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21% infected on ship with 27 serious; 4000 likely deaths; super-spreader a reality? China reverses case definition; doubling time in Korea 2 days

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CMAAO Update 21st February on COVID-19

21% on ship got infected, 27 cases on ship in serious condition, over 4000 likely deaths, super-spreader a reality?

China reverses case definition, includes only nucleic acid-positive cases (no CT + cases)

Inputs: Dr Rajan Sharma, Dr R V Asokan, Dr KK Kalra, Dr Sushil Kumar, Dr Anita Arora, Dr Upasana Arora, Dr SS Srivastava, Dr Shilpi Khanna, Ms Swati, Dr Rahiul Shukla, Dr Arti Verma, Dr Anil Kumar, Dr G S Gyani, Dr Sonal Saxena, Dr CM Bhagat, Dr Vikas Manchanda, Dr Nandani Sharma, Dr Suneela Garg, Dr TK Joshi, Dr Mamta Jajoo, Dr Shariga Qureshi, Dr Manish Kumar, Dr Harmeet Singh, Dr Dr Rai, Dr VK Monga, Dr AP Singh, Dr Ramesh Datta, Dr Maj Prachi Garg, Dr Anil Kumar, Dr Ragini Agrawal, Dr Rajeev Kumar, Dr Harish Grover, Dr Mini Mehta, Dr Lalan Bharti, Dr Rajeev Sood, Dr N V Kamat, Dr Atin Kumar, Dr RN Tandon, Dr Kaushik Sinha Deb, Dr Tarun Mittal, Dr Dinesh Sahay, Dr SK Poddar

Summary

COVID-19 virus possibly behaves like SARS; causes mild illness in 82%, severe illness in 15%, critical illness in 3% and death in 2.3% cases (15% of admitted serious cases, 71% with comorbidity); affects all ages but predominantly males (56%) with median age 59 years (2-74 years, less in children below 15); with mean incubation period 2-14 days (3 days based on 1,324 cases); 5.2 days (based on 425 cases), 6.4 days in travellers from Wuhan); mean time to symptoms 5 days, mean time to pneumonia 9 days, mean time to death 14 days, 3-4 reproductive number R0 (flu 1.2 and SARS 2), epidemic doubling time 7.5 days (Korea 2 days probably due to super-spreader), has origin possibly from bats, spreads via large droplets and predominantly from people having lower respiratory infections and hence, standard droplet precautions are the answer for the public and close contacts and airborne precautions for the healthcare workers dealing with the secretions.

Clinically all patients have fever, 75% have cough; 50% have weakness; 50% have breathlessness with low total white count and deranged liver enzymes. About 20% need ICU care and 15% of them are fatal.

Close Contacts are defined as those with healthcare-associated exposure, including those providing direct care for COVID-19 patients, working with healthcare workers infected with COVID-19, visiting patients or staying in the same close environment of a COVID-19 patient OR working together in close proximity or sharing the same classroom environment with a COVID-19 patient OR traveling together with COVID-19 patient OR Living in the same household as a COVID-19 patient OR the epidemiological link may have occurred within a 14-day period before or after the onset of illness.

Daily Statistics

Total cases: 75,779

New cases yesterday: 2008

Deaths: 2,130

Recovered: 16917 (89%)

Currently Infected Patients: 56,732

Mild cases: 44,668 (79%)

Serious or Critical cases: 12,065 (21%)

Deaths yesterday: 118

Serious or critical mortality 15%

Likely minimum deaths 2130 + 1810 (12065x15) = 3940 with the present trend and available treatment (plus deaths linked to daily new cases)

20th February

24 new cases in South Korea (31 cases, 24 of which were announced after midnight GMT and 7 previously reported cases). Cases have increased more than two-fold (+165% increase) over the last 24 hours, rising from 31 to 82 (+51).

(31 cases, 24 of which were announced after midnight GMT and 7 previously reported cases). Cases have increased more than two-fold (+165% increase) over the last 24 hours, rising from 31 to 82 (+51). 1 new case in Singapor 3 more discharged.

3 more discharged. 13 new cases on the Diamond Princess

10 new cases in Japan , including: a woman in her 60s, wife of a previous case; a man in his 80s, got infected at a hospital; a man in his 80s in Okinawam, no contact with passengers of the cruise ship; a woman in her 70s; a man in his 40s with no recent travel history abroad, attended the Sapporo Snow Festivalthat was visited by a previously infected case; 2 government employees who had done office work on the Diamond Princess cruise ship.

, including: a woman in her 60s, wife of a previous case; a man in his 80s, got infected at a hospital; a man in his 80s in Okinawam, no contact with passengers of the cruise ship; a woman in her 70s; a man in his 40s with no recent travel history abroad, attended the Sapporo Snow Festivalthat was visited by a previously infected case; 2 government employees who had done office work on the Diamond Princess cruise ship. 3 new cases in Iran.

1 death in South Korea .

. The mayor of Daegu, South Korea, urged all residents toavoid going outside and to wear masks even indoors, if possible. Vice Health and Welfare Minister cautioned that at this stage COVID-19 is being judged as spreading locally with a limited scope. Virus alert was not raised, its level is kept at "orange" (third highest).

The Shincheonji Church of Jesus in Daegu has been shut downafter about 10 members tested positive for the virus. The church was attended by the 31st case who is being considered as a possible "super spreader". About 1,000 members attended worship at the church.

2 deaths among the passengers of the Diamond Princess cruise ship in Japan: a man and a woman in their 80s , both with an underlying illness .

among the passengers of the cruise ship in Japan: a man and a woman , both with an . 1 new case in Taiwan , a 60-year-old woman with no travel history abroad in the last two years, taking the total to 24. Possibility of community-based transmission is being investigated. Patient is.

, a 60-year-old woman with no travel history abroad in the last two years, taking the total to 24. Possibility of is being investigated. Patient is. 60 new cases and 6 new deathsoutside of Hubei province in China on February 19 [National Health Commission (NHC) of China].

New updates

Namaste: Let’s not shake hands Time for facts, not fear; for rationality, not rumors and for solidarity, not stigma. Help line: 23978046, ncov2019@gmail.com, mohfw.gov.in/node/4904 Total number = Lab-confirmed + CT-diagnosed cases 12-19 February; before and after - only lab-confirmed cases No evidence to support the possibility of vertical transmission from the mother to the baby. [Lancet Feb 20] Sudden jump in deaths and new cases on 12th due to inclusion of CT-diagnosed cases. Secondary Cases: Thailand, Taiwan, Germany, Vietnam, Japan, France, US, Korea Seven Deaths outside China: Philippines, Hong Kong, Japan, Taiwan, France and Iran WHO: Epidemic could still ‘go in any direction’ Global experts say that the outbreak is just ‘beginning’ outside China Coronavirus vaccine could be ready in 18 months (WHO) Human-to-human contact requires prolonged contact (possibly ten minutes or more) within three to six feet. 14th Feb: 1,716 medical workers have contracted the virus and six of them have died; 1,502 belong to Hubei Province, with 1,102 from Wuhan. The numbers of infected workers amount to 3.8% of China’s confirmed infections as of Feb 11. (18th Feb: Director of Wuhan Hospital died). Two workers who were sent to Wuhan in January to help build new hospital have been infected. The central banking authorities of China are disinfecting, stashing and even destroying cash in a bid to stop the spread of coronavirus. Fan Yifei, deputy governor of the People’s Bank of China, stated that the cash being collected by commercial banks must be disinfected before being released to customers. Maharishi Valmiki Hospital in Delhi stops biometric attendance. China has more than 80 running or pending clinical trials on potential treatments for COVID-19. WHO demands to know more about sick doctors. Bangkok: A health worker was found to have been infected by coronavirus, bringing the total number of infections in the country to 34 since January. 634 infected people have been found among 3,011 passengers and crew members tested (21% infection rate) out of 3,711 people on the cruise ship; 2 deaths, 27 serious. Growing number of clusters of coronavirus cases: a party in a boat in Japan with 90 guests where one case spread infection to more than a dozen, or a church where 43 were infected. This can be explained in 2 possible ways: a “super-spreader,” or a person who can spread more germs than others; or people contracting the virus from infected surfaces. It is not yet known as to how long the germs stay on surfaces, but similar viruses can live for as long as a week. Chinese researchers have published the largest analysis of coronavirus cases till date. While men and women have been found to be infected in roughly equal numbers, the death rate among men was 2.8% compared with 1.7% among women.

Travel Restrictions

Travel advisory: Level 1 in all countries (Exercise normal standard hygiene precautions), Level 2 in all affected countries and states including Kerala (Exercise a high degree of caution), Level 3 in countries with secondary cases (Reconsider need to travel), done by India and Level 4 (Do not travel), done by US. Hong Kong has enforced 14-day quarantine on people arriving from China.

Travel preferable seat: Choose a window seat and stay there to lower the risk

Travel and trade restrictions: WHO says no to countries

Leave china all together: UK, condemned by many countries

Entry to India not allowed: Foreigners who went to China on or after January 15

Visas Suspended: All visas issued to Chinese nationals before February 5 (not applicable to aircrew)

Flight suspended: IndiGo and Air India have suspended all flights between the two countries.

SpiceJet continues to fly on Delhi-Hong Kong route.

Evacuation

Many countries including US, Japan, and India have evacuated their citizens.

Case fatality

COVID-19 2%; MERS 34% (2012, killed 858 people out of the 2,494 infected); SARS 10% (Nov. 2002 - Jul. 2003, originated from Beijing, spread to 29 countries, with 8,096 people infected and 774 deaths); Ebola 50%; Smallpox 30-40%; Measles 10-15% developing countries; Polio 2-5% children and 15-30% adults; Diphtheria 5-10%; Whooping cough 4% infants < 1yr, 1% children < 4 years; Swine flu < 0.1-4 %; Seasonal flu 0.01%; COVID-19 in Wuhan 4.9%; COVID-19 in Hubei Province 3.1%; COVID-19 Nationwide 2.1%; COVID-19 in other provinces 0.16%.

Number of flu deaths every year: 290,000 to 650,000 (795 to 1,781 deaths per day)

Public Health Emergency of International Concern 30th Jan 2020

It is mandatory to report each human and animal case to the WHO.

Prior 5 PHEICs:

26th April 2009 Swine flu: 10 August 2010, WHO announced that the H1N1 influenza virus has moved into the post-pandemic period. Localized outbreaks of various magnitudes may; however, continue.

May 2014 Polio: resurgence of wild polio. In October 2019, there were continuing cases of wild polio in Pakistan and Afghanistan, besides new vaccine-derived cases in Africa and Asia. The status was reviewed and it continues to be a PHEIC. It was extended on 11 December 2019.

August 2014 Ebola: It was the first PHEIC in a resource-poor setting.

Feb 1 2016 Zika: There is a link with microcephaly and Guillain–Barré syndrome. This was the first time a PHEIC was declared for a mosquito‐borne disease. The declaration was lifted on 18 November 2016.

2018–20 Kivu Ebola: A review of the PHEIC was planned at the fifth meeting of the EC on 10 October 2019 and as of 18 October 2019, it continues to be a PHEIC.

Kerala: State public health emergency lifted on 12th Feb. Three primary cases were identified in North, South and Central Kerala - Kasaragod district in north Kerala, Thrissur in central Kerala and Alappuzha in South Kerala. Four Karnataka districts bordering Kerala — Kodagu, Mangaluru, Chamarajanagar and Mysuru - were put on high alert.

About the Virus

Single-strand, positive-sense RNA genome that ranges from 26 to 32 kilobases in length; A beta coronavirus from Corona family.

‘Corona’ means crown or the halo around the sun. Heart is considered a crown. Therefore, the arteries that supply oxygen to the heart are also called coronary arteries. Under an electron microscope, the virus appears round with spikes poking out from its periphery.

Three deadly human respiratory coronaviruses: Severe acute respiratory syndrome coronavirus [SARS-CoV], Middle East respiratory syndrome coronavirus [MERS-CoV]) and COVID-19: The current virus is 75-80% identical to the SARS-CoV.

Origin: Wuhan, China, December 2019. 1st case informed to the world by Dr. Li Wenliang; died on Feb 6.

The virus is likely to be killed by sunlight, temperature, and humidity. SARS was reported to have stopped around May-June, 2003 owing to more sunlight and more humidity. Alive on surface: possibly 3-12 hours.

Link to ACE: COVID-19 might be able to bind to the angiotensin-converting enzyme 2 receptor in humans.

Pathogenesis

High viral load: Detection of COVID-19 RNA in specimens from the upper respiratory tract with low Ct values on day 4 and day 7 of illness suggests high viral loads and potential for transmissibility. [NEJM]

COVID-19 uses the same cellular receptor as SARS-CoV (human angiotensin-converting enzyme 2 [hACE2]), so transmission is expected only after signs of lower respiratory tract disease develop.

SARS is high [unintelligible] kind of inducer. When it infects the lower part of the lung, a very severe reaction occurs against it which leads to inflammation and scarring. In SARS, after the first 10 to 15 days, it wasn’t the virus but the body’s reaction was what was killing patients. Is this new virus in the MERS or SARS kind picture or is this some other type of virus - a milder coronavirus like the NL63 or the 229? It may be the mild (unintelligible) kind of inducer. [Dr John Nicholls, University of Hong Kong]

COVID-19 thrives better in primary human airway epithelial cells as compared to the standard tissue-culture cells, unlike SARS-CoV or MERS-CoV. COVID-19 will likely behave more like SARS-CoV.

Both SARS-CoV and MERS-CoV affect the intrapulmonary epithelial cells more than the upper airway cells. Transmission thus occurs principally from patients with known illness and not from patients with mild, nonspecific signs. However, NEJM has reported a case of COVID-19 infection acquired outside of Asia in which transmission appears to have occurred during the incubation period in the index patient, but the same has been challenged now.

This new virus attacks the lungs and not just the throat. Patients so far have not presented with a sore throat, because the COVID-19 attacks the intraepithelial cells of lung tissue.

Transmission

Zoonotic and linked to Huanan Seafood Wholesale Market as 55% with onset before January 1, 2020 originated there vs. only 8.6% of the subsequent cases. The Chinese government has put a ban on wildlife trade until the epidemic passes.

This new coronavirus has a close relation with bat coronaviruses. Bats are the primary reservoir. While SARS-CoV was transmitted to humans from exotic animals in wet markets, MERS-CoV transmitted from camels. The ancestral hosts were probably bats; however.

The virus has been traced to snakes in China. Snakes often hunt for bats. According to reports, snakes were sold in the local seafood market in Wuhan, thus raising the likelihood that COVID 19 might have moved from the host species, i.e., bats, to snakes and then to humans. It is still not understood as to how the virus could adapt to both the cold-blooded and warm-blooded hosts. It cannot be transmitted by eating wild animals as it is a respiratory secretions disease.

It transmits predominantly via droplets, like common flu and not like airborne illnesses (TB, Measles, Chicken pox).

Kissing scenes have been banned in movies in China. In Kerala air crew are exempted from breath analyser tests and China has banned death ceremonies, and people gathering together. NEJM has reported a small cluster of five cases suggesting transmission from asymptomatic individuals during the incubation period; all patients in this cluster had mild illness. But the same has been challenged. Another patient got infected while using gown, but eyes were not covered.

Serious illnesses in other countries are less as patients with breathlessness are unlikely to board and patients will mild illness or asymptomatic illness are less likely to transmit infections. NEJM has reported of a taxi driver infected with SARS-CoV-2 in Thailand, potentially from Chinese tourists; the infection appears not to have spread to others.

Legal Implications India: Section 270 in the Indian Penal Code: 270. Malignant act likely to spread infection of disease danger­ous to life.—Whoever malignantly does any act which is, and which he knows or has reason to believe to be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of either description for a term which may extend to two years, or with fine, or with both.

Quarantine has Limitations

China imposed quarantines across Hubei province, thus locking in about 56 million people, in order to stop COVID-19 from spreading. Millions of others cities, far from the epicenter, are also under travel restrictions.

Vietnam villages with 10,000 people near the nations capital have been placed under quarantine after cases of the new coronavirus were identified there. The lock down of the commune of Son Loi represents the first mass quarantine outside of China.

The people on quarantine are subjected to a 14-day quarantine. While placed together, if anyone is diagnosed with the infection during that period, the quarantine will add another 14 days. The longer several thousand people are place together, waves of infection are propagated. A better way is to divide the people into smaller groups and quarantine them separately. Why quarantine children <15 years of age when the virus is not risky for them. Why not separate elderly people with comorbid conditions at high risk of death and quarantine them separately in one to one or small groups. What is the need to allow people to celebrate and have cultural programs during quarantine, as was seen in India, when people danced together with surgical masks during quarantine period. Ventilation system can connect one room to the other. There have been concerns that coronavirus can spread through pipes. Stress and anxiety suppress the immune system, thus rendering people more vulnerable to contracting the virus. Quarantine the people the way it was done in TB sanatoriums with both sun-balconies and a rooftop terrace where the patients would lie all day either in beds or on specially designed chairs.

Standard Respiratory Droplets Precautions

At triage: Surgical 3-layered mask for patients; Isolation of at least 1 m distance; Cough etiquette; Hand hygiene.

Droplet precautions: Surgical 3-layered mask for patients, their contacts and healthcare workers, in an adequately ventilated isolation room; healthcare workers caring with secretions should use eye protection, face shields/goggles. Limit patient movement, restrict attendants and observe hand hygiene.

Contact precautions: Entering room – use gown, mask, goggles, gloves; remove before leaving the room; Dedicated equipment/disinfection after every use; Care for environment - door knobs, handles, articles, laundry; Avoid patient transport and practice hand hygiene.

Airborne precautions when handling virus in the lab and while performing aerosol-generating procedures . Room should be with negative pressure with minimum of 12 air changes per hour or at least 160 litres/second/patient in facilities with natural ventilation. There should be restricted movement of other people and gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or equivalent, or higher level of protection) to be used by all.

Public

Strict self-quarantine if sick with flu-like illness for 2 weeks

Wash hands often and for at least 20 seconds with soap and water or use an alcohol-based hand sanitizer.

Avoid touching eyes, nose, and mouth with unwashed hands.

Avoid close contact (within 3-6 feet) with people sick with cough or breathlessness.

Cover your cough or sneeze with a tissue, then throw the tissue in the trash.

Clean and disinfect frequently touched objects and surfaces.

Masks

Surgical 3-layered Masks: For patients and close contacts

N 95 Masks: For healthcare providers when handling respiratory secretions.

Lab tests

Two ways to detect a virus: through the genetic material DNA or RNA and to detect the protein of the virus. The rapid tests look at the protein. It takes 8-12 weeks to make commercial antibodies. Currently, PCR is being used which gives a turnaround in 1-2 hours. BOTH the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) AND lower respiratory tract (LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage) Use PPE in the lab Use viral swabs (sterile Dacron or rayon, not cotton) and viral transport media In US, in January, all testing had to be done in CDC laboratories. However, on February 4, the US FDA issued an emergency-use authorization for the CDCs COVID-19 Real-Time RT-PCR Diagnostic Panel, allowing its use at any CDC-qualified laboratory in the United States. Lab precautions: BSL 2 (3 for viral culture labs)

Treatment

No proven antiviral treatment. With SARS, in 6 months the virus was gone and it never came back. Pharmaceutical companies may not be willing to spend millions to develop a vaccine for something which may never come back. Secondary infection is the most likely cause of death of the patients in the Philippines and Hong Kong. A combination of lopinavir and ritonavir showed promise in lab in SARS. Combination of lopinavir, ritonavir and recombinant interferon beta-1b was tested in case of MERS. Scientists in Australia have reportedly recreated a lab-grown version of COVID 19. Chloroquine had potent antiviral activity against the SARS-CoV, has been shown to have similar activity against HCoV-229E in cultured cells and against HCoV-OC43 both in cultured cells and in a mouse model. Thailand: Oseltamivir along with lopinavir and ritonavir, both HIV drugs. Experimental drug: From Gilead Sciences Inc., called remdesevir (started on 6th Feb as a trial) Russia and China drug: Arbidol, an antiviral drug used in Russia and China for treating influenza, could be combined with Darunavir, the anti-HIV drug, for treating patients with the coronavirus. (COVID-19 shares some similarity to HIV virus also) PVP-I mouthwashes and gargles reduce viral load in the oral cavity and the oropharynx. PVP-I has potent viricidal activity against hepatitis A and influenza, MERS and SARS. The Drug Controller General of India has approved the "restricted use" of a combination of drugs (Lopinavir and ritonavir) used widely for controlling HIV infection in public health emergency for treating those affected by novel coronavirus. In SARS, people were put on long-term steroids ending with immunosuppression and late complications and death. The current protocol is short-term treatment.

Case Definitions

Suspect case

Severe acute respiratory infection (fever, cough, need hospital admission), with no other cause that can explain the clinical presentation PLUS at least one of the following:

a history of travel to or residence Wuhan, Hubei Province, China in the 14 days before symptom onset, or

patient is a healthcare worker who has worked in an environment where severe acute respiratory infections of unknown etiology are being cared for.

Any acute respiratory illness PLUS at least one of the following:

close contact with a confirmed or probable case of COVID-19 in the 14 days before illness onset, or

visit to or having worked in a live animal market in Wuhan, Hubei Province, China in the 14 days before symptom onset, or

worked or attended a healthcare facility in the 14 days before symptom onset where patients with hospital-associated COVID-19 have been reported.

Probable case

A suspect case with inconclusive COVID-19 testing or testing was positive on a pan-coronavirus assay.

Confirmed case

Laboratory confirmation of COVID-19 infection, regardless of clinical signs and symptoms.

Severe acute respiratory infection ( SARI)

ARI with history of fever or temperature ≥38°C and cough; onset within the last 10 days; need for hospital admission. Absence of fever does NOT exclude viral infection.

SARI in a person, with history of fever and cough requiring hospital admission, with no other cause to explain the clinical presentation (clinicians should be alert to the possibility of atypical presentations in immunocompromised patients)

AND any of the following:

a) A history of travel to Wuhan, Hubei Province, China in the 14 days before symptom onset; or b) the disease in a healthcare worker working in an environment where patients with severe acute respiratory infections are being cared for, irrespective of place of residence or history of travel; or c) development of an unusual or unexpected clinical course, especially sudden deterioration despite appropriate treatment, irrespective of place of residence or history of travel, even if another etiology has been identified that can explain the clinical presentation

OR

A person with acute respiratory illness of any severity who, within 14 days before illness onset, had any of the following exposures:

a) close physical contact with a confirmed case of COVID-19 infection, while the patient was symptomatic: or b) a healthcare facility where hospital-associated COVID-19 infections have been reported.

Uncomplicated illness

Patients with uncomplicated upper respiratory tract viral infection, may have non-specific symptoms such as fever, cough, sore throat, nasal congestion, malaise, headache, muscle pain or malaise. The elderly and immunosuppressed may have atypical symptoms. These patients have no signs of dehydration, sepsis or shortness of breath

Mild pneumonia

Pneumonia and no signs of severe pneumonia. Child has cough or difficulty breathing + fast breathing: fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40 and no signs of severe pneumonia

Severe pneumonia

Adolescent or adult: fever or suspected respiratory infection, AND one of respiratory rate >30 breaths/min, severe respiratory distress, or SpO2 <90% on room air

Child: cough or difficulty in breathing, AND at least one of the following: central cyanosis or SpO2 <90%; severe respiratory distress (e.g. grunting, very severe chest indrawing); signs of pneumonia with a general danger sign: inability to breastfeed or drink, lethargy or unconsciousness, or convulsions. Other signs of pneumonia may be seen: chest indrawing, fast breathing (in breaths/min): <2 months, ≥60; 2–11 months, ≥50; 1–5 years, ≥40.

Diagnosis is clinical; chest imaging can help rule out complications.

Acute Respiratory Distress Syndrome

Onset: new or worsening respiratory symptoms within one week of known clinical insult.

Chest imaging: bilateral opacities, not fully explained by effusions, lobar or lung collapse, or nodules.

Origin of edema: respiratory failure not fully explained by cardiac failure or fluid overload. Need objective assessment (e.g. echocardiography) to exclude hydrostatic cause of edema if no risk factor present.

Oxygenation (adults):

Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥5 cm H2O, or non-ventilated)

Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤200 mmHg with PEEP ≥5 cm H2O, or non-ventilated)

Severe ARDS: PaO2/FiO2 ≤ 100 mmHg with PEEP ≥5 cmH2O, or non- ventilated)

PaO2 not available: SpO2/FiO2 ≤315 suggests ARDS (including in non-ventilated patients)

Oxygenation (children; OI = Oxygenation Index and OSI = Oxygenation Index using SpO2)

Bilevel NIV or CPAP ≥5 cmH2O via full face mask: PaO2/FiO2 ≤ 300 mmHg or SpO2/FiO2 ≤264

Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5

Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3

Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3

Sepsis

Adults: life-threatening organ dysfunction due to a dysregulated host response to suspected or proven infection, with organ dysfunction.

Signs of organ dysfunction: altered mental status, difficult or fast breathing, low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood pressure, skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia.

Children: suspected or proven infection and ≥2 SIRS criteria; of these one must be abnormal temperature or white blood cell count.

Septic shock

Adults: persisting hypotension in spite of volume resuscitation, need for vasopressors to maintain MAP ≥65 mmHg and serum lactate level >2 mmol/L

Children: any hypotension (SBP <5th centile or >2 SD below normal for age) or 2-3 of the following: altered mental state; tachycardia or bradycardia (HR <90 bpm or >160 bpm in infants and HR <70 bpm or >150 bpm in children); prolonged capillary refill (>2 sec) or warm vasodilation with bounding pulses; tachypnea; mottled skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia

(Source: https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf)

Common Myths

People receiving packages from China do not have a risk of contracting the COVID-19 as the virus does not survive for long on objects, such as letters or packages. There is no evidence that animals/pets such as dogs or cats can be infected with COVID19. Pneumococcal vaccine and Haemophilus influenza type B (Hib) vaccine provide no protection against COVID-19. Regularly rinsing the nose with saline does not protect against infection with COVID-19 or respiratory infections although it may hasten recovery from the common cold. There is no evidence to suggest that using mouthwash protects from infection with COVID-19 although some brands of mouthwash can eliminate certain microbes for a few minutes in the saliva in your mouth. There is no evidence that eating garlic protects people from COVID-19. Sesame oil does not kill the new coronavirus. Chemical disinfectants that can kill the COVID-19 on surfaces are bleach/chlorine-based disinfectants, either solvents, 75% ethanol, peracetic acid and chloroform. People of all ages can be infected by COVID-19. Older people, and people with pre-existing medical conditions are at increased odds of becoming severely ill with the virus. Antibiotics do not work against viruses. There is no specific medicine recommended to prevent or treat COVID-19.

Trolls and conspiracy theories: Not validated and are fake news

COVID-19 is linked to Donald Trump,and US intelligence agencies or pharmaceutical companies are behind it. Eating snakes, wild animals or drinking bat soup causes coronavirus infection. Keep your throat moist, avoid spicy food and load up on vitamin C. Avoiding cold or preserved food and drinks, such as ice cream and milkshakes, for "at least 90 days". Experts have been aware of the virus for years. The virus was part of Chinas "covert biological weapons programme" and may have leaked from the Wuhan Institute of Virology. Linked to the suspension of a researcher at Canadas National Microbiology Lab. China wants to kill 20,000 COVID-19 patients is totally false. The site is linked to a sex website.

Experts Opinions on COVID 19

“I think this virus is probably with us beyond this season, beyond this year, and I think eventually the virus will find a foothold and well get community-based transmission and you can start to think about it like seasonal flu. The only difference is we dont understand this virus”

Dr. Robert Redfield, Director, CDC, US Centers for Disease Control and Prevention, Feb. 13, 2020

“What makes this one perhaps harder to control than SARS is that it may be possible to transmit before you are sick. I think we should be prepared for the equivalent of a very, very bad flu season, or maybe the worst-ever flu season in modern times.”

Prof. Marc Lipsitch, Prof. of Epidemiology, Harvard School of Public Health, Head, Harvard Ctr. Communicable Disease Dynamics, Feb. 11, 2020

“I hope this outbreak may be over in something like April’

Prof. Nanshan Zhong, Leading epidemiologist, first to describe SARS coronavirus, Feb. 11, 2020

“It could infect 60% of global population if unchecked”

Prof. Gabriel Leung, Expert on coronavirus epidemics, Chair of Public Health Medicine, Hong Kong University, Feb. 11, 2020

“It’s a new virus. We don’t know much about it, and therefore we’re all concerned to make certain it doesn’t evolve into something even worse”

Prof. W. Ian Lipkin, Epidemiology Director, Columbia University, Feb. 10, 2020

“We are estimating that about 50,000 new infections per day are occurring in China. [...] It will probably peak in its epicentre, Wuhan, in about one-month time; maybe a month or two later in the whole of China. The rest of the world will see epidemics at various times after that.”

Prof. Niall Ferguson, Director, Institute for Disease and Emergency Analytics, Imperial College, London Feb. 6, 2020

“This looks far more like H1N1’s spread than SARS, and I am increasingly alarmed”

Dr. Peter Piot, Director, The London School of Hygiene and Tropical Medicine, Feb. 2, 2020

“It sounds and looks as if it’s going to be a very highly transmissible virus [...] This virus may still be learning what it can do, we don’t know its full potential yet.”

Robert Webster, Infectious disease and avian flu expert at St. Jude Children’s Research Hospital, Feb. 2, 2020

“Increasingly unlikely that the virus can be contained”

Dr. Thomas R. Frieden, Former Director of CDC, Feb. 2, 2020

“It’s very, very transmissible, and it almost certainly is going to be a pandemic. But will it be catastrophic? I don’t know “

Dr. Anthony S. Fauci, Director, National Inst. Allergy and Infectious Disease, Feb. 2, 2020

“Until [containment] is impossible, we should keep trying”

Dr. Mike Ryan, Head of the WHO’s Emergencies Program, Feb. 1, 2020

“The more we learn about it, the greater the possibility is that transmission will not be able to be controlled with public health measures”

Dr. Allison McGeer, Director of Infection Control, Mount Sinai Hospital

Confirmed cases and deaths

Country,Other Total Cases NewCases TotalDeaths NewDeaths TotalRecovered Serious,Critical China 74,579 +394 2,119 +115 16,707 12,017 Diamond Princess 634 +13 2 +2 17 27 S. Korea 104 +46 1 +1 16 Japan 94 +10 1 20 4 Singapore 85 +1 37 4 Hong Kong 67 +2 2 6 6 Thailand 35 17 2 Taiwan 24 +1 1 2 1 Malaysia 22 17 Germany 16 9 Vietnam 16 14 Australia 15 11 USA 15 3 France 12 1 7 Macao 10 6 U.K. 9 8 U.A.E. 9 3 1 Canada 8 2 Iran 5 +3 2 Philippines 3 1 2 India 3 3 Italy 3 2 Russia 2 2 Spain 2 2 Belgium 1 1 Cambodia 1 1 Egypt 1 1 Finland 1 1 Nepal 1 1 Sri Lanka 1 1 Sweden 1

Highlighted in green

= all cases have recovered from the infectio