Coronavirus Facts and Myth Buster : What is my risk ?

Author :Dr KK Aggarwal , President CMAAO

Minutes of Virtual Meeting of CMAAO NMAs on “Am I at risk?”

13^th June, 2020, Saturday; 9.30am-10.30am

India

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New Delhi, June 16, 2020 :

Participants Member NMAs: Dr KK Aggarwal; President CMAAO, Dr Rajan Sharma, National President, IMA; Dr N Gnanabaskaran, President Malaysian Medical Association; Dr Marie Uzawa Urabe, Japan; Dr Alvin Yee-Shing Chan, Hong Kong; Dr Md Jamaluddin Chowdhary, Bangladesh; Dr Prakash Budhathoky, Nepal

Invitees: Dr Russell D’Souza, UNESCO Chair in Bioethics, Australia; Dr Sanchita Sharma, Editor IJCP Group

This webinar was dedicated to Mr Sanjay Sharma, Asst. Manager – IT & Election Work, Indian Medical Association (IMA), who passed away due to Covid-19.

All participating NMAs observed a minute’s silence to condole the sad demise of the mother of Dr Qaiser Sajjad, Secretary General of the Pakistan Medical Association (PMA).

Calculate your risk to know your chances of developing the disease

The revised Geneva Declaration (The Physician’s Pledge) asks the physicians to also take care of their health – “I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard”. Hence, doctors should be concerned about their health, particularly during the time of COVID-19. To do so, calculate your risk to know your chances of developing the disease.

What is my risk?

• High risk:Being male, 65 years or older, smoker, uncontrolled hypertension/diabetes, BMI >30, post transplant, CKD, heart failure, post cardiac bypass, cancer patients receiving chemotherapy/radiotherapy
• Low risk:Being female, below 65 years of age, if you have quit smoking since 2 years, BMI <30, controlled hypertension/diabetes/heart failure, if more than 4 years since bypass, if you are on aspirin/oral anticoagulant, recovering cancer patient

Is my family at risk?

 If you are below 65 years of age, but have people older than 65 years living in the same house, they are at risk.

 Is my environment at risk?

 Low risk: Fully ventilated house, high AC vents, sitting side to side, driving yourself, if 100 sq m space per person

 High risk:Not ventilated house, AC, people sitting between you and the AC, public dealing, working in hospital, using a driver for your vehicle, shopping

Avoid having two high risk situations at the same time. A high risk person cannot be a caregiver for a COVID-positive person.

What is my risk if I develop Covid-19?

Calculate risk on the day of diagnosis.

• Low risk:Lymphocyte count >1000, Normal CRP, ESR, LDH, Negative D-dimer
• High risk: Lymphocyte count <1000 (<800 severe), CRP >26, ESR >100, ferritin >500, high D-dimer

People die of specific complications in COVID-19. Our priority now should be how to prevent or reduce mortality if a person develops COVID-19. If we can identify the triggers, complications and deaths can be prevented.

Fever subsides, hypoxia appears – this is a trigger. It usually happens between Day 7 and Day 9, so monitor oxygen level.

If on the day of diagnosis, leukocyte count, ESR, CRP and D-dimer are normal, then complications are not likely to occur.

If loss of smell and loss of taste – they are indicative of less severe illness. Sour taste is retained.

Presence of diarrhea: ? Super spreader

About 33% of deaths occur in persons without comorbid condition. The virus causes microvasculitis in lungs, lung elasticity is preserved, carbon dioxide is washed out normally and so these individuals do not develop symptoms. Microclots are formed due to vascular endothelial dysfunction with resultant intussusception of the artery (partially thrombosed artery, partial blood flow). So, they develop severe hypoxia. At this point of time, if a single dose of LMWH is given, oxygen 4-5 liter/minute (maintain saturation >92%), water-soluble aspirin stat, one dose of remdesivir, and then the patient is shifted to the hospital, death can be prevented.

Remdesivir is maximally effective if administered at the onset of hypoxia. If we miss microthrombi and delay heparin, death may be sudden due to hypoxia or clot. Therefore, the trigger in such patients is hypoxia or microthrombi or endothelial dysfunction. Which of these three is primary, we do not know yet.

Any fall of oxygen by 4 while walking or talking should raise the suspicion of silent hypoxia. Do not miss exertional hypoxia; this may be a sign of micro-or macrovascular emboli.

This virus can precipitate silent or evident disease such as inflammatory bowel disease; it can precipitate immune-inflammation or thrombotic disorders.

 Cohort isolation: Two positive patients or multiple infected patients from a colony can stay together. There is no evidence that this will increase their viral load.

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