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Covid-19: Japan declares state of emergency as Tokyo cases soar

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1447 (Published 09 April 2020) Cite this as: BMJ 2020;369:m1447

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Rapid Response:

COVID 19 : Certain salient points

Dear Editor,

We have read this news and are shaken up [1]. World is also quite shaken with Covid 19, which has a high infectivity rate, and will pass on the infection to others easily. But the virulence of this infection is limited. Word needs to go out that COVID 19 infection may be present as a positive test will tell, but this will not make everyone ill or sick, and not everyone who is detected positive is going to die. Four fifths of cases who are infected, don't even know it or have or had any symptoms [2].

The world can take notice of three public figures who were recently sick with COVID 19 infection and now they are totally well. We have the British Prime Minister and the Prince of Britain, along with the Chancellor of Germany are on our minds.
Based on facts, at least now, this wave of panic, desperation, awe, phobia, helplessness, feeling of nothing going right and of impending doom, and death for all those who get infected, must be dispelled at the earliest [3-5]. Much has already been written by us about COVID 19 on this count, and more [6-11].

Now we also have the hindsight of whatever has happened since December 2019. We have not seen the deaths of all elderly people, and of all people who were up against multiple other diseases. However we have witnessed deaths of all those frail elderly individuals of ripe age, who were suffering from multiple other morbidities and might have delayed seeking help before it became too late. We have also seen deaths amongst weak and impoverished sick individuals. It is just that when some more effort was required and anticipated for keeping afloat, that's when they couldn't bear anymore and they sunk. Covid 19 seems more like the last straw that broke the camel's back [2]. Young adults, who had serious issues with health and were probably weak with poor reserves and immunity, also took the bullet. By far children and individuals upto 40 years of age have escaped serious illness from Covid 19.

Even if Covid 19 happens to progress into a severe disease in some individual, it is never from the word go. Covid 19 is a type of FLU, and normally behaves like a flu that clears off by itself in over 80 % of all those infected. Dry cough, sore throat, fever, with or without chills, headache, bodyache, occasional diarrhea and vomiting, are the usual symptoms. Chest pain may follow when breathing starts to become difficult, but usually not on the very first day and not as the first manifestation of this illness. To put it straight, Covid 19 is a cough or flu that has turned bad, and 80 % will have either no symptoms or a mild to moderate severity illness which will clear off in a week or so. . Period. Anyone would know when a cough has turned bad. Wouldn't that be the time to consult a doctor and seek appropriate advice, before it gets too late? From what is known, around 80% or so would not be landing up in a hospital or in an ICU. Requirement for needing a ventilator will also not be coming suddenly or abruptly. Surely one would understand that avoidance of self medication is a must. For fever and bodyache Paracetamol / Acetaminophen could be the right choice. People suffering from cough must avoid taking cough suppressant, and instead use a cough expectorant which will help in letting the phlegm get out. Even if hospitalized, general population must be reassured that maximum percentage is getting well with the modern treatment.

Essentially hope must not be lost. While caution and a bit of fear is needed, panic should certainly be erased. Truth be told that even a pauper or a prince may get infected. Since this particular virus is so infective, perhaps not even an Alcatrez type security can prevent infection from Covid 19. Complete isolation will not be of help to everyone, but may be of help for those who are at risk of having poor prognosis. We are looking at those individuals to be isolated who are also frail, weak, and infirm, bed ridden patients, patients with chronic diseases of the lungs, heart, liver, kidneys, blood, HIV / AIDS, reduced immunity, transplants, extensive Tuberculosis and other chronic respiratory infections, bronchial asthma, COPD, community acquired pneumonia, uncontrolled diabetes, poor cardiopulmonary reserves, malignancy, etc, and specially those elderly who are already suffering from some severe diseases. They will have to be given special care and protection until this pandemic is finally over, which is not going to be soon. It is not that every elderly will die, or that only an elderly will succumb to Covid 19. Nursing care and home based care can be provided either by those people who have escaped this infection, or after having been infected, they have developed strong antibodies against Covid 19 and are not carriers for this virus. Unless contraindicated, all of them will require to be vaccinated once a vaccine is available against Covid 19.

Doctors and all paramedical staff will have to take extra precautions, as they are more exposed to any infection that a patient may be carrying, and more so if it is Covid 19 [12]. All isolation and quarantine centres need to be disinfected daily. Similar exercise may be needed for all hospitals so as to prevent hospital acquired infection and to allay risk for the medical staff and the doctors.

New researches removes doubts about Covid 19 infection in mothers during delivery [13-14]. However the possibility of congenital deformities as seen in Rubella or with the infection by Zika virus must be ruled out at the earliest, and a word of caution given out to delay conception until this aspect is thoroughly checked out.

Best regards.

Dr (Lieutenant Colonel) Rajesh Chauhan
MBBS (AFMC), Master in Medicine (CMC Vellore), PGDGM (Geriatric Medicine), PGDDM (Disaster Management), AFIH (Industrial Health), DFM (Family Medicine), FISCD, ADHA (Hospital Administration) & LLB

Dr. V.T.K. Titus.
MS (Ortho), Diploma National Board (Ortho), Diploma Orthopedics
Professor & Head, Department of Orthopedics,
CMC Vellore, Tamil Nadu. INDIA.

Dr. Ajay Kumar Singh, MD (Medicine)
Asst Professor, Department of Medicine,
Index Medical College, Indore. India.

Dr. Shruti Chauhan, MDS
Reader, Index Dental College, Indore. India.

References:

1. Looi Mun-Keat. Covid-19: Japan declares state of emergency as Tokyo cases soar BMJ 2020; 369 :m1447

2. Day Michael. Covid-19: four fifths of cases are asymptomatic, China figures indicate BMJ 2020; 369 :m1375

3. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet2020;395:497-506. doi:10.1016/S0140-6736(20)30183-5 pmid:31986264

4. Onder G, Rezza G, Brusaferro S. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA. Published online March 23, 2020. doi:10.1001/jama.2020.4683

5. Chen Tao, Wu Di, Chen Huilong, Yan Weiming, Yang Danlei, Chen Guang et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study BMJ 2020; 368 :m1091

6. Chauhan Rajesh. COVID 19 : Fresh approach, initiative, and opportunity. BMJ 24 March 2020. Available at : https://www.bmj.com/content/368/bmj.m1141/rr-4 Accessed on 08 April 2020

7. Chauhan R, Singh AK, Chauhan S.. Covid-19 : Catch the tiger by its tail.
BMJ 28 March 2020. Available at : https://www.bmj.com/content/368/bmj.m1190/rr-1 Accessed on 08 April 2020

8. Chauhan R, Titus VTK. COVID 19 : Alcatraz type maximum security for only those who really need it. BMJ 03 April 2020. Available at : https://www.bmj.com/content/369/bmj.m1375/rr-3 Accessed on 08 April 2020

9. Chauhan R, Titus VKT. It shall be prudent to start testing seniors first for new corona virus infection (COVID-19). BMJ 04 April 2010. Available at : https://www.bmj.com/content/369/bmj.m1392/rr-0 Accessed on 08 April 2020

10. Chauhan R, Singh AK, Chauhan S.. COVID 19: The last straw that broke a weak camel's back. BMJ 01 April 2020. Available at : https://www.bmj.com/content/368/bmj.m1199/rr-11 Accessed on 08 April 2020

11. Chauhan R, Titus VTK. COVID-19 : Stop this panic and be more reasonable fellas, huh? BMJ 08 April 2020. Available at : https://www.bmj.com/content/369/bmj.m1373/rr Accessed on : 16 April 2020.

12. Godlee Fiona. Protect our healthcare workers BMJ 2020; 369 :m1324

13. Sutton D, Fuchs K, D'Alton M, Goffman D. Universal Screening for SARS-CoV-2 in Women Admitted for Delivery. N Engl J Med. 2020 Apr 13. doi: 10.1056/NEJMc2009316.

14. Mayor Susan. Covid-19: Nine in 10 pregnant women with infection when admitted for delivery are asymptomatic, small study finds BMJ 2020; 369 :m1485

Competing interests: No competing interests

17 April 2020
Dr (Lieutenant Colonel) Rajesh Chauhan
Consultant Family Medicine, Geriatrics,Industrial Health, Disaster Management
Dr. V.T.K. Titus, Professor & Head, Department of Orthopedics, CMC Vellore, Tamil Nadu. INDIA; Dr. AK Singh, MD (Medicine), Asst Professor Department of Medicine, Index Medical College, Indore; Dr. Shruti Chauhan, MDS. Reader Index Dental College, Indore, INDIA.
Family Healthcare Centre, 154 Sector 6-B (HIG), Avas Vikas Colony, Sikandra, AGRA -282007. INDIA.