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With inputs from Dr Monica Vasudev
1029: Update on COVID-19
IMA-CMAAO Webinar on “Paradigm shifts in COVID-19”
25th July, 2020, 4-5pm
Participants: Dr RV Asokan, Hony Secretary General IMA; Dr Ramesh K Datta, Hony Finance Secretary IMA; Dr Jayakrishnan Alapet; Dr Brijendra Prakash; Dr Sanchita Sharma
Faculty: Dr KK Aggarwal, Padma Shri Awardee, President CMAAO & HCFI
Dr KK Aggarwal elaborated on the paradigm shifts in the management of COVID-19 from the month of March to July, based on his experiences of patients with COVID-19.
Key points from the discussion
- COVID-19 was first considered to be a viral pneumonia, but now it is known as a mysterious virus, which is predictably unpredictable.
- It spares joints and larynx, so no joint involvement or hoarseness of voice; also, no lymph nodes involvement.
- COVID-19 was earlier believed to be non-inflammatory, but now we know that it is predominantly an inflammatory disease.
- Earlier, it was thought that the patient could become critical on any day of the illness; now we know that Days 3-6 are the days to watch.
- Social distancing has changed to physical distancing.
- From macrodroplets (surface to human transmission) earlier, we now talk of microdroplets (crowded ill-ventilated rooms).
- Surface to human transmission was the most important route of transmission; now it has become less important (heat and humidity).
- The shift from no masking to mandatory masking in public has become the norm.
- From simple masks, we have moved to N95 masks for all high risk patients (COPD, asthmatics).
- Masking only when going out, is now joined by masking also at home.
- Distancing of 3 feet has changed to 6 feet; with microdroplets, this distance is now 9 feet.
- We started in the pandemic with very high mortality (10%); now mortality is around 0.3%.
- Institutional care has shifted to home care.
- In the early days, no treatments were available, but individualized treatment is now available. If inflammatory parameters are raised, then give steroids; if D-dimer is high, give anticoagulant; if early presentation, give antiviral, etc.
- From mandatory ventilation, the concept has changed to noninvasive ventilation.
- Children to grandparents; now children pose no risk for transmission to adults or other children.
- Menstruation reduces severity of illness.
- We have shifted to no steroids to early low dose steroids.
- Hydroxychloroquine (HCQ) for all to no HCQ for mild cases.
- Late discharge – Earlier patients were kept for 30-40 days; now patients are discharged early (Day 6) if no complications, to home quarantine.
- Thinking of death to thinking of recovery.
- No pooled test to pooled test.
- We have now understood that after 9 days of illness, the virus is non-culturable and the person is non-infectious; the presentation is post-COVID sequelae due to persistent inflammation, or hypercoagulable state. Before 9 days, it is COVID.
- No Ct value to Ct value of RTPCR to find out if cohort isolation can be done; low Ct value means high viral load.
- Testing has moved from antigen RTPCR to rapid antigen and now antibodies testing (total vs IgG).
- Isolation to cohort isolation (multiple infected persons in a family can stay together).
- Isolation; and now isolation/quarantine/monitoring.
- From no oxygen at home to oxygen at home.
- Closed camps/OPDs to open sunlight camps – microdroplets are killed in sunlight.
- Earlier, testing was done only for symptomatic persons, but now liberal testing.
- A mandatory government prescription has now become non-mandatory.
- When it first began in Wuhan, China, it was pulmonary COVID and CT diagnosis was a must; but now it is also recognized as non-pulmonary COVID, involving GIT, CNS.
- Typically, fever at the time of presentation; now no fever presentation.
- Asymptomatic persons are really not asymptomatic; they may have some atypical symptoms such as diarrhea, sore throat, etc.
- High grade fever, which is classically associated with viral illness to low grade (100oF) exertional persistent fever, due to persistent inflammatory process.
- The six minute walk test (6MWT) was meant for only COPD, heart failure patients, but it is now mandatory from Day 3-6. If the patient desaturates by 5% on walking, this is indicative of pneumonia with thrombosis. This is an emergency.
- Transmission from joint families to nuclear families.
- No toilet transmission; now toilets are recognized as a COVID chamber.
- Contact time from 30/10 minutes to 15/5 minutes in closed areas.
- Testing till Ag negative to no testing to confirm when Ag will become negative.
- Fear to no or less fear.
- Mortality is two times that of the government figures reported.
- For every tested person, there are 20 untested individuals; for every 20 COVID patients, there are 80 patients with corona-like illness.
- Stigma to less stigma.
- Low mortality to high mortality amongst doctors.
- Ignorance to knowledge.
- Engineering (AII rooms) to social engineering: test for 5 parameters when screening – temperature (low grade, does not respond to paracetamol), SpO2 (happy hypoxia), loss of smell, loss of taste (give jaggery – first taste to go is sweet taste) and hand grip strength.
- New loss of smell and taste has been seen in 20-30% of patients; the disease is mild in nature.
- We now know that plasma therapy is effective if given early.
Dr KK Aggarwal
President CMAAO, HCFI and Past National President IMA