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Introduction
Its COVID times, probably the most difficult times faced by human beings since the 1918 Spanish Flu
pandemic. The situation is worse than world war, because we are unable to see the enemy ―CORONA
VIRUS‖. And this virus is entering in our lives from everywhere and anywhere.
Here are some tips to keep your home safe from CORONA entry.
How to sanitize home items is compiled by various inputs and experiences.
Vegetables and fruits (Virus Stays 6-8 hrs)
1. Keep all vegetables and fruits outside for 4 hrs in a packet;
Wash in warm water with baking soda; or
Wash with potassium permanganate solution.
Finally wash with clean water.
2. No sanitizer should be sprayed on food items.
Wash in water with Ozonizer for 30 minutes
Wear a mask while washing vegetables.
3. For Vegetables and Fruits which cannot be washed in hot water (e.g. onions, banana) or which cannot be
kept in sun as these are perishable, so keep them for 4 hrs under a fan and clean with edible/ friendly
washing material (Stericlean).
4. For sanitizing vegetables and fruits prepare a spray at home- 2 spoons vinegar, 1 full spoon lime juice / 1
spoon salt, 1 spoon baking soda mixed in 200 ml water. Spray by a spray gun on fruits & vegetables, leave
for 2 min and then wash with clean water says a leading homeopath Dr. Sidharth Mishra.
Medicine Strips
Keep in a closed box at room temperature 6 hrs – 12 hrs, or keep in a U.V. box.
Clean with Enviroguard, Stericlean, alcohol spray on even sodium hypochloride & hydrogen per oxide.
Conclusion
The virus is here to stay with mankind for a very long time, may be forever, so we just need to be careful
and follow S.M.S. (Sanitize : Mask : Social Distancing). Do not get paranoid or panic, just be careful and
teach others to be careful.
Acknowledgements
W.H.O., C.D.C., Government of India, Ministry of Health & Family Welfare, ICMR, IMA, FOGSI.
CORONA UPDATE 2
SOCIAL LIFE AFTER COVID TIME : THE NEW NORMAL 2020: CATCH 22
Compiled By:
Dr. Neharika Malhotra Bora, Dr. Narendra Malhotra, Dr. Jaideep Malhotra, Prof. Nehal S Jain
Introduction
Humanity today has been attached by an unknown enemy, which is deadly, highly contagious and can only be
prevented. This virus is going to live with mankind for a long-long time till we have a vaccine and medicine to kill.
So How will people live now, What will be the new normal ?
1. No handshakes only “Namaste” or elbow shake or heel touch. When you meet anyone just nod your head and
bend to say hello or put your hands to your heart.
2. Designer masks matching with sarees & suits & shirts. Mask will be the most essential & compulsory dress to
wear to go ahead & #maskyourself #maskindia.
3. No lipsticks for women unless they wear a plastic transparent mask and now we will have the masks which will
open like a fish mouth whenever you want to eat.
4. No coughing, sneezing shouting, spitting allowed in public. Respiratory manners will strictly have to be followed
cough & sneeze in the mask or on your elbow or sleeve.
5. Classroom will have only 10 children per room only sitting 6 feet apart & wearing masks with subject / class /
school and their name on the T-Shirt name on mask
6. There will be no parties, no wedding parties(only 50 members allowed in weddings). All social gatherings will
have to follow social distancing strictly and transparent cover all with masks and gloves will be in vogue as the
new normal.
BAPTISM and NAAM KARAAN will all be online or from far away maintaining social distance.
7. Even in funerals more than 20 members will not be allowed. This will be sad as friends, family and near relatives
will not be able to wish you good bye on your last journey.
8. Honeymoon in home will be the new normal and hugging thru plastic coverings and kissing masks will be
available. Premarital health check and covid test might become a routine.
9. No International tourism travel for next 2 years, only very essential business travels (No hand baggage allowed
& social distancing). Long waits at airports, no eating, no newspaper, no reading marerial in planes will be the
new normal meditate while you travel with protective gear.
10. People will take virtual tours on 3D / 4D Software on laptops to visit beaches museums, restaurants & prayer
places.
https://youtu.be/coKs3KnIcao
https://www.airpano.com/
Physically visiting places may be delayed for the next two years.
11. The latest fashion will be wearing trikni on beaches as masks will be compulsory.
16. Prefer vegetarian food, Increase immunity. Take lots of antioxidants, zinc & Vit-D.
17. Don't bring the shoes into your house. Leave them outside. Follow the Indian tradition of barefoot inside.
18. Clean your hands & legs when you come home from outside, better have a full bath with soap & hot water.
19. Do not go to the Cinema, Mall and Crowded Market for 6 Months now. If possible also Park, Gyms, Party, etc.
should also be avoided. The new normal is stay home.
20. Be very careful while at Barber shop or at beauty Salon parlor.
21. When you feel you have come nearer to a suspected patient take a thorough bath with soap & hot water.
b. After 7 pm, corona takes walk till 7am. Don't venture out even in night.
c. If you carry liquor from shop, corona won't mind. But it will catch you, if you sit in bar and drink.
d. If you travel with pass between Zones you won't get it. But it will hold on to you if you travel without
pass.
e. You won't get it, if you buy from vendor or shops. But corona is waiting for you in a market. Order for
home delivery.
f. CORONA won't touch politicians and their crony, without mask. But if it happens to see a common man
without mask, it will run to embrace him (CORONA भी एक POLITICIAN है ).
h. It will surely catch you if you dine in hotels. But it doesn't bother if you sit there waiting to take away
food (Social Distancing).
i. It is not invited in rich marriages with less number of guests. But in poor man's marriage, it accompanies
51st man (So not more than 50).
23. The threat of CORONA is not going to end soon. Learn to live with this deadly enemy.
So be careful and learn to live with it CORONA our deadly enemy...
Acknowledgements
W.H.O., C.D.C., Government of India, Ministry of Health & Family Welfare, ICMR, IMA, FOGSI.
(With inputs from Prof. Nihal Singh Jain, Dr. Jaideep Malhotra, Dr. Keshav Malhotra)
Corona Virus is here to stay with humans for a long-long time, may be forever let us accept this fact and
not panic and make our lives miserable unnecessarily. We need to learn to live with the fact. “CORONA IS
HERE TO STAY”.
This novel virus has posed so many questions to the medical fraternity, epidemiologists and to the policy
makers. Almost all agree that this virus will persist in the future as an endemic disease, which will surface
in episodes and cause periodic epidemics. As of today most of the world population has not yet got
infected and out of those who have almost 80% or more are asymptomatic or with mild disease. Yes a
susceptible co-morbidity and older male population is at greater risk of serious critical illness and even
death.
Already we have 4 types of corona virus which are endemic in the world and cause seasonal common cold
and flu like diseases. COVID-19 is probably going to be the fifth corona virus which has come to our planet
to stay.
The worry now is how do humans adapt to live safely with corona. The world is looking for a quick fix
solution to this pandemic and a lot of knee jerk actions are being taken and revoked, leaving everyone in
confusion of what is the right step. Lockdowns and unlocking has been seen to help but at the cost of an
economic pandemic which we are facing now in June-2020.
What will work, no one is sure, will a vaccine help, we are not sure. What will be that one thing to
eradicate corona. It’s for our good that we must realize there is no one thing that will work, including the
quick fix vaccine. Only two viral disease small pox & polio have been eradicated by a vaccine and that too
at the cost of millions of lives and over a period of almost 200 years. How this vaccine will fare, we have no
clue yet.
It was postulated that the summer heat will reduce the effects of this virus and corona will die off, but that
has not happened, corona has survived in extreme of weather conditions of heat and cold and is attacking
human beings as virulently all over the world, in all climates.
The only ways of keeping this virus at bay is :- S.M.S. (Sanitizing, washing hands with soap & water for 20
seconds and wearing mask in public places and maintaining a 1.8 meters social distancing).
Getting paranoid about newspapers, letters, courier packets, hot water drinking, gargles, too much alcohol
spraying and washing is an overreaction. Just washing hands, respiratory manners of coughing & sneezing,
wearing an appropriate mask and social distancing will reduce your chance of catching the infection to 1%.
Remember wearing gloves is not a good idea as the virus can stick to the surface of cloth gloves and be
transmitted to your face if wearing surgical gloves, hand washing & hands sanitization over gloved hands is
still needed.
As of now in June-2020, many believe now that COVID disease (SARS-COV-2) will become relatively milder
because the human immune system will develop a memory to respond to the virus (HERD IMMUNITY) and
the likelihood of severe “cytokine storms” occurring and making people very sick may reduce. This will
ultimately happen, but in how much time we don’t know, may be years. Finally this disease will settle in to
an endemic seasonal flu like disease.
Yes a vaccine is on the way, but the medical community is not yet sure on the dosage schedules for this
year for next years (2021-2022) and for the next ten years. The availability of this vaccine is expected by
December 2020 but tell global demand will be much more than the supply and will lead to hoarding, black
marketing and ineffective dosing campaigns.
The was against corona is not an easy was to win and needs a great deals of public awareness and public
participation in just 3 simple measures S.M.S.
We hope and pray humankind will learn sanitization, wearing masks and social distancing
1. Sanitize proper hand washing & fogging of rooms & deep mopping of floors and furniture.
[Fig-2]
3. Social distancing of 2 meters
[Fig-3]
4. Yoga – Breathing exercises
[Fig-4]
5. Meditation – Positive affirmations
[Fig-5]
6. Warm saline gargles, mouthwash, steam inhalations, aroma oil (eucalyptus oil steam inhalation), lavender oil &
peppermint oil for relaxation and sleep.
[Fig-6]
7. Warm water drinking / “Kadas” – Tulsi + Turmeric + Black pepper
[Fig-7]
8. Cough lozenges (Phytorelief / vicks / strepsils)
[Fig-8a, 8b]
9. Immunoboost spray
[Fig-9]
10. Vitamin C + Zn + B Complex + Vitamin (CITRAVITE XT) (CFIZZ) (ARACHITOLO)(PYROMMUNE) or others
[Fig-11a, 11b]
12. Sleep over tummy (Prone) & do balloon blowing (Medicated balloons available)
[Fig-12a, 12b]
13. Monitor Temperature (Infrared) Oxygen (Pulseoximeter)
[Fig-14a] [Fig-14b]
15. Sleep in well ventilated rooms, avoid A.C. in closed room.
16. Keep your home care kit
17. Assess your risk
[Fig-17a]
[Fig-17b]
0
18. Consult doctor – covid helpline if Fever (100 ), cough, cold, body aches, loss of smell, loss of taste.
19. Download Arogya-Setu app (https://play.google.com/store/apps/details?id=nic.goi.aarogyasetu&hl=en_IN)
20. Pray and stay safe.
CONCLUSION:- Be safe as only prevention is available as of now. There is no definite treatment or vaccination as of 22-06-2020,
so just take precautions.
Acknowledgements
W.H.O., C.D.C., Government of India, Ministry of Health & Family Welfare, ICMR, IMA, FOGSI.
CORONA UPDATE – 5
WHAT TO DO IF OUR FAMILY MEMBER GETES COVID – [SARS- COV -2 INFECTIONS]
Compiled By: Dr. Narendra Malhotra, Dr. Neharika Malhotra Bora, Dr. Jaideep Malhotra, Dr. Keshav Malhotra
Corona virus is very-very infective contagion and spreads mostly by droplet infection to close human contacts, other
ways of transmission are not common. An English movie released a few years back “CONTAGION” it describes this
deadly pandemic which we are facing these days. Click on link to watch movie “CONTAGION”
https://youtu.be/jPL23-XFrYU
How infection is caused and What is the time line of infections ? (Fig-1)
Infected person with mild disease, not requiring oxygen and quarantine at home is advised. Such persons to stay and
can recover at home without hospitalization. Do not leave your home, except to get medical care. Do not visit public
areas.
Almost 80% will have only mild symptoms [Fever, severe body aches, loss of smell/taste, cough, sneezing, cold GI
symptomes etc] they should stay at home in self quarantine and in tele consultation with COVID helpline and
physician team.
(Govt. COVID helpline 011-23978046 or 1075) Rainbow Hospital Helpline : +91 81910 22444, 0562-2600531-538
(Dr. Pankaj Bhatia : +91 94128 95978, Dr. Vishwa Deepak : +91 99588 82595, Dr. Shubham Jain : +91 70423 57955,
In case of Pregnancy - Dr. Manpreet Sharma : +91 93191 02069, Dr. Shemi Bansal : +91 98976 37828,
Dr. Sarita Dixit : +91 96109 62978)
Symptoms last a few days, and people usually feel better after a week. But they need 2 negative RT-PCR and
minimum 3 days of feeling good, before they can come out of isolation.
The family members are not at higher risk for severe illness from SARS-COV-2(COVID) except for older age over 60,
diabetics, BP patients, heart disease, kidney problem patients. These persons should not come in contact with the
COVID positive case in the family.
1. Limit contact & Sanitize. Limit contact between the person who is sick and their family, friends and pet(s). If
family members and cleaning staff have to enter the room, they should wear PPE (Refer fig PPE kits – Fig-2).
4. The person who is sick or test positive should use a separate bedroom and bathroom away from others.
5. Shared space: If you have to share space, make sure the room has good air flow and ventilation. (Fig-5)
[Fig-5: Air circulation]
(Open the window and turn on a fan (if possible) to increase air circulation. Improving ventilation helps remove
respiratory droplets from the air. Don’t switch on the A.C. in closed room).(Fig-5)
6. Avoid having any unnecessary visitors, especially visits by people who are at higher risk for severe illness. (No
visitors sign outside the main gate).
[Fig-6: No Visitors]
7. Provide the infected family member support and help to cover basic needs
8. Crocin / Paracetamol / Acetaminophen / Tylenol and other medicines as advised by physician should be
started and taken along with Vitamins (B complex, Vitamin C, Vitamin D3) and Zn.
Take over-the-counter medicines, such as Crocin/Paracetamol, to help you feel better. Rest all medicines
should be taken only on medical advice. (Fig-7)
[Fig-8]
10. Towels, bath and hand towels, tissues etc should be separate and soaked in sodium hypochlorite water after
use.
11. Good healthy diet with lots of fresh leafy vegetables and citrus fruits should be given. (Consider having the
items delivered to the sick family member in disposable plates and containers. They (or you can arrange)
wash their dishes and utensils using gloves and hot water, or disposable plates. Handle any dishes,
cups/glasses, or silverware used by the person who is sick with gloves wear mask. Wash them with soap and
hot water or in a dishwasher. (Fig-8, 9, 10)
[Fig-14 : Telemedicine]
16. Many antiviral medicines are used for treatment, Favipiravir, Ivermectine, Remdesvir, Tocilizumab, HCQ,
Asprin & Heparin (LMWH) and Steroid (Dexamethasone Tab & Methylprednisolone) & many other medicines
are being tried to treat this disease. All these are given only to very sick patients who are hospitalized.
Plasma therapy and interleukin injections are experimental treatment. Do not take any such medicines on
your own. These are given to very sick patients who are in need of critical care and ICU care.
[Fig-15]
20. Assess your risk and take precautions and download Aarogya Setu App
(https://play.google.com/store/apps/details?id=nic.goi.aarogyasetu&hl=en_IN)
Acknowledgements
W.H.O., C.D.C., Government of India, Ministry of Health & Family Welfare, ICMR, IMA, FOGSI.
CORONA UPDATE-6
CORONA INDIA IN JULY
Compiled by: Dr. Narendra Malhotra, Dr. Neharika Malhotra, Dr. Jaideep Malhotra, Dr. Keshav Malhotra
Special Inputs
Prof. K. K. Aggarwal
SARS-COV-2 pandemic is still on the way of spreading. The curve has not flattened and the disease has not shown any signs of
regression in numbers. The pandemic is predicted to worsen in India in the coming month. A major awareness drive needs to be
undertaken and the hospital facilities need to be increased.
CASE RISE AS SEEN:
THE SEQUENCE OF SPREAD:
Ground Zero: Wuhan in live animal market or cafeteria for animal pathogens: 10th January; Total cases are based on RT PCR,
67% sensitivity
Doubling time India 15 days, USA 33 days, Brazil 13days, Russia 18 days, Spain 47 days, UK 35 days, Italy 55 days, France 49
days, Turkey 37 days,
Likely minimum deaths (586820 + 59617 x 15 == 8943) = 595762
Coronavirus Cases: 13,691,570
Deaths: 586,820
Recovered: 8,037,140
ACTIVE CASES 5,067,610
Currently Infected Patients 5,007,993 (99%) in Mild Condition
59,617 (1%) Serious or Critical
CLOSED CASES 8,623,960
Cases which had an outcome: 8,037,140 (93%) Recovered / Discharged
586,820 (7%) Deaths
India crosses Russia, will cross 1 million cases and 25000 deaths today
# Country, Total New Total New Total Active Serious, Tot Cases/ Deaths/ Total Tests/ Population
Other Cases Cases Deaths Deaths Recovered Cases Critical 1M pop 1M pop Tests 1M pop
World 13,683,686 +234,245 586,193 +5,754 8,031,267 5,066,226 59,616 1,755 75.2
1 USA 3,616,747 +71,670 140,140 +997 1,645,962 1,830,645 16,459 10,924 423 44,844,982 135,450 331,081,677
2 Brazil 1,970,909 +39,705 75,523 +1,261 1,255,564 639,822 8,318 9,270 355 4,572,796 21,507 212,620,008
3 India 970,169 +32,682 24,929 +614 613,735 331,505 8,944 703 18 12,412,664 8,991 1,380,530,110
4 Russia 746,369 +6,422 11,770 +156 523,249 211,350 2,300 5,114 81 23,754,645 162,773 145,937,175
Tocilizumab 400mg single dose IV infusion over 60mins (for rising ferritin/cytopenia/H score >170
(https://www.mdcalc.com/hscorereactive-hemophagocytic-syndrome#evidence)
Not to be given if
Absolute Neutrophil count(ANC) <2000/cu mm
Platelet count <100000/cu mm
ALT or AST > 1.5 times the upper limit of normal
IVIg: 0.3- 0.5 g/Kg/day for 5 days
Convalescent Plasma
Systemic Corticosteroid ≤ 0.5-1.0 mg/Kg/day of Methyl prednisolone OR
Equivalent for < 1 week
(Disclaimer: All the interventions in special consideration are off-label uses, no evidence for any of these treatments. To be
decided on individual case basis).
COVID PROTOCOL
MILD MODERATE SEVERE
Clinical Criteria
SPO2 > 94 % in Room Air 90 - 94 % in Room Air < 90 % in Room Air
RR < 24 / min 24 – 30 > 30
No Pneumonia Pneumonia + Pneumonia ++
CT Chest Criteria
Normal or < 25 % 25 % - 75 % 75 % to 100 %
Grade I Grade II / III Grade IV
Laboratory Findings (Expected)
NLR1,2 < 3.2 > 3.2 > 5.5
CRP3 < 40 40 – 125 > 125
Ferritin2 < 500 > 500 > 800
D-Dimer4 < 0.5 > 0.5 > 1.0
LDH < 300 300 – 400 > 400
IL6 < 4.8 5 – 50 > 80
LFT5 Normal Slight Derangement Moderate Derangement
Treatment
Routine T. Paracetamol 500 mg TDS T. Paracetamol 500 mg T. Paracetamol 500 mg
TDS TDS
Anti-tussives SOS Anti-tussives SOS Anti-tussives SOS
T. Vitamin C 500 mg OD T. Vitamin C 500 mg BD T. Vitamin C 500 mg BD
T. Zinc 50 mg BD T. Zinc 50 mg BD T. Zinc 50 mg BD
C. Omeprazole 20 mg BD C. Omeprazole 20 mg BD Inj. Pantoprazole 40 mg IV
OD
Fluids Adequate Hydration - Oral Adequate Hydration - NS Conservative Fluids
HCQ T. HCQ (In high risk patients T. HCQ (In high risk -
(Not prescribed routinely) – DM / HT / CVA / CKD / patients – DM / HT / CVA /
CLD / Obesity / Age > 60 CKD / CLD / Obesity / Age
yrs) Day 1 - 400 mg BD > 60 yrs) Day 1 - 400 mg
Followed by 400 mg OD x 4 BD
Days Followed by 400 mg OD x 4
(avoid in cardiac disease or Days
if QTc > 480 ms) – MOHFW (avoid in cardiac disease or
Guidelines if QTc > 480 ms) – MOHFW
Guidelines
Antibiotics T. Azithromycin 500 mg OD T. Azithromycin 500 mg T. Azithromycin 500 mg
x 5 Days (or) OD x 5 Days OD x 5 Days
T. AmoxClav 625 BD if T. + +
Azithromycin is Inj. Ceftriaxone 1 gm IV BD Inj. Piptaz 4.5 mg/ Inj
Contraindicated and Elderly if secondary bacterial meropenam 500mg IV TDS
> 60 yrs. infection suspected if secondary bacterial
infection suspected
Anticoagulation - Inj. Enoxaparin 40 mg SC Inj. Enoxaparin 40 mg SC
OD x 5 Days (can be BD x 5 Days (can be
started as prophylactic started as prophylactic
without D DIMER) without D DIMER)
(Contraindicated in ESRD, (Contraindicated in ESRD,
active bleeding, active bleeding,
emergency surgery, emergency surgery,
platelets < 20,000/mm3, platelets < 20,000/mm3,
BP > 200/120) Inj. BP > 200/120) Inj.
Dalteparin 2500 IU SC OD Dalteparin 5000 IU SC OD
×5 days × 5 day In ESRD, UH –
In ESRD, UH – 5000U SC 5000U SC BD can be used
BD can be used
Steroids - Inj. Dexamethasone 0.1 – Inj. Dexamethasone 0.2 –
0.2 mg /kg ≈ 6 mg IV OD x 0.4 mg /kg ≈ 6 mg IV BD x
5 Days 10 Days
or or
inj. Methyl Prednisolone inj. Methyl Prednisolone
0.5 -1 mg/kg ≈ 60mg x 5 1.0 -2.0 mg/kg ≈ 80 mg x
Days 10 Days
Oxygen Support Not Required Maintain Target SPo2 of Maintain Target SPo2
92 to 96 % > 90 %
Nasal Prongs (4 lit / min) NRM (10 -15 lit / min)
↓ ↓
Face Mask (5-10 lit / min) HFNC (10 - 60 lit / min)
↓ ↓
NRM (10 -15 lit / min) CPAP (TV 6ml/kg; PEEP 5-
↓ 15 cm H20; Target PP 30
HFNC (10 - 40 lit / min) cm H20)
↓ ↓
CPAP (TV 6ml/kg; PEEP 5- MV (ARDS Protocol)
15 cm H20; Target PP 30
cm H20)
Proning - Awake Proning (if > 4 L / Prone Ventilation
min) 16 to 18 hrs / Day
- 30 to 120 mins prone
- 30 to 120 mins left lateral
- 30 to 120 mins right
lateral
- 30 to 120 mins upright
– Contraindicated in
altered mental status and
hemodynamic instability,
pregnancy
Cytokine Storm - Inj. Toculizumab 400 mg -
(max 800 mg) slow IV in
100 ml NS over 1 Hour
Repeat Dose after 12
hours if needed
Contra Indications – Active
Infections, TB, Hepatitis,
Platelets < 1L/mm3, ANC <
2000/mm3
COMORBIDITY AND COMPLICATIONS
Comorbidity Treat Appropriately Treat Appropriately Treat Appropriately
CAD, HT, DM, Hypothyroid,
Epilepsy
Complications Treat Appropriately Treat Appropriately Treat Appropriately
Septic Shock
AKI, MODS
Delirium
Electrolytes
ECG-abnormalities
Stress Ulcers
Liver Dysfunction
Trial Therapies
1 - Inj. Remdesivir -
200mg IV OD on Day 1 and
100 mg IV OD x 4 Days
Contraindication – Liver
Dysfunction/ CKD /
Pregnancy / Lactation /
Children
DI – avoid HCQ, Dexa use
Methyl Prednisolone
2 - Convalescent Plasma -
200 ml slow IV
Single Dose
3 - (Lopinavir 400 mg + -
Ritonavir 100 mg) Twice
Daily x 14 Days
Suspended by WHO wef
4.7.20.
4 - (Lopinavir 400 mg + -
Ritonavir 100 mg) Twice
Daily x 14 Days
+
Interferon Beta 8 Million
IU on Alternate Days x 3
Doses
MONITORING
BP / HR Daily 6th Hourly 4th Hourly
RR / WOB /spO2 6th Hourly 2nd Hourly Continuously
CBC / NLR / RFT / LFT Baseline Every 2 Days Daily
COVID Profile Baseline Once every 4 days Once every 2 days
D Dimer Repeated 4th day Once every 4 days Once every 2 days
ECG Baseline Once every 2 days Daily
ABG - - Daily
X Ray - If Clinical Deterioration
DISCHARGE CRITERIA
Afebrile > 3 Days without Afebrile > 3 Days without Afebrile > 3 Days without
antipyretics antipyretics antipyretics
+ + +
No Breathlessnes No Breathlessnes No Breathlessnes
10 Days from Symptom 10 Days from Symptom Clinical Recovery
Onset Onset
- No O2 Requirement for 3
Days
Acknowledgements
W.H.O., C.D.C., Government of India, Ministry of Health & Family Welfare, ICMR, IMA, FOGSI.
CORONA UPDATE - 7
WHAT KILLS CORONA VIRUS ?
Compiled by: Dr. Keshav Malhotra, Dr. Narendra Malhotra, Dr. Jaideep Malhotra, Dr. Neharika Malhotra
Inputs by :
Dr. R. L. Sharma, Mr. Glydin George, Mr. APS Chadda
This SARS-COV-2 pandemic has affected almost all the countries of the world (only a few 10-12 have not reported
any case) over 7 million people are infected and 0.5 million dead.
Never has the world been under attack of a height infectious contaigen. This has left every one wondering and WHO,
CDC, infection control agencies, scientists all trying to find out the best disinfectants against COVID 19 (SARS-COV-2).
Various studies have shown that SARS-COV can persist on surfaces upto 96hrs and retain infectively for as long as 6
days (upto 9 days). It has a strong survival and only after 9 days does SARS-COV-2 loose its infectivity.
WHO and other agencies have advocated use of standard and also virucidal disinfectants to sanitize and sterilize
potential infective sources.
Disinfections
DISINFECTION
Disinfectants to be used during COVID-19 pandemic
[Fig-2]
• Alcohol (70% isopropyl or 70% ethyl alcohol) can be used on metal surfaces.
[Fig-3]
• Automated high-level disinfection can be done by UV radiation type C, codex and matricide solutions.
[Fig-4]
High touch surfaces like doorknobs, telephone, call bells, bedrails, stair rails, light switches, should be cleaned every
3 - 4 hrs.
Low touches surfaces like walls, mirror and should be mopped daily once.
Office spaces, including conference rooms should be cleaned every evening after office hours or early in the morning
before the rooms are occupied. If contact surface is visibly dirty, it should be cleaned with soap and water prior to
disinfection. Prior to cleaning, the worker should wear disposable rubber boots, gloves (heavy duty), and a triple
layer mask.
• Start cleaning from cleaner areas and proceed towards dirtier areas.
• All indoor areas such as entrance lobbies, corridors and staircases, escalators, elevators, security guard
booths, office rooms, meeting rooms, cafeteria should be mopped with a disinfectant with 1% sodium
hypochlorite or phenolic disinfectants. The guidelines for
[Fig-5]
• High contact surfaces such elevator buttons, handrails / handles and call buttons, escalator handrails, public
counters, intercom systems, equipment like telephone, printers/scanners, and other office machines should
be cleaned twice daily by mopping with a linen/absorbable cloth soaked in 1% sodium hypochlorite.
Frequently touched areas like table tops, chair handles, pens, diary files, keyboards, mouse, mouse pad,
tea/coffee dispensing machines etc. should specially be cleaned.
• For metallic surfaces like door handles, security locks, keys etc. 70% alcohol can be used to wipe down
surfaces where the use of bleach is not suitable.
• Hand sanitizing stations should be installed in office premises (especially at the entry) and near high contact
surfaces.
• Carefully clean the equipment used in cleaning at the end of the cleaning process.
• Remove PPE, discard in a disposable PPE in yellow disposable bag and wash hands with soap and water.
In addition, all employees should consider cleaning the work area in front of them with a disinfecting wipe
prior to use and sit one seat further away from others, if possible
70% Alcohol can be used to wipe down surfaces where the use of bleach is not suitable, e.g. metal. (Chloroxylenol
(4.5-5.5%) / Benzalkonium Chloride or any other disinfectants found to be effective against coronavirus may be used
as per manufacturer’s instructions)
• Do not use disinfectants spray on potentially highly contaminated areas (such as toilet bowl or surrounding
surfaces) as it may create splashes which can further spread the virus.
• To prevent cross contamination, discard cleaning material made of cloth (mop and wiping cloth) in
appropriate bags after cleaning and disinfecting. Wear new pair of gloves and fasten the bag.
• Disinfect all cleaning equipment after use and before using in other area
Personal Protective Equipment (PPE): Wear appropriate PPE which would include the following while carrying out
cleaning and disinfection work.
• Wear disposable rubber boots, gloves (heavy duty), and a triple layer mask
• Gloves should be removed and discarded damaged, and a new pair worn.
• All disposable PPE should be removed and discarded after cleaning activities are completed.
• Hands should be washed with soap and water immediately after each piece of PPE is removed, following
completion of cleaning.
• Close off areas visited by the ill persons. Open outside doors and windows and use ventilating fans to
increase air circulation in the area. Wait 24 hours or as long as practical before beginning cleaning and
disinfection.
• Cleaning staff should clean and disinfect all areas such as offices, bathrooms, common areas, shared
electronic equipment (like tablets, touch screens, keyboards, remote controls, and ATM machines) used
by the ill persons, focusing especially on frequently touched surfaces.
If it has been more than 7 days since the person with suspected/confirmed COVID-19 visited or used the facility,
additional cleaning and disinfection is not necessary.
[Fig-6]
SOFT (POROUS) SURFACES
For soft (porous) surfaces such as carpeted floor, rugs, and drapes, remove visible contamination if present and
clean with appropriate cleaners indicated for use on these surfaces. After cleaning:
• If the items can be laundered, launder items in accordance with the manufacturer’s instructions using the
warmest appropriate water setting for the items and then dry items completely.
• Otherwise, use products that are EPA-approved for use against the virus that causes COVID-19external
icon and that are suitable for porous surfaces
[Fig-7]
ELECTRONICS
For electronics such as tablets, touch screens, keyboards, remote controls, and ATM machines, remove visible
contamination if present.
• Follow the manufacturer’s instructions for all cleaning and disinfection products.
• Consider use of wipeable covers for electronics.
• If no manufacturer guidance is available, consider the use of alcohol-based wipes or sprays containing at
least 70% alcohol to disinfect touch screens. Dry surfaces thoroughly to avoid pooling of liquids.
The risk of exposure to cleaning staff is inherently low. Cleaning staff should wear disposable gloves and gowns for
all tasks in the cleaning process, including handling trash.
MODES OF SANITIZER
1. Hand washing
[Fig-8]
2. Deep Moping
[Fig-12]
4. Sanitizer Tunnel
[Fig-13]
5. Sanitizer Fan
[Fig-14]
FURTHER READINGS
1. WHO guidelines
2. CDC guidelines
3. IC guidelines
4. MOHFW India guidelines
5. ICMR guidelines
Acknowledgements
W.H.O., C.D.C., Government of India, Ministry of Health & Family Welfare, ICMR, IMA, FOGSI.
CORONA UPDATE 8
With inputs from
Dr KK Aggarwal
Compiled by Dr. Narendra Malhotra, Dr. Neharika Malhotra, Dr. Jaideep Malhotra, Dr. Keshav Malhotra
Global Rainbow Healthcare, Agra
Doubling Time
Date Daily new cases New Deaths Total cases Total Deaths
5th August 56626 919 1963239 40739
4th August 51282 849 1906613 39820
3rd August 50629 810 1855331 38971
2nd August 52783 758 1804702 38783
1st August 54865 852 1751919 37403
30th July 57704 765 1697054 36551
29th July 54966 783 1639350 35786
28th July 49632 776 1532135 34224
27th July 49632 776 1532135 34224
26th July 50525 716 1436019 32812
25th July 48472 690 1385494 32096
24th July 48892 761 1337022 31406
23rd July 48446 755 1288130 30645
22nd July 45599 1120 1239684 29890
21st July 39168 671 1194085 28770
20th July 36810 596 1154917 28099
19th July 40243 675 1118107 27503
18th July 37407 543 1077864 26828
17th July 34820 676 1040457 26285
16th July 35468 680 1005637 25609
15th July 32682 614 970169 24929
14th July 29842 588 937487 24315
13th July 28179 540 907645 23727
12th July 29108 500 879446 23187
11th July 27755 543 850358 22687
10th July 27761 521 822603 22144
9th July 25790 479 794842 21623
India predictions
1. Death Rate is deaths today vs number of cases today
2. Corrected Death Rate is deaths today vs number of cases 14 days back
3. For one symptomatic test positive case there are 10-30 asymptomatic cases and 20 untested cases
4. Estimated Number of deaths = Reported deaths x 2
5. Number of deaths today should be 15% of the serious patients present 14 days back
6. Undocumented cases for each documented case [Iceland: 1: 2; German: 1: 5; New York City grocery
store shoppers: 1: 10; California 1.5%]
7. Amongst active 2.37% are serious, 1.82% need oxygen, and 0.41% need ventilator support.
Facts
1. India: In states with average population density of 1185 /sk km the average number of cases were 2048. On
the contrary in states with population density of 909/ sk km the number of cases were 56. (When Chandigarh
and Pondicherry were taken out from this group) the Average Density of other states were 217 and the
average number of cases were 35 [HCFI]
2. COVID Sutras: It’s a COVID-19 Pandemic due to SARS 2 Beta Corona Viruses (different from SARS 1 where
spread was only in serious cases); with over eleven virus sequences floating; has affected up to 22.8% of Delhi
population, Causes Mild or Atypical Illness in 82%, Moderate to Severe Illness in 15%, Critical Illness in 3% and
Death in 2.3% cases (15% of admitted serious cases, 71% with comorbidity< Male > Females); affects all ages
but Predominantly Males (56%, 87% aged 30-79, 10% Aged < 20, 3% aged > 80); with Variable Incubation
Period days (2-14; mean 5.2 days); Mean Time to Symptoms 5 days; Mean Time to Pneumonia 9 days, Mean
Time to Death 14 days, Mean Time to CT changes 4 Days, Reproductive Number R0 1.5 to 3 (Flu 1.2 and SARS
2), Epidemic Doubling Time 7.5 days; Origin Possibly from Bats (Mammal); Spreads via Human to Human
Transmission via Large and Small Droplets and Surface to Human Transmission via Viruses on Surfaces for up
to three days. Enters through MM of eyes, nose or mouth and the spike protein gets attached to the ACE2
receptors. ACE2 receptors make a great target because they are found in organs throughout our bodies (heart
muscle, CNS, kidneys, blood vessels, liver) Once the virus enters, it turns the cell into a factory, making millions
and millions of copies of itself — which can then be breathed or coughed out to infect others.
3. Prevalence: New York: 13.9%; New York City at 21.2%, S Korea 5.7%, world 5%; Ohio prison: 73% of inmates;
New York: 21% mortality April 22 in JAMA.
4. Viral particles seen in tears, stool, kidneys, liver, pancreas, heart, semen, peritoneal fluid, CSF.
5. Thrombosis: University of Pennsylvania clots are seen in patients even on blood thinners. Netherlands study,
31%
6. Other human beta-coronaviruses has immunity lasting only for one year with no IMMUNITY PASSPORT.
7. In absence of interventions, prolonged or intermittent social distancing (till 2022-24)
2. Low levels of cross immunity from the other beta-coronaviruses against SARS-CoV-2 could make SARS-CoV-2
appear to die out, only to resurge after a few years. Surveillance till 2024.
3. During peak (trace and treat) and after the peak (trace and treat the close contacts
4. Increased spread: close environment, crowded place with close physical contacts with no ventilation
5. Strategies: From community mitigation to individual containment; broader good over individual autonomy;
perfect cannot be the enemy of the good; pandemics are fought on the grounds and not the hospitals., Treat
the patient and not the test report, Consider every surface and every asymptomatic person as virus carrier
6. HCW: Direct patient exposure time < 30 minutes; 7 days work and 7 days holidays.
7. Italy mortality reduced when they were short of ventilators.
8. Hospital at HOME: CHF, mild pneumonia, exacerbations of asthma and COPD, cellulitis, and urinary tract
infections.
9. Great Imitator (protean manifestation).
10. IgM can be false positive in pregnancy, immunological diseases; Pooled tests (< 5, 20 Kerala, 64 Singapore
RTPCR) when seroprevalence is < 2%.
11. Early treatment, day 3-5, to reduce the viral load and prevent cytokine storm using hydroxychloroquine with
azithromycin or ivermectin with doxycycline with IV remdesivir and IV single dose Tocilizumab interleukin (IL-6
receptor inhibitor) if very high D-dimer and IL-6; convalescent plasma therapy (given early; donor 14 days
symptoms free, between day 28-40, single donation can help 4 patients), Lopinavir-ritonavir and Favipiravir if
very low CD 4 counts.
12. Hypoxia: Low flow oxygen < 6l/mt, titrated to high flow oxygen using non rebreathing mask, Venturi mask,
HFNC and helmet CPAP, NIV in supine or prone position.
13. Early intubation with prone ventilation only if progressive. Hypoxia (walking dead) have capillary problem
and not alveoli.
14. Formulas: Deaths in symptomatic cases 1%; Deaths X 100= expected number of symptomatic cases; Cases
after seven days: Cases today x 2 (doubling time 7 days); Cases expected in the community: Number of deaths
occurring in a five-day period and estimate the number of infections required to generate these deaths based
on a 6.91% case fatality rate; Compare that to the number of new cases actually detected in the five-day
period. This can then give us an estimate of the total number of cases, confirmed and unconfirmed; Lock down
effect = Reduction in cases after average incubation period (5 days); Lock down effect in reduction in deaths:
On day 14 (time to death); Requirement of ventilators on day 9: 3% of number of new cases
detected; Requirement of future oxygen on day seven: 15% of total cases detected today; Number of people
which can be managed at home care: 80% of number of cases today; Requirement of ventilators: 3% of
Number of cases today; Requirement of oxygen beds today: 15% of total cases today.
Venturing out into a public setting? What to consider before you go.
As communities and businesses across the United States are opening, you may be thinking about resuming some
activities, running errands, and attending events and gatherings. There is no way to ensure you have zero risk of
infection, so it is important to understand the risks and know how to be as safe as possible.
People who are pregnant, and those who live with them, should consider their level of risk before deciding to go out
and ensure they are taking steps to protect themselves and others. Consider avoiding activities where taking
protective measures may be difficult, such as activities where social distancing can’t be maintained. Everyone should
take steps to prevent getting and spreading COVID-19 to protect themselves, their communities, and people who
are at increased risk of severe illness.
In general, the more people you interact with, the more closely you interact with them, and the longer that
interaction, the higher your risk of getting and spreading COVID-19.
If you decide to engage in public activities, continue to protect yourself by practicing everyday preventive
actions.
Keep these items on hand and use them when venturing out: a cloth face covering, tissues, and a hand
sanitizer with at least 60% alcohol, if possible.
If possible, avoid others who are not wearing cloth face coverings or ask others around you to wear cloth
face coverings.
Every one has to understand, that corona is here to stay and simple measures of S.M.S. (Social distancing, Masks &
Sanitizing) have to be followed to be safe.
Humans all over the world have to wakeup to fight this long term war against CORONA and its time to change our
behavior and life style to a NEW NORMAL.
Acknowledgements
W.H.O., C.D.C., Government of India, Ministry of Health & Family Welfare, ICMR, IMA, FOGSI.
CORONA UPDATE - 9
COVID-19 AND PREGNANCY CONSIDERATIONS
Compiled by Dr. Neharika Malhotra, Dr. Narendra Malhotra, Dr. Jaideep Malhotra, Dr. Keshav Malhotra
Dr. Manpreet Sharma, Dr. Shemi Bansal, Dr. Sarita Dixit
Global Rainbow Healthcare, Agra
Based on what we know at this time, pregnant women might be at increased risk for severe illness from COVID-19
compared to non-pregnant women. Additionally, there may be an increased risk of adverse pregnancy outcomes,
such as preterm birth, among pregnant women with COVID-19.
Take precautions to prevent getting COVID-19 when you do interact with others.
Make sure that you have at least a 30-day supply of your medicines and a reliable shop which can deliver.
Talk to your healthcare provider about how to stay healthy and take care of yourself during this COVID-19
pandemic. (Helplines)
(Govt. COVID helpline 011-23978046 or 1075)
Rainbow Hospital Helpline: +91 81910 22444, 0562-2600531-538
(Dr. Pankaj Bhatia: +91 94128 95978, Dr. Vishwa Deepak: +91 99588 82595, Dr. Shubham Jain: +91 70423 57955,
In case of Pregnancy - Dr. Manpreet Sharma : +91 93191 02069, Dr. Shemi Bansal : +91 98976 37828,
Dr. Sarita Dixit : +91 96109 62978)
If you don’t have a healthcare provider, contact your nearest community health center or health department
or your doctor (Video conferencing helps).
Call your healthcare provider if you have any questions related to your health. (Consult IMumz pregnancy
care app).
Seek care immediately if you have a medical emergency.
You may feel increased stress during this pandemic. Fear and anxiety can be overwhelming and cause strong
emotions. Learn about stress and coping. (IMumz, Digital support groups, helplines).
Learn more about how to reduce your risk of getting COVID-19.
Download Arogya-Setu app (https://play.google.com/store/apps/details?id=nic.goi.aarogyasetu&hl=en_IN)
Plastic face shields for newborns and infants are NOT recommended. There are no
data supporting the use of infant face shields for protection against COVID-19 or other
respiratory illnesses. An infant face shield could increase the risk of sudden infant
death syndrome (SIDS) or accidental suffocation and strangulation. Infants, including
newborns, move frequently, which could increase the possibility of their nose and
mouth becoming blocked by the plastic face shield or foam components. The baby’s
movement could also cause the face shield to become displaced, resulting in
strangulation from the strap.
Cloth face coverings for children, parents, and other caregivers
CDC recommends that everyone 2 years and older wear a cloth face covering that covers their nose and mouth when
they are out in the community. Because of the danger of suffocation,
do NOT put cloth face coverings on babies or children younger than 2
years. Cloth face coverings should also not be worn by anyone who has
trouble breathing, is unconscious, can’t move, or is otherwise unable to
remove the face covering without assistance.
Parents and other caregivers should keep in mind that wearing a cloth
face covering is not a substitute for social distancing, frequent hand
washing, or other everyday preventive actions – please wear your cloth
face covering in addition to practicing other prevention steps. A cloth
face covering is not intended to protect you, the wearer, but it may
prevent you from spreading the virus to others. This would be especially
important if you are infected but do not have symptoms of COVID-19.
Please remember that medical face masks and N95 respirators are
reserved for healthcare personnel and other first responders.
Newborn visits. Ideally, newborn visits should be done in person so that your pediatric healthcare provider can
check your baby’s growth and feeding, check your baby for jaundice, make sure your baby’s newborn screening tests
were done, and get any repeat or follow-up testing, if necessary. At the newborn visit, your pediatric healthcare
provider will also check how you and your baby are doing overall. Newborn screening tests include a bloodspot,
hearing test, and test for critical congenital heart defects. Learn more about newborn screening tests.
Well child visits. Your pediatric healthcare provider will check your child’s development at well child visits. You can
track your child’s developmental milestones with CDC’s free Milestone Tracker app.
Vaccine visits. Vaccines are an important part of keeping your child healthy, especially if your child is under 2 years
old. Vaccines help provide immunity before being exposed to potentially life-threatening diseases. Although there is
not yet a vaccine to help protect against COVID-19, vaccines for illnesses such as measles, influenza (flu), whooping
cough (pertussis), and other infectious diseases are important for your child’s health. This will help to prevent
outbreaks of vaccine-preventable diseases among young children during the COVID-19 pandemic.
Ask your healthcare provider how they are taking steps to separate healthy patients from those who may be sick.
Some health care providers may choose to delay visits like well-child checks and routine vaccine visits. These
decisions will be based on circumstances in your community and your child’s individual care plan. Call your
provider’s office to ask about any upcoming appointments or about when your child’s vaccinations are due.
Coping with stress
Pandemics can be stressful for everyone. Fear and anxiety about
a disease can be overwhelming and cause strong emotions in
both adults and children. Coping successfully with stress will
make you, the people you care about, and your community
stronger.
Talk with your children about the pandemic. It is important to try
to stay calm and to give children information that is truthful and
appropriate for their ages and developmental levels. Children
respond differently to stressful situations than adults. CDC offers
resources to help you talk with your children about COVID-19.
Depression during and after pregnancy is common and can be
treated. Postpartum depression is depression that can happen
after having a baby. If you think you may be experiencing
depression, seek treatment from your health care provider as
soon as possible. Find more information on depression during
and after pregnancy.
Acknowledgements
W.H.O., C.D.C., Government of India, Ministry of Health & Family Welfare, ICMR, IMA, FOGSI, Imumz app.
CORONA UPDATE 10
WHEN WILL CORONA GO?
Compiled by Dr. Narendra Malhotra, Dr. Jaideep Malhotra, Dr. Neharika Malhotra, Dr. Keshav Malhotra
Global Rainbow Healthcare, Agra
COVID 19 or SARS-CoV-2 may never go away even with a vaccine. This disease is
likely to remain with human kind for years to come and will eventually become
endemic like many others viral diseases (Measles, Chickenpox, HIV etc). Also it now
is less likely that this virus will have seasonal outbreaks, as the last 6 months have
shown corona to survive in extremes of weather all over the world. It is also
becoming clearer that the disease is not going to vanish completely with HERD
immunity and is going to come back repeatedly may be ever 3-4 months or just
remain throughout the year. It is also becoming clearer that getting once infected
does not make you immune forever as reports of reinfection are surfacing.
At this point, how long immunity to COVID-19 will last is unclear; the virus simply
hasn’t been infecting humans long enough for us to know. But related coronaviruses are reasonable points of
comparison: In SARS, antibodies—which are one component of immunity—wane after two years. Antibodies to a
handful of other coronaviruses that cause common colds fade in just a year. “The faster protection goes away, the
more difficult for any project to try to move toward eradication,”
The virus is here to stay! So the question is, How do humans live safely with it? This needs a huge political will,
sustained efforts from all world countries towards improving healthcare facilities and caution towards complete
unlocking. Countries are already showing “Response fatigue”.
All of us are under tremendous economic pressure to open up, not understanding the gravity of the second or third
waves of the disease lurking around the corner. We all are asking:- tell us one thing we have to do ? Well there is no
one thing or a quick fix solution. The hope that vaccine will be an all out solution to this infection may not hold true.
In the past only smallpox has been eradicated by a vaccine, while all other viral diseases are still endemic despite the
vaccines (Measles, Mumps rubella, chickenpox, dengue, influenza etc). Four novel corona virus diseases are already
existing in our world as common colds and probably SARS-CoV-2 may be the fifth one which we have to live with.
The coronavirus is simply too widespread and too transmissible. The most likely scenario, experts say, is that the
pandemic ends at some point—because enough people have been either infected or vaccinated—but the virus
continues to circulate in lower levels around the globe. Cases will wax and wane over time. Outbreaks will pop up
here and there.
All the potential vaccines being developed are under phase III trials and expected to be commercially available by
end of this year. Please note the vaccine trials have been all fast tracked and still the long term beneficial and
harmful effects need to be documented. Yes vaccination is an answer but the requirement is billions of doses – how
many years it will take to all population reach the un-affording is a challenge. Even when a much-anticipated vaccine
arrives, it is likely to only suppress but never completely eradicate the virus. (For context, consider that vaccines exist
for more than a dozen human viruses but only one, smallpox, has ever been eradicated from the planet, and that
took 15 years of immense global coordination and vaccinating each & every child.) In the best-case scenario, a
vaccine and better treatments blunt COVID-19’s severity, making it a much less dangerous and less disruptive
disease. Over time, SARS-CoV-2 becomes just another seasonal respiratory virus, like the four other coronaviruses
that cause a sizable proportion of common colds: 229E, OC43, NL63, and HKU1. These cold coronaviruses are so
common that we have likely all had them at some point, maybe even multiple times. They can cause serious
outbreaks, especially in the elderly, but are usually mild enough to fly under the radar. One endgame is that SARS-
CoV-2 becomes the fifth coronavirus that regularly circulates among humans. Till then follow simple precaution as
S.M.S. We will probably be living with this virus for the rest of our lives.
So the numero one step we all have to take is to understand that
CORONA virus is here to stay and it is contagious infection and it
can make us very sick and also kill us.
To prevent every one getting sick, simple long term efforts have to
be made like social distancing (1.8- 2mts), Mask & sanitizing
(washing hands) [S.M.S.].
Looking at the human nature, people will not shift towards simple
long range thinking unless someone they know closely gets
infected and very sick.
A gross neglect of these 3 simple measures is being seen all over the world with unlocking. Even the educated,
advanced nation’s people are not listening to repeated appeals by W.H.O., and there seems to be a lack of strong
political statements in favour of Mask & Social distancing. All countries should make these mandatory.
One by one there are three basic points:
1. Keep a distance between people
2. Wear a mask
3. Wash hands frequently
CORONA FACTS and MYTHs with COVID from all over the world
Kim Jong-un, North Korea’s leader, placed Kaesong City, near the country’s border with the South, under
lockdown and declared a national emergency after acknowledging that his country might have its first case
of the coronavirus. A North Korean who defected to South Korea three years ago but secretly crossed back
into Kaesong City last week was “suspected to have been infected with the vicious virus,” the North’s official
Korean Central News Agency said on Sunday. Until now, North Korea, one of the world’s most isolated
countries, has said that it has no cases of Covid-19, although outside experts have questioned the claim.
Vietnam, which had gone 100 days without a case of locally transmitted coronavirus, said on Saturday that a
57-year-old man in the central city of Danang had tested positive for the virus. A second man has since
tested positive. How they were infected remained a mystery. Vietnam, will evacuate tens of thousands of
tourists from Danang after four residents there tested positive this weekend.
President Jair Bolsonaro of Brazil said on Saturday that he no longer had the coronavirus, appearing to have
experienced only mild symptoms from a scourge he has repeatedly downplayed. More than 86,000 people in
Brazil have died from the virus.
Australia on Sunday reported its highest one-day death toll — 10 people, all in the state of Victoria.
France will do COVOD 19 testing free for all
Biocon suffered a setback on Sunday with the Union health ministry announcing that the firm’s itolizumab
drug has not been included in national treatment protocol for Covid-19 patients. Less than two weeks ago,
the Drug Controller General of India had given permission for the drug’s use on moderate to severe
coronavirus patients, leading to a surge in the company’s share price.
Hong Kong is shutting down all dine-in restaurant service and limiting public gatherings to two people after it
recorded more than 100 new cases for the sixth day in a row.
President Trump’s national security adviser, Robert O’Brien, has tested positive for the coronavirus, making
him the most senior White House official known to have contracted the virus.
Japan takes masks to a new level: In Japan, where masks were widespread even before the pandemic,
there has been a big push to innovate. Inventors have dreamed up masks with motorized air purifiers,
Bluetooth speakers and even sanitizers that kill germs. In South Korea, the electronics giant LG has created a
mask powered with fans that make it easier to breathe. One company is trying to build a mask with a
translator. Masks were first used in epidemics in the early 20th century, when Wu Lien-teh, a doctor of
Chinese descent, began promoting simple gauze masks to battle an outbreak of pneumonic plague. During
the 1918 flu, the practice went global.
Perinatal transmission of COVID-19 unlikely if precautions taken: Mothers positive for severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) at delivery are unlikely to transmit the infection to their
infants during the perinatal period provided proper precautions are undertaken, a study in The Lancet Child
& Adolescent Health has found. "This is the largest cohort of neonates born to mothers positive for SARS-
CoV-2 at the time of delivery, with prospective follow-up up to 1 month of life," Christine M Salvatore,
Departments of Pediatrics, Weill Cornell Medicine, New York Presbyterian—Komansky Children's Hospital,
New York, NY, and colleagues noted.
Japan has decided to coexist with the new coronavirus!
Announced the "new life model", calling the people to be prepared to follow this model for an extended
period of time and learn to live and work with the virus lurking around the corner.
Looking closely at these new life models, it can be seen that the Japanese government established these very
practical set of SOPs using principles of rationality, science, and risk assessment.
Maybe it is related to the Japanese understanding that "bad" things can't be forsaken for all times. Using
risk assessment models in principle, humans can continue to live well.
The Japanese are genetically a very disciplined nation and they do things and follow instructions
scrupulously.
Shigeru Oo, chairman of the Japanese government committee, said that it takes at least one and a half years
for the vaccine to be fully developed and officially put into use.
In fact, most of the above methods have been implemented in China. Many Indians have also changed their behavior
with the changing scenario, but we are observing impatience in people and most have started ignoring these
measures. We are also scared that “response fatigue” will set in, in the coming months and the Government &
Healthcare agencies and administration will become slack in their efforts.
Wakeup humankind to face this difficult challenge of living with an enemy which we can’t see and against which we
have no current effective specific treatment.
The coronavirus that causes COVID-19 has sickened more than 20 million people across six continents. It is raging in
countries that never contained the virus. It is resurging in many of the ones that did. If there was ever a time when
this coronavirus could be contained, it has probably passed. One outcome is now looking almost certain: This virus is
never going away.
Even if the virus were somehow eliminated from the human population, it could keep circulating in animals—and
spread to humans again. SARS-CoV-2 likely originated as a bat virus, with a still-unidentified animal perhaps serving
as an intermediate host, which could continue to be a reservoir for the virus. (SARS also originated in bats, with
catlike palm civets serving as an intermediate host—which led officials to order the culling of thousands of
civets.) Timothy Sheahan, a virologist at the University of North Carolina at Chapel Hill, wonders if, with SARS-CoV-2
so widespread across the globe, humans might be infecting new species and creating new animal reservoirs. “How
do you begin to know the extent of virus spread outside of the human population and in wild and domestic
animals?” he says. So far, tigers at the Bronx Zoo and minks on Dutch farms seem to have caught COVID-19 from
humans and, in the case of the minks, passed the virus back to humans who work on the farm.
Everyone understands that it is a long-term war; it is worth changing our behavior and lifestyle.
CORONA is going to stay, let’s learn to live with it and be SAFE.
Acknowledgements
W.H.O., C.D.C., Government of India, Ministry of Health & Family Welfare, ICMR, IMA, FOGSI.
CORONA UPDATE 11
TESTING FOR CORONA VIRUS
Compiled by Dr. Narendra Malhotra
Corona is here to stay and it is predicted that over 70% of population will get the infection (fortunately not
all will fall sick or very sick). (Recovery rate of over 74% & Death rate around 2%).
A lot of confusion exists regarding testing for covid and what test to do, when and how to interpret these
tests.
For any disease the attack virus or the contagion is called “ANTIGEN” and when this “antigen” enters our
body, our body defenses (known as ANTIBODIES) try and kills the contagion. Our body has general
antibodies present which are known as our “IMMUNITY”.
If the general antibodies are not able to kill the ANTIGEN or it’s a new antigen our body defense
mechanism is activated and our body produces specific ANTIBODY IgM & IgG and Cytokines against the
attacking CONTAGION. This takes some time (7 days for IgM) and then 14 days for IgG. These antibodies
remain in plasma and prevent further attack by that CONTAGION. These antibodies last from some months
to years & some cases forever. This is how vaccines work. In a vaccine there is a dead or inactive (Live
attenuated contagion) which is injected and this produces antibodies against that disease. Vaccination has
eradicated small pox and polio and has saved many children from TB, Mumps, Rubella, Measles, Rota virus,
Encephalitis, Hepatitis, Chicken pox (There are some the diseases against which a vaccine is available).
Very soon we will have a vaccine against CORONA (SARS-COV-2/ COVID 19) like we have for influenza
(H1N1 flu – INFLUVAC-TETRA vaccine).
CORONA Tests- lets understand corona infection (ANTIGEN & ANTIBODY)(Fig 1)
[Fig 1]
Following tests are available for Corona virus detection (Antigen & Antibody)
The sample for Corona virus test can be taken as-
a. Swab Test (from nose & throat)
b. Nasal aspirate (saline solution in nose & suction)
c. Tracheal aspirate – by bronchoscope from inside lungs
d. Sputum test – cough out sputum from lungs
e. Blood test – venous blood
f. New – from saliva (still experimental stage)
These samples can be tested for the presence of virus RNA(Antigen) (contagion) and from blood we can
also test for presence of Antibody.
Tests-
a. Viral – Antigen Test – This test tells if person is suffering from current infection. Positive report
indicates Corona infection negative report signifies person is not infected at time of testing.
High specificity but limited sensitivity especially by Rapid antigen test. (Fig 2)
b. Antibody test (IgG evaluation) tells us Total Antibody. Test is possible and should be more than the
normal value which indicates that the person has had antigen. In persons if CPR & ESR are not
increased, increase the immunity is developed less. (Antibody develop less if infection is mild)(Fig 2).
c. Other tests for severity of infection and for monitoring the disease(Fig 3).
[Fig 2]
[Fig 3]
COMMUNITY TESTING
To test in the community we can do a community RTPCR test in groups of asymptomatic cohorts to pick up
corona infection. If cohort test comes positive, then all are tested.
Also in community serosenstivity testing (Antibody Test) can be applied to pickup herd immunity in
community.
CONCLUSION
We hope we have clarified a few facts about tests which are available and what the indication for which
test.
Until we have an effective vaccine to be used for masses, kindly take simple precautions of sanitizing –
masks – social distancing.
Be Safe !
Further reading guidelines of WHO, CDC, FDA, ICMR, IMA & FOGSI
Brought to you for public awareness by Rotary Club Agra Taj City.
CORONA UPDATE 12
COVID SO WHAT ?
Compiled by Dr. Narendra Malhotra
It is now clear that Corona virus is here to stay with us for a long-long time and recent seropositiveness
studies in Delhi and Pune have shown antibodies in almost 29% of surveyed population – this shows that
most of us have caught the infection and a ‘HERD’ immunity seems to be developing.
The statics of corona as on 24th August in India is-
World Covid Meter 24rd August (Courtesy Prof. K.K. Agarwal)
Acute manageable immuno-thrombo- inflammatory viral disease with post virus phase
213 Countries
Cases:1M: April 2, 2 M April 15, 3 M: April 27, 4 M May 8; 5 M 20 May, 6 M 30 th May, 7 M 7th June, 8M by 15 June, 9
M 22nd June, 10 M 29th June. 11 M 4th July, 16 M , 17 M 29 July, 18 M ist August, 21 .8 M 16 August
Ground Zero: Wuhan in live animal market or cafeteria for animal pathogens: 10th January; Total cases are
based on RT PCR, 67% sensitivity
Coronavirus Cases: 23,368,637
Deaths: 808,380
Recovered: 15,898,052
ACTIVE CASES 6,662,206
Currently Infected Patients 6,600,472 (99%) in Mild Condition
61,734 (1%) Serious or Critical
CLOSED CASES 16,706,432
Cases which had an outcome: 15,898,052 (95%) Recovered / Discharged
808,380 (5%) Deaths
Doubling Time
India Brazil difference over 20000 per day, or one lac in 3-4 days
Total difference 5 lac
In one month may cross Brazil
23rd August: New cases 61749, New deaths 846, Total cases 3105185, Total deaths 61749
22nd August: New cases 70068; new deaths 981; Total cases 3043436; Total Deaths 56846
21st August: New Cases 69039; new deaths 953, Total cases 2973368, total deaths 55928
20th August: Cases 68507, 981 deaths, 2904329 total cases, 54975 total deaths
19th August: Cases 69196, 980 deaths, 2835822 total cases, 53994 total deaths
18th August: cases 65022, 1089 deaths, 2766626 total cases, 65022 total deaths
17th August: 54288 cases, 880 deaths, 2701604 total cases, 51925 total deaths
16th August: 58108 cases, 961 deaths, 2647316 total cases, 51045 deaths
15t August: 63986 new cases, 950 deaths, 2589208 total cases, 50084 deaths
India predictions
1. Death Rate is deaths today vs number of cases today
2. Corrected Death Rate is deaths today vs number of cases 14 days back
3. For one symptomatic test positive case there are 10-30 asymptomatic cases and 20 untested cases
4. Estimated Number of deaths = Reported deaths x 2
5. Number of deaths today should be 15% of the serious patients present 14 days back
6. Undocumented cases for each documented case [Iceland: 1: 2; German: 1: 5; New York City
grocery store shoppers: 1: 10; California 1.5%]
7. Amongst active 2.37% are serious, 1.82% need oxygen, and 0.41% need ventilator support.
Facts
1. India: In states with average population density of 1185 /sk km the average number of cases were
2048. On the contrary in states with population density of 909/ sk km the number of cases were 56.
(When Chandigarh and Pondicherry were taken out from this group) the Average Density of other
states were 217 and the average number of cases were 35 [HCFI]
2. COVID Sutras: COVID-19 Pandemic is due to SARS 2 Beta Corona Viruses (different from SARS 1
where spread was only in serious cases); with over eleven virus sequences floating; has affected up
to 22.8% of Delhi population, Causes Mild or Atypical Illness in 82%, Moderate to Severe Illness in
15%, Critical Illness in 3% and Death in 2.3% cases (15% of admitted serious cases, 71% with
comorbidity< Male > Females); affects all ages but Predominantly Males (56%, 87% aged 30-79,
10% Aged < 20, 3% aged > 80); with Variable Incubation Period days (2-14; mean 5.2 days); Mean
Time to Symptoms 5 days; Mean Time to Pneumonia 9 days, Mean Time to Death 14 days, Mean
Time to CT changes 4 Days, Reproductive Number R0 1.5 to 3 (Flu 1.2 and SARS 2), Epidemic
Doubling Time 7.5 days; Origin Possibly from Bats (Mammal); Spreads via Human to Human
Transmission via Large and Small Droplets and Surface to Human Transmission via Viruses on
Surfaces for up to three days. Enters through MM of eyes, nose or mouth and the spike protein gets
attached to the ACE2 receptors. ACE2 receptors make a great target because they are found in
organs throughout our bodies ( heart muscle, CNS, kidneys, blood vessels, liver) Once the virus
enters, it turns the cell into a factory, making millions and millions of copies of itself — which can
then be breathed or coughed out to infect others.
3. Prevalence: New York: 13.9%; New York City at 21.2%, S Korea 5.7%, world 5%; Ohio prison: 73% of
inmates; New York: 21% mortality April 22 in JAMA.
4. Viral particles seen in tears, stool, kidneys, liver, pancreas, heart, semen, peritoneal fluid, CSF.
5. Thrombosis: University of Pennsylvania clots are seen in patients even on blood thinners.
Netherlands study, 31%
6. Other human beta-coronaviruses has immunity lasting only for one year with no IMMUNITY
PASSPORT.
7. In absence of interventions, prolonged or intermittent social distancing (till 2022-24)
8. Low levels of cross immunity from the other beta-coronaviruses against SARS-CoV-2 could make
SARS-CoV-2 appear to die out, only to resurge after a few years. Surveillance till 2024.
9. During peak (trace and treat) and after the peak (trace and treat the close contacts
10. Increased spread: close environment, crowded place with close physical contacts with no
ventilation
11. Strategies: From community mitigation to individual containment; broader good over individual
autonomy; perfect cannot be the enemy of the good; pandemics are fought on the grounds and not
the hospitals., Treat the patient and not the test report, Consider every surface and every
asymptomatic person as virus carrier
12. HCW: Direct patient exposure time < 30 minutes; 7 days work and 7 days holidays.
13. Italy mortality reduced when they were short of ventilators.
14. Hospital at HOME: CHF, mild pneumonia, exacerbations of asthma and COPD, cellulitis, and urinary
tract infections.
15. Great Imitator (protean manifestation)
16. IgM can be false positive in pregnancy, immunological diseases); Pooled tests (< 5, 20 Kerala, 64
Singapore RTPCR) when seroprevalence is < 2%
17. Early treatment, day 3-5, to reduce the viral load and prevent cytokine storm using hydroxy
chloroquine with azithromycin or ivermectin with doxycycline with IV remdesivir and IV single dose
Tocilizumab interleukin (IL-6 receptor inhibitor) if very high DDimer and IL 6; convalescent plasma
therapy ( given early; donor 14 days symptoms free, between day 28-40, single donation can help 4
patients), Lopinavir-ritonavir and Favipiravir ivf very low CD 4 counts).
18. Hypoxia: Low flow oxygen < 6l/mt, titrated to high flow oxygen using non breathing mask, Venti
mask, HFNC and helmet CPAP, NAV in supine or prone position.
19. Early intubation with prone ventilation only if progressive. Hypoxia (walking dead) have capillary
problem and not alveoli.
Formulas
1. Deaths in symptomatic cases: Less than one percent (best of the care)
Therefore, Deaths X 100= expected number of symptomatic cases
2. Cases after seven days: Cases today x 2 (based on doubling time 7 days, will change as per doubling
time of the country)
3. Cases expected in the community
a) Get number of deaths occurring in a five-day period
b) Estimate the number of infections required to generate these deaths based on the country
or area case fatality rate
c) Compare that to the number of new cases actually detected in the five-day period.
d) This can then give us an estimate of the total number of cases, confirmed and unconfirmed
4. Lock down effect = Reduction in cases after average incubation period (5 days)
5. Lock down effect in reduction in deaths: Reduction in number of deaths on day 14 (average time to
death of that country)
6. Requirements of ventilators on day 9: 1-3% of number of new cases detected
7. Requirement of future oxygen on day seven: 10 of total cases detected today
8. Number of people which can be managed at home care: 90% of number of cases today
9. Requirements of ventilators: 1-3% of Number of cases admitted 7-9 days back
10. Requirement of oxygen beds today: 10% of total cases admitted seven days back
11. Case fatality rate: Number of total deaths as on date / number of total RTPCR positive cases as on
today
12. Infection fatality rate: Number of total deaths as on date / number of total calculated cases as on
today
13. Number of reported deaths = Number of confirmed deaths x 2
14. Number of unreported or untested cases = Number of reported cases x (10-30 depending on the
country, New York 10, Delhi 23.8, Pakistan 30)
15. Number of asymptomatic cases ( for 6 symptomatic cases 200 asymptomatic cases)
16. Oxygen requirement on that day in the hospital at 6am: Number of cases detected to have hypoxia
on six minutes’ walk test
So friends time has come to say SO WHAT ? to Corona and covid illness and the “दे खी जायेगी” attitude
needs to be encouraged to get life back to normal. Of course this does not say to not take precaution.
Strict precautions of sanitization, hand wash, social distancing and mask in public need to be followed. As
of date (now) these simple methods one only way to keep corona away and say “दे खी जायेगी” & Covid SO
WHAT ?
Please take care of the following: Fig – 1, 2, 3, 4, 5, 6, 7, 8, 9.
[Fig-1] [Fig-2]
[Fig-3] [Fig-4]
[Fig-6]
[Fig-5] [Fig-7]
[Fig 8] [Fig 9]
[Fig 1-9: Rainbow Advices]
Let’s all follow the simple ways and change of life style to the “NEW NORMAL” and when corona or covid
comes we can say SO WHAT ?
Stay safe and stay in the green zone (Fig 10, 11).
[Fig-10]
[Fig-11]
Adjust to the NEW NORMAL and protect yourself by taking precautions.
Further reading guidelines of WHO, CDC, FDA, ICMR, IMA & FOGSI
Brought to you for public awareness by Rotary Club Agra Taj City.