Common fevers of Chennai

Chennai (previously known as Madras), is the capital of this southern state of Tamil Nadu. The weather is so hot that the British have a dish named after this city called Chicken Madras. Despite being dry most of the year, many infectious disease are prevalent throughout the year, only that some are more common during the rainy season. Infections are an important reason for high temperatures in the city.

The 5 common endemic infections in Chennai are:

1. Malaria – Vivax malaria is seen more often compared to falciparum malaria and typically cause high fevers with intense shivering (rigors). A person suffering typically experiences a cold phase with shivering, a hot phase with high fever and a sweating phase with drenching sweating. This happens periodically once a day or once in 2-3 days.

2. Typhoid fever (Enteric fever) – this is food borne infection caused by salmonella gastroenteritis. This can present variously but what is usual is that there would be some degree of a gastrointestinal upset. The patient could present with fever,shivering, body pains, headache,rash etc.

3. Dengue Fever – is another mosquito borne viral infection spread by the day biting Aedes aegypti (tiger mosquito – with white stripes on it) which is believed to bite below the knee. Fever can be high with shivering and severe back pain. A rash is also possible in light skinned patients.

4. Leptospirosis or Rat fever is caused by a family of 400 bacteria and causes fever with severe body pains. Some subtypes can cause jaundice, bleeding tendencies along with the fever whereas some others can cause kidney failure. This bacteria enters the body when water contaminated by rat urine (containing the bacteria) comes in contact with the body of the patient.

5. Scrub Typhus -happens due to a organism called Rickettsia and is a mite borne infection. The bite usually occurs in people who travel to heavily wooded areas such as IIT Madras or Raj Bhavan. The fever can be very high and the patient can have a very severe headache. Usually a black ulcer is found in the flexures of the body (under the breasts and in the groins)

The number one fever in Chennai over the last 2 years has been Covid 19. Patients usually have a fever with upper respiratory symptoms such as a headache, sore throat, runny nose, sneezing and cough with some phlegm production. A small proportion of patients develop a severe immune mediated pneumonia during the second week of the infection.

Urine infections, Intestinal infections, Skin infections are other common causes for fever. These infections are usually easily treated.Early diagnosis will help ensuring an early cure and rapid return to normal living.

All you wanted to know about the Covid-19 Disease

I write this article to give my patients a little clarity with regards to what they should know and what they should do in case they develop any fever or other symptoms this season.
I would like to make a disclaimer that this article is being written on the 24th of March 2020 and is intended for the people of Tamil Nadu in India who have been locked down at home. The information given below is subject to change as and when new information is available. I hope that my effort would be of some use to you.

  1. What do we know about the SARS-COV2 Virus?
    ​The SARS-COV2 virus belongs to the family of Corona Virus which includes the SARS and MERS viruses. It is a Zoonotic virus that has spread from animals to human beings. SARS-CoV2 refers to Severe Acute Respiratory Syndrome Corona Virus 2 (to differentiate it from the “old” SARS virus). It is believed to have spread from bats at Wuhan to humans and then by human to human contact.

The virus is called the Corona Virus because its surface is studded with spikes (like that on a crown).These spikes are believed to enable the virus to attach itself to the ACE2 receptor on the cell surface (found in high concentration on the Respiratory and Gastrointestinal mucosal cell surfaces). It is also for this reason that the virus causes a predominantly respiratory disease.

The disease spreads via Droplets and Fomites. Every time a patient of COVID-19 coughs or sneezes, he releases thousands of droplets containing millions of infectious viral particles. These Viral particles enter the body of its next victim when these droplets land on the eyes, nose or mouth of the person standing close by. It is believed that these droplets generally travel upto 6ft from the person coughing or sneezing. After an incubation period of 2-14 days, the unfortunate person could also develop the disease. The second mechanism by which the virus gains entry into a new host is by fomites. Fomites refers to any surface on which the droplets land. The virus then enters the next patient when he transfers the virus by inadvertently touching his eyes, nose or mouth. The virus is believed to be viable for upto 72hrs in the droplets and on fomites. Further virus shedding by an infected person can happen for 8-37 days (median 20 days). This dramatically increases the chances of spreading the infection in the community. This is why we need to lock ourselves at home for 2 weeks when we have a cough, however minor.

While anyone could be infected by the virus, most people only suffer from a mild disease with some cold, cough and fever. Most of us would recover by just staying at home and taking symptomatic treatment (such as Paracetamol, Cetrizine and a cough syrup). People above the age of 50 and those suffering from Hypertension, Diabetes, Heart disease, Kidney failure are more likely to suffer from severe disease requiring hospitalisation and even ICU care. The mortality rate is highest for this group of people.

The common symptoms of Covid infection are high fever, severe dry cough, breathlessness, extreme fatigue, loss of smell, sore throat, running nose and diarrhoea. 85% of those who catch the infection will have a minor illness and will recover within 2 weeks. About 10% will need admission to hospital for oxygen treatment. Only 5% will be sick enough to require intensive care.

  1. What do we know about the Covid-19 Pandemic?
    ​The Covid-19 pandemic began in Wuhan, Hubei province in China in December 2019. The virus is believed to have spread to man at the Huanan seafood wholesale market. The virus then rapidly spread from China to Italy, Iran and South Korea and then to the rest of the world. To date, more than 600,000 cases have been reported in more than 190 countries resulting in 28,300 deaths. Since this virus is highly contagious and has spread very quickly, travel restrictions, curfews, quarantines have been enforced throughout the world. The mortality rate has varied from 2 to 10% across the world.

China enforced a strict lockdown after which the number of new cases reduced drastically and the overall infection came under control. Like with all epidemics, it is believed that strict lockdown might help stopping the spread of virus by June 2020.

It is encouraging that the Janata curfew enforced in India for just 14 hours was followed by a reduction in the number of new cases detected as shown in the graph above. I believe that if we behave as responsible adults, cooperate completely with the Government agencies and strictly practice social distancing and the highest standards of personal hygiene, we could control this pandemic even earlier.

The Covid-19 pandemic has serious implications for the nation as a whole. If left unchecked, our health care services would be completely overwhelmed and lakhs of Indians could die. People talk about “flattening the curve”.

If you look in the graph given above, the red curve refers to the number of cases that may be detected if we do not practice social distancing, self-quarantining and complete cooperation with the lockdown enforced by our Government. Chennai has a population of 70 lakhs. If this virus affects all of us in Chennai and has a 10% hospitalisation rate and a 2% mortality, it would mean 7 lakh patients would require hospital admission and 1.4 lakh people would die. This would be catastrophic like in the movies and every family could lose a loved one to this infection. The consequences would be unimaginable if you took the population of India as a whole. I recommend that you watch the movie “the Contagion” to get an idea of what it could be like.

  1. What is the usual clinical course of the Covid-19 infection?
    ​The mean time from exposure to SARS-COV2 virus and development of symptoms is 5-6 days (range 2-14 days). 80% of those who develop an infection will only have mild symptoms and will recover completely within 2 weeks time. Of those patients who went to hospitals in China after developing symptoms, 40% had only mild illness and were sent home. 40% had moderate symptoms and needed admission. 15% required admission to the ICU and 5% became critically ill. It is heartening to note that only 10-12% of those with infection with mild disease progressed to severe disease. It is therefore important to stay at home when your symptoms are mild, take treatment online from your own doctor, practice strict social distancing and quarantine (even amongst members of your own family) and go to the hospital only if you have breathlessness. Unnecessary visits to the hospital will only increase the risk of spreading the infection to the health care workers as well as other patients who are admitted for other reasons.

Severe cases can take upto 6 weeks to recover and have a high mortality rate. Elderly patients (age above 60yrs) and those with Hypertension, Diabetes, Heart disease, Kidney failure, Cancer (within 5 yrs), Strokes and Dementia are at higher risk for severe disease. Such patients should practice strict social distancing, fantastic hand and personal hygiene in order to prevent infection. The CDC (Center for Disease Control) recommends that those at high risk of Covid-19 complications should:
​stock up supplies
​avoid contact with (sick) people
​wash hands frequently
​don’t share towels and utensils
​stay at home as much as possible
​develop a plan in case of illness

  1. What should you do if you are presently healthy and well?
    ​I would strongly recommend that you limit your time on social media and avoid reading pessimistic articles (gloom and doom). Staying positive and following the instructions given below would go a long way in helping you keep you sanity when you are locked down at home.

The recommendations are as follows:

  1. Social distancing – stay at home, work from home
    ​​ – restrict or better still avoid the entry of delivery boys and domestic help
    ​​​ into your house
    ​​ – avoid gatherings of more than 5 people (conference, meetings)
    ​​ – avoid going for a walk or jog with a friend
    ​​ – keep a 2-3 metre gap from other people
    ​​ – avoid shaking hands, hugging and hi-5s
    ​​ – go outside your home only for essential shopping and basic requirements
  2. Improve personal standards of hygiene
    ​​ – wash hands with soap and water for 20 seconds every 20 minutes
    ​​ – use hand sanitiser if water isn’t available
    ​​ – avoid touching your mouth, eyes and nose (MEN)
    ​​ – bathe twice a day in hot water with soap especially after returning home
    ​​ – Cough/sneeze into your sleeve (Note:Face masks are not 100% protective)
  3. Improve standards of cleanliness in your house
    ​​ – clean and disinfect all surfaces – floor, chair, table, door knobs, handles
    ​​​ and switches
    ​​ – spray 2.5% Lysol to disinfect surfaces (add 50ml of Lysol in 200ml of water
    ​​​ and use in a plastic spray can) or alternately, use 1% Hypochlorite
    ​​​ solution (100gm of bleaching powder in 3lts of water)
    ​​ – clean A/c vents and fittings
  4. What should you do if you have a minor cough, cold or sneeze?
    ​Do not panic, as there are many causes for cough, cold and sneezing. Your new penchant for keeping your house clean or using Lysol or bleaching powder itself may be a reason. Dust allergy, acid reflux, sinusitis could be other causes. Consult your doctor by phone and take his advice. Please follow all the recommendation for social distancing, personal and home hygiene as described above. Wearing a Face mask would reduce the droplet contamination of your surroundings.
  5. What should you do if you have a fever?
    ​There are many causes for fever in India including Malaria, Dengue, Chikungunya (mosquito borne), Typhoid fever, Gastroenteritis, Hepatitis (food and water borne) or any other virus. Urinary infections could also give you a fever. Most fevers do not require any investigations for 3 days. You can discuss your symptoms with your own doctor and take his advice.
  6. What are the different definitions used with regards to the current Covid-19 epidemic?

Who is a SUSPECTED CONTACT?
​A SUSPECTED CONTACT is someone who is healthy, without fever or respiratory symptoms but has recently travelled through a Covid-19 country, area or territory.

Who is a CLOSE CONTACT?
​A CLOSE CONTACT is someone who has visited or stayed/lived with or worked with or travelled with a Covid-19 patient (any duration of time).

Who is a SUSPECTED CASE of Covid-19 infection?
​A SUSPECTED CASE is one who has high fever with a cough or sore throat or ​​​breathlessness within 14 days of:
​​1. Travel to a Covid-19 prevalent country, area or territory OR
​​2. Was in close contact with a confirmed or probable case of Covid-19

Who is a PROBABLE CASE?
​A PROBABLE CASE is a SUSPECTED case in whom the Covid-19 report was inconclusive or for someone for whom a Pan Corona Virus Assay was positive.

Who is a CONFIRMED CASE?
​A CONFIRMED case is someone whose Covid-19 tests are positive irrespective of whether he has symptoms or not.

What is Social Distancing?
​Social Distancing is a term applied to certain activities that are taken by public health officers to slow down or stop the spread of a highly contagious disease. This includes avoidance of gatherings of people, closure of schools and colleges, closure of offices and working from home, closure of malls, cinemas, theatres and cessation of mass transport systems such as bus, train and air travel.

What is Quarantine?
​The term quarantine is used to describe isolation of a person who is currently healthy but has been exposed to an infectious agent and can become ill and spread the disease to others. The quarantine period for Covid-19 is 14 days.

What is Isolation?
​Isolation is used on an individual who is sick to separate him from others (healthy people). People in isolation can be cared for at the hospital or at their own homes.

  1. How should a SUSPECTED CONTACT or a CLOSE CONTACT be managed?
    All people who are considered contacts with Covid-19 illness must be immediately quarantined. They should strictly follow all recommended preventive strategies with regards to social distancing, improving standards of personal and home hygiene as described above. They should be isolated from other family members for a period of 28 days from the date of exposure to Covid-19 or from the date of return from a Covid-19 country or territory. Prophylactic dose of HydroxyChloroquine Sulfate may be tried after discussing with your doctor. The 14 day quarantine may have been increased to 28 days recently. However please note that testing is for the symptomatic contacts only.
  1. How should a SUSPECTED CASE be managed?
    Mildly symptomatic patients can be managed at home. They should be strictly isolated at home. All recommendation regarding social distancing and improved personal and home hygiene must be immediately enforced. The patient must be kept away from family members and must use a mask at all times. It would be better for him to get tested for Covid-19 and also admitted in case of worsening symptoms of increasing cough and breathlessness.
    Patients with severe symptoms of constant dry cough with increasing breathless must be immediately admitted to the Isolation Ward of the (Government or certified Private) hospital. All relevant tests would need to be taken (including Covid-19 testing). Chest X-rays and HRCT scans of the chest would need to be done to identify those with Viral Pneumonia with risk of rapid deterioration to ARDS (Acute Respiratory Distress Syndrome). If hypoxic, patients would need supplemental O2 (by nasal prongs/Face mask/ High flow non- rebreathing masks/Non-Invasive ventilation etc) and may need treatment in the ICU. Appropriate early treatment will prevent deterioration in many patients.
    Apart from isolation and appropriate treatment , contact tracing and informing the relevant Government agencies would be mandatory. The Tamil Nadu state help line number is 044-29510500, National Help line 011-23978046 and email id is ncov2019@gov.in.
  2. How should you manage a PROBABLE CASE of Covid-19?
    A probable case of Covid-19 must be isolated and treated according to his symptoms. A Covid-19 test may be repeated after 2 days.
  3. How should a CONFIRMED CASE of Covid-19 be managed?
    A Confirmed case of Covid-19 must be admitted and Isolated.
    a. They must be treated symptomatically with antihistamines, cough syrups and nebulisers b. Supplemental O2 must be given for those who are hypoxic.
    c. ICU care has been found to be useful in managing patients who are very ill.
    d. Non-invasive ventilation with high O2 flow and cPAP has been found to be useful.
    e. Restrictive fluid prescription has been found to be useful.
    f. No medication has been proven to be curative. However Hydroxychloroquine Sulfate along with Azithromycin has been used with some success ( more rapid reduction in inflammatory markers and reduction of Viraemia) in China. Newer Antivirals (Lopinavir- Ritonavir) and Corticosteroids haven’t been found to be useful. IL-1 antagonist and Inhaled GMSF have been used in experimental studies.
    g. If intubated and ventilated, Prone ventilation is helpful
    h. Patient may be discharged once he has fully recovered symptomatically and repeated
    nasal swabs are negative for Covid-19.
  4. What are the tests that are useful in a hospitalised patient?
    The following tests have been found to be useful in monitoring the progress of hospitalised patients and in identifying those who will progress from mild to severe infection.
    • Total white cell count
    • Neutrophil Lymphocyte count ratio >3.13
    • Increasing LDH
    • Increasing D-Dimer
    • Increasing Ferritin
    • Increasing Troponin-I

Although this is not done in India, the PCR was tested on every alternate day in China until it became negative.

  1. Who are the patients at highest risk for severe Covid-19 infection?
    ​Read Answer 3
  2. Do we have any preventive treatments available?
    ​Preventive treatment may be considered for people who have had a close contact with a proven case of Covid-19 infection or have returned from a Covid-19 prevalent area or have worrying high risk factors. Preliminary information available from China suggests that Hydroxy Chloroquine Sulphate and Chloroquine may be beneficial. As these medicines have side effects, I recommend that you contact your doctor for advise.
  3. What do we know about testing for Covid-19?
    ​A PCR (Polymerase Chain Reaction) test is now available to diagnose SARS-CoV2 infection. However, there is a shortage of kits in our country. It was recently in the news that MyLabs of Pune have a new kit that not only costs Rs1200/- but also gives quicker results. The currently available tests cost about Rs.4500-5000/- and the kits are imported.

With regards to who should be tested, the CDC guidelines suggest that:
​the doctor exercises his clinical judgement
​the patient has compatible signs and symptoms of Covid-19 illness
​patient has a severe respiratory illness irrespective of pertinent history of travel and
​​contact
The CDC also recommends that hospital patients with respiratory symptoms, high risk symptomatic patients and those with history of recent travel or contact be given priority over others.

The following specimen yield the highest results on PCR testing, BAL 93%, sputum 72%, nasal swabs 63%, brush biopsy 46%, throat swab 32%, faeces 29% and blood 1%.

The Pan-Corona Virus kits are not useful in detecting SARS-CoV2 infection. There is a new test measuring the IgM antibodies and is found to be 93% positive in suspected cases even when the PCR is negative.

Preliminary reports suggest that the PCR has a low false positive rate.

Home testing can be arranged in Chennai (Neuberg Labs) and this could reduce the risk of infection to others.

  1. What are the myths and misconceptions circulating regarding the Covid-19 infection?
    ​The following perceptions are false:
    • ​All Covid-19 infections are fatal and everyone is going to die
    • ​Covid-19 only affects the elderly. If you are young, you won’t catch the infection.
    • ​The pandemic is all hype and fear mongering
    • ​Masks are enough to protect you from the virus
    • ​A vaccine is already available for use in prevention
    • ​Pneumococcal vaccine will protect against the infection
    • ​Antibiotics can cure the infection
    • ​Vitamin C is protective against the infection
    • ​Using Gaumuthra will clear the infection
    • ​Summer (warm and humid weather) will prevent the spread of the infection
    • ​Herbal remedies would protect and cure you of the infection
    • ​Applying alcohol to skin will protect you form the virus
    • ​Drinking alcohol will protect against the virus
    • ​Eating non-veg foods can cause corona virus infection
    • ​If you can hold your breath for 10 sec, you don’t have COVID
    • ​Taking a hot bath will prevent corona virus infection
    • ​Mosquitoes can transmit the infection
    • ​Handheld dryers are effective in killing the new virus
    • ​Thermal scanners can detect the virus infection
  2. What can we do to slow down and arrest the spread the infection in our community?
    ​The SARS-CoV2 infection is best avoided and prevented than treated. We must do everything to prevent the spread of the infection in the community.

I recommend the following:

Stay at home, “let outsiders stay outside your home”. That includes the domestic help! If you ​​​must, keep them with you 24 X 7.
Keep safe distance from all (including family members)
Restrict travel outside home to the barest minimum – to buy essentials only
Avoid direct contact with neighbours and friends. Exercise alone!
Avoid gatherings of more than 4 people (including family)
Bathe twice daily
Wash your hands for 20 sec every 20 min with water and soap – especially if you touch your face.
Surface disinfect your house, tables, chairs, switches, knobs, handles etc.
Wash hands after touching anything that may be touched by others such as plastic bags, food ​​​parcels, milk bottles and packets, fruits and vegetables etc.
Wear a mask if you are going outside your house. Wear a mask inside your house if you are ​​​coughing.
Make a time-table, plan your day and keep your mind engaged. Avoid negative thinking and ​​​negative people (especially on social media). Stay positive and cheerful.
Develop your own support group, people who can keep you cheerful and provide help in case of ​​an emergency. This is a best time to reconnect with all your friends and long lost family. Take an antihistamine and cough syrup if you even have a minor cough, runny nose or sneeze.
​This will make all around you more comfortable and reduce the risk of Covid19.
Take all your vitamins, supplements and Green tea and anything else that you may take to stay ​​​healthy. Even if it has not been shown to protect you from Covid-19, it will keep your ​​​immune system “fighting fit”. Do your daily exercise (albeit alone), yoga meditation etc.
Stock up provisions but don’t hoard and cause a shortage in the community.
Contact your doctor for any health queries. Most of us will be happy to help online!

So isolate, isolate, isolate, keep clean, don’t panic, take treatment over phone and go to the hospital only if you have breathlessness!