CME INDIA Presentation by Admin.
MASK is the VACCINE, Take it Properly.
And with 31 million known coronavirus infections worldwide so far, a few reinfections might not be cause to worry — yet.
– Virologist Thomas Geisbert (the University of Texas).
Panic button to REINFECTION of COVID pressed in newspapers, 23/09/2020. So even if you are ex-corona positive, one thing is clear, MASKING is mandatory.
First, see CME INDIA discussion, before we discuss Reinfection Truth:
Dr Deepak K Singh, Internist, Ranchi: Now having experience of seeing quite a good number of cases not in ICU but in OPD set up. Patients up to 84% oxygen not going to hospital, either monetary reasons or other doing good. Most common complaint is weakness, other fever and cough.
Dr P D Gokhale, Internist, Jamshedpur: If true, then we and government agencies are not taking it seriously for further investigation. If this is proven scientifically, then possibly in our country, this will be first series, not cases of recurrence.
Dr Ambrish Mithal, DM Endo, Delhi: Every single day some of my diabetes patients are testing positive. Almost all of them get it in the office.
One CEO says they wear a mask when they go to other floors but on their own floor, there are only 20 people, so they don’t wear a mask!
The biggest spread is in having lunch or tea coffee together in the office or cafeteria as you pull down your mask.
Unfortunately, even some doctor colleagues don’t follow these basics. While careful with patients they tend to relax with colleagues. And still use the cafeteria or lounge.
Open air transmission is rare. Fomite transmission is there but much less than originally thought.
It’s all about masking and physical distancing.
Why is hospital spread more in India than more developed countries? Even in the best equipped private hospitals? We should introspect rather than saying govt does not do anything or ‘we all have to get it one day”. Why are rates of spread among doctors lower in the US and UK??? We all need to think about this. When our surgical infection rates are comparable to the best in the world why this?
Dr N K Singh: Yes, USA data is very important, by taking measures, no significant nosocomial infection.
JAMA Network Open. 2020;3(9): e2020498. doi:10.1001/jamanetworkopen.2020.20498 (R) says:
Key Points Question: Is the incidence of hospital-acquired coronavirus disease 2019 (COVID-19) at a large US academic medical centre?
- Findings In this cohort study of 9149 patients admitted to a large US academic medical centre over a 12-week period, 697 were diagnosed with COVID-19. In the context of a comprehensive and progressive infection control program, only 2 hospital-acquired cases were detected. These findings suggest that overall risk of hospital-acquired COVID-19 was low and that rigorous infection control measures may be associated with minimized risk.
Dr Anil Motta, Sr Consultant, Delhi: Though I don’t have any statistics but I know of a lot of colleagues getting infected in hospital. As Dr Vijay Arora in one of his earlier posts talked of a good no of Intensive Care people getting infected. I tend to agree with him. They didn’t have any other obvious reasons to get infected. But not having any proper statistics can’t really trash JAMA article, though it presents a very different picture than what we observe!
Dr Ambrish Mithal, DM Endo, Delhi:
- WEAR YOUR N95 MASK WHENEVER YOU ARE WITH SOMEONE WHO DOES NOT LIVE WITH YOU. FRIEND, FAMILY, COLLEAGUE, PATIENT – WHOEVER IT IS.
- DON’T HAVE DRINKS OR MEALS WITH COLLEAGUES IN OFFICE.
We may still get it through our patients. But it does reduce the risk- substantially
Dr Vasanth Kumar, President Elect RSSSDI, Hyderabad: Very important points mentioned to avoid COVID. Even our patients tend to unmask when they enter our room and quite a few of them are COVID cases. So, it is important for us to tell every patient to cover their face with proper mask throughout the time they are in the room. It is very important because sometimes we cannot maintain distance while examining the patient.
Dr Ambrish Mithal, DM Endo, Delhi: Very true. Happens every day. Keep the physical interaction as short as possible.
Dr Arpandev Bhattacharya, Endo, Bangalore: Most importantly nose, a general tendency of people to drag down when they talk.
Dr Ambrish Mithal, DM Endo, Delhi: 100% true. Instead of listening to history I keep correcting my patients 😞 As I said many of us will still get it. but it’s foolish not to observe precautions. Colleagues in large hospitals could be as important sources of spread as patients. We have to accept this and take steps.
Dr Meena Chhabra, Diabetologist, Delhi: No one is listening. In fact, doctors make fun of colleagues who are careful by calling them “darpok.” Dr Sat’s assistant outside the OPD puts a micropore tape over the bridge of nose. Fixes it there before they enter his OPD! Please start putting micropore over the mask.
Dr Raju Sharma, Internist, Jamshedpur: That’s a good idea but the assistant should be very careful himself since he is touching a potentially infected mask. Half inch micropore.
Dr Purvi Chawla, Diabetologist, Mumbai: That’s also a good idea as it might prevent fogging of glasses which makes adherence slightly better.
Dr Vasanth Kumar, President Elect RSSSDI, Hyd: Now the tapes will be in short supply 😀
While the current trend of infection is very scary, recent news of Reinfection has given super added panic. Is it significant? Any relevance to transmission from reinfection cases? Have we learnt enough to these new happenings?
Dr Narsingh Verma, Internist, Lucknow:
“There is nothing to learn in COVID it’s just a viral infection and prevention is the only key… less you study about it and less confusion…”
Reinfection of COVID cases: Story so far…
- Hong Kong
- All started when an immunocompetent 33-year man found to have second infection.
- He was asymptomatic.
- Slightly elevated C-reactive protein.
- A relatively high viral load.
- A seroconversion of SARS-CoV-2-IgG.
- It was not prolonged PCR positivity after the first infection.
- Confirmed through whole genome analysis.
- Nevada, USA
- 25-year-old immunocompetent male.
- He tested positive for SARS-CoV-2 on 18 April 2020, 24 days post-symptom onset.
- The patient tested negative twice in the weeks following symptom resolution and felt well until 31 May 2020.
- Developed again fever, headache, dizziness, cough, nausea and diarrhoea, deteriorated with hypoxia and shortness of breath.
- RT-PCR was positive for SARS-CoV-2.
- Seven days post-symptom onset during the second episode the patient was reactive for IgG/IgM for SARS-CoV-2.
- Then genome sequencing was performed.
- SARS-CoV-2 sequences determined from both episodes were found to cluster in the same clade, but with seven nucleotide differences between them.
- Three months (10 June 2020) after her initial symptoms, the patient presented with headache, cough, fatigue and rhinitis.
- Her nasopharyngeal swab was again positive for SARS-CoV-2 (Ct value 32.6).
- The symptoms lasted for one week and again resolved without hospitalisation.
- Neutralising antibodies were assessed six weeks after the second episode’s symptom onset and were present at that time (1/320).
- Full length genome sequencing showed 11 differences between the two episodes’ isolates, confirming infection with different strains.
- A case of reinfection in a 46-year-old immunocompetent male who presented on 12 May 2020 after three days of headache and drowsiness.
- At 11 days post-symptom onset, an oropharyngeal swab was positive for SARS-CoV-2 with a Ct value of 36.85 (ORF3a gene).
- The patient’s symptoms improved and a repeat PCR on 3 June 2020 was negative.
- In July 2020, the patient reported close contact with a relative that was later diagnosed with COVID-19.
- Two days following this contact, on 20 July 2020, the patient presented with symptoms including headache, fever, cough and shortness of breath.
- On 22 July 2020, another oropharyngeal sample tested positive for SARS-CoV-2 (no Ct values reported).
- Although the patient’s symptoms during the second episode were more severe than the first episode, hospitalisation was not required.
- Qualitative IgG/IgM was negative for IgG and positive for IgM on 16 May 2020.
- A test for antibodies on 18 August during the second episode was positive for IgG and IgM.
- Genome sequencing and phylogenetic analysis showed that the infection episodes belonged to different clades with nine variant differences.
- A 25-year-old man, was found PCR positive on 5 May 2020 (Ct: 36) during routine surveillance of health workers.
- He was asymptomatic.
- He was found PCR-positive again on 17 August (Ct 16.6).
- Sequencing of samples from both episodes was performed along with genomic analysis.
- The first and second episodes revealed nine variant differences.
- Another 28-year-old woman, was found PCR positive on 17 May 2020 (Ct: 28.16).
- She was asymptomatic but isolated.
- She was found PCR-positive again on 5 September (Ct 16.92).
- Sequencing of samples from both episodes was performed along with genomic analysis; the first and second episodes revealed 10 variant differences.
- A genetic variation 22882T>G (S: N440K) within the receptor-binding domain was detected in the sample from the second episode.
CME INDIA Learning Points:
- Reviews of the published literature indicate that most patients (>91%) develop IgG seropositivity and neutralising antibodies (>90%) following primary infection with SARS-CoV-2.
- The protective role of antibodies or T-cell-induced immunity against SARS-CoV-2 is still not understood.
- That most patients do appear to mount an immune response following a first SARSCoV-2 infection, but that this immunity may wane over time. This appears to be more likely in individuals with a less severe primary infection.
- Immune assessment tests − Duration/persistence, type and titres of antibodies [range] − Detection of neutralising antibodies − If available: paired serological specimens from both the first (day 0 and 14) and the second infection (day 0 and 7, possibly also day 14) − T cell immunity and biomarkers such as CD40L.
- Diagnosis of Reinfection: Virus culture from multiple specimen types /Comparative genomic analyses − WGS – the number of single nucleotide variations (SNVs) between the episodes, including differences in high confidence minority variants, correlates with the likelihood that the different episodes are caused by different viruses. Sequence/phylogenetic analysis: Whole genome sequencing of the virus can support to assess whether the second episode is caused by a different virus variant compared with the first.
- An RT-PCR positive test does not confirm reinfection. Only whole genome sequencing (WGS) of the viral isolates from the different episodes can confirm a reinfection-PCR results can remain persistently positive due to the detection of viral RNA fragments, even if viable virus would not be present in the patient/sample.
- Virus culture: It can be used to verify whether the prolonged PCR positivity is just a result of non-viable viral RNA shedding (i.e. non-viable virus) or the result of persistent, infectious viral RNA shedding (i.e. viable virus).
- The possibility of reinfection implies that individuals that have been infected once cannot be definitively considered to be immune.
- Although so far confirmed reinfections appear to be very uncommon events.
- In the six cases highlighted above there has been no evidence of onward transmission from the re-infected individuals to any close contacts.
- D614G mutation, known for having a spike protein that makes it easier for the virus to infect people. The D614G mutation is associated with severe infections in people.
- The second infection was “severe” only in comparison to their earlier infection.
CME INDIA Tail Piece:
(by Dr Ambrish Mithal, DM Endo, Delhi)
1. Consistent hygiene:
Washing your hands “is essential to stopping the transfer of infectious droplets from surfaces to your nose, mouth, and eyes,” Gawande writes, “But frequency makes a bigger difference than many realize. “For instance, he cites a study conducted at a military boot camp that found that requiring hand-washing five times a day reduced medical visits for respiratory infections by 45%. And still other research, on the SARS outbreak of 2002, found that washing hands more than 10 times each day reduced infection rate by at least 55%.
“The key … is, washing or sanitizing your hands every time you go into and out of a group environment, and every couple of hours while you’re in it, plus disinfecting high-touch surfaces at least daily,” Gawande writes. But he cautions that this step—while necessary—is, like all the others he outlines, not enough to stand alone; in fact, he cites research showing that “environmental transmission may account for as little as six percent of COVID-19 infections.”
2. Keeping physical distance:
In addition to frequent handwashing, Gawande writes that Mass General Brigham has introduced rules to make sure staff and patients maintain physical distance from each other. For example, Mass General Brigham has asked people to maintain distance on escalators and waiting in line for elevators. Those elevators, which Gawande writes “used to carry more than 20,” are now limited to four passengers at a time.
The hospital is also making all internal meetings, visits with patients, and team huddles virtual when possible. And when face-to-face encounters are unavoidable, the hospital relies on Plexiglas barriers and increased physical distance between work stations, he writes.
Spending less time around people who have COVID-19 can also reduce a person’s risk of developing the disease, Gawande writes. “We don’t know exactly how long is too long, but less than 15 minutes spent in the company of an infected person makes spread unlikely. “However, Gawande again cautions that distance alone is an insufficient barrier to infection. “It has now become well recognized that, under the right conditions of temperature, humidity, and air circulation, forceful coughing or sneezing can propel a cloudburst of respiratory droplets more than twenty feet,” he writes, adding, “six feet was simply a choice guided by practicality.”
3. Screening employees, patients, and visitors for COVID-19 daily:
Mass General Brigham also mandates that everyone entering the hospital confirm they have no symptoms of COVID-19. For instance, as an employee, Gawande writes that he logs onto a website to confirm he doesn’t have any COVID-19 symptoms. After doing so, “[a] green pass on my phone indicates no symptoms and grants me access to the hospital,” he writes. “Otherwise, I can’t work. In that case, the website directs me to call our occupational-health clinic and arrange for possible testing.”
And while Gawande acknowledges that anyone could lie in self-screening for symptoms of COVID-19, that occurrence—at least at Mass General Brigham—has been minimal to non-existent. “Through the first week of May, symptoms, often mild, prompted more than 11,000 staff members to stay home and receive testing,” Gawande writes. “Fourteen hundred of them tested positive for SARS-CoV-2 and avoided infecting patients and colleagues.”
Nonetheless, Gawande also points out that testing alone is insufficient—particularly for people infected with COVID-19, who are not showing symptoms.
4. Consistent wearing of masks:
The delayed onset of symptoms is one reason, Mass General Brigham adds another preventive measure to the mix: The hospital requires every employee to wear a disposable surgical mask. According to Gawande, a study published last month in Nature found that, when worn properly and with the right fit, surgical masks can block 99% of respiratory droplets expelled by COVID-19 patients or those with influenza.
Even double-layered cotton masks, much like what many people make at home, have the ability to block respiratory emissions, Gawande writes. And in fact, according to Gawande, a review of research suggests if at least 60% of the population wore masks that were 60% effective at blocking respiratory emissions, the COVID-19 epidemic could be stopped. But masks alone are an imperfect solution, Gawande explains. That’s because supply cannot meet demand, especially for N95 masks, and people often wear poorly fitting masks or, because they cannot breathe comfortably through cloth ones, move them under their nose or otherwise reduce their efficacy, he writes.
5. Change the culture:
Ultimately, according to Gawande, since none of these preventive measures are perfectly effective in isolation, it’s the fifth pillar—culture—that’s perhaps the most critical, especially when trying to figure out how to implement Mass General Brigham’s workplace regimen beyond the hospital walls. It’s also perhaps the most difficult measure to address, because changing culture requires people care not only about their own safety, but the safety of others. Recalling Mass General Brigham’s ongoing efforts in this regard, he writes, “This requires absorbing detailed practices that keep us from transmitting germs in a given setting—like the rule at the operating table that, once you’re scrubbed in, you never let your hands fall below your waist.” He adds, “Even more, this requires developing norms about how to address lapses in rules, so you can comfortably call one another out when you see a standard slipping and still enjoy working together.”
There is still a lot to learn about which practices are most effective at stemming the spread of the new coronavirus, Gawande writes. He notes, “The four pillars of our strategy—hygiene, distancing, screening, and masks—will not return us to normal life, but, when signs indicate that the virus is under control, they could get people out of their homes and moving again.”
He concludes, “Answers will come only through commitment to, abiding by new norms and measuring results, not through wishful thinking” (Gawande, New Yorker, 5/13; Dyrda, Becker’s Hospital Review Written in May by Atul Gawande. Still true. Close to zero medical personnel affected now in the Boston- Harvard system).
(European Centre for Disease Prevention and Control. Reinfection with SARS-CoV: considerations for public health response: ECDC; 2020).
Discover CME INDIA
- Explore CME INDIA Repository
- Examine CME INDIA Case Study
- Read History Today in Medicine
- Register for Future CMEs