COVID-19

JUNAYYAH A. SARIP
Post Graduate Intern
DJNRMHS
 Coronavirus disease 2019 (COVID-19)
Defined as illness caused by the
severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), a newly
emergent coronavirus, that was first
recognized in Wuhan, Hubei province,
China, in December 2019.
 SARS-CoV-2

• Positive-sense single-stranded RNA virus

• a group 2b beta-coronavirus that has at least 70%
similarity in genetic sequence to SARS-COV
• Originated in bats
• Intermediate host: pangolins
• Uses angiotensin converting enzyme (ACE2)
receptor for attachment
 EPIDEMIOLOGY

World Health Organization as of July 17, 2021

•Confirmed Cases- 188,655,968
•Confirmed Deaths- 4,067,517

PH as of July 17, 2021

•Confirmed Cases- 1,496,328
•Confirmed Deaths- 26,476
 COVID-19 in the Philippines
• January 30, 2020 – first case was confirmed (38 y/o, F, Chinese National)

• February 2, 2020 – 1st COVID-19 death in the Philippines was reported

• March 7, 2020 – DOH confirms local transmission of COVID-19 in the

Philippines, raising the alert level to code red sublevel 1.

• March 9, 2020 – President Rodrigo Duterte signs Proclamation No. 922

declaring a state of Public Health Emergency following
confirmed local transmission
 COVID-19 in the Philippines
• March 11, 2020 – DOH confirms new cases in Visayas and Mindanao

• March 12, 2020 – WHO declares COVID-19 a pandemic.

Code alert has been raised to code red sublevel 2

• March 16, 2020 – President Duterte orders an enhanced community

quarantine of the entire Luzon until April 12, 2020.

• March 20, 2020 – DOH designates the Lung Center of the Philippines,
Dr. Jose N. Rodriguez Memorial Hospital, and UP-PGH as
COVID-exclusive centers
 COVID-19 in the Philippines
• May 2020 – Cases plateaued which led to the relaxation of quarantine
measures.

• June 2020 – there has been a resurgence of cases within the National Capital
Region and in Cebu

• July 2020 – more than 60,000 reported cases with more than 1,000 deaths
 PATHOPHYSIOLOGY

TRANSMISSION INCUBATION PERIOD RISK FACTORS

Person to Mean: 5.1 days Elderly, those with
person spread (4.5-5.8 days); comorbidities and
via respiratory 98% manifesting those with
droplets within 11.5 days pneumonia
 PATHOGENESIS OF COVID-19

STAGE 1: ASYMPTOMATIC STATE

(INITIAL 1–2 DAYS OF INFECTION)
1. The inhaled virus SARS-CoV-2 likely binds its spike (S)
protein to angiotensin-converting enzyme 2 (ACE2)
receptor of the epithelial cells in the nasal cavity
2. Local replication, and propagation of the virus
a. After the virus enters the cells, the viral RNA genome is released
into the cytoplasm
Mason, R. (2020). Pathogenesis of COVID-19 from a cell biology perspective. European Respiratory
Journal 2020 55: 2000607; DOI: 10.1183/13993003.00607-2020
 PATHOGENESIS OF COVID-19

STAGE 1: ASYMPTOMATIC STATE

(INITIAL 1–2 DAYS OF INFECTION)
b. Viral genome is translated into two polyproteins, and
structural proteins
c. The viral genome begins to replicate
d. The newly formed envelope glycoproteins are inserted
into the membrane of the endoplasmic reticulum or
Golgi, and the nucleocapsid is formed by the
combination of genomic RNA, and nucleocapsid protein.
 PATHOGENESIS OF COVID-19

STAGE 1: ASYMPTOMATIC STATE

(INITIAL 1–2 DAYS OF INFECTION)
e. Then, viral particles germinate into the endoplasmic
reticulum-Golgi intermediate compartment (ERGIC).
f. Lastly, the vesicles containing the virus particles then
fuse with the plasma membrane to release the virus
2. Limited innate immune response.
3. At this stage the virus can be detected by nasal swabs.
 PATHOGENESIS OF COVID-19

STAGE 2: UPPER AIRWAY AND CONDUCTING

AIRWAY RESPONSE (NEXT FEW DAYS)

1. The virus propagates and migrates down the respiratory tract

along the conducting airways
2. More robust innate immune response is triggered
3. Nasal swabs or sputum should yield the virus (SARS-CoV-2)
4. Disease is clinically manifested
5. 80% of patients will present with a mild disease
 PATHOGENESIS OF COVID-19

STAGE 3: HYPOXIA, GROUND GLASS

INFILTRATES, AND PROGRESSION TO ARDS

1. About 20% of the infected patients will progress to stage 3

disease and will develop pulmonary infiltrates
2. The virus now reaches the gas exchange units of the lung
and infects alveolar type II cells
3. SARS-CoV propagates within type II cells
4. Large number of viral particles are released
 PATHOGENESIS OF COVID-19

STAGE 3: HYPOXIA, GROUND GLASS

INFILTRATES, AND PROGRESSION TO ARDS

5. Cells undergo apoptosis and die

6. Released viral particles infect adjacent type II pneumocytes
7. Damaged cells induce innate inflammation in the lungs that is
largely mediated by pro-inflammatory macrophages and
granulocytes.
8. Lung inflammation is the main cause of life-threatening
respiratory disorders at the severe stage
 CLINICAL PRESENTATION
Anosmia
Fever
Ageusia/
Dysgeusia
Cough
Sore throat
Shortness of
Breath
Rhinorrhea
Muscle Ache
Chest pain
Confusion
Diarrhea,
nausea and
Headache vomiting
 SCREENING & diagnosis

An initial screening for COVID-19 by

checking for any influenza-like illness
symptoms and typical COVID-19
symptoms within the past 14 days in
apparently healthy adults.
 SCREENING & diagnosis

14-day symptom-based test is a screening

strategy wherein the presence of any influenza-
like illness symptoms within the past 14 days is
designated as presumptive for COVID-19. It
should be noted that since the recommendation
is for initial screening, a follow-up confirmatory
diagnostic test should be done.
TESTS FOR SARS COV-2 (COVID-19)
A. Real-time reverse transcription-polymerase chain reaction
(RT-PCR) assay
 Nasopharyngeal swab is the current gold
standard specimen used for RT-PCR.
 Alternative specimens to nasopharyngeal swab
RT-PCR among asymptomatic patients:
 oropharyngeal swab
 saliva drool/spit and oral saliva
 nasal swab/wash
 throat swab
 SCREENING & diagnosis

RT-PCR testing should be repeated when

the initial RT-PCR test is negative among
symptomatic patients with high index of
suspicion for COVID-19 infection.
 SCREENING & diagnosis

Repeat testing is usually done 24 hours to

4 days after a negative initial RT-PCR
among hospitalized adults suspected to
have COVID-19.
 SCREENING & diagnosis

High index of suspicion for COVID-19 infection is

considered in symptomatic patients presenting
with, but not limited to:
a. Clinical deterioration in the presence of an
established disease etiology and with
adequate treatment and severe or progressive
disease, with possible coinfection with
COVID-19.
 SCREENING & diagnosis

High index of suspicion for COVID-19 infection is

considered in symptomatic patients presenting
with, but not limited to:
b. No other etiology for the patient's signs and
symptoms has been identified despite work-
up.
c. Clinical specimen(s) initially sent was/were
deemed to be unsatisfactory or insufficient
(delay in transport and processing, only NPS
or OPS was sent)
TESTS FOR SARS COV-2 (COVID-19)
B. Rapid Tests Based on Antigen Production
 Detects the presence of viral proteins (antigens)
 The use of rapid antigen test under all these
conditions in patients suspected of COVID-19
infection:
• Symptomatic
• Early phase </=7 days from onset of
symptoms
• Specific brands that demonstrated
sensitivity ≥80% and have very high
specificity (≥97-100%))
 Using both clinical risk assessment and RT-PCR
are recommended to screen for COVID-19
among asymptomatic individuals scheduled for
non-emergency surgery.
 Both clinical risk assessment and Antigen-Rapid
Diagnostic Test (Ag-RDT) are recommended to
screen for COVID-19 among asymptomatic
individuals scheduled for non-emergency surgery
when RT-PCR testing is not available or when
prolonged turnaround time is considered
TESTS FOR SARS COV-2 (COVID-19)
C. Antibody test
 Antibodies are classified as neutralizing antibodies,
i.e., cause virus particles to lose infectivity, and
binding antibodies
 Available laboratory techniques to detect anti-SARS-
CoV-2 antibodies include:
 Lateral flow immunoassay (LFIA)
 Enzyme-linked immunosorbent assays (ELISA)
 Chemiluminescent immunoassay (CLIA)
 Electrochemiluminescence Immunoassay (ECLIA)
 Fluorescent immunoassays (FIA)
• Antibody tests with high sensitivity
and specificity (e.g., total antibody
or IgG assays, ELISA, ECLIA) is
used to determine COVID-19
seroprevalence among adults
• Several cases of reinfection with
SARS-CoV-2 have been reported
with a median interval from initial
COVID-19 infection of 71 days
(range: 19-250)
• NAAT (RT-PCR) and Genomic
sequencing are the recommended
diagnostic tests to confirm COVID-19
reinfection.
 Criteria for allowing workers who
were previously infected with
COVID-19 to return for work

 Symptom-based strategy for the

discontinuation of isolation and return to work
clearance of the following:
1. Asymptomatic adults who are not
severely immunocompromised if they
fulfill the following:
• remained asymptomatic throughout
their infection
• 10 days have passed from the first
positive viral diagnostic test
 Criteria for allowing workers who
were previously infected with
COVID-19 to return for work

2. Adults who had mild to moderate

COVID-19 who are not severely
immunocompromised if they fulfill the
following:
• Afebrile for at least 24 hours without
use of antipyretic medications
• Respiratory symptoms have
improved
• 10 days have passed from symptom
onset
 Criteria for allowing workers who
were previously infected with
COVID-19 to return for work

3. Adults who had severe to critical

COVID-19 who are not severely
immunocompromised if they fulfill the
following:
• Afebrile for at least 24 hours without
use of antipyretic medications
• Respiratory symptoms have
improved
• 21 days have passed from symptom
onset
A repeat negative RT-PCR test is no longer
needed for discharge of immunocompetent
patients with probable or confirmed COVID-19
regardless of severity, because, in most cases,
it results in prolonged isolation of patients who
continue to shed detectable SARS-CoV-2 RNA
but are no longer infectious.
Test-based strategy using RT-PCR for the
discontinuation of isolation and return to
work clearance of the following:

1. Severely immunocompromised adults

2. Health care workers
 if they fulfill the following:
• Afebrile for at least 24 hours without use
of antipyretic medications
• Respiratory symptoms have improved
• With at least one negative RT-PCR test
of a respiratory specimen
Severely immunocompromised: Ongoing chemotherapy
for cancer, or within one year from receiving a
hematopoietic stem cell or solid organ transplant;
untreated HIV infection with CD4 count < 200,
combined primary immunodeficiency disorder, and
receipt of prednisone >20mg/day for more than 14
days, may cause a higher degree of
immunocompromised and require actions such as
lengthening the duration of work restrictions.
ANCILLARY TESTS
• Complete Blood Count (CBC)
• Metabolic panel: creatinine, LFTs, sodium,
potassium, magnesium, calcium, albumin
• Inflammatory markers: lactate dehydrogenase
(LDH), Ferritin, C-reactive protein (CRP), and
procalcitonin
• Prothrombin and D-Dimer
• Arterial blood gas (ABG) measurement
• Blood cultures if concomitant bacterial
infection is suspected
ANCILLARY TESTS
• Respiratory tract specimen for influenza testing
• Sputum, endotracheal aspirate (ETA), or bronchoalveolar lavage
fluid culture and sensitivity
• Chest x-ray
• to facilitate rapid triage, infection control and clinical
management among any of the following:
 mild features of COVID 19 at risk for progression
 moderate to severe features of COVID 19
 with symptoms of at least 5 days duration
ANCILLARY TESTS
• High resolution chest CT scan plain
• If RT-PCR test is not available, a non-contrast chest CT
scan for symptomatic patients suspected of having
COVID-19 is requested to guide early triage and
management under the following conditions:
 Mild COVID-19 patients who are at risk for
progression
 Moderate to severe COVID-19 patients
• ECG
MANAGEMENT
MANAGEMENT
Classification of Covid-19
Non-severe COVID-19
Mild COVID-19 No pneumonia or hypoxia, acute onset of
fever and cough or any three or more of the
following:
fever, cough, coryza, sore throat,
diarrhea, anorexia/nausea/vomiting, loss
of sense of smell or taste, general
weakness/body malaise/fatigue,
headache, myalgia
MANAGEMENT
Classification of Covid-19
Non-severe COVID-19
Moderate COVID-19 a. With pneumonia, no difficulty of
breathing, RR <30 cpm, O2 sat ≥94%
b. Without pneumonia but with risk factors
for progression:
Elderly and/or with comorbidities
MANAGEMENT
Classification of Covid-19
Severe COVID-19
with pneumonia and signs of respiratory distress, O2 sat<94%.
RR >30 cpm, requiring oxygen supplementation

Critical COVID-19
with pneumonia and impending respiratory failure requiring
high flow oxygen, non-invasive or invasive ventilation, acute
respiratory distress syndrome, sepsis or shock, deteriorating
sensorium, multi-organ failure
MANAGEMENT
Classification of Covid-19
Severe COVID-19
with pneumonia and signs of respiratory distress, O2 sat<94%.
RR >30 cpm, requiring oxygen supplementation

Critical COVID-19
with pneumonia and impending respiratory failure requiring
high flow oxygen, non-invasive or invasive ventilation, acute
respiratory distress syndrome, sepsis or shock, deteriorating
sensorium, multi-organ failure
Triage & Evaluation Asymptomatic Covid-19
Triage & Evaluation Asymptomatic Covid-19
Triage & Evaluation Mild Covid-19
Triage & Evaluation Mild Covid-19
Triage & Evaluation Mild Covid-19
Triage & Evaluation Moderate Covid-19
Triage & Evaluation Moderate Covid-19
Triage & Evaluation Moderate Covid-19
Triage & Evaluation Severe Covid-19
Triage & Evaluation Severe Covid-19
Triage & Evaluation Severe Covid-19
Triage & Evaluation Critical Covid-19
Triage & Evaluation Critical Covid-19
Triage & Evaluation Critical Covid-19
Management Asymptomatic Covid-19
Management Mild Covid-19
Management Mild Covid-19
Management Moderate Covid-19
Management Moderate Covid-19
Management Moderate Covid-19
Management Severe Covid-19
Management Critical Covid-19
Management Critical Covid-19
Discharge & Reintegration Asymptomatic Covid-19
Discharge & Reintegration Mild Covid-19
Discharge & Reintegration Moderate Covid-19
Discharge & Reintegration Severe Covid-19
Discharge & Reintegration Critical Covid-19
Management Severe Covid-19
Investigational Drugs
HYDROXYCHLOROQUINE/CHLOROQUINE
The US-NIH recommends against the use of HCQ/CQ with or
without azithromycin in the treatment of COVID-19 in hospitalized
and non-hospitalized patients.

AZITHROMYCIN
Azithromycin is currently not recommended for the treatment of
COVID-19 outside of randomized trials.
Investigational Drugs
FAVIPIRAVIR
Major guidelines on COVID-19 have not issued a recommendation
for the use of favipiravir in their set of management options as there
is still insufficient and uncertain evidence for its use.

REMDISIVIR
IDSA suggested against remdesivir for routine treatment of patients
with oxygen saturation >94% and no supplemental oxygen and
strongly urges for continued study.
Addition of remdesivir to dexamethasone in patients with COVID-19
infection who have O2 sat < 94% and/or requiring oxygen supplementation
Investigational Drugs
TOCILIZUMAB
IDSA suggest the use of tocilizumab in adult hospitalized patients
with progressive severe or critical COVID-19 who have elevated
markers in addition to standard of care (i.e. steroids).

US-NIH recommends the use of tocilizumab in combination with

dexamethasone in hospitalized patients exhibiting rapid respiratory
decompensation (i.e. admitted to an ICU unit and who require mechanical
ventilation, non-invasive mechanical ventilator (NIV) or high-flow nasal
cannula (HFNC); non-ICU but who requires NIV or HFNC AND have
significantly increased markers of inflammation.
Investigational Drugs
CONVALESCENT PLASMA
Infectious Disease Society of America (IDSA) guidelines has
recommended the use of convalescent plasma for patients with
COVID-19 who are currently admitted in a hospital only in the
context of a clinical trial.

Further clinical trials are needed to determine if there is benefit with

treatment of COVID-19 patients using convalescent plasma.
Investigational Drugs
IBUPROFEN
Currently there are no clinical practice guidelines that recommend
the use of ibuprofen as treatment for COVID-19.

VIRGIN COCONUT OIL

Currently there are no clinical practice guidelines that make a
recommendation on the use of VCO as adjunctive treatment of
COVID-19.
Investigational Drugs
IVERMECTIN
There is insufficient evidence to recommend the use of ivermectin in
the treatment of patients with mild-to-moderate COVID-19

BARICITINIB
Both the US-NIH and IDSA recommend giving baricitinib in
combination with remdesivir only in cases where corticosteroids
cannot be given.
The US-NIH recommends the use of this treatment for hospitalized, non-
intubated COVID-19 patients who require oxygen supplementation and
cannot be given corticosteroids.
Investigational Drugs
LERONLIMAB
No recommendations on leronlimab have been released by the US
NIH, WHO, Australian Living CPG, and PSMID.
Currently, it has been granted emergency Interventional New Drug
(eIND) status by FDA, targeted to treat patients with respiratory
complications associated with COVID-19
CRITICAL CARE & RESPIRATORY MANAGEMENT

• Dexamethasone is recommended in patients with COVID-19 infection

who require supplemental oxygenation (i.e., including high-flow
device, non-invasive, invasive mechanical ventilation and ECMO).

• Prophylactic anticoagulation is recommended among hospitalized

patients with COVID-19 infection, unless with contraindications.

• Prophylactic dose anticoagulation is recommended rather than

therapeutic anticoagulation in critically ill patients with COVID-19
infection.
CRITICAL CARE & RESPIRATORY MANAGEMENT

• Routine use of antibiotics is not recommended in patients with severe

and critical COVID-19 infection, unless with suspicion of secondary
bacterial co-infection.

• For patients on empiric antibiotics, they should be assessed daily for

the need for discontinuation, continuation or escalation based on
clinical and laboratory parameters.
CRITICAL CARE & RESPIRATORY MANAGEMENT

• Hemoperfusion
• An extracorporeal blood purification method that may have the
potential to mitigate excessive inflammation in patients with
Covid-19 by removing inflammatory cytokines from the blood

• There is insufficient evidence on the use of hemoperfusion at

this time among patients with COVID-19 infection.
CRITICAL CARE & RESPIRATORY MANAGEMENT

• It is recommended to use conservative fluid management rather than

liberal fluid management strategy in mechanically ventilated adult
COVID-19 patients with acute respiratory distress syndrome who are
adequately resuscitated
CRITICAL CARE & RESPIRATORY MANAGEMENT

• self-proning is recommended to improve oxygenation status of non-

intubated hospitalized patients with COVID-19 infection requiring
oxygen supplementation.

• high-flow nasal cannula oxygenation rather than non-invasive

ventilation (e.g., helmet CPAP, mask NIV) inpatients with COVID-19
infection and acute hypoxemic respiratory failure who do not respond
to conventional oxygen therapy.
CRITICAL CARE & RESPIRATORY MANAGEMENT

• Lung protective ventilation strategy (tidal volume 4-8mL/kg predicted

body weight and plateau pressure less than 30 cmH2O in patients
with COVID-19 infection and ARDS.

• Individualize PEEP or employ a PEEP strategy based on respiratory

mechanics (i.e., compliance)

• Keep the driving pressure ≤ 14 cmH2O.

CRITICAL CARE & RESPIRATORY MANAGEMENT

• Rapid sequence intubation for COVID-19 patients to reduce infection

among healthcare workers performing the procedure.

• VV-ECMO for judiciously selected COVID-19 patients with severe

ARDS based on the ELSO criteria.

• Individualized pulmonary rehabilitation with preintervention medical

clearance for long COVID patients who show residual respiratory
symptoms
NON-pharmacologic intervention
Healthcare workers not directly taking care
of COVID-19 patients, and other persons
with high risk of exposure to COVID-19
should use properly fitted surgical masks
instead of cloth masks.
NON-pharmacologic intervention

Hydrogen Peroxide Vapor (HPV),

Ultraviolet Germicidal Irradiation (UVGI),
moist heat and peracetic acid dry
fogging system (PAF) are an options for
N95 mask decontamination as
recommended by the manufacturer based
on their ability to reduce SARS-COV-2 load
and infectivity while still maintaining N95
mask integrity.
NON-pharmacologic intervention
Ventilation, filtration and air cleaners such as the high
efficiency particulate air (HEPA) filter are believed to
assist in reducing the risk of transmission of infectious
diseases by removing the particles or large droplets to
which pathogens may be attached

HEPA filter is an option to improve air quality for

COVID-19 prevention and control in indoor spaces
with inadequate ventilation.
NON-pharmacologic intervention

Appropriate PPE includes mask (N95 or higher standard), fluid

repellent sealed well-fitting long gown, double gloves, apron, full face
shield or goggles or visor, scrub hat, and disposable shoe covers or
dedicated closed footwear among surgeons engaged in aerosol
generating procedures of suspected or confirmed COVID-19 patients.
REFERENCES

Philippine Society for Microbiology and Infectious Diseases. Unified COVID-19 Algorithms.
https://www.psmid.org/unified-covid-19-algorithms-5/

Philippine Society for Microbiology and Infectious Diseases. Philippine COVID-19living recommendations.
https://www.psmid.org/Philippine-covid-19-living-recommendations/

Philippine Society for Microbiology and Infectious Diseases,Philippine College of Chest Physicians,Philippine
College of Physicians,Philippine Rheumatology Association,Philippine College of Hematology and
Transfusion Medicine, 2020, July 20, ; INTERIM GUIDANCE ON THE CLINICAL MANAGEMENT OF ADULT
PATIENTS WITH SUSPECTED OR CONFIRMED COVID-19 INFECTION

WHO: 2021, January 25, ; INTERIM GUIDANCE ON THE CLINICAL MANAGEMENT OF ADULT PATIENTS
WITH SUSPECTED OR CONFIRMED COVID-19 INFECTION