key: cord-0832854-246x84u2
authors: Garg, Sunil Kumar; Garg, Pragya
title: The first (earliest) case definition of suspected case of COVID-19 by WHO: Whether it was incomplete?
date: 2021-05-21
journal: J Infect Public Health
DOI: 10.1016/j.jiph.2021.05.004
sha: e4c466416ba14395f5bc099f2b06dee729f1ce09
doc_id: 832854
cord_uid: 246x84u2

nan

A 32-year-old Filipino male prese0nted to our hospital on 1 st February 2020 with 10 days history of fever, dry cough, body ache and shortness of breath. Initially, he was admitted to the floor and started on antibiotics for community-acquired pneumonia. His chest x-ray revealed bilateral pneumonia. Initial lab investigations revealed white cell count 7300, neutrophils 86%, lymphocytes 9.6%, platelet count 175,000, C-Reactive protein 123 mg/l, procalcitonin 0.07 J o u r n a l P r e -p r o o f ng/ml, creatinine 0.98 mg/dl, serum sodium 131 mEq/l and negative upper respiratory infectious panel. He was given oxygen through the nasal cannula. On the subsequent day, he was shifted to the intensive care unit because of worsening oxygenation.

Based on the initial clinical picture and lab findings, the diagnosis of viral/atypical pneumonia was made, and the patient was shifted to ICU negative pressure isolation room. We planned to send testing for novel coronavirus as his upper respiratory infectious panel, which tests for viral and atypical pathogens were negative. As the patient did not meet the case definition of suspected coronavirus disease at that time, the sample for novel coronavirus could not be sent. [1, 2] The case definition of a suspected case, by both WHO & national guidelines, at that time included patient with respiratory symptoms consistent with the coronavirus disease along with a history of travel and/or residence in a specific geographical location or history of contact with a confirmed or probable case. Though respiratory symptoms, which could not be explained by any other diagnosis were present in our patient there was no history of travel, residence or contact. The patient condition continued to deteriorate over the next few days in terms of worsening of chest X-ray and his oxygen requirement continued to increase. Again, we planned to send a sample for coronavirus testing, but it could not be sent this time also because of the absence of an epidemiological link. Finally, he was intubated on the fifth day of admission, given worsening dyspnea and hypoxia. At this point, testing for novel coronavirus was requested third time and discussed with the epidemiologist and subsequently, the sample was sent. We received the positive report for novel coronavirus after few hours.

The patient condition continued to worsen on the ventilator, so he was shifted to a center where an ECMO facility was available. As per information, the patient was discharged from the hospital after about 120 days of hospital stay which included more than 90 days on the ventilator and more than 60 days on the ECMO.

We think case definition of a suspected case must also include those patients who present with typical symptoms and the symptoms cannot be explained by any other diagnosis irrespective of their travel, residence or contact history, as in our patient whose procalcitonin was normal, upper respiratory infectious panel testing negative and there was no epidemiological link in terms of contract, travel, or residence history.

Likely realizing missed patients based on earliest case definition hence to include them in suspected case category, the case definition of a suspected case for patients those who do not have an epidemiological link and their respiratory illness cannot be explained by any other J o u r n a l P r e -p r o o f diagnosis, as in our patient, authorities at our place acted swiftly and it was included in the national guideline on 11 th February itself and later 27 th February by WHO. [3, 4] We believe such considerations should be the part of case definition from the very beginning for the diseases which have the epidemic or pandemic potential, in which human to human transmission is possible and where the asymptomatic state is quite common since relying on the epidemiological link to meet the requirement of the case definition of a suspected case can be misleading particularly when it is difficult to identify a contact if the contact remains asymptomatic.

Global Surveillance for human infection with novel coronavirus (2019-nCoV): Interim guidance

National guidelines for Enhancing 2019 nCoV Surveillance Case definition. MOHAP nCoV case definition

Global surveillance for COVID-19 disease caused by human infection with the 2019 novel coronavirus: Interim guidance

Guidelines for the management of Novel coronavirus