212 Countries affected, Crosses 4.34M, Nearly 85,000 cases and 5000 deaths per day, Minimum Likely Deaths 299759, Deaths to Cross 300,000 by 15^th May and total number 5 M by 23^rd May

Nearly controlled in China, South Korea, Hong Kong, Australia and New Zealand.

Countries Spared: Asia: North Korea, Turkmenistan; Africa: Lesotho; Oceania: Kiribati, Tuvalu, Tonga, Samoa, Marshall Islands, Solomon Islands, Nauru, Palau, Vanuatu, Federated State of Micronesia

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

Ground Zero Wuhan 1^st Case: 10th January. 

Total cases are based on RT PCR which has only 67% sensitivity. Does not include clinical cases.

GOOD NEWS:  Learn to live with Corona with Social Distancing and Cleanliness.

Why Males: More ACE2 cells or androgens [Prostate cancer patients on androgen deprivation therapy less infected (May 7 in Annals of Oncology)]

Bad News:   For test to work in a disease that affects 2%-3% of the population, we need an antibody test with at least 99.7% specificity.

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

Situation Around the Globe: Likely minimum deaths (292808 + 46340 x 15 = 6951) = 299759

Coronavirus Cases: 4,339,824 (+85,335)

Deaths: 292,808 (+5320)

Recovered: 1,602,091

ACTIVE CASES: 2,444,925

Currently Infected Patients 2,398,585 (98%) in Mild Condition

46,340 (2%) Serious or Critical

CLOSED CASES: 1,894,899

Cases which had an outcome: 1,602,091 (85%) Recovered/Discharged

292,808 (15%) Deaths

 557 cases per million population (India 49) AND

37.6 deaths per million population (India 2)

India to cross China number of cases tomorrow and 100,000 cases by 20^th May  

India predictions

1. >90% of people are symptomatic within 2 weeks of infection
2. Death Rates3.25%; Corrected Death Rate 7.3%
3. Estimated cases in India: Number of deaths x 85 (number of serious patients 14 days before): with 175 new deaths on May 4, on 20^thApril expected serious cases would have been 666; expected cases 4440 as against 1239 reported (Undiagnosed cases >75%)
4. Undocumented cases for each documented case [Iceland: 1:2; Germany: 1:5; New York City grocery store shoppers: 1:10;California 1.5%]
5. If we take New York as bench-mark: minimum mortality 0.75% (Number of cases on 20^th278900)
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%; Gujarat 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 3.0 effect; 10^th May onwards extra cases post lock down 3.0 effect

 Extra Reading Background Material

China: Captured tiny droplets of viral genetic markers in 2 hospitals in Wuhan floating for > 2 hours. Infectivity? [Journal Nature]

Philippines: Attackers doused a nurse with bleach, blinding him.

CDC adds six more symptoms in diagnosis: Chills, repeated shaking with chills, muscle pain, headache, sore throat and new loss of taste or smell.

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 are then breathed or coughed out and infect others.

       Prevalence: New York: 13.9%; New York City at 21.2%; South Korea 5.7%; World 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].

       Viral particles seen in tears, stool, kidneys, liver, pancreas, heart, semen, peritoneal fluid, CSF.

      Thrombosis: Large-vessel clots, DVT, pulmonary emboli; clots in arteries, strokes; and small clots in tiny blood vessels in organs throughout the body. According to University of Pennsylvania, clots are seen in patients even on blood thinners. 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 absence of other innovations and interventions, the key successes will be prolonged or intermittent social distancing(till 2022-24) besides building up critical care capacities and surveillance till 2024 or more.

     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. Surveillance till 2024.

      During peak trace and treat and after the peak trace and treat the close contacts (close physical contacts starting 2 days before the symptoms and contact time of more than 30 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. 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.

16:       We must learn to live with corona now: Simple living. Walk or cycle shorter distances, prefer stairs over lifts, no passive smoking, 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 6 feet social distance and do not meet strangers for more than 30 minutes.

 17:      HCW: Direct patient exposure time <30 minutes; 7 days work and 7 days holidays

18:       Italy: mortality reduced when they were short of ventilators.

19:       Hospital at HOME: CHF, mild pneumonia, exacerbations of asthma and COPD, cellulitis, and urinary tract infections.

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

21:       Great Imitator (protean manifestation)

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

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

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

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

26:       Liver: Hepatopathy; Deranged liver enzymes

27:       Musculoskeletal: Muscle aches, fatigue

28:       Eye: Conjunctivitis, pink eye

29:       Endocrine: Diabetes and hyperglycemia without prior diabetes

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

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

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

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

34:       Thrombi-inflammatory: Microvascular thrombosis (high D Dimer)

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

36:       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.)

37:       Elderly: Sleep more, stop eating, apathetic or confused, losing orientation to their surroundings. They may become dizzy and fall. Sometimes, stop speaking or simply collapse.

38:       Symptoms: 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

39:       Insignificant Symptoms: Confused with ALI and Allergy

40:      Pre-symptomatic 20% of asymptomatic developing symptoms in 2-3 days.; Asymptomatic (6-70%)

41:       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

42:       Treat the patient and not the test report; IgM can be false positive in pregnancy, immunological diseases; Pooled tests (< 5) when seroprevalence is <2%

43:       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).

44:       Hypoxia: 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.

45:       Lung-protective ventilation:  Earlier, use a ventilator setting with a larger tidal volume but lower PEEP of 5.

46:       Vaccines: Mw Mycobacterium w or mycobacterium indicus pranii vaccine (CSIR and Cadila), Novavax (antigens derived from the Coronavirus spike (S) protein vaccine JV with Cadila), m RNA vaccines.

47:       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)

48:       Consider every surface and every asymptomatic person as virus carrier

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

50:       Mask Disposal: Used PPEs Red bag; Used masks:  3 layer mask, N95 mask, head cover/cap, shoe-cover, disposable linen Gown, non-plastic or semi-plastic coverall in Yellow bags.

51:       Decontamination of PPE for reuse: N95 respirators and face shields: UV light; Hydrogen peroxide vapor; Moist heat; Ethylene oxide

52:       Environmental disinfection: UV light, hydrogen peroxide vapor

 53:      Quarantine models: India - Early lock down; Wuhan - Selective sealing of epicenter; Germany, Sweden and Japan - Selective isolation of elderly and high-risk; South Korea - Intensify testing of high-risk individuals; Italy - 2 hospitals posted young doctors <40 years, 60% women on duties with no mortality in healthcare workers; Singapore - Surgical masks at reception, N 95 masks HCW, AII rooms; Germany - Random testing for antibodies. AII rooms: six air changes per hour (12 air changes per hour) OR portable HEPA unit.

 54:      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

55:       Timeline: WHO: a report that COVID-19 had emerged in December 27 in France

56:       Formulas: Deaths in symptomatic cases 1%; Deaths X 100= expected number of symptomatic cases; Cases after seven days: Cases today x 2 (doubling time 7 days); 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; Lock down effect = Reduction in cases after average incubation period (5 days); Lock down effect in reduction in deaths: On day 14 (time to death); Requirements of ventilators on day 9: 3% of number of new cases detected; Requirement of future oxygen on day seven: 15% of total cases detected today;  Number of people which can be managed at home care: 80% of number of cases today;  Requirements of ventilators: 3% of Number of cases today;  Requirement of oxygen beds today: 15% of total cases today.

Total cases and deaths across the world

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA