A landmark Webinar was conducted on 23 April 2020 between the Medical Expert Teams from People’s Republic of China and the President of Association of Private Hospitals Malaysia represented by me and Malaysian Medical Association by Hon General Secretary, Dr Thivunarukarasu.
Log on to hear the entire session: http://cutt.ly/OywFwNW
The topics included screening, anti cytokine therapy, convalescent serum treatment, occupational exposure and risk management, MCO, Diagnostic & screening Test for Co- Vid 19, Critical Care & fatality, Immunity & Reinfection and Psychological issues related to Co-Vid. The 2 hours webinar covered everything comprehensively with live audience on social media.
Summary by: Dr Nurul Yaqeen Mohd Esa
Clinical Updates in Covid-19: Experience sharing with General Practitioners and Private Hospitals Doctors
23 April 2020 (2.30pm -5pm)
Chairperson: Datuk Dr Christopher Lee
Moderators : Datuk Dr Kuljit Singh, dr Thirunavukarasu Rajoo, Dato Dr Goh Pik Pin
China Doctors panelists: Dr Li Jun, Dr Zhang Youping, Dr Yang Shifang, Dr Wen Miaoyun, Dr Luo Xiaodan, Dr Liu Tao, Dr Sun Jiufeng, Dr Liu Xiangxin
1. What is your opinion on usage of Ab rapid test to asses immunity among population?
Prof Dr Lee Jun: We’re not using any rapid test kit in China, because it is not sensitive enough and lots of false negative. We used PCR test, it may take more time, but it is more precise. After the pandemic, we may use Ab testing kits, to see how many have been infected, and how many were not infected
2. Studies have shown variable virus incubation period, some up to 27 days, for asymptomatic patient, how many days to quarantine?
Prof Dr Lee Jun: Virus shedding among some patients varies, some can go up to 30 to 50 days. In China, our belief is, if still positive, hence, still infectious, we will quarantine, until the test result is negative. After negative result, we will still monitor this patient for 2/52 more. In this way, we try to eliminate any risk or possibility of infection
3. When is the right time to start anti-cytokine treatment, any window period when this anti-cytokine rx will be effective?
Prof Dr Lee Jun: No one exact right time to start anti-cytokine rx, in view of cytokine release syndrome. In our clinical practice, we consider using anti-cytokine rx, when : 1. Sx of rapid progression to severe state, 3. radiological features showed rapid deterioration, 3. Increasing rapidly: IL-1, IL-6. In one of clinical research, we used Tocilizumab, no significant effect in patients
4. Use of immunosuppressive drug for RA, like IV Ig during cytokine storms? Your experience?
Not recommended for routine use. If we’re using, not recommended to use standard dose. If using combination of IgG, IgA, IgM,
5. How does convalescent serum work in critically ill patient ?
We don’t recommend to use regularly, because we don’t know the exact action mechanism for it to work. Whether there is antibody, Ig whether they have it, which one they’re taking it back. All these info, we don’t know yet, hence, we don’t recommend to use it on regular basis. We have used convalescent on 5 cases of Covid19 patients. 4 cases have seroconvert in 12 days, 4 cases of ARDS have recovered, due to limited no of samples, and no comparison, and also all 5 cases they range from 30 -70 y.o, with no co-morbids, but still, those are not good enough facts and evidence to use convalescent therapy regularly, and exact action mechanism still not clear
6. In a hospital, where u have frontliners, who could be potentially exposed, do u quarantine them for 14 days, or u test, and ask them to come back to work if test negative immediately ?
Prof Zhang Yu Pen (ID): If got 1 positive case, will do thorough medical survey in the hospital, if got healthcare worker exposed, they will need to be quarantine for 14 days. If situation allows, can be quarantine at hospital, if hospital can provide, 1 room for 1 person. After 14 days quarantine, will be given 2 PCR tests, 24 hours apart, if these 2 tests negative, then can go back to work. After quarantine end, the HCW still require to wear facemask (FM), and take body temperature every day for next 14 days. A for other HCW not exposed, they will be managed by specific dept, need to wear mask and take body temperature BD x 14 days. Not only doctors in fever clinic, or ID, but all doctors have to be involved in mx of covid19. These doctors will be trained for covid19 and given post to manage covid19. There will be 1 specific person to provide PPE equipment & procedures, and monitor whether we’re using them correctly. If any accident/exposure, and develop sx of cough, follow the procedure. All staffs in fever clinic, will have 2/52 shifts. For HCW in quarantine ward, will try to be shifted once per month, so every staff have time to rest
7. 7,000 private clinic, cater for simple acute illness. Exposed to covid19, as now, lacking in PPE, what is your practical advice?
Currently, in china, every community hospital and clinic, have 1 temporary quarantine room. For every patient, they will be taken body temperature, check for any respi/GI sx. Asked questions: any close contact with anyone from epidemic area within 14 days, any confirmed case in community, any h/o travelling to epidemic country, any contact with symptomatic person in home/school. If any of these answers are positive, they will be immediately quarantined in the temporary quarantined room, then be transferred to designated covid19 hospital, for further screening. Once we have done diverting of this patient, then, the doctor will just use standard clinical precautions: FM, white coat. For the doctor who come from dept with frequent aerosol-generating procedures, they will use N95 mask. Due to shortage of PPE, use appointment system, patient with high risk exposure – can be seen in 1 day, so doctor can only use full PPE in 1 day only.
8. What are the exit strategy from lockdown in China? What are the preparation for people who’re returning to work?
Prof in Epidemiology: 3 pre-condition:
1. Not lifting up MCO in all place on same time, depends on place. Divide into 3 categories, based on risk level. Low, moderate, high risk level. Lockdown lift different from all these 3 different level. Low risk : Daily life of citizen and normal business are all recovered. Moderate risk: Daily life & business are to some extent, limited. High risk : Business activities, very much limited.
2. High risk travelling to low risk, and will be quarantine, undergo thorough physical examination. In this process, china developed system called: Health code (QR code). Citizen who try to go to public place, or travel from place to place, they must declare their health condition in the system. After declare, if result is green, they can go to other places. If based on info declared, system detect that health condition is not safe, or there’s possibilities of carrying the infection, then she/he will be labelled yellow/red, hence need quarantine/treatment. QR code, info to be captured, are name, age, place of stay, any clinical symptoms of covid19. After they declare via the app, the system will automatically evaluate the health condition of the person. The person will have to scan the barcode at the supermarket, and tell the person, whether he/she is healthy enough to enter. If the health condition is green, means she/he is healthy, hence can enter supermarket. If not green, cannot enter supermarket
3. For all cities which have been lifted from lockdown. 1. Strengthened the health ctrl on the communities, and prevent any infection of covid19 in the community. To strengthened of health condition monitoring, and stop spreading fo covid19 at the hospital
9. Any role of Ab test to allow patient to go back to work ? as surveillance ?
China already published guideline for recovery, and for people to go back to work. For all those workers who come back from areas of infection, they need to be quarantine before they can start their work. Those workers will still be monitored.
10. Which Ab test is reliable to use? when to use it?
According to lab research, IgM is not sensitive enough. We’re trying to make sure whether patient is really infected with covid19, so we use PCR test, not Ab test. Another choice, nasopharyngeal, fecal. Blood sample, we didn’t take.
11. 3 SARS-CoV-2 strains A, B, C, how does different strains of virus affect the PCR test? any differences?
No effect of strains on PCR test
12. Most patients died after needing ventilators. What would be the right time to intubate patient to get better outcome?
Dr Yang Li Fang: We have to say that in the early stage, mortality rate in Wuhan actually very high. HCW or individual that time, didn’t really know much about covid19 that time. Huge influx of patients, the resources not enough. We also have to take into consideration, there’re elderly patients and with underlying disease during 1st generation of the disease. 2nd & 3rd generation of cases, no significant share of elderly/pts with co-morbidities. With support from gov & international, mortality decreased. Regarding time of intubation, few measures, High volume oxygen treatment, NIV. Need to pay close attention to oxygen index. This is just general principle, there’re circumstance, where we intubate at early stage. If SaO2 less than 90%, patient will usually deteriorate faster. For intubation, need proper PPE, tranquilizer, so intubation will succeed in 1 go
13. Intubation of covid19 patients, PPE have to be complete, what do u suggest for anaesth to use for complete protection ?
For intubation, we use highest level of PPE: N95,Face shield, PAPR, positive pressure ventilator
14. Use of negative pressure ventilation room, for Covid19 patients ?
Yes, we do use negative pressure room, but sufficient if use 1 room for 1 patient principle
15. How many % of patients in china developed Ab after infected by covid19 ? Does positive Ab means protection from Covid19 ? what’re the risk of reinfection in china ?
% to develop Ab in 2/52 is 70%
% to develop Ab in 3/52 is 95%
Strains of virus we found in China, A, B. C comes from imported cases
Ab will protect them from re-infection of covid19? still gathering data & doing research on this. From the data that we currently have, so far in china, there’s no cases in china for re-infection. There is case of re-positive after tested negative. The reason for this situation, we have several positive, during rx of covid19, some patients maybe given suppressive medications, after discharge, no more medication given so that’s maybe the cases. Based on research done in China regarding covid19 in rhesus monkeys, once the monkey recovered from covid19, no re-infection among the positively tested monkeys.
16. WHO reported only 2-3% develop Ab after covid19 infection. What’s your comment on this?
Not sure about WHO report, but from our experience, 70%, will develop neutralizing Ab within 2/52. After 3/52, more than 95% will develop neutralizing Ab
17. What is your advice to increase immune system among healthy community? any role of vitamin D, probiotics?
From our experience, it is better to have better personal protection. Example, to be fully covered, when going to public places. Hand hygiene. Make sure surface & air properly disinfected. Healthy living & eating habit. Stay active, keep yourself healthy. So far, in clinical literatures, some medications can be effective in certain extent in fighting covid19, but so far, no miracle drug to fight against covid19 for now. So far, no evidence that large dose of vitamin C, vitamin D, probiotics are helpful in fighting against covid19.
18. How far is development of vaccine in China?
Currently, there are 2 kinds of vaccine under development in china. 1 is inactive vaccine, another one, nucleic acid vaccine. Currently those 2 vaccines under development in phase 2 clinical test right now. If everything goes smoothly, phase 2 of clinical test will proceed to phase 3.
19. Treating covid19 is depressing among HCW. What is the most common mental illness ? Most effective way to treat this ?
Anxiety is the commonest mental illness. To cure this, protect them, make them go on shift, consideration for fasting of HCW.
Notes taken by :
Dr Nurul Yaqeen Mohd Esa
Consultant Respiratory Physician
Sunway Medical Centre Velocity
I would like to thank Dato Dr Goh Pik Pin who arranged this webinar and the Chairman of the session: Datuk Dr Christopher Lee.