Saturday 26 September 2020

The 28th WACEM-ACAIM Special Global Web Conference on COVID-19


28th in the series of WACEM-ACAIM Joint Group Meetings

We starting this weekly meeting with the grim recognition that Europe is indeed seeing a second wave of infection. We spoke again about the influence of blind spots on this second wave.

COVID-19: The Sri Lanka Story

Dr. Eranga Nrangoda (Sri Lanka)

The National Institute of Infectious Diseases (NIID), Colombo, Sri Lanka, is the only designated quarantine hospital and only specialized hospital for communicable diseases in Sri Lanka. 

The first case of COVID-19 in Sri Lanka was a Chinese tourist visiting Sri Lanka in January 2020. She presented with fever, retro-orbital pain, loss of appetite and sore throat. The hospital sent a nasopharyngeal swab for PCR, which confirmed coronavirus infection. She fortunately recovered from a mild course of disease in a period of 10 days. 

The first Sri Lankan patient, reported to hospital in early March. He again, had mild illness with good recovery. Most early patients had contact from international travelers. Studies from Sri Lanka showed a male preponderance, and mean age of 40.8 years, as well as co-morbidities, similar to those noted across the world. 

Like any other place, NIID also faced challenges initially. Among these, anxieties of healthcare personnel, short supply of PPE, poor understanding of a new disease, limitations in isolation rooms, labs, and imaging, which they overcame quite magnificently. 

Antibodies and Biomarkers

Dr. Neelika Malavige (Sri Lanka)

Dr. Malavige presented where Sri Lanka is presently, compared to other countries, which in short, is better positioned than most, with low level of cases and low mortality rate related to COVID. But her focus of discussion was antibody responses and vaccines.

They studied neutralizing antibody responses, but were faced with infrastructural limitations, not having the specialized laboratories to study these. With some help, they received kits to progress beyond this obstacle. They studied antibody responses and followed up patients in community. They found that the mean duration of hospital stay was 17 days. Many patients had prolonged viral shedding (in some cases, up to 50 days). Of the antibodies that were generated against the virus, neutralizing antibodies were thought to be associated with protective function, and they seemed to be present up to 8 weeks in relation to clinical severity. Nearly all patients had detectable antibodies after 5 weeks of illness, but became undetectable in many patients after >90 days of illness. 

Reinfection was confirmed by the differences in the virus strain causing the first versus the second infection. The second infection had a more severe illness. 

In developing vaccine, scientists have measured antibody responses, but not memory B cell responses, this provides some hope for future studies. Viruses, historically, also become less virulent with time, providing some more hope.

Role of Military in COVID

Col. (Dr) Saveen Semage (Sri Lanka)

Sri Lanka saw clusters of infections, mostly brought back from travel abroad, or brought to from travelers to Sri Lanka. Quarantine process, contact tracing and isolation, and point of entry operations (decontamination, thermal surveillance, passenger handling and seafarer crew exchange) were run by the military, in addition of course to maintaining law and order. They had a dedicated treatment center for military cases. Additionally, the military was assisting communities during the lock down. 

Their contact tracing system was a hybrid of public health surveillance and state intelligence services. Tracing carried on till the 3rd degree of contact. Decision between institutional quarantine versus home quarantine was dependent on vulnerability. People returning from overseas were tested, but regardless required to self-quarantine at home. 82% of infected patients were in quarantine centers. 

Some of the strengths of their response came from effective communication between health and military, hybrid contact tracing as mentioned above, testing strategy and timing, leadership commitment, strong public heath system, and of course the degree of military involvement in the pandemic response. 

Monday 14 September 2020

The 26th WACEM-ACAIM Special Global Web Conference on COVID-19


26th in the series of weekly WACEM-ACAIM Joint Group Meetings

Plant Products Nanotechnology: Integrated Indian Herbal (Ayurvedic) and Nanomedicine for COVID-19, by Dr. Shyam Mohapatra (USA)

Dr. Mohapatra opened his fascinating talk with the concept of integrated medicine: a combination of experimental and experiential, holistic and analytical, functional and structural aspects of care. He highlighted some benefits of herbal medicine, such as better membrane permeability, good bioavailability, decreased toxicity, and many more. With the advent of nanotechnology and the progress made in the last few decades, the ancient macroformulations of ayurvedic medicine can now be manufactured as nanoformulations. He gave an example of Withania somnifera (ashwagandha), a long used plant with medicinal properties. Scientific studies looking for adverse effects on multiple organ systems showed Withania somnifera to have a relatively safe drug profile, and its bioactive ingredients have been used in prevention and treatment of arthritis, amnesia, impotence, anxiety, cancer, cardiovascular disease, etc. It was shown to have immune-modulating action in other animal studies. Finally in relation to COVID-19, it is shown to engage ACE 2 receptor proteins. There are other similar examples of plant based therapeutics, which in Dr. Mohapatra's words, when explored in combination with nanotechnology, will prove to be a marriage made in heaven.

COVID 19 in Japan, by Dr. Jumpei Tsukeda (Japan)

Dr. Tsukeda regaled us with the fantastic approach toward COVID-19 which was used to good effect in Japan. He mentioned that the key to a well engaged response, was the availability of 24/7 information sharing. They implemented messaging, mobile and computer based voice applications, tele-ICU. Teams were divided to play to their strengths, and redeployed to areas that needed the redistribution. There were in-hospital teams and out of hospital teams with excellent follow up provided to both sets of patients. Hospitals were renovated to establish COVID units, COVID triage, and COVID ICU. The government and health sectors put out simple to understand messages, such as "AVOID 3 Cs - Closed Spaces, Crowded places, Close-contact settings". They, too, faced several challenges, but have continued to prove how Japanese discipline and understanding of healthcare of their people is a priority. 

Metamorphosis of COVID, by Dr. Indrani Sardesai (UK)

I had the honor and pleasure to be included in this wonderful panel of speakers. My topic alluded to the metamorphosing of COVID-19 from "just another viral infection" as thought back in January, to one that has caused devastating to the global population, to the economy, to both physical and mental health. At first thought to affect just the vulnerable above-60 population, to now affecting all without discrimination. In the current climate of social connection and the power of media-driven narrative, there has been information coming out fast, sometimes too fast to the detriment of trust between the common man and the healthcare sector or those who represent it. However, in all this, we also bear witness to the rising new disease as witnessed by people who understand science and those who don't. The scientific community is so focused on this disease, papers, publications, therapeutic trials abound. We have resigned ourselves to the fact that this disease is here to stay, but we are determined in finding out more, and taking away the power of the unknowns.

COVI-Sepsis from Qatar, by Dr. Hassan Al-Thani (Qatar)

Beginning his talk about the variety of ways COVID has presented at its worst, from the fatal pneumonia raving the lung, to the necrotizing fasciitis feasting on the body, Dr. Al-Thani highlighted the serious nature of the disease. The Qatar model of healthcare is particularly inspiring in its proficient and remarkably rapid response in dealing with the disease. In their anticipation of COVID reaching Qatar, they generated surge capacity for both ICU beds and general hospital occupancy. They went from a hundred ICU beds in one week to a thousand in the next. Their inpatient capacity increased by five fold. They paid a great deal of attention to staff health and well-being, realizing very early that weaknesses in staffing (be it from illness of self or family, burn-out, etc.) would result in a domino effect to take down the whole system. The speed of the response, government support, and subsequent results prove that Qatar means business. 

Malaysian COVID Response, by Dr. Mohammad Alwi (Malaysia)

Malaysia put into action the lessons learnt from its experiences with SARS, nipah virus, and MERS. Their regular table top exercises and simulation exercises kept them up to date and ready to deal with anticipated and unanticipated events. They were able to rapidly establish command centers, triage areas and communication hubs. They put a lot of effort into regular open communication which helped with a trusted and effective work environment, ultimately leading to safe and effective patient care. Dr. Alwi's hospital even managed to make their local and national news. The key to their success for regular training and good communication.

Operational Restructuring in COVID: The ED in NHS, by Dr. Joydeep Grover (UK)

Just like a lot of hospitals around the world, the NHS trust hospitals in the UK also created surge capacity at the outset in anticipation of COVID reaching the UK. Fortunately, more beds were created than utilized rather than the other way around. Secure areas or secure corridors/paths were created to limit cross contamination throughout various in-hospital areas. There was the general principle of process development, attended by experienced clinical and non-clinical staff, communication on a regular basis, and finally putting plans into operation in a systematic manner. Attention was paid to staff well-being across trusts, addressing the need to recognize and care for staff's health and morale. Risk assessment scores were developed taking into account that staff can also belong to the vulnerable groups, and due precautions taken to ensure safety. A pleasant experience for the NHS was the public lauding and "Clap for carers" initiated by the public themselves. Members of the public, local eateries and businesses would drop off spare PPE, food, cards etc, in a show that was touching and motivating to front-line workers in hospital and community based teams. 


These last 3 weeks, we have celebrated the occasion of regular weekly international meetings, and the completion of 25 meetings - no small feat - with a line up of speakers from across the world, experts in their field, all invested in the betterment of our handling of COVID and the wider aspects of the practice of medicine.

Tuesday 8 September 2020

The 25th WACEM-ACAIM Special Global Web Conference on COVID-19


25th in the series of WACEM-ACAIM Joint Group Meetings

COVID lessons, by Dr. Sagar Galwankar:

The pandemic highlighted a variety of problems - from the disease itself, people involved, supply and demand dynamics, hysteria. Practices lacking an evidence base were taking place generously. It is interesting to note and important to recognize the sometimes apparent but sometimes subtle difference between improvised practice versus compromised practice. With time and experience; with data, papers, analyses - solutions also came to light, in fact some are solutions are still evolving. 

Case based learning, by Dr. Chauhan:

Dr. Chauhan presented an unusual case of a young patient who died from a short neurological presentation with fever. The case had symptoms and signs, and events suggestive of rabies, alongside symptoms of COVID with a positive PCR test. We talked about the neurological presentations of COVID-19, as well as the potential to activate or exaggerate other concurrent illnesses, whether viral, bacterial, other or mixed causalities. 

POCUS/CT in COVID in the Netherlands, by Dr. Prabath;

This presentation, including a summary of an exciting study, talked about the use of point of care ultrasound and CT scans and their predictive values and usage in COVID-19. Coming to the conclusion that POCUS was indeed found to have excellent negative predictive value in the hands of trained users, however CT was the better imaging modality for ruling-in a diagnosis and providing further information.

Environmental Coronology, by Dr. Thakur:

Dr. Thakur's presentation was not only a nifty recap of the coronavirus, but also provided an insightful look at the environmental impact of COVID-19 and the impact of the environment on COVID-19 as well. Where it is fairly easy to become hyperfocused on singular aspects of the disease, the pandemic made us learn to divide our focus, necessitating the process of prioritization - to think about human factors, PPE, supply chain dynamics, diagnostics, data, and ever-changing discussions. 

Supply-chain resilience, by Prof. Venkat:

This much talked about topic reminded us of the behind-the-curtains processes that never ceased to persevere through the pandemic in its efforts to keep the "system" running. Apart from the vast array of clinical problems, this working and resilience of the supply chain - transport, waste management, equipment provision, etc. has also had its hurdles. Through a joint process of collaboration and innovation, perhaps the reason it is so under-recognized is because of how well it has coped.  

Telemedicine in Italian COVID-19, by Dr. Salvatore:

Italy was one of the pioneers for pushing the concept and demonstrating the execution of telemedicine in COVID-19. Circumstances necessitated innovation, quick-thinking, and optimal utilization of resources to allow reductions in avoidable admissions to hospitals while balancing the practice of safe medicine in recognizing the dynamical decision making in a rapidly evolving disease. Several papers came from Italy, and Dr. Salvatore presented the protocols suggested and used by his hospital which proved successful in sifting out the low severity COVID patients who benefited from avoidance of institutionalization while still receiving adequate, and frankly impressive medical tele-follow up. 

COVInventions from Israel, by Dr. Tal Or:

Israeli medicine is often involved in innovations and process exploration. In his presentation, Dr. Tal Or spoke about the nasal scent recorder, a unique little device which analyses exhaled breath of the individual being tested for coronavirus, and delivers the results to their smartphone application with results in remarkably short duration of time. The tests showed 85% accuracy. Combined with different considerations when evaluating patients, this would and has saved time and resource utilization.

More to come on September 12th...