CME INDIA Presentation by Dr N K Singh, Admin CME INDIA.

Understanding the exploded time bomb – planted as ultimate bioterrorist – is essential to cope with the life on earth today. Is nature nurturing itself? If so, is it not time to nurture ourselves? High mortality among doctors in India is something which is an understood story. Hidden enemy penetrates the health care workers while we do not follow the established norms. Time to remain in constant vigil – at least till the arrival of vaccine by April 2021.

Indian Cobweb dance

Europe is on move to handle “Decisive” Point in Pandemic – Calling on everyone to act decisively. But in India, things are very much dancing in cobweb, public is relaxed and trying to live fearlessly. Only those who are updating themselves, seem to be concerned.

Now COVID-19 is more contagious

COVID-19 is still mutating. New study finds and experts believe that COVID-19 is more contagious. One new US study shows that approximately 5,000 genetic sequences of the virus continue to mutate as it spreads through the population. It is said that mutations of the virus have not made it more lethal but is becoming easier to catch. Prevention is the core theme of controlling COVID-19. If you protect yourself, only then you can help others. Keep preventing it by using Namaste for greeting, physical distancing, taking off shoes at the entry of the house, washing hands, wearing mask, boosting immunity (meditation, yoga, exercise, good sleep, no addictions), respecting and caring of seniors, and working from home. Prevention is best achieved by enhancing immunity. The four types of immunity are: physical, organ specific (lung; steam inhalation; pranayama), mental and spiritual immunity.

Do not expect any Vaccine before April 2021 – as per WHO. More than 100 vaccine trials are going on worldwide, including 3 in India. An effective vaccine will not be available this year, so the best way to control is prevention and enhancing immunity.

Indian Typhoid Drama:

Very recently CDC has updated its guidelines for testing people who do not show symptoms of the novel coronavirus. Due to the significance of asymptomatic and pre-symptomatic transmission, this guidance further reinforces the need to test asymptomatic persons, including close contacts of a person with documented SARS-CoV-2 infection. But the recent trend among public is not to test due to fear and stigma and go for home self-treatment. These days, I usually get cases having fever lasting for 5 to 6 days, local GPs test for Widal test, it comes positive. Considering all as typhoid play, havoc comes on second week when these patients develop shortness of breath and rush. HRCT shows typical COVID findings.

Mad Rush for Plasma Therapy

India’s top medical research body ICMR stated that giving plasma had negligible effect on reducing death risk. Union Health Minister Ministry has just  cautioned against “routine use” of plasma therapy and anti-viral drug Remdesivir to treat COVID-19 patients, stating that these are “investigational therapies” and should be adopted “rationally”. Every day we are getting requests for searching plasma for some near and dear, public is thinking of it as a panacea, but realities are hard. Recent scientific paper says:  Effect of CP in the treatment of COVID-19 likely depends on numerous characteristics including antibody level, avidity, and target as well as neutralization activity. Understanding how to best screen CP (Convalescent plasma) donors to identify those with NAb titers and characteristics that may optimize use of CP as treatment may be important. (Salazar et al. Journal of Clinical Investigation, September 10, 2020). Plasma therapy is useless when the patient started to develop antibodies. That is why studies are not showing good results.

Preparing yourself is of utmost Priority

1. So, you get primary symptoms – fever, cough, body ache – today.
2. In pandemic times, you should take it as Corona, unless proven otherwise. Immediately stop going to work. Quarantine yourself at home and keep yourself confined in a separate room in your house.
3. Get some baseline investigations like CBC/LFT/KFT/CRP/X-ray chest. Certain investigations like IL6/D-Dimer/LDH/Ferritin/should also be done either in a nearby lab or through a franchisee lab. CT chest can also be done as per symptoms.
4. Get yourself tested for RT-PCR also remember that in very early period PCR might come negative. Thus, keep watch on progression or persistence of symptoms. If symptoms don’t subside after negative PCR then get retested after few days. RTPCR is the gold standard test for diagnosis. TrueNat and CBNAAT are used as screening tests and need confirmation by RT PCR tests. The rapid point of care antigen test can be used in field settings. All symptomatic negative patients need to be confirmed with RT PCR test. RTPCR is important around first 7 days. Its sensitivity is around 67% and as the duration increases, the sensitivity decreases. In 2nd week, it is only 54% and later on it is only 45%. The sensitivity of antibody titer goes on increasing as duration increases.
5. Do not self-treat yourself. Fix your care giver. Many of mortality in doctors happened because of late referrals.

Knowing and Updating everyday changing facts

• Senior practitioners better avoid seeing patients (including relatives) – Worth to remember: Asymptomatic cases constitute 5 to 28% of all COVID-19 cases. Fact Check: It is hardly being followed. See the latest data: SARS-CoV-2 exhibits high transmissibility between middle-aged (45 to 64 years old) and elderly (≥ 65 years old) people. Children (≤ 14 years old) have very low susceptibility to COVID-19. It suggests the most prevention measures should be applied to middle-aged and elderly people. https://idpjournal.biomedcentral.com/articles/10.1186/s40249-020-00735-x August26
• Uncontrolled Diabetics face 11% mortality. Controlled diabetes patients have similar mortality as general population. Message is crystal clear to maintain euglycemia.
• Latest consensus is that steroids should be started only when patients become symptomatic like having breathlessness and SpO2 below 94%. Such cases have usually typical COVID findings in HRCT. This is not to be started immediately after testing +ve for COVID-19.
• Favipiravir in my limited experience is worth a trial at earliest. It gives symptomatic relief and cut shorts the illness. Will decrease the duration of fever but not reduce mortality. LFT and Uric acid monitoring needed. Plenty of fluids must be taken. Some cases of Blue sclera and cornea have been reported after few days therapy of Favipiravir. (This case noted by Col Dr Ashutosh Ojha, Jamshedpur, CMEINDIA2) Significance of this adverse effect is at present unknown.

• N95 mask and face shield – most of the time – protects from acquiring COVID-19 infection. My observation is that Face Shields are extremely effective if used with N95 Mask. Buy a good quality Face Shield as most vital INVESTMENT today and use it even outside. While going for urgent travel or market, use it. We have to prevent our medical fraternity and community from getting the infection till we get an effective vaccine. This is the only vaccine till then.

Stop COVID Virus at all stages

There are seven steps in the lifecycle of the coronavirus:

Simple fact. Stop its entry through nose, mouth and eyes by using Proper Mask and Face Shield.

It is important to differentiate between cold, flu and coronavirus. There are three pathognomonic differentiating features of coronavirus: fever, cough and shortness of breath (clinical triad for diagnosis). But do not believe on this clinical triad. Many of cases simply developed Nasal Stiffness – tested positive/ Some developed only myalgia – tested positive/ Some developed only unusual weakness – tested positive.

No new drugs are available for COVID-19. Drugs used for other diseases are being repurposed (HCQ, azithromycin, ivermectin and remdesivir). Ivermectin has been the drug in debate. Note that ICMR has not recommended Ivermectin. After fiasco with HCQ, Ivermectin can be used both in prophylaxis and as treatment of coronavirus infection. Not to be given to children if weight is less than 15kg, else dosage for children: 200-400 microgram per kg.

An important pharmacokinetic feature is the longer terminal half-life of 81-91 hours. It has a prolonged mean residence time in the host associated with persistent effect, especially in the lung, where it can reside for up to 30 days. Its concentration in lungs is 3.5 times more than in the blood. These may be beneficial in COVID-19. It has a synergistic effect with doxycycline. Around 40 clinical trials are running worldwide, including 6 trials in India. There is 50 years of experience of using ivermectin; it is easily available and affordable; no resistance.

All started when UP became the PIONNEER player in India to use ivermectin as prophylaxis as well as treatment.

Ivermectin protocol of the UP government (As per Govt. of UP dated 6th Aug):

• For prophylaxis in household contacts of positive patients: Day 1 and Day 7 12 mg od.
• For prophylaxis in healthcare workers: Day 1, Day 7 and Day 30: 12 mg od; repeated once a month.
• For treatment of COVID positive patients (asymptomatic or mildly symptomatic): 12 mg od x 3 days along with doxycycline 100 mg twice daily x 5 days.
• It should be given 2 hours after food; avoid citrus juice, milk and alcohol. Use with caution in liver diseases and seizure disorders, asthma.
• Ivermectin is contraindicated in pregnant and lactating women and children younger than 2 years of age.
• Doxycycline is contraindicated in pregnant and lactating women and children younger than 12 years of age.

[A White Paper on ivermectin has been published in India on 26.7.20 in the Indian Journal of Tuberculosis. More than 10 experts from across the country have participated in formulation of this white paper; this is the first white paper on ivermectin in the world.]

CME INDIA Tail Piece:

1. Every day fear is persisting.
2. In 2007, it was predicted. “The presence of a large reservoir of SARS-CoV-like viruses in horseshoe bats … is a time bomb.” Time Bomb has exploded.
3. Be happy with the fact as published in Nature Magazine: Mutation in CoV-19 seems a natural selection by nature to self-nurture. “It may seem strange to compare threats posed by human interactions with winged mammals that sleep upside down in caves to that of a terrorist group or a nuclear-armed nation. But scientific evidence — and our collective daily experience coping with COVID-19 — tells us that pandemics may equal or surpass these dangers. It is time to significantly elevate our response to them so it is equal to the peril they present. “David M. Morens. (He is an infectious disease physician).
4. Be happy by pondering deep with Mother Nature. It has followed a natural transformation process to give checkmates to many of the environmental extremities. This is an opportunity to save the planet which will stabilize the world as a unitary ecosystem. Nature was waiting for a break to revive her individual ecosystems. It is now playing its game.

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