Covid 2019-pdf

Coronavirus Disease 2019
DR. ABUL KALAM AZAD
FICM,FCPS, MRCP(UK)
INTERNIST & INTENSIVIST

• On December 31 last year, China alerted WHO to several cases of unusual pneumonia in Wuhan, a
port city of 11 million people in the central Hubei province. The virus was unknown.
• Several of those infected worked at the city's Huanan Seafood Wholesale Market, which was shut down on
January 1.
• As health experts worked to identify the virus amid growing alarm, the number of infections exceeded 40.
• On January 5, Chinese officials ruled out the possibility that this was a recurrence of the severe acute
respiratory syndrome (SARS) virus - an illness that originated in China and killed more than 770 people
worldwide in 2002-2003.
• On January 7, officials announced they had identified a new virus, according to the WHO. The novel virus
was named 2019-nCoV and was identified as belonging to the coronavirus family, which includes SARS and
the common cold.

• On January 11, China announced its first death from the virus, a 61-year-old man who had purchased goods
from the seafood market. Treatment did not improve his symptoms after he was admitted to hospital and he
died of heart failure on the evening of January 9.
• On January 13, the WHO reported a case in Thailand, the first outside of China, in a woman who had arrived
from Wuhan.
• On January 16, Japan's health ministry reported a confirmed case in a man who had also visited Wuhan.
• On January 17, as a second death was reported in Wuhan, health authorities in the US announced that three
airports would start screening passengers arriving from the city.
• Authorities in the United States, Nepal, France, Australia, Malaysia, Singapore, South Korea, Vietnam and
Taiwan confirmed cases over the following days

Current Situation: COVID-19
125,048
cases
4,613
deaths
65,893
recovered
10 most affected places Cases Deaths
Mainland China 80778 3158
Italy 10149 631
Iran 8042 291
South Korea 7775 60
Spain 1622 36
France 1606 30
Germany 1296 2
United States 728 29
Diamond Princes 696 7
Japan 568 12

Transmission
• investigation in Wuhan at the beginning of the outbreak identified an
initial association with a seafood market that sold live animals, where
most patients had worked or visited and which was subsequently
closed for disinfection. However, as the outbreak progressed, person-
to-person spread became the main mode of transmission.
• Mainly by respiratory droplets by coughing, sneezing and talks.
• Droplets typically can not travel more than 6 feets ( about 2 metres)
• Not airborne

Virology
• COVID-19 is known as SARS-CoV-2
• It is a betacorona virus like MERS virus
• Binds to ACE2 for cell entry
• 2 different types: Type L(70%) and Type S(30%)

Incubation Period
• 14 days following exposure
• Most cases 4-5 days after exposure
• Typical Evolution:
-Dyspnea: 6 days post-exposure
-Admission: 8 days post-exposure
-ICU/intubation: 10 days post-exposure

Spectrum of illness
overall case fatality: 2.3%
Mild to moderate 81% No or mild pneumonia
Severe 14% Dyspnea, hypoxia,
>50% lung involvement
within 48 hours
Critical 5% Resp. failure, shock, MOF

Comparison of the pathological features of
lung biopsy of SARS-CoV-2
SARS SARS-CoV-2
Similarity Diffuse alveolar damage pattern:
-alveolar epithelia exudative and
proliferative
-Oedema
-Inflammatory Infiltrates
Interstitial fibrosis
- hyaline membranes
Diffuse alveolar damage pattern:
-alveolar epithelia exudative and
proliferative
-Oedema
-Inflammatory Infiltrates
Interstitial fibrosis
- hyaline membranes
Main differences Large amount of “mucus” in
bronchioles and alveoli.

COVID-19 case definition:
• Suspected Case
• A. Acute Respiratory Illness AND a history of travel to area of transmission of
COVID-19 (14 days)
• B. Acute respiratory illness AND contact with a confirmed COVID-19 case (14
days)
• C. Severe Acute Respiratory Illness AND requiring hospitalization AND with no
other etiology that fully explains the clinical presentation.
• Probable Case:
A suspected case with testing for COVID-19 is inconclusive.
• Confirmed Case:
Person with laboratory confirmation of COVID-19 irrespective of signs and
symptoms.

Age distribution
•
Age (years) %
>80 3
30-79 87
20-29 8
10-19 1
<10 1

Specimen Collection for test
• Nasopharyngeal and Oropharyngeal swab
• If intubated: tracheal aspirates
Test Done: RT-PCR
In china: IgM and IgG ( 7-10 days after infection)

Diagnostic studies
• No “Gold standard” test for COVID-19
• Specificity High
• Sensitivity Low
• Sensitivity of RT-PCR : 60-70%
• Single negative RT-PCR does not exclude the disease.
• It should be re-tested after re-sampling and isolation should be
continued.

• Suspected or confirmed cases should be managed in negative pressure
room.
• Strict compliance with hand hygiene and standard precautions.
• Airborne and contact isolation.
• Proper use of PPEs:
-fluid resistant gown
-fit tested N95 respirator
-goggles
- disposable gloves
Airborne precautions for aerosol-generating procedures (tracheal intubation,
NIV, CPR, manual ventilation before intubation, and bronchoscopy.

Clinical Features
• Incubation period: ᷉ 5 days
• Ranges from: 2-14 days
• Frequently signs and symptoms after the illness onset:
• --fever (83-98%)
• --dry cough (76-82%)
• ---myalgia or fatigue (11-44%)
• -- dyspnea
• Chest imaging have shown bilateral involvement in most patients.

Clinical Features Corona Virus Common Cold Flu
Onset Variable Slow to develop Sudden onset
Fatigue Not very frequent (35%) Infrequent Frequent
Cough Very common (usually dry)(77%), 23% had sputum Not severe Very common
Sneezing Less Common Less common
Bodyache Sometimes (11%) Very common Very common
Running Nose Not common (6%), (0% among survivors) Common Sometimes
Sore throat Sometimes Common Sometimes
Headache Sometimes (6%) Less common Sometimes
Dyspnea Sometimes(63%) Not present Not present
Fever Common (98%) Rare common

Comorbidities
Survivors Non-survivors All patients
Chronic Cardiac disease 10% 9% 5%
Chronic pulmonary disease 10% 6% 8%
Cerebrovascular disease 0 22% 13%
Diabetes 10% 22% 17%
Malignancy 0 0 4%
Dementia 0 0 2%%
Smoking 0 0 4%

Characteristics of Critically ill patients
• Male to female ratio: 2:1
• Comorbidities:
-Hypertension, Diabetes
-Not pregnant/lactating mother
• Organ failure:
-Hypoxemic respiratory failure (>90%) -IMV (70%)
-Shock (30%) -Vasopressor (30%)
-Acute Kidney injury ( 10-30%) -RRT (20%)

Lab test
• Lymphopenia is common. Also variable WBC, lypmhocytosis, high ALT
• Many patients had normal pro-calcitonin and CRP. Those needed ICU
support, had high level of pro-calcitonin and CRP.
• Chest X-ray and CT: like viral pneumonia, bilateral involvement. Some
had ground glass opacity.

Spectrum of disease
% OF CASES
MILD SEVERE CRITICAL
NON-PNEUMONIA
MILD PNEUMONIA
(81%)
DYSPNEA, HYPOXIA,
>50% LUNG INVOLVEMENT
(14%)
RESPIRATORY FAILURE ,
SEPTIC SHOCK, MOF
(5%)
CASE FATALITY RATE : 49%
10.5% FOR CARDIVASCULAR DISEASE
7.3 % FOR DIABETES
6.3% FOR CHRONIC RESPIRATORY DISEASE
6.0% HYPERTENSION
5.6% FOR CANCER

GUIDELINE
• Give empiric antibiotics to treat like pathogen of SARI within one hour
of patient assessment for patients with sepsis.
• Do not give systemic corticosteroids for treatment of viral pneumonia
or ARDS unless they are needed for another reason.

Shock
• Shock is present in sepsis in 5% cases.
• This is from superimposed bacterial infection and septic shock.
• Cause of death from COVID-19 is nearly always ARDS- which may be
exacerbated by fluid administration.
• Gentle CVP guided fluid administration could be considered in
hypoperfusion and hypovolemia specially in vomiting and diarrhea.

Cardiomyopathy
• COVID-19 does commonly cause troponin elevations
-7% of patients die of fulminant myocarditis
-33% of death
• Troponin elevations seems to be a strong prognostic indicator for
mortality.

Use of NIV/CPAP
• Selected patients in early stage of acute hypoxemic respiratory failure.
• Avoid in shock, Multi-organ failure or large amount of secretions.
• Patients who do not show early recovery, CPAP may well delay but
not avoid invasive ventilation.

High flow Nasal Cannula
• Systematic Review: HFNC may decrease need for tracheal intubation
and mechanical ventilation.
• In a study with severe RVI with influenza A (H1N1) showed that HFNC
was associated with avoidance of intubation in 45% of cases.
Although almost all patients with higher severity and shock were
eventually intubated.

Cardiovascular management
• Myocardial involvement is not uncommon
• Echocardiographic findings often include right or left ventricular
dysfunction.
• Myocarditis has associated with longer duration of vasoactive agents
and mortality and may sometimes require ECMO or other type of
supportive care.

Registered Clinical Trials
• Antivirals:
-Remdesivir
-Anti-retrovirals: Lopinavir-ritonavir, Darunavir, and Cobicistat,
ASC09/Ritonavir
-Anti-influenza antivirals: Arbidol, Baloxavir, Favipiravir, Azvudine
• Chloroquine phosphate: Hydroxychloroquine
• Recombinant human angiotensin-converting enzyme 2
• Ribavirin

Corticosteroid
• Not any evidence to show improvement:
• Used randomly in china.
• Should be avoided.

Remdesivir
• High priority antiviral by WHO prioritizations list.
• In vitro activity against MERS-CoV, SARS-Cov and Ebola virus.
• Ongoing trials in China for severe and non-severe COVOD-19 and in
USA.

Chloroquine phosphate
• 500 mg chloroquine phosphate contains 300 mg of chloroquine.
• 500mg PO twice daily for 10 days for patients without
contraindications
• May require dose adjustment in renal or hepatic dysfunction.

Lopinavir/ritonavir
• HIV tx, limited side effects.
• Lopinavir/ritonavir has been used for SARS.
• 41 patients with SARS compared with 111 historical records
• Fewer adverse clinical outcome
• lopinavir inhibited replication of MERS-CoV at levels below those that
occur in the circulation after a single oral dose of lopinavir/ritonavir
(400 mg lopinavir with 100 mg ritonavir).

Co-infections
• One small study: Among COVID-19, patients in Qingdao, 80% (24) of
them had IgM antibody against atleast one respiratory pathogen,
compared to 20% in Wuhan.
• 6% of patients with COVID-19 tested for other viruses had other
infections (influenza A, rhinovirus and influenza A (H3N3)

Intubation
• High risk procedure
• Need PPE during intubation.
• Use video laryngoscope for well visualization.
• Avoid bag-mask ventilation. If needed use viral filter to the bag-valve
mask before the procedure.
• Most experienced person should do the procedure.

Prolong NIV associated with high fatality
• Prolong NIV associated with high fatality
• Even with invasive mechanical ventilation.
• Prompt initiation of invasive mechanical ventilation highly
recommended by WHO interim guidance.
-HFNC or NIV should only be used in selected patients
-Should be closely monitored for deterioration.
• Do not try BiPAP.

Clinical criteria of NIV failure
• Refractory hypoxemia
• High tidal volume (>9 ml/kg IBW)
• Overt respiratory distress.

Myocardial injury in patients with COVID-19
• Elevated hypersensitivity troponin I (hscTnI) level:
-above ULN in 50% of patients
-above 5×ULN in 20% patients
-as high as 20000 pg/ml
• Mechanism: ͌stress cardiomyopathy
-not secondary to acute coronary syndrome
-Due to viral virulence to myocardium
• Sequele:
• -Ventricular arrhythmia or cardiogenic shock uncommon.
• -Late cardiovascular collapse usually unresponsive to fluid resuscitation and/or
vasoactive agents.

Infection Prevention and Control and COVID-19
Limit human-to-human transmission
Reduce secondary infections
Prevent transmission through
amplification and super-spreading events

Standard precautions
Hand hygiene (water and soap or alcohol-based solutions)
Use of personal protective equipment (PPE) according to risk
Respiratory hygiene (or cough etiquette)
Safe injection practices
Sterilization / disinfection of medical devices
Environmental cleaning
PAHO. Prevention and Control of Healthcare associated infections – Basic Recommendations”- PAHO, 2017 (adapted)

. . . Our focus will be on the use of personal
protective equipment (PPE) according to the risk

Transmission-based precautions
Contact precaution
Droplet precaution
Airborne precaution

As a reminder, transmission of
COVID-19
as of February 19, 2020 – subject to change as new evidence become available

Transmission-based precautions and
COVID-19
Scenario Precaution
For any suspected or
confirmed case of
COVID-19
Standard + contact + droplet precautions
For any suspected or
confirmed case of
COVID-19 and aerosol-
generating procedure
(AGP)
Standard + contact + airborne precautions
Source: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance

Some questions to consider . . .
Does the patient fulfill
case definition criteria
for the disease?
What is the infectious
agent and its mode of
transmission?
What type of
procedure will the
patient be undergoing?
Is there any risk of
contamination?
Where should the
patient be located?
What type of PPE will
need to be used?

Gloves (sterile / nonsterile)
❑Gloves are an essential item of
PPE and are used to prevent the
healthcare worker from being
exposed to direct contact with
the blood or body fluid of an
infected patient.
❑Gloves DO NOT replace hand
hygiene.
Source: https://apps.who.int/iris/handle/10665/69793

Gowns (and aprons)
❑Gowns are used in addition to
gloves if there is risk of fluids or
blood from the patient splashing
onto the healthcare worker’s
body.
❑The same gown can be used
when providing care to more
than one patient but only those
patients in a cohort area and
only if the gown does not have
direct contact with a patient.
❑Plastic aprons should be used in
addition to gowns if the material
of the gown is not fluid repellent
and the task to be performed
may result in splashes onto the
healthcare worker’s body.

Facial mucosa protection (face shield, eye visor,
goggles)
❑Masks, and eye protection, such
as eyewear and goggles, are also
important pieces of PPE and are
used to protect the eyes, nose
or mouth mucosa of the health-
care worker from any risk of
contact with a patient’s
respiratory secretions or
splashes of blood, body fluids,
secretions or excretions.

Putting on a PPE

Doffing a PPE

Respirator (N95) or medical mask?
“(…) The lack of research on facemasks and
respirators is reflected in varied and
sometimes conflicting policies and guidelines.
Further research should focus on examining
the efficacy of facemasks against specific
infectious threats such as influenza and
tuberculosis, (…)”

Respirator (N95) or medical mask?
“(…) SARS care often necessitated
aerosol-generating procedures [AGP]
such as intubation, which also may
have contributed to the prominent
nosocomial spread. (…)”
Fauci A. et al. JAMA 2020, doi:10.1001/jama.2020.0757
“(…) the factors associated with
transmission of SARS-CoV, ranging from
self-limited animal-to-human
transmission to human superspreader
events, remain poorly understood(…)”

Medical masks (droplet precaution)
❑Wear a medical mask when
within a 1 metre range of the
patient.
❑Put the patient in a single room
or in a room that contains only
other patients with the same
diagnosis, or with similar risk
factors, and ensure that every
patient is separated by at least
one metre.
❑Ensure that the transportation
of a patient to areas outside of
the designated room is kept to a
minimum.
❑Perform hand hygiene
immediately after removing the
medical mask.

Respirator [N95]
(airborne precaution)
❑Use a respirator
whenever entering and
providing care within the
patient isolation facilities
ensuring that the seal of
the respirator is checked
before every use.
❑Perform hand hygiene
immediately after
removing the respirator.
❑Aerosol-generating
procedures (AGP) . . .

Aerosol-generating procedures (AGP)
Aerosol-generating procedures (AGP)
Bronchoscopy
Cardiopulmonary resuscitation
Noninvasive ventilation (BiPAP, CPAP, HFOV)
Surgery
Tracheal intubation
Manual ventilation
Sputum induction
Suctioning
Laser plume
NecropsyNumber of healthcare providers
exposed should be limited
Judson SD et al., Viruses 2019, 11, 940; doi:10.3390/v11100940

Perform a particulate respirator seal check

Requirements and technical specifications, use
of PPE
• Technical guidance
based on WHO
documents
• Expert consultation
• Tailored to the region
needs
https://bit.ly/2HDK2bg

Use of PPE according to level ofcare
(https://bit.ly/2HDK2bg)
Level of care
Hand
hygiene
Gown
Medical
mask
Respirator
(N95 or
FFP2)
Goggle
(eye protection)
OR Face shield
(facial protection)
Gloves
Triage X X
Collection of specimensfor
laboratory diagnosis
X X X X X
Suspected or confirmedcase
of COVID-19 requiring
healthcare facility admission
and NO aerosol-generating
procedure
X X X X X
Suspected or confirmedcase
of COVID-19 requiring
healthcare facility admission
and WITHaerosol-generating
procedure
X X X X X

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