Covid19 corona virus

Etiology, Clinical features and Management of COVID-19 Corona Virus

1. Etiology, Clinical features & Management of COVID-19 Dr.S.Sesha Sai Assistant Professor Dept. of Pulmonary Medicine East Point College of Medical Sciences

2. WHO Situation Report as of 4/3/2020

3. Definitions Coronavirus disease 2019 (COVID-19) is a severe acute respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2/previously called as 2019-nCoV) The virus was identified as the cause of an outbreak of pneumonia of unknown cause in Wuhan City, Hubei Province, China, in December 2019

4. Etiology

5. Etiology Animal reservoir and intermediary host(s) - unknown Recombinant virus between the bat coronavirus and an origin-unknown coronavirus Person-to-person spread has been confirmed in community and healthcare settings in China and other countries. Perinatal transmission or transmission via breastfeeding – Possible but unlikely (based on data from SARS,MERS outbreaks) No evidence for intrauterine infection caused by vertical transmission in women who develop the infection late in pregnancy.

6. Risk Factors Diagnosis should be suspected in patients with fever and/or signs/symptoms of lower respiratory illness (e.g., cough, dyspnea) who reside in, or have traveled to a country/area or territory reporting local transmission of COVID-19 in the 14 days prior to symptom onset Close contact with infected individual

7. History & Clinical Features Travel history is key. Illness Mild 80% Severe 14% Critical 5% Severe in Older age and Underlying Co morbidities Incubation period varies from 2-14 days(New reports suggesting more than 20 days) Most cases deteriorates in 2 nd week of illness

8. History & Clinical Features Fever (83% to 98%) – Children may not present with fever Cough (59% to 82%) – Usually dry Dyspnea (31% to 55%) – Symptom onset to dyspnea takes 5-8 days (2 nd week of illness) GI Symptoms – Nausea, Vomiting, Diarrhea Common Fatigue(44-69%), Myalgia(11-44%), Anorexia(40%), Sputum Production(26-28%), Sore throat(5-17%) Bronchial breath sounds, Tachypnea , Tachycardia, Cyanosis, Crepitations in acute respiratory disease Uncommon Confusion, Dizziness, Headache, Hemoptysis, Rhinorrhea , Chest pain

9. Diagnostic Criteria A Patients with acute respiratory illness (i.e., fever and at least one sign/symptom of respiratory disease such as cough or shortness of breath) AND with no other etiology that fully explains the clinical presentation AND a history of travel to or residence in a country/area or territory reporting local transmission of COVID-19 disease during the 14 days prior to symptom onset B Patients with any acute respiratory illness AND having been in contact with a confirmed or probable COVID-19 case in the last 14 days prior to onset of symptoms C Patients with severe acute respiratory infection (i.e., fever and at least one sign/symptom of respiratory disease such as cough or shortness of breath) AND requiring hospitalization AND with no other etiology that fully explains the clinical presentation

10. Diagnostic Tests Test Result Pulse Oximetry Low saturation ABG Low pO2 CBC Leukopenia,lymphopenia,thrombocytopenia Coagulation Profile Elevated D-dimer, Prolonged PT Metabolic panel Elevated liver enzymes, decreased albumin, renal impairment Procalcitonin, CRP, LDH, Creatine kinase, Troponin Elevated Blood and Sputum Cultures Negative for bacteria RT-PCR (upper and lower resp tract specimens, blood, urine, stool) + ve for SARS-CoV-2 viral RNA Chest X-ray U/L(25%) or B/L(75%) lung infiltrates CT Chest Primary imaging modality in China. Bilateral ground glass opacity or consolidation. Cavity, nodules, pleural effusions, lymphadenopathy were absent

11. Management No specific treatments are known to be effective for COVID-19 Mainstay of management is optimized supportive care to relieve symptoms and to support organ function in more severe illness. Isolation Infection prevention and control procedures. Reporting

12. Management With Pneumonia/ Comorbities 23-32% require ICU Supportive therapy – O2, Fluids, Symptom relief, Antimicrobials Monitor for clinical deterioration such as respiratory failure, sepsis Mechanical ventilation for Hypoxemic respiratory failure and ARDS Low tidal volume(4-8ml/kg PBW) and lower plateau pressures(<30cm H2o), Prone ventilation Use of in-line suction catheters for suctioning Corticosteroids – found to be ineffective

13. Management Without Pneumonia or Comorbidities Home care can be considered on case-by-case basis. Mild symptoms, No warning signs, No comorbids .

14. Specific Anti Virals Remdesivir was considered the most promising candidate based on the broad antiviral spectrum, the in vitro and in-vivo data available for its use against coronaviruses and the extensive clinical safety database. Among the repurposed drugs, the investigation of the antiretroviral medicine (HIV protease inhibitors), lopinavir/ritonavir, either alone or in combination with IFNbeta1b, was considered a suitable second option for rapid implementation in clinical trials.

15. Complications ARDS Acute Cardiac injury Arrythmias Secondary infection Acute Resp failure AKI Septic Shock DIC

16. SARS-CoV-2 Prevention 16

17. Regularly and thoroughly clean your hands with an alcohol-based hand rub or wash them with soap and water. 17

18. Make sure you, and the people around you, follow good respiratory hygiene. 18

19. Maintain at least 1 meter (3 feet) distance between yourself and anyone who is coughing or sneezing. 19

20. Avoid touching eyes, nose and mouth without washing hands 20

21. Use Mask and personal protective equipment 21

22. Stay home if you feel unwell. If you have a fever, cough and difficulty breathing, seek medical attention . 22

23. Prevention

24. Vaccine No vaccine available. Vaccines are in development, but it may take up to 12 months before a vaccine is available. An mRNA vaccine (mRNA-1273) has been shipped to the National Institute of Allergy and Infectious Diseases for phase I clinical trials in the US, with an estimated start date of 6 March 2020.

25. Prognosis The natural course of infection and prognosis are unknown at this time. Based on a large case series of patients in China (72,314 reported cases from 31 December 2019 to 11 February 2020), the overall case fatality rate is 2.3% . The majority of deaths have been in patients aged 60 years and older and/or those who have pre-existing underlying health conditions (e.g., hypertension, diabetes, cardiovascular disease). Highest among critical cases (49%). Higher in patients aged 80 years and older (15%) males (2.8% versus 1.7% for females) with comorbidities (10.5% for cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory disease, 6% for hypertension, and 5.6% for cancer).

26. References Guidelines on Clinical management of severe acute respiratory illness (SARI) in suspect/confirmed novel coronavirus ( nCoV ) cases. MOHFW, India. BMJ Best Practice COVID-19, 2 nd March,2020 Clinical management of severe acute respiratory infection when novel coronavirus ( nCoV ) infection is suspected, WHO, Jan 2020 Home care for patients with suspected novel coronavirus ( nCoV ) infection presenting with mild symptoms and management of contacts, WHO, Feb 2020