Surabaya, 27 Juni 2020

Email : dr.diannegara.dn@gmail.com
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 Coronavirus
Four types of Coronaviruses:
1.Alpha Coronavirus  animal and human
2.Beta Coronavirus  animal and human
3.Gamma Coronavirus  animal
4.Delta Coronavirus animal

Six Coronaviruses infect human:

HCoV-229E (Alpha)
HCoV-NL63 (Alpha)
HCoV-OC43 (Beta) Mild Common Cold
HCoV-HKU1 (Beta)
SARS-CoV (Beta)
MERS-CoV (Beta)
SARSCoV-2 (Beta)
Member of subgenus Serbecovirus ( Beta CoV lineage B) approx 30.000 bases in length

Novel Coronavirus WHO Novel coronavirus (2019-nCoV).mp4

COVID-19 INFECTION

Subtle symptoms are very common in population!

The Surprise
• Culmination of works done
• A large number of SARS-related coronaviruses
(SARSr-CoVs) have been discovered in their natural
reservoir host, bats
Genetic relatedness

Relatedness to SARS CoV2

• SARS-CoV1 79.6%
• Bat CoV RaTG13 96%

Why the difference?

High Mutation risk
Recombination risk
Knipe DM et al (2013) Fields virology, vol 1, 6th ed.
Jinning County, Yunnan province, China
Dr. Zheng-Li Shi

www.scientificamerica.com
Yes… COVID-19 was predicted!

Thus, it is highly likely that future SARS- or

MERS-like coronavirus outbreaks will
originate from bats, and there is an increased
probability that this will occur in China.
COVID-19. The relentless onslaught. Updated
6 April 2020
COVID-19 Pandemic Timeline…

3th march 2020

1st Case report in
Indonesia

Modiefied from Seah I et al. 2020. Eye, pp. 1–3

Prevalensi COVID-19 di Indonesia – 1 Juni 2020

26.940

1.641

7.637
Lesson learned from Singapore :
Wuhan Phase Jan 23 - Feb 3
(Visitors from Wuhan)

Community Phase Feb 4 - Mar 9

(Wuhan Visitors to Community)

Imported Phase Mar 10 - Mar 19

(Returnees to Singapore  Local transmission)

Foreign Workers April - Now

Spreading of COVID-19 within foreign workers
dormitory
Singapore’s “CIRCUIT
BREAKER” Lockdown
equivalent
• Rising number of cases of
local transmission
• Caused by the secondary
transmission of imported
cases. RISING
• Overseas returnees to LOCAL
Singapore TRANS-
MISSION
• Most workplaces to close for FALLING
one month Imports
Singapore Circuit
Breaker (Lockdown)
Lockdown / Circuit

lockdown
Breaker – April 7
• Sudden spike in cases
• Primarily in Singapore’s
Foreign Worker
Dormitories
 Typical Night @ Foreign
TYPICAL NIGHT foreign worker dormitory
worker dormitory

Construction Site

Foreign worker
dormitory
GORDON’S TRIANGLE
PHILOSOPHY
Transmission of COVID-19 best with MAC
FOREIGN WORKERS
WORKSITE / DORM / RECREATION
1. Movements
TRAVELLING- SPREADING - SEEDING
2. Activities (Singing)
3. Crowds RECREATIONAL ACTIVITES
(Singing, Drinking, Partaking of meals)

PERFECT SETTING FOR RAPID TRANSMISSION

OF COVID-19 INFECTIONS
 It loves Movements

www.the-scientist.com
 53
patients

• …aided by “super-emitters” – people that release

more particles during speech than most people do.
• Close contact, fomite transmission, singing (loudness,
some individuals)

MMWR weekly May 15, 2020 / 69(19);606–610

Behaviour spreads Viruses

South Korea SINGAPORE

It spreads well

11th floor Call Centre, S Korea

94 / 216 employees
attack rate of 43.5%
(95% CI 36.9%–50.4%).
Super-spreading Events

1 10
• Total of 243 cases
• “Presymptomatic transmission occurred 1–3 days
before symptom onset in the presymptomatic
source patient.”
• 10 cases
• 6.4% of the 157 locally acquired cases.
 Asymptomatic Transmission
Xiaogan to Wuhan to Nanjing. Exposure to 11

Xiaogan Nanjing
Wuhan Zhejiang
(70km from stayed sisters /
(switched train)
Wuhan) mother

7 patients
(pre-symptomatic
transmission)
• Strike rate of
30.3% (76 / 82
tested)
• 23%
asymptomatic,
~50% presymp /
asymp
 Italian Village
50-75% asymptomatic

• The great majority of people infected with COVID-19—50-75%—

were asymptomatic, but represented “a formidable source” of
contagion.
• Contradicts WHO-China Joint Mission Report :
Asymptomatic transmission is uncommon
Asymptomatic / Presymptomatic Patients
• Each patient becomes a Trojan Horse
• You can’t identify them
• Each patient is invisible
• Wearing mask is the only option
Voanews.com
https://www.straitstimes.com
 www.scmp.com www.scmp.com

• 217 passengers and crew

• 128 positive COVID-19 (59%)
• 10 instances – cabin with two passengers, Neg / Pos
• 24 symptomatic. 104 asymptomatic (81%)
 Asymptomatic vs Symptomatic

• 26 patients found positive

• 78 Close contacts – CT scan x3 and PCR serial testing
• 33 patients asymptomatic (42.3%)
• 45 patients symptomatic (57.7%)
• PCR serial testing done every 24-48 hours
• 3 CT scans done. 0, +4-6 days, + 6-7 days later.
Younger, Women, Less liver injury, Less viral shedding, Faster
lung recovery (CT), Better CD4 recovery, No deaths
• Skilled Nursing Facility
• 57/89 residents positive – SARS-CoV-2
• (27/57) 56% were asymptomatic at testing.
All except 3 became symptomatic. 26% died.
• High viral load at pre-symptomatic phase
• Transmits better early. OUR UNDERSTAND AND APPROACH IS
INADEQUATE
• Harder to detect. Asymptomatic testing in
congregate living / prioritized settings.
Masks for general public
DRAMATIC
CHANGE
NO MASK
to
MASK
NO MASKS
WHY CHANGE?
Asymptomatic / Pre-symptomatic
transmitters

MASKS
• Hematology
• NLR
• CRP
• Thorax
• Ferritin
• D-dimer
• etc
 Waktu
pengambilan
dengan positivity
rate tertinggi

• Anti SARS-CoV-2 IgM & IgG

menggunakan sampel serum
bertujuan untuk mengetahui
ada tidak antibodi
• SARS-CoV-2 RNA ( PCR COVID-
19) di Prodia mendeteksi 3 gen
sekaligus yaitu gen E, N dan
RdRP untuk mengetahui
keberadaan virus SARS-CoV-2
melalui keberadaan materi
genetik menggunakan metode
real time RT-PCR
• SARS-CoV-2 RNA ( PCR COVID-
19) digunakan untuk skrining
maupun konfirmasi
SARS-CoV-2 RNA ( PCR COVID-19)
Kapasitas Pemeriksaan COVID-19 di Indonesia

This presentation has been prepared specifically by Prodia. The content of this presentation may not be used,
duplicated or transmitted in any form without the written consent from Prodia. All rights reserved.
Drawford, et. al. Improving American Healthcare Through “Clinical Lab
2.0”: A Project Santa Fe Report. Academic Pathology. 2017; 4: 1-8.
Gold standard Diagnosis COVID-19

Real-time Reverse Transcription Polymerase

Chain Reaction (rRT-PCR) is the current gold
standard for diagnosing suspected cases of Konfirmasi skrining
COVID-19 tambahan : Gen N

Konfirmasi skrining :

Target Gen
Gen RdRP
Diagnosis
COVID-19
Skrining pertama :
Gen E

WHO, 2020
International protocol (WHO) in house assay
Informasi Pemeriksaan
• Nama Pemeriksaan : SARS-CoV-2 RNA
(PCR COVID-19)
• Tujuan : Skrining sekaligus
konfirmasi COVID-19
• Metode : Real Time RT - PCR
• Gen target : Gen E, N, dan RdRp
• Janji Hasil (WSHP) : 4-5 hari

Prodia.co.id
Prodia.co.id
Swab Nasofaring dan Orofaring
• Swab nasofaring • Swab orofaring
Anti SARS-CoV-2 IgM & IgG
 Negatif palsu :
-Pasien periksa ketika antibodi belum muncul
-Kondisi imuno kompromise

Positif palsu :
• Hasil positif dapat disebabkan infeksi lampau
Antibodi SARS-CoV-2 mungkin tidak dapat dideteksi sebelum 3 oleh strains coronavirus non-SARS-CoV2,
hari setelah mulai gejala (atau setidaknya 7 hingga 10 hari seperti HKU1, NL63, OC43, atau 229E.
setelah infeksi). Oleh sebab itu dianjurkan periksa 2x
SIAPA & KAPAN
 Pedoman Pencegahan dan Pengendalian Coronavirus Disease
(COVID-19) - Rev 4

Hasil tes pemeriksaan negatif pada spesimen tunggal, terutama jika spesimen berasal dari saluran
pernapasan atas, belum tentu mengindikasikan ketiadaan infeksi. Oleh karena itu harus dilakukan
pengulangan pengambilan dan pengujian spesimen.

https://www.kemkes.go.id/article/view/20012900002/Kesiapsiagaan-menghadapi-Infeksi-Novel-
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PHILOSOPHY
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• systematic review and meta-analysis
• investigate the optimum distance for avoiding
person-to-person virus transmission
• 172 observational studies across 16 countries and
six continents. 44 relevant comparative studies
• n=25697 patients
MCD
Mask
Cover (port d’entry)  cleanse hand
Distance

CERTAINTY
RELATIVE
RISK
Adjusted estimates – FACE MASK
Adjusted estimates – EYES’ COVER
Physical Distancing – 0/ 1m / 2m

INCREASING DISTANCE
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