COVID-19

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Coronavirus Disease 2019 (COVID-19) is a recently discovered disease, caused by a Coronavirus,  named  SARS-CoV-2,  which  is  genetically  related  to  the  virus  causing  Severe  Acute  Respiratory  Syndrome (SARS) of 2003 and Middle East Respiratory Syndrome (MERS). This virus belongs to  the  family Coronaviridae,  of  the  order Nidovirales suspected  to  originate  from  an  animal  host  (zoonotic  origin)  followed  by  human-to-human  transmission.  The  disease  was  first  detected  in  Wuhan, the capital city of Hubei, China, in December of 2019 and declared by the WHO to be a  Public  Health  Emergency  of  International  Concern in  11  March  2020  due  to  its  evident  rapid  disease spread worldwide in less than 6 months. Most estimates of the incubation period for COVID- 19 range from 1-14 days, most commonly around five days. 

Current evidence suggests that COVID-19 spreads between people through direct, indirect (through  contaminated  objects  or  surfaces),  or  close  contact  with  infected  people  via  mouth  and  nose  secretions (saliva, respiratory secretions or secretion droplets). 

People with the virus in their noses and throats may leave infected droplets on objects and surfaces  (called  fomites)  when  they  sneeze,  cough  on,  or  touch  surfaces,  such  as  tables,  doorknobs  and  handrails. Other people may become infected by touching these objects or surfaces, then touching  their eyes, noses or mouths before cleaning their hands. 

Case definition 

The case definitions are based on the current information available and might be revised as new  information accumulates. 

Suspect  case:  A  patient  with  acute  respiratory  illness  (fever  and  at  least  one  sign/symptom  of  respiratory disease e.g., cough, shortness of breath), AND a history of travel to, or residence in a  location reporting  community  transmission  of  COVID-19  disease  during  the  14  days  prior  to  symptom onset. 

OR 

A patient with any acute respiratory illness AND having been in contact with a confirmed or probable COVID-19 case (see definition of contact) in the last 14 days prior to symptom onset; 

OR 

A patient with severe acute respiratory illness (fever and at least one sign/symptom of respiratory disease, e.g., cough, shortness of breath; AND requiring hospitalization) AND in the absence of an alternative diagnosis that fully explains the clinical presentation. 

Probable case: Any suspect case for whom testing for COVID-19 is inconclusive or is tested positive  using a pancoronavirus assay and without laboratory evidence of other respiratory pathogens. 

OR 

A suspect case for whom testing could not be performed for any reason 

OR 

Any suspect case or death with epidemiologic link to confirmed cases or outbreak 

OR 

Any suspect case with typical appearance of COVID-19 in Chest Computed Tomography (CT) or chest x-rays. 

Confirmed case: An individual (contact or suspect case) with a laboratory-confirmed COVID-19 by  real-time reverse-transcription polymerase chain reaction (rRT-PCR). 

OR 

A  suspect  case  with  a  strong  epidemiological  link  to  COVID-19  patient  and  detection  of  antigen using validated/adequate direct SARS-CoV-2 antigen detection tests. 

OR 

A suspect case with a strong epidemiological link to COVID-19 patient and detection of exposure to virus (Antibodies – IgM and/or IgG, IgA) using validated/adequate serology tests (indirect antibody  detection tests). 

Clinical Diagnosis 

Most common symptoms: 

  • Fever, Dry Cough and Tiredness

Less common symptoms: 

  • Headache,  Sore  throat,  Loss  of  taste  or  smell, Chills,  Runny  nose,  Headache,  Chest  pain, Muscle aches, Diarrhea, Conjunctivitis, Skin rash or Discoloration of fingers or toes 

Serious symptoms- Severe Acute Respiratory Infection (SARI): 

  • Difficulty breathing or shortness of breath
  • Chest pain or pressure
  • Loss of speech or movement

The  risk  of  serious  illness  from COVID-19 includes  serious  heart  diseases,  such  as  heart  failure,  coronary  artery  disease  or  cardiomyopathy,  Cancer,  Chronic  obstructive  pulmonary  disease  (COPD), Type 2 diabetes, Type 1 diabetes, Asthma, Liver Disease, Cystic Fibrosis, Severe obesity,  Chronic  kidney  disease,  Sickle  cell  disease,  Immunocompromized  patients  by  solid  organ  transplants, bone marrow transplant, HIV or cancer medications. 

Laboratory Investigation 

Rule out Community-Acquired Pneumonia (Streptococcus pneumonia, Haemophilus influenza type  b, Staphylococcus aureaus, Klebsiella pneumoniae, Legionella pneumophila, Influenza viruses, and  Respiratory Syncytial virus). 

Specimen collection, processing, and laboratory testing shall follow biosafety procedures. 

  • Collect blood cultures for bacteria that cause pneumonia and sepsis, ideally before antimicrobial therapy.
  • DO NOT delay antimicrobial therapy while waiting for blood culture results.
  • Collect specimens     from     BOTH     the    upper     respiratory       tract         (URT: nasopharyngeal and oropharyngeal) AND lower respiratory tract (LRT: expectorated sputum, endotracheal aspirate, or Broncho alveolar lavage) for SARS-CoV-2 testing by RT-PCR.

Clinicians may elect to collect only LRT samples when these are readily available (for example, in mechanically ventilated patients).

  • Use appropriate PPE for specimen collection (droplet and contact precautions for URT specimens; airborne precautions for LRT specimens).
  • When collecting URT  samples,  use  viral  swabs  (sterile  Dacron  or  Rayon,  not  cotton)  and  viral transport media.

Note: Do not take sample from the nostrils or tonsils 

Where  feasible  both  URT  and  LRT  specimens  can  be  tested  for  other  respiratory  viruses  like  Influenza A  and  B (including zoonotic influenza A), Respiratory syncytial virus,  Parainfluenza viruses,  Rhinoviruses,  Adenoviruses, Enteroviruses  (e.g.  EVD68),  Human  meta  pneumovirus, and Endemic human coronaviruses (i.e. HKU1, OC43, NL63, and 229E). 

Testing

  • Routine confirmation of cases of COVID-19 is based on detection of unique sequences of virus  RNA  by  Nucleic  acid  amplification  tests  (NAAT)  such  as  real-time  reverse-transcription polymerase chain reaction (rRT-PCR).
  • Serological testing (indirect antibody detection tests) can aid investigation of an ongoing outbreak and retrospective assessment of the attack rate or extent of an outbreak.
  • Viral  sequencing  to  providing  confirmation  of  the  presence  of  the  virus,  regular sequencing of a percentage of specimens from clinical cases can be useful to monitor for viral genome mutations
  • Viral culture is not recommended as a routine diagnostic procedure.

Severity of Illness Categories 

  • Asymptomatic or Pre-Symptomatic Infection: Individuals who test positive for SARS-CoV-2 using a virologic test (i.e., a nucleic acid amplification test or an antigen test), but who have no symptoms that are consistent with COVID-19.
  • Mild Illness: Individuals who have any of the various signs and symptoms of COVID-19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste and smell) but who do not have shortness of breath, dyspnea, or abnormal chest imaging.
  • Moderate Illness:  Individuals  who  show  evidence  of  lower  respiratory  disease  during  clinical assessment or imaging and who have saturation of oxygen (SpO2) ≥94% on room air at sea level.
    • Severe Illness: Individuals who have SpO2 <94% on room air at sea level, a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2 /FiO2) <300 mmHg, respiratory frequency >30 breaths per minute, or lung infiltrates >50%.
  • Critical Illness:  Individuals  who  have  respiratory  failure,  septic  shock,  and/or  multiple  organ dysfunction.

Management 

  • All patients with suspected COVID-19 who have severe acute respiratory infection should be triaged and isolated at the first point of contact with the health care system. 
    Emergency treatment should be started based on disease severity.
  • For those presenting with mild illness, hospitalization may not be required unless there is concern about rapid deterioration. If there is only mild illness, providing care at home may  be considered if available. 
  • Moderate to severe and critical cases must be admitted for management.
  • Admitted cases must be monitored for early identification of deterioration and appropriate treatment  offered  as  per  national  treatment  protocol  for  moderate  to  severe  COVID-19  patients. 
  • Oxygen is the mainstay of therapy for those whose SpO2 drops according the guideline.
  • Recovered  patients  may  be  discharged  if  2  RT-PCR  taken  at  least  24  hours  apart  are negative with clinical recovery (temperature resolved for more than 48 hours and no need for oxygen therapy). 

Note 

  • All areas for treatment of COVID-19 patients should be equipped with pulse oximeters, functioning oxygen systems and  disposable,  single-use,  oxygen-delivering  interfaces  (nasal  cannula,  simple face mask, and mask with reservoir bag).
  • Use contact precautions when handling contaminated oxygen interfaces of patients with SARS- CoV-2 infection.

Early General Supportive Therapy and Monitoring 

Patients with SARI shall be managed in isolated critical care units 

Give  supplemental  oxygen  therapy immediately to patients with SARI and respiratory distress, hypoxemia, or shock.

  • Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2≥90% in non-pregnant adults and SpO2≥92-95 % in pregnant patients.
  • Children with emergency signs (obstructed or absent breathing, severe respiratory  distress,  central  cyanosis,  shock,  coma  or  convulsions)  should receive oxygen therapy during resuscitation to target SpO2≥94%; otherwise, the target SpO2 is≥90%.

Use conservative fluid management in patients with SARI when there is no evidence of shock.

  • Treat cautiously with intravenous fluids, because aggressive fluid resuscitation may worsen oxygenation, especially in settings limited availability of mechanical ventilation.

Give empiric antimicrobials to treat all likely pathogens causing SARI.

  • Azithromycin  500mg  (PO)  day  1  following  initial  assessment,  then  followed  by 500mg (PO) 8hourly on Days 2-5 when sepsis or superimposed pneumonia is suspected (based on the clinical diagnosis).
  • Give Steroids: Prednisolone 10mg to 20mg (PO) once a day for 7 days OR Dexamethasone 6mg (PO/ IV) once a day for up to 7days or until hospital discharge, based on patient's conditions in ICU / Critical Care Units

Give Supplements

  • Magnesium 300mg or 400mg (PO) once a day for 7days
  • Zinc 7mg (PO) for children aged 1– years of age, increasing up to 25mg (PO) for adults and females of any age who are pregnant or lactating
  • Vitamin C dose of 70-150mg 24hourly for 7 days

Closely monitor the patient’s clinical condition 12 hourly

  • Monitor signs of SARI, clinical deterioration, like rapidly progressive respiratory failure and sepsis, and apply supportive care interventions immediately.

Note:

  • Application of timely, effective, and safe supportive therapies is the cornerstone of therapy for patients that develop severe manifestations of SARS-CoV-2 infection. 
  • Do not routinely give systemic corticosteroids for treatment of viral pneumonia. No  survival  benefit  and  possible  harms  of avascular  necrosis,  psychosis,  diabetes,  and delayed viral clearance.
  • Corticosteroid should be used with caution in the treatment of COVID-19 patients < 7 days: corticosteroids are not recommended for patients with mild conditions

Focused Supportive Management  Infection Control: 

  • For health  care  workers  who  are  performing  aerosol-generating  procedures  on  patients with  COVID-19,  use  an  N95  respirator  (or  equivalent  or  higher-level  respirator)  rather than surgical masks, in addition to other personal protective equipment (i.e., gloves, gown, and eye protection such as a face shield or safety goggles)
  • Endotracheal intubation  in  patients  with  COVID-19  to  be  performed  by  health  care providers with extensive airway management experience, if possible
  • Intubation be performed using video laryngoscopy, if possible

Hemodynamic Support: 

  • Norepinephrine as the first-choice vasopressor
  • For adults with COVID-19 and refractory septic shock who are not receiving corticosteroids to treat their COVID-19 Low-dose corticosteroid therapy (“shock-reversal”) over no corticosteroid therapy 

Ventilatory Support: 

  • For adults  with  COVID-19  and  acute  hypoxemic  respiratory  failure  despite  conventional oxygen  therapy,  high-flow  nasal  cannula  (HFNC)  oxygen  over  noninvasive  positive pressure ventilation (NIPPV) (BI).
  • For patients with persistent hypoxemia despite increasing supplemental oxygen requirements in whom endotracheal intubation  is  not  otherwise  indicated,  considering  a  trial  of  awake  prone  positioning  to  improve oxygenation 
  • For mechanically ventilated adults with COVID-19 and acute respiratory distress syndrome (ARDS), use low tidal volume (VT) ventilation (VT 4–8 mL/kg of predicted body weight) over higher tidal volumes (VT >8 mL/kg)
  • For mechanically  ventilated  adults  with  COVID-19  and  refractory  hypoxemia  despite optimized ventilation, prone ventilation for 12 to 16 hours per day over no prone ventilation

Acute Kidney Injury and Renal Replacement Therapy: 

  • For critically  ill  patients  with  COVID-19  who  have  acute  kidney  injury  and  who  develop indications for renal replacement therapy, provide continuous renal replacement therapy (CRRT),  if  available.  If  CRRT  is  not  available  or  not  possible  due  to  limited  resources, provide prolonged intermittent renal replacement   therapy rather than intermittent hemodialysis

Pharmacologic Interventions: 

  • For the  therapeutic  management  of  patients  with  COVID-19  use  of  Dexamethasone  and Remdesivir, either alone or in combination.
  • In patients  with  COVID-19  and  severe  or  critical  illness,  there  are  insufficient  data  to recommend empiric broad-spectrum antimicrobial therapy in the absence of another indication. 

Implementation of additional Precautions for suspected SARS-CoV-2 infections 

Contact and Droplet precautions for suspected SARS-CoV-2 infection: 

  • Place patients in adequately ventilated single rooms. For naturally ventilated general ward rooms this is considered to be 160 L/second/patient;
  • Apply  Infection  prevention  and  control  measures  when  providing  health  care  where  novel coronavirus (SARS-CoV-2) infection is suspected, the Interim Guidance is to:
    • Place patient beds at least 1m apart;
    • Where possible, cohort HCWs to exclusively care for cases to reduce the risk of spreading transmission due to inadvertent infection control breaches;
    • Use of PPE (medical mask, use eye/facial protection (i.e. goggles or a face shield); Use a clean, non-sterile, long-sleeved fluid resistant gown; Use gloves)
    • 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;
    • 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;
    • Maintain a record of all persons entering the patient’s room including all staff and visitors.

Prevention 

Application of Standard Precautions for all patients and people at risks in the public include hand  and respiratory hygiene; use of personal protective equipment (PPE) depending on risk; in hospitals  use safe waste management; environmental cleaning and sterilization of patient-care equipment and linen. Ensure the following respiratory hygiene measures. 

  • Offer a medical mask (N95) or double cloth mask in health care settings
  • 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) 

  • Rational,  correct,  and  consistent  use  of  available  PPE  and  appropriate  hand  hygiene  helps  to  reduce the spread of the pathogens. PPE effectiveness depends on adequate and regular supplies,  adequate staff training, proper hand hygiene and specifically appropriate human behavior. 

Health care workers and Administrators should ensure that environmental cleaning and disinfection  procedures are followed consistently and correctly. Thorough cleaning of environmental  surfaces with water and detergent and applying commonly used hospital level disinfectants (such  as sodium hypochlorite)  is  an  effective  and  sufficient  procedure.  Laundry,  food  service  utensils  and  medical waste should be managed in accordance with safe routine procedures. 

Public Health Control Measures 

  • Establish an alert management system e.g. call center with hotlines.
  • Verify the alerts to determine if they meet the standard case definition for COVID-19.
  • Respond as for suspected case if they meet the standard case definition.
  • Record all alerts in an alert/rumor log sheet.
  • Provide epidemiological information to conduct risk assessment at the national, regional and global level.
  • Conduct epidemiological investigation to identify risk factors for infection and populations at risk for severe disease.
  • Maintain  strict  acute  respiratory  disease  infection  control  practices  throughout  the epidemic.
  • Mobilize the community for early detection and care and conduct community education about how the disease is transmitted and how to implement IPC at the home care setting and during funerals and burials. Consider social distancing strategies.
  • Conduct contact follow-up and active searches for additional community cases or deaths that may not come to the health care setting.
  • Distribute laboratory specimen collection kits to health care facilities.
  • Establish treatment unit to handle additional cases that may come to the health center in line with the national protocols.
  • Maintain  strict  acute  respiratory  disease  infection  control  precautions  and  establish  an isolation ward to manage additional cases who may present for care.