CORONA-COVID-19 : SARS-COV-2

CORONA UPDATE-1
HOW TO SANITIZE HOME ITEMS
(Compiled By)
Dr. Neharika M Bora, Dr. Narendra Malhotra, Dr. Jaideep Malhotra, Dr. Keshav Malhotra, Prof. Nihal S Jain
Introduction
Its COVID times, probably the most difficult times faced by human beings since the 1918 Spanish Flu
pandemic. The situation is worse than world war, because we are unable to see the enemy ―CORONA
VIRUS‖. And this virus is entering in our lives from everywhere and anywhere.
Here are some tips to keep your home safe from CORONA entry.
How to sanitize home items is compiled by various inputs and experiences.
Vegetables and fruits (Virus Stays 6-8 hrs)
1. Keep all vegetables and fruits outside for 4 hrs in a packet;
Wash in warm water with baking soda; or
Wash with potassium permanganate solution.
Finally wash with clean water.
2. No sanitizer should be sprayed on food items.
Wash in water with Ozonizer for 30 minutes
Wear a mask while washing vegetables.
3. For Vegetables and Fruits which cannot be washed in hot water (e.g. onions, banana) or which cannot be
kept in sun as these are perishable, so keep them for 4 hrs under a fan and clean with edible/ friendly
washing material (Stericlean).
4. For sanitizing vegetables and fruits prepare a spray at home- 2 spoons vinegar, 1 full spoon lime juice / 1
spoon salt, 1 spoon baking soda mixed in 200 ml water. Spray by a spray gun on fruits & vegetables, leave
for 2 min and then wash with clean water says a leading homeopath Dr. Sidharth Mishra.
Medicine Strips
Keep in a closed box at room temperature 6 hrs – 12 hrs, or keep in a U.V. box.
Clean with Enviroguard, Stericlean, alcohol spray on even sodium hypochloride & hydrogen per oxide.
Perishable Grocery (milk, cheese, meats etc)
Packed grocery items in a box can be washed with soap water, contents emptied and packing box disposed
in a way that it does not come in contact with human beings. Do all this wearing a mask. .Preferably to be
kept at room temperature if it does not require refrigeration. Refrigerate after opening the contents.
Cooked Food from Outside
Virus is deactivated by cooking so cooked food eating (even from outside) is not a problem. The concern is
the packing box and the person delivering. (Zomato etc.) Make sure that the person is wearing gloves and a
mask and sanitize the box with alcohol or sodium hypochloride spray.
Just microwave and reheat the food you get from outside.
Dry or / and sanitize the boxes, empty the food and discard the box (wear mask & gloves).

Paper Items (cash, stationary, newspaper and books)
As paper items are porous the droplets will dry soon and virus cannot survive long. (2-3 hrs).
It is preferable to keep all paper items outside or under a fan to dry for 2-3 hrs before use.
Plastic items such as pencils, pens, pencil boxes etc. can be sanitized by spraying or mopping (sodium hypo-
chloride, sanitizer, Enviroguard, LOC, Stericlean etc.)
News papers do not spread the virus and are relatively safe.
Clothes and Shoes
Shoes worn outside should be removed and left outside the home. Also clothes worn outside should be
removed on returning home and dipped in bleach solution (Sodium Hypo-chloride).
Newly purchased clothes and shoes should be left out for 48 hrs and should be washed before use.
Letters and Courier Items
All posts, couriers, letters should be left in sunlight or under fan to dry for at least 3-4 hrs. Plastic & metal
boxes should be sanitized and disinfected by spraying and leaving sanitizing material for 10mins before
mopping dry.
It’s better to be over careful than getting infected. Please be safe, take precautions, maintain hand hygiene,
wear mask respect physical distancing. Follow SMS (Sanitize – Mask – Social Distancing).
Conclusion
The virus is here to stay with mankind for a very long time, may be forever, so we just need to be careful
and follow S.M.S. (Sanitize : Mask : Social Distancing). Do not get paranoid or panic, just be careful and
teach others to be careful.
“YES WE CAN BEAT CORONA! JUST SANITIZE!”
Acknowledgements
W.H.O., C.D.C., Government of India, Ministry of Health & Family Welfare, ICMR, IMA, FOGSI.

CORONA UPDATE 2
SOCIAL LIFE AFTER COVID TIME : THE NEW NORMAL 2020: CATCH 22
Compiled By:
Dr. Neharika Malhotra Bora, Dr. Narendra Malhotra, Dr. Jaideep Malhotra, Prof. Nehal S Jain
Introduction
Humanity today has been attached by an unknown enemy, which is deadly, highly contagious and can only be
prevented. This virus is going to live with mankind for a long-long time till we have a vaccine and medicine to kill.
So How will people live now, What will be the new normal ?
1. No handshakes only “Namaste” or elbow shake or heel touch. When you meet anyone just nod your head and
bend to say hello or put your hands to your heart.
2. Designer masks matching with sarees & suits & shirts. Mask will be the most essential & compulsory dress to
wear to go ahead & #maskyourself #maskindia.
3. No lipsticks for women unless they wear a plastic transparent mask and now we will have the masks which will
open like a fish mouth whenever you want to eat.
4. No coughing, sneezing shouting, spitting allowed in public. Respiratory manners will strictly have to be followed
cough & sneeze in the mask or on your elbow or sleeve.

5. Classroom will have only 10 children per room only sitting 6 feet apart & wearing masks with subject / class /
school and their name on the T-Shirt name on mask
6. There will be no parties, no wedding parties(only 50 members allowed in weddings). All social gatherings will
have to follow social distancing strictly and transparent cover all with masks and gloves will be in vogue as the
new normal.
BAPTISM and NAAM KARAAN will all be online or from far away maintaining social distance.
7. Even in funerals more than 20 members will not be allowed. This will be sad as friends, family and near relatives
will not be able to wish you good bye on your last journey.
8. Honeymoon in home will be the new normal and hugging thru plastic coverings and kissing masks will be
available. Premarital health check and covid test might become a routine.

9. No International tourism travel for next 2 years, only very essential business travels (No hand baggage allowed
& social distancing). Long waits at airports, no eating, no newspaper, no reading marerial in planes will be the
new normal meditate while you travel with protective gear.
10. People will take virtual tours on 3D / 4D Software on laptops to visit beaches museums, restaurants & prayer
places.
https://youtu.be/coKs3KnIcao
https://www.airpano.com/
Physically visiting places may be delayed for the next two years.
11. The latest fashion will be wearing trikni on beaches as masks will be compulsory.
12. For Doctors
OPD attire....sarees  Only PPE
Lipstick  or Transparent Mask
Blow dry hair  Hairs to be tied
Watch  Time seeing on mobiles
Necklace  Bare neck looks the best
Fancy pen  Simple Pens
Fancy mobile  Simple Phones, No phone covers
Fancy purse  Simple one-two pocket purses
13. Shopping henceforth only for eye make-up and diamond
earrings good perfume and designer masks, don’t wear belt,
rings, when you go out. Watch is not required. Your mobile has
got time.

14. No hand kerchief. Take sanitizer & tissue if required.
15. Do not eat outside food for 1 year. If going to restaurants maintain social distancing.
16. Prefer vegetarian food, Increase immunity. Take lots of antioxidants, zinc & Vit-D.
17. Don't bring the shoes into your house. Leave them outside. Follow the Indian tradition of barefoot inside.
18. Clean your hands & legs when you come home from outside, better have a full bath with soap & hot water.
19. Do not go to the Cinema, Mall and Crowded Market for 6 Months now. If possible also Park, Gyms, Party, etc.
should also be avoided. The new normal is stay home.

20. Be very careful while at Barber shop or at beauty Salon parlor.
21. When you feel you have come nearer to a suspected patient take a thorough bath with soap & hot water.
22. For General Public : Future is changing
a. Only 3 persons can travel in a car... the 4th person attracts the Covid, the pillion rider on a two wheeler
is Covid prone !!, only 30 persons in a bus. 31st will bring corona.
b. After 7 pm, corona takes walk till 7am. Don't venture out even in night.
c. If you carry liquor from shop, corona won't mind. But it will catch you, if you sit in bar and drink.

d. If you travel with pass between Zones you won't get it. But it will hold on to you if you travel without
pass.
e. You won't get it, if you buy from vendor or shops. But corona is waiting for you in a market. Order for
home delivery.
f. CORONA won't touch politicians and their crony, without mask. But if it happens to see a common man
without mask, it will run to embrace him (CORONA भी एक POLITICIAN है).
g. CORONA is waiting in temples, mosque and churches.
h. It will surely catch you if you dine in hotels. But it doesn't bother if you sit there waiting to take away
food (Social Distancing).
i. It is not invited in rich marriages with less number of guests. But in poor man's marriage, it accompanies
51st man (So not more than 50).

23. The threat of CORONA is not going to end soon. Learn to live with this deadly enemy.
So be careful and learn to live with it CORONA our deadly enemy...
Acknowledgements
Welcome to year 2020: “The New Normal 2020”.

CORONA UPDATE 3
WILL CORONA VIRUS GO AWAY?
Dr. Narendra Malhotra
M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S., F.M.A.S., A.F.I.A.P.
Managing Director
Global Rainbow Healthcare, Agra
Prof. Dubrovnick International University
Director IAN Donald School (India)
V.P. WAPM (world association of prenatal medicine)
Member Education Committee IAPM
Past President ISPAT (2017-2019), ISAR (2017)
Past President FOGSI (2008)
Founder Editor SAFOG Journal
Mobile no. 9837033335
Email id: mnmhagra3@gmail.com
Dr. Neharika Malhotra
M.D Obs-Gyn, FICMCH, FMAS
Infertility Consultant at Rainbow IVF Hospital,AGRA from June 2015 to present
Asst. Prof in Bharati vidyapeeth Medical College from June 2013 to June 2015
Consultant at Malhotra Hospitals from May 2011 till May 2012
Jr. Consultant and Fellow in Reproductive medicine at Patankar Hospital Pune
Mobile No. 8055387886
Email Id: dr.neharika@gmail.com
(With inputs from Prof. Nihal Singh Jain, Dr. Jaideep Malhotra, Dr. Keshav Malhotra)
Corona Virus is here to stay with humans for a long-long time, may be forever let us accept this fact and
not panic and make our lives miserable unnecessarily. We need to learn to live with the fact. “CORONA IS
HERE TO STAY”.
This novel virus has posed so many questions to the medical fraternity, epidemiologists and to the policy
makers. Almost all agree that this virus will persist in the future as an endemic disease, which will surface
in episodes and cause periodic epidemics. As of today most of the world population has not yet got
infected and out of those who have almost 80% or more are asymptomatic or with mild disease. Yes a
susceptible co-morbidity and older male population is at greater risk of serious critical illness and even
death.
Already we have 4 types of corona virus which are endemic in the world and cause seasonal common cold
and flu like diseases. COVID-19 is probably going to be the fifth corona virus which has come to our planet
to stay.
The worry now is how do humans adapt to live safely with corona. The world is looking for a quick fix
solution to this pandemic and a lot of knee jerk actions are being taken and revoked, leaving everyone in
confusion of what is the right step. Lockdowns and unlocking has been seen to help but at the cost of an
economic pandemic which we are facing now in June-2020.
What will work, no one is sure, will a vaccine help, we are not sure. What will be that one thing to
eradicate corona. It’s for our good that we must realize there is no one thing that will work, including the
quick fix vaccine. Only two viral disease small pox & polio have been eradicated by a vaccine and that too
at the cost of millions of lives and over a period of almost 200 years. How this vaccine will fare, we have no
clue yet.

It was postulated that the summer heat will reduce the effects of this virus and corona will die off, but that
has not happened, corona has survived in extreme of weather conditions of heat and cold and is attacking
human beings as virulently all over the world, in all climates.
The only ways of keeping this virus at bay is :- S.M.S. (Sanitizing, washing hands with soap & water for 20
seconds and wearing mask in public places and maintaining a 1.8 meters social distancing).
Getting paranoid about newspapers, letters, courier packets, hot water drinking, gargles, too much alcohol
spraying and washing is an overreaction. Just washing hands, respiratory manners of coughing & sneezing,
wearing an appropriate mask and social distancing will reduce your chance of catching the infection to 1%.
Remember wearing gloves is not a good idea as the virus can stick to the surface of cloth gloves and be
transmitted to your face if wearing surgical gloves, hand washing & hands sanitization over gloved hands is
still needed.
As of now in June-2020, many believe now that COVID disease (SARS-COV-2) will become relatively milder
because the human immune system will develop a memory to respond to the virus (HERD IMMUNITY) and
the likelihood of severe “cytokine storms” occurring and making people very sick may reduce. This will
ultimately happen, but in how much time we don’t know, may be years. Finally this disease will settle in to
an endemic seasonal flu like disease.
Yes a vaccine is on the way, but the medical community is not yet sure on the dosage schedules for this
year for next years (2021-2022) and for the next ten years. The availability of this vaccine is expected by
December 2020 but tell global demand will be much more than the supply and will lead to hoarding, black
marketing and ineffective dosing campaigns.
The was against corona is not an easy was to win and needs a great deals of public awareness and public
participation in just 3 simple measures S.M.S.
We hope and pray humankind will learn sanitization, wearing masks and social distancing
We are headed towards a new normal on planet earth.

Acknowledgements

CORONA UPDATED 4
RAINBOW ADVICE
EVERY ONE PLEASE TAKE PREVENTIVE MEASURES
Compiled By: Dr. Neharika Malhotra, Dr. Narendra Malhotra, Dr. Jaideep Malhotra, Dr. Keshav Malhotra
INTRODUCTION:- Dear friends, remember all will not get sick with SARS-COV-2 disease, 80% will remain asymptomatic carriers
only. Out of all those who become corona virus test positive 80% will have mild symptoms of fever, severe bodyache, loss of
smell, loss of taste, dry cough & sneezing, these patients can stay in home quarantine, monitor their temperature, oxygen
saturation and take antibiotics, vitamin C, B complex, vitamin D and Zinc and local measures of warm gargles and drinking
“KADA”.
Home quarantined, asymptomatic and mild disease people should take extra care of sanitization – mask – social distancing.
Medical advice and hospitalization is needed if there is breathing trouble, pressure and pain in chest, high fever, tiredness and
sleepy feeling, bluish lips & face and mental confusion.
Symptomatic cases should get admitted in COVID L-2 care hospitals
Everyone Please Take Preventive Measures
1. Sanitize proper hand washing & fogging of rooms & deep mopping of floors and furniture.
[Fig-1a] [Fig-1b] [Fig-1c]
2. Mask prevents infections
[Fig-2]
3. Social distancing of 2 meters
[Fig-3]

4. Yoga – Breathing exercises
[Fig-4]
5. Meditation – Positive affirmations
[Fig-5]
6. Warm saline gargles, mouthwash, steam inhalations, aroma oil (eucalyptus oil steam inhalation), lavender oil &
peppermint oil for relaxation and sleep.
[Fig-6]
7. Warm water drinking / “Kadas” – Tulsi + Turmeric + Black pepper
[Fig-7]
8. Cough lozenges (Phytorelief / vicks / strepsils)
[Fig-8a, 8b]

9. Immunoboost spray
[Fig-9]
10. Vitamin C + Zn + B Complex + Vitamin (CITRAVITE XT) (CFIZZ) (ARACHITOLO)(PYROMMUNE) or others
[Fig-10a, 10b, 10c]
11. HCQ 400mg weekly for 3 weeks, Fabi Flu Tablet (for mild cases) (Only prescription by Doctor after check up)
[Fig-11a, 11b]
12. Sleep over tummy (Prone) & do balloon blowing (Medicated balloons available)
[Fig-12a, 12b]

13. Monitor Temperature (Infrared) Oxygen (Pulseoximeter)
[Fig-13a, 13b, 13c]
14. Wear protective face shield and plastic gowns / PPE
[Fig-14a] [Fig-14b]
15. Sleep in well ventilated rooms, avoid A.C. in closed room.
16. Keep your home care kit
17. Assess your risk
[Fig-17a]
[Fig-17b]

18. Consult doctor – covid helpline if Fever (100
0
), cough, cold, body aches, loss of smell, loss of taste.
19. Download Arogya-Setu app (https://play.google.com/store/apps/details?id=nic.goi.aarogyasetu&hl=en_IN)
20. Pray and stay safe.
CONCLUSION:- Be safe as only prevention is available as of now. There is no definite treatment or vaccination as of 22-06-2020,
so just take precautions.
For more information call:-
Dr. Vishwa Deepak : +91 99588 82595
Dr. Pankaj Bhatia : +91 94128 95978
Dr. Shushant Dhavan : +91 8308007868
Dr. Shubham Jain : +91 70423 57955
In case of pregnancy call:-
Dr. Manpreet Sharma : +91 93191 02069
Dr. Shemi Bansal : +91 98976 37828
Dr. Sarita Dixit : +91 96109 62978
Rainbow Hospital Helpline : +91 81910 22444, 0562-2600531-538
Acknowledgements

CORONA UPDATE – 5
WHAT TO DO IF OUR FAMILY MEMBER GETES COVID – [SARS- COV -2 INFECTIONS]
Compiled By: Dr. Narendra Malhotra, Dr. Neharika Malhotra Bora, Dr. Jaideep Malhotra, Dr. Keshav Malhotra
Corona virus is very-very infective contagion and spreads mostly by droplet infection to close human contacts, other
ways of transmission are not common. An English movie released a few years back “CONTAGION” it describes this
deadly pandemic which we are facing these days. Click on link to watch movie “CONTAGION”
https://youtu.be/jPL23-XFrYU
How infection is caused and What is the time line of infections ? (Fig-1)
[Fig-1 : Time Line of Corona Infection]
Infected person with mild disease, not requiring oxygen and quarantine at home is advised. Such persons to stay and
can recover at home without hospitalization. Do not leave your home, except to get medical care. Do not visit public
areas.
Almost 80% will have only mild symptoms [Fever, severe body aches, loss of smell/taste, cough, sneezing, cold GI
symptomes etc] they should stay at home in self quarantine and in tele consultation with COVID helpline and
physician team.
(Govt. COVID helpline 011-23978046 or 1075) Rainbow Hospital Helpline : +91 81910 22444, 0562-2600531-538
(Dr. Pankaj Bhatia : +91 94128 95978, Dr. Vishwa Deepak : +91 99588 82595, Dr. Shubham Jain : +91 70423 57955,
In case of Pregnancy - Dr. Manpreet Sharma : +91 93191 02069, Dr. Shemi Bansal : +91 98976 37828,
Dr. Sarita Dixit : +91 96109 62978)
Symptoms last a few days, and people usually feel better after a week. But they need 2 negative RT-PCR and
minimum 3 days of feeling good, before they can come out of isolation.
Family members in the same house must take extra care:-
The family members are not at higher risk for severe illness from SARS-COV-2(COVID) except for older age over 60,
diabetics, BP patients, heart disease, kidney problem patients. These persons should not come in contact with the
COVID positive case in the family.

1. Limit contact & Sanitize. Limit contact between the person who is sick and their family, friends and pet(s). If
family members and cleaning staff have to enter the room, they should wear PPE (Refer fig PPE kits – Fig-2).
[Fig-2a] [Fig-2b] [Fig-2c]
2. Mask (N95) by patient & all in home. (Refer fig masks) (Fig-3)
[Fig-3a: Mask Prevents Transmission] [Fig-3b]
3. Social distance and mask and as little talk as possible, from a distance (Fig-4)
[Fig-4: Social Distancing]
4. The person who is sick or test positive should use a separate bedroom and bathroom away from others.
5. Shared space: If you have to share space, make sure the room has good air flow and ventilation. (Fig-5)

[Fig-5: Air circulation]
(Open the window and turn on a fan (if possible) to increase air circulation. Improving ventilation helps remove
respiratory droplets from the air. Don’t switch on the A.C. in closed room).(Fig-5)
6. Avoid having any unnecessary visitors, especially visits by people who are at higher risk for severe illness. (No
visitors sign outside the main gate).
[Fig-6: No Visitors]
7. Provide the infected family member support and help to cover basic needs
8. Crocin / Paracetamol / Acetaminophen / Tylenol and other medicines as advised by physician should be
started and taken along with Vitamins (B complex, Vitamin C, Vitamin D3) and Zn.
Take over-the-counter medicines, such as Crocin/Paracetamol, to help you feel better. Rest all medicines
should be taken only on medical advice. (Fig-7)
[Fig-7: First Aid Box]
9. Drinks a lot of fluids and rest. Water, cold drinks, hot drinks, immunity booster drinks should be supplied in
ample. (Fig-8)
[Fig-8]

10. Towels, bath and hand towels, tissues etc should be separate and soaked in sodium hypochlorite water after
use.
11. Good healthy diet with lots of fresh leafy vegetables and citrus fruits should be given. (Consider having the
items delivered to the sick family member in disposable plates and containers. They (or you can arrange)
wash their dishes and utensils using gloves and hot water, or disposable plates. Handle any dishes,
cups/glasses, or silverware used by the person who is sick with gloves wear mask. Wash them with soap and
hot water or in a dishwasher. (Fig-8, 9, 10)
[Fig-9] [Fig-10] [Fig-11]
12. Clean hands after taking off gloves or handling used items. Regular and correct soap water hand washing and
sanitization and fogging of rooms and deep mopping of floor and furniture should be done.
13. Patient must take care of themselves. Get rest and stay hydrated. Monitor symptoms: Fever, cough, oxygen
saturation and if O2 oximeter available, that will be nice but not necessary. Keep a daily log of temperature
twice a day, cough, hours of sleeping, liquid intake, daily weight. (All monitoring devices to be kept in
patient’s room). (Fig-12)
[Fig-12 : Monitoring Devices]
14. Deep breathing, Pranayamas, Yoga and Meditation helps in immunity boosting and in relaxation and helps
making everyone stress free. Exercise, stay active, Avoid long and excessive rest periods.
Patients can be use whatsapp video calls or zoon calls with Yoga instructors for regular exercise schedules.
(Fig-13)
[Fig-13 : Yoga, Pranayam, Meditation]

15. Patient must stay in touch with their doctor on telemedicine and video consultation. (Fig-12)
[Fig-14 : Telemedicine]
16. Many antiviral medicines are used for treatment, Favipiravir, Ivermectine, Remdesvir, Tocilizumab, HCQ,
Asprin & Heparin (LMWH) and Steroid (Dexamethasone Tab & Methylprednisolone) & many other medicines
are being tried to treat this disease. All these are given only to very sick patients who are hospitalized.
Plasma therapy and interleukin injections are experimental treatment. Do not take any such medicines on
your own. These are given to very sick patients who are in need of critical care and ICU care.
[Fig-15]
17. Seek Emergency Medical Attention if:
a. Trouble breathing
b. Persistent pain or pressure in the chest
c. New confusion
d. Inability to wake or stay awake
e. Bluish lips or face
f. High fever and persistent cough

18. Certain immune system booster medicines and measures should be taken by all. (Over the counter)
 Breathing exercises
 Zn, B Complex, Vitamin C, Vitamin D3, Ashwagandha, Tulsi, Turmeric
 Warm saline / betadine gargles / mouth wash
 Prophylactic HCQ weekly for 7 weeks (only after cardiac check up) and advice of doctor.
 Steam inhalations with Eucalyptus oil / Balms / Vicks etc
 Drinking of “Kada” etc. (No scientific proof this helps)
 Alternative Medicine therapy (Homeopathy & Ayurveda) (No documented scientific evidences)
 Chyawanprash & other such products.
19. Be Covid prepared
L1 Facility:- Asymptomatic healthy patients with positive test (Hotels, Colleges Hospitals, Private nursing
homes and now home quarantine is allowed in certain states).
L2 Facility:- For those patients who have symptoms and test is positive for CORONA admit in hospital.
L3 Facility:- For those patients who are very sick and need critical care management (ICU)(Covid hospitals be
covid prepared as per guidelines given by AIIMS and ICMR, Delhi (Fig-13)).
[Fig-16: AIIMS covid preparedness document]

CORONA virus is a highly contagious viral disease which as of today 22-06-2020 has no definitive treatment or
vaccine. Prevention is the best strategy and mild infections can be managed and treated at home or in quarantine
areas under proper medical supervision.
[Fig-17a : Self Risk Assessment]
[Fig-17b: Risk Stratification]
20. Assess your risk and take precautions and download Aarogya Setu App
(https://play.google.com/store/apps/details?id=nic.goi.aarogyasetu&hl=en_IN)
[Fig-18: Aarogya Setu App]
Acknowledgements

CORONA UPDATE-6
CORONA INDIA IN JULY
Compiled by: Dr. Narendra Malhotra, Dr. Neharika Malhotra, Dr. Jaideep Malhotra, Dr. Keshav Malhotra
Special Inputs
Prof. K. K. Aggarwal
SARS-COV-2 pandemic is still on the way of spreading. The curve has not flattened and the disease has not shown any signs of
regression in numbers. The pandemic is predicted to worsen in India in the coming month. A major awareness drive needs to be
undertaken and the hospital facilities need to be increased.
CASE RISE AS SEEN:
THE SEQUENCE OF SPREAD:
Ground Zero: Wuhan in live animal market or cafeteria for animal pathogens: 10th January; Total cases are based on RT PCR,
67% sensitivity
Doubling time India 15 days, USA 33 days, Brazil 13days, Russia 18 days, Spain 47 days, UK 35 days, Italy 55 days, France 49
days, Turkey 37 days,
Likely minimum deaths (586820 + 59617 x 15 == 8943) = 595762
Coronavirus Cases: 13,691,570
Deaths: 586,820
Recovered: 8,037,140
ACTIVE CASES 5,067,610
Currently Infected Patients 5,007,993 (99%) in Mild Condition
59,617 (1%) Serious or Critical
CLOSED CASES 8,623,960
Cases which had an outcome: 8,037,140 (93%) Recovered / Discharged
586,820 (7%) Deaths
India crosses Russia, will cross 1 million cases and 25000 deaths today
# Country,
Other
Total
Cases
New
Cases
Total
Deaths
New
Deaths
Total
Recovered
Active
Cases
Serious,
Critical
Tot Cases/
1M pop
Deaths/
1M pop
Total
Tests
Tests/
1M pop
Population
World 13,683,686 +234,245 586,193 +5,754 8,031,267 5,066,226 59,616 1,755 75.2
1 USA 3,616,747 +71,670 140,140 +997 1,645,962 1,830,645 16,459 10,924 423 44,844,982 135,450 331,081,677
2 Brazil 1,970,909 +39,705 75,523 +1,261 1,255,564 639,822 8,318 9,270 355 4,572,796 21,507 212,620,008
3 India 970,169 +32,682 24,929 +614 613,735 331,505 8,944 703 18 12,412,664 8,991 1,380,530,110
4 Russia 746,369 +6,422 11,770 +156 523,249 211,350 2,300 5,114 81 23,754,645 162,773 145,937,175
Doubling Time 21 days
Date Daily new
cases
New Deaths Total cases Total Deaths
14
th
July 32682 614 970169 24929
13
th
July 28179 540 907645 23727
12
th
July 29108 500 879446 23187
11
th
July 27755 543 850358 22687
10
th
July 27761 521 822603 22144
9
th
July 25790 479 794842 21623
8
th
July 25571 491 769052 21444
7
th
July 23135 479 743481 20653
6
th
July 22510 474 720346 20174
5
th
July 23932 421 697836 19700
4
th
July 24015 610 673904 19279
3
rd
July 22721 444 649889 18669
2
nd
July 21948 377 627168 18225
1
st
July 19428 216 654405 17848
30
th
June 18256 506 585792 17410
29
th
June 18339 417 567536 16904
28
th
June 19620 384 549197 16487
27
th
June 20131 414 529577 16103
26
th
June 18276 381 509446 15689
25
th
June 18185 401 491170 15308 (3.11%)

India predictions
1. >90% of people are symptomatic within 2 weeks of infection
2. Death Rate is deaths today vs number of cases today
3. Corrected Death Rate is deaths today vs number of cases 14 days back
4. For one symptomatic test positive case there are 10-30 asymptomatic cases
5. Estimated Number of deaths = Reported deaths x 2
6. Number of deaths today should be 15% of the serious patients present 14 days back
7. Undocumented cases for each documented case [Iceland: 1: 2; German: 1: 5; New York City grocery store shoppers: 1: 10;
California 1.5%]
8. Amongst active 2.37% are serious, 1.82% need oxygen, and 0.41% need ventilator support.
Extra Reading Background Material
1. China: Captured tiny droplets of viral genetic markers in 2 hospitals in Wuhan floating for > 2 hours. Infectivity? [Journal
nature]
2. India: In states with average population density of 1185 /sk km the average number of cases were 2048. On the contrary in
states with population density of 909/ sk km the number of cases were 56. (When Chandigarh and Pondicherry were taken out
from this group) the Average Density of other states were 217 and the average number of cases were 35 [HCFI]
3. Revised COVID Sutras: It’s a COVID-19 Pandemic due to SARS 2 Beta Corona Viruses (different from SARS 1 where spread
was only in serious cases); with three virus sequences floating (one similar to Wuhan, second similar to Iran and the third strain
similar to USA – UK); has affected up to . 10% (5.7 % S Korea) of the population; Causes Mild or Asymptomatic Illness in
82%, Moderate to Severe Illness in 15%, Critical Illness in 3% and Death in 2.3% cases (15% of admitted serious cases, 71% with
comorbidity< Male > Females); affects all ages but Predominantly Males (56%, 87% aged 30-79, 10% Aged < 20, 3% aged > 80);
with Variable Incubation Period days (2-14; mean 5.2 days); Mean Time to Symptoms 5 days; Mean Time to Pneumonia 9 days,
Mean Time to Death 14 days, Mean Time to CT changes 4 Days, Reproductive Number R0 1.5 to 3 (Flu 1.2 and SARS 2),
Epidemic Doubling Time 7.5 days; Origin Possibly from Bats (Mammal); Spreads via Human to Human Transmission via Large
and Small Droplets and Surface to Human Transmission via Viruses on Surfaces for up to three days. Enters through MM of eyes,
nose or mouth and the spike protein gets attached to the ACE2 receptors. ACE2 receptors make a great target because they are
found in organs throughout our bodies ( heart muscle, CNS, kidneys, blood vessels, liver) Once the virus enters, it turns the cell
into a factory, making millions and millions of copies of itself — which can then be breathed or coughed out to infect others.
4. Prevalence: New York: 13.9%; New York City at 21.2%, S Korea 5.7%, world 5%; Ohio prison: 73% of inmates; New York:
21% mortality April 22 in JAMA.
5. Viral particles seen in tears, stool, kidneys, liver, pancreas, heart, semen, peritoneal fluid, CSF.
6. Thrombosis: University of Pennsylvania clots are seen in patients even on blood thinners. Netherlands study, 31%
7. Other human beta-coronaviruses has immunity lasting only for one year with no IMMUNITY PASSPORT.
8. In absence of interventions, prolonged or intermittent social distancing (till 2022-24)
9. Low levels of cross immunity from the other beta-coronaviruses against SARS-CoV-2 could make SARS-CoV-2 appear to die
out, only to resurge after a few years. Surveillance till 2024.
10. During peak (trace and treat) and after the peak (trace and treat the close contacts)
11. Increased spread: close environment, crowded place with close physical contacts with no ventilation
12. Strategies: From community mitigation to individual containment; broader good over individual autonomy; perfect cannot be
the enemy of the good; pandemics are fought on the grounds and not the hospitals., Treat the patient and not the test report,
Consider every surface and every asymptomatic person as virus carrier
13. HCW: Direct patient exposure time < 30 minutes; 7 days work and 7 days holidays.
14. Italy mortality reduced when they were short of ventilators.
15. Hospital at HOME: CHF, mild pneumonia, exacerbations of asthma and COPD, cellulitis, and urinary tract infections.
16. Great Imitator (protean manifestation)
17. IgM can be false positive in pregnancy, immunological diseases); Pooled tests (< 5) when seroprevalence is < 2%
18. Early treatment to reduce the viral load and prevent cytokine storm using off label use of drugs like hydroxy chloroquine with
azithromycin; ivermectin, remdesivir; Tocilizumab interleukin (IL)-6 receptor inhibitor; convalescent plasma therapy ( given
early; bridge compassionate therapy, donor 14 days symptoms free, single donation can help 4 patients), Lopinavir-ritonavir and
Favipiravir).
CLASSIFICATION OF DISEASE
Group 0:
Mild disease/No risk for COVID/Throat swab not done
Group 1:
Group 1x- Mild disease/Report Awaited
Group 1a- Mild disease /Report Negative
Group 1b- Mild disease / Report Positive
Group 2:
Group 2x- Moderate disease/ Report awaited
Group 2a- Moderate disease / Report Negative
Group 2b- Moderate disease/ Report Positive
Group 3:
Group 3x- Severe disease/ Report Awaited
Group 3a- Severe disease/ Report Negative
Group 3b- Severe disease/ Report Positive

CASE DEFINITION
Mild disease:
 Symptoms of URTI and fever with no breathlessness/ hypoxia and haemodynamically stable.
Moderate disease: (If Any one of the following present)
 RR >24/min
 SpO2 ≤ 93% on Room air
 Confusion/drowsiness
 S.B.P <90mmHg and/or D.B.P <60mmHg
Severe Disease:
(Features of moderate disease plus any one of the following)
 SpO2/FiO2 <315
 PaO2/FiO2 <300
 Radiology(CT/CXR) showing bilateral opacities not fully explained by effusion/lung collapse/nodules
 Worsening of underlying illness in the last 1 week despite adequate management
[Extrapulmonary manifestations of COVID-19]
The pulmonary manifestation of COVID-19 caused by infection with SARS-CoV-2, including pneumonia and ARDS, are well
recognized. In addition, COVID-19 is associated with deleterious effects on many other organ systems. Common extrapulmonary
manifestations of COVID-19 are summarized here.
COVID19 TESTS AND SIGNIFICANCE
1) RT PCR
gold std
Highly expensive
Read ORF of proteins and E gene
Result is in 3hrs
(Throat Swab) -
If positive, Cycle Threshold (Ct) values have to be compulsorily given in report according to new ICMR rules
Ct value is the number of cycles required to detect the viral antigen. Lower the value (more viral load) higher the risk.
Ct Values:
Value between 17 to 24 - High Viral Load.
Value between 24 to 31 -Moderate Viral Load
Above both have to be admitted in hospital immediately.
Value above 31 - Low Viral Load.
Can be treated under home quarantine under constant observation.

2) CBNAAT
detect E&N gene in one go
Both for screening and confirmation
Less expensive than RTPCR
Result is in 2hrs
ICMR adviced for SARI&ICU patients
3) TRUENAT
Detect E gene in first level for screening suspected patients
RDRP gene in next level for confirmation
Result is in 1hr
Highly economic with low maintenance cost
ICMR adviced it for screening
4) Rapid antigen test
Most economic
ICMR adviced it for containment zones
Result in just 30mts
Moderate sensitivity and high specificity
5) Antibody tests
It is meant for seroprevalance survay
IgM starts from 3rd day and present till 22nd day
IgG starts from 7th day and persist till some good length of period
E gene for screening
N gene, RDRP gene &ORF protein for confirmation
RADIOLOGICAL FINDINGS IN COVID
 Chest x-ray (CXR) is typically the first line imaging modality for patients with suspected Covid-19, although less sensitive than
chest CT. It may be normal in early or mild disease. Even with serious disease, about 31% had normal CXR at the time of
admission. Findings are most extensive about 10-12 days after onset of symptoms.
 Findings on CXR: most frequent are airspace opacities (described as consolidation or ground glass opacities), which are often
bilateral, peripheral and mainly in the lower zone. Pleural effusion is very rare (if patient has pleural effusion, chances are
that it may not be Covid).
 Oblique CXR is done when lesion (subpleural or close to chest cavity) is not seen on routine AP view but there may be some
data on CT.
 Point of care ultrasound: It is useful to monitor disease progression in patients who have hypoxemia and hemodynamic
failure. It is not a sensitive and specific modality, but its advantages are inexpensive, ease of use, repeatability and no
exposure to radiation. However, there is high risk of exposure to the operator, so used less.
 Findings on USG: Multiple B-lines, subpleural consolidation, irregular thickened pleural line with scattered discontinuities,
alveolar consolidation, reappearance of bilateral A-lines; return of normal A-lines from B-lines suggest that the patient is
improving.
 CT chest: A systematic meta-analysis of 49 studies of CT features of Covid-19 by CARING showed that the commonest finding
at all stages of the disease was diffuse bilateral ground glass opacity. The next common findings were consolidations and
mixed density lesions. Around 78% of patients with RT-PCR positive had either ground-glass opacities or consolidation or
both.
 There is a significant overlap of CT scan findings between Covid and non-Covid patients, who present as SARI or ILI.
 Common CT findings: Ground glass opacities, consolidation, mixed lesions, crazy paving pattern, reticulations, septal
thickening (can be inter- or intra-lobular; commonly seen in advanced disease)
 Specific CT findings: Halo sign, reverse Halo sign (focal rounded area of GGO surrounded by a complete ring of consolidation;
one of the typical findings of Covid-19 as per RSNA), spider web sign, pulmonary vessel engorgement (prominent pulmonary
vessels in relation to the lesions; it is a potential early predictor of lung impairment), vacuolar sign (vacuole-like transparent
shadow <5mm in length observed in the lesion)
 Infrequent CT findings: Architectural distortion, lymph node enlargement and pleural effusion
 In initial stages, GGOs can be unilateral and patchy progressing to multifocal confluent lesions with advancing
disease.
 If crazy paving pattern and vascular engorgement, the patient needs to be treated more aggressively.
 Pulmonary embolism is emerging as main pathogenesis in Covid-19, which can lead to pulmonary infarction. A contrast-
enhanced CT pulmonary angiography is done when PE is suspected.
 CT severity score: it scores lung opacities in all 6 lung zones (3 on each side), the sum of scores from all 6 is the overall CT
score (maximum score 24). The severity of lung involvement on CT correlates with disease severity.

 Extra-thoracic Covid manifestations: Covid-19-associated acute hemorrhagic necrotizing encephalopathy, multisystem
inflammatory syndrome (airway inflammation and rapid development of pulmonary edema on thoracic imaging, coronary
artery aneurysms and extensive right iliac fossa inflammatory changes on abdominal imaging)
 CT should not be used as initial screening or diagnostic tool. It can be used to identify early markers for lung impairment in
symptomatic patient with RTPCR positive for Covid-19 or for patients with non-resolving symptoms to evaluate disease
progression.
 The role of CT in stable pediatric patients is limited.
 X-ray should not be used as initial screening tool for Covid-19. In suspected patients with history of fever, dry cough, do a RT
PCR first instead of chest x-ray.
 All patients coming to Radiology with any respiratory symptoms should be considered a potential Covid-19 patient.
Accordingly, all precautions should be taken. No mixing with other patients, maintain social distancing, sanitize equipment
before using it for the next patient.
 Portable x-rays are used for temporal progression and resolution and also for serial follow-ups. Use a dedicated machine
wherever logistically possible.
WHO says the virus may be surviving in air for 8 hours, so that makes the disease air borne spread and this makes it mandatory
for all to wear masks and have good open ventilation and fan. Regular fogging of homes also becomes important.
Corona virus is here to stay with us for a long-long time various new treatments are being tried and trials are on for successful
drug and vaccine. Until we have a definitive treatment and vaccine, prevention is the only core. So be safe.
Revised Management protocol for covid-19
Group 0:
Investigations: No investigations to be done unless recommended by COVID Physician
Treatment:
 T.Desloratidine 5mg/ T.Levocetrizine 5mg 0-0-1
 T.Paracetamol 650mg (15mg/Kg/dose) SOS if fever
 100F/bodypain
 Salt water Gargle 1-1-1-1
Report for physician/pulmonologist’s consultation if worsening
Group 1:
Investigations: No investigations to be done unless recommended by COVID Physician
Treatment:
 C.Oseltamivir 75mg 1-0-1 for 5 days
 T.Azithromycin 500mg 1-0-0 for 3 days
 T.Desloratidine 5mg OR T.Levocetrizine 5mg 0-0-1
 T.Paracetamol 650mg (15mg/Kg/dose) SOS if fever >100F/ body pain
 Salt water Gargle 1-1-1-1
Group 2:
Investigations:
Routine:
CBC, CRP, RFT, LFT, Procalcitonin, Blood culture, S.Ferritin, ABG, CXR, ECG,
2D ECHO, Urine Routine, Urine Culture.
Optional:
CK, CK-MB, Troponin-I, BNP as recommended by COVID Physician/
Cardiologist
Treatment:
Supportive :
 Oxygen therapy via nasal prongs/mask, titrated to achieve SPO2 >93%.
 C. Oseltamivir 75mg 1-0-1 for 5 days
 IV Antibiotics if infective parameters are high
 Inj.Ceftriaxone 1g IV Q 12H, or
 Inj.Amoxiclav 1.2g IV Q8H
(may be modified based on culture reports after 48-72hrs)
 T.Desloratidine 5mg/ T.Levocetrizine 5mg 0-0-1
 MDI. Duolin (Ipratropium 20mcg+Levosalbutamol 100mcg) 2 puffs Q8H via spacer
 MDI.Budesonide(200mcg) 2 puffs Q12H via spacer
COVID specific:
 IV Remdesivir 200mg on day1 F/B 100mg daily for 5 days
 IV Dexamethasone 6mg once daily for 10 days
 T. Hydroxychloroquine 400mg 1-0-1 on day 1, followed by
400mg 1-0-0 for 4 days
OR
 T.Lopinavir+Ritonavir (200mg+50mg) 2-0-2 for 10 days

Note: HCQs/ Lopinavir+Ritonavir may be withdrawn once the COVID test report is Negative.
Group 3:
Investigations:
Routine:CBC, CRP, RFT, LFT, Procalcitonin, Blood culture, S.Ferritin, ABG,
CXR, ECG, 2D ECHO, Urine Rouine, Urnie Culture.
Optional: CK, CK-MB, Troponin-I, BNP as recommended by COVID
Physician/Cardiologist
Treatment:
Supportive :
 Oxygen Therapy & Ventilatory management as per ICU Team
 C. Oseltamivir 75mg 1-0-1 for 5 days
 Prophylactic UFH or LMWH( Enoxaparin 0.5mg/kg SC twice daily
 IV Antibiotics if infective parameters are high
 Inj.Ceftriaxone 1g IV Q 12H, or
 Inj.Amoxiclav 1.2g IV Q8H
(may be modified based on culture reports after 48-72hrs)
 T. Desloratidine 5mg/ T.Levocetrizine 5mg 0-0-1
 MDI. Duolin (Ipratropium 20mcg+Levosalbutamol 100mcg) 2puffs Q6H via spacer
 MDI. Budesonide(200mcg) 2 puffs Q12H via spacer
COVID specific:
 IV Remdesivir 200mg on day1 F/B 100mg daily for 5 days
 IV Dexamethasone 6mg once daily for 10 days
 T.Hydroxychloroquine 400mg 1-0-1 on day 1, followed by
200mg 1-0-1 for 5 days
OR
 T.Lopinavir+Ritonavir (200mg+50mg) 2-0-2 for 10 days
Special considerations:
 Inj.Azithromycin 500mg Q24H for 5 days can be added, Monitor QTc especially if it is combined with HCQs.
Guided by the following score:
 Tocilizumab 400mg single dose IV infusion over 60mins (for rising ferritin/cytopenia/H score >170
(https://www.mdcalc.com/hscorereactive-hemophagocytic-syndrome#evidence)
Not to be given if
 Absolute Neutrophil count(ANC) <2000/cu mm
 Platelet count <100000/cu mm
 ALT or AST > 1.5 times the upper limit of normal
 IVIg: 0.3- 0.5 g/Kg/day for 5 days
 Convalescent Plasma

 Systemic Corticosteroid ≤ 0.5-1.0 mg/Kg/day of Methyl prednisolone OR
Equivalent for < 1 week
(Disclaimer: All the interventions in special consideration are off-label uses, no evidence for any of these treatments. To be
decided on individual case basis).
COVID PROTOCOL
MILD MODERATE SEVERE
Clinical Criteria
SPO2 > 94 % in Room Air 90 - 94 % in Room Air < 90 % in Room Air
RR < 24 / min 24 – 30 > 30
No Pneumonia Pneumonia + Pneumonia ++
CT Chest Criteria
Normal or < 25 % 25 % - 75 % 75 % to 100 %
Grade I Grade II / III Grade IV
Laboratory Findings (Expected)
NLR1,2 < 3.2 > 3.2 > 5.5
CRP3 < 40 40 – 125 > 125
Ferritin2 < 500 > 500 > 800
D-Dimer4 < 0.5 > 0.5 > 1.0
LDH < 300 300 – 400 > 400
IL6 < 4.8 5 – 50 > 80
LFT5 Normal Slight Derangement Moderate Derangement
Treatment
Routine T. Paracetamol 500 mg TDS T. Paracetamol 500 mg
TDS
T. Paracetamol 500 mg
TDS
Anti-tussives SOS Anti-tussives SOS Anti-tussives SOS
T. Vitamin C 500 mg OD T. Vitamin C 500 mg BD T. Vitamin C 500 mg BD
T. Zinc 50 mg BD T. Zinc 50 mg BD T. Zinc 50 mg BD
C. Omeprazole 20 mg BD C. Omeprazole 20 mg BD Inj. Pantoprazole 40 mg IV
OD
Fluids Adequate Hydration - Oral Adequate Hydration - NS Conservative Fluids
HCQ
(Not prescribed routinely)
T. HCQ (In high risk patients
– DM / HT / CVA / CKD /
CLD / Obesity / Age > 60
yrs) Day 1 - 400 mg BD
Followed by 400 mg OD x 4
Days
(avoid in cardiac disease or
if QTc > 480 ms) – MOHFW
Guidelines
T. HCQ (In high risk
patients – DM / HT / CVA /
CKD / CLD / Obesity / Age
> 60 yrs) Day 1 - 400 mg
BD
Followed by 400 mg OD x 4
Days
(avoid in cardiac disease or
if QTc > 480 ms) – MOHFW
Guidelines
-
Antibiotics T. Azithromycin 500 mg OD
x 5 Days (or)
T. AmoxClav 625 BD if T.
Azithromycin is
Contraindicated and Elderly
> 60 yrs.
T. Azithromycin 500 mg
OD x 5 Days
+
Inj. Ceftriaxone 1 gm IV BD
if secondary bacterial
infection suspected
T. Azithromycin 500 mg
OD x 5 Days
+
Inj. Piptaz 4.5 mg/ Inj
meropenam 500mg IV TDS
if secondary bacterial
infection suspected
Anticoagulation - Inj. Enoxaparin 40 mg SC
OD x 5 Days (can be
started as prophylactic
without D DIMER)
(Contraindicated in ESRD,
active bleeding,
emergency surgery,
platelets < 20,000/mm3,
BP > 200/120) Inj.
Dalteparin 2500 IU SC OD
×5 days
In ESRD, UH – 5000U SC
BD can be used
Inj. Enoxaparin 40 mg SC
BD x 5 Days (can be
started as prophylactic
without D DIMER)
(Contraindicated in ESRD,
active bleeding,
emergency surgery,
platelets < 20,000/mm3,
BP > 200/120) Inj.
Dalteparin 5000 IU SC OD
× 5 day In ESRD, UH –
5000U SC BD can be used

Steroids - Inj. Dexamethasone 0.1 –
0.2 mg /kg ≈ 6 mg IV OD x
5 Days
or
inj. Methyl Prednisolone
0.5 -1 mg/kg ≈ 60mg x 5
Days
Inj. Dexamethasone 0.2 –
0.4 mg /kg ≈ 6 mg IV BD x
10 Days
or
inj. Methyl Prednisolone
1.0 -2.0 mg/kg ≈ 80 mg x
10 Days
Oxygen Support Not Required Maintain Target SPo2 of
92 to 96 %
Nasal Prongs (4 lit / min)
↓
Face Mask (5-10 lit / min)
↓
NRM (10 -15 lit / min)
↓
HFNC (10 - 40 lit / min)
↓
CPAP (TV 6ml/kg; PEEP 5-
15 cm H20; Target PP 30
cm H20)
Maintain Target SPo2
> 90 %
NRM (10 -15 lit / min)
↓
HFNC (10 - 60 lit / min)
↓
CPAP (TV 6ml/kg; PEEP 5-
15 cm H20; Target PP 30
cm H20)
↓
MV (ARDS Protocol)
Proning - Awake Proning (if > 4 L /
min)
- 30 to 120 mins prone
- 30 to 120 mins left lateral
- 30 to 120 mins right
lateral
- 30 to 120 mins upright
– Contraindicated in
altered mental status and
hemodynamic instability,
pregnancy
Prone Ventilation
16 to 18 hrs / Day
Cytokine Storm - Inj. Toculizumab 400 mg
(max 800 mg) slow IV in
100 ml NS over 1 Hour
Repeat Dose after 12
hours if needed
Contra Indications – Active
Infections, TB, Hepatitis,
Platelets < 1L/mm3, ANC <
2000/mm3
-
COMORBIDITY AND COMPLICATIONS
Comorbidity
CAD, HT, DM, Hypothyroid,
Epilepsy
Treat Appropriately Treat Appropriately Treat Appropriately
Complications
Septic Shock
AKI, MODS
Delirium
Electrolytes
ECG-abnormalities
Stress Ulcers
Liver Dysfunction
Treat Appropriately Treat Appropriately Treat Appropriately
Trial Therapies
1 - Inj. Remdesivir
200mg IV OD on Day 1 and
100 mg IV OD x 4 Days
Contraindication – Liver
Dysfunction/ CKD /
Pregnancy / Lactation /
Children
DI – avoid HCQ, Dexa use
Methyl Prednisolone
-

2 - Convalescent Plasma
200 ml slow IV
Single Dose
-
3 - (Lopinavir 400 mg +
Ritonavir 100 mg) Twice
Daily x 14 Days
Suspended by WHO wef
4.7.20.
-
4 - (Lopinavir 400 mg +
Ritonavir 100 mg) Twice
Daily x 14 Days
+
Interferon Beta 8 Million
IU on Alternate Days x 3
Doses
-
MONITORING
BP / HR Daily 6th Hourly 4th Hourly
RR / WOB /spO2 6th Hourly 2nd Hourly Continuously
CBC / NLR / RFT / LFT Baseline Every 2 Days Daily
COVID Profile Baseline Once every 4 days Once every 2 days
D Dimer Repeated 4th day Once every 4 days Once every 2 days
ECG Baseline Once every 2 days Daily
ABG - - Daily
X Ray - If Clinical Deterioration
DISCHARGE CRITERIA
Afebrile > 3 Days without
antipyretics
+
No Breathlessnes
antipyretics
+
No Breathlessnes
antipyretics
+
No Breathlessnes
10 Days from Symptom
Onset
10 Days from Symptom
Onset
Clinical Recovery
- No O2 Requirement for 3
Days
RT-PCR not Required RT-PCR not Required Repeat RT-PCR if Swab
Negative Transfer to Non
Covid Care Ward – if
clinical recovery is delayed
POST DISCHARGE ADVICE Isolation + Self Monitoring
for 7 Days
Isolation + Self Monitoring
for 7 Days
Isolation + Self Monitoring
for 7 Days
* based on clinical management protocol, Covid 19 – MOHFW GOI dt 03.07.20
Bibiliography
1. Minping et al., doi: 10.21203/rs.3.rs-28850/v1
2. Chuan Qin et al., doi: https://doi.org/10.1093/cid/ciaa248
3. Ruan Q et al., doi: 10.1007/s00134-020-05991-x
4. Zhou et al., doi: 10.1016/S0140-6736(20)30566-3
5. Zhang et al., doi.org/10.1016/S2468-1253(20)30057-1

Data suggest that male older adults and subjects with immune dysfunctions might be more susceptible to the worse viral
disease from SARS-CoV-2. One of the virulence factors most discussed is the malnutritional status of the host since strong
evidence supports the notion that any infection outcome is highly dependent on the nutritional status of the host. Viruses
subject the host's body to a considerable energetic effort to sustain costly defenses. If a previous malnutritional status exists, or
if no nutritional care is provided, the host easily encounters the emptying of body reservoirs with increased harm caused by the
virus. A possible link between the nutritional status of the host, the virulence of SARS-CoV-2, and the clinical outcome of COVID-
19 is discussed at the following link:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191079/
RECOVERY IS THE RULE (SOURCE UNKNOWN)
 Timely action can save lives as most cases are mild; few are moderate and less than 5% are serious.
 Death rate is reducing as we are now able to better manage cases.
 In all patients who have loss of smell/taste, recovery is the rule and mortality is an exception. Analysis of 100 patients
with loss of smell/taste showed that none needed oxygen or ventilator or hospitalization. Occurred more often in
males, at any age and recovery is the rule within 4 weeks.
 Recovery if the rule means that the disease is salvageable at every step. It does not mean that mortality is zero.
 After 9 days, the virus becomes non-replicative and after 9 days, the illness is a post-Covid complication.
 Day 1 is the day when any of the symptom/s recognized by the CDC/MOHFW guidelines such as fever, throat irritation,
subconjuctival hemorrhage, rash, diarrhea, headache, calf pain etc.; test may or may not be positive.
 Post-Covid inflammation is very common. It can be in the form of persistent fever/sore
throat/bronchitis/diarrhea/cystitis/ exertional tachycardia.
 Doctors have high viral load because of repeated exposure and they have more hypercoagulable state. So, if all HCWs
are given anticoagulant + short course of steroids, even in mild cases, recovery is the rule.
 In non-HCW group of patients, if there are signs of chest congestion on Day 3-4, do an immediate chest CT scan and
give 10-day course of steroids, antiviral and anticoagulant, then recovery should be the rule and death an exception.
 RT PCR may be positive for up to 40 days; this does not mean that the virus is culturable. The virus is culturable for only
9 days, after 9 days, the virus is present but is non-culturable. This data is available for patients who are not on
ventilator.
 If any illness is developed during the 9 days, then the post-Covid illness (post-Covid inflammatory state) may last for up
to 6 weeks.
 A delayed cytokine storm, which occurs between Day 14 and18, has been observed in Mumbai. A 6-minute walk test is
now mandatory at the time of discharge to look for drop in oxygen saturation. This is a valid marker for delayed

cytokine storm. Give 5-10 days of LMWH/oral anticoagulant and small dose of statin at the time of discharge, especially
to those who have been in hospital for >28 days and are >55 years age. This can reduce mortality.
 Initially steroids were given only in serious cases, but now their indication has also shifted to moderately severe cases.
And the time may well come when steroid may become mandatory in all patients starting from Day 3. Timely steroids
can prevent secondary cytokine crisis.
 Capacity building not just of HCWs but also RWAs etc. as many patients are in home care; issues like stigma and
discrimination also need to be addressed. The word “contact” needs to be eliminated as it is a type of stigma.
 Indian vaccine is a live attenuated vaccine (Bharat Biotech); Moderna vaccine is mRNA vaccine; all vaccines have
different technologies. Three things to be detected when a vaccine is given: Cellular antibodies, humoral protection and
non-specific immunity building (innate immunity). By 15th August, we may only be able to tell whether antibodies are
produced or not. Since this is a live attenuated virus, will there be a delayed response (cytokine crisis), we do not know.
 Isolate for 9 days, quarantine for 5 days and then monitoring with rest for next 2 weeks. Monitoring means that the
person is not contagious, but is still likely to get secondary complications.
 Plasma therapy is effective if given within first 7 days of illness; plasma should be donated between 28 and 40 days.
Need some clarifications with surgeons including gynecologists
1. How you are dealing with elective cases, If you are postponing, how long to postpone.
2. Regarding delivery cases: do we need to send COVID testing of all pregnant women, If yes, when to send, & what to do if it's
positive.
3. What personal protective measures you are using in your OT and LABOR ROOMS, and based on what recommendations.
I realize you folks are seeing lot of sick Covid patients: Here some tips that I wanted to share with you about precautions during
the Covid times. I and some of close friends are following. See if these are applicable, please do consider.
 If you are in direct care of Covid patients, you are at high risk of getting infected. please try to isolate yourself or
minimize your close contact with your family as much as possible . I have separate room for me in my home, since I do
deal with patients in the hospital. (You be solution to the problem, not the problem ( spreader) in your home
 Keep your car separate and don’t let your family commute in that.
 Wear scrubs (no watches and no fancy rings)
 Once you come home, make sure you keep your scrubs in the laundry bin, before entering home.
 Don’t take your work shoes inside the home. One set of shoes in the hospital, Other shoes stay in the garage.
 Your nutrition (water and food) is carried from home daily in plastic bag, and it does not touch anything until you keep
on your designated place in your office.
 Forget about hangout or food in the cafeteria for some time.
 Shower as soon as you enter your home.
In the hospital
 Minimize face 2 face visits
 Try to do as many tele visits or video options( thanks to Doximity)
 Before you meet your pt, you should’ve already gathered all the possible information about your patient (no surprises)
 Your encounter should not be more than quick focused exam.
 Tell your Pt that you will call them on their phone.
 Ask your staff to be meticulous about enquiring about Covid related questions and respiratory symptoms.
 Your work station to complete the notes for the visit is separate from your exam room (this is must)
 Your office is yours, don’t let anyone come in (not your friendly staff or colleagues)
 Don’t travel in crowded elevators. Carry the wipe to press the button on your elevator. Don’t touch any surfaces or lean
on the wall.
 Avoid extended conversation with your friends in the hospital.
 If you are seeing any sick patients, make sure you wear appropriate PPE including eye glasses.
 Try not to use the public restrooms
 If you are doing procedures, plan for electives. If you anticipate risk, do the Covid testing on everyone. If
urgent/emergent, you have to use full PPE.
 Spend less time in the hospital. This is not the time for face to face teaching. You can face time with your friends.
 Get good sleep, meditate and hydrate, stay away from crowd, isolate, and lesser TV.

Corona is here to stay with humans for long time
Take care. You all be safe!! Good luck.
Acknowledgements

CORONA UPDATE - 7
WHAT KILLS CORONA VIRUS ?
Compiled by: Dr. Keshav Malhotra, Dr. Narendra Malhotra, Dr. Jaideep Malhotra, Dr. Neharika Malhotra
Inputs by :
Dr. R. L. Sharma, Mr. Glydin George, Mr. APS Chadda
This SARS-COV-2 pandemic has affected almost all the countries of the world (only a few 10-12 have not reported
any case) over 7 million people are infected and 0.5 million dead.
Never has the world been under attack of a height infectious contaigen. This has left every one wondering and WHO,
CDC, infection control agencies, scientists all trying to find out the best disinfectants against COVID 19 (SARS-COV-2).
Various studies have shown that SARS-COV can persist on surfaces upto 96hrs and retain infectively for as long as 6
days (upto 9 days). It has a strong survival and only after 9 days does SARS-COV-2 loose its infectivity.
WHO and other agencies have advocated use of standard and also virucidal disinfectants to sanitize and sterilize
potential infective sources.
Disinfections
How disinfectants kill the virus.
QAC Action Surfactant Action
[Fig-1: Dual Action, better destruction of COVID]
DISINFECTION
Disinfectants to be used during COVID-19 pandemic
• 1% freshly prepared sodium Hypochlorite can be used as disinfectant.
• The solution should be prepared fresh.
• Leaving the solution for contact time 10 min is recommended.
[Fig-2]

• Alcohol (70% isopropyl or 70% ethyl alcohol) can be used on metal surfaces.
[Fig-3]
• Automated high-level disinfection can be done by UV radiation type C, codex and matricide solutions.
[Fig-4]
High touch surfaces like doorknobs, telephone, call bells, bedrails, stair rails, light switches, should be cleaned every
3 - 4 hrs.
Low touches surfaces like walls, mirror and should be mopped daily once.
Office spaces, including conference rooms should be cleaned every evening after office hours or early in the morning
before the rooms are occupied. If contact surface is visibly dirty, it should be cleaned with soap and water prior to
disinfection. Prior to cleaning, the worker should wear disposable rubber boots, gloves (heavy duty), and a triple
layer mask.
• Start cleaning from cleaner areas and proceed towards dirtier areas.
• All indoor areas such as entrance lobbies, corridors and staircases, escalators, elevators, security guard
booths, office rooms, meeting rooms, cafeteria should be mopped with a disinfectant with 1% sodium
hypochlorite or phenolic disinfectants. The guidelines for
• preparing fresh 1% sodium hypochlorite solution is at Annexure I
[Fig-5]

• High contact surfaces such elevator buttons, handrails / handles and call buttons, escalator handrails, public
counters, intercom systems, equipment like telephone, printers/scanners, and other office machines should
be cleaned twice daily by mopping with a linen/absorbable cloth soaked in 1% sodium hypochlorite.
Frequently touched areas like table tops, chair handles, pens, diary files, keyboards, mouse, mouse pad,
tea/coffee dispensing machines etc. should specially be cleaned.
• For metallic surfaces like door handles, security locks, keys etc. 70% alcohol can be used to wipe down
surfaces where the use of bleach is not suitable.
• Hand sanitizing stations should be installed in office premises (especially at the entry) and near high contact
surfaces.
• In a meeting/conference/office room, if someone is coughing, without following respiratory etiquettes or
mask, the areas around his/her seat should be vacated and cleaned with 1% sodium hypochlorite.
• Carefully clean the equipment used in cleaning at the end of the cleaning process.
• Remove PPE, discard in a disposable PPE in yellow disposable bag and wash hands with soap and water.
In addition, all employees should consider cleaning the work area in front of them with a disinfecting wipe
prior to use and sit one seat further away from others, if possible
70% Alcohol can be used to wipe down surfaces where the use of bleach is not suitable, e.g. metal. (Chloroxylenol
(4.5-5.5%) / Benzalkonium Chloride or any other disinfectants found to be effective against coronavirus may be used
as per manufacturer’s instructions)
ALWAYS USE FRESHLY PREPARED 1% SODIUM HYPOCHLORITE.
• Do not use disinfectants spray on potentially highly contaminated areas (such as toilet bowl or surrounding
surfaces) as it may create splashes which can further spread the virus.
• To prevent cross contamination, discard cleaning material made of cloth (mop and wiping cloth) in
appropriate bags after cleaning and disinfecting. Wear new pair of gloves and fasten the bag.
• Disinfect all cleaning equipment after use and before using in other area
• Disinfect buckets by soaking in bleach solution or rinse in hot water
Personal Protective Equipment (PPE): Wear appropriate PPE which would include the following while carrying out
cleaning and disinfection work.
• Wear disposable rubber boots, gloves (heavy duty), and a triple layer mask
• Gloves should be removed and discarded damaged, and a new pair worn.
• All disposable PPE should be removed and discarded after cleaning activities are completed.
• Hands should be washed with soap and water immediately after each piece of PPE is removed, following
completion of cleaning.
Facility that does not house people overnight:
• Close off areas visited by the ill persons. Open outside doors and windows and use ventilating fans to
increase air circulation in the area. Wait 24 hours or as long as practical before beginning cleaning and
disinfection.

• Cleaning staff should clean and disinfect all areas such as offices, bathrooms, common areas, shared
electronic equipment (like tablets, touch screens, keyboards, remote controls, and ATM machines) used
by the ill persons, focusing especially on frequently touched surfaces.
At a facility that does house people overnight:
• Close off areas visited by the ill persons. Open outside doors and windows and use ventilating fans to
increase air circulation in the area. Wait 24 hours or as long as practical before beginning cleaning and
disinfection.
• In areas where ill persons are being housed in isolation, This includes focusing on cleaning and disinfecting
common areas where staff/others providing services may come into contact with ill persons but reducing
cleaning and disinfection of bedrooms/bathrooms used by ill persons to as-needed.
• In areas where ill persons have visited or used, continue routine cleaning and disinfection as in this guidance.
If it has been more than 7 days since the person with suspected/confirmed COVID-19 visited or used the facility,
additional cleaning and disinfection is not necessary.
HARD (NON-POROUS) SURFACES
If surfaces are dirty, they should be cleaned using a detergent or soap and water prior to disinfection
[Fig-6]
SOFT (POROUS) SURFACES
For soft (porous) surfaces such as carpeted floor, rugs, and drapes, remove visible contamination if present and
clean with appropriate cleaners indicated for use on these surfaces. After cleaning:
• If the items can be laundered, launder items in accordance with the manufacturer’s instructions using the
warmest appropriate water setting for the items and then dry items completely.
• Otherwise, use products that are EPA-approved for use against the virus that causes COVID-19external
icon and that are suitable for porous surfaces
[Fig-7]

ELECTRONICS
For electronics such as tablets, touch screens, keyboards, remote controls, and ATM machines, remove visible
contamination if present.
• Follow the manufacturer’s instructions for all cleaning and disinfection products.
• Consider use of wipeable covers for electronics.
• If no manufacturer guidance is available, consider the use of alcohol-based wipes or sprays containing at
least 70% alcohol to disinfect touch screens. Dry surfaces thoroughly to avoid pooling of liquids.
LINENS, CLOTHING, AND OTHER ITEMS THAT GO IN THE LAUNDRY
• In order to minimize the possibility of dispersing virus through the air, do not shake dirty laundry.
• Wash items as appropriate in accordance with the manufacturer’s instructions. If possible, launder items
using the warmest appropriate water setting for the items and dry items completely. Dirty laundry that has
been in contact with an ill person can be washed with other people’s items.
• Clean and disinfect hampers or other carts for transporting laundry according to guidance above for hard or
soft surfaces.
The risk of exposure to cleaning staff is inherently low. Cleaning staff should wear disposable gloves and gowns for
all tasks in the cleaning process, including handling trash.
MODES OF SANITIZER
1. Hand washing
[Fig-8]
2. Deep Moping
[Fig-9] [Fig-10] [Fig-11]
3. Fogging
[Fig-12]

4. Sanitizer Tunnel
[Fig-13]
5. Sanitizer Fan
[Fig-14]
FURTHER READINGS
1. WHO guidelines
2. CDC guidelines
3. IC guidelines
4. MOHFW India guidelines
5. ICMR guidelines
Acknowledgements

CORONA UPDATE 8
With inputs from
Dr KK Aggarwal
Compiled by Dr. Narendra Malhotra, Dr. Neharika Malhotra, Dr. Jaideep Malhotra, Dr. Keshav Malhotra
World Covid Meter 6th
August INDIA
213 Countries
President CMAAO, HCFI and Past National President IMA
Cases:1M: April 2, 2 M April 15, 3 M: April 27, 4 M May 8; 5 M 20 May, 6 M 30
th
May, 7 M 7
th
June, 8M by 15 June, 9
M 22
nd
June, 10 M 29
th
June. 11 M 4
th
July, 16 M , 17 M 29 July, 18 M ist August
Ground Zero: Wuhan in live animal market or cafeteria for animal pathogens: 10th January; Total cases are based on
RT PCR, 67% sensitivity
India race with Brazil
Coronavirus Cases: 18,971,698
Deaths: 711,116
Recovered: 12,160,946
ACTIVE CASES 6,099,636
Currently Infected Patients 6,034,096 (99%) in Mild Condition
65,540 (1%) Serious or Critical
CLOSED CASES 12,872,062
Cases which had an outcome: 12,160,946 (94%) Recovered / Discharged
711,116 (6%) Deaths
# Country,
Other
Total
Cases
New
Cases
Total
Deaths
New
Deaths
Total
Recovered
Active
Cases
Serious,
Critical
Tot Cases/
1M pop
Deaths/
1M pop
Total
Tests
Tests/
1M pop
Population
World 18,965,479 +271,406 710,287 +6,838 12,156,387 6,098,805 65,511 2,433 91.1
1 USA 4,973,568 +55,148 161,601 +1,311 2,540,137 2,271,830 18,424 15,017 488 62,381,295 188,353 331,192,837
2 Brazil 2,862,761 +54,685 97,418 +1,322 2,020,637 744,706 8,318 13,459 458 13,329,028 62,664 212,706,570
3 India 1,963,239 +56,626 40,739 +919 1,327,200 595,300 8,944 1,421 29 21,484,402 15,554 1,381,307,956
Doubling Time
Date Daily new cases New Deaths Total cases Total Deaths
5th August 56626 919 1963239 40739
4th August 51282 849 1906613 39820
3rd August 50629 810 1855331 38971
2nd August 52783 758 1804702 38783
1st August 54865 852 1751919 37403
30th July 57704 765 1697054 36551
29th July 54966 783 1639350 35786
28th July 49632 776 1532135 34224
27th July 49632 776 1532135 34224
26th July 50525 716 1436019 32812
25th July 48472 690 1385494 32096
24th July 48892 761 1337022 31406
23rd July 48446 755 1288130 30645
22nd July 45599 1120 1239684 29890
21st July 39168 671 1194085 28770
20th July 36810 596 1154917 28099
19th July 40243 675 1118107 27503
18th July 37407 543 1077864 26828
17th July 34820 676 1040457 26285
16th July 35468 680 1005637 25609
15th July 32682 614 970169 24929
14th July 29842 588 937487 24315
13th July 28179 540 907645 23727
12th July 29108 500 879446 23187
11th July 27755 543 850358 22687
10th July 27761 521 822603 22144
9th July 25790 479 794842 21623
India predictions
1. Death Rate is deaths today vs number of cases today

2. Corrected Death Rate is deaths today vs number of cases 14 days back
3. For one symptomatic test positive case there are 10-30 asymptomatic cases and 20 untested cases
4. Estimated Number of deaths = Reported deaths x 2
5. Number of deaths today should be 15% of the serious patients present 14 days back
6. Undocumented cases for each documented case [Iceland: 1: 2; German: 1: 5; New York City grocery
store shoppers: 1: 10; California 1.5%]
7. Amongst active 2.37% are serious, 1.82% need oxygen, and 0.41% need ventilator support.

Facts
1. India: In states with average population density of 1185 /sk km the average number of cases were 2048. On
the contrary in states with population density of 909/ sk km the number of cases were 56. (When Chandigarh
and Pondicherry were taken out from this group) the Average Density of other states were 217 and the
average number of cases were 35 [HCFI]
2. COVID Sutras: It’s a COVID-19 Pandemic due to SARS 2 Beta Corona Viruses (different from SARS 1 where
spread was only in serious cases); with over eleven virus sequences floating; has affected up to 22.8% of Delhi
population, Causes Mild or Atypical Illness in 82%, Moderate to Severe Illness in 15%, Critical Illness in 3% and
Death in 2.3% cases (15% of admitted serious cases, 71% with comorbidity< Male > Females); affects all ages
but Predominantly Males (56%, 87% aged 30-79, 10% Aged < 20, 3% aged > 80); with Variable Incubation
Period days (2-14; mean 5.2 days); Mean Time to Symptoms 5 days; Mean Time to Pneumonia 9 days, Mean
Time to Death 14 days, Mean Time to CT changes 4 Days, Reproductive Number R0 1.5 to 3 (Flu 1.2 and SARS
2), Epidemic Doubling Time 7.5 days; Origin Possibly from Bats (Mammal); Spreads via Human to Human
Transmission via Large and Small Droplets and Surface to Human Transmission via Viruses on Surfaces for up
to three days. Enters through MM of eyes, nose or mouth and the spike protein gets attached to the ACE2
receptors. ACE2 receptors make a great target because they are found in organs throughout our bodies (heart
muscle, CNS, kidneys, blood vessels, liver) Once the virus enters, it turns the cell into a factory, making millions
and millions of copies of itself — which can then be breathed or coughed out to infect others.
3. Prevalence: New York: 13.9%; New York City at 21.2%, S Korea 5.7%, world 5%; Ohio prison: 73% of inmates;
New York: 21% mortality April 22 in JAMA.
4. Viral particles seen in tears, stool, kidneys, liver, pancreas, heart, semen, peritoneal fluid, CSF.
5. Thrombosis: University of Pennsylvania clots are seen in patients even on blood thinners. Netherlands study,
31%
6. Other human beta-coronaviruses has immunity lasting only for one year with no IMMUNITY PASSPORT.
7. In absence of interventions, prolonged or intermittent social distancing (till 2022-24)
2. Low levels of cross immunity from the other beta-coronaviruses against SARS-CoV-2 could make SARS-CoV-2
appear to die out, only to resurge after a few years. Surveillance till 2024.
3. During peak (trace and treat) and after the peak (trace and treat the close contacts
4. Increased spread: close environment, crowded place with close physical contacts with no ventilation
5. Strategies: From community mitigation to individual containment; broader good over individual autonomy;
perfect cannot be the enemy of the good; pandemics are fought on the grounds and not the hospitals., Treat
the patient and not the test report, Consider every surface and every asymptomatic person as virus carrier
6. HCW: Direct patient exposure time < 30 minutes; 7 days work and 7 days holidays.
7. Italy mortality reduced when they were short of ventilators.
8. Hospital at HOME: CHF, mild pneumonia, exacerbations of asthma and COPD, cellulitis, and urinary tract
infections.
9. Great Imitator (protean manifestation).
10. IgM can be false positive in pregnancy, immunological diseases; Pooled tests (< 5, 20 Kerala, 64 Singapore
RTPCR) when seroprevalence is < 2%.
11. Early treatment, day 3-5, to reduce the viral load and prevent cytokine storm using hydroxychloroquine with
azithromycin or ivermectin with doxycycline with IV remdesivir and IV single dose Tocilizumab interleukin (IL-6
receptor inhibitor) if very high D-dimer and IL-6; convalescent plasma therapy (given early; donor 14 days
symptoms free, between day 28-40, single donation can help 4 patients), Lopinavir-ritonavir and Favipiravir if
very low CD 4 counts.
12. Hypoxia: Low flow oxygen < 6l/mt, titrated to high flow oxygen using non rebreathing mask, Venturi mask,
HFNC and helmet CPAP, NIV in supine or prone position.
13. Early intubation with prone ventilation only if progressive. Hypoxia (walking dead) have capillary problem
and not alveoli.
14. Formulas: Deaths in symptomatic cases 1%; Deaths X 100= expected number of symptomatic cases; Cases
after seven days: Cases today x 2 (doubling time 7 days); Cases expected in the community: Number of deaths
occurring in a five-day period and estimate the number of infections required to generate these deaths based
on a 6.91% case fatality rate; Compare that to the number of new cases actually detected in the five-day
period. This can then give us an estimate of the total number of cases, confirmed and unconfirmed; Lock down
effect = Reduction in cases after average incubation period (5 days); Lock down effect in reduction in deaths:
On day 14 (time to death); Requirement of ventilators on day 9: 3% of number of new cases
detected; Requirement of future oxygen on day seven: 15% of total cases detected today; Number of people

which can be managed at home care: 80% of number of cases today; Requirement of ventilators: 3% of
Number of cases today; Requirement of oxygen beds today: 15% of total cases today.
Protect yourself and your family from COVID-19
Based on what we know at this time, pregnant people might be at an increased risk for severe illness from COVID-
19 compared to non-pregnant people. Additionally, there may be an increased risk of adverse pregnancy outcomes,
such as preterm birth, among pregnant people with COVID-19. Therefore, if you are pregnant, be mindful about
reducing your risk of getting sick. If you are caring for children, you can teach them everyday steps (such as proper
handwashing) to help them stay healthy and, in turn, help protect yourself and your family.
Reduce your risk of getting COVID-19
It is especially important for people at increased risk for severe illness from COVID-19, and those who live with
them, to protect themselves from getting COVID-19.
The best ways to protect yourself and to help reduce the spread of the virus that causes COVID-19 are to:
 Limit your interactions with other people as much as possible.
 Take precautions to prevent getting COVID-19 when you do interact with others.
If you start feeling sick and think you may have COVID-19, call your healthcare provider within 24 hours.
Venturing out into a public setting? What to consider before you go.
As communities and businesses across the United States are opening, you may be thinking about resuming some
activities, running errands, and attending events and gatherings. There is no way to ensure you have zero risk of
infection, so it is important to understand the risks and know how to be as safe as possible.
People who are pregnant, and those who live with them, should consider their level of risk before deciding to go out
and ensure they are taking steps to protect themselves and others. Consider avoiding activities where taking
protective measures may be difficult, such as activities where social distancing can’t be maintained. Everyone should
take steps to prevent getting and spreading COVID-19 to protect themselves, their communities, and people who
are at increased risk of severe illness.
In general, the more people you interact with, the more closely you interact with them, and the longer that
interaction, the higher your risk of getting and spreading COVID-19.
 If you decide to engage in public activities, continue to protect yourself by practicing everyday preventive
actions.
 Keep these items on hand and use them when venturing out: a cloth face covering, tissues, and a hand
sanitizer with at least 60% alcohol, if possible.
 If possible, avoid others who are not wearing cloth face coverings or ask others around you to wear cloth
face coverings.
Every one has to understand, that corona is here to stay and simple measures of S.M.S. (Social distancing, Masks &
Sanitizing) have to be followed to be safe.
Humans all over the world have to wakeup to fight this long term war against CORONA and its time to change our
behavior and life style to a NEW NORMAL.
Acknowledgements

CORONA UPDATE - 9
COVID-19 AND PREGNANCY CONSIDERATIONS
Compiled by Dr. Neharika Malhotra, Dr. Narendra Malhotra, Dr. Jaideep Malhotra, Dr. Keshav Malhotra
Dr. Manpreet Sharma, Dr. Shemi Bansal, Dr. Sarita Dixit
Based on what we know at this time, pregnant women might be at increased risk for severe illness from COVID-19
compared to non-pregnant women. Additionally, there may be an increased risk of adverse pregnancy outcomes,
such as preterm birth, among pregnant women with COVID-19.
Actions to take if you are pregnant
 Do not skip your prenatal care appointments. Regular ANC is the crux to safe pregnancy. (Minimum 5, ideal
every month).
 Limit your interactions with other people as much as possible.
 Take precautions to prevent getting COVID-19 when you do interact with others.

 Make sure that you have at least a 30-day supply of your medicines and a reliable shop which can deliver.
 Talk to your healthcare provider about how to stay healthy and take care of yourself during this COVID-19
pandemic. (Helplines)
(Govt. COVID helpline 011-23978046 or 1075)
Rainbow Hospital Helpline: +91 81910 22444, 0562-2600531-538
(Dr. Pankaj Bhatia: +91 94128 95978, Dr. Vishwa Deepak: +91 99588 82595, Dr. Shubham Jain: +91 70423 57955,
In case of Pregnancy - Dr. Manpreet Sharma : +91 93191 02069, Dr. Shemi Bansal : +91 98976 37828,
Dr. Sarita Dixit : +91 96109 62978)
 If you don’t have a healthcare provider, contact your nearest community health center or health department
or your doctor (Video conferencing helps).
 Call your healthcare provider if you have any questions related to your health. (Consult IMumz pregnancy
care app).
 Seek care immediately if you have a medical emergency.
 You may feel increased stress during this pandemic. Fear and anxiety can be overwhelming and cause strong
emotions. Learn about stress and coping. (IMumz, Digital support groups, helplines).
 Learn more about how to reduce your risk of getting COVID-19.
Download Arogya-Setu app (https://play.google.com/store/apps/details?id=nic.goi.aarogyasetu&hl=en_IN)
Vaccines during pregnancy
Although there is no vaccine available to protect against the virus that
causes COVID-19, routine vaccines are an important part of protecting
your health. Receiving some vaccines during pregnancy, such as the
influenza (flu) and Tdap vaccines, can help protect you and your baby. If
you are pregnant, you should continue to receive your recommended
vaccines. Talk with your doctor about visits for vaccines during
pregnancy.
Prenatal and postpartum care
It is important to take care of yourself and your baby during pregnancy
and after delivery.
Delivery locations during the COVID-19 pandemic
Delivering your baby is always safest under the supervision of trained
healthcare professionals. If you have questions about the best place to
deliver your baby, discuss them with your family doctor and your
obstetrician.
Much is still unknown about the risks of COVID-19 to newborns.
(Newborns born to mothers with suspected or confirmed COVID-19)
 Newborns can be infected with the virus that causes COVID-19
after being in close contact with an infected person (Mother
should wear mask).
 Some babies have tested positive for the virus shortly after birth.
It is unknown if these babies got the virus before, during, or after
birth.
 Most newborns who have tested positive for COVID-19 had mild
or no symptoms and have recovered fully. However, there are a
few reports of newborns with severe illness.
 A small number of other problems, such as preterm (early) birth
and other problems with pregnancy and birth, have been
reported in babies born to mothers who tested positive for
COVID-19. We do not know if these problems were related to the
virus.

SARS-CoV-2 and breastfeeding
Mothers who choose to breastfeed:
 Breast milk provides protection against many illnesses and is the best source of nutrition for most infants.
 You, along with your family and healthcare providers, should decide whether and how to start or continue
breastfeeding.
 We do not know for sure if mothers with COVID-19 can spread the virus to babies in their breast milk, but
the limited data available suggest this is not likely.
 If you have COVID-19 and choose to breastfeed:
o Wear a cloth face covering while breastfeeding and wash your hands with soap and water for at least 20
seconds before each feeding.
 If you have COVID-19 and choose to express breast
milk:
o Use a dedicated breast pump (not shared).
o Wear a cloth face covering during expression and
wash your hands with soap and water for at least
20 seconds before touching any pump or bottle
parts and before expressing breast milk.
o Follow recommendations for proper pump
cleaning (sanitizers) after each use, cleaning all
parts that come into contact with breast milk.
o If possible, expressed breast milk should be fed to
the infant by a healthy caregiver who does not
have COVID-19 and is not at high-risk for severe
illness from COVID-19, and is living in the same
home.
 Parents and other caregivers should follow
recommendations described in the Discontinuation of Isolation for Persons with COVID-19 Not in Healthcare
Settings. (Home isolation guidelines to be followed as given by Government of India, I.C.M.R. & I.M.A.)
SARS-CoV-2 and children
There is much more to be learned about how this disease affects children. While some children and infants have
been sick with COVID-19, most illnesses have been among adults. Some reports suggest that infants under 1 year old
and those with underlying medical conditions might be at higher risk of serious illness from COVID-19 than other
children.
 Children with COVID-19 generally have mild, cold-like symptoms, such as fever, runny nose, and cough.
Vomiting and diarrhea have also been reported in some children.
 Children with certain underlying medical conditions, such as chronic lung disease or moderate to severe
asthma, serious heart conditions, or weak immune systems, might be at higher risk for severe illness from
COVID-19. Call your child’s healthcare provider if you are worried about your child’s health or if your child
has symptoms of COVID-19.
 In case of emergency, call 108 or go to your local emergency department. Emergency departments have
infection prevention plans to protect you and your child from getting COVID-19 if your child needs
emergency care. Do not delay getting emergency care for your child because of COVID-19.
Plastic face shields for newborns and infants are NOT recommended. There are no
data supporting the use of infant face shields for protection against COVID-19 or other
respiratory illnesses. An infant face shield could increase the risk of sudden infant
death syndrome (SIDS) or accidental suffocation and strangulation. Infants, including
newborns, move frequently, which could increase the possibility of their nose and
mouth becoming blocked by the plastic face shield or foam components. The baby’s
movement could also cause the face shield to become displaced, resulting in
strangulation from the strap.

Cloth face coverings for children, parents, and other caregivers
CDC recommends that everyone 2 years and older wear a cloth face covering that covers their nose and mouth when
they are out in the community. Because of the danger of suffocation,
do NOT put cloth face coverings on babies or children younger than 2
years. Cloth face coverings should also not be worn by anyone who has
trouble breathing, is unconscious, can’t move, or is otherwise unable to
remove the face covering without assistance.
Parents and other caregivers should keep in mind that wearing a cloth
face covering is not a substitute for social distancing, frequent hand
washing, or other everyday preventive actions – please wear your cloth
face covering in addition to practicing other prevention steps. A cloth
face covering is not intended to protect you, the wearer, but it may
prevent you from spreading the virus to others. This would be especially
important if you are infected but do not have symptoms of COVID-19.
Please remember that medical face masks and N95 respirators are
reserved for healthcare personnel and other first responders.
Safe sleep for infants during the COVID-19 pandemic
During the COVID-19 pandemic, parents of infants may experience increased stress and fatigue that could affect
their infants’ sleep practices. Safe sleep is an important part of keeping infants healthy, including during the COVID-
19 pandemic. If you have an infant, you can help reduce your baby’s risk of sudden infant death syndrome (SIDS) and
other sleep-related deaths by doing the following:
 Place your baby on his or her back for all sleep
times – naps and at night.
 Use a firm, flat sleep surface, such as a mattress
in a crib, covered by a fitted sheet.
 Have the baby share your room but not your
bed. Your baby should not sleep on an adult bed,
cot, air mattress, or couch, or on a chair alone,
with you, or with anyone else.
 Keep soft bedding such as blankets, pillows,
bumper pads, and soft toys out of your baby’s
sleep area.
 Do not cover your baby’s head or allow your
baby to get too hot. Signs your baby may be
getting too hot include if he or she is sweating or
if his or her chest feels hot.
 Do not smoke or allow anyone to smoke around your baby.
Newborn visits. Ideally, newborn visits should be done in person so that your pediatric healthcare provider can
check your baby’s growth and feeding, check your baby for jaundice, make sure your baby’s newborn screening tests
were done, and get any repeat or follow-up testing, if necessary. At the newborn visit, your pediatric healthcare
provider will also check how you and your baby are doing overall. Newborn screening tests include a bloodspot,
hearing test, and test for critical congenital heart defects. Learn more about newborn screening tests.
Well child visits. Your pediatric healthcare provider will check your child’s development at well child visits. You can
track your child’s developmental milestones with CDC’s free Milestone Tracker app.
Vaccine visits. Vaccines are an important part of keeping your child healthy, especially if your child is under 2 years
old. Vaccines help provide immunity before being exposed to potentially life-threatening diseases. Although there is
not yet a vaccine to help protect against COVID-19, vaccines for illnesses such as measles, influenza (flu), whooping
cough (pertussis), and other infectious diseases are important for your child’s health. This will help to prevent
outbreaks of vaccine-preventable diseases among young children during the COVID-19 pandemic.
Ask your healthcare provider how they are taking steps to separate healthy patients from those who may be sick.
Some health care providers may choose to delay visits like well-child checks and routine vaccine visits. These
decisions will be based on circumstances in your community and your child’s individual care plan. Call your
provider’s office to ask about any upcoming appointments or about when your child’s vaccinations are due.

Coping with stress
Pandemics can be stressful for everyone. Fear and anxiety about
a disease can be overwhelming and cause strong emotions in
both adults and children. Coping successfully with stress will
make you, the people you care about, and your community
stronger.
Talk with your children about the pandemic. It is important to try
to stay calm and to give children information that is truthful and
appropriate for their ages and developmental levels. Children
respond differently to stressful situations than adults. CDC offers
resources to help you talk with your children about COVID-19.
Depression during and after pregnancy is common and can be
treated. Postpartum depression is depression that can happen
after having a baby. If you think you may be experiencing
depression, seek treatment from your health care provider as
soon as possible. Find more information on depression during
and after pregnancy.
INPUTS FROM Prof. OP Abraham, Prof of ID at CMC and H, Vellore
Every aspect of COVID management
Learning points :
1. Symptoms of Covid are fairly distinctive as they evolve from day to day, and so are fairly diagnostic. So a
syndromic diagnostic approach is still valid and it is possible to distinguish it from other ILIs and seasonal
fevers like Dengue and Typhus.
2. But neither laboratory nor radiology nor the complications like Type 1 Resp failure, sepsis, septic shock,
hyperinflammatory syndrome and multiorgan dysfunction are unique to Covid. But the thrombotic
complications seem to be more distinctive in Covid.
3. So we have to fall back on RTPCR with its own sensitivity issues. So a syndromic clinical diagnosis helps
greatly. If in doubt with RTPCR, test again !
4. Presently there is NO role for CT in screening or diagnosis.
5. There is no treatment for mild Covid. HCQ, Azithro, Amoxycillin, Ceftriaxone, Oseltamivir etc are NOT
indicated.
6. Antibiotic policy for pneumonia and sepsis are as per hospital protocols keeping the infective organism in
mind.
7. Prophylactic or therapeutic anticoagulation is now standard of care but will depend on the risk factors for
the former and evidence for the latter.
8. The only antiviral drug for which we have evidence is Remdesivir.HCQ, Lopinavir, Ritonavir, Ribavirin etc
have no evidence in favor. Favipiravir is experimental and should only be offered with informed consent.
9. Benefit in the hypoxic patient from Dexamethasone is now proven and has become standard of care.
10. Roche, the manufacturer, has conceded that Tocilizumab has shown no evidence of benefit in severe
illness.It is toxic. The immunosuppression may lead to severe infections.
11. CPT. Adequate amount of neutralizing antibodies need to be demonstrated. Wait for results of ICMR trial.
12. Surgery in Covid- limited to emergency only. Covid Surge study in Lancet showed very high peri- op
mortality.
13. Prognosis: Well controlled DM, HT, Asthma or COPD are not at high risk. But in the seriously and critically ill
patient, with comorbidity, the options of either continuing/ dwescalating / palliative care to be discussed
with family every day.
14. HCW safety. High incidence but less severe illness and mortality. PPE and training help. PPE is the last line of
defense, and safety depends entirely on avoiding any breach.
Most HCWs get infected in community.
Acknowledgements
W.H.O., C.D.C., Government of India, Ministry of Health & Family Welfare, ICMR, IMA, FOGSI, Imumz app.

CORONA UPDATE 10
WHEN WILL CORONA GO?
Compiled by Dr. Narendra Malhotra, Dr. Jaideep Malhotra, Dr. Neharika Malhotra, Dr. Keshav Malhotra
COVID 19 or SARS-CoV-2 may never go away even with a vaccine. This disease is
likely to remain with human kind for years to come and will eventually become
endemic like many others viral diseases (Measles, Chickenpox, HIV etc). Also it now
is less likely that this virus will have seasonal outbreaks, as the last 6 months have
shown corona to survive in extremes of weather all over the world. It is also
becoming clearer that the disease is not going to vanish completely with HERD
immunity and is going to come back repeatedly may be ever 3-4 months or just
remain throughout the year. It is also becoming clearer that getting once infected
does not make you immune forever as reports of reinfection are surfacing.
At this point, how long immunity to COVID-19 will last is unclear; the virus simply
hasn’t been infecting humans long enough for us to know. But related coronaviruses are reasonable points of
comparison: In SARS, antibodies—which are one component of immunity—wane after two years. Antibodies to a
handful of other coronaviruses that cause common colds fade in just a year. “The faster protection goes away, the
more difficult for any project to try to move toward eradication,”
The virus is here to stay! So the question is, How do humans live safely with it? This needs a huge political will,
sustained efforts from all world countries towards improving healthcare facilities and caution towards complete
unlocking. Countries are already showing “Response fatigue”.
All of us are under tremendous economic pressure to open up, not understanding the gravity of the second or third
waves of the disease lurking around the corner. We all are asking:- tell us one thing we have to do ? Well there is no
one thing or a quick fix solution. The hope that vaccine will be an all out solution to this infection may not hold true.
In the past only smallpox has been eradicated by a vaccine, while all other viral diseases are still endemic despite the
vaccines (Measles, Mumps rubella, chickenpox, dengue, influenza etc). Four novel corona virus diseases are already
existing in our world as common colds and probably SARS-CoV-2 may be the fifth one which we have to live with.
The coronavirus is simply too widespread and too transmissible. The most likely scenario, experts say, is that the
pandemic ends at some point—because enough people have been either infected or vaccinated—but the virus
continues to circulate in lower levels around the globe. Cases will wax and wane over time. Outbreaks will pop up
here and there.
All the potential vaccines being developed are under phase III trials and expected to be commercially available by
end of this year. Please note the vaccine trials have been all fast tracked and still the long term beneficial and
harmful effects need to be documented. Yes vaccination is an answer but the requirement is billions of doses – how
many years it will take to all population reach the un-affording is a challenge. Even when a much-anticipated vaccine
arrives, it is likely to only suppress but never completely eradicate the virus. (For context, consider that vaccines exist
for more than a dozen human viruses but only one, smallpox, has ever been eradicated from the planet, and that
took 15 years of immense global coordination and vaccinating each & every child.) In the best-case scenario, a
vaccine and better treatments blunt COVID-19’s severity, making it a much less dangerous and less disruptive
disease. Over time, SARS-CoV-2 becomes just another seasonal respiratory virus, like the four other coronaviruses
that cause a sizable proportion of common colds: 229E, OC43, NL63, and HKU1. These cold coronaviruses are so
common that we have likely all had them at some point, maybe even multiple times. They can cause serious
outbreaks, especially in the elderly, but are usually mild enough to fly under the radar. One endgame is that SARS-
CoV-2 becomes the fifth coronavirus that regularly circulates among humans. Till then follow simple precaution as
S.M.S. We will probably be living with this virus for the rest of our lives.

So the numero one step we all have to take is to understand that
CORONA virus is here to stay and it is contagious infection and it
can make us very sick and also kill us.
To prevent every one getting sick, simple long term efforts have to
be made like social distancing (1.8- 2mts), Mask & sanitizing
(washing hands) [S.M.S.].
Looking at the human nature, people will not shift towards simple
long range thinking unless someone they know closely gets
infected and very sick.
A gross neglect of these 3 simple measures is being seen all over the world with unlocking. Even the educated,
advanced nation’s people are not listening to repeated appeals by W.H.O., and there seems to be a lack of strong
political statements in favour of Mask & Social distancing. All countries should make these mandatory.
One by one there are three basic points:
1. Keep a distance between people
2. Wear a mask
3. Wash hands frequently
CORONA FACTS and MYTHs with COVID from all over the world
 Kim Jong-un, North Korea’s leader, placed Kaesong City, near the country’s border with the South, under
lockdown and declared a national emergency after acknowledging that his country might have its first case
of the coronavirus. A North Korean who defected to South Korea three years ago but secretly crossed back
into Kaesong City last week was “suspected to have been infected with the vicious virus,” the North’s official

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