As more and more cases of coinfection are reported by doctors, the Union Ministry of Health has issued guidelines for the management of coinfection of coronavirus disease (Covid-19) with other seasonal diseases prone to epidemics such as dengue, la malaria, seasonal influenza (H1N1), etc.
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“Given the seasonal pattern of epidemic diseases that are observed each year in our country, diseases such as dengue, malaria, seasonal influenza, leptospirosis, chikungunya, enteric fever, etc. Not only can they present a diagnostic dilemma but they can coexist in Covid-19 cases. This poses challenges in the clinical and laboratory diagnosis of Covid-19, and can influence clinical management and patient outcomes, ”read a statement from the Ministry of Health.
“The scope of this document is to provide clear guidelines on the prevention and treatment of co-infections …,” the statement reads.
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The document is based on the standards established by international health agencies such as the World Health Organization (WHO), which say that in addition to fever, patients could present other symptoms that mimic Covid-19, making diagnosis difficult.
“This document has been published largely as reference material to benefit the doctors who treat these cases on a daily basis,” said a Health Ministry official with knowledge of the matter.
Approach to the diagnosis of suspected coinfection
A high index of suspicion should be maintained for these epidemic-prone diseases that are prevalent in a particular geographic region during the monsoon and post-monsoon seasons. Bacterial coinfections should also be suspected in moderate or severe cases of Covid-19 that do not respond to treatment.
Malaria / Dengue
Confirmation of malaria or dengue infection does not rule out the possibility that the patient does not have Covid-19. Similarly, there should be a high index of suspicion for malaria or dengue when fever is diagnosed as a symptom of Covid-19, particularly during the rainy and post-rainy season.
Seasonal flu
Both Covid-19 and seasonal influenza present symptoms of influenza-like illness ((ILI / SARI), therefore, all ILI and SARI cases in areas reporting Covid-19 cases should be evaluated and analyzed both for Covid-19 as for seasonal influenza.
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Chikungunya
Chikungunya presents with an acute onset of continuous moderate to high-grade fever and general malaise followed by skin rash, myalgia (muscle pain), and arthralgia (joint pain). Respiratory failure can occur in late stages. Co-infection with Covid-19 may be suspected in chikungunya endemic areas during the monsoon.
Leptospirosis (rat fever)
Leptospirosis, in addition to the symptom of fever, also tends to manifest as an acute respiratory illness, leading to respiratory distress and shock. In areas where leptospirosis is known to cause outbreaks during the monsoon or after the monsoon, clinicians should take this co-infection into account when evaluating a patient.
Scrub typhus
Scrub typhus is known to be prevalent in the foothills of the Himalayas in places like Jammu and Kashmir, Himachal Pradesh, Sikkim, Manipur, Nagaland, Meghalaya, etc. However, in the recent past, outbreaks of scrub typhus have also been reported in Delhi. Haryana, Rajasthan, Maharashtra, Uttarakhand, Chhattisgarh, Tamil Nadu, and Kerala. The clinical picture consists of sudden high-grade fever, severe headache, listlessness, myalgia, and generalized lymphadenopathy (swollen lymph nodes). Patients can develop complications including interstitial pneumonia (30% to 65% of cases), meningoencephalitis (inflammation of the brain), and myocarditis (inflammation of the heart muscles).
Bacterial infections
Few Covid-19 patients experience a secondary bacterial infection. In such cases, empirical antibiotic therapy should be considered.
“Despite the possibility of co-infections mentioned above, in the current times of the pandemic, the approach to diagnosing Covid-19 essentially remains the same. The testing protocol will be followed according to the ministry of health and family welfare and the guidelines of the Indian Council of Medical Research. However, in addition, more tests will also be carried out for a possible co-infection, whenever it is suspected ”, read the ministry’s guidelines.
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