With input from Dr Monica Vasudev

1169:    Minutes of Virtual Meeting of CMAAO NMAs on “COVID-19 and winter”

21^st November, 2020, Saturday, 9.30am-10.30am

Participants: Member NMAs: Dr KK Aggarwal, President CMAAO, Dr Yeh Woei Chong, Singapore Chair CMAAO, Dr Marthanda Pillai, India, Member World Medical Council, Dr Md Jamaluddin Chowdhury, Bangladesh, Dr Marie Uzawa Urabe, Japan

Invitees

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

Key points from the discussion

• Overall, the global mortality is showing a ‘W’ pattern, which is not seen in any country. The mortality is increasing worldwide and is proportionate to the rising number of cases.
• In US, Canada, Europe (Italy, Germany, Spain), Japan, Australia, the cases are increasing and mortality is decreasing. These countries have highly developed health infrastructure with uniform protocols and are strictly regulated.
• In countries like Russia, India, Brazil, Bangladesh, Nepal, Pakistan, Iran, Iraq, Saudi Arabia, South Africa, the mortality is proportionate to the number of cases; more cases, more mortality; fewer cases, less mortality.
• Countries like China, Taiwan, Hong Kong, Singapore and New Zealand have been able to control the number of cases and substantially reduced their mortality.
• The important natural anticoagulants are protein C, protein S and antithrombin. Hypercoagulation does not always mean absence of protein C and S. Even acquired resistance can cause hypercoagulable state.
• Several factors influence COVID deaths: Treatment protocols, weather (winter), health financing, population factors, political leadership, health infrastructure and adherence to preventive measures, availability of tertiary care facilities, early detection of cases, early institution of steroids (to control inflammatory reaction) and anticoagulants. There is sketchy data on genetic predisposition to the disease.
• In Europe and North America, the young are getting the infection, so mortality is less.
• Masks are a must in view of the increase in cases.
• The WHO has recommended against the use of remdesivir (which prevents viral replication) for treatment of COVID-19, even as it has received emergency use authorization by the FDA in the US.
• Virus infectivity is highest within the first five days.
• Virus initiates interferon response on Day 1, lymphocytes on Day 2; pneumonia starts developing from Day 3. Once the cytokine response is initiated, the virus has no role. Therefore, antiviral drugs will be effective in the first 48 hours. In the SOLIDARITY trial, the indication of remdesivir was the development of hypoxia, which appears on Day 5. Remdesivir should be used judiciously on cases to case basis.
• There is no evidence yet that the virus remains viable after 9 days. Virus shedding continues longer in serious patients. “SARS-CoV-2 viral load in the upper respiratory tract reached a maximum during the first week of illness based on cycle threshold values, a systematic review and meta-analysis found, though individuals continued to shed viral matter for more than 2 weeks. But none of the 79 studies in the review found "live" virus beyond 9 days, (maximum 83), reported Müge Çevik, MD, of the University of St. Andrews in Scotland, and colleagues. Pooled mean viral shedding was associated with age, but not sex, they wrote online in The Lancet Microbe” (Medpage Today).
• Remdesivir has received emergency use authorization; Singapore has not used this drug; it has also not been used in Japan outside of a clinical trial in one hospital.
• The virus has more than 100 proteins; so far 32 have been recognized. Work is going on to identify immunogenic protein.
• The United States has a point of care T-cell test.
• The T-cell response starts at 24 hours.
• Leukopenia occurs on Day 2.
• Reducing TLC (leukopenia) means the virus is active with high viral load.
• The clinical parameter is absolute lymphocyte count. 
• Singapore has started rapid antigen tests. While RATs have high specificity, their sensitivity is low.
• Self collection of samples may soon be the norm. The correct way of collecting samples is very important.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA