With input from Dr Monica Vasudev

1147: Minutes of Virtual Meeting of CMAAO NMAs on “Early blood thinners in COVID-19”

7^th November, 2020, Saturday, 9.30 am-10.30 am

Participants: Member NMAs: Dr KK Aggarwal, President CMAAO; Dr Yeh Woei Chong, Singapore Chair CMAAO; Dr Alvin Yee-Shing Chan, Hong Kong, Treasurer, CMAAO;  Dr Marthanda Pillai, India, Member World Medical Council; Dr Md Jamaluddin Chowdhury, Bangladesh

Invitees: Dr Russell D’Souza, UNESCO Chair in Bioethics, Australia; Dr S Sharma, Editor IJCP Group

Key points from the discussion 

• Worldwide there is a single wave of daily new cases with three spikes; but the pattern differs among countries.
• There is a second wave of infection in Europe.
• In the US, there are three waves and the mortality is showing a reverse pattern, i.e., it is now reducing. UK is experiencing a second wave and the mortality is reducing in this second wave, unlike in the first wave, when the mortality was high.
• Bangladesh is within the first wave of infection.
• Mortality in Singapore does not correlate with the new cases.
• In Sri Lanka, the second wave is bigger than the first; mortality in the second wave is higher than in the first wave.
• In India, the pattern of daily new cases and deaths follows the same pattern. There is a single wave overall, but the wave is different in different cities. Delhi is experiencing a third wave of the infection; Maharashtra is in the midst of the first wave; there is a second wave in Kerala.
• There is a gap of almost two months between the two waves in Europe, while in countries like India, Pakistan, Bangladesh, US, cases have not touched zero.
• Home quarantine is not allowed in the US; this means that practically everybody is receiving thromboprophylaxis unless contraindicated.
• If aspirin is given to all high risk persons or oral anticoagulant is started on Day 1, the disease may become self-limiting.
• Cytokine crisis is predictable and so preventable/can be subdued.
• CRP starts rising within 4-6 hours and doubles every 8 hours. It peaks within 36-50 hours.
• If CRP does not become normal by Day 4 or 8, this suggests cytokine crisis.
• CRP between 1-3 is indicative of mild inflammation; immediately put on aspirin prophylaxis, add statin if LDL >70.
• If blood thinners are given on Day 1, steroids may not be needed when microclots form.

Singapore Update

• In Singapore, there is only one wave of infection; majority of cases were in migrant workers (around 54,000), which is now under control; there were only about 2000 cases in the community.
• Dengue deaths have been also high this year. There have been 28 deaths each due to dengue and COVID.
• All migrant workers are fit, young and healthy, so there were not many ICU admissions and very few needed oxygen.
• In the last few days, the community cases have been two to zero.
• Persons returning home are immediately shifted to a hotel from the airport/seaport, where they are quarantined for 2 weeks.
• Singapore is trying to establish a travel bubble with Hong Kong. Singapore has unilateral arrangements with New Zealand and Australia, i.e., people from these countries are not quarantined when they come to Singapore.
• The biggest challenge is opening up the economy.  There is a fear of a second wave.
• For electronic contact tracing, all citizens are required to carry a physical “electronic token”; the tokens will record if two tokens are near. This is being rolled out in phases and is not mandatory yet.
• A safe entry check-in is required before entering a mall, clinic or any premises. All are supposed to scan a QR code. The onus is on premise owners.
• Trace Together is a phone App for contact tracing.
• Measures in Singapore: Contact tracing, restrictions, masking, social distancing, App, Token.
• Singapore did not see much problems with coagulopathy, probably due to reduced Factor V Leiden and protein C and S deficiencies.
• All 300,000 migrant workers were swabbed in two weeks. Now targeted swabbing is being done for those with URTI symptoms.
• The entire airport staff (5000) was swabbed as there were 1-2 cases amongst the airport staff.

Hong Kong Update

• The challenges are exemptions from quarantine and testing and illegal workers.
• Around 40000 people enter Hong Kong without testing as they are exempted. This is a loop hole and so, local cases still linger.

India Update

• India also has a phone app for contact tracing, but it requires cooperation of the individual. The individual status has to be updated every day. The data must be entered truthfully, which is then analyzed by the government.
• The health infrastructure in India is not very strong, which may account for the mortality.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA