CMAAO Update 16th February on COVID-19

Authors: Dr K K Aggarwal, Dr Rajan Sharma, Dr R V Asokan, Dr KK Kalra, Dr Sushil Kumar, Dr Anita Arora, Dr Upasana Arora, Dr SS Srivastava, Dr Shilpi Khanna, Ms Swati, Dr Rahiul Shukla, Dr Arti Verma, Dr Anil Kumar, DSr G S Gyani, Dr Sonal Saxena, DSr CM Bhagat, Dr Vikas Manchanda, Dr Nandani Sharma, Dr Suneela Garg, Dr TK Joshi, Dr Mamta Jajoo, Dr Shariga Qureshi, Dr Manish Kumar, Dr Harmeet Singh, Dr Dr Rai, Dr VK Monga, Dr AP Singh,  Dr Ramesh Datta, Dr Maj Prachi Garg, Dr Anil Kumar,  Dr Rajni, Dr Rajeev Kumar, Dr Harish Grover,  Dr Mini Mehta, Dr Lalan Bharti,  ( More to be added)

Summary

COVID-19 virus possibly behaves like SARS; causes mild illness in 82%, severe illness in 15%, critical illness in 3% and death in 2% cases ( 15% of admitted serious cases, 71% with comorbidity); affects all ages but predominantly males (56%) with median age 59 years (2-74 years, less in children below 15);  with mean incubation period 5.2 days (2-214 days); mean time to symptoms 5 days,  mean time to pneumonia 9 days, mean time to death 14 days,  3-4 reproductive number R0  ( flu 1.2 and SARS 2); epidemic doubling time 7.5 days; has origin possibly from bats; spreads via large droplets and predominately from people having lower respiratory infections and hence standard droplet precautions are the answer for the public and close contacts and airborne precautions for healthcare workers dealing with the secretions.

Clinically all patients have fever, 75% have cough; 50% weakness; 50% breathlessness with low total white count and deranged liver enzymes. About 20% need ICU care and 15% of them are fatal.

Close Contacts are defined as healthcare-associated exposure, which includes providing direct care for COVID-19 patients, working with health care workers infected with COVID-19, visiting patients or staying in the same close environment of a COVID-19 patient OR working together in close proximity or sharing the same classroom environment with a with COVID-19 patient  OR traveling together with COVID-19 patient OR Living in the same household as a COVID-19 patient OR the epidemiological link may have occurred within a 14-day period before or after the onset of illness in the case under consideration.  

 New updates

1. Namaste: Let’s not shake hands.
2. Time for facts, not fear; for rationality, not rumors and for solidarity, not stigma.
3. Help line India:  +91-11-23978046, ncov2019@gmaildotcom, mohfw.gov.in/node/4904
4. Total number includes lab-confirmed plus CT-Ddagnosed cases.
5. No reliable evidence to support the possibility of vertical transmission of COVID-19 infection from the mother to the baby. [Lancet Feb 20]
6. There has been a sudden jump in deaths and new cases on 12^th due to inclusion of CT-diagnosed cases. The National Health Commission of China, in its 14 Feb report deducted 108 previously reported deathsand 1,043 previously reported cases from the total in Hubei Province due to "repeated statistics."
7. 218 (6%) cases have been confirmed on a ship quarantined in Japan (three  Indians)
8. Secondary Cases: Thailand, Taiwan, Germany, Vietnam, Japan, France, US, Korea.
9. Five Deaths outside China: Philippines (Feb 2, 44-year-old Chinese man, primary, comorbid), Hong Kong (4^th Feb 39 M, local, comorbid, primary), Japan (2 Feb, 18 F, Secondary), France (15 Feb, 80-yr, M, Chinese visitor), Taiwan.
10. WHO warns epidemic could still ‘go in any direction’ and global experts say that the outbreak is just ‘beginning’ outside China.
11. Coronavirus vaccine could be ready in 18 months (WHO). 
12. Human-to-human contact requires prolonged contact (possibly ten minutes or more) within three to six feet.
13. 14^th Feb: 1,716 medical workers have contracted the virus and six of them have died. Of those people, 1,502 were in Hubei Province, with 1,102 in Wuhan. National Health Commission, said the numbers of infected workers represented 3.8% of China’s overall confirmed infections as of Feb. 11.
14. At least two workers who were sent to Wuhan at the end of January to help build one of the new hospitals to treat victims of coronavirus have been infected with it.
15. The central banking authorities of China are disinfecting, stashing and even destroying cash in an attempt to stop the spread of the coronavirus. Fan Yifei, deputy governor of the People’s Bank of China, said that the cash collected by commercial banks must be disinfected before being released back to customers.
16.  Maharishi Valmiki Hospital in Delhi stops biometric attendance.
17.  China has more than 80 running or pending clinical trials on potential treatments for COVID-19.
18. WHO demands to know more about sick doctors, insists group of 12 virus experts will reach Beijing over the weekend.
19. Bangkok: A health worker has been found to have been infected by coronavirus, bringing the total number of infections in the country to 34 since January.

Daily Statistics 15^th February, 29  countries

Total cases: 71329

New cases yesterday: 2008

Deaths: 1,775

Recovered: 10973 (86%)

Currently Infected Patients: 58581

Mild cases: 47282 (81%)

Serious or Critical: 11,298 (19%)

Deaths yesterday: 105

Serious or critical mortality 15%

Likely minimum deaths 1775 +1695 = 3470 with the present trend and available treatment (plus deaths linked to daily new cases)

Around the globe

February 17:

• 1 new case in South Korea: 68-year-old wife of previously confirmed case.
• 115 new cases and 5 new deaths outside of Hubei province in China on February 16, as reported by the National Health Commission (NHC) of China.

February 16:

• Report from Hubei province:

1,933 new cases

100 new deaths

58,182 cumulative total cases

6,639 cumulative total hospital discharges

40,814 currently hospitalized, of which:

- 31,007 (76.0%) mild

- 8,024 (19.7%) serious

- 1,773 (4.3%) critical

1,016 new hospital discharges

191,434 close contacts tracked

• 1 new case in the United Arab Emirates.
• 3 new cases in Singapore: A family member of a previously confirmed case; 2 people linked to the Grace Assembly of God church, including a Republic of Singapore Air Force (RSAF) serviceman.
• 1 new death in Taiwan: A 61-year-old man with no travel history abroad but being taxi driver, serving clients from Hong Kong, Macau and mainland China, who had underlying conditions (diabetes and hepatitis B).
• 2 new cases in Taiwan.
• 6 new cases in Japan.
• 1 new case in Hong Kong: A 54-year-old man with no travel history and no known contacts with confirmed cases. 
• 70 new cases on board the cruise ship in Japan. About 1 out of 10 passengers and crew (9.6%) have tested positive so far (355 cases out of 3,711 passengers and crew).  The 952-foot cruise ship carries the highest infection rate of the coronavirus anywhere in the world.
• 1 new case in South Korea: An 82-year-old man in Seoul, with no travel history to China.
• 166 new cases and 3 new deaths outside of Hubei province in China on February 15 (National Health Commission (NHC) of China).

Travel Restrictions

Travel advisory:  Level 1 in all countries (Exercise normal standard hygiene precautions), Level 2 in all affected countries and states including Kerala (Exercise a high degree of caution), Level 3 in all countries with secondary cases (Reconsider your need to travel), done by India, and Level 4 (Do not travel), done by US. Hong Kong has imposed 14 days quarantine on people arriving from China. The Karnataka government has ordered that anybody arriving from the 23 COVID-19-affected countries must stay in isolation at home for 28 days. The home isolation requirement is irrespective of the virus symptoms. To date, 72 countries have implemented travel restrictions.

Travel preferable seat: Choosing a window seat and staying there lowers the risk

Travel and trade restrictions: WHO says no to countries

Leave China all together: UK, condemned by many countries

Entry to India not allowed: Foreigners who went to China on or after January 15

Visas Suspended: All visas issued to Chinese nationals before February 5 (not applicable to aircrew)

Flight suspended: IndiGo and Air India have suspended all of their flights between the two countries. SpiceJet continues to fly on Delhi-Hong Kong route.Evacuation

 Many countries including US, Japan, India have evacuated their citizens.

Case fatality

COVID-19 2%; MERS 34% (2012, killed 858 people out of the 2,494 infected); SARS 10% (Nov. 2002 - Jul. 2003, originated from Beijing, spread to 29 countries, with 8,096 people infected and 774 deaths); Ebola 50%; Smallpox 30-40%; Measles 10-15% developing countries; Polio 2-5% children and 15-30% adults; Diphtheria 5-10%; Whooping cough 4% infants < 1yr, 1% children < 4 years; Swine flu < 0.1-4 %; Seasonal flu 0.01%; COVID19 in Wuhan 4.9%; COVID-19 in Hubei Province 3.1%; COVID19 Nationwide 2.1%; COVID19 in other provinces 0.16%.

Number of flu deaths every year: 290,000 to 650,000 (795 to 1,781 deaths per day)

Public Health Emergency of International Concern - 30^th January, 2020

Mandatory to report to WHO each human and animal case.

Prior 5 PHEICs: 

26^th April 2009 Swine flu: 10 August 2010, WHO announced that the H1N1 influenza virus has moved into the post-pandemic period. However, localized outbreaks of various magnitudes are likely to continue.

May 2014 Polio: resurgence of wild polio. October 2019, continuing cases of wild polio in Pakistan and Afghanistan, in addition to new vaccine-derived cases in Africa and Asia; the status was reviewed and it remains a PHEIC. It was extended on 11 December, 2019.

August 2014 Ebola: It was the first PHEIC in a resource-poor setting.

Feb 1 2016 Zika: link with microcephaly and Guillain–Barré syndrome. This was the first time a PHEIC was declared for a mosquito‐borne disease. This declaration was lifted on 18 November 2016.

2018–20 Kivu Ebola: A review of the PHEIC had been planned at the fifth meeting of the EC on 10 October 2019 and as of 18 October 2019, it continues to be a PHEIC.

Kerala: State public health emergency. Three primary cases in North, South and Central - Kasaragod district in north Kerala, Thrissur in central Kerala and Alappuzha in South Kerala. Four Karnataka districts bordering Kerala — Kodagu, Mangaluru, Chamarajanagar and Mysuru - have been put on high alert.

 About the Virus

Single-strand, positive-sense RNA genome ranging from 26 to 32 kilobases in length, Beta corona virus from Corona family.

‘Corona’ means crown or the halo around the sun. Heart is considered crown and hence the arteries that supply oxygen to the heart are also called coronary arteries. Under an electron microscope, is the virus appears round with spikes poking out from its periphery.

Three deadly human respiratory coronaviruses: Severe acute respiratory syndrome coronavirus [SARS-CoV], Middle East respiratory syndrome coronavirus [MERS-CoV]) and COVID 19: The current virus is 75-80% identical to the SARS-CoV

Origin: Wuhan, China December 2019. 1^st case informed to the world by Dr. Li Wenliang; died Feb 6^.

The virus is likely to be killed by sunlight, temperature, and humidity. SARS stopped around May and June in 2003 probably due to more sunlight and more humidity.  Alive on surface: possibly 3-12 hours.

Link to ACE: COVID-19 might be able to bind to the angiotensin-converting enzyme 2 receptor in humans.

Pathogenesis

High viral load: Detection of COVID-19 RNA in specimens from the upper respiratory tract with low Ct values on day 4 and day 7 of illness suggests high viral loads and potential for transmissibility. [NEJM]

COVID-19 uses the same cellular receptor as SARS-CoV (human angiotensin-converting enzyme 2 [hACE2]), so transmission is expected only after signs of lower respiratory tract disease develop.

SARS is high [unintelligible] kind of inducer. This means that when it infects the lower part of the lung, the body develops a very severe reaction against it and leads to lots of inflammation and scarring. In SARS, after the first 10 to 15 days, it wasn’t the virus killing the patients it was the body’s reaction. Is this virus in the MERS or SARS kind picture or is this the other type of virus which is a milder coronavirus like the NL63 or the 229? It may be the mild (unintelligible) kind of inducer. [Dr John Nicholls, University of Hong Kong]

COVID-19 seems to thrive better in primary human airway epithelial cells as compared to standard tissue-culture cells, unlike SARS-CoV or MERS-CoV. COVID-19 will likely behave more like SARS-CoV.

SARS-CoV and MERS-CoV affect the intrapulmonary epithelial cells more than cells of the upper airways. Transmission thus occurs primarily from patients with recognized illness and not from patients with mild, nonspecific signs. However, NEJM has reported a case of COVID-19 infection acquired outside of Asia wherein transmission occurred during the incubation period in the index patient, but the same has been challenged now.

This new virus attacks the lungs as well, and not just the throat. Patients so far have not presented with a sore throat, because COVID-19  attacks  the intraepithelial cells of lung tissue.

Transmission

Zoonotic and linked to Huanan Seafood Wholesale Market as 55% with onset before January 1, 2020 originated there vs. only 8.6% of the subsequent cases. The Chinese government has banned wildlife trade until the epidemic passes. 

This new coronavirus is closely related to bat coronaviruses. Bats are the primary reservoir. While SARS-CoV was transmitted to humans from exotic animals in wet markets, MERS-CoV transmitted from camels. The ancestral hosts were probably bats; however.

The virus has been traced to snakes in China. Snakes often hunt for bats. According to reports, snakes were sold in the local seafood market in Wuhan, thus raising the likelihood that COVID 19 might have moved from the host species, i.e., bats, to snakes and then to humans. It is still not understood as to how the virus could adapt to both the cold-blooded and warm-blooded hosts. 

It cannot be transmitted by eating wild animals as it is a respiratory secretions disease.  

It transmits predominantly via droplets, like common flu and not like airborne illnesses (TB, Measles, Chickenpox).

Kissing scenes have been banned in movies in China. In Kerala, air crew have been exempted from breath analyser tests and China has banned death ceremonies, people gathering together. NEJM reported a small cluster of five cases suggesting transmission from asymptomatic individuals during the incubation period; all patients in this cluster had mild illness. But the same has been challenged. Another case got infected while using gown, but eyes uncovered.

Serious illnesses in other countries are less as patients with breathlessness are unlikely to board and patients will mild illness or asymptomatic illness are less likely to transmit infections. NEJM reports of a taxi driver infected with SARS-CoV-2 in Thailand, potentially from Chinese tourists; the infection appears not to have spread to others.

Legal Implications India: Section 270 in the Indian Penal Code: 270. Malignant act likely to spread infection of disease danger­ous to life.—Whoever malignantly does any act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both.

Quarantine has Limitations

China has imposed quarantines across Hubei province, locking in about 56 million people, in an attempt to stop it from spreading. Millions of others cities far from the epicenter are also enduring travel restrictions.

Villages in Vietnam with 10,000 people close to the nations capital have also been placed under quarantine after six cases of the deadly coronavirus were identified there. The locking down of the commune of Son Loi, about 40 kilometres from Hanoi, is the first mass quarantine outside of China since the virus emerged from central China late last year.

1. The people on quarantine are kept under a 14-day quarantine. If they are placed together and if anyone is diagnosed with the infection during that period, the quarantine will add another 14 days.
2. The longer several thousand people are cohoused, it goes on to propagate waves of infection.
3. A better way is to divide these people into smaller groups and quarantine them separately.
4. Why quarantine children <15 years when the virus is not risky for them.
5. Why not separate elderly people with comorbid conditions at high risk of death and quarantine them separately in one-to-one or small groups.
6. Why allow people to celebrate and have cultural programs during quarantine, as was seen in India, when people danced together with surgical masks during quarantine period.
7. Ventilation system can connect one room to the other. There has been concern that the coronavirus can spread through pipes.
8. Stress and anxiety suppress the immune system, thus rendering people more vulnerable to contracting the virus. 
9. Quarantine them the way it was done in TB sanatoriums with both sun-balconies and a rooftop terrace where the patients would lie all day either in beds or on specially designed chairs.

Standard Respiratory Droplets Precautions

At triage: Surgical 3 layered mask to the patient; Isolation of at least 1m distance, cough etiquette and hand hygiene

Droplet precautions: Three layer surgical mask by patients, their contacts and health care workers, in an adequately ventilated isolation room, health care workers while caring with the secretions should use eye protection, face shields/goggles. One should limit patient movement, restrict attendants and observe hand hygiene.

Contact precautions: When entering room - gown, mask, goggles, gloves – remove before leaving the room; Dedicated equipment/disinfection after every use; Care for environment- door knobs, handles, articles, laundry; Avoid patient transport and practice hand hygiene.

Airborne precautions when handling virus in the lab and while performing aerosol-generating procedures. Room should be with negative pressure with minimum of 12 air changes per hour or at least 160 litres/second/patient in facilities with natural ventilation. There should be restricted movement of other people and all should use gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or equivalent, or higher level of protection)

Public

Strict self-quarantine if sick with flu like illness: 2 weeks

Wash your hands often and  for at least 20 seconds with soap and water or use an alcohol-based hand sanitizer.

Avoid touching:  Eyes, nose, and mouth with unwashed hands.

Avoid close contact:  (3-6 feet) with people who are sick with cough or breathlessness

Cover your cough or sneeze with a tissue, then throw the tissue in the trash.

Clean and disinfect frequently touched objects and surfaces.

Masks

Surgical 3 layered Masks: For patients and close contacts

N 95 Masks: For health care providers when handling respiratory secretions.

 Lab tests

1. There are two ways to detect a virus: through the genetic material DNA or RNA and to detect the protein of the virus. The rapid tests look at the protein. It takes 8-12 weeks to make commercial antibodies. Currently, for the diagnostic tests, PCR is being used which gives a turnaround in 1-2 hours.
2. BOTH the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) AND lower respiratory tract (LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage)
3. Use PPE in the lab
4. Use viral swabs (sterile Dacron or rayon, not cotton) and viral transport media
5. In US, in January, all testing had to be done in CDC laboratories. However, on February 4, the US FDA issued an emergency-use authorization for the CDCs COVID-19 Real-Time RT-PCR Diagnostic Panel, allowing its use at any CDC-qualified laboratory in the United States.
6. Lab precautions: BSL 2 (3 for viral culture labs)

Treatment

1. No proven antiviral treatment.
2. With SARS, in 6 months the virus was gone and it never came back.  Pharmaceutical companies may not spend millions to develop a vaccine for something which may never come back.
3. Secondary infection, E. coli, is most likely the cause of death of the patients in the Philippines and Hong Kong.
4. A combination of lopinavir and ritonavir showed promise in lab in SARS. Combination of lopinavir, ritonavir and recombinant interferon beta-1b was tried in MERS.
5. Scientists in Australia have reportedly recreated a lab-grown version of COVID 19.
6.  Chloroquine had potent antiviral activity against the SARS-CoV, has been shown to have similar activity against HCoV-229E in cultured cells and against HCoV-OC43 both in cultured cells and in a mouse model.
7. Thailand: Oseltamivir along with lopinavir and ritonavir, both HIV drugs.
8.  Experimental drug: From Gilead Sciences Inc., called remdesevir (started on 6^th Feb as a trial)
9.  Russia and China drug: Arbidol, an antiviral drug used in Russia and China for treating influenza, could be combined with Darunavir, the anti-H.I.V. drug, for treating patients with the coronavirus. (The COVID-19 virus shares some similarity to HIV virus also)
10. PVP-I mouthwashes and gargles are known to reduce viral load in the oral cavity and the oropharynx. PVP-I has high potency for viricidal activity against hepatitis A and influenza, MERS and SARS
11.  The Drug Controller General of India has approved the "restricted use" of a combination of drugs (Lopinavir and ritonavir) used widely for controlling HIV infection in public health emergency for treating those affected by novel coronavirus.
12. In SARS, people were put on long-term steroids ending with immunosuppression and late complications and death. The current protocol is short-term treatment.

Case Definitions

Case Definitions

Suspect case

1. Patients with severe acute respiratory infection (fever, cough, need admission to hospital), with no other etiology that can explain the clinical presentation AND at least one of the following:

• a history of travel to or residence in the city of Wuhan, Hubei Province, China in the 14 days before symptom onset, or
• patient is a health care worker who has been working in an environment where severe acute respiratory infections of unknown etiology are being cared for.

1. Patients with any acute respiratory illness AND at least one of the following:

• close contact with a confirmed or probable case of COVID-19 in the 14 days before illness onset, or
• visit to or working in a live animal market in Wuhan, Hubei Province, China in the 14 days before symptom onset, or
• worked or attended a healthcare facility in the 14 days before symptom onset where patients with hospital-associated COVID 19 infections have been reported.

Probable case

A suspect case for whom testing for COVID 19 is inconclusive or for whom testing was positive on a pan-coronavirus assay.

 Confirmed case

A person with laboratory confirmation of COVID 19 infection, irrespective of clinical signs and symptoms.

Severe acute respiratory infection (SARI)

An ARI with history of fever or measured temperature ≥38 C° and cough; onset within the last ~10 days; and requiring hospitalization. Absence of fever does NOT exclude viral infection

SARI in a person, with history of fever and cough requiring hospital admission, with no other etiology that can fully explain the clinical presentation (clinicians should also be alert to the possibility of atypical presentations in immunocompromised patients)

AND any of the following:

1. a)  A history of travel to Wuhan, Hubei Province China in the 14 days before symptom onset; or
2. b)  the disease occurs in a health care worker who has been working in an environment where patients with severe acute respiratory infections are being cared for, irrespective of place of residence or history of travel; or
3. c)  the person develops an unusual or unexpected clinical course, especially sudden deterioration despite appropriate treatment, regardless of place of residence or history of travel, even if another etiology has been identified that fully explains the clinical presentation

OR A person with acute respiratory illness of any severity who, within 14 days before onset of illness, had any of the following exposures:

1. a)  close physical contact with a confirmed case of COVID 19 infection, while that patient was symptomatic; or
2. b)  a healthcare facility in a country where hospital-associated COVID 19 infections have been reported

Uncomplicated illness

Patients with uncomplicated upper respiratory tract viral infection, may have non- specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache, muscle pain or malaise. The elderly and immunosuppressed may present with atypical symptoms. These patients have no signs of dehydration, sepsis or shortness of breath

Mild pneumonia

Patient with pneumonia and no signs of severe pneumonia. Child has cough or difficulty breathing + fast breathing: fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40 and no signs of severe pneumonia

Severe pneumonia

Adolescent or adult: fever or suspected respiratory infection, AND one of respiratory rate >30 breaths/min, severe respiratory distress, or SpO2 <90% on room air

Child:  cough or difficulty in breathing, AND at least one of the following: central cyanosis or SpO2 <90%; severe respiratory distress (e.g. grunting, very severe chest indrawing); signs of pneumonia with a general danger sign: inability to breastfeed or drink, lethargy or unconsciousness, or convulsions. Other signs of pneumonia may be seen: chest indrawing, fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40.

Diagnosis is clinical; chest imaging can help exclude complications.

Acute Respiratory Distress Syndrome

Onset: new or worsening respiratory symptoms within a week of known clinical insult.

Chest imaging: bilateral opacities, not fully explained by effusions, lobar or lung collapse, or nodules.

Origin of edema: respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of edema if no risk factor present.

Oxygenation (adults):

Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥5 cm H2O, or non-ventilated)

Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP ≥5 cm H2O, or non-ventilated)

Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cmH2O, or non- ventilated)

PaO2  not available: SpO2/FiO2 ≤315 suggests ARDS (including in non-ventilated patients)

Oxygenation (children; OI = Oxygenation Index and OSI = Oxygenation Index using SpO2)

Bilevel NIV or CPAP ≥5 cmH2O via full face mask: PaO2/FiO2 ≤ 300 mmHg or SpO2/FiO2 ≤264

Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5 Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3

Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3

Sepsis

Adults: life-threatening organ dysfunction due to a dysregulated host response to suspected or proven infection, with organ dysfunction.

Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia.

Children: suspected or proven infection and ≥2 SIRS criteria; of these, one must be abnormal temperature or white blood cell count

Septic shock

Adults: persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP ≥65 mmHg and serum lactate level >2 mmol/L

Children: any hypotension (SBP <5th centile or >2 SD below normal for age) or 2-3 of the following: altered mental state; tachycardia or bradycardia (HR <90 bpm or >160 bpm in infants and HR <70 bpm or >150 bpm in children); prolonged capillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea; mottled skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia

Common Myths

1. People receiving packages from China are not at risk of contracting the COVID 19 as the virus does not survive long on objects, such as letters or packages.
2. There is no evidence that animals/pets such as dogs or cats can be infected with COVID-19.
3. Pneumococcal vaccine and Haemophilus influenza type B (Hib) vaccine, provide no protection against COVID-19.
4. Regularly rinsing the nose with saline does not protect people from infection with COVID-19 or respiratory infections although it can hasten recovery from the common cold.
5.  There is no evidence that using mouthwash will protect you from infection with COVID 19 although some brands or mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth.
6. There is no evidence that eating garlic protects people from COVID-19.
7. Sesame oil does not kill the new coronavirus. Chemical disinfectants that can kill the COVID-19 on surfaces are bleach/chlorine-based disinfectants, either solvents, 75% ethanol, peracetic acid and chloroform.
8. People of all ages can be infected by COVID-19. Older people, and people with pre-existing medical conditions (such as asthma, diabetes, heart disease) have increased odds of becoming severely ill with the virus.
9. Antibiotics do not work against viruses.
10. To date, there is no specific medicine recommended to prevent or treat COVID-19.

 Trolls and conspiracy theories: Not validated and are fake news

1. COVID-19 is linked to Donald Trump,and US intelligence agencies or pharmaceutical companies are behind it.
2. Eating snakes, wild animals or drinking bat soup cases coronavirus infection.
3. Keep your throat moist, avoid spicy food and load up on vitamin C.
4. Avoiding cold or preserved food and drinks, such as ice cream and milkshakes, for "at least 90 days".
5. Experts have been aware of the virus for years.
6. The virus was part of Chinas "covert biological weapons programme" and may have leaked from the Wuhan Institute of Virology.
7. Linked to the suspension of a researcher at Canadas National Microbiology Lab.  
8. China wants to kill 20,000 COVID-19 patients is totally false. The site is linked to a sex website.

 Experts Opinions on COVID-19

“I think this virus is probably with us beyond this season, beyond this year, and I think eventually the virus will find a foothold and well get community-based transmission and you can start to think about it like seasonal flu. The only difference is we dont understand this virus”

Dr. Robert Redfield

Director, CDCUS Centers for Disease Control and PreventionFeb. 13, 2020

 “What makes this one perhaps harder to control than SARS is that it may be possible to transmit before you are sick. I think we should be prepared for the equivalent of a very, very bad flu season, or maybe the worst-ever flu season in modern times.”

Prof. Marc Lipsitch

Prof. of Epidemiology, Harvard School of Public Health

Head, Harvard Ctr. Communicable Disease Dynamics

Feb. 11, 2020

 “I hope this outbreak may be over in something like April’

Prof. Nanshan Zhong

Leading epidemiologist, first to describe SARS coronavirus

Feb. 11, 2020

 “It could infect 60% of global population if unchecked”

Prof. Gabriel Leung

Expert on coronavirus epidemics

Chair of Public Health Medicine

Hong Kong University

Feb. 11, 2020

“It’s a new virus. We don’t know much about it, and therefore we’re all concerned to make certain it doesn’t evolve into something even worse”

Prof. W. Ian Lipkin

Epidemiology Director

Columbia University

Feb. 10, 2020

 “We are estimating that about 50,000 new infections per day are occurring in China. [...] It will probably peak in its epicenter, Wuhan, in about one-month time; maybe a month or two later in the whole of China. The rest of the world will see epidemics at various times after that.”

Prof. Niall Ferguson

Director, Institute for Disease and Emergency Analytics

Imperial College, London Feb. 6, 2020

 “This looks far more like H1N1’s spread than SARS, and I am increasingly alarmed”

Dr. Peter Piot

(Director, The London School of Hygiene and Tropical Medicine)

Feb. 2, 2020

 “It sounds and looks as if it’s going to be a very highly transmissible virus [...] This virus may still be learning what it can do, we don’t know its full potential yet.”

Robert Webster

Infectious disease and avian flu expert at St. Jude Children’s Research Hospital

Feb. 2, 2020

 “Increasingly unlikely that the virus can be contained”

Dr. Thomas R. Frieden

Former Director of CDC

Feb. 2, 2020

“It’s very, very transmissible, and it almost certainly is going to be a pandemic. But will it be catastrophic? I don’t know “

Dr. Anthony S. Fauci

Director, National Institute of Allergy and Infectious Diseases

Feb. 2, 2020

 “Until [containment] is impossible, we should keep trying”

Dr. Mike Ryan

Head of the WHO’s Emergencies Program

Feb. 1, 2020

 “The more we learn about it, the greater the possibility is that transmission will not be able to be controlled with public health measures”

Dr. Allison McGeer

Director of Infection Control, Mount Sinai Hospital

Jan. 26, 2020

Confirmed cases and deaths

 Role of CMAAO and other Medical Associations

 Get prepared for containment, including active surveillance, early detection, isolation and case management, tracking contacts and prevention of spread of the virus and to share full data with WHO.   All countries should emphasize on reducing human infection, prevention of secondary transmission and international spread. Intensify IEC activities.

CMAAO IMA FOMA MAMC Recommendations

1. Price control of PPE
2. Accreditation of private labs for testing
3. Private insurance should cover the infection
4. IEC and CME activities to be intensified
5. Allow paid leaves for airborne and droplet infections
6. Allow teleconsultations in flu-like diseases
7. CSR funds for vaccine research
8. Surgical three-layered masks at public places
9. Start National program on respiratory secretions borne illnesses
10. In India, incorporate respiratory infection control under Swatchh Bharat

CMAAO _ Suggestions so far

1. 7^th January: CMAAO Alert: WHO to monitor Chinas mysterious p