With input from Dr Monica Vasudev

1094: Minutes of Virtual Meeting of CMAAO NMAs on “CMAAO countries consensus on COVID-19 as on date”

26^th September, 2020, Saturday, 9.30am-10.30am

Participants, Member NMAs: Dr KK Aggarwal, President CMAAO; Dr Alvin Yee-Shing Chan, Hong Kong, Treasurer, CMAAO; Dr Prakash Budhathoki, Nepal; Dr Md Jamaluddin Chowdhury, Bangladesh; Dr SM Qaisar Sajjad, Secretary General, Pakistan Medical Association

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

Key points from the discussion

10 Sutras to remember

1. Universal masking (correct, consistent and 3-layered) is THE prevention. A study in the Journal of General Internal Medicine has proposed that use of masks can lead to milder or asymptomatic infections (J Gen Intern Med. 2020;1-4).

There are two types of masks: Fabric masks and medical masks (surgical and N95). All should be three-layered. Fabric masks can be used when disease transmission is low or in an open space (low risk). Patients/caregivers should wear a medical mask as should healthcare workers, depending on hospital policy.

Outer layer should be water resistant, inner layer must be water absorbent and the middle layer acts as the filter. NRP masks - “N,” if they are not resistant to oil, “R” if somewhat Resistant to oil, and “P” if they are oil proof. Higher the efficiency, lower will be the breathability. Fabric masks are not meant for use if air pollution levels (PM 2.5) are high. In such conditions, shift to medical masks.

2. RTPCR Ct is THE gold standard test for diagnosis (J Clin Microbiol. 2020;58(6):e00512-20).Ct value may help to know if the test is false positive.

 “Although the Ct value in a rRT-PCR test is relatively accurate, error of 1~2 cycles are not uncommon in a Ct value depending on various factors, including the skill of the examiner. Therefore, when there is ambiguity in the Ct value, such as 33~34, the result may be interpreted as false negative or false positive depending on the Ct cut-off value (35)” (Am J Phys Med Rehabil. 2020;99(7):583-85).

3. Zinc is THE mineral (Front Immunol. 2020;11:1712); D is THE vitamin (PLoS One. 2020 Sep 25;15(9):e0239799).

4. Day 5 is THE crucial day in COVID phase (Lancet. 2020;395(10229):1054-62). In the COVID phase, Day 3 is the day when pneumonia may develop. If steroids and dabigatran are not started by Day 5, the illness may become serious. By Day 5, diagnosis of pneumonia must be made to reduce mortality.

5. Day 90 is THE day after which the word COVID ends (CDC Duration of isolation and precautions for adults with COVID-19. Updated Sept. 10, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html). It becomes a non-COVID illness after 90 days. After 90 days, it is a new disease and not written as post-COVID.

6. Home isolation is THE modality of treatment (Int J Surg. 2020;77:206-16). The policy may vary from country to country.

7. 12 years is THE age when the mortality starts (Annex: Advice on the use of masks for children in the community in the context of Covid-19, Aug 21, 2020, WHO UNICEF).According to WHO-UNICEF new guidelines, children 12 years or older should wear masks as recommended for adults. Mortality increases after 12 years of age.

8. CRP is THE lab test for seriousness (BMJ. 2020;370:m3339). IL-6 produces fibrinogen and CRP. Fibrinogen produces D-dimer. CRP is an indirect marker of IL-6. If CRP is >10mg/L in the first 10 days of illness, this is suggestive of pneumonia.

10. Loss of smell and taste are THE symptoms equal to RTPCR test(ORL J Otorhinolaryngol Relat Spec. 2020;82(4):175-80). Loss of smell can be present in flu with obstructive nasal symptoms. If loss of smell and taste occur together, RTPCR can be presumed to be positive.
11. 15 minutes is THE contact time to get the infection (CDC Contact Tracing for COVID-19).  Singapore says 30 minutes.

• COVID-19 is a potential hypercoagulable state. Start patient on anticoagulant such as dabigatran or equivalent drug on Day 1 in high risk persons. It is thrombosis, which may be fatal. If pneumonia develops, treatment is simple, but when added with clots, it becomes complicated pneumonia. In patients with COVID, MI may occur without blockages due to red clots and not white platelets clots.  
• All hospitalized patients should be given LMWH.
• Criteria for starting anticoagulation on Day 1: All high-risk patients (HCWs, high CRP, high LDL, prolonged immobilization, diabetes, hypertension, underlying hypercoagulable states or all conditions where we start NOAC or LMWH prophylaxis before surgery).
• Steroids are given when pneumonia is evident.
• Chest X-ray becomes positive on Day 5-7, while CT scan becomes positive on Day 2/3.
• If CRP reduces and then starts rising or if CRP is more than 150, it indicates superadded bacterial infection. CRP doubles every 8 hours. Start with broad spectrum antibiotic and then shift to narrow-spectrum.
• The University of Washington’s Institute for Health Metrics and Evaluation (IHME) makes forecasts based on what is known about a disease and how people’s actions may affect that. The IHME’s latest COVID-19 forecasts say the U.S. will reach nearly 317,000 deaths by Dec. 1, at the current rate of mask-wearing, which dropped to slightly below 50% nationally last week. But increasing mask wearing in public to 95% could save more than 67,000 lives.
• R0 is the average number of people who will catch the disease from a single infected person, in a population that’s never seen the disease before. So, if R0 is 3, that means one case will create an average of three new cases. When that transmission rate of infection occurs at a specific time, it’s called an “effective R,” or “Rt.”
• The third wave in Hong Kong has subsided now; only one to few new local cases, all with traceable origin. Government has been urged to not exempt people (who cross borders) from testing. If citizens are lax, the fourth wave could come back any time.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA