandemics have two endings: a medical one, when death rates plummet; and a social one, when the wave of fear over the disease wanes.

Bad News:  

UK PM Boris Johnson, Russia PM Mikhail V. Mishustin suffered with COVID-19; Out-of-hospital cardiac arrests increased 58% during the peak in Lombardy, Italy, compared with last year.

JAMA Network Open: COVID virus present in the semen of patients, both those recovering and those with acute disease

Antibody test is not reliable: For test to work in a disease that affects 2%-3% of the population, a test with at least 99.7% specificity is needed.

ICN: Over 90,000 healthcare workers worldwide are infected with COVID-19; over 260 have died.

India: Hotspot (Red zone) classification

Highest case load districts contributing to more than 80% of cases in India or Highest case load districts contributing to more than 80% of cases for each state in India or Districts with doubling rate less than 4 days (calculated every Monday for last 7 days, to be determined by the state government. Subject to: No new confirmed cases for last 28 days (Green zone)

Situation around the Globe

Likely minimum deaths (283850 + 47040 x 15 = 7056) = 290900    

Coronavirus Cases: 4,179,839 (+79,875)

Deaths: 283,850 (+3510)

Recovered: 1,490,511

ACTIVE CASES: 2,405,478

Currently Infected Patients 2,358,438 (98%) in Mild Condition

47,040 (2%) Serious or Critical

CLOSED CASES: 1,774,361

Cases which had an outcome: 1,490,511 (84%) Recovered/Discharged

283,850 (16%) Deaths

536 cases per million population (India 49)

36.4 deaths per million population (India 2)

India

India predictions

1. Death Rates as on today: India: 3.29 %
2. Corrected Death Rate = Number of deaths today/Number of cases 14 days back: 2212/ 29451= 7.5%
3. Estimated cases in India: Number of deaths on a given day x 85 = number of serious patients 14 days before 

With 175 new deaths on 4th May, on 20^th April, we should have had 666 serious cases. Expected cases on 20th should have been 4440 as against 1239 reported (Undiagnosed cases 3201 > 75%)

4. Formula: >90% of people are symptomatic within 2 weeks of infection, with fatalities occurring on average 2 weeks after
5. 3.29 % of people tested in the iceberg tip have died. The question is, how much iceberg is under the water?

Assumption: Iceland: 1:2; Roughly two undocumented cases of COVID-19 for each documented case.

German: 1:5; 70 out of 500 (14%) people tested in a hard-hit area had coronavirus antibodies.

New York City grocery store shoppers: 1:10; 20 % seroprevalence rate.

California seroprevalence study of 3300 individuals: 1:85; 1.5% positive

So, numbers will vary from zone to zone.

If we take New York as example: number of cases on 20^th = 278900 and corrected mortality = 0.75%

6. Doubling time:11.5 days
7. Death rates on 8^thMay: World: 6.9%; Europe: 9.6%; North America: 6 %; Asia: 3.4%; South America: 5.1%; Africa: 3.8%; Oceania: 1.4%
8. Deaths per Million Population: USA: 232; Spain: 558; World: 34; India:2
9. 10^thMay: % of tests positive: USA 15%, Italy 8.7%, UK 12.4%, Spain 10.4%, India 3.9%
10. Mortality on 11^thMay: Delhi 1%; Maharashtra 3.7%; Gujrat 6%; MP 5.9%; Kerala 0.78%, Rajasthan 2.8%; Andhra 2.3%; Bihar 0.9%; West Bengal 9.5%; UP 2.3%
11. Test Positive: West Bengal 4.4%, Gujrat 7.2%; MP 5%, Delhi 7.3%; Kerala 1.3; Maharashtra 9.8%; Rajasthan 2.3%, UP 2.7%
12. Lock down effect: May 3 Number of cases 3062; till 9^thMay all cases are prior to lock down effect; 10^th May extra 1000 cases post lock down effect
13. India expected to cross China number of cases on 14^th May
14. India expected to cross 100,000 cases by 20^thMay   

 Others

1. China: Captured tiny droplets containing the virus’ genetic markers in two hospitals in Wuhan. However, the scientists don’t know if it was capable of transmitting the virus [Journal Nature]. Researchers stated that these stayed in the air floating around for at least two hours.
2. In the Philippines, attackers doused a nurse with bleach, blinding him.
3. CDC adds six more symptoms in diagnosis: Chills, repeated shaking with chills, muscle pain, headache, sore throat and new loss of taste or smell.
4. India: In states with average population density of 1185/sq km, the average number of cases were 2048. On the contrary, in states with population density of 909/sq km, the number of cases were 56. When Chandigarh and Pondicherry were taken out from this group, 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 Coronaviruses (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 up to 10%  (5.7% South 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%, South 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/Biopsy: Viral particles seen in tears, stool, kidneys, liver, pancreas, heart and CSF. Reported in semen also.

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. According to University of Pennsylvania, clots are occurring at high rates even when patients are on blood thinners for clot prevention. In a 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). In the 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. About 70% persons need to be immune for no outbreak to occur.

Longitudinal serological studies are required to ascertain 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 fade away, only to return after a few years. Therefore, even when there is apparent elimination, SARS-CoV-2 surveillance should be maintained since a resurgence in contagion could be possible as late as 2024.

During the peak, what is most important is to trace and treat the patients and after the peak, the key 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, and lay 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 or cycle shorter distances, prefer stairs to lifts, do not allow anyone to smoke cigarette, bidi or hooka in front of you; Wear long sleeve shirt; Carry hand sanitizer; 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 Barre Syndrome (6 cases), seizures, confusion, meningitis, large vessel stroke (5 cases)

GI: Nausea, Diarrhea, 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 hyperkalemia, hyperphosphatemia, and profound metabolic acidosis to a degree not seen in typical kidney failure patients)

Liver: Hepatopathy; deranged liver enzymes

Musculoskeletal: Muscle aches, fatigue

Eye: Conjunctivitis, pink eye

Endocrine: Diabetes and hyperglycemia without prior diabetes

Hematology: 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 appear unusually apathetic or confused, losing orientation to their surroundings. They may even become dizzy and fall. Sometimes, they stop speaking or simply collapse.

Autopsy and biopsy: Virus present in nasal passages, throat, tears, stool, urine, vaginal fluids, CSF, kidneys, liver, pancreas, and heart.

Summary: Fever, Cough, Dyspnea (new or worsening over baseline), Anosmia or other smell abnormalities, Ageusia or other taste abnormalities, Sore throat, Myalgias, Chills/rigors, Headache, Rhinorrhea, Nausea/vomiting, Diarrhea, Fatigue, Confusion, Chest pain or pressure

Insignificant Symptoms: Confused with ALI and Allergy

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

Asymptomatic: 6-70%

High-risk: Age ≥65 years; Residence in a nursing home or long-term care facility; Immunocompromising condition; Chronic lung disease or moderate to severe asthma; Cardiovascular disease (including hypertension); Severe obesity (body mass index ≥40 kg/m2); Diabetes mellitus; Chronic kidney disease (undergoing dialysis); Cerebrovascular disease; Chronic liver disease; Tobacco use disorder

Moderate risk: Age 20 to 64 years with none of the specific comorbidities listed above; Age <20 years with underlying medical conditions other than those listed above.

Low risk: Age <20 years without underlying medical conditions

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 ELISA 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 day 1).

7. IgM, if positive, needs confirmation with RT PCR (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 South 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 of the hour.

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 hydroxychloroquine 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 patients (walking dead) have capillary problem and not alveoli. Do not allow normal lung to hyperventilate due 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.

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 South Korea

• 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, 13.7% were found to have 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, rotavirus, routine immunization 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 plasma therapy: start early to reduce 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

Healthcare Workers: N 95 or Double Surgical mask (3 ply outer layer hydrophobic polypropylene, middle filter and inner layer hydrophilic) or double protection surgical over N 95 or triple protection surgical- N95 and Surgical.

Disposal:

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.

Used masks and gloves generated from 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.

 Optimizing the supply of PPE 

Canceling non-urgent procedures or visits

Favoring home care rather than hospitalization when appropriate

Limiting movement outside the patients room

Prioritizing the use of certain PPE for aerosol-generating procedures

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

Limiting the number of people who examine the patient

Using medications with extended intervals

Allowing some providers to perform telephone interviews with hospitalized patients.

Extended or limited reuse of PPE

The same medical mask can be used for repeated close contact encounters with several different patients (if it is not visibly damaged or soiled).

While using this strategy, the provider should not touch or remove the mask between patient encounters, since the outside surface is presumably contaminated.

If the provider touches the mask, they must immediately perform hand hygiene.

The CDC suggests that masks can be used for 8 to 12 hours while the WHO is of the opinion that 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 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 is sealed and warmed in an oven to 65°C/150°F for at least three hours; it is then opened, the respirator is placed on the rack, and the container is resealed and placed back in the oven for an additional 30 minutes. No residual H1N1 infectivity has been found with this process. 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 that 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 accomodated or been used for aerosol-generating procedures on patients with COVID-19.

Environmental services workers should be trained in conducting the cleaning in appropriate PPE.  Workers should wear N95 respirators and face shields 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. They can use droplet and contact precautions, besides eye protection (surgical mask, face shield or goggles, gown, and gloves) when cleaning areas used by healthcare workers caring for COVID-19 patients.

In a Singapore study, 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 before routine cleaning. Viral RNA was not detected on similar surfaces in the rooms of two other symptomatic patients following routine cleaning (with sodium dichloroisocyanurate). Viral RNA detection does not necessarily point to 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 you reuse the N95 respirator, leave the used mask in the dry atmosphere for 3-4 days to dry it out. Polypropylene in N95 is hydrophobic and carries no moisture. 

If the respirator is dry for 3-4 hours, the virus would not have likely survived. It is best 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. And so on.

Another way 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 undergo degradation by UV light so they should be kept 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.

China and COVID

The cost of API used in hydroxychloroquine reached 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, had stated that the epidemic situation was still severe and complex, the most severe challenge since SARS in 2003, and was likely to develop into a major public health event. Yet in the following six days, Wuhan went on to host 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". On the same day, a leading Chinese epidemiologist, Zhong Nanshan, announced that the virus could be transmitted from person to person on national television. However, by then, over 3,000 people had already been infected. (TOI)

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. This was despite the fact that hundreds of patients were appearing in hospitals not just in Wuhan but all across the country. On January 2, 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. (TOI)

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 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. [NDTV]

According to a Lancet study, over 232,000 people may have been infected in the first wave of COVID-19 in mainland China, four times the official figures, suggested a study by Hong Kong researchers.

• The coronavirus crisis has killed over 7,000 people at nursing homes across the country in USA

• To expedite things, US FDA allowed a free-for-all for developers to begin marketing antibody teststhat had not been subjected the agencys usual evaluation and validation process.  This resulted in a flood of over 90 unapproved tests with dubious quality. The FDA quickly moved into damage control, and conducted evaluations of the tests in order to distinguish the potentially useful from the useless. The agency has successfully issued 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 epicenter, isolate, contact monitor, elderly lockdown, buy 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 Lebanese 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

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

Italy: Deploy younger healthcare 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 healthcare 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 single-patient rooms have 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). In case of non-availability of an AII room, 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 healthcare 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 transesophageal echocardiogram); Swallowing evaluation, Nebulization

Timeline

Weeks prior to China acknowledged that the coronavirus could be transmitted by humans, and nearly a month before the first officially recorded cases in Europe, a 42-year-old fishmonger presented at a hospital in suburban Paris coughing, feverish and trouble breathing. It was on Dec. 27.

Now, doctors in France say that the December patient may have been the earliest known coronavirus case in Europe. If confirmed, this case would mean that the virus appeared on the continent long before officials there began tackling it. Such a discovery would bring a strange new wrinkle to the story of the virus in Europe, one that has the potential of blowing up the previously established chronology. The French government says it is looking into the report. The doctors who made the finding said that they are confident, and that they tested the patient’s old sample twice to avoid false positives. But they acknowledged that they could not completely rule out that possibility. (First Post)

WHO: a report that COVID-19 had emerged in December in France, sooner than previously thought, was not at all surprising, and called for countries to investigate any other early suspicious cases. The disease later identified as COVID-19 was first reported by Chinese authorities to the WHO on Dec. 31 and was not previously believed to have spread to Europe until January.

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%.

Total cases and deaths across the world

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA