Covid 19 Dr. MADHUKIRAN, MD.PULMONOLOGY

COVID 19
Dr. V. M. KIRAN. OGIRALA
MD. PULMONOLOGY

• Coronaviruses (CoV) are a large family of viruses that cause a
wide range of illness from the common cold to more severe
diseases i.e., Middle East Respiratory Syndrome [MERS] and
Severe Acute Respiratory Syndrome [SARS].
• A novel coronavirus (nCoV) is a new strain that has not been
previously identified in humans.
• On 31 December 2019, the WHO China Country Office was
informed of pneumonia cases of unknown cause in Wuhan City,
Hubei Province of China. A novel coronavirus (COVID19) was
isolated and identified as the causative virus by Chinese authorities
on 7 January.

 Nearly 80,000 cases and approximately 2800 deaths have been
reported in China (as of 1 March2020). The majority of cases
are in Hubei Province.
 Cases outside of China
At least 7000 cases and 104 deaths have been reported in
the following 58 countries outside of China (as of 1 March 2020)

 Incubation period - 1-12.5 days (median 5-6 days). Estimates
will be refined as more data become available.
 More information needed to determine whether transmission can
occur from asymptomatic individuals or during the incubation
period.
 Modes of transmission: droplets sprayed by affected individuals,
contact with patient respiratory secretions, contaminated
surfaces, fomites and equipment.
 Airborne spread is NOT documented so far.

Symptoms
 Early Stage: Fever (>38C) AND Respiratory symptoms: Cough,
Shortness of breath, Runny nose, Weakness, Malaise,
Nausea/vomiting, Diarrhea, Headache
 Advanced Stage: All of the earlier symptoms plus Pneumonia,
Bronchitis
 The people most at risk of infection are those who are in close
contact with a COVID-19 patient or who care for COVID- 19
patients

Primary prevention
General prevention measures:
The only way to prevent infection is to avoid exposure to the virus and people should be
advised to:
 Wash hands often with soap and water or an alcohol-based hand sanitiser and avoid
touching the eyes, nose, and mouth with unwashed hands
 Avoid close contact with people (i.e., maintain a distance of at least 1 metre [3 feet]),
particularly those who have a fever or are coughing or sneezing.
 Practice respiratory hygiene (i.e., cover mouth and nose when coughing or sneezing,
discard tissue immediately in a closed bin, and wash hands)
 Seek medical care early if they have a fever, cough, and difficulty breathing, and share
their previous travel and contact history with their healthcare provider
 Avoid direct unprotected contact with live animals and surfaces in contact with live
animals when visiting live markets in affected areas
 Avoid the consumption of raw or undercooked animal products, and handle raw meat,
milk, or animal organs with care as per usual good food safety practices.

Medical masks
 The World Health Organization (WHO) does not recommend that
people wear a medical mask in community settings if they do not have
respiratory symptoms as there is no evidence available on its
usefulness to protect people who are not ill.
 However, masks may be worn in some countries according to local
cultural habits. Individuals with fever and/or respiratory symptoms are
advised to wear a mask, particularly in endemic areas.
 It is mandatory to wear a medical mask in public in certain areas of
China, and local guidance should be consulted for more information.

Screening and quarantine
 People travelling from areas with a high risk of infection may be screened using
questionnaires about their travel, contact with ill persons, symptoms of infection, and/or
measurement of their temperature.
 Combined screening of airline passengers on exit from an affected area and on arrival
elsewhere has been relatively ineffective when used for other infections such as Ebola
virus infection, and has been modelled to miss up to 50% of cases of COVID-19,
particularly those with no symptoms during an incubation period, which may exceed 10
days.
 Symptom-based screening processes have been reported to be ineffective in detecting
SARS-CoV-2 infection in a small number of patients who were later found to have
evidence of SARS-CoV-2 in a throat swab.
 Enforced quarantine has been used in some countries to isolate easily identifiable
cohorts of people at potential risk of recent exposure (e.g., groups evacuated by
aeroplane from affected areas, or groups on cruise ships with infected people on board).
The psychosocial effects of enforced quarantine may have long-lasting repercussions.

Screening
 Management of contacts
People who may have been exposed to individuals with suspected COVID-19 (including
healthcare workers) should be advised to monitor their health for 14 days from the last day
of possible contact, and seek immediate medical attention if they develop any symptoms,
particularly fever, respiratory symptoms such as coughing or shortness of breath, or
diarrhoea. Some people may be put into voluntary or compulsory quarantine depending on
the guidance from local health authorities.
 Screening of travellers
Exit and entry screening may be recommended in some countries, particulary when
repatriating nationals from affected areas. Travellers returning from affected areas should
self-monitor for symptoms for 14 days and follow local protocols of the receiving country.
Some countries may require returning travellers to enter quarantine. Travellers who
develop symptoms are advised to contact their local health care provider,preferably by
phone.

Secondary prevention
 Early recognition of new cases is the cornerstone of prevention of
transmission. Immediately isolate all suspected and confirmed cases
and implement recommended infection prevention and control
procedures according to local protocols, including standard
precautions at all times, and contact, droplet, and airborne
precautions while the patient is symptomatic.
 Report all suspected and confirmed cases to your local health
authorities.

 Additional precautions are required by healthcare workers to
protect themselves and prevent transmissions in the
healthcare setting.
 Precautions to be implemented by healthcare workers caring
for patients with COVID-19 disease include using personal
protective equipment (PPE) appropriately; this involves
selecting the proper PPE and being trained in how to put on,
remove and dispose of it.
 PPE includes gloves, medical masks, goggles or a face
shield, and gowns, as well as for specific procedures,
respirators (i.e., N95 masks) and apron.

Note:
Patients presenting with URTI symptoms should be
advised to self-quarantine for 14 days and seek
medical advice only if they develop any signs of
severity.
Isolation and testing facilities are available in
Government hospital, Vijayawada can be utilised.

When to suspect
Any patient with acute respiratory illness with:
1. A history of travel to or residence in China in the 14 days prior to
symptom onset, or
2. Close contact with a confirmed/ suspected case of 2019-nCoV in the
14 days prior to symptom onset, or
3. Healthcare worker taking care of confirmed/ suspected patients of
2019-nCoV

Case Definition of 2019-nCoV
Suspected case
Patients with acute respiratory infection (sudden onset of at least one of the following:
cough, sore throat, shortness of breath) requiring hospitalisation or not
AND
In the 14 days prior to onset of symptoms, met at least one of the following
epidemiological criteria:
 Were in close contact with a confirmed or probable case of 2019-nCoV infection;
OR
 Had a history of travel to areas of China with ongoing community transmission of
2019-nCoV;
OR
 Worked in or attended a health care facility where patients with 2019-nCoV
infections were being treated.

Close contact
Close contact is defined as:
 Healthcare associated exposure, visiting patients or staying in the same
close environment as a nCoV patient.
 Working together in close proximity or living in the same household with
a nCoV patient.
 Travelling together with a nCoV patient in any kind of conveyance
The epidemiological link may have occurred within a 14‐day period before
or after the onset of illness in the case under consideration.

Probable case
 A suspected case for whom testing for 2019- nCoV is
inconclusive (the result of the test reported by the
laboratory) or for whom testing was positive on a pan-
coronavirus assay.
Confirmed case
 A person with laboratory confirmation of 2019-nCoV
infection, irrespective of clinical signs and symptoms

Clinical Features
The clinical and radiological manifestations of 2019-nCoV
include:
 Fever (83%)
 Cough (82%)
 Shortness of breath (31%)
 Sore throat (5%)
 Rhinorrhoea (4%)
 Diarrhea (2%)
 Bilateral pneumonia on imaging (75%)
 ARDS (10-17% of admitted patients)

Laboratory Diagnosis
Whom to test:
a) For persons with travel history to the Wuhan province in China after
15th January 2020, respiratory samples (nasopharyngeal swab,
oropharyngeal swab) and blood samples should be collected for all
persons whether symptomatic or asymptomatic
b) For travel history to rest of China, respiratory and blood samples will
be collected only from symptomatic cases
*All suspected cases to be mandatorily reported to the District &
State Surveillance Officers

IPC strategies to prevent or limit infection transmission in health-care
settings include the following:
1. Standard Precautions
1.1 Hand hygiene
1.2 Respiratory hygiene
1.3 Personal protective equipment (PPE)
2. Additional Precautions
3. Bio Medical waste management
4. Laundry management
5. Sample collection, storage and transportation
6. Monitor health of HCWs providing care to cases of 2019-
nCoV Acute Respiratory Disease
7. Hospital Disinfection (Environmental

Respiratory Hygiene
 Offer a medical/surgical mask for suspected 2019-
nCoV acute respiratory disease case for those who can
tolerate it.
Cover nose and mouth during coughing or sneezing
with tissue or flexed elbow for others.
Perform hand hygiene after contact with respiratory
secretions.

Personal Protective Equipment (PPE)
PPE includes shoe cover, gown, mask, eye
protection & gloves.
 Shoe cover should always be worn before entering
the patient care area (Isolation ward etc.).
If gowns are not fluid resistant, use a waterproof
apron for procedures with expected high fluid
volumes that might penetrate the gown.

Additional precautions
 Cohort HCWs to exclusively care for cases to reduce the risk of spreading transmission.
 Place patient beds at least 1m apart;
 Perform procedures in an adequately ventilated room; i.e. at least natural ventilation with at least 160
l/s/patient air flow or negative pressure rooms with at least 12 air changes per hour (ACH) and
controlled direction of air flow when using mechanical ventilation
 Limit the number of persons present in the room to the absolute minimum required for the patient’s
care and support.
 Use either single use disposable equipment or dedicated equipment (e.g. stethoscopes, blood pressure
cuffs and thermometers). If equipment needs to be shared among patients, clean and disinfect between
each patient use (e.g. ethyl alcohol 70%);
 Refrain from touching eyes, nose or mouth with potentially contaminated hands;
 Some aerosol generating procedures have been associated with increased risk of transmission of
coronaviruses such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary
resuscitation, manual ventilation before intubation and bronchoscopy. Ensure that HCWs performing
aerosol-generating procedures use PPE with particulate respirator at least as protective as a NIOSH-
certified N95, EU FFP2 or equivalent. When putting on a disposable particulate respirator, always
perform the seal-check. Note that if the wearer has facial hear (beard) this can prevent a proper
respirator fit.

 Avoid the movement and transport of patients out of the room or area unless medically necessary.
 Use designated portable X-ray equipment and/or other important diagnostic equipment.
 If transport is required, use pre-determined transport routes to minimize exposures to staff, other
patients and visitors and apply medical mask to patient;
 Ensure that HCWs who are transporting patients wear appropriate PPE as described in this section and
perform hand hygiene;
 Notify the receiving area of necessary precautions as soon as possible before the patient’s arrival;
 Routinely clean and disinfect patient-contact surfaces;
 Limit the number of HCWs, family members and visitors in contact with a patient with suspected 2019
nCoV- Acute Respiratory Disease;
 Maintain a record of all persons entering the patient’s room including all staff and visitors.
 Duration of contact and droplet precautions for 2019 nCoV- Acute Respiratory Disease Standard
precautions should always be applied at all times. Additional contact and droplet precautions should
continue until the patient is asymptomatic.

Bio Medical Waste Management from suspected case of nCoV
 All articles like swab, syringes, IV set, PPE etc are to be
discarded in yellow bag.
 All sharps like needle etc are to be collected in puncture proof
container which should be discarded in yellow bag.
Laundry
 All soiled clothing bedding and linen should be gathered
without creating much motion / fluffing.
 Do not shake sheets when removing them from the bed.
 Always perform hand hygiene after handling soiled laundry
items.
 Laundry should be disinfected in freshly prepared 1% bleach
and then transported to laundry in tightly sealed and labeled
plastic bag.

Sample collection, storage and
transportation
 Collection and handling of laboratory specimens from patients with suspected
2019 nCoV- Acute Respiratory Disease. All specimens collected for laboratory
investigations should be regarded as potentially infectious, and HCWs who
collect, or transport clinical specimens should adhere rigorously to Standard
Precautions to minimize the possibility of exposure to pathogens.
 Ensure that HCWs who collect specimens use appropriate PPE (eye protection,
medical mask, long-sleeved gown, gloves).
 If the specimen is collected under aerosol generating procedure, personnel
should wear a particulate respirator at least as protective as a NIOSH-certified
N95, EU FFP2 or equivalent
 Ensure that all personnel who transport specimens are trained in safe handling
practices and spill decontamination procedures (As per Hospital Policy).

Samples to be collected:
 Nasopharyngeal swab / Nasal Swabs – 2
 Throat Swab
 Before collecting the samples, it requires to be ensured that neck is in extended position. Nasopharyngeal swab will
be collected with the per nasal swab provided in the kit, after taking out the swab it is passed along the floor of nasal
cavity and left there for about five second and transferred into VTM and transported to the designated lab at 4
degree Celsius as soon as possible (same day).
 For collection of samples from throat area the other sterilized swab is swabbed over the tonsillar area and posterior
pharyngeal wall and finally transferred into VTM and stored and transported to the designated lab at 4 degree
Celsius as soon as possible (same day).
 Other respiratory material like endotracheal aspirated / broncheo-alveolar lavage in patients with more severe
respiratory disease can also be collected and transported in the same way.
 Place specimens for transport in leak-proof specimen bags /Zip lock pouch (secondary container) with the patient’s
label on the specimen container (primary container), and a clearly written laboratory request form.
 Ensure that health-care facility laboratories adhere to appropriate biosafety practices and transport requirements
according to the type of organism being handled.
 Deliver all specimens by hand whenever possible.
 Document patients full name, age / date of birth of suspected 2019-nCoV case of potential concern clearly on the
accompanying laboratory request form.
 Notify the laboratory as soon as possible that the specimen is being transported.

Monitor health of HCWs providing care to cases of
2019-nCoV Acute Respiratory Disease
 HCWs and housekeeping staff providing care to cases of 2019-
nCoV acute respiratory diseases cases shall be monitored daily for
development of any symptoms as per the suspect case definition
including charting of their temperature twice daily for 14 days after
last exposure.
 If they develop any symptoms then standard protocol laid down
for management of suspect case of 2019-nCoV acute respiratory
disease shall be followed

Hospital Disinfection (Environmental)
 Environmental surfaces or objects contaminated with blood, other body fluids, secretions or excretions should be
cleaned and disinfected using standard hospital detergents/disinfectants
e.g. freshly prepared 1%Sodium Hypochlorite or5% Lysol. Spray the surface with 0.5% to 1% solution of Sodium
Hypochlorite.
 The contact period of the chemical with the surface should be min. of 30 Minutes.
 Disinfect all external surfaces of specimen containers thoroughly (using an effective disinfectant) prior to
transport.
 Environmental surfaces or objects contaminated with blood, other body fluids, secretions or excretions should be
cleaned and disinfected using standard hospital detergents/disinfectants
 Do not spray (i.e. fog) occupied or unoccupied clinical areas with disinfectant. This is a potentially dangerous
practice that has no proven disease control benefit.
 Wear gloves, gown, mask and closed shoes (e.g. boots) when cleaning the environment and handling infectious
waste. Cleaning heavily soiled surfaces (e.g. soiled with vomit or blood) increases the risk of splashes. On these
occasions, facial protection should be worn in addition to gloves, gown and closed, resistant shoes. Wear gloves,
gown, closed shoes and goggles/facial protection, when handling liquid infectious waste (e.g. any secretion or
excretion with visible blood even if it originated from a normally sterile body cavity). Avoid splashing when
disposing of liquid infectious waste.
 Clean and disinfect mattress impermeable covers.
 Non-critical instruments /equipment (that are those in contact with intact skin and no contact with mucous
membrane) require only intermediate or low level disinfection before and after use.

LIQUID SPILL MANAGEMENT:
 Promptly clean and decontaminate spills of blood and other potentially infectious
materials.
 Wear protective gloves.
 Using a pair of forceps and gloves, carefully retrieve broken glass and sharps if any, and
use a large amount of folded absorbent paper to collect small glass splinters. Place the
broken items into the puncture proof sharps container.
 Cover spills of infected or potentially infected material on the floor with paper towel/
blotting paper/newspaper. Pour 0.5%freshly prepared sodium hypochlorite.
 Leave for 30 minutes for contact
 Place all soiled absorbent material and contaminated swabs into a designated waste
container.
 Then clean the area with gauze or mop with water and detergent with gloved hands

Case Management
 The management will need to be individualized as patient may present
with a wide spectrum of illness ranging from uncomplicated illness, mild
pneumonia, severe pneumonia, ARDS, sepsis and septic shock.
General supportive measures (as per our existing protocols for SARI)
● Oxygen supplementation
● Conservative fluid management if there is no evidence of shock
● Give empiric antimicrobials to treat all likely pathogens causing SARI.
Give antimicrobials within one hour of initial patient assessment for patients
with sepsis
● Ventilator management as required
● Systemic corticosteroids are not recommended, unless indicated for other
reasons
*Close monitoring for worsening clinical status is of paramount
importance (designated team)

Antivirals:
● Lopinavir/Ritonavir to be considered in:
 Laboratory confirmation of 2019-nCoV infection by RT-PCR from
recommended sample
 Symptomatic patients with any one of the following:
 Hypoxia as defined as requirement of supplemental oxygen to maintain
oxygen saturation > 90%
 Hypotension as defined as systolic blood pressure <90 mm Hg or need
for vasopressor / inotropic medication
 New onset organ dysfunction (one or more)
● Increase in creatinine by 50 % from baseline, GFR
reduction by >25 % from baseline or urine output of <0.5 ml/Kg for 6
hours
● Reduction of GCS by 2 or more
● Any other organ dysfu
 High risk group
● Age > 60 years
● Diabetes mellitus , renal failure , chronic lung disease and
immunocompromised persons

Dosage:
 Lopinavir/ritonavir (200mg/50 mg) - 2 tablets
twice daily
 For patients who are unable to take
medications by mouth, lopinavir 400 mg/
ritonavir 100 mg 5-ml suspension twice daily
Duration: 14 days or for 7 days after becoming
asymptomatic

When to discharge?
 If the laboratory results for 2019-nCoV are negative, discharge
is to be decided as per discretion of the treating physician based
on his provisional/confirmed diagnosis
 In case of high suspicion of 2019-nCoV repeat samples are to
be sent
 Confirmed case- Resolution of symptoms, radiological
improvement with a documented virological clearance in 2
samples at least 24 hours apart

Covid 19 Dr. MADHUKIRAN, MD.PULMONOLOGY

Covid 19 Dr. MADHUKIRAN, MD.PULMONOLOGY

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Covid 19 Dr. MADHUKIRAN, MD.PULMONOLOGY