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Bangladesh medical Association of North America (BMANA) is very concerned at the alarming
spread of COVID-19 viral infection pandemic. BAMAN expresses grave concern for the safety of
its members and the community and the country as a whole. To help guide our professional
colleague, we have decided to periodically update our members about the clinical aspects of
the disease. The following is our first advisory.
BMANA COVID advisory 1
1. The name of the disease: COVID-19
2. The causative agent – a novel coronavirus named SARS-CoV-2
3. It can infect people via airborne droplet route to people in very close contact, via fomite and via sewer contamination. Because it’s a large RNA virus and creates large droplets, its not the most effective airborne transmitter. People in close contact (3-6 feet) may have airborne infection. Most common route of infection is sneeze, cough, sewer created a fine layer of fomites on surfaces like roads, hallways, chairs, tables, doorknobs, Gasoline pump nozzle, Elevator button, mobile phone, eyeglasses etc. By touching those surfaces, the had gets infected. When the contaminated person touches his own eyes, tongue, mouth- the virus enters the victim’s airway or GI tract.
4. The incubation period is estimated at 4 days (range is 2 to 7 days) i.e. patient’s usually have a very recent sick contact. But because there are asymptomatic cases of COVID-19, it is not required to have a demonstrable sick contact for clinical suspicion.
5. Most common signs and symptoms are fever (seen in 77–98% cases), dry cough (seen in 46%–82%), myalgia or fatigue (seen in 11–52%), and shortness of breath (seen in 3-31% cases). A minority of the patients developed diarrhea and nausea prior to developing fever and lower respiratory tract signs and symptoms.
6. Data from large Chinese studies suggest that 80% of the patients infected with SARS-CoV-2 shows mild symptoms which doesn’t require treatment or hospitalization. 20% patients’ developed more serious complications like pneumonia and 5% developed ARDS with acute respiratory failure. ARDS is the most common cause of death, however one Chinese study showed that one third of all death were due to viral myocarditis. Septic shock like circulatory failure was uncommon. Nearly 50% of the patients who developed respiratory failure didn’t survive the illness.
7. The case fatality rate was 2.3% among confirmed cases of COVID-19 in China. Data from Kore puts this number at 0.6%. It is expected that when full extent of community prevalence will be estimated more accurately, the case fatality rate will be much lower. Case fatality is higher and patient demographic is being reported to be younger in the Italian cohort. However, these are based on personal anecdotes rather than systemic epidemiologic studies. We need to wait for a few more weeks to get a clearer epidemiological picture of the Italian outbreak,
8. The most common laboratory abnormalities reported among hospitalized patients with COVID-19 pneumonia is lymphopenia. Leukopenia, leukocytosis and elevated alanine aminotransferase and aspartate aminotransferase levels are also seen less frequently. Most patients have normal serum levels of procalcitonin on admission. An elevated procalcitonin should suggest an alternative bacterial infection. Chest CT images have shown bilateral peripheral areas of consolidation and ground glass opacities. C-reactive protein and serum ferritin level has shown promise as a reliable diagnostic and prognostic agent.
9. A variety of testing kits are being developed, and although most kits use NAAT by RT-PCR, they differ in the exact methodology. So far per the published data, the sensitivity of SARS-CoV-2 RT-PCR NAAT is about 60-70%. That means at up to 40% negative tests may be falsely negative. That’s why when there is high clinical suspicion, the test should be repeated after 24 hours and a non-contrast CT scan of the chest may be obtained. From day 3 onwards of infection, nearly 86% of all CT chests showed specific pattern of abnormalities.
10. For personal protection equipment, please use your local hospital or CDC guideline. At the time the recommendation is full body wet resistant gown, eye shield, face mask and one pair of gloves. Donning and doffing of PPE need to be done in a secure and enclosed space.
11. Please follow your local laboratory guideline about sample collection method. Some lab requires nasopharyngeal swab, and some require both nasopharyngeal and oropharyngeal swab. At this time no laboratory is collecting the samples, your office will have to collect sample in viral swab kit and ship those to respective laboratory. Please train your office staff in necessary self-protection with PPE and correct method of Nasopharyngeal swab collection.
12. Although SARS-CoV-2 NAAT RT-PCR testing capacity has been seriously inadequate as of now, it seems the daily testing capacity is increasing dramatically by the hour. It is predicted that while state and public health laboratories will remain very restrictive, there will be more and more availability of commercial testing. As of March 13, 2020, the following is the daily testing capacity in the USA.
13. Below is a pictorial guide to correct swab collection method.
Insert the probe in the nostril and direct it parallel to the tongue, not nasal bridge. The swab must go deep enough to hit the nasopharynx. Nasopharynx is at external ear level. You may first measure the distance from nostril to external ear to know how deep you’ll have to go.
Collect oropharyngeal swab after depressing the tongue, visualizing the posterior pharynx beyond the uvula and collecting the swab from the space in between the tonsils. Avoid tonsils.
14. Dyspnea and hypoxemia should be the warning signs to hospitalize a patient.
a. At this time there is no approved or proven therapy of COVID-19. Experimental antiviral Remdesivir may be used either under a clinical trial or under compassionate use criteria. For Remdesivir compassionate use, please contact the manufacturer, Gilead Sciences via this email: [email protected]
b. Although there is no supporting human data and negative animal data, based on one in-vitro data some groups in China used Chloroquine Sulfate 500 mg PO twice daily for 10 days in patients without contraindications.
c. If Remdesivir cannot be obtained, based on invitro data and SARS CoV-1 data from 2004, lopinavir/ritonavir (KALETRA) with Ribavirin combination can be considered.
d. Again, none of the drugs mentioned above have been established through rigorous process of science and we do not know with certainty that those will work.
15. WHO clinical movement guidelines and clinician leaders from China recommended against delaying intubation with the use of non-invasive ventilation or High Flow Oxygen. With onset of hypoxemia and respiratory distress, please contact critical care medicine early on and do not in intubation.
16. With this note we end BMANA COVID advisory 1. We’ll return with more updates as situation or evidence data changes. Please feel free to contact BMANA with questions, concerns or for any other help. In the interim we urge all of you to closely monitor CDC, WHO, local state and your network guidelines and recommendations. Their recommendation will always take precedence over our advisory.
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