Covid 19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new coronavirus that emerged in 2019 and causes coronavirus disease2019(COVID-19).1,2 SARS-CoV-2ishighlycontagious.Itdiffers from other respiratory viruses in that it appears that human-tohuman transmission occurs approximately 2 to 10 days prior to the individual becoming symptomatic.2–4 The virus is transmitted from person to person through respiratory secretions. Large droplets from coughing, sneezing or rhinorrhoea land on surfaces within 2 m of the infected person. SARS-CoV-2 remains viable for at least 24 hours on hard surfaces and up to 8 hours on soft surfaces.5 The virus is transferred to another person through hand contact on a contaminated surface followed by touching the mouth, nose or eyes. Aerosol airborne infected particles created during a sneeze or cough remain viable in the air for3 hours.5 These airborne particles of SARS-CoV2 can then be inhaled by another person or land on the mucosal membranes of the eyes.

1. Coronavirus Disease (COVID-19) DR. NIRAJ KUMAR , PT BPT, MPT (ORTHO), MHA, Ph.D. Physiotherapy (Orthopedics)* Associate Professor Physiotherapy Dept. Shri Guru Rai Institute Of Paramedical Sciences , Dehradun

2. COVID-19 Current outbreak of an infectious disease throughout the world. Outbreak was declared a Public Health Emergency of International Concern on 30 January 2020. WHO has officially named it Coronavirus Disease 2019 (COVID-2019)

3. As on 7th March, 2020 More than 90 countries affected Worst affected: China (>80,000 cases) South Korea: >5,000 cases Italy and Iran: around 3,000 cases More than 1 lakh infected More than 3,000 deaths Travel advisory for China, South Korea, Italy, Iran, and Japan

4. What causes COVID-19? A virus Virus was initially called 2019 novel coronavirus (2019-nCoV) Later renamed by WHO as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) SARS-CoV-2 belongs to a group of viruses called Coronaviruses Corona (Latin=crown)

5. What are the infections caused by Coronaviruses? Respiratory: Common cold, sore throat, pneumonia, etc., Gastro-intestinal: diarrhea Most cause mild disease Severe disease were earlier caused by: SARS- CoV : China (2003) [CFR:9.6%] MERS- CoV : Saudi Arabia (2012) [CFR: 34.4%]

6. Coronaviruses infect both humans and animals

7. How did COVID-19 start? In December, 2019, a cluster of pneumonia cases was reported in a live animal ( even selling wild animals ) market in Wuhan, China However, person to person transmission has resulted in a large number of cases worldwide

8. What is the source? COVID-19 is a zoonotic disease Animal reservoir of COVID-19 are probably bats Intermediate host is probably pangolin Pangolin

9. Why did the virus infect humans? Probably the virus mutated to adapt in humans (host adaptation) OR Increased contact between humans and animals containing the mutated virus

10. What are the important modes of transmission? Primarily through droplets containing virus during coughing, sneezing ( upto 1 meter) [ DROPLET ROUTE ] Also, contact of droplets with eyes, nose, and mouth with contaminated hands/ fomites [ CONTACT ROUTE ]

11. What are the other modes of transmission? Rarely airborne route, but this does not seem an important route Virus is isolated in stool, but feco -oral route does not seem important route Additionally, from/to animals???

12. How long does the virus survive on surfaces? Probably from a few hours upto several days depending on the type of surface (based on data on SARS- CoV ) Probably for 20-30 minutes on hand

13. What is the incubation period? For most cases: 2-14 days Average: 5 days

14. When are the patients infectious? Some in the incubation period may shed the shed the virus, but their impact on the spread is minimal Asymptomatic persons can also shed the virus, but asymptomatic patients are rare Virus shedding is maximum in patients exhibiting severe symptoms Virus shedding may occur after resolution of symptoms

15. How does the virus cause disease? Protein S-spikes of the virus bind to Angiotensin Converting Enzyme-2 (ACE-2) receptors ACE-2 receptors are present in lungs, heart, kidneys, stomach, intestines, and other organs

16. Pathogenesis…cont’d Virus may spread to different organs through blood ( viremia ) Virus multiplies intracellularly and causes cell death by diverting the cell’s protein synthesis apparatus for its own use

17. What are the symptoms? Asymptomatic (rare) Fever (87.9%) Dry cough (67.7%), Fatigue (38.1%), Sputum production (33.4%), Shortness of breath (18.6%), Sore throat (13.9%), Headache (13.6%), Myalgia or arthralgia (14.8%), Chills (11.4%), Nausea or vomiting (5.0%), Nasal congestion (4.8%) , Diarrhea (3.7%), Hemoptysis (0.9%), Conjunctival congestion (0.8%)

18. How does the virus kill? Atypical Pneumonia  Acute Respiratory Distress Syndrome (most common) Kidney failure Cardiac failure Secondary bacterial pneumonia and sepsis

19. What are the specimens used for diagnosis of COVID-19? Nasal or throat swabs, Sputum, Broncho -alveolar lavage , etc.,

20. How is COVID-19 diagnosed? Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) [Sensitivity of upto 70% , but high specificity] No serological test available so far

21. COVID-19 testing centers in India

22. Is there a more sensitive test than RT-PCR? Yes! Chest CT ( Sensitivity of >95%, but less specificity than RT-PCR ) CT findings: Scattered bilateral ground glass opacities  consolidation crazy paving pattern Chest X-ray not so sensitive as CT, but useful in resource poor settings

23. Ground glass opacities in Chest CT

24. How many develop severe disease? Mild to moderate: 80% Severe (requiring admission and oxygen): 14% Critical (requiring ICU admission and life support): 6% Most cases are mild  less reporting disease more widespread than actual figures.

25. What is the case fatality/death rate (CFR)? Death rate=Number of deaths/Number of cases Crude fatality rate: 3.4% <0.4% (< 50 years) to 14.8% (>80 years) Disease in children: relatively rare and mild (CFR:0.2%) Note: This is very early data from China

26. CFR of COVID-19 based on age

27. What is the death rate in different comorbid conditions? Pre-existing condition Death rate of all cases Cardiovascular disease 13.2% Diabetes 9.2% Chronic respiratory disease 8.0% Hypertension 8.4% Cancer 7.6% None 1.4%

28. When can patients be discharged from the hospital? Absence of fever without use of anti- pyretics Absence of any other symptoms like cough Negative test for virus (RT-PCR) from respiratory specimens taken atleast 24 hours apart

29. Is there a specific vaccine or treatment? Not yet! However, vaccines and treatment are in development, and may be available in a few months Some early candidate drugs: Hydroxy Chloroquine , Favipiravir (anti-Influenza), and Remdesivir (anti-Ebola)

30. How are patients managed in the hospital? Only supportive care is given: 1. fluids, 2. oxygen, 3. ventilator, 4. dialysis, 5. inotropes, etc.,

31. How can we prevent the transmission? Avoid close contact with cases Maintain social distancing (> 1 meter) Do frequent (every 30 minutes) hand hygiene (wash/rub), and avoiding touching of eyes, nose, and mouth Avoid gatherings unless absolutely necessary Avoid close contact with animals Cook animal products thoroughly

32. Hand Hygiene Hand Wash (when soiled ) Hand Rub

33. What is Cough Etiquette? During coughing or sneezing, cover the mouth and nose with disposable tissue (inner side of elbows if tissue is not available) and immediately discard the tissue Hand hygiene after coughing or sneezing It should be practiced by everyone, irrespective of having COVID-19 or not

34. Should everyone wear masks? Which are better, face masks or N95 masks? No! Masks are very effective for halting spread of virus from sick patients (not only of COVID-19) Masks are not advised for general population However, masks offer some protection and are advised for health care workers and for close contacts

35. What are N95 masks and HAZMAT suits? N95 masks are more effective than face masks for the exposed, but require training to wear HAZMAT (Hazardous Materials) suit offer best protection to Health Care Workers

36. N95 masks

37. HAZMAT Suits

38. What should I do if I develop respiratory symptoms? If fever, cough, and shortness of breath, contact a doctor The advisory of eliciting a history of travel to countries having the epidemic and close contacts may become less important once declared a pandemic

39. Is it an epidemic or a pandemic? Declared a pandemic on 11 th March, 2020 Goal will now shift from containment of spread to mitigation of effects

40. Flattening the epidemic curve

41. What is the possible outcome of COVID-19? The pandemic may infect the majority of population (60-70%) until herd immunity develops, before dying out Mortality will be seen in a small proportion If a vaccine/treatment becomes available, mortality will be much lower

42. Recommendations regarding Personal protective equipment( PPE) for physiotherapists . It is imperative that physiotherapists understand the measures in place to prevent transmission of COVID-19. Recurrent use of shoe covers is not recommended, as repeated removal is likely to increase the risk of staff contamination.12 PPE must remain in place and be worn correctly for the duration of exposure to potentially contaminated areas. PPE (particularly masks) should not be adjusted during patient care. All personal items should be removed before entering clinical areas and donning PPE. This includes earrings, watches, lanyards, mobile phones, pagers, pens, etc. Stethoscope use should be minimised. If required, use dedicated stethoscopes within isolation areas.

43. Physiotherapy management A irway clearance techniques:- A irway clearance techniques include P ositioning, Active cycle of breathing, Manual and/or ventilator hyperinflation, Percussion and vibrations, positive expiratory pressure therapy (pep) and mechanical insufflation- exsufflation . N on-invasive ventilation and inspiratory positive pressure breathing physiotherapists may use inspiratory positive pressure breathing. non-invasive ventilation may be applied as part of airway clearance strategies in the management of respiratory failure or during exercise.

44. Techniques to facilitate secretion clearance Techniques to facilitate secretion clearance include assisted or stimulated cough manoeuvres and airway suctioning . Other Physiotherapists prescribe exercise and assist patients to mobilise. Physiotherapists also play an integral role in the management of patients with a tracheostomy. COVID-19 poses significant considerations for respiratory physiotherapy interventions due to their aerosol-generating procedures.     Physiotherapy management principles – mobilisation, exercise and rehabilitation interventions Physiotherapists are responsible for providing musculoskeletal, neurological and cardiopulmonary rehabilitation tasks, as outlined below . Range of motion exercises Passive, active-assisted, active or resisted joint range of motion exercises may be performed to maintain or improve joint integrity, range of motion and muscle strength. Mobilisation and rehabilitation Examples of mobilisation and rehabilitation include bed mobility, sitting out of bed, sitting balance, sit to stand, walking, tilt table, standing hoists, upper/lower limb ergometry and exercise programs. Box 4 outlines recommendations for implementing these activities in patients with COVID-19.

45. Summary COVID-19 is a disease with high transmission, but relatively low mortality Spreads by droplet and contact route Patients primarily develop fever and respiratory symptoms Most recover on their own, and few require special care Masks are advised for sick patients and close contacts/care givers only Frequent hand hygiene and cough etiquette should be practised by everyone Close contact with cases, and gatherings should be avoided, especially by the vulnerable population (elderly and with underlying conditions) Vaccines and treatment may be available in a few months

46. THANK YOU