Acute manageable immunogenic thrombogenic inflammatory viral disease pandemic
Dr KK Aggarwal
October 11, 2020
Cases: 1M April 2, 2M April 15, 3M April 27, 4M May 8, 5M May 20, 6M May 30, 7M June 7, 8M June 15, 9M June 22, 10M June 29th, 11M July 4, 12M July 8, 13M July 13, 14M July 17, 15M July 23, 16M July 25, 17M July 29, 18M August 1, 19M August 6, 20M August 10, 21M August 16, 22M August 19, 23M August 21, 24M August 27, 25M August 30, 26M September 3, 27M September 7, 28M September 10, 29M September 14, 30M September 18, 31M September 21, 32M September 23, 33M September 28, 34M October 1, 35M October 4, 36M October 8 Ground Zero: Wuhan – in live animal market or cafeteria for animal pathogens: 10th January; Total cases are based on RT PCR, 67% sensitivity Coronavirus Cases: 37,099,134 Deaths: 1,072,605 Recovered: 27,890,943 ACTIVE CASES 8,135,586 Currently Infected Patients 8,067,176 (99%) in Mild Condition 68,410 (1%) Serious or Critical CLOSED CASES 28,963,548 Cases which had an outcome: 27,890,943 (96%) Recovered / Discharged 1,072,605 (4%) Deaths
DENSITY: India: In states with average population density of 1185/sq km, the average number of cases were 2048. On the contrary, in states with population density of 909/sq km, the number of cases were 56. When Chandigarh and Pondicherry were taken out from this group, the Average Density of other states were 217 and the average number of cases were 35. [HCFI]
COVID Sutra: COVID-19 pandemic is due to SARS 2 Beta-coronaviruses (different from SARS 1 where spread was only in serious cases); with over eleven virus sequences floating; has affected up to 22.8% of Delhi population, Causes Mild or Atypical Illness in 82%, Moderate to Severe Illness in 15%, Critical Illness in 3% and Death in 2.3% cases (15% of admitted serious cases, 71% with comorbidity< Male > Females); affects all but Predominantly Males (56%, 87% aged 30-79, 10% Aged < 20, 3% aged > 80); with Variable Incubation Period days (2-14; mean 5.2 days); Mean Time to Symptoms 5 days; Mean Time to Pneumonia 9 days, Mean Time to Death 14 days, Mean Time to CT changes 4 Days, Reproductive Number R0 1.5 to 3 (Flu 1.2 and SARS 2), Epidemic Doubling Time 7.5 days; Origin Possibly from Bats (Mammal); Spreads via Human to Human Transmission via Large and Small Droplets and Surface to Human Transmission via Viruses on Surfaces for up to three days. Enters through MM of eyes, nose or mouth and the spike protein gets attached to the ACE2 receptors. ACE2 receptors make a great target because they are found in organs throughout our bodies (heart muscle, CNS, kidneys, blood vessels, liver). Once the virus enters, it turns the cell into a factory, making millions of copies of itself, which are then breathed or coughed out and infect others.
The most important
Masking is THE prevention
RT PCR Ct is THE test for diagnosis
Zinc is THE Vitamin
Day 5 is THE day in COVID phase for mortality prevention
Day 90 is THE day after which the word COVID ends
Home Isolation is THE modality of Treatment
12 years is THE age when the mortality starts
CRP is THE lab test for seriousness
Loss of Smell is THE symptom equal to RT PCR test
15 minutes is THE time to get the infection
Numbers to remember
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2770945: RDW at admission 14.5%
Prevalence: New York: 13.9%; New York City at 21.2%; S Korea: 5.7%; World: 5%; Ohio prison: 73% of inmates; New York: 21% mortality [April 22 in JAMA].
Viral particles are seen in tears, stool, kidneys, liver, pancreas, heart, semen, peritoneal fluid, CSF.
Thrombosis: University of Pennsylvania has reported that clots are seen in patients even on blood thinners.
Other human beta-coronaviruses have immunity lasting only for one year with no IMMUNITY PASSPORT.
In absence of interventions, prolonged or intermittent social distancing (till 2022-24) is the key.
Low levels of cross immunity from other beta-coronaviruses against SARS-CoV-2 could make SARS-CoV-2 appear to fade away, only to show resurgence after a few years. Surveillance till 2024.
During peak, trace and treat, and after the peak, trace and treat the close contacts.
Increased spread: close environment, crowded place with close physical contacts with no ventilation.
Strategies: From community mitigation to individual containment; broader good over individual autonomy; perfect cannot be the enemy of the good; pandemics are fought on the grounds and not the hospitals. Treat the patient and not the test report; consider every surface and every asymptomatic person as virus carrier.
HCW: Direct patient exposure time < 30 minutes; 7 days work and 7 days holidays.
Italy: mortality reduced when they were short of ventilators.
Hospital at HOME: CHF, mild pneumonia, exacerbations of asthma and COPD, cellulitis, and urinary tract infections.
Great Imitator (protean manifestation).
IgM can be false positive in pregnancy, immunological diseases; Pooled tests (< 5, 20 Kerala, 64 Singapore RTPCR) when seroprevalence is <2%.
Early treatment, day 3-5, to reduce the viral load and prevent cytokine storm using hydroxychloroquine with azithromycin or ivermectin with doxycycline with IV remdesivir and IV single dose tocilizumab (IL-6 receptor inhibitor) if very high D-dimer and IL-6; convalescent plasma therapy (given early; donor 14 days symptoms free, between day 28-40, single donation can help 4 patients), Lopinavir-ritonavir and Favipiravir if very low CD 4 counts.
Hypoxia: Low flow oxygen < 6l/mt, titrated to high flow oxygen using non rebreathing mask, Venturi mask, HFNC and helmet CPAP, NIV in supine or prone position.
Early intubation with prone ventilation only if progressive. Hypoxia (walking dead) have capillary problem and not alveoli.
Formulas and Predictions
The goal is to save lives. Monitoring deaths is important, especially when testing is limited.
Daily deaths are the best indicator of the progression of the pandemic, although there is generally a 17- to 21-day lag between infection and deaths.
Deaths in symptomatic cases: Less than one percent (best of the care).
Therefore, Deaths X 100 = expected number of symptomatic cases
Some may count “probable” or “presumptive” COVID-19 deaths when cases are not confirmed with a positive test but are based on symptoms and medical history. New York added 3,700 presumptive deaths in one day in April when testing was more limited.
Case fatality rate: Number of total deaths as on date/number of total RT PCR positive cases as on today
Infection fatality rate: Number of total deaths as on date/number of total calculated cases as on today
Number of reported deaths: Number of confirmed deaths x 2
The University of Washingtons Institute for Health Metrics and Evaluation (IHME):
Is based on what is known about a disease and how peoples actions may affect that.
The latest forecasts state the U.S. will reach nearly 317,000 deaths by December 1, at the current rate of mask-wearing, which currently is slightly below 50% nationally and increasing mask wearing in public to 95% could save over 67,000 lives. Forecasts are not fixed but change depending on public behavior. When people learn that new cases are rising, they start wearing masks and using social distancing again; and when they realize that fresh cases are dropping, they tend to drop their guard. IHME makes use of real-time infection data from Johns Hopkins Universitys Coronavirus Resource Center to represent disease transmission and estimate how many Americans will die. The researchers then estimate how many Americans are wearing masks or using social distancing, which can modulate the final model.
The rate of infection in a population is based on the “R0,” or reproduction number. R0 represents the average number of people who will contract the infection from a single infected person, in a population thats never been witness to the disease before. If R0 is 3, it suggests that one case will create an average of three new cases. When that transmission rate of infection occurs at a specific time, its called an “effective R,” or “Rt.” R0 less than 1 means the epidemic is under control; and when its higher than 1, it is still spreading.