Corona Medtalks – Telemedicine Guidelines, More Tests

For attention of Doctors

India

healthysoch

Should India adopt a mass testing policy similar to South Korea?

New Delhi, March 28, 2020 :

The CDC has provided a “Coronavirus Self-checker” called Clara on its website for US citizens. People can use this online symptom checker to make decisions about what they should do, if they think that they have symptoms of COVID-19. Following a series of questions, the tool gives recommendations if they need medical care. The CDC has; however, made clear that it is not a diagnostic tool for the disease.

Should everyone who has symptoms of corona-like illness be tested for the COVID-19 virus? Testing helps to identify people who are infected with the virus; but there is also a concern, perhaps reasonable, that it would be a drain on resources (personal protective equipment, swabs, viral transport media, etc.).

South Korea has been aggressively testing its citizens through a mass testing program, including drive-through testing centers and mobile alerts about people who have tested positive for the virus. It has been successful in slowing down the spread of the disease. From a peak of 851 new cases per day on 3rd March, the number of new cases has declined to 100 cases per day, as on 26th March.

Initially, India carried out “need-based testing” i.e., only people with history of travel to areas with active transmission and their close contacts were tested. But, last week, the ICMR has revised the strategy of COVID-19 testing in India –

• “All asymptomatic individuals who have undertaken international travel in the last 14 days:

o They should stay in home quarantine for 14 days.

o They should be tested only if they become symptomatic (fever, cough, difficulty in breathing)

o All family members living with a confirmed case should be home quarantined

• All symptomatic contacts of laboratory confirmed cases.
• All symptomatic health care workers.
• All hospitalized patients with Severe Acute Respiratory Illness (fever AND cough and/or shortness of breath).
• Asymptomatic direct and high-risk contacts (those who live in the same household with a confirmed case and healthcare workers who examined a confirmed case without adequate protection) of a confirmed case should be tested once between day 5 and day 14 of coming in his/her contact”

India has the second largest population in the world, at 1.3 billion. Latest data show that India has over 700 coronavirus positive cases with 17 deaths.

Are we seeing just the tip of the iceberg when it comes to the number of positive cases? Or, have we managed to escape the worst? We do not know. This is a matter of speculation.

ICMR has been emphatic in its assertion that there is no need for “indiscriminate testing” in the country.

Social distancing is the answer to prevent the spread of the infection. If you think that you have symptoms of coronavirus, the best approach would be to self-quarantine or self-isolate, which also means staying away from others at home and adopt all infection control measures (hand washing, face masks, etc.).

[https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/index.html; https://www.mohfw.gov.in/pdf/ICMRrevisedtestingstrategyforCOVID.pdf]

New telemedicine guidelines released: Urgent need of the hour

The government has released new telemedicine guidelines. These guidelines were much needed and have come at an opportune time.

A doctor at a Mohalla Clinic in Delhi has tested positive for COVID-19. His wife and daughter have also tested positive for the virus. Following this, over 800 people who recently visited the clinic have been put under home quarantine and have been asked to contact the control room if they develop any symptoms. The clinic has been closed and sanitized (Business Today). It has been reported that the doctor developed the infection after contact with an infected woman who returned from Saudi Arabia (TOI).

Modalities like telemedicine are now absolutely essential if we are to prevent many more such scenarios. The number of positive COVID-19 cases is increasing every day in India. The entire country is under a lockdown with the intent to break the chain of transmission.

Teleconsultations will help to prevent cross infection of flu or corona-like illnesses among the large number of patients waiting to see the doctor.

We have been asking the government to permit teleconsultations, especially for cases of respiratory infections, for precisely this reason. We had written to the PMO in this regard as early as on 7th February (PMOPG/E/2020/0066034, dated Feb 7, 2020), when the PMO had cancelled Holi celebration events.

Teleconsultations are useful for routine checkups and follow-up. In cases of flu, it is easy to identify patients who need hospitalization as they will be breathless.  The guidelines have been developed by the Board of Governors in partnership with Niti Aayog.

All Registered Medical Practitioners can provide telemedicine consultation to patients from any part of the country. But they are bound by the same professional standards and ethical regulations as they apply to the regular consultations in the clinic.

Four types of telemedicine consults have been identified according to:

• Mode of communication (video, audio, text-based)
• Timing of the information transmitted (real time or asynchronous – accessed as per need or convenience)
• Purpose of the consultation (Non-Emergency or emergency)
• Interaction between the individuals involved (RMP-to-patient/caregiver, or RMP to RMP).

Five scenarios have been defined:

1. Patient to Registered Medical Practitioner
2. Caregiver to Registered Medical Practitioner
3. Health Worker to Registered Medical Practitioner
4. Registered Medical Practitioner to Registered Medical Practitioner
5. Emergency Situations

Both the patient and the doctor need to know each other’s identity. Patient consent is necessary for telemedicine. If the patient initiates the telemedicine consultation, then the consent is implied.

The complete guidelines are available at the Health Ministry’s website.

Here are some safe practice guidelines for doctors:

• Provide as many paid tele consultations as possible at least for the duration of the lockdown.
• Doctors aged more than 65 years with uncontrolled diabetes, immunocompromised, who have six minutes’ walk distance <200 meters, are unvaccinated for flu and pneumonia (with common secondary or co-infections) should completely stop OPDs and only give tele consultations.
• Inform all patients that if they or any close contact has fever, they should call first and not visit the clinic/hospital without tele consultation.
• Always wear surgical masks; if doing any procedure where aerosols may be produced, use N95 masks.
• Doctor with cough and fever should go for self-quarantine and COVID-19 assessment. In a WHO study from Italy, it has been shown that 90% of doctors attending patients were asymptomatic when they were tested COVID-19 positive.
• Install air purifiers with 10 air exchanges per hour rate at the clinic.
• When you come back home from your clinic, wash feet first, then hands, face, change cloths (keep them in separate box for washing), decontaminate all surfaces you have touched including your car, wash hands again with soap and water.
• Stay away from elderly people in your home if possible.

Author: Dr K K Aggarwal, President CMAAO, HCFI and Past National President IMA