With co-infection cases increasingly being reported by doctors, the Union health ministry has issued guidelines for the management of co-infection of the coronavirus disease (Covid-19) with other seasonal epidemic-prone diseases such as dengue, malaria, seasonal influenza (H1N1), etc.
“Given the seasonal pattern of epidemic-prone diseases observed every year in our country, diseases like dengue, malaria, seasonal influenza, leptospirosis, chikungunya, enteric fever, etc. can not only present a diagnostic dilemma but may co-exist in Covid-19 cases. This poses challenges in the clinical and laboratory diagnosis of Covid-19, and may have a bearing on clinical management and patient outcomes,” a health ministry statement read.
“The scope of this document is to provide clear guidelines on prevention and treatment of co-infections…” the statement further read.
The document is based on the standards set up by international health agencies such as the World Health Organization (WHO), which say that apart from fever, patients could present other symptoms mimicking Covid-19 making the diagnosis difficult.
“This document has been put out largely as a reference material to benefit treating doctors who are dealing with such cases on a daily basis,” said a health ministry official in the know of things.
Approach to diagnosis of suspected co-infection
A high index of suspicion must be maintained for these epidemic-prone diseases prevalent in a particular geographic region during monsoon and post-monsoon seasons. Bacterial co-infections must also be suspected in moderate or severe cases of Covid-19 not responding to treatment.
Confirmation of malaria or dengue infection does not rule out the possibility of the patient not suffering from Covid-19. Similarly, a high index of suspicion of malaria or dengue must be there when a fever is diagnosed as a symptom of Covid-19, particularly during the rainy and post-rainy season.
Both Covid-19 and seasonal influenza present symptoms influenza like illness ((ILI/SARI), hence all ILI and SARI cases in areas reporting Covid-19 cases must be evaluated and tested for both Covid-19 and seasonal influenza.
Chikungunya manifests itself with an acute onset of moderate to high-grade continuous fever and malaise followed by rash, myalgia (muscle pain) and arthralgia (joint pain). Respiratory failure may ensue in late stages. Co-infection with Covid-19 may be suspected in chikungunya-endemic areas during monsoon.
Leptospirosis (rat fever)
Leptospirosis, apart from the symptom of fever, also has a tendency to manifest as acute respiratory illness, leading to respiratory distress and shock. In areas where leptospirosis is known to cause outbreaks during monsoon or post-monsoon, doctors need to keep in mind this co-infection while evaluating a patient.
Scrub typhus is known to be prevalent in the foothills of Himalayas in places such as Jammu & Kashmir, Himachal Pradesh, Sikkim, Manipur, Nagaland, Meghalaya, etc. However, in the recent past, scrub typhus outbreaks have also been reported from Delhi, Haryana, Rajasthan, Maharashtra, Uttarakhand, Chhattisgarh, Tamil Nadu and Kerala. The clinical picture consists of sudden high-grade fever, severe headache, apathy, myalgia and generalised lymphadenopathy (swelling of lymph nodes). The patients may develop complications that include interstitial pneumonia (30% to 65% of cases), meningoencephalitis (brain swelling) and myocarditis (swelling of heart muscles).
Few patients with Covid-19 experience a secondary bacterial infection. In such cases, empiric antibiotic therapy needs to be considered.
“Despite the possibility of above mentioned co-infections, in present times of the pandemic, the approach to diagnosis for Covid-19 essentially remains the same. Testing protocol as per the ministry of health and family welfare and Indian Council of Medical Research guidelines will be followed. However, in addition, further tests for a likely co-infection will also be undertaken, whenever suspected,” the ministry guidelines read.