Post Publication Independent Reviews COVID-19

Humble Thanks to His Excellency Hon'ble Dr. Harsh Vardhan, Union Minister for Health & Family Welfare, Science & Technology and Earth Sciences, Government of INDIA for reciprocating (within 180 seconds, amidst the COVID-19 National containment & treatment protocols) the communications titled "A faint beam of light at the end of the tunnel.... ", which is a continuous set of Post Publication Independent Reviews of Research Articles on COVID-19, submitted to the Govt. of INDIA

Ref:

1. Screenshot (below)

2. Copy of Communication as pdf file (below)

3. https://www.prabhubritto.org/post-publication-independent-reviews-covid-19 (this webpage)

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Thanks from HE Honble Dr Harsh Vardhan.pdf

Table of Contents:

Part I. A faint beam of light at the end of the tunnel.... Post Publication Independent Review of "Viral dynamics in mild and severe cases of COVID-19" Published: March 19, 2020 DOI: https://doi.org/10.1016/S1473-3099(20)30232-2

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A faint beam of light at the end of the tunnel....

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Post Publication Independent Review of

"Viral dynamics in mild and severe cases of COVID-19"

Yang Liu, Li-Meng Yan, Lagen Wan, Tian-Xin Xiang, Aiping Le, Jia-Ming Liu et al.

Published: March 19, 2020 DOI: https://doi.org/10.1016/S1473-3099(20)30232-2

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30232-2/fulltext

https://www.thelancet.com/action/showPdf?pii=S1473-3099%2820%2930232-2

http://www.icmje.org/icmje-recommendations.pdf


Review Comments:

1. Title inappropriate. Mild & Severe has been classified by the Authors later in the Manuscript. No Universal Standard has been cited. Consequently, authors need not have included the keywords mild and severe in the title, for the reason that these are the first few research articles that are appearing on COVID-19. Authors cannot enforce Mild and Severe conditions so early. Else, they should have indicated subjective conditions in the title instead of generic objectivity.

2. Authors declare COVID-19 as a new pandemic disease in the first line of the manuscript. Citation required. Else, they could have substantiated in the manuscript that it is a pandemic. Heightening human anxiety in the first line of a research manuscript may amount to author bias.

3. In the second sentence of the manuscript, authors are disclosing the information that they had previously published on SARS-CoV-2. Was there any urgent necessity for the authors to declare to the scientific community that they have previously published on SARS-CoV-2 and they are now publishing on COVID-19. Do the authors intend to indicate that they are an authority on the area and related areas and consequently all that they publish needs to accepted as it is? When any simple search on Google.com or Google Scholar or any other internet search engine can throw light on the previous research exploits of the authors, why is there a necessity for the authors to indicate that they have published on SARS-CoV-2, right in the second sentence of this manuscript. Again, this might amount to author bias.

4. This manuscript has been declared as published on March 19, 2020. In third sentence of this manuscript, authors are citing Reference 3 with DOI:10.1056/NEJMoa2002032. Cited article is Clinical Characteristics of Coronavirus Disease 2019 in China

List of authors. Wei-jie Guan, Ph.D., Zheng-yi Ni, M.D., Yu Hu, M.D., Wen-hua Liang, Ph.D., Chun-quan Ou, Ph.D., Jian-xing He, M.D., Lei Liu, M.D., Hong Shan, M.D., Chun-liang Lei, M.D., David S.C. Hui, M.D., Bin Du, M.D., Lan-juan Li, M.D., et al., for the China Medical Treatment Expert Group for Covid-19*

Extract from cited article:

medical records and compiled data

as reported to the National Health Commission between December 11, 2019, and January 29, 2020; the data cutoff for the study was January 31, 2020

4a. Did the National Health Commission certify that the data reported is error-free? Is National Health Commission Certification attached to cited manuscript DOI:10.1056/NEJMoa2002032 ?

4b. Attention is drawn to https://www.worldometers.info/coronavirus/country/china/

(i) Jan 31, 2020:

Total Cases: 11,791.

Daily New Cases: 2,099.

Active Cases: 11,289.

Total Deaths: 259

Daily New Deaths: 46

Newly Infected vs. Newly Recovered: 2,099 vs 72

Outcome of Cases (Recovery or Death): Recovery rate vs death rate: Not Available

(ii) Peak Rates:

Total Cases: 81, 218 as on 25.03.2020

Daily New Cases: 14,108 as on 12.02.2020

Active Cases: 58,016 as on 17.02.2020

Total Deaths: Gradient of curve indicates gradual slope upto Feb 16, further becoming more gradual until Feb 22, and growing still more gradual post Feb 23.

Daily New Deaths: Peaks observed at Feb 12, Feb 14, Feb 15, Feb 18, Feb 23. Graph is not steady. Waxing and Waning nonsystematic.

Newly Infected vs. Newly Recovered: New Cases Peak at Feb 12. New Recoveries Peak at Feb 27. Also noted that Lowest Recovery does not coincide with New Cases Peak and Lowest New Cases does not coincide with Peak New Recoveries. Nonsystematic behaviour observed.

(iii) Total Cases as on 25.03.2020: 81,218

4c. DOI:10.1056/NEJMoa2002032

Quote "As of February 25, 2020, a total of 81,109 laboratory-confirmed cases had been documented globally.5,6,9-11" End of Quote

Quote "We obtained the medical records and compiled data for hospitalized patients and outpatients with laboratory-confirmed Covid-19, as reported to the National Health Commission between December 11, 2019, and January 29, 2020; the data cutoff for the study was January 31, 2020" End of Quote

Did the authors draft the article after Feb 25, 2020, coz there is no possibility that they can include a futuristic statistic as globally documented data. Consequently, this manuscript should have been drafted after Feb 25, 2020. If this manuscript has been drafted after Feb 25, 2020, why was the data cut off for the Study fixed as January 31, 2020?

Quote "Written informed consent was waived in light of the urgent need to collect data. " End of Quote.

Read together with http://www.icmje.org/icmje-recommendations.pdf, when written informed consent itself was given an allowance and bypassed, then except for the data of the last few hours, the rest of the data would have been available even upto Feb 25, 2020 (minus a few hours, perhaps upto Feb 24, 2020).

Attention is drawn to the phenomena observed under 4b (i-iii), it raises a question whether some very significant clinical information has been left out? If so, what would be the significance of the outcome of the results of such a manuscript which is suspected to have left behind very significant clinical information?

4d. Attention is drawn to Article Metrics https://www.nejm.org/doi/metrics/10.1056/NEJMoa2002032

Social Media seems to have been enchanted by this article with questionable results

Twitter 24420

Facebook 32

Blog 35

Didnt anyone check whether this article can be relied upon? What would be the spread of information via so many twitter and facebook feeds and blogs?

On top of it, 67 citations for this research article? Didnt other researchers or authors start getting the same questions that crop up here? How could they blindly follow this research article?

5. Resuming again from Comment 3., article "Viral dynamics in mild and severe cases of COVID-19" also depends on the above article discussed in comment 4., and authors are banking heavily on the above article by citing it in the third sentence of their manuscript. When the merit of the cited article raises so many questions as in comment 4., how could the authors bank on the above article? When the merit of the base article becomes questionable, wont the merit of this article (that banks on the base article) also become questionable?

6. Quote "Findings from Feb, 2020, indicated that the clinical spectrum of this disease can be very heterogeneous." End of Quote. Article analysed in Comment 4 is indicated as reference for this statement. When the original article itself has restricted data upto Jan 31, 2020, how can this article indicate Findings from Feb, 2020, when this banks on the original article whose data is only upto Jan 31, 2020? Does this indicate carelessness by the authors? Further, another question arises, that when the foundation itself is shaky, how can another article ride piggy back on it, especially by citing it erroneously too? Suspected propagation of error and amplication of error from foundation article to this article?

7. Quote "Here, we report the viral RNA shedding patterns observed in patients with mild and severe COVID-19". This is the 4th sentence in the article. So far the authors have not defined or cited definition of mild and severe with reference to COVID-19. Should mild and severe be read as mild and severe for all conventional diseases or should mild and severe be read on a different scale with relevance to COVID-19? Authors are suggested to first introduce/explain various parameters that they would be using in the manuscript prior to using them? Else, the reader might get accustomed to the defines mild and severe and accept everything that follows without any scientific inquiry. Suspected Author bias.

8. Quote "76 patients admitted to the First Affiliated Hospital of Nanchang University (Nanchang, China) from Jan 21 to Feb 4, 2020, were included in the study" End of Quote

Quote "Coronavirus disease 2019 (COVID-19) is a new pandemic disease." End of Quote.

As per the Authors statement, the COVID-19 is a new pandemic disease. For investigating a pandemic disease (as per the authors statement), would a sample population of 76 be sufficient? Wouldnt the sample population be considered as insufficient to be considered as representative of the whole? In such a case, wouldnt the findings be trivial?

9. Quote "Parameters did not differ significantly between the groups, except that patients in the severe group were significantly older than those in the mild group, as expected.4" End of Quote. The authors are referring to https://doi.org/10.1016/S2213-2600(20)30079-5 cited as Reference no. 4 and stating that Parameters across mild and severe groups were the same, except that patients in the severe group were older than those in the mild group, which was as expected as per Reference no. 4, which is https://doi.org/10.1016/S2213-2600(20)30079-5 published online on Feb 24, 2020.

9a. Preliminary examination of https://doi.org/10.1016/S2213-2600(20)30079-5 indicated the following interesting extract

Quote "In this single-centered, retrospective, observational study, we enrolled 52 critically ill adult patients with SARS-CoV-2 pneumonia who were admitted to the intensive care unit (ICU) of Wuhan Jin Yin-tan hospital (Wuhan, China) between late December, 2019, and Jan 26, 2020" End Quote

The sample population itself was only 52 and they were adult and critically ill.

Further, Quote "The mean age of the 52 patients was 59·7" End Quote

So, if a sample population was 52 adult patients with a mean age of 59.7, enrolled for study when they were already critically ill, then, however experimented, the finding is going to be only about adult patients who are critically ill, and the finding cannot reflect any younger age group who were not critically ill, coz the choice was adult patients who were critically ill. Stated in simple terms, the spoon can serve only what is already there in the vessel.

9b. Reading Comment 9 & 9a together, what do the authors mean that they investigated and found that older patients were in the severe group as expected, based on results on another study which studied only older patients. Isnt this absurd/ridiculous? Do the authors expect that the reader will be so careless to accept whatever is written? Author bias suspected.

9c. On top of it, reading together Comment 4d, so many people seem to have become so engrossed by this article, flooding social media and causing such widespread dissemination of such questionable research reporting?

10. Quote "Overall, our data indicate that, similar to SARS in 2002–03,6 patients with severe COVID-19 tend to have a high viral load and a long virus-shedding period. " End of Quote. Authors seem to be banking their results on Reference No. 6 https://doi.org/10.1503/cmaj.1040398

10a. Preliminary Examination of https://doi.org/10.1503/cmaj.1040398 indicates that

Quote "It is difficult to compare case-fatality ratios between different cohorts and countries. Differences in distribution in terms of age, sex, disease activity (reflected by lactate dehydrogenase level) and proportion of cases confirmed by virologic tests have been cited as possible reasons for differences in case-fatality ratios.12 Our results suggest that such variation should be interpreted in light of host factors (age and comorbidity) and viral factors (viral load). In future studies, viral load should be monitored and analyzed, so that it can be considered in the interpretation of outcome data." End Quote.

10b. The article that the authors are banking on as indicated in Comment 10a does not directly emphasize on high viral load and long virus-shedding period but rather indicates that variations can be there due to differences between cohorts (societal/community populations), countries, age, sex, disease activity. Further it emphazises that viral load should be monitored and analyzed, so that it can be considered in the interpretation of outcome data.

10c. Reading together Comments 10, 10a and 10b, the authors are trying to bank significance on high viral load and long virus-shedding period on another article which states that there can be differences due to various factors and viral load needs to be monitored and analysed. In such a case, what is the point that the authors are trying to make by attempting to add significance to concerns which might manifest differently? So, does it mean that patients with severe COVID-19 can have variability due to viral load and virus-shedding period? If there is variability, then what is the significance of the findings of this paper?

11. Quote "This finding suggests that the viral load of SARS-CoV-2 might be a useful marker for assessing disease severity and prognosis." End Quote.

Reading together Comment 10, 10a-c, when the finding itself has lost its significance, how can the viral load of SARS-CoV-2 might be a useful marker for assessing disease severity and prognosis?

12. Apart from insight obtained via Comment 10a, there doesnt seem any significant research information in this article. Or have the authors failed to defend their point? However, Comment 10a stands out, and that seems to show a brighter side. Perhaps, the key to handling COVID-19 lies in Comment 10a. Exploitation of significance of Comment 10a might show a way for the world to win the battle against the COVID-19.

13. In the midst of such storms caused by COVID-19, have we accidentally identified "A faint beam of light at the end of the tunnel.... " !!!


Part II. A faint beam of light at the end of the tunnel.... Post Publication Independent Review of "How will country-based mitigation measures influence the course of the COVID-19 epidemic?" Published: March 09, 2020 DOI: https://doi.org/10.1016/S0140-6736(20)30567-5


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Post Publication Independent Review of

How will country-based mitigation measures influence the course of the COVID-19 epidemic?

Roy M Anderson, Hans Heesterbeek, Don Klinkenberg, T Déirdre Hollingsworth

Published:March 09, 2020 DOI: https://doi.org/10.1016/S0140-6736(20)30567-5

Review Comments:

1. The title gives an impression that this article might provide valuable insight regarding effectiveness or expected outcomes of country based mitigation measures with reference to COVID-19.

2. Quote "Governments will not be able to minimise both deaths from coronavirus disease 2019 (COVID-19) and the economic impact of viral spread" End of Quote. The first line of the manuscript states so. It gives rise to a doubt whether the manuscript is only one sentence long. In the title, the authors have asked a question. In the first line of the manuscript they have answered in the negative. Does it mean that the manuscript is only one sentence long?

2a. What was the need for the authors to make such an opening statement? Is it supported by any analysis? But no analysis is found, coz between the title and the first line, there is only some blank space. Blank space cannot be accepted as a defense/justification for making such a statement in a research article.

2b. Were the authors already Heads of many Governments that they are making such a statement from their experience as Heads of Government of various nations?

2c. Were the authors trying to heighten reader anxiety by exploiting the fact that fatality due to COVID-19 has been high?

2d. Authors need to realize that making such opening statements will not help provide any significant research outcome from their article, as this is a research manuscript and is not any brochure (to attempt to make an opening impression).

3. Quote "Keeping mortality as low as possible will be the highest priority for individuals" End of Quote. How can individuals try to keep mortality as low as possible with a high priority. Authors need to understand that as far as an individual is concerned, he is either going to be alive or dead. There are only two options, that is being either alive or dead and there is no possibility that the patient cannot be neither alive nor dead and also there is no possibility that the patient can be both alive and dead (applying Quantum Superposition). So, the only possibility is that the individual can be either alive or dead. When there are only two states, similar to on-off states, the above sentence "Keeping mortality as low as possible will be the highest priority for individuals" has no meaning.

4. Quote "Keeping mortality as low as possible will be the highest priority for individuals; hence governments must put in place measures to ameliorate the inevitable economic downturn" End of Quote. What is the relation between an individual trying to stay alive and govt. reaction to economic downturn? Maybe it can be explained with a simile. If it is said that the Devil and the Deep Sea are related to each other, atleast they have two alphabets similar "De". How are the authors trying to relate the action of an individual trying to stay alive and govt. reaction to encomic downturn? Especially with no defense or justification?

5. Quote "In our view, COVID-19 has developed into a pandemic, with small chains of transmission in many countries and large chains resulting in extensive spread in a few countries, such as Italy, Iran, South Korea, and Japan.1 " End of Quote.

This sentence cites the following article (listed as Reference 1)

WHO

Coronavirus disease 2019 (COVID-19) situation report—44.

https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200304-sitrep-44-covid-19.pdf?sfvrsn=783b4c9d_2

Date: March 4, 2020

(accessed March 5, 2020).

Preliminary examination of the cited WHO article indicates that it is an official document of the WHO and authors list doesnt seem to be provided, which implies that the authors of this article may not have been authors of the WHO document. So, how can the authors state that "In our view" and cite a WHO article, when there doesnt seem any evidence that they have authored the WHO document?

Then, the WHO document is published on March 4, 2020; accessed by the authors on March 5, 2020 and this research article is published on March 09, 2020.

Even if the authors wrote this research article on the same day, that is March 5, 2020 and submitted on the same day, how was the article published on March 09, 2020 in a matter of just a few days? Was this article able to be processed, evaluated and processed in such a short time?

If the authors were not able to complete the article on the same day that is March 5, 2020, then they could have submitted it later, in which case, the processing time for the article becomes still more reduced. How were the authors able to get this research article, involving a very serious current health concern of the world, processed and published in a matter of just a few days or hours?

Further, why are the authors focussing attention on Italy, Iran, South Korea and Japan?

Examination of the WHO document

Table 2. Countries, territories or areas outside China with reported laboratory-confirmed COVID-19 cases and

deaths. Data as of 04 March 2020

classified as Western Pacific Region, European Region, South-East Asia Region, Eastern Mediterranean Region, Region of the Americas, African Region.

The countries mentioned by the authors, namely Italy, Iran, South Korea, and Japan appear as follows.

European Region S. No. 1. Italy 2502

Eastern Mediterranean Region S. No. 1. Iran (Islamic Republic of) 2336

Western Pacific Region S. No. 1. Republic of Korea 5328 S. No. 2. Japan 284

Either the authors should have chosen the first serial number in each classification and indicated, but they have not done so.

If they have chosen the first and second serial numbers in each classification, then choice of the first and second items in Western Pacific Region might stand justified, but again they have not done so.

What was the rationale in choosing a random set of 4 nations with specific concentration to the Western Pacific Region?

On top of it, the authors never provided a defense or justification regarding how they could use the phrase "In our view" when there is no mention of it became their view.

6. Quote "Most countries are likely to have spread of COVID-19, at least in the early stages, before any mitigation measures have an impact." End of Quote. This sentence can also be written more precisely as "During the infinitesimal small duration between initiation and impact of mitigation measures, there can be a minimal spread of COVID-19", because what the authors have written boils down only to this statement. However the manner that the authors have written is that most countries are going to get affected before mitigation effects have an impact, and used the beauty of the language to disguise it. Now, why should the authors try to heighten reader anxiety by scaring them? Or were the authors trying to scare governments of various nations by their seemingly innocent statement? Author bias suspected.

7. Quote "What has happened in China shows that quarantine, social distancing, and isolation of infected populations can contain the epidemic.1 " End of Quote.

7a. Citing a WHO document, authors are very magnanimous in their praise for China. Is this a research article or are the authors trying to gain any undue advantage from China by singing its praise?

7b. Reading together Comment 6 and 7, according to the authors, the mitigation model of China alone can contain the epidemic compared to most other Nations. This article has been published on March 09, 2020.

Attention is drawn to https://www.worldometers.info/coronavirus/country/china/

As on March 09, 2020, total number of cases is 80,754. Number of active cases is 17,721. Number of deaths is 3,136. Number of new recoveries is 1,297. Number of new cases 19.

As on March 25, 2020, total number of cases is 81,285. Number of active cases is 3,947. Number of deaths is 3,287. Number of new recoveries is 401. Number of new cases 67.

If according to the authors, if the epidemic has been contained (for instance, taking the publication date of this research article as a reference), the figures are promising and are showing a good trend, but the disturbing factor is that beyond March 09, 2020, the number of new recoveries (which should have been showing an upward trend) displays a downward trend. It is supplemented by the number of new cases (which should be showing a downward trend) displays an upward trend.

When the statistics is examined, neither on the publication date of this research article were the trends very good nor did the trend start improving (post publication of this article) even if an futuristic allowance is permitted.

8. Reading Comment 6 and 7 together, it can be seen that China had its difficulties in mitigation measures and other Nations too could have possibly had difficulties in mitigation measures. But it is a disturbing sign that the authors have chosen to ignore facts but have tried to lavish their praise on China but at the same time discounting most other nations. Suspected absence of ethics in authors research statements.

9. Attention is drawn to News Item https://www.dailymail.co.uk/news/article-8155405/Up-14-cent-recovered-coronavirus-patients-China-test-positive-doctors-reveal.html PUBLISHED: 13:08 GMT, 26 March 2020 | UPDATED: 15:32 GMT, 26 March 2020

Highlights from news item:

Start of Highlights:

Three to 14 per cent of the patients tested positive after recovery, it is reported

Experts wondered if nucleic acid tests were reliable to detect traces of the virus

Medics said it was crucial to closely monitor those who were given the all-clear

China had discharged over 90 per cent of the infected as of Wednesday

Up to 14 per cent of the recovered coronavirus patients in China have tested positive again, medical experts have revealed.

Research showed about three to 14 per cent of the former patients were diagnosed with the virus once more after being given the all-clear.

The news came as experts feared that China is facing a second outbreak due to the increasing number of imported cases as well as the 'silent carriers' who show no symptoms.

End of Highlights:

Reading together with Comments 6, 7 & 8, a latest news item (while this Post Publication Review was being written),seems to indicate that China is facing difficulties even after clearing off people with complexities due to a second outbreak and silent carriers.

Reading together with Comments 5, 6, 7 & 8, what was the necessity for the authors to prepare submit a paper and get it published in a very short period of a few days or hours, singing praise of China and discounting other Nations, especially when other Nations had not felt the heat of COVID-19 outbreak (as on publication date of this paper)?

Manuscript seems to fail on ethics.

10. Quote "This impact of the COVID-19 response in China is encouraging for the many countries where COVID-19 is beginning to spread. However, it is unclear whether other countries can implement the stringent measures China eventually adopted" End of Quote. Authors sing more praise for China, perhaps never expected that reality might go against their research statements. Is this a research paper or have the authors tried to do a propaganda machine in support of China?

11. Quote "Singapore and Hong Kong, both of which had severe acute respiratory syndrome (SARS) epidemics in 2002–03, provide hope and many lessons to other countries. In both places, COVID-19 has been managed well to date, despite early cases, by early government action and through social distancing measures taken by individuals." Here the authors are singing praise of Singapore and Hong Kong. But above review comments do not permit attaching any scientific merit to these statements by the authors.

12. Quote "This is a very worst-case scenario for a number of reasons. We are uncertain about transmission in children, some communities are remote and unlikely to be exposed, voluntary social distancing by individuals and communities will have an impact, and mitigation efforts, such as the measures put in place in China, greatly reduce transmission." End of Quote. It is rather amusing to note that whatever the authors attempt to state, they eventually end up singing praise of China.

13. The authors are next discussing disease parameters. However, all those research discussions seem to lose their merit with relevance to News Item https://www.dailymail.co.uk/news/article-8155405/Up-14-cent-recovered-coronavirus-patients-China-test-positive-doctors-reveal.html PUBLISHED: 13:08 GMT, 26 March 2020 | UPDATED: 15:32 GMT, 26 March 2020. Hence discussions on disease parameters is unable to be accepted.

14. Quote "No vaccine or effective antiviral drug is likely to be available soon. Vaccine development is underway, but the key issues are not if a vaccine can be developed but where phase 3 trials will be done and who will manufacture vaccine at scale" End of Quote. Unwarranted statement by the authors. They cannot discount medical processes without any scientific reasoning and asking silly questions as "but the key issues are not if a vaccine can be developed but where phase 3 trials will be done and who will manufacture vaccine at scale". Authors scientific reasoning seems questionable and without merit.

15. Quote "The number of cases of COVID-19 are falling quickly in China,4 but a site for phase 3 vaccine trials needs to be in a location where there is ongoing transmission of the disease. Manufacturing at scale requires one or more of the big vaccine manufacturers to take up the challenge and work closely with the biotechnology companies who are developing vaccine candidates. This process will take time and we are probably a least 1 year to 18 months away from substantial vaccine production." The authors are discussing about vaccines, but again try to bring in a praise for China, without even realizing absurdity. What if the number of cases of COVID-19 are falling in China? Is there any rule that a site for phase 3 vaccine trials has to be setup/established only in China? Why cant a ite for phase 3 vaccine trials be set up in another Nation where there is ongoing transmission of disease at that time?

16. Quote "School closure, a major pillar of the response to pandemic influenza A,14 is unlikely to be effective given the apparent low rate of infection among children, although data are scarce." End of Quote. Authors shouldnt have made this statement when they already knew that data is scarce. Even if data is scarce, how can the authors state that school closure is unlikely to be effective? Dont the authors realize that when children go to school, so many processes and people and parents of children, teachers and others get involved so that the school processes are functional? Do the authors think that only children are involved in the school processes? Do the authors think that the children go to school, open the school, study, learn, teach, manage and also administer the school, and the processes, inclusive of financial processes? Children are only a part of the school processes as learners, and there are many others who are part of the school system. How can the authors make such irresponsible statements?

17. Quote "Avoiding large gatherings of people will reduce the number of super-spreading events; however, if prolonged contact is required for transmission, this measure might only reduce a small proportion of transmissions." End of Quote. If prolonged contact is required for transmission, what the authors state might be correct. But when the authors themselves are unable to state whether prolonged contact is required for transmission or only a infinitesimally small contact duration is sufficient for transmission, why should the authors discount the method of avoiding large gatherings of people?

18. Quote "Therefore, broader-scale social distancing is likely to be needed, as was put in place in China. This measure prevents transmission from symptomatic and non-symptomatic cases, hence flattening the epidemic and pushing the peak further into the future. " End of Quote. Again the authors have found an opportunity to sing praise of China. But at the same time, News Item https://www.dailymail.co.uk/news/article-8155405/Up-14-cent-recovered-coronavirus-patients-China-test-positive-doctors-reveal.html PUBLISHED: 13:08 GMT, 26 March 2020 | UPDATED: 15:32 GMT, 26 March 2020, seems to indicate otherwise. Authors should not have been in a hurry.

19. Figure with title "Illustrative simulations of a transmission model of COVID-19" seems to provide some infomation but is seen to carry a disclaimer that "Timing and width of peak uncertain due to Stochasticity in early dynamics, Heterogeneities in contact patterns, Spatial variation and Uncertainty in key epidemiological parameters". When such a disclaimer is provided for a transmission model of a disease, then the entire model cannot be relied upon.

20. Quote "Personal, rather than government action, in western democracies might be the most important issue. " End of Quote.

In the first line of this manuscript, authors state as below:

Quote "Governments will not be able to minimise both deaths from coronavirus disease 2019 (COVID-19) and the economic impact of viral spread" End of Quote.

Initially the authors discount the Governments of various nations. Then they shift the concerns to the individuals, clearing the Govt. off. Why are the authors incoherent?

21. Quote "There are difficult decisions ahead for governments. How individuals respond to advice on how best to prevent transmission will be as important as government actions, if not more important. Government communication strategies to keep the public informed of how best to avoid infection are vital, as is extra support to manage the economic downturn." End of Quote. This statement has just lost its significance with relevance to the National Lockdown enforced by India along with other support measures. This is the concluding statement of this manuscript and it has lost its significance too. Other insufficiencies observed have been discussed in Comments above.

22. Major observations about the manuscript is the seemingly harmless title, accompanied with discounting Governments of other Nations (right from the first line of the manuscript), while at the same time, praising China at every opportunity, with questionable insufficiencies related to author bias, ethics, and scientific merit.

Part III. A faint beam of light at the end of the tunnel.... Post Publication Independent Review of COVID-19: what is next for public health? Published: February 13, 2020 DOI: https://doi.org/10.1016/S0140-6736(20)30374-3


Part III. A faint beam of light at the end of the tunnel....

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Post Publication Independent Review of

COVID-19: what is next for public health?

David L Heymann

Nahoko Shindo

on behalf of the WHO Scientific and Technical Advisory Group for Infectious Hazards†

Published: February 13, 2020 DOI: https://doi.org/10.1016/S0140-6736(20)30374-3

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30374-3/fulltext?hss_channel=tw-27013292

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Review Comments:

1. Quote "The WHO Scientific and Technical Advisory Group for Infectious Hazards (STAG-IH), working with the WHO secretariat, reviewed available information about the outbreaks of 2019 novel coronavirus disease (COVID-19) on Feb 7, 2020, in Geneva, Switzerland, and concluded that the continuing strategy of containment for elimination should continue, and that the coming 2–3 weeks through to the end of February, 2020, will be crucial to monitor the situation of community transmission to update WHO public health recommendations if required." End of Quote. The authors have been quite reasonable to take time to update public health recommendations, so that more observation data will be at hand and better insight can be obtained through analysis of the same.

2. Quote "Genetic analysis early in the outbreak of COVID-19 in China revealed that the virus was similar to, but distinct from, severe acute respiratory syndrome coronavirus (SARS-CoV), but the closest genetic similarity was found in a coronavirus that had been isolated from bats.1" End of Quote. The authors have made an important statement here, that the virus was similar to, but distinct from SARS-CoV.

This paper was published on February 13, 2020 and maybe this article was not given the much needed attention, as another article "Viral dynamics in mild and severe cases of COVID-19" Yang Liu, Li-Meng Yan, Lagen Wan, Tian-Xin Xiang, Aiping Le, Jia-Ming Liu et al. Published:March 19, 2020 DOI: https://doi.org/10.1016/S1473-3099(20)30232-2 (whose post publication review is available at https://www.prabhubritto.org/post-publication-independent-reviews-covid-19 ) is comparing with SARS data as follows:

Quote "Overall, our data indicate that, similar to SARS in 2002–03,6 patients with severe COVID-19 tend to have a high viral load and a long virus-shedding period. " End of Quote. Ofcourse, there was another difficulty with this statement of those authors, which is available as Review Comment 10 in Part I. A faint beam of light at the end of the tunnel.... at https://www.prabhubritto.org/post-publication-independent-reviews-covid-19

Reverting back to the discussion herewith, the authors of this article have made an important statement that the virus was similar to, but distinct from SARS, but the research community does not seem to have understood the significance of this statement and published their research articles based on erroneous understanding, without giving due significance to the point mentioned in this research article.

3. Quote "As there was in early January, 2020, scarce information available about the outbreak, knowledge from outbreaks caused by the SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV) formed the basis for WHO public health recommendations in mid-January.2 " End of Quote. Acceptable.

4. Quote "However, the availability of more evidence in the past month has shown major differences between the outbreaks and characteristics of COVID-19 compared with those of SARS-CoV." End of Quote. This statement is quite significant as the protocols, procedures and handling is going to be unique. This indicates that the outbreak of COVID-19 cannot be handled as other outbreaks were handled earlier. This makes essential the cooperation at Levels of Governments & Nations to formulate unique contingency plans to contain and treat the outbreak.

5. Quote "Recognising the Wuhan-focused and nationwide outbreak responses in China, WHO has encouraged countries with heavy air travel exchange with Wuhan to take precautionary public health measures2 and, if there is imported infection, to undertake activities that could lead to the elimination of the virus in human populations as occurred during the 2003 SARS outbreak.3 " End of Quote. This indicates that the primary channels of communication of the disease into each Nation are going to be those populations that come into proximity with travellers from Wuhan in specific and China in general. Identification & Quarantine of people with travel history relating to Wuhan & China will have to be done, so that the outbreak can be contained better.

6. Quote "COVID-19 is thought to have been introduced to human populations from the animal kingdom in November or December, 2019, as suggested by the phylogeny of genomic sequences obtained from early cases.7 The genetic epidemiology suggests that from the beginning of December, 2019, when the first cases were retrospectively traced in Wuhan, the spread of infection has been almost entirely driven by human-to-human transmission, not the result of continued spillover. There was massive transmission in a matter of weeks in Wuhan, and people in the resulting chains of transmission spread infection by national and international travel during the Chinese New Year holidays." End of Quote. This statement is quite significant with relevance to the expected outcome that through the international travellers, the whole world would get infected; and the effect will be felt on a very large footprint of the people, as a diverse cross section of the society comes into contact with an international traveller at multiple points.

7. Quote "COVID-19 seems to have different epidemiological characteristics from SARS-CoV. COVID-19 replicates efficiently in the upper respiratory tract and appears to cause less abrupt onset of symptoms, similar to conventional human coronaviruses that are a major cause of common colds in the winter season.8 Infected individuals produce a large quantity of virus in the upper respiratory tract during a prodrome period, are mobile, and carry on usual activities, contributing to the spread of infection. " End of Quote. This statement indicates that a client carrying the virus, would have maximally spread the virus, during the time that the client is active in the prodrome period. After the client is diagnosed positive, it will be a very difficult task to perform contact tracing to search and identify other prospective human beings who have come in contact and took a portion of the virus with them; the difficulty being that it is not going to be a linear path but branching out as a new path at every intersection or meeting point with another human being; in short it will be a web that spreads out radially and rapidly; within no time, engulfing the entire population and the population also will not be aware that they have contacted the virus as they will also be active during their prodrome period. This statement by the authors should have been given or should be given due respect to prevent the spread of the outbreak.

8. Quote "By contrast, transmission of SARS-CoV did not readily occur during the prodromal period when those infected were mildly ill, and most transmission is thought to have occurred when infected individuals presented with severe illness, thus possibly making it easier to contain the outbreaks SARS-CoV caused, unlike the current outbreaks with COVID-19.6" End of Quote. This statement needs to be read together with Review Comment 7.

9. Quote "COVID-19 also has affinity for cells in the lower respiratory tract and can replicate there, causing radiological evidence of lower respiratory tract lesions in patients who do not present with clinical pneumonia.8 There seem to be three major patterns of the clinical course of infection: mild illness with upper respiratory tract presenting symptoms; non-life-threatening pneumonia; and severe pneumonia with acute respiratory distress syndrome (ARDS) that begins with mild symptoms for 7–8 days and then progresses to rapid deterioration and ARDS requiring advanced life support" End Quote. This statement indicates that there is going to be a surprise after a short period. Treatment protocols are usually based on symptoms. When the symptoms are non-life threatening, the treatment protocol will not call for emergency procedures. But, immediately after a few days, symptoms turn from mild to critical, calling for emergency treatment protocols. This is where the difficulty actually lies. All patients with mild symptoms cannot be put on emergency protocols even when they dont display life-threatening symptoms; expecting that all will test positive for COVID-19 in a few days. Rapid deterioration of an otherwise healthy population into one with life-threatening symptoms will place an unbearable load on the treatment facilities and clinical personnel; coz make-shift Intensive Care Units cannot be commissioned at will, with ventilator facility for each bed (as the manifestation of the disease is going to be more prevalently felt in the respiratory function).

10. Quote "The case fatality ratio with COVID-19 has been difficult to estimate. The initial case definition in China included pneumonia but was recently adjusted to include people with milder clinical presentation and the current estimate is thought to be about 1–2%, which is lower than that for SARS (10%).9 The actual case fatality ratio of infection with COVID-19 will eventually be based on all clinical illness and at the time of writing information on subclinical infection is not available and awaits the development of serological tests and serosurveys." End of Quote. If what the authors have written is true, then the fatality rate of COVID-19 is going to be very much higher than actuals; coz the actual fatality rate can be decided only after including subclinical infection; that means that many deaths recorded under various reasons might have actually been caused by COVID-19.

11. Quote "Presently COVID-19 seems to spread from person to person by the same mechanism as other common cold or influenza viruses—ie, face to face contact with a sneeze or cough, or from contact with secretions of people who are infected. The role of faecal–oral transmission is yet to be determined in COVID-19 but was found to occur during the SARS outbreak.10" End of Quote. Reference 10 cited here gives indepth insight into the spread of SARS https://jech.bmj.com/content/jech/57/9/652.full.pdf If COVID-19 can spread as SARS spread, then the entire sewage connectivity itself will blow the disease into most people. Though the role of faecal-oral transmission is yet to be determined in COVID-19, it doesnt rule out that COVID may not spread like or spread more worse than SARS via faecal-oral transmission through sewage pathways.

12. Quote "A plausible scenario based on the available evidence now is that the newly identified COVID-19 is causing, like seasonal influenza, mild and self-limiting disease in most people who are infected, with severe disease more likely among older people or those with comorbidities, such as diabetes, pulmonary disease, and other chronic conditions." End of Quote. This statement indicates that people with existing comorbidities are at more risk of infection from COVID-19 compared to healthy individuals.

13. Quote " Health workers and carers are at high risk of infection, and health-care-associated amplification of transmission is of concern as is always the case for emerging infections. People in long-term care facilities are also at risk of severe health consequences if they become infected." End of Quote. This statement needs to be given attention, because it indicates the potential for collateral damage.

14. Quote "Non-pharmaceutical interventions remain central for management of COVID-19 because there are no licensed vaccines or coronavirus antivirals. If the situation changes towards much wider community transmission with multiple international foci, the WHO strategy of containment for elimination could need to be adjusted to include mitigation strategies combined with the following activities currently recommended by STAG-IH on the WHO website." End of Quote. The need for strategic containment of the spread of the outbreak is spelt out here. Either a risky restricted community interaction can be maintained or a less risky total lockdown may be explored. If people can be made to co-operate, the less risky total lockdown may be a better solution.

15. Quote "First, close monitoring is needed of changes in epidemiology and of the effectiveness of public health strategies and their social acceptance." End of Quote. Since all existing functionaries of the Govt. will have their own roles to play in such nationwide outbreaks, a special team can be conveyed to implement this suggestion.

16. Quote "Second, continued evolution is needed of enhanced communication strategies that provide general populations and vulnerable populations most at risk with actionable information for self-protection, including identification of symptoms, and clear guidance for treatment seeking." End of Quote. Again, a new dedicated team needs to conveyed to fulfil this suggestion.

17. Quote "Third, continued intensive source control is needed in the epicentre in China—ie, isolation of patients and persons testing positive for COVID-19, contact tracing and health monitoring, strict health facility infection prevention and control, and use of other active public health control interventions with continued active surveillance and containment activities at all other sites where outbreaks are occurring in China.

Fourth, continued containment activities are needed around sites outside China where there are infected people and transmission among contacts, with intensive study to provide information on transmissibility, means of transmission, and natural history of infection, with regular reporting to WHO and sharing of data.

Fifth, intensified active surveillance is needed for possible infections in all countries using the WHO-recommended surveillance case definition.11" End of Quote. Hereagain, it could be any Nation instead of China, and dedicated new teams may be convened for each of these suggestions.

18. Quote "Sixth, preparation for resilience of health systems in all countries is needed, as is done at the time of seasonal influenza, anticipating severe infections and course of disease in older people and other populations identified to be at risk of severe disease." End of Quote. May be handled at the level of the Ministry of Health.

19. Quote "Seventh, if widespread community transmission is established, there should then be consideration of a transition to include mitigation activities, especially if contact tracing becomes ineffective or overwhelming and an inefficient use of resources. Examples of mitigation activities include cancelling public gatherings, school closure, remote working, home isolation, observation of the health of symptomatic individuals supported by telephone or online health consultation, and provision of essential life support such as oxygen supplies, mechanical ventilators and extracorporeal membrane oxygenation (ECMO) equipment." End of Quote. India seems to be doing this (at the time of writing down this review).

20. Quote "Eighth, serological tests need to be developed that can estimate current and previous infections in general populations." End of Quote. May be handled at the level of the Ministry of Health, nationwide.

21. Quote "Finally, continued research is important to understand the source of the outbreak by study of animals and animal handlers in markets to provide evidence necessary for prevention of future coronavirus outbreaks." End of Quote. This suggestion can be extended as all-inclusive and a dedicated vertical structure can be built in National Interests.

Part IV. A faint beam of light at the end of the tunnel.... Post Publication Independent Review of COVID-19 and Italy: what next? Published: March 13, 2020 DOI: https://doi.org/10.1016/S0140-6736(20)30627-9


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Post Publication Independent Review of

COVID-19 and Italy: what next?

Prof Andrea Remuzzi, EngD

Prof Giuseppe Remuzzi, MD

Published: March 13, 2020 DOI: https://doi.org/10.1016/S0140-6736(20)30627-9

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30627-9/fulltext

Review Comments:

1. Quote "A global response to prepare health systems worldwide is imperative. Although containment measures in China have reduced new cases by more than 90%, this reduction is not the case elsewhere, and Italy has been particularly affected. There is now grave concern regarding the Italian national health system's capacity to effectively respond to the needs of patients who are infected and require intensive care for SARS-CoV-2 pneumonia." End of Quote. The authors seem to make an attempt to bring out new research insights which might be helpful for Italy and for all Nations due to the well accepted treatise that "Italy’s healthcare system is routinely ranked among the best in the world, based on its overall quality, equity of access, and the general health and life expectancy of the Italian population" https://www.italymagazine.com/featured-story/healthcare-italy-what-you-need-know

2. Quote "Our analysis might help political leaders and health authorities to allocate enough resources, including personnel, beds, and intensive care facilities, to manage the situation in the next few days and weeks. " End of Quote. Authors statement is sufficient. Doesnt need a further comment.

3. Quote "If the Italian outbreak follows a similar trend as in Hubei province, China, the number of newly infected patients could start to decrease within 3–4 days, departing from the exponential trend. However, this cannot currently be predicted because of differences between social distancing measures and the capacity to quickly build dedicated facilities in China." End of Quote. The authors are more pragmatic in their approach and not quick to jump in with supporting decisions only coz a unique trend was observed.

Further, read together with https://www.moneycontrol.com/news/india/coronavirus-pandemic-johns-hopkins-university-distances-self-from-report-claiming-40-crore-indians-may-get-coronavirus-by-july-5079281.html , it can be understood why a more pragmatic approach is required in research analysis and inferences, else research inferences may spin out of practicality into utopia and can even create an environment of psychosis in the society. Hence, as the authors of this research article have done, research inferences have to be more pragmatic in their approach.

4. Quote "Therefore, a coordinated global response is desperately needed to prepare health systems to meet this unprecedented challenge." End Quote. A multi-national tactical command and control center may be established in any Nation that is willing to offer this service to the World. Distributed Centers may be established in the Capital of ever Nation, connecting upto grassroots level.

5. Quote "Countries that have been unfortunate enough to have been exposed to this disease already have, paradoxically, very valuable lessons to pass on." End of Quote. The authors are right on this point. It is time to learn valuable lessons for the sake of our Nations and pass on the significant insights to other Nations

6. Quote "Although the containment measures implemented in China have—at least for the moment—reduced new cases by more than 90%, this reduction is not the case in other countries, including Italy and Iran.2" End of Quote.

The authors have cited https://www.economist.com/graphic-detail/2020/03/07/tourism-flows-and-death-rates-suggest-covid-19-is-being-under-reported as Reference number 2. The cited article gives more valuable insight as following:

Quote "

As covid-19 reaches countries unwilling or unable to monitor it, officials must use educated guesswork to track its evolution.

The number of cases each country reports depends both on the number of infections and on how many people get tested.

To derive fresh estimates, The Economist built a similar model. We tested the link within the oecd—a club of mostly rich countries, which should have strong detection capacity—between Chinese tourism in 2019 and confirmed covid-19 cases. As expected, oecd states that swapped lots of tourists with China, such as Switzerland, tend to report higher infection rates than do ones with small flows, like Belgium.

Applied worldwide, our model finds big outliers. The outbreaks in Iran, Italy and South Korea, where the virus is spreading internally, are bigger than tourist flows suggest. At the other extreme, countries like Singapore may have fewer diagnoses than expected because of strong containment efforts. But the Philippines, Russia, Myanmar and Indonesia have lots of people and tourism to and from China, and just eight confirmed cases in total. Thousands more have probably gone undetected.

Another pattern bolsters this finding. South Korea and China test regularly. In both places—excluding Hubei, where the virus began claiming lives before authorities formulated a response—0.5-1% of people who have tested positive have died. In other countries with at least one death, this rate is five times higher. Deaths are easier to count than infections are. The most likely explanation for this gap is that for every person diagnosed in these countries, four more do not know they are infected

" End of Quote.

These insights are crucial for Nations to prepare, evolve and continuously modify their COVID-19 National-Level containment and treatment protocols.

7. Quote "The mean age of those who died in Italy was 81 years and more than two-thirds of these patients had diabetes, cardiovascular diseases, or cancer, or were former smokers. It is therefore true that these patients had underlying health conditions, but it is also worth noting that they had acute respiratory distress syndrome (ARDS) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia, needed respiratory support, and would not have died otherwise. " End of Quote.

The Healthcare system in Italy is known to be one of the best in the world. Consequently, the mean age of those who died in Italy may have been 81 years, but we cannot derive any direct inference from it, for the simple reason that it is going to vary among ethnicities, populations and nations; also dependent on the quality of healthcare in that Nation.

Further, it can be seen that comorbities make things more difficult for a COVID-19 patient. The COVID-19 patient may progress into Acute Respiratory Distress Syndrome (ARDS), but when comorbities are present, it paints a more critical picture. This means that containment & treatment strategies for otherwise normal population and those with pre-existing comorbities may be unique and distinct and may need to be given more attention while devising plans & during adaptive implementation.

8. Quote "On March 8, 2020, the Italian Government implemented extraordinary measures to limit viral transmission—including restricting movement in the region of Lombardy—that intended to minimise the likelihood that people who are not infected come into contact with people who are infected. This decision is certainly courageous and important, but it is not enough. At present, our national health system's capacity to effectively respond to the needs of those who are already infected and require admission to an intensive care unit for ARDS, largely due to SARS-CoV-2 pneumonia, is a matter of grave concern." End of Quote.

Quote "In Italy, we have approximately 5200 beds in intensive care units. Of those, as of March 11, 1028 are already devoted to patients with SARS-CoV-2 infection, and in the near future this number will progressively increase to the point that thousands of beds will soon be occupied by patients with COVID-19. Given that the mortality of patients who are critically ill with SARS-CoV-2 pneumonia is high and that the survival time of non-survivors is 1–2 weeks, the number of people infected in Italy will probably impose a major strain on critical care facilities in our hospitals, some of which do not have adequate resources or staff to deal with this emergency."

This observation by the authors may raise alarm bells throughout all Nations, as patients with COVID-19 may have to be admitted into ICU, and with a survival time of non-survivors being 1-2 weeks, bed occupancy is going to be a major factor. The Nations will have to find new ways and means to improvise more ICU units into hospitals or new standalone ICU units.

At the time of writing this review, India is seen taking concrete steps in this direction, as evidenced by the following links.

https://www.news18.com/news/buzz/anand-mahindra-offers-to-provide-ventilators-opens-up-resorts-for-coronavirus-care-facility-2546463.html

https://www.nytimes.com/reuters/2020/03/28/world/asia/28reuters-health-coronavirus-southasia.html

9. Quote "We present the following predictions to prepare our political leaders—those who bear the greatest responsibility for national health systems and the government at the regional level, as well as local health authorities—for what is predicted to happen in the days and weeks to come. They can then implement measures regarding staff resources and hospital beds to meet the challenges of this difficult time. " End of Quote.

The authors are appreciated for this measure, wherein they have exhibited their foresight.

10. Some enlightening observations by the authors is summarised below.

Quote "On the basis of the exponential curve prediction, and the assumption that the duration of infection ranges from 15 to 20 days, it is possible to calculate that the basic reproduction number ranges from 2·76 to 3·25. This number is similar to that reported for the initial phase of the infection outbreak in the city of Wuhan, China3 and slightly higher than 2·2, as reported by Li and colleagues in a more recent report.4" End of Quote.

Quote "The number of patients admitted to intensive care units increased similarly in Italy, with an exponential trend up until March 8. " End of Quote.

Quote "The data available up until March 8 show that the trend in the number of patients who will need admission to intensive care units will increase substantially and relentlessly in the next few days. We can predict with quite a good degree of accuracy that this number will push the national health system to full capacity in a matter of days. " End of Quote.

Quote "At this point, the most important question is whether the increase in the number of patients who are infected and those requiring intensive care admittance will continue to rise exponentially and for how long. If the change in the slope of the curve does not take place soon, the clinical and social problems will take on unmanageable dimensions, which are expected to have catastrophic results. " End of Quote.

Quote " If the Italian outbreak follows a similar trend to that in China, we can suggest that the number of newly infected patients might start to decrease within 3–4 days from March 11. Similarly, we can foresee that the cumulative curve of patients who are infected will peak 30 days later, with the maximum load for clinical facilities for the treatment of these patients foreseen for that period." End of Quote.

In Summary, we can understand that initially there may be a high proportion of new infections which will start reducing over a given period, but the cumulative number of patients will be steadily increasing, and if the infection is assumed to range between 15 to 20 days, the cumulative demand on ICU beds with respiratory support is going to exponentially shoot over a period of time.

While this review is being written, India is taking drastic steps to boost its capacity for tougher challenges ahead.

https://www.businesstoday.in/latest/trends/coronavirus-impact-india-boosts-capacity-for-tougher-challenges-ahead/story/399504.html

https://www.theweek.in/news/biz-tech/2020/03/28/india-to-double-number-of-ventilators-by-making-40000-units-reports.html

https://theprint.in/health/aiims-plans-to-use-prototype-of-ventilators-for-covid-19-patients-due-to-shortage/388680/

https://economictimes.indiatimes.com/news/company/corporate-trends/maruti-suzuki-to-help-produce-ventilators-masks-and-protective-equipment-to-fight-against-covid-19/articleshow/74859601.cms

11. Quote "Finally, our analysis tends to suggest that measures to reduce transmission should certainly be implemented, as our government did on March 9, by inhibiting people's movement and social activities, unless strictly required. Rather than revising the Schengen visa-free zone, the most effective way to contain this viral outbreak in European countries is probably to avoid close contact at the individual level and social meetings in each country." End of Quote.

At the time of writing this review, India is currently under a nationwide 21 day lockdown, severely restricting human movement (unless essential). To prevent transit of migrant labourers (who might be rendred jobless during this 21 day National lockdown), the Union Home Ministry has empowered the various States in India to use the State Disaster Relief Fund for relief measures for migrant laborers (rendered jobless) during this 21 day National lockdown.

https://www.news18.com/news/india/govt-has-committed-all-support-to-migrant-workers-during-covid-19-lockdown-says-amit-shah-2555179.html

https://www.thehindu.com/news/national/centre-tells-states-to-set-up-camps-for-migrant-workers/article31194860.ece

https://www.indiatoday.in/india/story/govt-committed-support-migrant-workers-lockdown-amit-shah-1660831-2020-03-29

Part V. A faint beam of light at the end of the tunnel.... Post Publication Independent Review of "Online mental health services in China during the COVID-19 outbreak" Published: February 18, 2020 DOI: https://doi.org/10.1016/S2215-0366(20)30077-8

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Post Publication Independent Review of

Online mental health services in China during the COVID-19 outbreak

Shuai Liu, Lulu Yang, Chenxi Zhang, Yu-Tao Xiang, Zhongchun Liu, Shaohua Hu et al.

Published: February 18, 2020 DOI: https://doi.org/10.1016/S2215-0366(20)30077-8

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30077-8/fulltext

Review Comments:

1. Quote "Since January, 2020, the National Health Commission of China have published several guideline documents, starting with the notification of principles for emergency psychological crisis intervention for the COVID-19 epidemic on January 26, then the notice on establishing psychological assistance hotlines for the epidemic on February 2, and most recently, guidelines for psychological assistance hotlines during the COVID-19 epidemic on February 7.3" End of Quote. This article points to an additional load on the National Health System in areas related to psychiatry.

2. Quote " The popularisation of internet services and smartphones, and the emergence of fifth generation (5G) mobile networks, have enabled mental health professionals and health authorities to provide online mental health services during the COVID-19 outbreak." End of Quote. Capability to provide solutions exist and is not a burden to create as a new health infrastructure.

3. Quote "One such multicentre survey involving 1563 medical staff, with our centre at Nanfang Hospital, Southern Medical University (Guangzhou, China) as one of the study sites, found the prevalence of depression (defined as a total score of ≥5 in the Patient Health Questionnaire-9) to be 50·7%, of anxiety (defined as a total score of ≥5 in the Generalized Anxiety Disorder-7) to be 44·7%, of insomnia to be 36·1% (defined as a total score of ≥8 in the Insomnia Severity Index), and of stress-related symptoms (defined as a total score of ≥9 in the Impact of Events Scale-Revised) to be 73·4%. These findings are important in enabling health authorities to allocate health resources and develop appropriate treatments for medical staff who have mental health problems." End of Quote. Every Nation may not have the same percentage distribution, but this can be taken as a ground truth model or as an evolutionary model. Surveys and Analysis may need to be done afresh, as variations might be manifested due to variations in demographies, ethnicities, populations, etc.

4. Quote "Secondly, online mental health education with communication programmes, such as WeChat, Weibo, and TikTok, has been widely used during the outbreak for medical staff and the public. In addition, several books on COVID-19 prevention, control, and mental health education have been swiftly published and free electronic copies have been provided for the public. " End of Quote. These options can be explored.

5. Quote "As of February 8, 29 books associated with COVID-19 have been published, 11 (37·9%) of which are on mental health, including the “Guidelines for public psychological self-help and counselling of 2019-nCoV pneumonia”, published by the Chinese Association for Mental Health" End of Quote. The Ministry or Department of Health/Health Research can take a call whether the same guidelines can be used generically or unique guidelines need to be issued for the Nation.

6. Quote "Finally, online psychological counselling services (eg, WeChat-based resources) have been widely established by mental health professionals in medical institutions, universities, and academic societies throughout all 31 provinces, municipalities, and autonomous regions in mainland China, which provide free 24-h services on all days of the week. Online psychological self-help intervention systems, including online cognitive behavioural therapy for depression, anxiety, and insomnia (eg, on WeChat), have also been developed. In addition, several artificial intelligence (AI) programmes have been put in use as interventions for psychological crises during the epidemic. For example, individuals at risk of suicide can be recognised by the AI programme Tree Holes Rescue,5 by monitoring and analysing messages posted on Weibo, and alerting designated volunteers to act accordingly." End of Quote. Seems to be good and feasible solutions. Can be implemented generically or with unique guidelines designed for the Nation.

7. Quote "online mental health services being used for the COVID-19 epidemic are facilitating the development of Chinese public emergency interventions, and eventually could improve the quality and effectiveness of emergency interventions." End of Quote. These may be solutions that can help to prepare for handling future health outbreaks, and also for handling unexpected contingencies that arise. For instance, the migrant labourers mass exodus to their native places from their place of work, caused inconvenience both to the migrant labourers and also to the health system which was enforcing a 21 day lockdown with reference to containing the spread of COVID-19, causing the Prime Minister of India to issue an apology as an immediate damage control measure to prevent it from spiralling out of control.

The absence of such counselling services fuelled the hundreds and thousands of migrant laborers to hit the roads on a massive scale, while the Central & State Govts were preparing to handle it, the issue exploded even before & while the Central Govt. could authorize & was authorizing the State Governments to use the Disaster Relief Fund to provide immediate relief.

https://www.deccanherald.com/national/migrant-workers-in-india-on-move-as-covid-19-stalls-world-818723.html

https://www.theweek.in/news/india/2020/03/28/state-disaster-funds-to-be-used-for-immediate-relief-to-migrants.html

https://www.news18.com/news/buzz/pm-modis-apology-for-harsh-coronavirus-lockdown-on-mann-ki-baat-leaves-twitter-divided-2555981.html

Everytime, the Prime Minister cannot pitch in with an apology to save the situation, and such a precedence should not be set. The Office of the Prime Minister should always be let to maintain its dignified standing in the National and International Levels, and the Prime Minister should not be forced into a situation as issuing an apology, and such a precedence should not be set too. Consequently, such counselling services may need to be treated as an immediate priority and established nationwide, via radio, television and internet channels of communication, to prevent outbreak of unexpected outcomes during National/International Level Disasters/Emergencies/HealthCalamities.

Part VI. A faint beam of light at the end of the tunnel.... Post Publication Independent Review of Mental health care for medical staff in China during the COVID-19 outbreak Published: February 18, 2020 DOI: https://doi.org/10.1016/S2215-0366(20)30078-X

Published at:

https://www.prabhubritto.org/post-publication-independent-reviews-covid-19

https://www.facebook.com/notes/prof-dr-prabhu-britto-albert/part-vi-a-faint-beam-of-light-at-the-end-of-the-tunnel/3659697177434679/

https://www.linkedin.com/pulse/part-vi-faint-beam-light-end-tunnel-profdr-prabhu-britto-albert

Post Publication Independent Review of

Mental health care for medical staff in China during the COVID-19 outbreak

Qiongni Chen, Mining Liang, Yamin Li, Jincai Guo, Dongxue Fei, Ling Wang et al.

Published: February 18, 2020 DOI: https://doi.org/10.1016/S2215-0366(20)30078-X

https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30078-X/fulltext

Review Comments:

1. Quote "The Second Xiangya Hospital—workplace of the chairman of the Psychological Rescue Branch of the Chinese Medical Rescue Association—and the Institute of Mental Health, the Medical Psychology Research Center of the Second Xiangya Hospital, and the Chinese Medical and Psychological Disease Clinical Medicine Research Center responded rapidly to the psychological pressures on staff." End of Quote.

The Authors bring out an essential aspect of the entire COVID-19 containment and treatment protocols, viz., "Psychological Rescue" for Medical Staff (Doctors, Nurses, Allied Medical Staff, Volunteers, etc.) involved in COVID-19 containment and treatment protocols. The Medical Staff stand on the first line of service with the COVID-19 patients, screening populations, etc. If the Medical Staff get overwhelmed, the first line of service can start get deficiencies, which might even affect the entire COVID-19 containment and treatment protocols. Hence, it is essential that Medical Staff are provided Quality Psychological Rescue to cope up with the stress of the COVID-19 containment and treatment.

2. Quote "A detailed psychological intervention plan was developed, which mainly covered the following three areas: building a psychological intervention medical team, which provided online courses to guide medical staff to deal with common psychological problems; a psychological assistance hotline team, which provided guidance and supervision to solve psychological problems; and psychological interventions, which provided various group activities to release stress. " End of Quote.

The text speaks for itself.

3. Quote "However, the implementation of psychological intervention services encountered obstacles, as medical staff were reluctant to participate in the group or individual psychology interventions provided to them. Moreover, individual nurses showed excitability, irritability, unwillingness to rest, and signs of psychological distress, but refused any psychological help and stated that they did not have any problems." End of Quote. This would exhibit as strange behaviour, but the reasons that follow in the next paragraphs are thought provoking.

4. Quote "First, getting infected was not an immediate worry to staff—they did not worry about this once they began work. Second, they did not want their families to worry about them and were afraid of bringing the virus to their home. Third, staff did not know how to deal with patients when they were unwilling to be quarantined at the hospital or did not cooperate with medical measures because of panic or a lack of knowledge about the disease. Additionally, staff worried about the shortage of protective equipment and feelings of incapability when faced with critically ill patients. Many staff mentioned that they did not need a psychologist, but needed more rest without interruption and enough protective supplies. Finally, they suggested training on psychological skills to deal with patients' anxiety, panic, and other emotional problems and, if possible, for mental health staff to be on hand to directly help these patients." End of Quote.

The points raised by the Medical Staff are something that every Nation needs to attend to, right from the very beginning; as the Medical Staff play the pivotal role in containing and treating COVID-19. Only when the Medical Staff are empowered to handle the concerns, they will be able to serve well, and also help maintain themselves to continue the service that is most valuable.

5. Quote "Accordingly, the measures of psychological intervention were adjusted. First, the hospital provided a place for rest where staff could temporarily isolate themselves from their family. The hospital also guaranteed food and daily living supplies, and helped staff to video record their routines in the hospital to share with their families and alleviate family members' concerns. Second, in addition to disease knowledge and protective measures, pre-job training was arranged to address identification of and responses to psychological problems in patients with COVID-19, and hospital security staff were available to be sent to help deal with uncooperative patients. Third, the hospital developed detailed rules on the use and management of protective equipment to reduce worry. Fourth, leisure activities and training on how to relax were properly arranged to help staff reduce stress. Finally, psychological counsellors regularly visited the rest area to listen to difficulties or stories encountered by staff at work, and provide support accordingly." End of Quote.

These and other relevant measures may immediately be deployed Nationwide, by all Nations that are fighting COVID-19.

6. Quote "The learning from these psychological interventions is expected to help the Chinese government and other parts of the world to better respond to future unexpected infectious disease outbreaks." End of Quote.

True, the authors have provided valuable insight into an important part of the COVID-19 containment and treatment process, which can also be utilized for any other similar outbreaks in future too.

Hope, all Nations will immediately improve or modify their processes suitably to bring these findings of the authors into the COVID-19 containment and treatment processes.

Part VII. A faint beam of light at the end of the tunnel.... Post Publication Independent Review of Protecting health-care workers from subclinical coronavirus infection Published: February 13, 2020 DOI: https://doi.org/10.1016/S2213-2600(20)30066-7

Published at:

https://www.prabhubritto.org/post-publication-independent-reviews-covid-19

https://www.linkedin.com/pulse/part-vii-faint-beam-light-end-tunnel-post-publication-albert

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Post Publication Independent Review of

Protecting health-care workers from subclinical coronavirus infection

De Chang, Huiwen Xu, Andre Rebaza, Lokesh Sharma, Charles S Dela Cruz,

Published: February 13, 2020 DOI: https://doi.org/10.1016/S2213-2600(20)30066-7

https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30066-7/fulltext

Review Comments:

1. Quote "Health-care workers face an elevated risk of exposure to infectious diseases, including the novel coronavirus (COVID-19) in China. It is imperative to ensure the safety of health-care workers not only to safeguard continuous patient care but also to ensure they do not transmit the virus" End of Quote.

The condition is the same for all Nations.

2. Quote "According to recent guidelines from the China National Health Commission, pneumonia caused by COVID-19 was included as a Group B infectious disease, which is in the same category as other infectious viruses such as severe acute respiratory syndrome (SARS) and highly pathogenic avian influenza (HPAI). However, current guidelines suggest ensuring protective measures for all health-care workers similar to those indicated for Group A infections—a category reserved for highly infectious pathogens, such as cholera and plague." End of Quore.

This indicates that the health care workers will be more susceptible to the disease. Unless they are protected, it will be very difficult to contain and treat the population.

3. Quote "Recent evidence suggests that even someone who is non-symptomatic can spread COVID-19 with high efficiency, and conventional measures of protection, such as face masks, provide insufficient protection" End of Quote.

Conventional measures of protection may be sufficient for the people who might come in contact with the disease seldom. However, conventional measures of protection may not be sufficient for health care workers who are in close proximity to the disease always, through the patient.

4. Quote " not only can subclinical patients transmit the virus effectively but patients can also shed high amounts of the virus and infect others even after recovery from the acute illness. These findings warrant aggressive measures (such as N95 masks, goggles, and protective gowns) to ensure the safety of health-care workers during this COVID-19 outbreak, as well as future outbreaks" End of Quote.

This statement needs to be given due attention, and all Nations may have to immediately manufacture on a large scale N95 masks, goggles and protective gowns for the healthcare workers and also ensure a steady supply of N95 masks, goggles and protective gowns, so that they can be changed periodically, ensuring maximum safety for the healthcare workers.

Part VIII. A faint beam of light at the end of the tunnel.... Post Publication Independent Review of “COVID-19: the medium is the message” Published: March 11, 2020 DOI: https://doi.org/10.1016/S0140-6736(20)30600-0

Published at:

https://www.prabhubritto.org/post-publication-independent-reviews-covid-19

https://www.linkedin.com/pulse/part-viii-faint-beam-light-end-tunnel-post-review-covid-19-albert

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Post Publication Independent Review of

COVID-19: the medium is the message

Laurie Garrett

Published: March 11, 2020

DOI: https://doi.org/10.1016/S0140-6736(20)30600-0

https://www.thelancet.com/article/S0140-6736(20)30600-0/fulltext

Review Comments:

1. Quote "In a world of polarising distrust and trade tensions, the spread of coronavirus disease 2019 (COVID-19), both within nations and internationally, is aided and abetted by misinformation that circumnavigates the planet in microseconds. Such misinformation is not all malevolent, although its impact can be devastating. " End of Quote.

The statement of the authors speaks for itself.

Attention is drawn to the Migrant Labour exodus which caused the Prime Minister to intervene and apologise.

Attention is further drawn to the Tablighi Jamaat event (attracting media attention while this review is being written), which has potential for further inconvenience, due to misinformation.

2. Quote "Some have sought to limit misinformation about COVID-19 on social media by pressuring corporations, such as Facebook, Weibo, and Twitter, to censor bad actors" End of Quote.

This may be the need of hour, but it is not sure how far censure of Facebook, Weibo or Twitter will help, when the main source of information could be mainstream media, and social media only adds more color and flavour to mainstream media reporting.

3. Quote "The “truth” can, and should, change as investigations and data analysis of COVID-19 proceed, but its bottom line ought to consistently reflect empiricism, a solid dose of scepticism and scrutiny, and absolute conviction in timely dissemination of life-saving research and analysis. And those bastions must resist attempts to sway their messaging to reflect institutional or political interests." End of Quote.

Reading together with content from this research article quoted in Review Comments 1-3, along with the review comments provided in the same serial numbers, provides a "not too rosy" picture.

Accompany this with "wilful miscommunication" and "nonwilful miscommunication", the negative effects can be devastating.

Correct information should be disseminated and misinformation should be censured, to prevent negative backlashes from a population that is already suffering with a prolonged lockdown, accompanied with personal, social and misinformation stress, and a psychotic fear of the unknown due to COVID-19.

Suggested that a suitable team be put in to watch, censure and take corrective immediate action on miscommunication.

4. Quote "However, there is even less funding for professional communications staffing at WHO, the various Centers for Disease Control and Prevention in Africa, Europe, North America, and Asia, or their counterpart offices nested in local departments of public health. If the media isn't getting the message, in all likelihood the messengers have insufficient resources for delivery." End of Quote.

The authors point out a pathetic state of affairs globally.

Disease containment and treatment protocols may take center stage, but at the same time, Professional Communications and Censure of Miscommunication need to be given priority immediate attention, so that the efforts of disease containment and treatment protocols reap the success of their efforts. Polarisation of any section of the society, wilful & nonwilful noncooperation by the stressed members of the society may have a weighted negative effect. Attention is drawn to migrant labor exodus and the Tablighi Jamaat event, both of which have the potential of alienating/polarising sections of the society accompanied with wilful & nonwilful noncooperation by the stressed members of the society. If political polarisation also moves in, the effects can be more devastating.

Consequently, Professional Communications should be given a more important part in the disease containment and treatment protocols of the COVID-19 outbreak.

5. Quote "The current global COVID-19 epidemic features mechanisms of delivery of scientific information that are frankly unprecedented, adding to pressure for proper interpretation by the media and public. Scientific and medical publications are expediting research and analysis through peer review, while preprint services are publishing unreviewed work. Some researchers are engaging in open online venues, debating the calculus of crucial epidemic COVID-19 features, such as its basic reproduction number (R0), case fatality rates, age and gender distributions of severe and deceased cases, or the accuracy of case reporting, itself. Those debates have fuelled media reporting, even when the evidence is still uncertain and research is ongoing." End of Quote.

These observations by the authors strengthen the review comments presented above.

6. Quote "The difficulty in sifting fact from inaccurate information is aggravated by the speed of unfolding events, how much is still to be researched and understood by scientists and clinicians about COVID-19" End of Quote.

These observations by the authors strengthen the review comments presented above.

7. Quote "Had China allowed physician Li Wenliang and his brave Wuhan colleagues to convey their suspicions regarding a new form of infectious pneumonia to colleagues, social media, and journalists without risking sanction, and had local officials not for weeks released false epidemic information to the world, we might not now be facing a pandemic. Had Japanese officials allowed full disclosure of their quarantine and testing procedures aboard the marooned Princess Diamond cruise ship, crucial attention might have helped prevent spread aboard the ship and concern in other countries regarding home return of potentially infectious passengers. Had Shincheonji Church and its supporters within the South Korean Government not refused to provide the names and contact information on its members and blocked journalists' efforts to decipher spread of the virus in its ranks, lives in that country might have been spared infection, illness, and death. Had Iran's deputy health minister, Iraj Harirchi, and members of the country's ruling council not tried to convince the nation that the COVID-19 situation was “almost stabilised”, even as Harirchi visibly suffered from the disease while on camera, the Middle East might not now find itself in grave danger from the spread of the disease, with Saudi Arabia suspending visas for pilgrims seeking to visit Mecca and Medina. Neither Iran nor Saudi Arabia has free and open journalism, and both nations seek to control narratives through social media censorship, imprisonment, or even execution. And had the Trump administration not declared criticism of its slow response to the encroaching epidemic a “hoax”, claiming it was a political attack from the left, the US CDC might have been pressured to do widespread testing in early February, discovering pockets of community transmission before they dispersed widely." End of Quote.

The authors are now presenting observations on a case by case basis.

This post-publication review does not comment on the political observations quoted in Review 7, but seeks to draw insights that can help to improve current disease containment and treatment protocols of COVID-19.

It is quite possible that there could be deeply rooted in the observation (content quoted in Review 7), some aspect of miscommunication, which has found its way to the authors to a research article. If the miscommunication had been handled at the initial stages itself, it would not have found its way to various published content (print or electronic), and eventually into a research article. After a long time, the actual communication might have been forgotten from societal memory, but only the miscommunication may be remembered.

If the future should not bring out such or similar observations due to wilful or nonwilful miscommunication that can find its way into print & electronic media eventually landing in research articles, then it is essential that a suitable structure be put in to handle correct Professional Communications on Disease Containment and Treatment Protocols and Associated Processes.

8. Quote "If governments, agencies, and health organisations want people at risk of infection to respond to COVID-19 with an appropriate level of alert, to cooperate with health authorities, and to act with compassion and humanity, I believe that they must be willing to fund their messengers on an unprecedented scale, with genuine urgency. It's time to put information in the driver's seat of global and national epidemic responses." End of Quote.

The authors are presenting an insight here that can speak for itself and may not need a review comment.

9. Quote "When WHO named the disease COVID-19, the choice was based on scientific standards. But it also matters how the global public might use the name. COVID-19 seems to be a tough term for news media worldwide and the general public. Perhaps even more confusing to the general public is the notion that the disease and the virus (SARS-CoV-2) have seemingly unrelated monikers. Parts of the media have settled for calling the microbial threat the coronavirus. One assumption could be that no expert in communications was asked to weigh in on the namings. But had WHO given serious consideration to future control of the public narrative, the agency's communications staff would have had opportunity to capture online brands and social media monikers before public announcement, such as #COVID19 or a myriad of Facebook page names using permutations of SARS-CoV-2 and COVID-19. This was not done, and online public discourse using those tags is in private hands." End of Quote.

The authors are presenting an insight here that can speak for itself and may not need a review comment.

10. Quote "Scientists and public health leaders, from local city tiers all the way to WHO headquarters in Geneva, need to understand that press conferences and government media releases are necessary, but are not enough in the emotionally charged atmosphere of 24/7 virally distributed social media stories and news about COVID-19, laced with sensationalism, at times massaged by some government agencies, and exploited by trolls and disruptors. Getting ahead of COVID-19 requires not only slowing its spread, adequate funding for the health response, supporting research to advance our knowledge of it, integrated actions to mitigate the health, economic, and social impacts of the epidemic, among others, but also control of narratives regarding its scientific and clinical attributes and pandemic containment efforts—an effort that I do not think can be successful if executed on inadequate budgets by sleep-deprived communicators." End of Quote.

The authors are presenting an insight here that can speak for itself and may not need a review comment.

11. Quote "Social media companies like Facebook, Google, WeChat, YouTube, Amazon, and Instagram are devoting some resources to identifying and removing disease trolls and liars from their internet services. But these social media platforms remain packed with anti-science and conspiracy claims. " End of Quote.

This observation by the authors strengthen the need for a National Level Activity to disseminate authentic information, while at the same time, censuring wilful and nonwilful miscommunication.

12. Quote "Public fear in some sectors is rising as COVID-19 spreads in many countries. I propose a potential mechanism to help allay fear. " End of Quote.

This observation, if exhibited by society, has the potential to derail the good efforts undertaken for the containment and spread of outbreak of COVID-19.

13. Quote "As Canadian social analyst Marshall McLuhan put it in the 1960s, “The medium is the message”, and today that message is chaos." End of Quote.

If the observation of the authors is correct, then it can potentially derail all good activity undertaken with regard to COVID-19.

Further, the Disaster Management Bill of 2005 (Disaster Management Act of 2005) https://www.ifrc.org/Docs/idrl/512EN.pdf does not seem to discuss about Media Censure of wilful and nonwilful miscommunication, which is an immediate concern .

It is upto to the National Governments now, to create order from chaos, establish a suitable structure for communication, monitor and censure wilful and nonwilful miscommunication, identify potentially polarising (political, religious, ethnic, discriminatory, etc.) miscommunication and ensure that polarisation of society does not take place, so that the containment and treatment processes of COVID-19, and further rehabilitation/recovery of the Nation (from devastation due to COVID-19) is able to be done on a good scale.

COVID-19 and its devastation (whether it be due to deterioration of health or polarisation due to miscommunication), has the potential to make/break Governments, which will again fall back on the society as more stress in related areas, and may lead to cyclic devastating processes.

Consequently, Professional Communications needs to be given due significance in COVID-19 processes, and identification & censure of miscommunication needs to be done at microlevel, and suitable structures established to achieve it, so that the massive efforts of disease containment and treatment processes of COVID-19 may reap the success expected of their efforts.

Part IX. A faint beam of light at the end of the tunnel.... Post Publication Independent Review of Guidelines for pregnant women with suspected SARS-CoV-2 infection Published: March 03, 2020 DOI: https://doi.org/10.1016/S1473-3099(20)30157-2

Published at:

https://www.prabhubritto.org/post-publication-independent-reviews-covid-19

https://www.linkedin.com/pulse/part-ix-faint-beam-light-end-tunnel-post-publication-review-albert

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Post Publication Independent Review of

Guidelines for pregnant women with suspected SARS-CoV-2 infection

Guillaume Favre, Léo Pomar, Xiaolong Qi, Karin Nielsen-Saines, Didier Musso, David Baud

Published: March 03, 2020 DOI: https://doi.org/10.1016/S1473-3099(20)30157-2

https://www.thelancet.com/journals/laninf/article/PIIS14733099(20)30157-2/fulltext#sec1

Review Comments:

Quote "Consequences of infection with SARS-CoV-2 for pregnancies are uncertain, with no evidence so far of severe outcomes for mothers and infants; however, the possibility should be considered.4 The recent experience with Zika virus suggests that when a new pathogen emerges, the health-care community should be prepared for the worst-case scenario.5 Therefore, recommendations for management of pregnant women at risk of SARS-CoV-2 infection are urgently needed. To this end, we propose a detailed management algorithm for health-care providers (appendix)." End of Quote.

Appendix/Supplementary Material provided for this paper (link given below), provides a flow chart for suggested Guidelines for treating pregnant women with suspected SARS-CoV-2 infection

https://www.thelancet.com/cms/10.1016/S1473-3099(20)30157-2/attachment/43fed2cd-623a-495a-a16c-691355138a81/mmc1.pdf


An algorithm for healthcare management of pregnant women is suggested by the authors as below.

Quote

1. any pregnant woman who has travelled in a country affected by SARS-CoV-2 within the previous 14 days or who has had close contact with a patient with confirmed SARS-CoV-2 infection should be tested with a SARS-CoV-2 nucleic acid amplification test,6 even if asymptomatic

2. Pregnant women with laboratory-confirmed SARS-CoV-2 infection who are asymptomatic should be self-monitored at home for clinical features of COVID-19 for at least 14 days.

3. These patients and those recovering from mild illness should be monitored with bimonthly fetal growth ultrasounds and Doppler assessments because of the potential risk for intrauterine growth restriction.

4. Pregnant women with COVID-19 pneumonia should be managed by a multidisciplinary team at a tertiary care centre.

5. When quick Sepsis-related Organ Failure Assessment criteria are met, the patient should be transferred to an intensive care unit.

6. For pregnant women with confirmed infection, the choice of delivery timing should be individualised depending on the week of gestation and maternal, fetal, and delivery conditions.

7. Whenever possible, vaginal delivery via induction of labour, with eventual instrumental delivery to avoid maternal exhaustion, should be favoured to avoid unnecessary surgical complications in an already sick patient.

8. Septic shock, acute organ failure, or fetal distress should prompt emergency cesarean delivery (or termination if legal before fetal viability).

9. Newborns of mothers positive for SARS-CoV-2 should be isolated for at least 14 days or until viral shedding clears, during which time direct breastfeeding is not recommended.

10. These recommendations should be adapted to local health-care facilities, as well as in response to any further updates on SARS-CoV-2 and COVID-19."

End of Quote.

The above recommendations may help to assist healthcare providers, pregnant women, patients and the society in suggesting/taking informed decisions, planning/implementing healthcare protocols and processes for the good of the mother and the baby.