CMAAO Coronavirus Facts and Myth Buster 81

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Density of population has a direct association with the number of COVID-19 positive cases. The chances of infection spreading are greater in densely populated areas. But, a place can have dense population, yet people can isolate, work remotely and practice social distancing. Density of population becomes a risk factor for spread of infection where people live in close confined spaces and therefore are in close contact with one another. Social distancing becomes more difficult or practically impossible in such places.

In India, in states with average population density of 1185/sq km, average number of cases were 2048.

These, when compared to states with population density of 909/sq km, the number of cases were 34.6.

If these two sates (Chandigarh and Pondicherry) with high population density were taken out, the Average Density of other states were 217 and the average number of cases were 35.

This shows that high density states have larger number of cases and low density states have significantly less number of cases. The exceptions are Chandigarh and Pondicherry which shows disciplined social distancing in high density states can make a difference.

“Cruise ships are examples of dense mixing of many persons in a confined space over a relatively long period. The density of the group of people on board the COVID-19-infected Diamond Princess, quarantined in Yokohama earlier this year, was estimated around four times higher than that in Wuhan, as was also the R0 before the onset of countermeasures” (J Travel Med. 2020 Mar 29).

The 40-day lockdown, has been extended for two weeks till 17th May. The districts have been categorized into Red (hotspot), Green and Orange Zones based on their risk profiling.

Green Zones will be districts with either zero confirmed cases till date, or no confirmed case in the last 21 days, while districts will be placed in Red Zones depending on the total number of active cases, doubling rate of confirmed cases, extent of testing and surveillance feedback from the districts.

All metros and major cities in the country have been placed in the Red Zone (hotspots).

Population density according to the 2011 census of India:

Delhi: 11,312/sq km

Kolkata: 24,252/sq km

Chennai: 26,903/sq km

Mumbai: 20,482/sq km

Hyderabad: 10,477/sq km

Indore: 25,170/sq km

Lucknow: 1,815/sq km

Surat: 14,000/sq km

Ahmedabad: 12,000/sq km

Jaipur: 6500/sq km

Chandigarh: 9252/sq km

Green Zone

Goa: 394/sq km

Arunachal Pradesh: 17/sq km

Manipur: 122/sq km

Thirty out of 33 districts in Assam are in the green zone; no red zone. The population density in Assam is 397/sq km. Puducherry has a population density of about 2547/sq km; three out of 4 districts are green zones; there is no red zone.

Number of cases linked to population density in India: Migrant decongestion is the answer




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In print: IJCP May Issue

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

CMAAO Coronavirus Facts and Myth Buster 79

Health Care Comments Off

With regular inputs from Dr Monica Vasudev

790: Social distancing reduces COVID-19 infection: Evidence from China

Intensive non-pharmaceutical interventions were introduced in China to stop transmission of the novel coronavirus disease. As transmission increases in other countries, the link between age, contact patterns, social distancing, susceptibility to infection, and COVID-19 dynamics remains unclear. To answer some of these questions, researchers assessed contact surveys data for Wuhan and Shanghai prior to and during the outbreak and contact tracing information from Hunan Province.

Daily contacts were decreased about 7-8-fold during the COVID-19 social distancing period, with most interactions restricted to the household.Investigators noted that children 0-14 years are less prone to SARS-CoV-2 infection as compared to adults 15-64 years of age (odd ratio 0.34, 95%CI 0.24-0.49), while individuals over 65 years are more susceptible to infection (odd ratio 1.47, 95%CI: 1.12-1.92). Based on these data, a transmission model was designed to study the impact of social distancing and school closure on transmission.It was noted that social distancing alone, as implemented in China during the outbreak, is sufficient to control COVID-19.Proactive school closures cannot interrupt transmission on their own, but they can diminish peak incidence by 40-60% and delay the epidemic.[Juanjuan Zhang J , Maria Litvinova, Yuxia Liang , et al. Changes in contact patterns shape the dynamics of the COVID-19 outbreak in China. J. Zhang et al., Science 10.1126/science.abb8001 (2020).]

791: Rare inflammatory syndrome seen in US child with COVID-19(CNN): US doctors have stated that they may have seen a possible complication of coronavirus infection in a young child – a rare inflammatory condition known as Kawasaki disease.National Health Service England has sent an alert to doctors and the Paediatric Intensive Care Society also tweeted it out to members. It cautioned about a small rise in cases of critically ill children with “common overlapping features of toxic shock syndrome and atypical Kawasaki disease with blood parameters” with some children testing positive for COVID-19.Some reports have also been there in Italy and Spain.Kawasaki disease leads to inflammation in the walls of the arteries and can limit blood flow to the heart. It is a treatable condition and most children recover without serious problems, but it can be fatal. It is not known what causes Kawasaki disease, but some studies have suggested a link between viruses or a bacterial infection. [Hospital Pediatrics].

792: In the first three weeks after symptom onset, the majority of RT-PCR results were positive for SARS-CoV-2.It has been noted in a study in Clinical Infectious Diseases that over the first three weeks after symptom onset, the majority of RT-PCR results were positive for SARS-CoV-2. From week three onward, negative results increased. All tests were negative at week six after symptom onset.The rate of positive results was highest at week one (100%), followed by 89.3%, 66.1%, 32.1%, 5.4% and 0% at weeks two, three, four, five and six, respectively.Patients were divided into non-prolonged and prolonged shedding groups based on nucleic acid conversion time (up to or more than 24 days). Patients with longer viral shedding were older and more likely to have comorbidities such as diabetes and hypertension. [Medscape]

793: Protect yourself and your pets: CDC says keep animals 6 feet apartWhile the principal way of virus spread is from person to person, transmission between animals and humans cant be ruled out until more testing is done. While taking your dog on a walk, dont let the social distancing guard down. The same applies to your indoor/outdoor cat. The Centers for Disease Control and Prevention says that its best to take precautions and keep your pets away from other people and animals presently. Not only should you maintain a physical distance of at least 6 feet from others, the CDC says your animals should also maintain that distance.

794: In the U.S. multiple animals, including a familys pug in North Carolina, two pet cats, and five tigers and three lions at the Bronx Zoo in New York have tested positive for COVID-19. Two pet dogs and a pet cat in Hong Kong also tested positive.The CDC says that theres no evidence that animals have a significant role in spreading SARS-CoV-2. The principal way the virus spreads is from person to person, but transmission between animals and humans cant be ignored until more testing is done. Dr. McCarthy, President of the Oregon Veterinary Medical Association, says that during the COVID-19 outbreak, people should not let their pets interact with anyone – two-legged or four-legged – outside of the household. You should also avoid petting other peoples dogs. Restrain from bringing your pups to dog parks and letting them run around off leash. Wash your hands and maintain good hygiene, around people and around animals.

795: Two rare neurologic conditions in patients hospitalized with COVID-19A 50-year-old man developed Miller Fisher syndrome and a 39-year-old man developed polyneuritis cranialis. Both these conditions are variants of Guillain-Barré syndrome (GBS), which physicians in China and Italy have also linked to COVID-19 infection [Medscape]

760: Remdesivir now‘standard of care’for COVID-19Hospitalized patients with advanced COVID-19 with lung involvement and who received the antiviral agent remdesivir (Gilead Sciences) were found to recover faster than similar patients who received placebo, revealed a preliminary data analysis from a U.S.-led randomized, controlled trial.The interim results, discussed in a NIAID press release, revealed that time to recovery (i.e., being well enough for hospital discharge or to return to normal activity level) was 31% faster for patients who received remdesivir compared to those who received placebo (P < .001).The median time to recovery was 11 days for patients treated with remdesivir, compared to 15 days for those given placebo. There was a survival benefit, with a mortality rate of 8.0% for the group receiving remdesivir and 11.6% for the patients who received placebo (P = .059).The study – the Adaptive COVID-19 Treatment Trial (ACTT) – is the first clinical trial launched in the United States to assess an experimental treatment for COVID-19. It is underway at 68 sites – 47 in the United States and 21 in countries in Europe and Asia.

761: The Infectious Disease Society of America has released new guidelines on the use and reuse of personal protective equipmentThe guidelines recommend the following for encounters with suspected or confirmed COVID-19 patients:Either a surgical mask or N95 (or N99 or PAPR [powered & supplied air respiratory protection]) respirator for routine patient care in a conventional setting.Either a surgical mask or reprocessed respirator over no mask for routine care in a contingency or crisis setting.No recommendation on the use of double gloves vs. single gloves.No recommendation on the use of shoe covers for any setting.An N95 (or N99 or PAPR) respirator for aerosol-generating procedures in a conventional setting.A reprocessed N95 respirator over a surgical mask for aerosol-generating procedures in a contingency or crisis setting.Adding a face shield or surgical mask as a cover for an N95 respirator to facilitate extended use during respirator shortages when performing aerosol-generating procedures in a contingency or crisis setting. This recommendation carries a caveat: It assumes correct doffing sequence and hand hygiene before and after taking off the face shield or surgical mask cover.Adding a face shield or surgical mask over the N95 respirator so it can be reused, again assuming the correct sequence for hand hygiene.

762: SGLT2 and COVIDA recently-launched study of the type 2 diabetes agent dapagliflozin in patients with mild-moderate COVID-19 is raising concerns, provided that several expert groups have advised that drugs in this class, i.e., the sodium-glucose cotransporter 2 (SGLT2) inhibitors, be stopped in all patients hospitalized with COVID-19 due to the increased risk for diabetic ketoacidosis (DKA).

763: A Third of COVID-19 Hospital Patients May DieA third of patients in hospital with COVID-19 may be dying, suggests to preliminary UK research. The preprint also noted that being male or obese decreased the odds of survival from the disease. Over half of patients mechanically ventilated are dying, stated the authors. The prospective observational cohort study, which has not been peer reviewed, was conducted by a consortium of researchers, known as ISARIC4C, and was led by the University of Liverpool, University of Edinburgh, and Imperial College London (ICL).

764: Increase in out-of-hospital cardiac arrests in Italy linked to COVID-19 A study published in The New England Journal of Medicine showed a correlation between out-of-hospital cardiac arrests and COVID-19 in Lombardy, Italy. Using the Lombardia Cardiac Arrest Registry, Enrico Baldi, MD, University of Pavia, Pavia, Italy, and colleagues compared out-of-hospital cardiac arrests that occurred in the provinces of Lodi, Cremona, Pavia, and Mantua during the first 40 days of the COVID-19 outbreak (February 21-March 31, 2020) with those that occurred during the same period in 2019 (February 21-April 1, 2019 to account for the leap year). During the 2020 study period, 9,806 cases of COVID-19 were reported. During this period, 362 cases of out-of-hospital cardiac arrest were identified, compared with 229 cases during the same period in 2019, reflecting a 58% increase. Increases of various magnitudes in the numbers of cases of out-of-hospital cardiac arrest were noted in all 4 provinces. Of the 362 cases of out-of-hospital cardiac arrest in 2020, 103 were suspected to have or had received a diagnosis of COVID-19 (87 and 16 patients, respectively). These numbers account for 77.4% of the increase in cases of out-of-hospital cardiac arrest observed in these provinces in 2020.The authors stated that the cumulative incidence of out-of-hospital cardiac arrest in 2020 had a robust associated with the cumulative incidence of COVID-19 (Spearman rank correlation coefficient, 0.87; 95% confidence interval, 0.83-0.91; P< 0.001), and that the rise in the number of cases of out-of-hospital cardiac arrest over the number in 2019 followed the time course of the COVID-19 outbreak.

765: COVID-19: Anticoagulation Recommended Even After Discharge”I have never, ever, ever seen such high levels of D-dimer in any of the hundreds of other patients with venous thrombosis that Ive seen over the past 15 years,” said Behnood Bikdeli, MD, of NewYork-Presbyterian Hospital/Columbia University Irving Medical Center in New York City. “Its just mind-blowing.” [Medpage Today]

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

CMAAO Coronavirus Facts and Myth Buster 78

Health Care Comments Off

(With regular inputs from Dr Monica Vasudev)

Post lock down surveillance

A surveillance initiative was implemented in Shenzhen, China, to isolate and contact trace people suspected of having the COVID-19 coronavirus. This resulted in faster confirmation of new cases and reduced the window of time during which people were infectious in the community. This potentially decreased the number of new infections arising from each case, revealed a study of patients and contacts over 4 weeks (Lancet Infect Dis. 2020 Apr 27. doi: 10.1016/S1473-3099[20]30287-5).

Cases of large-vessel stroke in young patients with COVID-19

A study published in The New England Journal of Medicine has revealed that large-vessel stroke may be another complication of COVID-19. Over a 2-week period from March 23 through April 7, 2020, 5 patients younger than 50 years of age presented with new-onset symptoms of large-vessel ischemic stroke, wrote Thomas J. Oxley, MD, Mount Sinai Health System, New York, New York. All the patients tested positive for COVID-19. The author mentioned that every 2 weeks over the previous 12 months, their service has treated, on average, 0.73 patients younger than 50 years of age with large-vessel stroke.

All patients presented with signs and symptoms of stroke, including reduced level of consciousness, hemiplegia, and dysarthria. Patients 1, 4, and 5 had COVID-19 symptoms, including cough, fever, and lethargy. Two patients delayed calling an ambulance owing to concerns about going to a hospital during the pandemic. [NEJM]

A study, published in Clinical Infectious Diseases, showed that the majority of patients with SARS-CoV-2 developed robust antibody responses between 17 and 23 days after illness onset, with delayed but stronger antibody responses in critical patients.

Jiuxin Qu, MD, Third People’s Hospital of Shenzhen, Shenzhen, China, and colleagues analyzed data from 41 patients with confirmed SARS-CoV-2 (two back-to-back tests). Patients with mild, moderate, and severe disease were included. IgG and IgM antibodies against SARS-CoV-2 were measured using the iFlash-SARSCoV-2 IgG/IgM chemiluminescent immunoassay kit. According to the instructions, the sensitivity and specificity of the kits was 90% and 95% for IgG, and 80% and 95% for IgM. Combined nucleocapsid protein and spike glycoprotein were used as coated antigens to increase the sensitivity.

Of the 41 patients, 40 (97.6%) patients were positive with IgG and 36 (87.8%) were positive with IgM. The median time of seroconversion after disease onset was 11 days for IgG and 14 days for IgM. The level of IgG antibody attained the highest concentration on day 30, while the highest concentration of IgM antibody appeared on day 18, but then began to decline.

The IgG level of those in the mild and moderate group was still rising on day 28; however, the IgG response of the critical group was found to be significantly stronger than that of non-critical groups within 4 weeks after illness onset (P = 0.0001). For IgM, the fitting curve of the critical group rose above the cut-off value on day 10, peaked on day 23, and then began to decline. The IgM levels of non-critical groups increased above the cut-off value as early as day 5, peaked on day 16, and then decreased.

In the majority of the patients, antibody responses to SARS-CoV-2 were observed during the first 3 weeks of the disease. The seroconversion time of IgG antibody was earlier than that of IgM antibody. The kinetics of anti-SARS-CoV-2 antibodies should assist in epidemiologic surveys, particularly in clinical diagnoses since the immunoassays can efficiently compensate the false negative limitations of nucleic acid testing. [Clinical Infectious Diseases]

Viral Shedding Continues Up to 6 Weeks after Coronavirus Symptom Onset

Patients may continue to shed the SARS-CoV-2 virus for up to six weeks after symptom onset, suggested a small study of recovered COVID-19 patients. In the convalescence period, a trace of virus may still be detected; however, similar to other virus infections, this does not suggest transmission ability of the infected individual.

As reported in Clinical Infectious Diseases, 299 RT-PCR assays were performed (about five tests per patient). The longest duration between symptom onset and an RT-PCR test was 42 days, while the median duration was 24 days. Over the first three weeks following symptom onset, the majority of RT-PCR results were positive for SARS-CoV-2. From week three onward, negative results increased. All tests were negative at week six after symptom onset. The rate of positive results was found to be the highest at week one (100%), followed by 89.3%, 66.1%, 32.1%, 5.4% and 0% at weeks two, three, four, five and six, respectively.

784: What is prolonged shedding

It is nucleic acid conversion time more than 24 days

785: What is the risk factor for prolonged shedding

Patients with longer viral shedding have been noted to be older and more likely to have comorbidities such as diabetes and hypertension.

From a public health perspective, experts state that there is a need to emphasize that the public should not be scared by those seemingly prolonged positive cases. It is much harder to prove no transmission ability than potentially transmissible.”

What does 14 days isolation means

People must understand that a 14-day isolation is appropriate for seeing if one will go on to develop symptoms after a known exposure to an infected person. Fourteen days is not a sufficient amount of time to be infected, recover and then be virus free.

787: What is the HCW return policy

Dr. Robert Quigley, Senior Vice President and Regional Medical Director of International SOS, noted in an email to Reuters Health, “The question that remains is how great does the viral load need to be to infect another person if in fact the viral load actually decreases over time. Regardless, until this virologic feature is defined, it is clear that infected healthcare professionals (HCPs) should have two consecutive negative tests before returning to the healthcare arena where they could potentially infect a fragile patient.” [Medscape]

When should non-HCPs return to the workplace after testing positive for COVID-19

The absence of symptoms may not annihilate the risk of transmission to co-workers for up to 42 days following the onset of symptoms. This could clearly impact our present practices of quarantine and isolation. [SOURCE: Clinical Infectious Diseases, online April 19, 2020.]

Confirmation of COVID-19 in Two Pet Cats in New York

The U.S. Centers for Disease Control and Prevention (CDC) and the United States Department of Agriculture’s (USDA) National Veterinary Services Laboratories (NVSL) announced the first confirmed cases of SARS-CoV-2 infection in two pet cats. These are the first pets in the United States that have tested positive for SARS-CoV-2.

The cats belong to two separate areas of New York state. Both had mild respiratory illness and are expected to make a full recovery. SARS-CoV-2 infections have been reported in very few animals across the globe, mostly in those that had close contact with a person with COVID-19.

Routine testing of animals is currently not recommended. If other animals are confirmed positive for SARS-CoV-2 in the United States, USDA will post the findings. State animal health and public health officials will determine whether animals should be tested for SARS-CoV-2.

  • In the NY cases, a veterinarian tested the first cat after it exhibited mild respiratory signs. None of the members in the household were confirmed to be ill with COVID-19. The virus seems to have been transmitted to the cat by mildly ill or asymptomatic household members or through contact with an infected person outside its home.
  • Samples were obtained from the second cat after it showed signs of respiratory illness. The owner of the cat tested positive for COVID-19 before the cat showed signs. Another cat in the household has no signs of illness.

Both cats tested presumptive positive for SARS-CoV-2 at a private veterinary laboratory and the result were reported to state and federal officials. The confirmatory testing was done at NVSL and included collection of additional samples.

The World Organisation for Animal Health (OIE) considers SARS-CoV-2 an emerging disease, and therefore USDA is required to report confirmed U.S. animal infections to the OIE.

Public health officials are still learning about SARS-CoV-2, but there is no evidence that pets have a role in spreading the virus in the United States. Taking measures against companion animals that may compromise their welfare therefore does not seem justified. Further studies will help understand if and how different animals, including pets, could be affected.

CDC recommends the following, until more information is available:

  • Do not let pets interact with people or other animals outside the household.
  • Keep cats indoors when possible to prevent them from interacting with other animals or people.
  • Walk dogs on a leash, maintaining at least 6 feet from other people and animals.
  • Avoid dog parks or public places where a large number of people and dogs gather.

If you are sick with COVID-19 (either suspected or confirmed by a test), limit contact with your pets and other animals.

  • When possible, have another member of your household care for your pets while you are sick.
  • Avoid contact with your pet, including petting, snuggling, being kissed or licked, and sharing food or bedding.
  • If you must care for your pet or be around animals while you are sick, wear a cloth face covering and wash your hands before and after an interaction with them. [CDC]

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

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