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Round Table Expert Zoom Meeting on “Recovery is the rule in COVID-19 and death is an exception”
4th July, 2020, 11am-12noon
Participants: Dr KK Aggarwal, Dr Shashank Joshi, Prof Mahesh Verma, Dr Ashok Gupta, Dr Suneela Garg, Dr JA Jayalal, Dr Jayakrishnan AV, Dr Alex Thomas, Dr Shiv K Harti, Vaidya Sushil Dubey, Mrs Upasana Arora, Dr K Kalra, Ms Ira Gupta, Dr S Sharma
Key points from the discussion
- Timely action can save lives as most cases are mild; few are moderate and less than 5% are serious.
- Death rate is reducing as we are now able to better manage cases.
- In all patients who have loss of smell/taste, recovery is the rule and mortality is an exception. Analysis of 100 patients with loss of smell/taste showed that none needed oxygen or ventilator or hospitalization. It occurred more often in males, at any age and recovery is the rule within 4 weeks.
- Recovery is the rule means that the disease is salvageable at every step. It does not mean that mortality is zero.
- After 9 days, the virus becomes non-replicative and after 9 days, the illness is a post-COVID complication.
- Day 1 is the day when any of the symptom/s recognized by the CDC/MoHFW guidelines such as fever, throat irritation, subconjuctival hemorrhage, rash, diarrhea, headache, calf pain, etc., develop; test may or may not be positive.
- Post-COVID inflammation is very common. It can be in the form of persistent fever/sore throat/bronchitis/diarrhea/cystitis/exertional tachycardia.
- Doctors have high viral load because of repeated exposure and they have more hypercoagulable state. So, if all HCWs are given anticoagulant + short course of steroids, even in mild cases, recovery is the rule.
- In non-HCW group of patients, if there are signs of chest congestion on Day 3-4, do an immediate chest CT scan and give 10-day course of steroids, antiviral and anticoagulant; then recovery should be the rule and death an exception.
- RT PCR may be positive for up to 40 days; this does not mean that the virus is culturable. The virus is culturable for only 9 days; after 9 days, the virus is present but is non-culturable. This data is available for patients who are not on ventilator.
- If any illness is developed during the 9 days, then the post-COVID illness (post-COVID inflammatory state) may last for up to 6 weeks.
- A delayed cytokine storm, which occurs between Day 14 and 18, has been observed in Mumbai. A 6-minute walk test is now mandatory at the time of discharge to look for drop in oxygen saturation. This is a valid marker for delayed cytokine storm. Give 5-10 days of LMWH/oral anticoagulant and small dose of statin at the time of discharge, especially to those who have been in hospital for >28 days and are >55 years of age. This can reduce mortality.
- Initially, steroids were given only in serious cases, but now their indication has also shifted to moderately severe cases. And the time may well come when steroids may become mandatory in all patients starting from Day 3. Timely steroids can prevent secondary cytokine crisis.
- Capacity building, not just of HCWs but also RWAs, etc., as many patients are in home care; issues like stigma and discrimination also need to be addressed. The word “contact” needs to be eliminated as it is a type of stigma.
- Indian vaccine is a live attenuated vaccine (Bharat Biotech); Moderna vaccine is mRNA vaccine; all vaccines have different technologies. Three things to be detected when a vaccine is given: Cellular antibodies, humoral protection and non-specific immunity building (innate immunity). By 15thAugust, we may only be able to tell whether antibodies are produced or not. Since this is a live attenuated virus, will there be a delayed response (cytokine crisis), we do not know.
- Isolate for 9 days, quarantine for 5 days and then monitoring with rest for next 2 weeks. Monitoring means that the person is not contagious, but is still likely to get secondary complications.
- Plasma therapy is effective if given within first 7 days of illness; plasma should be donated between 28 and 40 days.
Dr KK Aggarwal
President CMAAO, HCFI and Past National President IMA