“Our discharge criteria are too broad!” Wuhan University People’s Hospital Respiratory and Critical Care Medicine Deputy Chief Physician and Associate Professor Zhang Chanshan said recently. Recently, Chengdu, Wuhan and Guangdong and other places appeared in the discharge of patients retested positive, including Guangdong 14% of the discharged patients have retested positive phenomenon. 24 February, Zhang Chan in the “Wuhan University People’s Department of Respiratory and Critical Care Medicine II,” WeChat public number, said in an article, “We in the patients ( With the cooperation of the patients (comprising our medical and nursing staff), we delayed the discharge of a total of 18 patients who met the discharge criteria of the national guidelines, and continued to review the nucleic acid of the throat swabs for a total of five times, and found that 13 patients had positive results for the third time. 5 patients continued to have negative results of the nucleic acid test for five times, and were then discharged. The specimens were collected by the patients themselves, to avoid false negative results caused by different personnel collection on a daily basis. 5 consecutive negative patients also collected their own specimens in the past appeared positive, so there is no false negative due to manipulation of sampling and other reasons.” Wuhan doctors recommend 3 negative nucleic acid tests before discharge According to the New Coronavirus Pneumonia Diagnostic and Treatment Program (Trial Sixth Edition) issued by the National Health Commission, there are 4 criteria for lifting isolation and discharge from the hospital, the 4th of which is: two consecutive respiratory specimens with negative nucleic acid tests (with at least 1 day interval between sampling times). However, nowadays, many patients have positive nucleic acid tests 2 weeks after discharge. In this regard, Mr. Zhang pointed out that since these patients have already produced a high level of IgG antibody to the new coronavirus, the possibility of re-infection is small. In order to solve this problem, Mr. Zhang believes that Article 4 of the criteria for release from isolation and discharge in the treatment plan should be revised to read, “Nucleic acid test of respiratory specimens is negative for 3 consecutive times.” As early as January 31, Zhang Qian published an article saying that she found that in clinical practice, patients who met the criteria for lifting isolation in the national diagnosis and treatment program were discharged from the hospital about 8 days after their family members became ill. The family members were not exposed to anyone else during the patient’s home quarantine. Meanwhile, after the first diagnosed healthcare worker at the WU People’s Hospital was discharged and returned to work, he was tested again for viral nucleic acid, and the results were still positive. After learning about the situation, Zhang Qian immediately reported to the hospital command. The hospital listened to the opinions of frontline doctors, such as Zhang Qian, and requested the infected medical staff to continue to be isolated for 2 weeks after 2 negative throat swabs, and to be retested for viral nucleic acid before returning to work, and the results were negative before returning to work. To continue to study this issue, Chang Chun performed multiple viral nucleic acid tests on 44 healthcare workers with two negative results for new cases of coronary artery disease, including the aforementioned 18 individuals. Of those 44, about 26 had a third positive nucleic acid result, a very high probability. “The current data show that five patients who had three negative nucleic acid tests had five consecutive negative tests. That is, if all three tests are negative, it is essentially certain that there will be no more positives. In terms of probability, the probability that a patient will test positive again after three negative tests is greatly reduced. What is certain is that the discharge criteria in the current diagnostic and treatment program are too loose, and there are many cases of positivity after two negatives.” Accordingly, Zhang Chan suggested that patients who have been discharged from the hospital should go back to the hospital for a viral nucleic acid test after two weeks of isolation at an isolation site, and then be retested again four weeks after being discharged from the hospital. Zhang Chan explained that there may be two reasons for this situation. On the one hand, it could be a problem with the kit, i.e. the test result before discharge was false negative. The other, more likely reason has to do with the viral replication cycle. As the patient gets better, the viral load drops and intermittent detoxification occurs, so this may result in a negative result during the intermittent period and a positive result at the time of detoxification. Shanghai need to measure anal swabs Zhang Channan told reporters that Jiangsu, Zhejiang, Shanghai and Guangdong are currently practicing discharge criteria more stringent than the current “diagnosis and treatment program” of the release of isolation standards. Professor Lu Hongzhou, party secretary of the Shanghai Public Health Clinical Center, told China News Weekly that when patients in Shanghai are discharged from the hospital, they not only have to meet the criteria of obvious absorption of exudative lesions in the lungs, improvement of clinical symptoms and negative nucleic acid test of the virus in the throat swabs, but also require that patients discharged from the hospital be negative for nucleic acid in the anal swabs (fecal matter). He said that because Shanghai’s discharge standards are more stringent than the “Diagnostic and Treatment Program”, so far, there has not been a single case of positive nucleic acid in patients discharged from the hospital in Shanghai. Lu Hongzhou also pointed out that, at present, Shanghai will be “treatment program” in the second week, the fourth week of discharged patients to the hospital follow-up, re-examination of the recommendations, to the first week after discharge, the third week for review. He explained, “If the patient is discharged with a re-positive, then we can detect it in time in the first week. Although so far there is no conclusive evidence on whether a patient who is re-positive after discharge is contagious, if a patient who is re-positive is still contagious, it may lead to more infections, so why do we have to wait until the second week to review? For a new infectious disease, we would rather be more strict. Instead of having the patient recheck in two weeks, it’s a little more reassuring to have the patient come back for a recheck in the first week.” As a member of the Infectious Disease Group of the National Expert Group on Medical Treatment of New Crown Pneumonia, Lu Hongzhou said, “I believe that the seventh edition of the Diagnostic and Treatment Program will definitely take into account the issue about positive anal swab (fecal) nucleic acid. As we continue to recognize the emerging diseases and the basis of evidence-based medicine increases, the Diagnostic and Treatment Program will be more practical and scientific from one edition to the next. In response to this question, Zhao Jianping, director of the Department of Respiratory and Critical Care Medicine at Wuhan Tongji Hospital, said, “This is a new virus, and at that time, when we formulated the diagnostic and treatment criteria, we drew on the discharge criteria for some other viruses. But this virus may be more cunning than the viruses we recognized before, so removal may not be as easy as we expected. Situations such as two negatives and one positive, three negatives and one positive indicate that the virus has not been cleared, the two previous negatives are not true negatives, they are false negatives, and the throat swabs of the upper respiratory tract may not reflect the actual condition of the virus.” On February 25, at a press conference in Guangdong Province, Song Tie, deputy director of the province’s CDC, explained, “Pneumonia is a disease with a long delay, and it is possible that some two or three months before recovery. We observe that a similar situation may occur with new crown pneumonia. From the current point of view, a large part of the inflammation in the lungs is in the process of absorption, it can’t be said that it has completely reached clinical healing, and there may also be intermittent presence of detoxification.” Zhao Jianping told China News Weekly, “False negatives may be affected by factors such as the sampling staff’s technique and the intermittent detoxification of the disease itself. Wuhan currently requires discharged patients to go to an isolation site for two weeks in order to avoid the possible risk of contagion caused by a very small number of patients who return to positive during the recovery process. The more nucleic acid tests you have the more insurance you have, but you also need to consider the feasibility.” Source: Newsweek China