959:  Minutes of Virtual Meeting of CMAAO NMAs on “Covid-19 treatment experiences in CMAAO countries”

27^th June, 2020, Saturday; 9.30am-10.30am

Participants

Member NMAs: Dr KK Aggarwal, President CMAAO; Dr Yeh Woei Chong, Singapore Chair CMAAO; Dr Ravi Naidu, Past President CMAAO, Malaysia; Dr Marthanda Pillai, Member, World Medical Council; Dr Marie Uzawa Urabe, Japan; Dr Md Jamaluddin Chowdhary, Bangladesh; Dr Sajjad Qaisar, Pakistan; Dr Deborah Cavalcanti, Brazil; Dr Prakash, Nepal

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

• If the patient comes after 9 days of symptoms or 9 days of Covid positive test, he/she is presenting with Covid sequelae and not Covid per se. Treatment of post-Covid sequelae is as per their standard treatment guidelines or protocols.
• The virus becomes non-replicating from 9th day onwards in mild cases; RT-PCR test may remain positive for up to 48 days. In non-hospitalized patients, isolation may be stopped after 9^thday, followed by 4 days of quarantine and then monitoring (with precautions like masking).
• Loss (partial) of smell and taste usually means mild illness; it may be intermittent and may last up to 3 months. Bitter and sour tastes and sour (lime) smell are retained. In women, it may be associated with single episode of diarrhea or skin rash.
• If the patient has fever (<100.4⁰F), evidence of hyper immune inflammatory response (high ESR, CRP or ferritin), treat with hydoxychloroquine (HCQ) and colchicine.
• If patient comes within first 4 days of symptoms, give antibiotics with anti-viral response (doxycycline or azithromycin x 5 days). Antibiotics may have no role if patient presents after 9 days.
• Anti-parasitic drug ivermectin 12 mg single dose as prophylaxis to whole family.
• If patient develops exertional hypoxia or pneumonia (very high D-dimer and ferritin levels) (day 4-7), give IL-6 pathway inhibitor (tocilizumab IV 8 mg/kg as a single dose) or IV remdesivir or methylprednisolone alone or in combination.
• In high risk case (HT, DM), give favipiravir x 7 days (in India, given for 14 days) in the first three days of onset of symptoms; it probably has no action after 72 hours. Remdesivir acts best when given at the time of hypoxia. Tocilizumab is given when CRP is >100.
• If cytokine response is very high, the two options are tocilizumab and prednisolone.
• In all high risk patients, if they develop hypoxia (day 4), give LMWH.
• Give prednisolone 1 mg per kg stat in case of sudden development of hypoxia (exertional or rest), as an alternative to remdesivir or tocilizumab.
• Advise patients to sleep prone; oxygen concentrator at home or in hospital @ 5 liters/min.
• Give elemental zinc 75 mg daily; vitamin D 60,000 units x 3 days and then 2000 units per day; vitamin C 1000 mg x 3 days and then 500 mg daily.
• Ranitidine 150 mg twice daily to reduce acidity; mefenamic acid, naproxen, indomethacin for fever.
• Regularly monitor SpO2 and pulse, especially between days 4 and 7.
• Inform if temperature >103°F or lasts >14 days or breathlessness, SpO2 falls by >4 after six minutes walking, persistent chest pain.
• Sudden loss of smell and taste is not a serious sign, may persist for some time, may come and go, may come before fever.
• Conjunctivitis may occur in one eye and is not a serious sign.
• Rash may occur on any part of body (more in women) and is not a serious sign.
• Pus cells may be present in urine, indicating viral cystitis and not secondary infection (low TLC).
• High monocytes indicate high viral response; if CRP >100, this means very high inflammatory response.
• If diarrhea (more common in women), this means a superspreader; it may be intermittent.
• Povidone iodine gargles twice daily.
• Do CBC with ESR, CRP, LDH on day 1 and day 5 onwards, every 3rd day.
• If lymphocyte count is <1000, give ritonavir + lopinavir combination.

Treatment experience in CMAAO countries

• Singapore:The pandemic is slowing down; there are very few patients in ICU.
• Pakistan:Antiviral drugs are being used; tocilizumab and dexamethasone are also being used.
• Bangladesh: Stopped using HCQ, as not recommended by WHO. Favipiravir and remdesivir are being used. Ivermectin is not officially recommended, though it is being used by some; there is a difference of opinion about this drug.
• Nepal:Antiviral and/or HCQ are not used; if critical patients, then physicians can use.
• Malaysia:Cases are now in single digits; infection is mostly coming from overseas and migrant workers. All Covid patients are referred to designated government hospitals and not treated in private sector.
• Japan:Around 100 people diagnosed positive a day, mostly young and no serious cases. 3000 patients have been given favipiravir; but no RCT because of lack of numbers.
• Brazil: Cases are increasing, more than one million diagnosed cases; ivermectin is being used as prophylaxis.
• Australia: Melbourne has some amount of community transmission; 6 suburbs have been identified as hotspots and everyone will be tested.
• Kerala, India: The number of cases is decreasing. Less than 6% need ICU care; mortality is around 1%. Azithromycin is preferred; treatment covers monsoon fevers like dengue. HCQ is not used as patients have lot of comorbidities and renal and liver functions have to be strictly monitored. Strict titration of medication and monitoring of patients has to be done. Also, selective use of medicine has helped to reduce mortality.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA