1195:  HCFI Round Table Expert Zoom Meeting on “COVID-19 virus is infectious for 10 days in human body as per reports, so why quarantine/isolate for 14-17 days?”

5^th December, 2020, 11am-12pm

Participants: Dr KK Aggarwal, Dr JA Jayalal, Dr Jayakrishnan Alapet, Dr YK Gupta, Dr Vikas Manchanda, Dr Anita Arora, Dr Anita Chakravarti, Dr Ashok Gupta, Mr Bejon Misra, Dr Suresh Mittal, Ms Upasana Arora, Mr Vivek Kumar, Dr KK Kalra, Ms Ira Gupta, Dr S Sharma

Consensus Statement of HCFI Expert Round Table

• CDC guidelines on discontinuing home isolation (3.12.20)

o   Persons with COVID-19 who have symptoms and were directed to care for themselves at home may discontinue isolation under the following conditions: At least 10 days have passed since symptom onset and at least 24 hours have passed since resolution of fever without the use of fever-reducing medications and other symptoms have improved.

o   Persons infected with SARS-CoV-2 who never develop COVID-19 symptoms may discontinue isolation and other precautions 10 days after the date of their first positive RT-PCR test for SARS-CoV-2 RNA.

• WHO criteria for discharging patients from isolation(i.e., discontinuing transmission-based precautions) without requiring retesting (27.5.20)

o   For symptomatic patients: 10 days after symptom onset + at least 3 additional days without symptoms (including without fever and without respiratory symptoms)

o   For asymptomatic cases: 10 days after positive test for SARS-CoV-2

• The NHS, UKrecommends stopping self-isolation after 10 days if there are no symptoms or there is just cough or changes to sense of smell or taste (which can last for weeks after the infection is gone). NHS recommends continuing self-isolation if you feel unwell or any of the following symptoms are present after 10 days:  a high temperature or feeling hot and shivery, a runny nose or sneezing, feeling or being sick or diarrhea. Stop self-isolation only when these symptoms have gone.

• MOH home isolation guidelines (2.7.20): “5. When to discontinue home isolation Patient under home isolation will stand discharged after 10 daysof symptom onset and no fever for 3 days. Thereafter, the patient will be advised to isolate at home and self-monitor their health for further 7 days. There is no need for testing after the home isolation period is over”.
• The Health Ministry guidelines need better clarity. It says “discharged after 10 days” of onset of symptoms and “no fever for 3 days”.  Are these 3 days included in the 10 days of home isolation? After 10 days, the patient is “advised to isolate at home”. How do the two home isolations differ?
• In almost 99% of cases, the virus does not replicate after 10 days (average) in immunocompetent persons. The patient is non-infectious after 10^thday (±3 SDs).
• According to the CDC, 1% risk still remains (acceptable risk).
• All antiviral drugs work on RdRp and block translation of the viral protein. If there is no replication after 10 days, then RdRp blockers have no role.
• The replication of virus depends on immune status, viral load and type of the virus.
• The MOH guidelines mention “no fever” but do not specify what is fever. Perception of fever has to change. Fever is body temperature >100.4^o Many are unaware of this.
• Inflammatory symptoms should not be the criteria for isolation. This decision should be made on case to case basis.
• It’s not clear if there is a need of testing after the home isolation period is over.
• The MOH guidelines need revision in view of the knowledge available today.
• Doctors should differentiate between viral fever and cytokine fever; viral phase and post-viral phase.
• The initial week is the viral phase (for 5-7 days); immunological phase begins from 8^th/9^thday onwards (cytokine fever); initial viral fever followed by fever-free period (48 hours) and then inflammatory fever. Sometimes, the initial fever is prolonged and merges with fever of immunological phase.
• Vaccine is a controlled stimulus; in natural infection, the dose is technically uncontrolled. The immune response is different in the two situations. What will be the duration of immunogenicity? The answer to this is largely unknown today.
• Treating doctors should be able to certify that the patient is non-infectious as patients who are recovered are still not allowed to resume work until they test negative.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA