CMAAO IMA HCFI Corona Myth Buster 21

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Loss of Smell & Taste is not a screening test

NEJM: The American Academy of Otolaryngology — Head & Neck Surgery has proposed to add anosmia and dysgeusia to the list of screening items for potential COVID-19 disease.

Informally, these symptoms have been noted among some patients whove tested positive for COVID-19, and in some cases, anosmia was the only symptom.

Depression is uncommon in COVID-19

JAMA Network Open study of 1300 healthcare workers in China (mostly from Hubei) in late January and early February noted that 50% of the subjects had symptoms of depression, 45% had anxiety, 34% had insomnia, and 72% had symptoms of distress. Nurses, women, frontline workers, and those in Wuhan had more severe symptoms.

The infection rate is 3.4%

No. A report published in MMWR provides details of COVID-19 cases aboard cruise ships. On the Diamond Princess, 19% of the 3700 passengers and crew got infected. Nearly half were asymptomatic when they tested positive, although many developed symptoms later.

Cardiac injury is uncommon in COVID-19

No. Cardiac injury is a common complication among those hospitalized with COVID-19 and it is associated with significantly increased mortality as per a report in JAMA Cardiology.

Researchers studied over 400 patients hospitalized with COVID-19 in Wuhan, China. Around 20% had cardiac injury, defined as elevated cardiac biomarkers (e.g., high-sensitivity troponin).

Patients with cardiac injury were more likely than those without cardiac injury to require non-invasive ventilation (46% vs. 4%) and invasive ventilation (22% vs. 4%). Patients with cardiac injury also had a higher mortality rate (51% vs. 5%). After adjusting for confounders, including acute respiratory distress syndrome, cardiac injury was still a significant predictor of mortality.

We cannot predict the advantage of social distancing

A new study published in Lancet Infectious Diseases bolsters support for strict social distancing measures. Making use of simulation models, researchers in Singapore estimated the number of SARS-CoV-2 infections that would occur at 80 days after the first 100 cases of community spread were confirmed, assuming that 7.5% of infections were asymptomatic.

In a setting when the virus was least infectious (assuming each case infects another 1.5 people), a median 279,000 infections is estimated to occur by day 80. This would decrease with increasing social distancing measures, coming down to 1800 when all of the following were put into place: isolation of infected individuals and family quarantine, workplace distancing, and school closures.

Notably, assuming that the virus is more infectious (one case infects another 2.5 people), there would be over 1.2 million infections at day 80 with no social distancing measures — and 258,000 with all measures in place.

Italy’s 7.2% mortality is not true

JAMA viewpoint analyzed the high case-fatality rate in Italy — 7.2% as of mid-March.

The authors note that this could be attributed to three major factors: 1) nearly one-fourth of Italys population is 65 years of age and above; 2) some deaths may have been due to comorbid illness rather than the SARS-CoV-2 infection; and 3) mild and asymptomatic cases were rarely tested after late February and were therefore, not included in the denominator.

Still, the 7.2% rate in symptomatic cases is higher.

Undocumented COVID-19 Infections are linked to Transmission

No, it’s a hidden disaster. In China, undocumented infections fueled the rapid early spread of SARS-CoV-2. The number of individuals infected with SARS-CoV-2 with minimal symptoms is an important determinant of the pathogens pandemic potential, as these infections are likely to go undiagnosed.

Using mathematical modeling, investigators estimated the number of undocumented infections and their contribution to SARS-CoV-2 transmission in China.

Subjects were segregated into two groups: those with symptoms severe enough to elicit care-seeking and a documented COVID-19 diagnosis, and those with undocumented infections. The model also accounted for changes in human mobility between cities based on recent historic data adjusted for the escalating restrictions on such movement.

At the beginning of the epidemic, the estimated basic reproductive number (R0) was 2.38 and the percentage of undocumented infections was 86.0%. Undocumented infections were estimated to cause 86.2% of all infections.

Later in the epidemic and with increased testing, the proportion of undocumented infections fell to 35%, and the R0 dropped to 1.36 and then to 0.99 as restrictions on geographic movement tightened. (Science 2020 Mar 16)

Lung involvement is unilateral

No. In a report from a hospital in Shanghai, investigators reviewed the key initial CT findings in 51 consecutive patients hospitalized due to COVID-19 disease. All patients had thin-section noncontrast scans. Mean age was 49 (range, 16–79), and median time from symptom onset to CT was 4 days. (Radiology 2020 Apr)

Almost all patients had extensive multifocal involvement; bilateral abnormalities were seen in 86% of cases. Lesions were seen in the lower lobes, posterior lung fields, and peripheral lung zones. Three quarters of patients had ≥3 involved lobes.

Various combinations of pure ground-glass opacities (GGOs), GGOs plus reticular or interlobular septal thickening, and GGOs plus consolidation were commonly noted. GGOs were predominant in patients whose symptoms started ≤4 days prior to CT, and areas of consolidation became increasingly evident in those with >4 days of symptoms.

Pleural effusion is common in COVID-19

No. Only four patients had pleural effusions. [Radiology 2020 Apr:]

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Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

Corona Medtalks – Telemedicine Guidelines, More Tests (For attention of Doctors)

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Should India adopt a mass testing policy similar to South Korea?

The CDC has provided a “Coronavirus Self-checker” called Clara on its website for US citizens. People can use this online symptom checker to make decisions about what they should do, if they think that they have symptoms of COVID-19. Following a series of questions, the tool gives recommendations if they need medical care. The CDC has; however, made clear that it is not a diagnostic tool for the disease.

Should everyone who has symptoms of corona-like illness be tested for the COVID-19 virus? Testing helps to identify people who are infected with the virus; but there is also a concern, perhaps reasonable, that it would be a drain on resources (personal protective equipment, swabs, viral transport media, etc.).

South Korea has been aggressively testing its citizens through a mass testing program, including drive-through testing centers and mobile alerts about people who have tested positive for the virus. It has been successful in slowing down the spread of the disease. From a peak of 851 new cases per day on 3rd March, the number of new cases has declined to 100 cases per day, as on 26th March.

Initially, India carried out “need-based testing” i.e., only people with history of travel to areas with active transmission and their close contacts were tested. But, last week, the ICMR has revised the strategy of COVID-19 testing in India -

“All asymptomatic individuals who have undertaken international travel in the last 14 days:
o They should stay in home quarantine for 14 days.

o They should be tested only if they become symptomatic (fever, cough, difficulty in breathing)

o All family members living with a confirmed case should be home quarantined

All symptomatic contacts of laboratory confirmed cases.
All symptomatic health care workers.
All hospitalized patients with Severe Acute Respiratory Illness (fever AND cough and/or shortness of breath).
Asymptomatic direct and high-risk contacts (those who live in the same household with a confirmed case and healthcare workers who examined a confirmed case without adequate protection) of a confirmed case should be tested once between day 5 and day 14 of coming in his/her contact”
India has the second largest population in the world, at 1.3 billion. Latest data show that India has over 700 coronavirus positive cases with 17 deaths.

Are we seeing just the tip of the iceberg when it comes to the number of positive cases? Or, have we managed to escape the worst? We do not know. This is a matter of speculation.

ICMR has been emphatic in its assertion that there is no need for “indiscriminate testing” in the country.

Social distancing is the answer to prevent the spread of the infection. If you think that you have symptoms of coronavirus, the best approach would be to self-quarantine or self-isolate, which also means staying away from others at home and adopt all infection control measures (hand washing, face masks, etc.).

[https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/index.html; https://www.mohfw.gov.in/pdf/ICMRrevisedtestingstrategyforCOVID.pdf]

New telemedicine guidelines released: Urgent need of the hour

The government has released new telemedicine guidelines. These guidelines were much needed and have come at an opportune time.

A doctor at a Mohalla Clinic in Delhi has tested positive for COVID-19. His wife and daughter have also tested positive for the virus. Following this, over 800 people who recently visited the clinic have been put under home quarantine and have been asked to contact the control room if they develop any symptoms. The clinic has been closed and sanitized (Business Today). It has been reported that the doctor developed the infection after contact with an infected woman who returned from Saudi Arabia (TOI).

Modalities like telemedicine are now absolutely essential if we are to prevent many more such scenarios. The number of positive COVID-19 cases is increasing every day in India. The entire country is under a lockdown with the intent to break the chain of transmission.

Teleconsultations will help to prevent cross infection of flu or corona-like illnesses among the large number of patients waiting to see the doctor.

We have been asking the government to permit teleconsultations, especially for cases of respiratory infections, for precisely this reason. We had written to the PMO in this regard as early as on 7th February (PMOPG/E/2020/0066034, dated Feb 7, 2020), when the PMO had cancelled Holi celebration events.

Teleconsultations are useful for routine checkups and follow-up. In cases of flu, it is easy to identify patients who need hospitalization as they will be breathless.

The guidelines have been developed by the Board of Governors in partnership with Niti Aayog.

All Registered Medical Practitioners can provide telemedicine consultation to patients from any part of the country. But they are bound by the same professional standards and ethical regulations as they apply to the regular consultations in the clinic.

Four types of telemedicine consults have been identified according to:

Mode of communication (video, audio, text-based)
Timing of the information transmitted (real time or asynchronous – accessed as per need or convenience)
Purpose of the consultation (Non-Emergency or emergency)
Interaction between the individuals involved (RMP-to-patient/caregiver, or RMP to RMP).
Five scenarios have been defined:

Patient to Registered Medical Practitioner
Caregiver to Registered Medical Practitioner
Health Worker to Registered Medical Practitioner
Registered Medical Practitioner to Registered Medical Practitioner
Emergency Situations
Both the patient and the doctor need to know each other’s identity. Patient consent is necessary for telemedicine. If the patient initiates the telemedicine consultation, then the consent is implied.

The complete guidelines are available at the Health Ministry’s website.

Here are some safe practice guidelines for doctors:

Provide as many paid tele consultations as possible at least for the duration of the lockdown.
Doctors aged more than 65 years with uncontrolled diabetes, immunocompromised, who have six minutes’ walk distance <200 meters, are unvaccinated for flu and pneumonia (with common secondary or co-infections) should completely stop OPDs and only give tele consultations.
Inform all patients that if they or any close contact has fever, they should call first and not visit the clinic/hospital without tele consultation.
Always wear surgical masks; if doing any procedure where aerosols may be produced, use N95 masks.
Doctor with cough and fever should go for self-quarantine and COVID-19 assessment. In a WHO study from Italy, it has been shown that 90% of doctors attending patients were asymptomatic when they were tested COVID-19 positive.
Install air purifiers with 10 air exchanges per hour rate at the clinic.
When you come back home from your clinic, wash feet first, then hands, face, change cloths (keep them in separate box for washing), decontaminate all surfaces you have touched including your car, wash hands again with soap and water.
Stay away from elderly people in your home if possible.
Dr K K Aggarwal,

President CMAAO, HCFI and Past National President IMA

Every adversity is an opportunity: COVID-19 will end with a healthier society (For attention of Doctors)

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We have got an answer to pollution health emergency: Lock down for a week. In Anand Vihar we are seeing PM 2.5 levels of 24 -50.

In Nigam Bodh Ghat: number of deaths 21 on 24th March
In January 1976, there was a strike in Los Angeles County, California. Doctors went on strike against the increasing medical malpractice insurance premiums. Over a period of five weeks, nearly half of the doctors in the county reduced their practice and withheld care for anything except emergency services. An analysis by Cunningham and colleagues noted that the strike may have actually prevented more deaths than it caused.

The study, “Doctors strikes and mortality: A review,” suggests that elective, or non-emergency surgery, tends to stop during doctors strike, which seems to be a major factor. Mortality showed a steady decline from week one (21 deaths/100,000 population) to weeks six (13) and seven (14), when mortality rates were found to be lower than the averages of the previous five years.

TB notification will increase. Over next three months, all cases of cough will go for testing and more TB cases will be detected. In initial phase, there will be drop as patients may like to self-isolate for two weeks for any cough.
Long-term reduction in typhoid, diarrhea and jaundice due to frequent hand washing.
Long-term reduction of flu season in the coming months.
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Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

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