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24 is the Cut-off for Cycle Threshold

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In a video message circulating on Facebook and WhatsApp, Past President of the Indian Medical Association Dr. KK Aggarwal advised people to pay attention to the number 24 as the cut-off for cycle threshold (Ct) value. Following this widely circulated video clipping, there was a discussion including a note of ICMR.

However, the video statement by Dr. KK Aggarwal that “the number 24 should be considered as the cut-off for Ct value” in COVID management is backed by recent studies and the same has been included now in the UpToDate as authentic.

Ct guides decisions regarding infectivity in patients with persistently positive tests; the higher the Ct, the fewer the RNA copies. A recent study1 by Bullard, et. al. published in Clinical Infectious Diseases, 2020 states, infectivity was not observed in patients with symptoms greater than eight days or a Ct value >24.

The study aimed to determine the relationship between E gene SARS-CoV-2 RT-PCR Ct values from respiratory samples, symptom onset to test (STT) and infectivity in cell culture. Results showed SARS-CoV-2 Vero cell infectivity was only observed for RT-PCR Ct <24 or STT <8 days, and for every 1 unit increase in Ct, the infectability further reduces, thus proving that infectivity of patients with Ct >24 or duration of symptoms >8 days may be low.  The area under the receiver operating characteristic curve for Ct vs. positive culture was OR 0.91 with 97% specificity obtained at a Ct of >24. By these results, a Ct value of 24 can tell us that the patient is non-infectious. However, medical science is an ever-evolving field and nothing is absolute. The Ct test may not predict seriousness of infection but does inform of the viral load that can guide the prevention and precautions to be taken.

Source:
1. Bullard J, et al. Clin Infect Dis. 2020;ciaa638. 10.1093/cid/ciaa638 

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Coronavirus

If I have already had COVID-19 and recovered, do I still need to get vaccinated with a COVID-19 vaccine?

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Health Patrol has carried out numerous reports on the possibility of reinfection and severe health risks associated with COVID-19.1Due to these health risks associated with COVID-19 and the fact that re-infection with COVID-19 is possible, you should take the vaccine irrespective of whether you already had COVID-19 infection.

At this time, experts do not know how long someone is protected from getting sick again after recovering from COVID-19—which is also because the immunity someone gains from having an infection, called natural immunity, varies from person to person. Some early evidence suggests natural immunity may not last very long. As the system learns to fight back the infection, it develops COVID antibodies. Right now, from what studies have shown, it has been suggested that antibodies may last anywhere between 3-6 months for a person, after which they can start to wane. Asymptomatic persons and those with milder cases of infection are thought to have lower immunity than others.

A recently discussed publication in this regard has been the one by Harvey et al. that concluded that antibody positivity to SARS-CoV-2 is associated with a decreased risk of future infection. The study, currently unpublished, states that using real-world data from more than 3 million people, National Cancer Institute researchers have found that people who have had evidence of a prior infection with the deadly Coronavirus, appear to have some degree of protection against being reinfected with the virus.2

Another recent study3 published on January 06, 2021 in the journal Science, reports COVID-19 patients who recovered from the disease still have robust immunity from the coronavirus up to eight months after infection. The result is an encouraging sign that the study authors interpret to mean immunity to the virus probably lasts for many years, and it should alleviate fears that the COVID-19 vaccine would require repeated booster shots to protect against the disease and finally get the pandemic under control.

We still do not know how long immunity produced by vaccination lasts until we have more data on how well the vaccines work. Both natural immunity and vaccine-induced immunity are important aspects of COVID-19 that experts are trying to learn more about, and we at Health Patrol will keep you updated, as new evidence becomes available.

Source

1 https://healthpatrol.in/2020/10/22/is-there-a-possibility-of-reinfection-in-covid-patients/
2 Harvey RA, Rassen JA, Kabelac CA, et al. doi: https://doi.org/10.1101/2020.12.18.20248336
3 Dan JM, Mateus J, Kato Y, et al. Immunological memory to SARS-CoV-2 assessed for up to 8 months after infection. Science 06 Jan 2021: eabf4063. DOI: 10.1126/science.abf4063

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Vaccine is safe for women desirous of getting pregnant

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Earlier this week, Health Patrol published a report on vaccines being safe for pregnant women.1 Since then, we have received a few queries from women in their reproductive age desirous of getting pregnant and whether they should get the vaccine once it is available for them. The answer is YES.

However, it is pertinent to be aware of the usual body responses to the COVID-19 vaccine. Studies have shown that COVID-19 vaccination can cause fever in some patients (up to 16% of those vaccinated and mostly after the second dose); however, the study further reiterates that this risk should not be a concern when deciding whether to vaccinate a patient desiring pregnancy. Additionally, the most common symptom of COVID-19 infection itself is fever (83-99% of affected patients). Patients who experience fever following vaccination should take an antipyretic medication, such as acetaminophen pr paracetamol.2

According to the December 2020 Update3 from the American Society for Reproductive Medicine (ASRM) Patient Management and Clinical Recommendations During the Coronavirus (COVID-19) Pandemic, patients who conceive in the window between the first and second dose of the vaccine should be offered the second dose of the vaccine at the appropriate interval.

The CDC4 has also added to this information saying that, “Routine testing for pregnancy before COVID-19 vaccination is not recommended. Women who are trying to become pregnant do not need to avoid pregnancy after receiving an mRNA COVID-19 vaccine.”

Source

1 https://healthpatrol.in/2021/01/11/covid-vaccines-are-safe-for-pregnant-women/
2 Polack FP, et al. Safety and Efficacy of the BNT162b2 mRNA COVID-19 Vaccine. New Engl J Med. Dec. 10, 2020 (DOI: 10.1056/NEJMoa2034577).
3 Update 11. December 16, 2020. https://www.asrm.org/globalassets/asrm/asrm-content/news-and-publications/covid-19/covidtaskforceupdate11.pdf
4 https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html#:~:text=Routine%20testing%20and%20pregnancy,an%20mRNA%20COVID%2D19%20vaccine.

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Coronavirus

Headache is a common symptom in COVID-19

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After the emergence of a novel coronavirus, COVID-19 was initially characterized by fever, sore throat, cough, and dyspnea, mainly manifestations of respiratory system.1 However, other manifestations such as headache, abdominal pain, diarrhea, loss of taste and smell were added to the clinical spectrum, during the course of the COVID-19 pandemic. Headache here, leads the charts as the reports on the neurological findings are increasing rapidly.2 Headache was reported in 11-34% of the hospitalized COVID-19 patients, but clinical features of these headaches were totally missing in available publications for any reference points for the treating clinicians of healthcare staff.

Thankfully, a lot of research is being done on the subject and studies show that bilateral, long-lasting headaches, resistance to analgesics and having male gender were more frequent in people with COVID-19 in conjunction with anosmia/ageusia and gastrointestinal complaints. These features may be helpful for diagnosing the headache related to COVID-19 during the pandemic.3

A study published in the journal Headache noted, “The headaches had migraine-like features, including throbbing and/or pressing nature in almost all patients, aggravation with routine movements and bending over, sensory disturbances such as photophobia and/or phonophobia, nausea, and recovery within several days.”However, the headaches also had some unusual features, including new unrelenting pain, rapid onset, higher intensity, and association with anosmia/ageusia, diarrhea, reduced appetite, and weight loss. Study researchers observed a partial response or temporary recovery lasting hours following use of analgesics, mainly paracetamol or nonsteroidal anti-inflammatory drugs.4

Another study5 by Seth, et al. published in the journal Headache reported the case of a young male patient who went with a headache to the emergency room. He had increased intracranial pressure and tested positive for SARS-CoV-2, suggesting new headaches during the pandemic should not be ignored and any change in the character of chronic headache should prompt testing for COVID‐19. 

Bottomline is, clinicians and patients should not overlook headache, which is a common non-respiratory symptom of COVID-19, and its characteristics should be recorded with scrutiny.

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Coronavirus

Do I still need to wear a mask after the vaccine?

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With the success of vaccines and India announcing vaccine dates, the question on everyone’s mind therefore is do they still need to wear a mask and physically distance if they have taken the vaccine? The answer is a BIG YES!

According to the American Academy of Family Physicians, “While the vaccines provide protection against COVID-19 disease, they have not been shown to prevent infection, so people who are immunized may still be able to transmit the virus. Additionally, the greater than 94% efficacy in preventing disease was not observed until several weeks after the second dose of the vaccines. Everyone will still need to wear a mask and practice physical distancing until a large section of the population has developed immunity, which may not be until late 2021. Even then, more data will be needed to see how long immunity lasts, and maybe additional rounds of immunizations may also be needed.”1

According to a recent report2 published in the New York Times, the new vaccines will probably prevent you from getting sick with COVID-19, butno one knows yet whether they will keep you from spreading the virus to others so until that information is clear, it is pertinent to maintain the same social distancing and mask measures because some vaccinated people could get infected without developing symptoms, and could then silently transmit the virus — especially if they come in close contact with others or stop wearing masks.

If vaccinated people are silent spreaders of the virus, they may keep it circulating in their communities, putting unvaccinated people at risk.

Experts are not yet sure how long the vaccine will be effective, and at this time the recommendation is to get both doses and then continue to wear a mask and practice social distancing and good hygiene.

Moreover, trials that have been conducted on and around the vaccines have shown that the vaccine could prevent people from becoming sick, but whether people who have been vaccinated can still transmit the virus, is still not researched in detail.

Which is why eminent cardiologist and Padma Shree Awardee, Dr. KK Aggarwal emphasizes in each of his weekly shows that we need to continue with the social distancing and hygiene measures that we have been carrying out since the beginning of 2020. The Ministry of Health & Family Welfare also states that after receiving the COVID-19 vaccine, we must continue to take all precautions like use of face cover or masks, hand sanitization and ‘do gaj ki doori’ – physical distancing of 6 feet.3

The report by the American Academy of Family Physicians1 also reiterates the following key points of note, with regards to the vaccines:

  1. The vaccine may cause mild pain at the injection site, fatigue, headache, fever and muscle aches are common reactions.
  2. The vaccines do not contain a live virus; therefore, they cannot cause COVID-19.
  3. Vaccines provide protection against COVID-19 but won’t prevent infection. Those who are immunized may still be able to transmit the virus.
  4. It is important to continue wearing a mask, wash hands and physically distance even after getting the vaccine.

Readers are also urged to check the priority list4 for the vaccination drive in India in the report carried out by Health Patrol recently: https://healthpatrol.in/2020/12/31/the-indian-government-has-released-a-covid-19-vaccine-registration-website/

Source

1 https://www.aafp.org/dam/AAFP/documents/patient_care/public_health/COVID19-Vaccine-FAQs.pdf
2 https://www.nytimes.com/2020/12/08/health/covid-vaccine-mask.html
3 https://www.mohfw.gov.in/pdf/FrequentlyAskedQuestionsonCOVID19vaccineFLWEnglish.pdf
4 https://healthpatrol.in/2020/12/31/the-indian-government-has-released-a-covid-19-vaccine-registration-website/

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Melatonin has a role in COVID-19 Therapy

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Patients with COVID-19 are reported to present with fever, dry cough, myalgia, fatigue, and diarrhea, etc. In some cases, the severe progression of the disease results in debilitating conditions such as acute respiratory distress syndrome (ARDS), respiratory failure, heart failure, sepsis, and sudden cardiac arrest within a few days.1,2Studies have reported the findings of pathogenic examination of lung specimens from mild COVID-19 patients (who were retrospectively found to have COVID-19 at the time of lung cancer surgery)  such as edema, proteinaceous exudate with globules, patchy inflammatory cellular infiltration and moderate formation of hyaline membranes.3 In a postmortem assessment of a COVID-19 patient with severe ARDS, specimens of infected lungs demonstrated bilateral diffuse alveolar damage with edema, pneumocyte desquamation and hyaline membrane formation.1 Based on the genetic homology and pathologic features of the infected lung, it is inferred that cytokine storm also prevails in patients with COVID-19. This has led to the rationale for the use of melatonin in COVID-19 patients.

Melatonin is a bioactive molecule with an array of health-promoting properties; melatonin has been successfully used to treat sleep disorders, delirium, atherosclerosis, respiratory disease and viral infections.4 Previous research has documented the positive effects of melatonin in alleviating acute respiratory stress induced by virus, bacteria, radiation, etc. 

Melatonin is not viricidal, meaning the ability to kill viruses, but it has indirect anti-viral actions4 due to its anti-inflammation, anti-oxidation and immune enhancing features.5-8 There are situations in which melatonin suppresses the features of viral infections. In previous respiratory syncytial virus models, melatonin caused down-regulation of acute lung oxidative injury, pro-inflammatory cytokine release and inflammatory cell recruitment. These findings, along with those recently summarized by Reiter et al.4, support a rationale for melatonin use in viral diseases. Also, the features such as melatonin’s anti-inflammation, anti-oxidation and immune enhancing actions support its potential attenuation of COVID-19 infection.9

Source

1 Chen N, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet (London, England) 2020;395:497–506. doi: 10.1016/S0140-6736(20)30183-5.
2 Tian S, et al. Pulmonary Pathology of Early Phase SARSCoV-2 Pneumonia.
3 Xu Z, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir. Med. 2020 doi: 10.1016/S2213-2600(20)30076-X.
4 Reiter RJ, et al. Treatment of Ebola and other infectious diseases: melatonin “goes viral”. Melatonin Res. 2020;3:43–57. doi: 10.32794/mr11250047.
5 Junaid A, et al. Ebola hemorrhagic shock syndrome-on-a-chip. IScience. 2020;23 doi: 10.1016/j.isci.2019.100765.
6 Boga JA, et al. Beneficial actions of melatonin in the management of viral infections: a new use for this “molecular handyman”? Rev. Med. Virol. 2012;22:323–338. doi: 10.1002/rmv.1714.
7 Anderson G, et al. Ebola virus: melatonin as a readily available treatment option. J. Med. Virol. 2015;87:537–543. doi: 10.1002/jmv.24130.
8 Reiter RJ, et al. Melatonin in mitochondria: mitigating clear and present dangers. Physiology (Bethesda) 2020;35:86–95. doi: 10.1152/physiol.00034.2019.
9 Zhang R et al. COVID-19: Melatonin as a potential adjuvant treatment. Life Sci. 2020;250: 117583. doi: 10.1016/j.lfs.2020.117583

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