Topic: Home Isolation treatment for Covid-19 & Country Updates

10^th July, 2021, Saturday

9.30am-10.30am

Key points from the discussion

#1. A presentation on “Covid care at home” was given by Dr Shashank Joshi, Consultant Endocrinologist and Member Covid-19 Task Force Maharashtra, India

• Covid care at home is like a double-edged sword.
• Home care may not be suitable for people with terminal illnesses or very chronic diseases like dementia, COPD), while taking into account the recommendations of extreme precautions for infection for professionals, family and caregivers.
• If there is adequate immune response to SARS-CoV-2, the innate response is timely; there is good type 1 IFN response with activation of efficient antiviral response (macrophages) and activation of Th1 cells and B cells for production of neutralising antibodies.
• In inadequate immune response, there is delayed type 1 IFN response, endothelial cell death, epithelial/endothelial leakage, overactivation of T cells and NK cells and accumulation of activated macrophages resulting in cytokine storm.
• It is critical to recognise, which patient will progress to the next stage.
• Stage 1 is asymptomatic and there is innate immune activation. Stage 2 is non severe symptomatic and there is adaptive immune activation (generation of specific antibodies and T cell response). Stage 3 is severe inflammatory response with cytokine release syndrome.
• Diagnosis is by NAAT using nasopharyngeal, nasal or oropharyngeal specimens, but it should not be repeated in an asymptomatic person within 90 days of a previous SARS-CoV-2 infection. Serology (antibody testing) is not needed to diagnose or to determine immunity to the infection.
• There are three subtypes of Covid-19: Naive first infection, breakthrough infection (vaccine failure) and reinfection. All three subtypes are seen in population dense areas like India; cases of naive first infection predominantly by the delta variant are still seen.
• Biomarkers in home care: CBC (increased WBC, decreased platelets), RDW (>14.5), LDH (increased), D-dimer (increased), CRP, ferritin, PCT, IL-6 and NLR (all increased) suggest a likelihood of progression. In resource-limited setting, CBC and CRP are the two parameters used, which will indicate the need to shift the patient in home care to the hospital.
• The ATM approach was aggressively followed in the Mumbai model in the second wave: Assessment (at home/virtually/direct using PPE kit; make sure to talk to the patient and not to any relative), Triage/Transfer and Management. This simple approach will give better home care.
• The vital seven parameters to be monitored at home are: Temperature (if >100, paracetamol), pulse (if >100; red flag if inappropriate tachycardia), respiratory rate (>24, red flag), BP (>140/90; ensure that the patient is taking BP medication), SpO2 (if 3% drop in baseline saturation on 6MWT or <93%, transfer the patient to hospital), glucose (self-monitoring; alert if 140-180 mg%) and digital/telephonic connectivity (via telephone, video calls; if unavailable, quarantine the patient in a quarantine facility).
• In assessment, look for persistence of fever/dry cough/breathlessness/fatigue, it may be appropriate to transfer the patient. Also assess the ability of the patient to self monitor.  Covid can sometimes present with mimics such as stroke, ACS, seizures, diabetic ketoacidosis.
• In high risk areas, presume every patient to be positive unless proven otherwise.
• The NEWS score (National Early Warning Score) is often used in home care and in emergency. The six parameters used are respiratory rate, oxygen saturations, temperature, systolic BP, pulse rate and level of consciousness. It determines the type of response needed for that particular patient.
• Timely diagnosis of silent hypoxia is the key in home care.
• There are pocket oximeters and smart phone-based systems, but it’s important to keep in mind that their accuracy may not be appropriate. It is also important to understand the pitfalls of pulse oximetry as well as the types of pulse oximeters and their principles of operation.
• When measuring the oxygen saturation at home, the individual should be at rest, breathing quietly and preferably unmasked. Nail polish must be removed; cold extremities must be warmed before measurement. Wait for 30-60 seconds before noting the value; measure oxygen saturation several times in a day.
• The 6MWT has the best yield in terms of detecting silent hypoxia.
• In triage, look for alternate diagnosis if patient is Covid-negative.
• Red flags are: NEWS score >5, sudden breathlessness, positive 6MWT.
• Triage decides the decision to transfer, including need for oxygenation, NIV/HFNO, MV, ICU care. Early and appropriate hospitalisation translates into lesser mortality.
• Outpatient management of Covid-19 involves supportive care, isolating the patient and advising when to seek in-person evaluation, triaging patients with symptoms of Covid-19 via teleconsultation before in-person care.
• All patients in home care with dyspnea, SpO2 <94% on room air or symptoms such as chest pain or tightness, dizziness, confusion or other mental status changes should be referred for an in-person evaluation by healthcare providers; the elderly with comorbidities should also be evaluated in-person.
• Acute Covid is 14-21 days (8-12 days are crucial), while post-Covid is after 3 months.
• Timing is important: right approach, right time, and right medications
• Antimicrobials or antiparasitic agents should not be used empirically.
• The only evidence-based treatment so far to treat outpatients with mild to moderate Covid-19 is anti-SARS-CoV-2 monoclonal antibodies (Casirivimab 1200 mg + imdevimab 1200mg; in India, the available doses are Casirivimab 600 mg + imdevimab 600mg).
• Indications of casirivimab + imdevimab include ambulatory patients with Covid-19 at high risk for subsequent complications, post exposure prophylaxis in household contacts and seronegative patients hospitalised for Covid-19. Though data is early, they appear efficacious against existing variants of concern including delta. The limiting factor for use is their high cost.
• The challenges are how to identify the patients, to be proactive or reactive, what are the criteria, where and how to infuse the drug.
• Early administration of inhaled budenoside in infected patients reduces the chances of requirement of urgent medical care and enhances clinical recovery.
• Colchicine lowered the rate of composite of death or hospitalization vs placebo. It may be a safe and inexpensive anti-inflammatory drug for use in patients at high risk of complications (COLCORONA trial).
• Factors responsible for severity of disease are high viral load, severe immune dysfunction, rapid deterioration of radiological parameters and desaturation.
• Favipiravir should be used within the first 48-72 hours as active viral replication occurs in the first 2-3 days.
• Healthcare provides should protect themselves (PPE) and maintain communication.
• About 80% of patients can be managed in home care (isolation) and save resources. Red flags should be recognised and diagnosed in time. If in doubt, transfer the patient to a Covid facility.
• Mental health should be taken care of as these patients are in isolation. Keep them positive.
• Asymptomatic are the biggest challenge in home care.
• Home precautions also involve family members; they too must be screened, tested and self-isolated as appropriate.
• Many home care patients may also need post-Covid care and must be evaluated.
• Adequate hydration and good nutrition (optimal calories and adequate protein) is important.
• Lifestyle mantra: Eat less, eat on time, eat in morning, eat right, walk more, detox digitally, sleep well and on time and smile.
• Ivermectin has excellent anecdotal evidence, but lacks quality evidence to merit a place in guidelines. It can be used at any time during the illness; it is economical, easily available but is not the standard of care.
• Remdesivir is not for home care; it is meant for use only in moderate to severe cases.
• If there is no access to healthcare facility, keep oxygen saturation between 88 and 92%, proning and steroids.
• Pyrexia with bradycardia is an ominous sign (anecdotal); the patient should be hospitalized. It has been seen more in hypertensive and diabetic persons. Both extremes of pulse are bad signs in home care.
• INSACOG has not reported gamma variant from India; alpha and delta variants have been reported.
• A person who does not have facility of self quarantine with single room/single bathroom use/digital connectivity should be put in institutional quarantine.
• Delta plus (AY.1) strain originated in UK and Nepal and is now found in India. It has a mutation 417 also found in the beta variant (first detected in South Africa), which has been resistant to vaccines and monoclonal antibodies. It is highly transmissible similar to the delta variant, binds strongly to ACE2 receptors in the lungs, is resistant to monoclonal antibodies and may have an immune escape. Evidence (clinical phenotype from the small cluster of patients) so far shows that it does not appear to be that sinister.

#2. Country Updates

• Singapore Update: There have been 1000 cases of delta variant in the country. Vaccination program has been accelerated; about 60% of population has been covered. The aim is to vaccinate about 70-80% of the population by the year end. Yesterday only one community case was detected. The policy is to trace, vaccinate, self-test and self-isolate. Home testing kits are now available. Singapore has been taking steps to prepare for COVID-19 becoming endemic.
• Malaysia Update: Cases are increasing, yesterday there were 9000 cases; 300-400 thousand people are being vaccinated every day. The country is still in a total lockdown.
• India Update: The second wave is flattening, but is not over yet. The Kappa variant has been detected in 4-5 patients. About 4 million vaccinations are done daily; it needs to be accelerated. Sputnik V vaccine is now also available in addition to Covaxin and Covishield.
• Australia Update: Cases in New South Wales (Sydney) are showing an exponential rise; the vaccination is slowest here. Melbourne has not reported any case for the last ten days.

Participants

Member National Medical Associations

Dr Yeh Woei Chong, Singapore, Chair CMAAO

Dr Ravi Naidu, Malaysia, Immediate Past President CMAAO

Dr Alvin Yee-Shing Chan, Hong Kong Medical Association, Treasurer, CMAAO

Dr Marthanda Pillai, India Member World Medical Council

Dr Angelique Coetzee, South Africa

Dr Akhtar Hussain, South Africa

Dr Qaiser Sajjad, Pakistan

Dr Marie Uzawa Urabe, Japan

Dr Mukti Shrestha, Nepal

Invitees

Dr Russell D’Souza, Australia UNESCO Chair in Bioethics

Dr Shashank Joshi, Mumbai, India

Dr Monica Vasudev, USA

Dr Tze Lee Tan

Dr Yang Ing Woei

Dr Cecilia Ngan

Dr Ching Ching

Dr Diane Jek

Dr Alan Lui

Dr Lim Li Ling

Dr Stephen Chang

Dr Keith Liao

Dr Khenghar Maureen Lim

Dr Lau Kit Wan

Dr Ng Thin Onn Tony

Dr Seow Hoon Poh

Dr Sylvia Choo

Dr Yoke Mei Lim

Dr Xinhuo Peter Liao

Dr Meenakshi Barnwal Soni

Dr S Sharma, Editor IJCP Group

Moderator

Mr Saurabh Aggarwal