Presented by Dr N. K. Singh, Admin – CME INDIA

It is common experience that those who remain aware are stressed and in depressed mode. Whether Delhi, Mumbai, Pune, Kolkata, Ahmedabad, Surat, Patna or any city in India, Social distancing, Proper masking and Sanitization [SMS] has become a joke. Some news keeps coming and panic mounts to a new height. So, what to do?

Someone rightly said that apply Osler’s advice with renewed conviction: attend to your patient with all five senses at full alert. They will teach you what you need to know.

  1. Asymptomatic case: Sudden death

Many patients with advanced COVID-19 disease bore none of the hallmarks of severe respiratory illness until they suddenly collapsed and died. Many such instances are in record especially from Karnataka, Telangana and Tamil Nadu. SARS-CoV-2 may be accompanied by underlying organ damage, ground-glass opacities and consolidation without displaying typical symptoms of pneumonia. This remains a mystery. So, absence of symptoms does not imply the absence of harm. Considering that current advice encourages patients to stay at home if they are asymptomatic then in some cases is it not a possibility that they will make late presentation to hospital and sudden death a distinct risk. And the nightmare doubles by knowing that the significant false-negative rate of up to 20% for screening tests – where people are wrongly told they don’t have the infection. These are the covert transmitters who continue to shed the virus for up to 14 days. How to cope with this challenge is unknown to us.

  1. CDC Blunder

On 28th august CDC did a blunder by not recommending testing for COVID-19 exposed individuals without symptoms. Later it was emphatically defended by saying that it came from public health experts at the CDC and was evidence based. There was “no direction” from the president, vice president, or other top Trump Administration officials. It was said that the decision to not recommend testing for COVID-19 exposed individuals without symptoms was intended to avoid testing too early after an exposure. This could provide a negative result before an infection has had enough time develop and register as positive on a test, thus giving an exposed person a false-assurance of being uninfected. It’s still unclear why the CDC did not instead provide a recommended time-frame for asymptomatic testing after an exposure, particularly given that some infected people may never develop symptoms. A positive test result is necessary to ensure COVID-19 patients receive proper care, isolation instructions, and appropriate follow-up. Identifying patients through testing is also critical for contact tracing.

  1. Asymptomatic transmission of COVID-19 on an airplane

A very interesting study has been done to assess asymptomatic transmission of COVID-19 on an aircraft. Previous studies reported that viral shedding can begin before the appearance of COVID-19 symptoms and evidence of transmission from presymptomatic and asymptomatic persons has been reported in epidemiologic studies of SARS-CoV-2.

They managed   strong infection control procedures during boarding; the medical staff and crew members were trained in infection control; all passengers, medical staff, and crew members were tested twice for SARS-CoV-2; and a precise epidemiologic investigation was conducted, the most plausible explanation for the transmission of SARS-CoV-2 to a passenger on the aircraft is that she became infected by an asymptomatic but infected passenger while using an onboard toilet. Other, less likely, explanations for the transmission are previous SARS-CoV-2 exposure, longer incubation period, and other unevaluated situations. New study suggests the following strategies for the prevention of SARS-CoV-2 transmission on an aircraft.

  1. Masks should be worn during the flight.
  2. Because contact with contaminated surfaces increases the risk for transmission of SARS-CoV-2 among passengers, hand hygiene is necessary to prevent infections.
  3. Physical distance should be maintained before boarding and after disembarking from the aircraft.

(Study: A study, published in Emerging Infectious Diseases, Volume 26, Number 11,2020,measured asymptomatic transmission of SARS-CoV-2 on an evacuation flight in March 2020. Out of the 310 passengers who boarded a flight from Milan, Italy, to South Korea, 11 passengers with symptoms were removed. For the remainder, N95 respirators were provided and passengers were kept 2 metres apart during pre-boarding. Other than at mealtimes, most passengers wore the N95 respirators throughout the flight. On arrival, all passengers were examined and quarantined for 2 weeks at a government quarantine facility in South Korea. They were tested for SARS-CoV-2 on quarantine day 1 and 14. Among the 299 passengers, 6 passengers (who did not have symptoms) tested positive for the virus on day 1 and were transferred immediately to hospital)

Covid-19 in Airplane

This research provides evidence of asymptomatic transmission of COVID-19 on an airplane.

  1. Panic of Re-infection:

Story: A 33-year-old man from Hong Kong who was treated at the hospital for a mild case in March tested positive for the virus again almost five months later, when returning from Europe, but did not develop disease the second time. Genomic analysis of the virus confirms that he was infected twice.

Should we Panic?

No reason to panic:

  1. It is not clear whether he developed neutralizing antibodies during the first infection
  2. The fact that he did not develop symptoms when re-infected is suggestive of an effective immune response that, while not avoiding infection, did avoid disease
  3. The frequency of reinfections and their role in viral spread still needs to be determined.
  4. It is important to note, that this is a singular finding. It does not provide any information to us with regard to the generalizability of this phenomenon.

Tail Piece:

  • The impossible has already happened.
  • We have reached a crossroads.
  • Things have suddenly overturned.
  • It is time to understand the helplessness of the science.  
  • Disaster teaches is that everything is connected.
  • When science is under pressure and trying to ravel the mystery, I propose to apply your own WISDOM and look forward to alternatives.

* Covido-Panic – term coined by Dr N. K. Singh.

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