CME INDIA Presentation:

Asks Dr B. Ghosh, Internist, Jamshedpur:

A person tested COVID +ve 5days after fever, cough and myalgia. Now home quarantine for 14 days. My question is from which date it will be counted, first symptom onset or testing date?

CME INDIA Discussion:

Dr Kamal Jain, Gauhati: Testing date.

Dr Kapil Sud, Internist, Aligarh: For govt. agencies, it is from the date of testing.

Dr Vipul Rustogi, Delhi: We count patient to be infective from 12 days after test. So, we can repeat rt pcr on 12th day and mostly turns out negative. Though there are many that come out positive for almost 40 days.

Dr Bhanu Pratap Singh, Physician, Siwan, Bihar: Usually, patient becomes symptomatic 5 days after infection and he or she remains infective up to 9-10 days after appearing of symptoms. We find a infectivity period of 4 (5+9) days from day of infection or 9 days after onset of symptoms. As some patients are negative by different tests even after classical symptoms and HRCT thorax findings, I don’t think day of test should be counted as first day for isolation. Also, in the beginning of symptoms, most of the tests are less likely to be positive (only 20 -25% positive on day one vs 60 -65% on 4th or 5th day of symptoms).

Dr Basab Ghosh, Agartala: Very much true. Scientifically correct. But when going for testing after few days symptoms, administration is flatly counting period of home quarantine or discharge from COVID care centre, from the data of confirmatory tests.

Dr N K Singh: ICMR says symptoms as day 1.

Dr A K Virmani, Diabetologist, Jamshedpur: Agreed. Day 1 should be when patient becomes symptomatic. Test is done on 3-5th day and report often comes after another 5 days. Unfortunately, by the time first report comes patient has been asymptomatic and is ready for the next report!! As per CDC no need to test again after 10 days.

Dr Bhanu Pratap Singh: Yes sir and duration of quarantine is 14 days from day of exposure (MoHFW) or 10 days of onset of symptoms (ICMR)

Dr Manohar, Bengaluru: Yes. Day from symptoms 10+ 7 more days of isolation.

Dr Arbind Kr Arya, Jamshedpur: If a person is COVID +ve & asymptomatic, he is put on Home Quarantine till the next report is – ve, which is usually done after 10 days of 1st sample. A person has to be in 14 days home quarantine, after COVID -ve report. It is counted 14 days from testing date. Symptoms onset will be variable & confusing from patient’s history.

Dr Noni G Singha, Dibrugarh, Assam: For management point of view the of the symptoms should be counted as day one and for administrative point of view day of testing is counted one for probably easy calculation. 7 days post negative report or discharge home quarantine.

Infectivity period is usually 1- 2 days before the symptoms onset to 14 – 17 days in mild and asymptomatic cases, 20- 21 days in moderate to severe cases, and in critical cases may be up to 4 – 5 days after recovery. For management, I meant medical treatment point of view.

(Opinions differ in discussion)

CME INDIA Learning Points: ICMR

[1] Definition of contact

 A contact is defined as a healthy person that has been in such association with an infected person or a contaminated environment as to have exposed and is therefore at a higher risk of developing disease. A contact in the context of COVID-19 is:

• A person living in the same household as a COVID-19 case;
• A person having had direct physical contact with a COVID-19 case or his/her infectious secretions without recommended personal protective equipment (PPE) or with a possible breach of PPE
• A person who was in a closed environment or had face to face contact with a COVID-19 case at a distance of within 1 metre including air travel; The epidemiological link may have occurred within a 14‐day period before the onset of illness in the case under consideration.

[2] Duration of home quarantine

The home quarantine period is for 14 days from contact with a confirmed case or earlier if a suspect case (of whom the index person is a contact) turns out negative on laboratory testing.

[3] Updated recommendation from WHO

Criteria for discharging patients from isolation (i.e., discontinuing transmission-based precautions) without requiring retesting:

• For symptomatic patients: 10 days after symptom onset, plus at least 3 additional days without symptoms (including without fever and without respiratory symptoms)
• For asymptomatic cases: 10 days after positive test for SARS-CoV-2.

For example, if a patient had symptoms for two days, then the patient could be released from isolation after 10 days + 3 = 13 days from date of symptom onset; for a patient with symptoms for 14 days, the patient can be discharged (14 days + 3 days =) 17 days after date of symptom onset; for a patient with symptoms for 30 days, the patient can be discharged (30+3=) 33 days after symptom onset).

*Countries may choose to continue to use testing as part of the release criteria. If so, the initial recommendation of two negative PCR tests at least 24 hours apart can be used.

[4] Why things are changing?

With widespread community transmission, these initial criteria for SARS-CoV-2 posed several challenges:

• Long periods of isolation for individuals with prolonged viral RNA detection after resolution of symptoms, affecting individual well-being, society, and access to healthcare.
• Insufficient testing capacity to comply with initial discharge criteria in many parts of the world. 
• Prolonged viral shedding around the limit of detection, having negative results followed by positive results, which unnecessarily challenges trust in the laboratory system.

[5] Current understanding of transmission risk (WHO)

• Factors that determine transmission risk include whether a virus is still replication-competent, whether the patient has symptoms, such as a cough, which can spread infectious droplets, and the behavior and environmental factors associated with the infected individual. Usually 5-10 days after infection with SARS-CoV-2, the infected individual starts to gradually produce neutralizing antibodies. Binding of these neutralizing antibodies to the virus is expected to reduce the risk of virus transmission.
• SARS-CoV-2 RNA has been detected in patients 1-3 days before symptom onset, and viral load in the upper respiratory tract peaks within the first week of infection, followed by a gradual decline over time. In the feces and lower respiratory tract, this viral load seems to peak in the second week of illness. Viral RNA has been detected in upper respiratory tract (URT) and lower respiratory tract (LRT) and feces, regardless of severity of disease.
• There seems to be a trend in longer detection of viral RNA in more severely ill patients. Some studies analyzed the risk of transmission related to symptom of onset, and the estimated risk of transmission was highest at or around the time of symptom onset and in the first 5 days of illness.
• Although viral RNA can be detected by PCR even after the resolution of symptoms, the amount of detected viral RNA is substantially reduced over time and generally below the threshold where replication competent virus can be isolated.
• Based on evidence showing the rarity of virus that can be cultured in respiratory samples 9 days after symptom onset, especially in patients with mild disease, usually accompanied by rising levels of neutralizing antibodies and a resolution of symptoms, it appears safe to release patients from isolation based on clinical criteria that require a minimum time in isolation of 13 days, rather than strictly on repeated PCR results.
• It is important to note that the clinical criteria require that patients’ symptoms have been resolved for at least three days before release from isolation, with a minimum time in isolation of 13 days since symptom onset.

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