 Good afternoon, ladies and gentlemen, the topic for today's webinar is COVID-19 and Missy, if I can call it, is multisystem inflammatory syndrome in children, also known as PMISC in USA. Why it is important because till now we used to think that the complications are not there in children and COVID-19 is not involving children and we had the report of two to three cases in our newspaper also that COVID-19 patient presented as Kawasaki disease like syndrome. And today this webinar will also be a tribute to Dr. Tomi Saka Kawasaki, who died exactly 10 days back on 5th of June in Tokyo. In fact, he was a pioneer who told us about the Kawasaki disease. So for this webinar today, we have three of us, firstly myself, Dr. Bakuni. I am from the Army after I became a senior citizen two years back. I came to this hospital and working here for the last one and a half years. And I did my training in clinical immunology and rheumatology from Sanjay Gandhi, PGI in Lucknow. And with me, our younger colleague Dr. Himachu Bhatra is there, who is a graduate of Grand Medical College, Mumbai. He did his diploma from Keem Hospital, Mumbai. After that, he came back to Delhi, did his DNP in pediatrics from Mata Chaland Devi Hospital. Then he worked as a consultant for the last 10 years in one of the corporate hospitals of Gurgaon. And for the last one year, he is heading the department of pediatrics in a medical hospital, Dwarka. And the third and most I will say, precious member of our today's webinar is Dr. Nandana, Dr. Smita Mishra, who is MD pediatrics and FNB in pediatrics cardiology. She is the secretary of the Indian Academy of Pediatrics at Delhi chapter. She is the current head of the department of pediatric cardiology in our hospital, Manipal Hospital, Dwarka. And she's the past president of National Pediatric and Fetal Cardiology Forum, which is a branch of Indian Academy of Pediatrics. And one of the most important things she has done is she is the author of disability criteria for the cardiac patients, which she has single-handedly, of course, with the help of others. But she had the main roles. She in previously she had been the editor or in chief of the IAP Bulletin and the executive board member. She has been the co-authors of Drugs in Pediatrics Cardiology. She also won the best doctor award in IMA 2013. And the role of Dr. Smita will be after our younger colleague, Dr. Bhattara, presents. She will be the moderator. She will be asking the question from me as well as Dr. Bhattara. And in between, I think she's a big fan of Karan Johar also. She will be having coffee with Karan type of questions like rapid fire round. And then rapid fire round out of two who's or wins. Our coordinator, Dr. Sakshi, who's sitting right far away from me. She will has promised that she will give a hamper. And preferably she should give me the hamper because I'm introducing the topic. Now, with this small introduction, I hand over the webinar to Dr. Himanshu Bhattara for the overview of COVID-19 and multi-system inflammatory syndrome in children or to him please. Thanks a lot, Dr. Dutchan for introduction. So, straight away, I am coming to the topic. So, the topic for today is COVID-19 and multi-system inflammatory syndrome in children. First of all, I would like to pay our tribute to the great pediatrician, Tommy Sibu Kawasaki, who has been good at 95 years of age just two weeks back. Contents of today's presentation will be just a brief introduction to COVID-19 followed by clinical presentation in children and multi-system inflammatory syndrome. And just a brief overview of Kawasaki disease. And then we will conclude the session with questions and so on. Just a brief introduction, in December 2019, after a cluster of pneumonia cases, which were reported from Wuhan city in China, the CDC in China named this virus as the novel coronavirus and which was renamed on 11th February 2020 as SARS-CoV-2 or COVID-19, that is coronavirus disease 2019. It was declared as a global pandemic on 11th March 2020. Globally, we have seen around 8 million cases so far with around 4.5 like that. And in India also, it is still in the rising case with more than three like cases reported and nearly 10,000 there. And it is estimated to affect more than half of the world population if stable vaccine doesn't come on time. Now, the transmission of COVID is by the droplet route to the aerosol which are generated and by inhaling those directly or through the nose, eyes or oral route. And also by touching on the surfaces which are infected with these droplets. Clinical spectrum in children and adolescents. So far we have reports from the major studies from the U.S. in China and which have reported around 2% only, 2% infection only in the children less than 18 years. Usually it is less severe. And there is a lot of hypothesis which are coming why it is less severe in children. First is the regarding endotensine converting design to receptors, which are found in less number on the nasal epithelium and respiratory epithelium in the children. How it's played a role, it is yet to be succeeded. Then there is a lower exposure so far of the children due to isolation and the containment measures carried out by the government. And also there is high likelihood of virus co-infection which is responsible for limited replication of SARS-CoV-2 in this setting. And more importantly is the role of innate immunity induced by the virus vaccine or the BCG vaccine in the children. But there are two concerns in the children. One is how they will behave in the transmitting this infection once the lockdown is over or once schools are open that needs to be turned off. And the second more common concern is the multi-system infamatory syndrome which is now recognized since last one or two months after the peak of the cases in European and U.S. countries. In children around 50% of cases are either present as asymptomatic or just as a viral problem. That is mild urethane like in the fever, cough, sore throat, running nose, which can be easily missed with other symptoms. And 40% cases present with lower respiratory tract infection on pneumonia. Always 40% that is mild pneumonia and hardly replying to hospitalization. Those present with fever, cough and mild tachypnea. And severe pneumonia with the fever, cough, dyspnea, oxygen level below 90% on the room air or sinosis. That is in only 5%. And critical cases those presenting with ARDS, respiratory failure, shock, insulopathy, cardiac failure or multi-organ dysfunction is same 0.62% only. Now the unusual infamatory illness which is nice is last three months in the European and U.S. countries where this disease has already peaked. So it is reported approximately one month after the emergence of COVID-19 in Europe and U.S. Variable presentation was seen in form of prolonged fever, headache, abdominal pain, mounting rash and it is associated with shock in more than 50 to 70% of cases and organ dysfunction. And the more prominent feature noticed in these is the race inflammatory markers like CRT, race counts, race DSR, associated with lymphoping and low albumin. Typical cover circuit disease features were seen in about 50% of those. And the majority were found to be SARS COVID-PCR negative but serology test was positive. That is IGG or IBM levels for the coronavirus. Now in Italy they have reported on 30 times increase in the incidence cover circuit disease in a one and a half month period of 18th, 24th, 28th after that they have reported 10 cases compared to 19 cases which they have seen in last five years before there. And the key features which they have noticed in these cases are there is evidence of serial conversion to COVID-19 in form of IGG or IGM antibodies. There is higher rate of shock compared to normal cover circuit disease and it is affecting mainly older children around 8 to 9 years. Multisystem involvement is noticed in the form of abdominal symptoms, manager's sign and myobarditis. And associated features of macrophage activation syndrome in terms of inflammatory markers were seen in significant number of cases. They have more severe disease course and resistance to IGG was noticed and need our dentist to write us there. In similar condition was reported from France where they named it as Kava COVID-19 and in those they have found 16 cases. The presentation in those cases was the main symptom or gastrointestinal in the 81%. And along with that the typical feature of Kava Cycle X or vital adenopathy if you were more than four days, gasses, grad lips, conjunctivitis, these all features are present. And the other thing which they have noticed are the symptoms of neurological signs in the form of headache and the coronary dilatation or eco-finance were noticed in 19% of those cases. And myobarditis was seen in around 86% of severe cases. So now the question is what we are actually dealing with. It is just a Kava Cycle disease in a severe form or it is similar to something what we have seen previously with stephalococcal or stephalococcal top six of syndrome or it is a form of macrophage activation syndrome or your cytokinesic form. Now to cover, answer these are WHO and CDC have come with this entity, multi-system inflammatory syndrome and children and which is definition proposed by WHO is there. It is labelled in children and adolescents 0 to 19 years who have persistent fever lasting more than three days and two of the following features. One of the features of Kava Cycle disease that is rash or bilateral non-coronal inflammatory is inflammation signs associated with hypotension or shock which is not seen to clean or Kava Cycle cases. Features of myobarditis and dysfunction in form of pericarditis, verbalitis or coronary abnormality in the ego. Raise inflammatory markers from the heart point that is stoppening or OVNT, evidence of coagulopathy, a QGI problem like diarrhea, vomiting, abdominal pain and associated evidence of inflammation in form of elevated CRT, pro-calcitonin, ESR, ferritin and no other microbial cause like bacterial sepsis, streptococcal, streptococcal is low and along with that they'll evidence needed for the COVID-19 as per WHO criteria either in form of antigen test or positive serology or even history of strong conduct with COVID-19 positive patient. You can see I just term some minor modification in this thing that is the age included is less than 21 years in this and fever for more than 24 hours is considered as a criteria for the CDC definition. Inflammation can be predicted by any marker like CRT, ESR, fibromyalgia and rediamorous clarity and associated lymphopenia or low elbow pain. Critical severe illness is a major criteria in this with more than two system environments, cardiac, kidney respiratory, hematology and there is no other possible other diagnosis that needs to be ruled out and along with that evidence of COVID-19 infection but they have also said that any pediatric death occurring with evidence of SARS-CoV-2 can be included in this criteria. In the UK they have labelled this entity as pediatric multi-system inflammatory syndrome temporally associated with SARS-CoV-2 and in this spectrum we see either just fabricated with inflammatory markers but no evidence of COVID-19 disease and no multi-environment or shock. Then secondly in this is a COVID-19 disease and third is inflammatory with multi-system environment. So this is a spectrum which was seen. The criteria included were almost similar that if you were more than four days with either GI symptoms as well as evidence of inflammation and presenting either as classic COVID-19 disease, incomplete COVID-19 disease or with cartogenic or distributed shock. Now treatment which was tried in all this condition was mainly sportive in form of oxygen, mechanical ventilation for fluid recitation or iron drop for the shock and just fever medicine. IVIG was given in all the cases we have the presentation like kawasaki disease and in the cases which are reflective with help in this long modules and extreme hurdles for the kawasaki-like patients then few immunomotor liters of few drugs like anti-intelukin-1 and akinra or anti-intelukin-6 proselytism was also considered. Anti-population was given and also chloroquine is used at trial in few of the cases. Now just a brief overview of kawasaki disease before finishing this presentation. Kawasaki disease we know is very long time as a wild self-limiting vascularity in many medium size artery and especially coronary artery and it is more commonly seen in Asian and less than 5 year old children and PKG is 1824 months. It is one of the leading cause of acquired heart disease in US and Japan and except cause we don't know so far and it is considered as aberrant in the response to some infections. Kawasaki's rest on the clinical feature mainly criteria for diagnosis are fever for at least 5 days the long-term sprays of 4 of the following conditions. Oral mucosa changes in the form of erythema of writing olives scobaritum, erythema of pharyngeal, oral mucosa bulbacunitival penetration bilateral without an exorbitant and limb sparing. So I don't know about it usually in later land more than 1.5 centimeter diameter. Skin rashes in the form echelopepular or diffuseridoderma edema of hands and feet and acute stages and peri-angle discommission in the subacute stage and there is no other non cause. There's also a reflux these are mucosa changes seen in the kawasaki and typically we see that there is no exoteric discharge compared to the common differential diagnosis of kawasaki which is middle. So I don't know about the unilateral and rashes in the form of polymorphic rashes actual changes like swelling in the acute stages and subacute stages we see a discommission. End differences what we see in this syndrome that is multi-system inflammatory syndrome and kawasaki that we are seeing older children more affected more severe myoparditis is seen abdominal pain and diarrhea is very prominent symptom in these cases shock and multi-organ discommission is very common and there is marked increase in inflammatory marker suggesting a different pathology than kawasaki disease like and lymphopenia and low platelet count which is in contrast to the kawasaki disease and in the treatment also we are seeing resistance by age in these cases. So just to conclude this multi-system inflammatory syndrome associated with COVID-19 can present as varied combination of kawasaki disease and kawasaki shock syndrome and we have to be alert on this and the pathogenesis looks to be uninhibited immune response to prior COVID-19 infection not direct viral injury that is psychocrats' norm and in some genitalis is applicable individual like in those studies mostly after African or Caribbean patients were noticed in these countries and the method why this is happening may be similar to what we have seen in that is anti-vortice enhancing this thing or causing cytokines from that still needs a lot of study and this has an important implication when we are considering development of vaccine whether they can do more harm by publishing these kind of anti-vortice which are more pathogenic or they will come for testing. So now I will invite Dr. Sita Mishra to moderate the session and just question answers are invited from all the participants. So So, Rami Sathu Kawasaki somebody wrote about him that he was Sherlock who was picking up finding about the Kawasaki disease and Charles Dickens when he was writing about those findings. So I must say that two months back we were thinking that pediatrician will not have any role in this COVID pandemic until evidence started to emerge that children have different way to present and may have a critical disease and Kawasaki like presentation. As the pediatric cardiologist let me assert that Kawasaki disease is close to my heart they are 25% chance of having long-term complication in the form of coronary artery aneurysm particularly if the aneurysm are more than eight millimeter large and they can lead to a life-threatening event in less than 10% of cases but definitely they can. Then on the other hand Kawasaki shock syndrome is a rare thing actually people started recognizing it in 2009 onwards and this is very rare in our own series we found 25% of coronary artery disease but only one child one girl child having Kawasaki shock syndrome and it was very really is difficult to control scenario the patient was admitted under Dr. Arvind Paneja and everybody knows Dr. Arvind Paneja for his because he was the person who reported first case of Kawasaki disease in 1979 from India. So definitely Kawasaki shock syndrome is immunologically mediated it causes myocarditis it causes carded dysfunction capillary permeability and so forth. So critical covid positive children have worst kind of multi-system involvement as we have learned just now from Dr. Imansu. Congress Dr. Imansu for excellently setting ball rolling for the today's webinar. So let's discuss coming first question goes to Dr. Imansu only. Do you think a new name is needed or Kawasaki disease or new co-cutaneous lymph nodes syndrome accommodate the spectrum of symptoms in MIS in children? We need a new name for this thing because Kawasaki disease has a name which says so that it is just showing the micro-cutaneous lymph node in moment only as the main features but in this syndrome what we are now seeing after covid we are seeing more multi-organized function more from and very high level of inflammatory markers anti-inflammatory markers which are seen in the body so we definitely need to involve all of those things that is it is multi-system it is included in inflammatory and that's why it is level as multi-system inflammatory syndrome in the children and the mechanism also seems to be different in the compared to Kawasaki disease. So Dr. Bhapani what the difference between toxic shock syndrome Kawasaki shock syndrome and MIS? Very nice question ma'am that toxic shock syndrome can occur at any age number one, number two they will always be mostly history of infection in the past maybe post-surgery maybe post some injury or in trauma to skin barrier so there's some amount of infection we will get either in the history or in the examination and if we do the culture examination of the blood it may show bacteria in the blood culture whereas in Kawasaki disease as you yourself said the shock syndrome is very very rare however if we see a covid 19 with MIS or multi-system inflammatory syndrome where the patients are usually elderly children right from varying from one year to 20 years of age as per the Americans and WHO says right from one year to 18 years or 19 years of age but the average age of these children coming as a shock with covid 19 positive or maybe negative is 9 to 11 years and they have the atypical features in most of the cases atypical features are Kawasaki disease meaning thereby they do not fulfill 4 out of 5 criteria along with the fever they may have only 2 or 3 criteria out of this Kawasaki disease and they have more of the GI symptoms like diarrhea, nausea, vomiting in 81% of the cases and most of them around 86% patient they come with myocarditis some arrhythmia and pericarditis in 25% of the patient and if we do investigations the C-reactive protein almost 40 times more than the normal meaning thereby more than 200 units serum ferritin goes more than 1400 micrograms per litre which is not there in the case of either TSS or in cases of Kawasaki disease and of course D-diameters are highly raised so that's how we differentiate toxic shops in Rome with Miss C okay so coming to Dr. Hemanshu you have told us just now but again a brief this thing description of classical symptom of COVID-19 do you get anosmia in children also and what about GI symptoms the classic symptoms of COVID-19 in children mainly the fever is the most common feature along with that cough or respiratory symptoms flu-like illness is seen and GI symptoms are seen in around 10% of cases in the form of diarrhea but that can be a major shock for the transmission later that needs to be seen because of the current transmission we're still are declining but with the diarrhea and these kinds of symptoms it can be a major shock and regarding anosmia firstly the children doesn't report such specific symptoms more precisely and also as far as the pathologies can die as to receptors which are there they are found in less number in the nasal epithelium of children so that may be the reason they don't show that much anosmia compared to but they are seen in adult patients so Dr. Bhapni what is this cytokinesis term we keep on listening that cytokinesis term is region for every issue related to covid-19 and does it happen in children also and that you have asked this question because as you said yourself everyone talks about cytokinesis term I'll tell in a very very simplistic way if we see the normal course of action what happens when an antigen in the form of bacteria or virus it comes to the body it is taken by the antigen presenting cell that is APC APC is that take the antigen inside and they process it after processing it goes to the cell surface there it meets the MHG class 2 protein with the help of this MHG class 2 protein and this processed antigen they go to T cell receptor and the T cell receptor takes it and it is through the T cell 2 secret cytokinesis but what happens in normal infection day to day infection these T cells only 0.01 to 0.1 percentage of T cells are involved so they give limited amount of cytokines to the body to fight that antigen but what is happening here in covid is very necessary to know that covid-19 virus it does not go through the antigen presenting cells it attacks directly the T cells and in attacks not 0.1 or 0.01 percentage it attacks 5 to 30 percent of T cells just imagine 30 percent of T cells if they are attacked directly and they are stimulated the cytokinesis they just flow like a uncontrollable you know river in our body so that is cytokine storm and in the bargain what happens it also you know the it also the T cells also separate gamma interferon what is the role of gamma interferon they go and suppress B cells and the function of B cells is to produce immunoglobulins so that protective antibody production is also suppressed so it is a double whammy condition for the body at one side 30 percent of T cells are giving us plenty of cytokines so they are damaging our body and on other side the protective antibodies are not being or they are being suppressed to be produced so the protective antibodies are not there and the attacker is there in the form of cytokines so this is called cytokine storm in simple language okay so Dr. Himanshu coming back to antibodies only as Dr. Bhavani said we know significant antibodies are formed in COVID-19 also so are they pathological are protective are they are really not significant so much as everybody is waiting for that herd immunity will come from protective antibodies so what is the status of antibodies production in COVID-19 antibody production is seen in all the cases of the COVID-19 infection as measured by the various tests which are determined IGG IGG as well as IGM levels the thing is that the whether they're productive or not that get new to be found because they have seen some neutralizing antibodies but they can't be sure whether they are sufficient whether they will give large normal lasting immunity and with over cases of mRNAs as we are discussing they are proven to be pathological it seems that they are maybe similar to like Dengu that is an antigen they are actually enhancing the antibody they are enhancing a disease process either by enhancing the viral application like thing or forming the new complexes which are damaging the body actually so it is yet need to be found out so that's why when we are considering vaccine we need to do a large safety trial first and see whether they are humming or not or any side effect occurring or not in this case so antibodies are definitely forming but they are productive or not that yet need to be found out what is your opinion Dr Bhapani on this antibodies are protective or not ma'am till now it has been proven that they are not protective the neutralizing antibody firstly they are few in numbers few in quantity and secondly it has not been proven by any experiment they are they are productive at the moment natural antibodies I'm talking about they are anecdotal reports that they it may be protective but we cannot say by sure okay so Dr Mowgli it is said the severe COVID-19 disease characterized by exhausted lymphocytes what do you mean by well if we go back to my question last my answer of the your last question as we said around 5 to 30 percent of T cells are already tired of you know giving the cytokines and B cells are being suppressed forcefully that don't produce antibodies thirdly this is adaptive adaptive immunology I mean adaptive immunity so adaptive immunity is being compromised as well as the innate immunities also compromising the form of NK cells it has been found that during the COVID-19 infection the number of NK cells and CD8 cells they go down why because there is an increase in the inhibitory molecule of NK cells known as NKG2A so that suppresses the natural clear cells so innate immunity suppressed adaptive immunity suppressed for our immunity you know isn't a shambles so our immunity is suppressed and it has also been seen that once the patient starts convalescing this inhibitory molecule NKG2A it goes down as well as the NK cells, CD8 cells, CD4 cells everything increases so basically this is the exhaustion of the immunity your immunity or the immune cells by working more whatever the function they are made to work more and some are made to work less so do you think Dr. Imanshi all the like this exhaustion lymphocytes and this cytokine storm is a normal phenomena in every case or is just a rare phenomena what do you think? it is not normal in all the patient that is not happening in every patient yes or no a little just brief it's not seen in all the cases it's not seen they are not seen in all the cases okay so so do you think cytokine storm happens in children also yes definitely so cytokine storm we have already seen in the cases of lymphocytic lymphocytes cytosis or in some major cases as well so this is happening in children with a well known entity and after a few viral infection like vaccine bar virus we have commonly seen this thing and see other viral message as well in the past also which has the intracellular pathology even in malaria also sometimes this kind of condition is seen so it is a common thing and in immunodeficiency it is a well known fact when I mean this is the cytokine storm is happening because of the imbalance between pro-inflammatory and anti-inflammatory medias so whenever the viral load is more and I mean antibodies are less compared to that thing at that time we can always see the cytokine storm so question number eight actually has been answered already so I go to next is that is or you want to say something significant antibodies are formed in body in COVID-19 are they pathological or protective yes thank you they are not pathological but as I said they hardly provide any humidity because they are usually produced after two weeks of this thing what I want to add that since the immunoprovincial products in less number or the antibodies are in a less number if we treat these patients we have to give double dose of IVIG like in kawasaki disease we just give two gram per kg body one day off one day milligram into you know five days or so here the condition comes that patient does not show any improvement within first 10 to 12 hours then we have to give a second dose what does it show it shows that the body is lacking the neutralizing antibodies against COVID-19 similarly in cases of Tosilusumab or Anakindra because of the cytokine storm we have to give two double dose also around 66% of the patient they require they require the double dose after 8 to 10 hours of Tosilusumab again it shows that there is a you know river of cytokines of IL-6 there in the body so basically that is the answer that immunoglobulins are not productive which are produced naturally in this case so how important is interleukin-6 you have just said interleukin-6 you named it how important is interleukin-6 in deciding the management plan interleukin-6 causes all the damages it is basically pro-inflammatory cytokines so inflammation goes regardless all over the body and how do you know it as I told you ma'am the seroactive protein increases by 30 to 40 times the sero-inferitein goes high sky I have more than 1400 micrograms per liter as well as D-dimmers with the poor thermo- thermotic state also increases so IL-6 has got a road in all these things if we control the cytokine storm most of the patients they recover in fact out of 100 in New York few weeks back out of 150 children treated with the tosylizumab and other drugs only three died that shows the importance of one of the drug is was tosylizumab to prevent the cytokine storm Dr. Himanshu how much importance you give to monitor interleukin-6 interleukin-6 has a role when we are treating it normally we see the normal inflammatory markers like the CRP, serotin and based on that we really prefer seroids but if we see that no response is coming or interleukin-6 level because they will not report will not come immediately but that is one line available to us if we are seeing poor response to initial therapy with IVIG or with the over seroids then we can consider it based on the IL-6 level can you do routinely in India, in Delhi interleukin-6 level can we do in India we can do so what is the meaning of apparent development of acquired immunity Dr. Himanshu normally the acquired immunity or adaptive immunity we call that is the specific immunity form of any particular antigen after it's exposure so in few cases when this immunity the antibodies which are forming instead of protecting us they are helping further in the viral application that application of the disease or they are forming immune complexes which are damaging the body so in these cases we call it is apparent development of the adaptive immunity form which we are well known with the dengue strains that we know that very particular dengue stages is changed so the antibodies which are formed they act against the body and they cause more damage enhance the basically disease so how do you Dr. Bhakini how do you interpret the coexistence of cover circuit disease with COVID-19 specifically in children is it a predictable association well back is not a predictable association more so that we can call it as a post infectious complications why I'm saying so for the one or two reasons because the miss or the multi system inflammatory syndrome in children it develops two to four weeks the exposure of the children to COVID not immediately along with COVID infection number one and we can correlate with reactive arthritis and rheumatology like the infection like UTI conjunctivitis other infection they take place today and the joints are involved after seven days, 14 days, 21 days or within 21, 28 days so basically there's no correlation but it is a complication of infection we can safely call it post infectious complication of COVID but no association otherwise okay so now we have completed over 10 questions so we are going for a rapid fire round five questions rapid fire round so the questions are like myth or fact so whoever says first thought Sakshi please keep counting so children are immune to COVID-19 infection not immune but they are less vulnerable okay so in fact infants are worst affected than periodic age group yes children may be nasopharyngeal carrier can shed virus in a stool for a longer period yes yes yes both of them evidence exists that closing the school brought down number of COVID patient in some countries no evidence no evidence but schools are now objecting they are resisting they want that what did you say definitely we have evidence there are evidence even so but there are no evidence although of course yes there are evidence then diarrhea less than 10% is common than the cough yes four out of five cases they had diarrhea more than you know other symptoms I mean two other questions right Sakshi this was wrong one okay so Dr. Himashu WHAO says now we have to live with COVID-19 do you think it's going to increase the incidence of cover circuit disease in general from the US and Europe externally it looks like that it will increase it is just a temporal association it is not a constant relationship but definitely when we don't know the exact pathogenesis why it is happening whether antibody which is formed it is causing this kind of condition so it is very much likely because even the cases which were seen in those countries the chain were asymptomatic for the COVID or there was just a mild symptom they have shown and just asymptomatic cases developing this condition after few weeks so it is very much likely that we are going to see a cell in number of cover circuit and similarly we have already seen few cases in India as well so far so Dr. Bhakuni triggers of cover circuit disease have been a mysterious puzzle what is your response to a statement now we have found a link between flu coronaviruses and mysterious cover circuit disease actually no direct casual relationship has been found however there was a study published in 2005 in general infectious disease that they found that new heaven coronavirus in cases 8 out of 11 that means around 72% of the cases were having corona new heaven coronavirus by RT-PCR so that time they said well there is definitely a correlation of new heavens coronavirus as well as cover circuit disease if you leave that study we have not found any evidence of any association till now except of course now this COVID-19 MS they have the correlation in the form of post infectious complications as I told you do you think this is a new understanding about the COVID relations between cover circuit disease and COVID and new opportunity to look for the link absolutely right mom absolutely right we have the now at least some clue that look this virus can also be involved in causing cover circuit disease may be a difficult picture who knows that it has a definitive role in that of course more work is required so Dr. Imansu is there any role of adult practices like hydroxychloroquine prophylaxis ejectromycin for the children also it has not been recommended or approved by any of the authorities so far in the adults we are using this as a immunomodulator mainly hydroxychloroquine as well as ejectromycin because we know that the mechanism by which coronavirus is acting or after just entry of the body it causes decrease in the body's immune response and enhances its replication so if we use immunomodulator early in those cases it will help in producing the progression to CGL1 but in children as we have seen that most cases are already mild and the severe cases which we have seen they are not associated with the virus load as such so I don't think it is of any help in the children so far hydroxychloroquine hydrolyzycin what is the role of IVIG how effective is IVIG in children with MIS ma'am there is a very very definitive role of IVIG as I told you that neutralizing antibodies produced in the body of the children they are not enough or sufficient to suppress the inflammation so we have to give IVIG so much so that we have to double the dose as I told you in one of the studies they found that 66% of the children who recovered they required double dose of IVIG so there is a definitive 100% role of IVIG in COVID-19 fraction in children so this double dose should be given like after one rason and another rason it should be like you have to decide and you just continue with the double dose no no ma'am how much time they have to double the dose yeah well around 30 to 34 to 35% of the patient they responded to one single dose say if you have given IVIG today and within 12 to 24 hours the patient should improvement clinically as well as by inflammatory markers also however if the patient does not show any improvement within next 24 hours we have to repeat the dose after 24 hours same 2 gram per kg in one single day so mostly in kava circuit this is when we give IVIG to be think about monitoring CRP and fever these two things yes may take time actually to come down so what about in this case where ferritin is high there are other inflammatory markers RD limer is high so what are the inflammatory markers you will be looking at not only fever or what will be your criteria for deciding that your IVIG working are not working simple formula ma'am if the patient is clinically improving his oxygen saturation is coming down if the patient neurological state is improving in the patient's arena or cardiac I mean myocarditis or pedicariditis is improving which if we show any clinical improvement within that 24 hours we have to we don't have to give this second dose if the patient is sane and the inflammatory markers are hardly any you know they have not come down sufficiently means maybe 10 percent 20 percent we have to repeat the dose because we have to give a chance if you do not treat the patient as it is the patient is going to have the complications but if we give the second dose you might never know that patient may come back again that's why we have to give a chance to the patient by giving him second dose if you have not shown any clinical or lab improvement within first 24 hours so Dr. Himanshu if IVIG is not working is there like in cover circuit disease we think about the steroid we think about the infliximab we think about the other this thing also so what is what about in MIS if IVIG is not working or maybe even if it is working would you like to start with steroids also because there is some kind of autoimmunity going on as we have seen the high level of the inflammatory marker in this condition which is similar to HLH so we prefer methylprenuosalone in these cases if we are seeing the high levels of all the inflammatory marker and more so if IVIG we have seen that no response in fever in patizic sour either we repeat the IVIG or the stativitis start with the steroids and methylprenuosalone will be used in subcenter they are using it as a pulse therapy for the three days or it can be used 1 root 2 mg patizic that is written in those for two days followed by tapering and if it is still not working and IL6 that is proselyzumab and that other options are also available so what are your red flag sign Dr. Imaj once you are dealing with a COVID MIS so what are your red flag sign where you think that you have to go for multi therapy with multiple anti-inflammatory drugs role of like roofing maybe so all those things so when what are your red flag sign any child who is eager enough to require ICU admission in the first place having shock requiring aino drops and high ferritin levels which are the one of the promosin marker seen in France already as well they have seen that older child and with more than 1400 level of the 14 micro rampa liter of ferritin they are both prone to develop seizure disease so in these cases we have to consider methylprotein so early that other way so you will go by biochemical markers okay the clinical distinct like blood pressure and all those things and mark some biocortil injury as well that probing and PN and other levels so the markers of inflammation will be guided to us and along with that the requirement of aino drops definitely so when will you intubate a child in this case any question prefer to go for high flow oxygen what will you do like in adults we have to follow same guideline as we are following in the steps is also the if any patient is in shock and having altered sensorium we will definitely prefer prefer endotracheal intubation again shy of intubating a patient if you need to but mostly like you will try to manage with high flow oxygen as we do in adults so we will follow same guideline for the oxygen therapy right so coming to role of anti-covalent in Dr. Bhakuni anti-covalent and low molecular weight comparing we give aspirin in the covers are going to be so often so what is your opinion about that luckily ma'am in this miss see the incidence of covalent Matthew is less however if the D-diamonds are raised and if there is a pro-thrombotic state you must give low molecular weight you know this thing hyperin or in our naraprexin is also you know is recommended low molecular weight hyperin acts also as a anti-inflammatory drug it also acts as a I mean it reduces the endothelial injury so that also helps to the covalent patient and last but not the least it also acts like an anti-viral agent how because it competes with the virus for the binding site in AAS2 inhibitors so AAS2 receptor sorry so it acts three ways so all the benefits are there if there's a pro-thrombotic state or the D-diamonds then we must give no molecular weight hyperin to the miss see the child so we know that in coronary artery disease there is a kind of endothelial endothelial damage then there might be a medial edema there may be a pan-artritis kind of situation all the conditions actually are very pro-cogulant because there may be chances of having the small thrombus formation in within the coronary artery and within the other middle size arteries across the body so definitely and actually Kawasaki himself wrote later that it's not only artery but the veins can also be involved so this is definitely as you said it is very very important to start with low molecular weighty perin or something like that so just prevent those complications which may be very very damaging like there may be a cardiac event or there might be chance of amputations in the if the peripheral arteries are involved so this is very important point you have raised Dr. Bhapni that LMWH is a important associate ancillary treatment for the a sick baby so role of anti-inflammatory does like ibuprofenanthalidomide Dr. Imansu halidomide has been tried in two studies now also and previously also it was used as an anti-inflammatory agent it is known to reduce fibrosis in the lungs as well and it will decrease the inflammation in the lung so that's why this role it has been tried in with patient patients who got well-being ARDS so it is definitely can be tried as far as we haven't achieved a definitive treatment so far so two trials are ongoing and maybe that result will become soon and regarding ibuprofenanthalidomide it is not that much recommended and it is not that important anti-inflammatory initially also consul were raised regarding its relation with IST but actually Dr. Imansu trial has been started in the London and in Utah the institute for ibuprofenanthalidomide because initially they said that ibuprofenanthalidomide should not be used then subsequently like this is what is happening with the COVID-19 all the time something is was like initially they said as inhibitor are not indicated now they say that you should give whatever medicine you are giving now they initially said ibuprofenanthalidomide you with hold now they are saying no we are going for trial it may be a like it may reduce the doge of steroid there is a different formulation which is more very friendly using that in that may be a thing mostly I then coming back to role of red miscivair Dr. Imansu yes the role of red miscivair is definitely there in fact USFD has approved it around two weeks back it is given to almost all the patients who are sick who are very sick rather is a five days course and it has the studies have shown over three days back the study were published that it has increased the recovery time by 31 percent meaning thereby instead of the those patients were recovering without remdesire in 15 days after giving red miscivair the other arm they recounted 11 days so that is a significant improvement of four days I mean it you know it saves a lot of money to the patient a lot of money to the government and a lot of improvement at the patient goes home early so it has a definitive role in almost all the cases that's why this drug has been approved in India also it is being given to the patients at covid hospitals at few centers I believe so this is this drug like their drugs which will reduce the viral loop there which will reduce the inflammatory response so this drug where it stands actually well the studies are still on man because other studies which are going around two months back they all show good results that's why in a hurry it has been approved to save the lives it definitely reduces the you know viral load as you said and the inflammatory markers also come down we do not we don't know how but it is beneficial and it has shown the early discharge of the patient and the patients patient becomes they recover fast that's all we know at the moment about this is there any moment to make this drug in India I believe few companies they have got the license from the original I'm forgetting the name of that come to Gillard or something like that ah the Gillard now it's it yeah so because that's probably jubilant he's trying to get it I don't think having some you know collaboration in Bangladesh in Pakistan in India so I think very shortly it will be available in our country cheaper rate it is available it comes in your mind of the Vakuni once any other cheaper alternative drug do you can you think of which is being the promoted nowadays no initially in Jaipur if you remember when the Italian patients came and they gave return of Iran and Lopinavir combination of HIV drug and the doctors they claim that they improve the patient but subsequently it has been proven that they have these anti-HIV drugs they do not have any role so now the other fact is hydroxychloroquine plus azithromycin I think regarding that Dr. Hemachu Bhattara has already told you other drugs ma'am all is not very much recommended of course if you talk about without Tocillizumab anacondra is the other drug which is being given as a IL-1 inhibitor and of course the anti-TNF drug is also infleximab also is being given in few patients who are not recovering either after Tocillizumab or after anacondra so that in cytokines some of the three cytokines which are to be blamed as blamed are IL-6, IL-1 and tumor necrosis factor so infleximab is one of the drug which can be used so the role of anti-HIV drug Dr. Hemachu what is your opinion on that you know the anti-HIV drug actually they are proteas inhibitor and they can reduce a step where the virus replicated coronavirus replicated it replicates by producing the enzyme which is essential to gain entry into the cells also so they can act at least pharmacological if we see that thing but the trials haven't proved this to be that much effective and another drug which we are we can think of with ivermectin actually so ivermectin also also name some studies to reduce the viral application or reduce the number or load in some studies so that is one of the cheaper option and maybe in India we can try on that thing but still we have to do studies for that so Dr. Hemachu we are coming back to your own very a drug which you are very fond of where you taken so many times the name of this drug that is the Tosyledumab so talk about it little more it's a wonderful drug as we have been using it in rheumatoid arthritis especially in GRI I mean it's still disease it's a wonderful drug still disease as it was you know gents in arthritis also tachycho arthritis also it is effective so similarly as I told in cytokine storm the most I mean common IL-6 I mean they found the label in the blood that's why rosin rosin rosin India I think it is being procured by CIPLA but they have to be free to China and they found it very effective and that yeah so it has improved the survival rate 54 percent against 44 percent and if you give Tosyledumab ma'am within 12 to 14 hours the oxygen requirement comes down saturation improves improves the TLC goes up TLC improves rather it comes normal side and the extra just findings of the opacity they also come down and if they don't as I told you we have to repeat the dose because we have to give a chance to the patient is a wonderful drug I'm not that I'm promoting it but the evidence is shows that it has really improved the survival by 54 percent against 44 percent so for a very sick patient it's kind of first-line drug yes yes so what is the herd immunity and what are the amounts herd immunity is seen in many infectious diseases so it is actually when most of the population has having immunity or is already infected with a particular agent so they prevent the spread to other who are not immune or are getting exposed to it first time so for like missiles chicken bog we are already saying this is very much in the understanding so for herd immunity either we need a certain amount of population to be affected or vaccine so vaccine is the best option to create the herd immunity like we have seen in the cases of polio missiles so we are all able to nearly eradicate or reach to the level of elimination because of the herd immunity only if we say 50 70 percent population is already immune so they will prevent other 20 30 percent to catch that infection by breaking the link between the carrier and the animalized person Dr. Smita your microphone is off your microphone so both of you tell me they we keep on saying there are no formation of protective antibodies still we are talking about herd immunity still we are talking about flattening up curve in many places like it Wuhan itself then Italy then Spain even UK is going down now so how it is possible if there's no protective antibodies then how and herd immunity can be generated for COVID-19 yeah the answer is of course complicated map firstly as we told that neutralizing antibodies are not effective that means the herd immunity by the infection itself will not come most likely not I'm not saying will not most likely how the herd immunity will come with will be by after vaccination only if we if the vaccination program is successful and most of the people of the population if it is vaccinated then the herd immunity is possible to save the people who did not have the vaccine and those who had you know vulnerable meaning thereby just by getting that I had COVID infection and I said a 10 out of 10 say if eight of us we had COVID infection and though we can we save those two people no as as on date then neutralizing antibodies have not been found effective however after in if 10 out of 10 people are giving vaccination that means we are you know protected and we are sorry eight out of 10 are given vaccination and out of those 10 two people can be saved because of antibodies which have been produced by vaccination not by the infection that is Dr. Bhakni you are a like you are expert in this field that is what I am asking I am contesting this statement everywhere the reason is why there is flattening of curve without any vaccination in Spain Italy Wuhan everywhere why there is a flattening of curve if the protective antibodies are not forming are there is a chance they are there the answer is ma'am Wuhan China we cannot believe their statement so that is out what about European countries what you told Spain France this thing they had the worst of peak and they started having their SOPs for the treatment number three most important at their lockdown as well as the practices of the population there they listen to their government they do what they have been taught they do all the social distancing they watched and now all those proceeds which we you know hesitate and our population also hesitate you have seen all the migration or we have seen wherever some Russian is being distributed whores of people they go but not in those countries because their population is less financial they financial they are well education wise they are much better than us fourthly their discipline is there in their citizen in our country well I am from the army background we have the discipline but not others pardon me by saying that haven't you seen the U.S. sorry thank you thank you well yes yeah but U.S. we can say that since they do not they have not kept their discipline which they were known for now their numbers you can see they are they are topping the list they are getting the gold medal in the infection because they are not following their discipline while European countries they followed and that's why they are flattening of course maybe because of that man that is my conviction can we start a blanket treatment in token mass because we are getting like many patients we talk to and they say that we are looking at mini ILI influenza like illnesses where it is really difficult to differentiate is it a COVID or it's a influenza itself flu virus so can you tell me shouldn't we start treating them with agitromycin which is a very regular drug for the pediatrics and if by chance they have COVID they may respond so do you think the agitromycin for children or any ILI is a valid option no man I still don't feel in the mild cases they are anyway recover within 2-3 days like most of the virus only when we consider this contrary bacterial infection like lamida or other things also happening if we were getting prolonged we consider agitromycin but as a blanket treatment we can't start giving them okay so you won't prefer to start agitromycin as a blanket when like ILI if you find that there is something which you think that requires agitromycin so you are like those restricted use of agitromycin I'm suggesting so now coming back to I think what are the chances of having coronary artery involvement in children of the M.R.S.U. so in the studies which are published from the UK where they have seen more around 100 cases so they have not 20 to 30 percent have developed coronary changes even those cases which are not fitting in the Kawasaki disease just having fever and raised inflammatory marker they were also showing the echo of the coronary artery direction so that's why they are telling that even if the children having the fever and know the fitting criteria for shock or for Kawasaki they should also be screened regularly by the echo for the finding of the coronary artery changes so around 20 to 30 percent is the rate which J.M.R.S.U. so how often you would recommend or how early you will recommend the echo for a patient M.I.S.U.C. After hospitalization within 24 hours we will prefer the first echo and then depending on the changes we can present subsequent rate good so coming to last question what is the status of vaccine Dr Bhavin yeah last but not the least one of the most important question man if you see that today's newspaper it has in a front way it has come that the Chinese company Sinovac is going to start the phase three trial of its vaccine on 9000 people after two weeks in Brazil because there is the active information active infection going on basically they are using the killed virus vaccine and which has I think there are two arms they gave on zero day and 14 days and in this arm they found neutralizing antibodies in those volunteers in phase two trial after a week or so they will have the results of the second up where they injected the patient with on zero day and on 28th day so they are going to have a phase three trial in Brazil most probably it may take one or two months or three months although it takes usual time it would have taken one to four years similarly a US company known as I think Moderna it is using messenger R&D 1273 and they have also shown neutralizing antibodies in you know volunteers and they are also going for the phase three trial in July in the month of July and 30,000 patients have been enrolled already 9000 by Chinese in Brazil and 30,000 by Americans for the third phase similarly Oxford AstraZeneca is also coming because they have also found neutralizing antibodies they are also going for the phase three trial and Johnson and Johnson also going to recruit 10,000 people for the phase three trial in one sentence if I may say that all the the companies which are there for the vaccine production they have cleared the phase two they are going for phase three trial and they have demonstrated neutralizing antibodies in a good number of volunteers probably we may have a vaccine by early this year or maybe end of this year so my question from both of you tell me any coronavirus where you got a very effective vaccine sorry please repeat the question when the coronavirus any coronavirus where you got a very effective vaccine SARS one no we didn't we didn't we didn't and the other also other like the Ebola and all we didn't get a vaccine the influenza vaccine is even not very effective because you have to just take it so how optimistic you are that COVID-19 vaccine is going to work in this period of gloom this is the period of gloom all over the world not even India or Europe or something so some good news is a very good news even if a little bit good news because it makes the highlight it makes a headline in the newspaper as I was telling you in Hindustan times today I saw I was coming in a hurry I I mean so I saw that news maybe in other newspapers also so anything good anything which can contribute to the treatment or prevention of COVID-19 even in adults or in children will be a good news and I think we should be hopeful we should not lose hope so Dr. Hemanshu what will you do to improve your immunity people say like COVID-19 had a chance on human race because we were falling like we were failing in our dietary part our exercise part and we were not keeping up with our immunity part so our innate immunity we were not doing anything to actually enhance that so now everybody says even Chinese paper have shown that the the antibodies and virus both can coexist even for 40 days and particularly in asymptomatic patients so these are the kind of paper coming up and they say that is your innate immunity is the only thing which will help you that is why they are like talking about the traditional Chinese medicine in their protocol traditional TCM traditional Chinese medicine is the first line of treatment and in few of the trials are going on so what about our trials about the Ayurveda about the Omniopathy the yoga so is there any role of these kind of things healthy diet masala in kitchen is it working for us BCG for you so there are a lot of question about the people are saying that India people are more resistant to COVID-19 people are saying so so tell me about general points what are your opinions both which is in favor of the innate immunity stronger in India children is BCG vaccine because BCG is routinely given in India and we know that the mechanism by which acts as a boost innate immunity or the initial that is first contact with the integer so it is already strong second with the multiple viral infection and vaccines which are used for other viral infection these also enhances our innate immunity to other viruses also to the most of the extent although there are few contradictory reports regarding infant the vaccine but still we are in favor of using infant the vaccine the other is going by that paper and other things which are coming from the mortality data of the US and other countries that races which are more affected are those who like vitamin D or have less sunlight exposure so role of vitamin D is definitely also coming in India that vitamin D definitely can help in boosting immunity so that is one part and other things in allopathy only we can say that vitamin C is in these are all known to enhance our immunity so that is the things we can always advise if anybody wants to use it although balance rate is nothing can take place the role of balance rate actually traditional Kada traditional Kada so I just want to know Dr. Bhagini what is this trained immunity what is about the training of your immune system trained immunity trained immunity like well people say that BCG it trains your immunity because you give multiple vaccinations so children are very adoptive that way and that is why they are fighting with the COVID-19 in a better way what is the training of immune system or immunity I mean what I'm asking yeah does it really work giving BCG and getting better results ma'am firstly all these are anecdotal reports and there is no definitive study going on anywhere in the world where they have except at one place that is acting in Russia they are like seeing whether BCG vaccination really help them or not otherwise just here say or I'll just keep just because we are not having so many tests in our country so we do not know exactly are our children really being safe from COVID-19 or not and BCG of course because everyone is having BCG so it's coming just like that there is no scientific evidence or no scientific paper I could lay my hands on where it says that BCG and other immunization are helpful for protecting our children or children in our country so if I say something you know dogmatically I think I'll be wrong which I don't want to so Sakshi be ready next rapid fire so breast milk does not contain COVID-19 yes express breast milk is preferred with hand hygiene for baby of affected mother must be separated till she is 72 hour to nasal swab is negative and has a no respiration no no so only precautions are needed but as for the WSU definitely prefer in India or in our country if mother is COVID positive new bond must be given immediately but no no no no immediate bath is not required like if mother is COVID positive then I'm asking no you think no I said yes yes we should both okay so children with MISC who have raised cardiac enzyme are more critical yes children with COVID may have myocarditis cardiogenic shock yes yes COVID positive children may have myocardial infarction early yes yes will be answered yes COVID positive children may develop coronary artery aneurysm and may need long-term anti platelet ferricide low molecular weight apparent must not be given to critically ill children with MISC so to summarize today's session thank you very much dr. Amanshu and thank you very much dr. Bhakini so now this is very clear that we have definite involvement of a critical involvement of the children by this COVID-19 it may not be direct infection but it may be a kind of autoimmunity or immune system which actually works against a child just like in the cover circuit disease but this cover circuit disease is not a COVID-19 MIS it is something different from it is more expanded it is more dangerous so definitely one has to be very careful once a family is having COVID-19 infection so children should be kept away the proper social hygiene is important hand washing is very very important way of keeping away few one month back we were thinking that children should be kept at a distance from the older people because they may be a carrier and this is in few of the studies they said they can be even a for a longer time they may have a nasopharyngeal this thing though these this virus may not enter in their lung causing a severe pneumonia as it happens in the adults but it may persist in the nasopharyngeal saw and that's how they remain a probable carrier and they can cause illness in the older people of the family grandparents the parents who are who are diabetic hypertensive and all but now we know that children themselves may have some kind of serious illness and it is very important if they develop some kind of races conduct why it is or something like they are having respiratory difficulty or gastroenteritis and when you know if there is some kind of exposure because it's the Indian government is saying that we are not reached to phase three we are not having community transmission so we must have we have to have a contact for calling it COVID-19 so that is what so we have to be very careful we have to once the baby is in a child's infants are more serious sufferer than the pediatric age group and if they are there then we have to use all our arm or whatever medicine adithromycin can be a good thing preliminary ILI in flanger like illness maybe maybe having some prophylactic there are many things like I was looking at data of hydroxychlorine hydroxychlorine is being approached by so many publications so strongly they are fighting tooth and nail against the hydroxychlorine so in UK and US these are the two places US in unofficially they are using but UK is not using hydroxychlorine at all but the other places if you see Iran if you see Italy if you see China even in China and as early as February they said that hydroxychlorine may be more effective than the than the remits itself so they said so so hydroxychlorine these are the unofficial repurposed drug we call them repurposed drug and we have to use them we have to be very careful where we are using what precaution we are taking ECG if it is required should be taken if ICU care is required should be taken so it is a very very tough time COVID-19 pandemic now this is very clear in June 15th that that children are not immune to a bad effect of COVID-19 so that is so the social distancing as Dr Hockney said Dr Imanchu said that nothing else will work even vaccine may not come up so till then if we are having our hand hygiene we are having the social distancing and we are isolating we are doing quarantine we are not opening up the school for a while till we are in a very stable situation so if we do all those things probably we are going to skip the major major mortality and morbidity due to COVID-19 so anything else you want to convey I think you covered the I mean the activities of the today's webinar very well ma'am I think both of us and all of and you also all three of us has covered almost all the aspects of this disease in this limited particular time I think I must thank you for conducting a very nice so we can leave yes thank you for your questions to me can you see the question answers ma'am if there are some questions no question I'm not getting in my this thing Dr Vikas Taneja question how to ascertain that Kawasaki disease is due to COVID I am not looking at this early that is there ma'am I'll repeat the question Dr Vikas Taneja asking how to ascertain that Kawasaki disease is due to COVID because most of the times COVID RTPCR is negative we also had a case of Kawasaki disease treated with IVIG but its COVID test was negative the answer to it is that Dr Vikas if you are listening that as I told you the COVID exposure is around two to four weeks before the patients you know the children are involved so COVID test may be negative or it may be positive also in there was one study where 60 percent patient they had positive immunoglobulins as well as positive PCR 33 percent patients they have only positive PCR sorry negative PCR but only immunoglobulin is positive and around seven percent patients they are negative for both so meaning thereby if we talk in simple terms it is like reactive arthritis as I told you earlier it is a post infectious complication this common Kawasaki disease like features are the post infectious complication of COVID please depend on the IGG presence if you are having the antibody seropositivity that is what like in rheumatic fever we look for the ASLU title Ajay second question is again Dr Vikas Taneja studies have shown that Tosilism map can reduce the severity of disease in the initial phase but how much impact is had on mortality is still not established what is your opinion on this I think I made myself clear that it has increased the survival rate from 54 percent versus 44 percent so the patient get discharged in 11 days rather than on 15 days and it helps to you know or to come over to come over the cytokine stop so this is definitely a good drug Dr Vikas Taneja another question is double dose of IVIG of second dose close of IVIG they are the same dose of 2g per kg body weight in one day we have to give anonymous are still cases of COVID in association with Kawasaki relation found in India are still you answer initially all here we have reported in the April 2 cases one from the Chennai and one from the Palkhata but these are not actually associated with COVID at that time because of pattern but we are seeing in the from the USA and Europe it is occurring two weeks after the Kawasaki and now in India we are at a peak stage so we can expect this kind of association maybe sometime later we'll be after two three weeks Dr Virkastan is again if antibodies are not protective is there a chance of reinfection of course yes the chances of reinfection will always be there as on date we have not proven that these antibodies bodies are protected next question five-year-old child negative but parent positive what to do five-year-old child COVID negative but parents positive now the if the parents are positive they have to definitely have to take help of some caregiver who can take care of the child if child is negative so far and home isolation if the I'm going to read question rest of questions I have got this huh so have any good word for you I just want to say Dr Bhavani you have inspired me to take up rheumatology and I follow you on Instagram thank you sir most welcome I am really pleased to increase one of the you know in my in our society one more member as rheumatology thanks who's over you are most welcome to join our very fascinating you know super speciality or subspeciality because rheumatology is nothing but a good internal medicine person who knows little bit extra than the others thank you very much for joining us or this is this have you dealt with this question five-year child COVID negative but parents positive what to do no we have to first see the parents whether they have only mild symptom or can be managed at home and regarding care of the child who is still negative we have to just keep on observing him for any symptom and a strict mask with a strict hand hygiene isolation if possible and a separate caregiver if anybody home is also not negative or if you have some arrangement to take care of the child in situation that will be better and regarding testing of the child it needs to be repeated as a protocol which is followed by the government presenting keep within five to 10 days if you have first test is negative we have to see for the symptom any symptom come then we have to give the treatment as well as repeat test otherwise we can repeat the test at time for the child