ChatGPT has potential in Healthcare field, but not as Replacement of Healthcare Professional

 The ground breaking story of the recent days is Google's medically focused generative artificial intelligence (AI) model achieved 85% accuracy on a U.S. Medical Licensing Examination (USMLE) practice test, the highest score ever recorded by an AI model.

The AI model, known as Med-PaLM 2 (Pathways Language Model), consistently performed at an "expert" physician level on the sample of USMLE-style practice questions. It achieved 85% accuracy, beating previous record.

ChatGPT also urged healthcare professionals to stay informed about the latest developments in the technology and to remain open to the possibilities of using it to improve patient care. The chatbot itself emphasized that it is "not capable of replacing human healthcare professionals."

It is good to take suggestion from the Chatbot, but not to depend on it wholly. The suggestions on the diagnosis can be seen in the light of differential diagnosis, rather than final diagnosis. General Public should not depend on it and indulge in self-treatment.  However, it is expected to improve further.

The main story appeared in MedpageToday

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Coagulopathy in COVID-19 Deaths and Possible Measures

SARS-CoV-2 is a new disease and the scientific community is still learning about it. COVID-19 emerged as a respiratory disease from China in the December, 2019. In recent studies on SARS-CoV-2, it has been found that there are unusual diffuse small thromboses in the lungs tissue of patients, as well as vascular damage in different tissues and organs. Evidence from post-mortem findings of occlusion and microthrombosis formation in pulmonary small vessels of deceased with critical COVID-19 has been reported. The features prompted some scientists to describe the disease as a disease of vascular system.

After, SARS-Cov infects the body, it up-regulates the expression of related genes in the coagulation pathway, leading to activation of coagulation. Studies have shown that the abnormal characteristics of blood coagulation indexes caused by SARS-CoV-2 are not the same as SARS-CoV, and it is more likely to cause multiple organ failures other than the lungs.

Dysregulated coagulation with hypercoagulability has been found to be common in COVID-19 and can progress to disseminated intravascular coagulation (DIC). A retrospective analysis of patients admitted with severe SARS-CoV-2 infection found that 71.4% of patients who ultimately died from COVID-19 developed overt DIC compared with only 0.6% of survivors. On admission, non-surviving patients presented with higher D-dimer levels and prolonged prothrombin times (PT) and activated partial thromboplastin times (aPTT) compared with surviving.

SARS-CoV-2 infection damages human immune system and results in systematic inflammatory response. Activation of monocytes produce cytokines, such as interleukin 6, tumor necrosis factor, and many more, which in turn induce activation of the endothelial cells and tissue factor that trigger the blood coagulation cascade.  Activation of the vascular endothelium, platelets, and leukocytes results in dysregulated thrombin generation that occurs both systemically and locally in the lungs of patients with severe pneumonia, resulting in the deposition of fibrin with subsequent tissue damage and microangiopathic pathology. The effects of dysregulated thrombin generation are further exacerbated by an inhibition of fibrinolysis and the impairment of natural anticoagulant mechanisms. In addition, the hypoxia found in severe COVID-19 can stimulate thrombosis through not only increasing blood viscosity, but also a hypoxia-inducible transcription factor-dependent signaling pathway. All events may lead to DIC.

The activation of blood coagulation is essential in counteracting viral infections along with the immune system trapping viruses by forming a fibrin network, thus limiting their dissemination. However, a massive inflammatory and coagulative response is dangerous because it can lead to a local thrombosis in the lungs. Acute respiratory distress syndrome (ARDS) has been described in approximately 40% of 201 patients with COVID-19 pneumonia, in a study, and it was crucial in increasing the risk of death. ARDS may result from pulmonary vascular microthrombosis.

The concept of pulmonary thrombosis has been recently proposed for conditions such as pneumonia, asthma, and chronic obstructive pulmonary disease. It is known that viral diseases such as those from EBOLA and cytomegaloviruses can induce DIC. Therefore, it is not surprising that SARS-CoV-2 could be capable of doing the same.

Elevated plasmin(ogen) is a common feature in people with underlying medical conditions, including hypertension, diabetes, cardiovascular disease, cerebrovascular disease, and chronic renal illness, who are susceptible to SARS-CoV-2 infection. Plasmin enhances the virulence and infectivity of SARS-CoV-2 virus by cleaving its spike proteins. Extremely increased D-dimer in COVID-19 patients results from plasmin-associated hyperactive fibrinolysis. D-dimer and viral load are independent risk factors of disease severity and mortality. Antiproteases targeting plasmin(ogen) may be a promising approach to combat COVID-19.

Measuring D-dimers, prothrombin time and platelet count (decreasing order of importance) in all patients who present with COVID-19 infection, may help in stratifying patients who may need admission and close monitoring or not. Any underlying condition (e.g.; liver disease) or medication (e.g.; anticoagulants) which may alter should be accounted for while using the algorithm.

Measuring D-dimer had been recommended for Covid-19 patients, however, the optimal cut off for D-dimer remains to be well-established. D-dimer = 2.0 ug/ml (fourfold increase) on admission might be the optimum cut off to predict in-hospital mortality for Covid-19. The in-hospital mortality was significant higher in patients with D-dimer ≥ 2.0 ug/ml than those who had D-dimer < 2.0 ug/ml on admission. Among routine tests, D-dimer might be the best early marker to improve management of Covid-19.

According to researchers, heparin treatment has been recommended for COVID-19, however, its’ efficacy remains to be validated. The 28-day mortality between heparin users and nonusers were compared in stratified patients. The 28-day mortality of heparin users were lower than nonusers in patients with SIC score ≥4 or D-dimer > 3.0 ug/mL. Heparin treatment appears to be associated with better prognosis in severe COVID-19 patients with coagulopathy.

They suggested, based on a review of the very limited current peer-reviewed literature with low quality of evidence combined with discussions with international clinicians on the frontlines

• All patients with COVID-19 should undergo coagulation studies at admission, in particular: D-dimer, prothrombin time, and platelet count.

• Because of the possibility of patients to develop coagulopathy later in their hospital course, routine serial measurements of coagulation studies should be undertaken in all COVID-19 patients. The ideal interval has not yet been defined.

• All patients with COVID-19 should be placed on prophylactic doses of anticoagulation, preferably with LMWH, unless there is a contraindication, such as acute kidney injury (AKI), wherein unfractionated heparin is preferred.

• Therapeutic anticoagulation should be strongly considered in patients at high-risk for coagulopathy (including CRRT and ECMO), demonstrating signs of microthrombi-induced organ dysfunction, or with documented or strongly suspected macro-thromboembolism.

• Determination of high-risk patients by laboratory measures of coagulopathy may include: platelet count, prothrombin time, fibrinogen, fibrinogen-degradation products, D-dimer, and TEG. Of note, some centers are therapeutically anticoagulating all patients on admission when no absolute contraindications exist.

• Given the significant rate of AKI seen in COVID, intravenous contrast for imaging should be used with caution. Duplex ultrasonography, echocardiography, and clinical suspicion can play an increased role in these cases.

• Some early reports support use of larger bolus-dose tPA (50mg or 100mg bolus) without holding anticoagulation in order to prevent recurrence of the suspected pulmonary microvascular thrombosis underlying COVID-19 ARDS, is worthy of consideration in  COVID-19 ARDS associated exceptionally high mortality, weighed against the risks of tPA having ~1% risk of catastrophic bleeding in non-stroke patients.

• Aspirin should be considered in cases with elevated troponin and cardiac dysfunction, particularly with elevated maximal amplitude on TEG.

This information has been compiled from the study of various literatures on the subject.

Credit:

1.      Wiley Online Library: Covid-19: Novel Coronavirus Outbreak

2.      COVID-19 complicated with DIC: 2 cases report and literatures review

 

 

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Unusual Presentations of COVID-19

          A novel coronavirus emerged in China in 2019, named as SARS-CoV-2, become a pandemic. Scientists, Researchers and Health care professionals are still learning about it. It is an endeavor to compile the unusual/atypical symptoms, as far as possible, from different reputed sources. It will help the health care personnel to remain aware of the possibility of dealing with a COVID-19 patient, when patients present with symptoms, similar to some other disease.

Fever, Cough, Shortness of breath; these are what have become known as the classic, tell-tale COVID-19 symptoms. However, there can be additional non-specific, atypical symptoms or different, less common ones that should alert the health care profession, the possibility of the infection. Those include, Sore throat, Diarrhea, Myalgia (muscle aches, body aches), abdominal pain, loss of smell or taste, conjunctivitis, Tiredness or fatigue.

At present the definition of a COVID-19 Suspected Case:

Suspected Case Definitions
A. Symptoms + Travel History	B. Symptoms + Epidemiologic Link	C. Severe Symptoms
A patient with ALL of the following: acute respiratory illness no other etiology that fully explains the clinical presentation a history of travel to or residence in a country, area or territory that has reported local transmission of COVID-19 disease during the 14 days prior to symptom onset	A patient with ALL of the following: ·       any acute respiratory illness ·       contact of a confirmed or probable case of COVID-19 disease during the 14 days prior to the onset of symptoms	A patient with ALL of the following: ·       severe acute respiratory infection ·       requires hospitalization ·       no other etiology that fully explains the clinical presentation

1.    Loss of smell and taste has been reported with such a frequency in COVID-19 that some medical professionals suggest to take it as a cardinal feature for diagnosis, if, associated with features of respiratory infection, even common cold or seasonal flu. According to Carol Yan, an otolaryngologist from the University of California San Diego in the US, “if, you have smell and taste loss, you are more than 10 times more likely to have COVID-19 infection than other causes of infection."

The loss of smell reported to be so profound that the patient starts nauseating just at the sight of food. He further says, while the most common first sign of a COVID-19 infection remains fever, fatigue/loss of smell and taste follow as other very common initial symptoms.

Based on the findings, UC San Diego Health has included loss of smell and taste as a screening requirement for visitors and staff, as well as a marker for testing patients who may be positive for the virus. The original article was published in The Week on April 14, 2020 15:14 IST, can be accessed here.

2.   Abdominal discomfort may be the presenting symptom in as many as 20 percent of patients. Recent literature has revealed that as many as 20 percent of patients present to the hospital with a digestive symptom, such as diarrhea, vomiting, pain, accompanying their respiratory symptoms. And, roughly 5 percent show up with an abdominal complaint alone.

This is where abdominal radiologists can play an integral role, said industry experts in a recent article published in the American Journal of Roentgenology. A team, led by Abraham Dachman, M.D., professor of radiology and abdominal imaging specialist with UChicago Medicine, shared three cases where patients were referred for abdominal imaging and providers distinguished findings indicative of COVID-19 infection in the lung base.

Axial CT of abdomen and pelvis shows left basilar round airspace and ground-glass opacities (arrow). Appearance is highly compatible with atypical infection such as coronavirus disease (COVID-19) pneumonia.

The article published on April 20, 2020, can be accessed here. 

3.   The gastrointestinal presentation can delay the initiation of COVID-19 diagnostic workup. Notably, however, the first case of COVID-19 infection confirmed in the United States reported a 2-day history of nausea and vomiting on admission followed by loose stools in hospital on day 2, and COVID-19 viral nucleic acids of loose stool and respiratory specimens were reported positive. In a recent report from Hubei, China, 204 COVID-19-infected patients were studied, and the authors reported that digestive symptoms are not uncommon in patients with COVID-19. The original article, published in The Karger, can be accessed here.

According to the WHO, digestive issues like diarrhea and nausea may be a more common symptom than previously thought.

4.   Conjuctivitis: Several reports suggest that SARS-CoV-2 can cause a mild follicular conjunctivitis otherwise indistinguishable from other viral causes, and possibly be transmitted by aerosol contact with conjunctiva. However, at this point in the COVID-19 pandemic, practically any patient seen by an ophthalmologist could be infected with SARS-CoV-2, regardless of presenting diagnosis, risk factors, indication for visit or geographic location. Updated on April 21, 2020, online by American Academy of Ophthalmology, can be accessed here.  Access the Ocular manifestations of a hospitalized patient with confirmed 2019 novel coronavirus disease in The British Journal of Ophthalmology here.

5.    Malaise and Confusion can be present in varied number of patients of COVID-19 are some of the atypical symptoms, according to an article published in The Lancet.

               In a study, the most common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhea (one [3%] of 38). More than half of patients (22 [55%] of 40) developed dyspnoea.

6.       Headaches and dizziness may also be signs of the viral infection: According to the study in The Lancet, about 8 percent of COVID-19 patients reported headaches. Dizziness has also been reported in some cases – frequent dizzy spells or very severe or abrupt bouts of dizziness could indicate a more serious health risk, according to the Cleveland Clinic.

7.       Chills or muscle aches occasionally accompany COVID-19. Aches and chills can be symptoms of many illnesses, including the flu, but coronavirus patients have reported them. It's not clear how prevalent these symptoms are, but about 11 percent of people studied reported chills, and 14 percent reported muscle aches, according to the WHO report.

8.       Runny nose is rarely a sign of coronavirus: It is more indicative of allergies or a cold. A minority of COVID-19 patients experience nasal congestion or a runny nose – less than 5 percent of people experience these symptoms, according to the WHO report.

9.       Acute myocarditis is thought to be a possible complication associated with COVID-19. While, it is required to closely monitor such patients for the complication, medical profession should keep in mind to test for the COVID-19, whenever other symptoms or epidemiologic link is available. Laboratory testing, including troponin levels, in individuals with recent symptoms of an acute illness should be performed to guarantee appropriate identification and prompt isolation of patients at risk of COVID-19 and eventually to reduce further transmission. The article published in JAMA Network on March 27, 2020, can be accessed here.

10.    Necrotizing encephalopathy: A woman who tested positive for COVID-19 developed a rare brain disease known as acute necrotizing encephalopathy, a condition that can be triggered by viral infections like influenza and herpes.

               At this point, the brain damage "has yet to be demonstrated as a result of COVID-19 infection," according to a case report published March 31 in the journal Radiology. However, as the novel coronavirus continues to spread, "clinicians and radiologists should be watching for this presentation among patients presenting with COVID-19 and altered mental status," the authors wrote.

               The original article published online by the Radiological Society of North America on Mar 31, 2020 can be accessed here.

11.                  Asymptomatic (subclinical): Now-a-days, a large number of asymptomatic (in pre-clinical/pre-symptomatic stage) patients are seen positive for COVID-19; many are also seen with mild symptoms (easily ignored). Many more asymptomatic contacts are also positive for COVID-19. It may go up to 80%. Another study suggests that the number can be between 5% and 80%.

                       In those mild cases, the predominant CT in Lungs can be diagnostic, with the findings of ground-glass opacification, consolidation, bilateral involvement, and peripheral and diffuse distribution. Notably, in Shi and colleagues' study, the asymptomatic (subclinical) group of patients showed early CT changes, supporting what was first observed in a familial cluster with COVID-19 pneumonia. Published on February 24^th, 2020 in The Lancet can be accessed here.

12.    Atypical symptoms of COVID‑19 can be more common in immune-suppressed or immune-compromised patients. They may present with the symptoms of COVID‑19; neutropenic sepsis and pneumonitis may be difficult to differentiate at initial presentation. Medical profession has to keep in mind to screen and triage all those patients to assess, whether they are known, suspected to have COVID‑19, or have been in contact with someone with confirmed infection. In that case, COVID-19 rapid guidance from National Institute for Health & Care Excellence, updated on April 17, 2020, can be followed. 

Atypical symptoms in COVID-19: the many guises of a common culprit: COVID-19 exhibits a diverse range of clinical presentations. Whilst classical respiratory symptoms of a dry cough have been underscored, these may be preceded by atypical symptoms. More generally, it is important not to neglect other disease manifestations, since they may represent alternative modes of viral dissemination.

In critically ill patients, evidence of raised inflammatory markers suggests that cytokine storm syndrome occurs in COVID-19 and may underlie some atypical presentations. Notably, the elderly and those with multiple co-morbidities are severely affected by COVID-19, and atypical symptoms in these susceptible groups warrant further investigation.

More Readings at:

1.    Published on Mar 31^st, 2020, 23:28 IST in The Business Insider, India; 10 coronavirus symptoms you may not be aware of, from malaise and dizziness to digestive issues.

2.    Published on 1^st April, 2020 in The Science^Alert; Some COVID-19 Symptoms Are Turning Out to Be Atypical. Here's What We Know So Far

3.    Published on 05 April 2020 in thebmj in a letter to the Editor, under caption, “Atypical symptoms in COVID-19: the many guises of a common culprit.”

4.    Published on April 17^th, 2020 in Medscape:   Unusual Presentations of COVID-19: 'Our Ignorance Is Profound'

 

 

(A Paradip Port Trust Hospital Document)

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SARS-CoV-2 Transmission & Possible Preventive Measures

A novel coronavirus emerged in China in 2019 named as SARS-CoV-2, become a pandemic. Scientists, Researchers and Health care professionals are still learning about it. It is an endeavor to compile all the possible modes of transmission of the virus from different reputed sources, so that it can help to understand the behavior of the virus and suitably modify the preventive measures practiced at present. This may change as more knowledge acquired on the virus.                                                                                                             

1. 1.  COVID-19 Outbreak Associated with Air Conditioning in Restaurant, Guangzhou, China, 2022:

     During January 26–February 10, 2020, an outbreak of 2019 novel coronavirus disease in an air-conditioned restaurant in Guangzhou, China, involved 3 family clusters. The airflow direction was consistent with droplet transmission. To prevent the spread of the virus in restaurants, the researchers recommend increasing the distance between tables and improving ventilation.                                                                            Reference                                                                                                                                                                           2. Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital Wards, Wuhan, China, 2020

      Contamination was greater in intensive care units than general wards. Virus was widely distributed on floors, computer mice, trash cans, and sickbed handrails and was detected in air ≈4 m from patients. 

      In this study, researchers tested surface and air samples from an intensive care unit (ICU) and a general COVID-19 ward (GW) at Huoshenshan Hospital in Wuhan, China. 

      The study led to 3 conclusions. First, SARS-CoV-2 was widely distributed in the air and on object surfaces in both the ICU and GW, implying a potentially high infection risk for medical staff and other close contacts. Second, the environmental contamination was greater in the ICU than in the GW; thus, stricter protective measures should be taken by medical staff working in the ICU. Third, the SARS-CoV-2 aerosol distribution characteristics in the GW indicate that the transmission distance of SARS-CoV-2 might be 4 m. 

     In addition, their findings suggest that home isolation of persons with suspected COVID-19 might not be a good control strategy. Family members usually do not have personal protective equipment and lack professional training, which easily leads to familial cluster infections. During the outbreak, the government of China strove to the fullest extent possible to isolate all patients with suspected COVID-19 by actions such as constructing mobile cabin hospitals in Wuhan, which ensured that all patients with suspected disease were cared for by professional medical staff and that virus transmission was effectively cut off. As of the end of March, the SARS-COV-2 epidemic in China had been well controlled.                                                                                                   Reference

       3.  Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the
            University of Nebraska Medical Center 

            SARS-CoV-2 is shed during respiration, toileting, and fomite contact, indicating 
            that infection may occur in both direct and indirect contact.                     Reference

4.      The Role of Particle Size in Aerosolised Pathogen Transmission:

In a review, particle sizes generated from breathing, coughing, sneezing and talking showed healthy individuals generate particles between 0.01 and 500 μm, and individuals with infections produce particles between 0.05 and 500 μm. This indicates that expelled particles carrying pathogens do not exclusively disperse by airborne or droplet transmission, but avail of both methods simultaneously and current dichotomous infection control precautions should be updated to include measures to contain both modes of aerosolised transmission.                                                                     Reference                                            

5.      Respiratory Virus RNA is Detectable in Airborne and Droplet Particles

In a study, on breathing, 58% of participants produced large particles (>5 µm) containing viral RNA and 80% produced small particles (≤5 µm) carrying viral RNA. On coughing, 57% of participants produced large particles containing viral RNA and 82% produced small particles containing viral RNA. Forty five percent of participants produced samples positive for hRV viral RNA and 26% of participants produced samples positive for viral RNA from parainfluenza viruses.                                                          Reference

6.      Potential for Airborne Transmission of Infection in the Waiting Areas of Healthcare Premises: Stochastic Analysis Using a Monte Carlo Model:

The researchers have found that under normal circumstances the risk of acquiring a TB infection during a visit to a hospital waiting area is minimal. Likewise, the risks associated with the transmission of influenza, although an order of magnitude greater than those for TB, are relatively small. By comparison, the risks associated with measles are high. While the installation of air disinfection may be beneficial, when seeking to prevent the transmission of airborne viral infection, it is important to first minimize waiting times and the number of susceptible individuals present, before turning to expensive technological solutions.                                                                                              Reference

7.                7.  COVID-19 Can Travel on Shoes:

          The floor swabs also had a high rate of positive tests, potentially due to virus droplets
          falling on the ground. Half of the ICU staff’s shoes also tested positive. As medical staff 
          walk around the ward, the virus can be tracked all over the floor, as indicated by the 100% 
          rate of positivity from the floor in the pharmacy, where there were no patients.      

                                                     

                                                                                                                        Reference 
     8. How COVID-19 Spreads

         COVID-19 is thought to spread mainly through close contact from person-to-person in
         respiratory droplets from someone who is infected. People who are infected often have 
         symptoms of illness. Some people without symptoms may be able to spread virus.
         Spread from contact with contaminated surfaces or objects. This virus is spreading
          more efficiently than influenza, but not as efficiently as measles, which is highly contagious.                                                                                                                               Reference 
9. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

Aerosol and fomite transmission of SARS-CoV-2 are plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days (depending on the inoculums shed.

SARS-CoV-2 remained viable in aerosols for 3 hours in experimental conditions, with a reduction in infectious titer from 10^3.5 to 10^2.7 TCID₅₀ per liter of air.

SARS-CoV-2 was more stable on plastic, viable virus was detected up to 72 hours after application to this surface, although the virus titer was greatly reduced (from 10^3.7 to 10^0.6 TCID₅₀ per milliliter of medium after 72 hours.  

SARS-CoV-2 was stable on stainless steel, although the virus titer was greatly reduced from 10^3.7 to 10^0.6 TCID₅₀ per milliliter after 48 hours.

On copper, no viable SARS-CoV-2 was measured after 4 hours.

On cardboard, no viable SARS-CoV-2 was measured after 24 hours

                                                                                                            Reference       Reference 
10. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations; WHO

Respiratory infections can be transmitted through droplets of different sizes: when the droplet particles are > 5-10 μm in diameter they are referred to as respiratory droplets, and when they are < 5μm in diameter, they are referred to as droplet nuclei. According to current evidence, COVID-19 virus is primarily transmitted between people through respiratory droplets and contact routes. In an analysis of 75,465 COVID-19 cases in China, airborne transmission was not reported.                                                                                                                                    Reference          
 11. Speed of a Sneeze.  

The largest droplets rapidly settle within 1 to 2 m away from the person. The smaller and evaporating droplets are trapped in the turbulent puff cloud, remain suspended, and, over the course of seconds to a few minutes, can travel the dimensions of a room and land up to 6 to 8 m away.                                                                                                                      Reference

12. Coughing and Aerosols

A maximum airspeed of 8 m per second (18 mph) has been observed by researchers, averaged during the half-second cough. The cough plume may project infectious aerosols into the surrounding air.

                                                                                                                                Reference 
13. Visualizing Speech-Generated Oral Fluid Droplets with Laser Light Scattering

It was calculated that the original diameters of the respiratory drop lets ranged from1to 2000 micron that 95% were between 2 and 100 micron and that the most common were between 4 and 8 micron.                                                                                                                    Reference 
14. Seasonality of Respiratory Viral Infections

There can be possible seasonal determinants in the epidemics of respiratory viruses as well as host factors affected by these contributing factors. These include seasonal changes in temperature, absolute humidity (AH), sunlight, vitamin status, and host behavior. Animal transmission studies with guinea pigs and ferrets have revealed that high RH (>60%) and low RH (<40%) seems to allow viability of influenza viruses in droplets, while in intermediate RH (40% to 60%) viruses become inactivated.

Since, the type II alveolar cells, where the angiotensin-converting enzyme II concentrated, are located deep in the respiratory tract, are not reachable by respiratory droplets with a diameter of more than 5 micrometers, it appears likely that at least, the severe cases of COVID-19 with viral pneumonia, are the result of air borne transmission events.

The combination of low humidity, temperature, and sunlight may trigger an impairment of the local and systemic antiviral defense mechanisms, leading to the increased host susceptibility to the respiratory viruses in winter.

In addition to vaccines and antiviral drugs, non-pharmaceutical interventions to prevent respiratory infections are gaining attention. Lifestyle (eating healthy, sleeping more than 7 h/day) and hygiene practices (washing hands, wearing facemasks) are known to increase antimicrobial resistance and prevent transmission, respectively. In addition to these measures, we might consider controlling the indoor environment to combat respiratory infections. Such interventions with humidifiers (RH~45) have been realized since the 1960s with promising results.                                                Reference

15. Possible Preventive Measures¹:

1. The first and foremost message emerging out of the researches is Social Distancing:

(i)                 2 meters (6 feet), instead of 1 meter, wherever possible, like market places, malls, hospital waiting areas, restaurants, and offices etc..

(ii)               Quick disposal of patients and customers in commercial establishments (Malls & Restaurants)

(iii)             At least, 1 meter (3 Feet) distance in Triage facility in Hospital and during home quarantine (If, no separate room is available).

(iv)             Barrier (Glass) communication at Reception Counters in Acute Respiratory Infection or Fever Clinic

(v)               Restriction of entry of non-essential health care staff to the ICU/Rooms of COVID-19 patients, multi-tasking.

(vi)             Sanitization of footwear, like two coir mat system²; standing for 1 minute on a mat soaked with 1% Sodium Hypochlorite solution, then drying foot on 2^nd coir mat. 

(vii)           As health care persons (as well as some other professions, like saloon staff), who cannot maintain distancing, Correct use of PPEs (separate donning & doffing) as recommended for ICU and other places.

(viii)         Healthcare supervised quarantine, in lieu of home quarantine.
2.  Use of Facemasks: At least, Home-made mask for all, while going out (only to collect essential items). Standard PPEs for Hospital staff as per protocol.

3. Use of HEPA (High Efficiency particulate Air Filter) filters in Hospital settings (Acute Respiratory Infection treatment ICU/WARDS).
4. Following Good Hand Hygiene practice (Minimum 30 second, instead of 20 seconds) & Cough Etiquette.
5. Correct way of hand Sanitization (20 seconds, six steps as hand washing.
6.    Maintaining healthy Lifestyle (eating healthy, sleeping more than 7 h/day), physical exercise (at least in Indoor), taking fresh fruits, and Vitamin D (Exposure to Sun is better).
7. Humidifier in Rooms to maintain RH (Relative Humidity = ~45).
8. Providing correct PPEs to patient.
9. Box-Shield Protected (as shown in NEJM video) Endotracheal Intubation/Ex-tubation/Splash generation procure.
10. Sanitization of frequently touched places, Bed-rail of patient, Door-knobs, Computer Key-board & Mouse, Lifts, stair-case rail, Hospital trolleys/stretchers/wheel-chairs, and  handles of trolley/cart in Malls etc.. Sanitization of card boards (files, not required, if, not exposed; however, UV sterilizer can be used or exposed to Sun).
11. Cupper coating of steel surfaces in Hospital Settings (Like, bed-rails, bathroom door-knobs, and wheel-chairs etc.).
12. Covering the wheel-chair and stretchers with rubber mackintosh sheets that can be sanitized later.
13. Designing AIR-Conditioners with HEPA filters for hospital use, like used in Airplanes.
14. Managing laundry according to SoP (Soaking in detergent & hot water-washing/Use Hypochlorite) with correct use of PPEs.
15. Vaccination (When available).              

(A Paradip Port Trust Hospital document)

Credits:

WHO

CDC

NEJM

Worldmeter Reference

WebMD

Acknowledgements

Sri Rinkesh Roy, IRTS, Chairman, Paradip Port Trust for reviewing of the article 

Dr Raja Ravi Varma, Chief Medical Officer, Chennai Port Trust for use of hypochloride soaked mat

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