First death in India: The case calls for implementation of IPC 270 and Epidemic Disease Act

Health Care Comments Off

Severe violation of epidemic guidelines in the first death

In an epidemic, one needs to follow one protocol, police should be informed for ‘left against medical advice’, suspected COVID-19 cases cannot be shifted to other state hospital. Suspected cases should be treated as positive cases unless tested negative. One such case with pneumonia (LRTI has high viral load) can make all the difference in the country and spread the disease like a wild fire.

As per India Today Report:

  • 76-year-old from Kalburagi died in Karnataka
  • The necessary contact tracing, isolation and other measures are being carried out as per protocol. Telangana government has also been informed since he went to a private hospital there.
  • He had visited Saudi Arabia from January 29 to February 29.
  • Reached in Hyderabad on February 29 and went to Kalaburagi in Karnataka.
  • The man had gone to a private hospital in Hyderabad earlier.
  • He was asymptomatic on his return from Saudi Arabia
  • Developed symptoms of fever and cough on 6th March.
  • One private doctor visited him at his home and treated him there.
  • On 9th March, the symptoms aggravated and he was shifted to a private hospital in Kalaburagi.
  • Provisionally diagnosed as mid-zone viral pneumonia and suspected COVID-19
  • Sample was collected on March 9
  • Without waiting for the test results, the attendees insisted and the patient was discharged against medical advice; he was taken to a private hospital in Hyderabad
  • The patient was admitted to a private hospital in Hyderabad and treated.
  • He died on Tuesday when he was being brought back to the Gulbarga Institute of Medical Sciences (GIMS) in Kalaburagi.
  • In addition to the deceased, Karnataka has confirmed five other positive cases of the novel coronavirus. The fifth case, confirmed on Thursday, is a 26-year-old man who recently returned from Greece.

Expected cases in India

Based on per million current infection rate:

  1. Average 17.3/million population = 22100
  2. Italy like situation: 250 per million = 325,000

iii. China scenario: 56 per million = 72800

  1. Iran scenario: 120 per million = 156,000
  2. US scenario: 5.2 per million = 6760
  3. New Zealand scenario: 1 per million = 1300

vii. Best scenario: 0.1 per million = 130

Out of them

  • 82% will be mild
  • 15% will be severe
  • 3% will be critical
  • 3% will die or 15% serious cases will die
  • 71% deaths will be in patients with comorbidity

How to diagnose severe cases early

  1. Do resting SPO2 levels; if low, needs oxygen
  2. Do walking SPO2 and if it falls by 4% within 1-2 minutes, it is a severe case
  3. Resting tachycardia
  4. Early oxygen

14-day quarantine period for COVID-19 may give a false sense of assurance

Cases of COVID-19 are increasing across the country. The total number of confirmed COVID-19 cases across India now stands at 73 (including foreign nationals, as on 12th March at 11:00 AM) as per the Health Ministry.

The two strategies commonly used to protect the public by preventing exposure to infected persons or to persons who may be infected are isolation and quarantine.

  • Isolation is intended at separating ill persons who have a communicable disease from healthy individuals. Isolation restricts the movement of ill persons to help check the spread of certain diseases. Hospitals use isolation for patients with infectious tuberculosis. More often, isolation is required for air-borne infections and precautions. MDR patients require strict isolation.
  • Quarantine is intended at separating and restricting the movement of a well person or group of well persons who may have been exposed to a communicable disease but are not yet symptomatic in order to see if they become ill. These people may have been exposed to a disease and do not know it, or they may have the disease but do not have symptoms yet. Quarantine can also help limit the spread of a communicable disease.

Government of India evacuated 647 Indian citizens from Wuhan, China, which was the epicenter of the current coronavirus outbreak. All these evacuees were quarantined and placed in isolation facilities for 14 days. Soon after, a video showed some persons at a facility during their quarantine, albeit with face masks and dancing together.

These evacuees were tested twice and found negative for the virus before they were discharged. But was it prudent to allow them to dance in a group during quarantine? These were at high risk of exposure to the virus and therefore were potentially infectious. They could have developed symptoms near or after they were discharged from the facility. This would have necessitated re-quarantine and contact tracing.

If you can potentially transmit infection to others, it is better to separate yourself from your partner, housemates and children. You should not even pet your dog, although pets are not known to transmit the coronavirus and there is no evidence yet that companion animals can transmit the infection.

You should have a room for your exclusive use, including a bathroom. Every surface you cough on or touch could become contaminated. There should be no visitors, and it is important to keep a distance of 3 to 6 feet between yourself and others.

As per the WHO, most estimates of the incubation period for COVID-19 range from 1-14 days, most commonly around 5 days. This has been corroborated in a recent analysis published March 10 in the Annals of Internal Medicine, which estimated the median incubation period of COVID-19 to be 5.1 days and expects that nearly all infected persons who have symptoms will do so within 12 days of infection. This is in line with the standard 14 days incubation period currently being followed. However, the study further says that “an estimated 101 out of every 10 000 cases will develop symptoms after 14 days of active monitoring or quarantine”.

So, data is still emerging, and it may well extend beyond the standard 2-week quarantine period in some cases. Who are these cases we do not know?

According to a study published March 1, 2006 in the American Journal of Epidemiology, results demonstrate that the number of infections averted (per initially infected individual) through the use of quarantine is expected to be very low provided that isolation is effective, but it increases abruptly and at an accelerating rate as the effectiveness of isolation diminishes.

The classical example of cohort quarantine was Diamond Princes ship where over 3700 people were kept in the ship together in a cohort and 23% got infected with estimated 10 deaths. We agree 1:1 quarantine was not possible in this set up but they could have divided them into a cohort of 80 + age high risk people; second cohort of 20 minus age (lowest risk); cohort of 20-40 age group (low risk) and last cohort of  40-80 with comorbidity. This way they would have prevented the death and infectivity.

For a disease which is still evolving and has many questions still unanswered, it is safer to practice 1:1 isolation even for quarantined persons; cohort (clusters) of contacts should be avoided.

India has closed International operations so they will have to deal with 60 infected and around 6000 contacts which is not a difficult task to 1:1 isolation and observation.

Stringent adherence to quarantine protocols is warranted.

Dr KK Aggarwal,

President CMAAO, HCFI and Past National President IMA