Coronavirus

Disease 2019 (COVID-19)

Transcribed by: Dr. Angelo Panelo (2 year IM resident)
nd

OUTLINE • The basic reproduction number (R0) of the virus has been
I. Virus estimated to be between 1.4 and 3.9, meaning that each
II. Incubation Period infection from the virus is expected to result in 1.4 to 3.9
III. Mode of Transmission new infections when no preventive measures are taken.
IV. Signs/Symptoms
V. Laboratory Findings B. Incubation Period
VI. People at Risk • Current estimates of the incubation period of the virus
VII. Prevention range: 1-12.5 days (median 5-6 days).
VIII. Management
C. Mode of Transmission
References: • COVID-19 is transmitted via droplets and fomites
1) Risk Factors for Death From COVID-19 Identified. (2020, (any inanimate substance or material that may be
March 9). Retrieved from contaminated with infectious organisms and serve in
https://www.medscape.com/viewarticle/926504 their transmission) during close unprotected contact
2) @Chenbariatrics1. (2020, March 09). 1/Notes from the front between an infector and infectee.
lines [Tweet]. Retrieved from • It may be possible to get COVID-19 by touching
https://twitter.com/Chenbariatrics1/status/12370252508538 surfaces and then touching your mouth, nose, or
47040 eyes.
3) Report of the WHO-China Joint Mission on Coronavirus • Airborne spread has not been reported, and is not
Disease 2019 (COVID-19) released 16-24 February 2020 believed to be a major driver of transmission.
4) Gao, J., Tian, Z., & Yang, X. (2020). Breakthrough:
Chloroquine phosphate has shown apparent efficacy in
treatment of COVID-19 associated pneumonia in clinical
studies. BioScience Trends, 14(1), 72–73. doi:
10.5582/bst.2020.01047
5) COVID-19. (n.d.). Retrieved March 16, 2020, from
https://bestpractice.bmj.com/topics/en-
gb/3000168/emergingtxs
6) Yan, G., Lee, C. K., Lam, L. T. M., Yan, B., Chua, Y. X., Lim,
A. Y. N., … Tambyah, P. A. (2020). Covert COVID-19 and
false-positive dengue serology in Singapore. The Lancet
Infectious Diseases. doi: 10.1016/s1473-3099(20)30158-4

A. SARS-COV02

• “Severe acute respiratory

syndrome coronavirus 2” Figure 1. Review on how airborne and fomites transmit
• Zoonotic virus diseases
• Reservoir: Bats
• Intermediate Hosts: Still have yet
to be identified
• Positive-sense single stranded RNA virus
• Had features typical of coronavirus family and belonged to
the Betacoronavirus 2B lineage.
• Alignment of the full-length genome sequence of the
Coronavirus Disease 2019 (COVID 19) virus and other
available genomes of Betacoronovirus showed the closest
relationship was with the bat SARS-like coronavirus strain
BatCov RaTG13.
• Is unique among known betacoronaviruses in its
incorporation of a polybasic cleavage site, a characteristic
known to increase pathogenicity and transmissibility in
other viruses.
Figure 2. REVIEW: Difference between airborne and droplet.

Compiled by: Dr. Salvador Angelo A. Panelo IV, 2nd year Internal Medicine resident UERM
March 2020
 • Fecal shedding has been demonstrated from some • Real-Time RT-PCR Diagnostic Panel: has only been
patients, however, the fecal-oral route does not established in upper and lower respiratory specimens.
appear to be a driver of COVID-19 transmission; its • Negative results do not preclude 2019-nCoV infection,
role and significance remain to be determined. and should not be used as the sole basis for treatment
of other patient management decisions.
D. Signs/Symptoms • Most consistent finding for a complete blood count was
lymphopenia (or decreased number of lymphocytes)
• Based on 55,924 laboratory confirmed cases, typical signs
with either leukocytosis or leukopenia
and symptoms include:
• Some reports say: ABG: Mild acidosis with normal
o Fever (87.9%)
lactate and severe base deficit with moderate
o Dry Cough (67.7%)
hypoxemia*
o Fatigue (38.1%)
• Elevated LDH, very high CRP, Elevated CK*
o Sputum production (33.4%)
• D-dimer may be elevated
o Shortness of breath (18.6%)
• Liver Function tests may be elevated
o Sore throat (13.9%)
• There have been reports in Singapore and China that
o Headache (13.6%)
some patients who were eventually found to be SARS-
o Myalgia or arthralgia (14.8%)
COV-02 positive were initially managed as a case of
o Chills (11.4%)
Dengue Fever due to having positive results from
o Nausea or vomiting (5.0%)
rapid serological tests (Dengue IgG and IgM)
o Nasal congestion (4.8%)
• Most consistent radiographic finding: bilateral
o Diarrhea (3.7%)
interstitial/ground glass infiltrates
o Hemoptysis (0.9%)
• Relation Between Chest CT Findings and Clinical
o Conjunctival congestion (0.8%)
Conditions of COVID-19 Pneumonia: A
• Most common presentation in one report done in the Multicenter Study: American Journal of
US: 1 week of prodrome of myalgia, malaise, cough, Roentgenology
low-grade fever leading to more severe trouble o Ground glass opacities (86.1%)
breathing in the 2nd week of illness. o Mixed ground glass opacities and consolidation
• An average of 8 days to development of dyspnea and (64.4%)
an average of 9 days to pneumonia/pneumonitis. o Vascular enlargement in the lesion (71.3%)
• Fever was not prominent in several cases, but if there o Peripheral distribution (87.1%)
was any, it persisted for a median of 12 days among all o Bilateral involvement (82.2%)
patients. o Lower lung predominant (54.5%)
• Cough persisted for a median of 19 days (45% of the o Multifocal (54.5%)
survivors in one study in the United States were still
noted to be coughing on discharge).
• Most people infected with COVID-19 have mild disease
and recover. Approximately 80% of laboratory
confirmed patients have had mild to moderate
disease, which incudes non-pneumonia and pneumonia
cases.
• 13.8% were noted to have severe disease (dyspnea,
RR of more than or equal to 30, blood oxygen saturation
of less than or equal to 93%, PAO2/FiO2 ratio <300,
and/or lung infiltrates >50% of the lung field within 24-
48 hours)
• 6.1% were considered critical (respiratory failure,
septic shock, and/or multiple organ dysfunction/failure)
• Asymptomatic infection has been reported, but the F. People at Risk
majority of the relatively rare cases who were • Individuals that are said to be at highest risk for severe
asymptomatic on the date of identification/report went disease and death include people aged over 60 years,
on to develop the disease. and those with underlying conditions such as
• There have been researches about presumed hypertension, diabetes, cardiovascular disease,
asymptomatic carrier transmission, but this has yet chronic respiratory disease, and cancer.
to be proven. • Disease in children appears to be relatively rare and
mild with approximately 2.4% of the total reported
E. Laboratory Findings cases reported amongst individuals aged under 19
years. A very small proportion of those aged under 19
• For initial diagnostic testing for COVID-19, CDC
years have developed severe (2.5%) or critical disease
recommends collecting and testing upper respiratory
(0.2%).
(nasopharyngeal AND oropharyngeal swabs) and
• Elderly patients are considered to be at highest risk due
lower respiratory (sputum, if possible) for those
to associated weakening of the immune system, and
patients with productive coughs. Induction of sputum is
increased inflammation, which damages organs, and
not recommended.
also promotes viral replication
Compiled by: Dr. Salvador Angelo A. Panelo IV, 2nd year Internal Medicine resident UERM
March 2020
 • Patients with underlying cardiopulmonary disease seem
to progress with variable rates to ARDS and acute
respiratory failure requiring BiPAP then eventually,
intubation.
• The odds of dying at the hospital increased with age,
higher SOFA score, and D-dimer level exceeding 1ug/L
on admission
G. Prevention
• Practice proper hand hygiene.
o Review: For healthcare workers, always remember
the 5 moments for Hand washing:
1) Before touching a patient
2) Before clean/aseptic procedures
3) After body fluid exposure/risk
4) After touching a patient
5) After touching patient surroundings
• Practice cough etiquette (cover your mouth with your
arm rather than your hand when coughing)
• Avoid going into mass gatherings or crowds.
• Make it a point to clean your gadgets.
• Avoid touching your face (according to the movie,
Contagion, “The average person touches their face
three to five times every minute. In between that,
we’re touching door knobs, water fountains, and each
other.”)
• Wear a face mask IF you have any respiratory
symptoms OR if your occupation entails you to
handle possible individuals with flu-like
symptoms.
What does Social Distancing actually mean?
• CDC defines it as “remaining out of congregate
settings, avoiding mass gatherings, and maintaining
distance (approx. 6 feet or 2 meters) from others
when possible”
• Many people in the world will, at some point, be
exposed to the virus, yet the speed at which the
outbreak plays out matters hugely for its
consequences.
• What epidemiologists fear most is that the health
care system would become overwhelmed with
the sudden explosion of illness that requires more
people to be hospitalized THAN it can handle. In that
scenario, more people will likely die due to the lack of
enough beds or facilities, such as ventilators to keep
these patients alive.
• This disastrous flood of patients going to hospitals can
likely be avoided with protective measures we’re
now seeing more of – suspending classes, cancelling
mass gatherings, work from home, self quarantine,
self-isolation, and avoidance of crowds – to keep the
virus from spreading fast.
Compiled by: Dr. Salvador Angelo A. Panelo IV, 2nd year Internal Medicine resident UERM
March 2020
Figure 3. This graph explains that with protective measures
cases are kept at a steady pace.
H. Management
• There is currently no specific treatment that has been
proven and confirmed for use against COVID-19.
• Various antivirals are being trialed in patients with
COVID-19, these include Oseltamivir,
Lopinavir/Ritonavir, Ganciclovir, Favipiravir, Baloxavir
Marboxil, Umifenovir, Interferon Alfa – however there
are no data to support their use.
• Currently, the anti-novel coronavirus, Remdesivir, is
still under clinical trial.
o A novel nucleotide analog prodrug
o Initially produced to treat Ebola virus, but its
efficiency was lower compared to other drugs.
o Has efficiency against MERS
o In late January 2020, it was administered to the
first US patient to be confirmed and infected
with SARS-COV-02 in Snohomish County,
Washington for “compassionate use” after he
progressed to pneumonia. While no broad
conclusions were made based on a single
treatment, the patient’s condition improved
dramatically the next day, and was eventually
discharged.
• Chloroquine and hydrochloroquine are being
trialed in some patients with COVID-19; however
there are currently no data to support this. A
number of clinical trials have been conducted in
China to test their efficacy and safety in the
treatment of COVID-19 associated pneumonia in
more than 10 hospitals in different areas of China
(including Wuhan). So far, results from more
than 100 patients have demonstrated that
chloroquine phosphate is superior to the control
treatment in preventing exacerbations of
pneumonia; improving lung imaging findings;
promoting virus-negative conversion, and
shortening of disease course according to news
briefing.
o Studies revealed that Chloroquine also has
broad spectrum antiviral activities by
increasing endosomal pH required for
virus/cell fusion, as well as, interfering
with the glycosolation of cellular
receptors of SARS-CoV.
 • Treatment Algorithm (based on BMJ Best VOLUME/LOW INSPIRATORY
Practices) for the ff: PRESSURE VENTILATION strategy.
o SUSPECTED SARS-CoV-02 infection Those with persistent severe hypoxic
§ 1st Line: Immediately ISOLATE all failure should be considered for PRONE
suspected cases in an area separate from VENTILATION.
other patients, and implement appropriate
infection prevention and control
procedures.
§ PLUS: Supportive care including the ff:
v OXYGEN: supplemental oxygen at
a rate of 5L/minute to patients with
severe acute respiratory infection,
and respiratory distress,
hypoxemia, or shock. Titrate flow
rates to reach a target of SpO2
≥90%.
v FLUIDS: Manage fluids
CONSERVATIVELY in patients with
severe acute respiratory infection B. Without Pneumonia or Comorbidities:
when there is no evidence of shock a. Consider home care and isolation
because aggressive fluid – consider in patients who have MILD
resuscitation MAY worsen symptoms (e.g. low grade fever,
oxygenation cough, fatigue, rhinorrhea, sore
v Symptom relief: given an throat) with NO warning signs (e.g.
antipyretic/analgesis for the relief shortness of breath or difficulty of
of fever and pain breathing, hemoptysis, increased
§ ADJUNCT: Empiric antibiotics sputum production, gastrointestinal
(Treatment recommended for SOME symptoms, mental status changes),
patients in selected patient group) and no underlying health conditions.
v Consider starting empiric i. Infection prevention and
antibiotics in patients with control procedures should still
suspected infection to COVER for be done at home. It is
other potential bacterial recommended to use a single room
pathogens that may cause and a single bathroom (if possible),
respiratory infection. Choice of minimize contact with other
antimicrobials should be based on household members, and wear a
the clinical diagnosis, local surgical mask if contact is
epidemiology and susceptibility necessary.
data. b. Supportive care PLUS monitoring
o CONFIRMED SARS-CoV-02 infection
A. With Pneumonia or Comorbidities:
a. 1st line: Promptly ADMIT patients with
pneumonia or respiratory distress to an
appropriate healthcare facility. Patients with
impending or established respiratory failure
should be admitted to an ICU
b. Supportive care
c. Adjunct: Mechanical Ventilation
(Treatment recommended for SOME
patients)
i. Intubation and mechanical ventilation
are recommended in patients who are
deteriorating and cannot maintain an
SpO2 ≥90% with oxygen therapy.
Some may develop severe hypoxic
respiratory failure, requiring a high
fraction of inspired oxygen, and high
air flow rates to match inspiratory flow
demand. Patients may also have
increased work of breathing,
demanding positive pressure breathing
assistance.
ii. Mechanically ventilated patients should
receive a lung-protective, LOW TIDAL
Compiled by: Dr. Salvador Angelo A. Panelo IV, 2nd year Internal Medicine resident UERM
March 2020
 Figure 5. Current algorithm for identifying and managing
patients with COVID-19
Figure 4 (on the RIGHT). How to properly wash your hands.
Don’t just read it. DO IT.

Compiled by: Dr. Salvador Angelo A. Panelo IV, 2nd year Internal Medicine resident UERM
March 2020


Compiled by: Dr. Salvador Angelo A. Panelo IV, 2nd year Internal Medicine resident UERM
March 2020