By Dr Edward Nazareth

Jul 4: As the COVID-19 positive cases are markedly increasing, people are anxious to know what may have to be done if they turn positive. In the monsoon season the incidence of common cold and common flu also rises. Many people with symptoms of common cold or common flu are scared to go to doctors or hospitals due to the fear of testing for COVID-19 infection and the aftermath following that if they turn positive. We have to realise that it is very risky to avoid testing if there are symptoms of upper respiratory tract infections such as fever, cough, body ache, headache etc. In this season, many people can develop upper respiratory tract infections from non-COVID-19 viruses and even if it is COVID-19 infection, the course of illness can be mild to moderate. By avoiding testing, if the infection from COVID-19 takes a serious turn, it can be fatal. This unfortunate event can be avoided by early detection and prompt intervention.

On June 27, 2020, the government of India has revised the protocol of clinical management of COVID-19 positive cases. Asymptomatic persons and patients with mild symptoms with a positive report need not be institutional quarantined or admitted to the hospital; they can be quarantined at their homes provided certain norms are followed. The Government of Karnataka has also formulated norms for home quarantine based on the above guidelines and are applicable now.

Common cold, flu or COVID-19?

The common cold is also a viral infection of the upper respiratory system (nose, throat, sinuses, and larynx). More than 200 different types of viruses may cause the common cold. The common cold also spreads from person to person in a manner similar to the COVID-19 infection. The common cold surfaces as an illness about 1 to 7 days after contracting the virus (the incubation period) whereas COVID-19 may manifest as an illness from 5 to 14 days after getting infected. The common cold normally subsides within a week but may last for two weeks. The most important feature of common cold is mild upper respiratory illness with a runny, stuffy nose without fever.

Influenza (commonly termed the flu) is again a viral infection of the upper respiratory and/or lower respiratory system. The flu is caused by influenza viruses. These influenza viruses usually cause more serious symptoms in the respiratory system than the viruses causing common cold. The flu is also contagious like the COVID-19 infection, spreading from person to person almost in the same way as COVID-19 infection. It has an incubation period of about 1 to 4 days. The flu's duration varies from about 5 days to 2 weeks depending upon the severity of the infection. The flu can also become intense and cause pneumonia like in COVID-19 infection and potentially fatal illness in vulnerable individuals. The main features of flu are mild to high fever, cough, fatigue, severe headache and body pain.

A lot of information is already available about COVID-19 infection. Most common symptoms are fever, dry cough and tiredness. There can be a variety of other symptoms like aches and pains, sore throat, diarrhea, conjunctivitis, headache, loss of taste or smell etc. The infection can take a serious turn with difficulty in breathing or shortness of breath.

If we go through the above, it may not be easy to differentiate one from the other. As in COVID-19 infection, 80 to 90 percent people infected by influenza viruses can also be asymptomatic, but they can spread the viruses.

When a pandemic like COVID-19 is hovering over us, it is not safe to neglect the symptoms of upper respiratory tract as common cold or common flu and invite complications. It is necessary to visit fever clinics and get appropriate advice from medical professionals and if needed get a throat swab tested for COVID-19 infection.

ILI and SARI

In COVID-19 reports there are two categories that are commonly mentioned – ILI (Influenza-like illness) and SARI (Severe acute respiratory illness).

Influenza-like illness (ILI) term is used to identify upper respiratory tract infection that manifests with fever of greater than or equal to 100°F, in addition to cough or sore throat. Other symptoms may be fatigue, body aches, headache, loss of appetite, and nausea. Influenza like illness is not always due to influenza virus, it can be due to several other viruses and exact causative virus is not known unless checked. Many of the patients who present with influenza like illness may be tested positive for COVID 19.

The term ‘SARI’ is used for an acute respiratory illness with fever of equal to or more than 38°C and cough. The illness is of more than 10 days duration requiring hospitalization. (In simple terms it is a persistent upper respiratory tract infection of more than 10 days duration.)

Mild, moderate and severe

During the initial period of COVID-19 infection in India, all the persons tested positive were hospitalized at designated hospitals and in certain states this procedure is still followed. Now the throat swab testing for COVID-19 infection is being done for symptomatic persons and in some cases for primary contacts. Most of the primary contacts are only quarantined and not tested if they do not develop symptoms within a specified period. These protocols change frequently and they differ from state to state.

Depending on the symptoms, the COVID-19 positive cases are grouped into mild, moderate and severe. The persons with moderate and severe symptoms need to be hospitalized and those with mild symptoms can stay at home and take care. However, if they are not able to take care at home they may have to be in Covid care centers which need not be hospitals.

The people with mild symptoms are those with uncomplicated upper respiratory tract infection. Their symptoms are mild such as fever, cough, sore throat, nasal congestion, fatigue and headache. These are people who do not find difficulty in breathing. The saturation of oxygen in their blood remains normal. These people recover without any intervention.

The people with moderate symptoms of COVID-19 are the ones with clinical and radiological (X-rays or CT scan) examination showing features of pneumonia with no signs of severe disease. People of any age group with presence of fever, cough and breathlessness (dyspnea) and blood showing less amount of oxygen (hypoxia) are grouped as people with moderate disease. These people need hospitalization in designated hospitals.

The severe form of COVID-19 infection is very critical. It is further grouped as severe pneumonia, acute respiratory distress syndrome (ARDS) and sepsis. Most of the people in this category need artificial respiratory support through ventilators.

Home quarantine

The government of India guidelines (issued on June 27, 2020) gives people who are tested positive with mild symptoms, two options, either to opt for home quarantine or to quarantine at Covid care centers. The guidelines for home quarantine which were earlier issued on May 10, 2020 are applicable. The Government of Karnataka has added few more points to these and they are published on July 1, 2020.

The treating medical officer has to decide if the person who is tested positive for COVID-19 is asymptomatic, pre-symptomatic or has very mild illness. The person should be of less than 50 years of age without any co-morbidity like renal impairment, stroke, tuberculosis and any other immune deficiency diseases. The diabetes, hypertension, thyroid problems should be under control.

Such a person should have the requisite facility at their residence for self-isolation and also for quarantining the family contacts. The person should have the facility for separate well ventilated room for isolation, preferably with attached toilet. The positive person should stay in the identified room and away from other persons in the home, especially the elderly and those with comorbid conditions like hypertension, cardiovascular disease, renal disease, etc. The person should fill an undertaking on self-isolation that he or she would follow home quarantine guidelines. The person shall have pulse oximeter, digital thermometer and personal protective equipment (facemasks, gloves) to be used during home isolation. The person or care giver is required to record the essential parameters in a document specified by the local authorities.

The most important requirement is a care giver who should be available to provide care on a 24 x7 basis. A communication link between the caregiver and hospital is a prerequisite for the entire duration of home isolation. The person should regularly inform his health status to the district surveillance team.

Immediate admission to the designated hospital may be needed if serious signs or symptoms develop. These could be difficulty in breathing, persistent discomfort in the chest, mental confusion or inability to arouse, or on the other hand when advised by the treating medical officer.

The home isolation is discontinued after 17 days of onset of symptoms or after 10 days of positive report in asymptomatic people. The guidelines do not insist on further testing after the home isolation.

Covid Care Centers

In the second week of April 2020, the central government had formulated guidelines to set up Covid Care Centers. The Karnataka Government has adopted these guidelines from July 2, 2020 to set up Covid Care Centers.

The Covid Care Centers are to take care of mild or very mild cases or Covid suspect cases. These centers were not needed in several states and districts as the number of positive cases were less and all the people with positive report were admitted to designated hospitals. This is still the practice in several states, but the Government of Karnataka has started Covid Care Centers at Bangalore. Covid Care Centers may be needed now as the numbers of positive cases are steadily rising.

The Covid Care Centers are makeshift facilities. These are basically for persons with positive report who need not be admitted to the hospital and those who are not suitable for home isolation. These centers are mainly to cater to the positive patients with critical state like pregnancy and all children below 10 years of age. These may be set up in hostels, hotels, schools, stadiums, lodges etc., both public and private. Some hospitals which are handling regular, non-COVID cases can also be designated as Covid Care Centers as a last resort. Every Covid Care Centre is attached to a dedicated/designated COVID-19 hospital for referral purpose. Any person developing signs of deterioration in the Covid Care Center is shifted to the designated hospital. The Covid Care Centre is also for those who are COVID-19 positive but have no home quarantine facility.

What is our responsibility?

- As the COVID-19 positive cases are exponentially rising, we all need to be careful to avoid infection. As there are many asymptomatic persons with shedding viruses all around extra precautions are needed.

- Unfortunately if there are symptoms, one has to seek appropriate medical advice. Better to go to a fever clinic and follow the advice of the medical professionals.

- Many a times our problem may be a simple common cold or common flu.

- If the report is positive and the disease is mild, there is option for home quarantine provided facilities are available. If the facilities are not available, the Covid Care Centers are likely to be established soon.

- But, avoiding testing and hiding the disease can be a fatal mistake not only for the person but also to his family and society.