COVID-19 - For indian healthcare professionals

1. COVID-19 #lets fight Dr.Shreyas.K PG in ENT JJMMC, Davangere, Karnataka.

2. CORONA VIRUS • cause illness in animals or humans. • In humans coronaviruses are known to cause respiratory infections • ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). • The most recently discovered coronavirus causes coronavirus disease COVID-19.

3. SARS-COV 2 • Severe acute respiratory syndrome corona virus 2 • New strain of corona virus • Unknown before outbreak in Wuhan,China in December 2019 • Previously called 2019 novel coronavirus. • ICTV(International Committee on Taxonomy of Viruses) announced SARS-CoV-2 as the name of the new virus on 11 February 2020. • This name was chosen because the virus is genetically related to the coronavirus responsible for the SARS outbreak of 2003. While related, the two viruses are different.

4. COVID -19 • COrona Virus Disease 2019 • WHO announced “COVID-19” as the name of this new disease on 11 February 2020. • Incubation period- not confirmed. • 1-14 days as suggested by WHO. • From 5 days to as long as 28 days as seen in various patients.

5. DISEASE TRANSMISSION • People can catch COVID-19 from others who have the virus. • droplets spread- when a person with COVID-19 coughs or exhales. • touching these objects or surfaces contaminated with droplets, then touching their eyes, nose or mouth. • if they breathe in droplets from a person with COVID-19 who coughs out or exhales droplets. • This is why it is important to stay more than 1 meter (3 feet) away from a person who is sick. • How long the virus stays on surfaces is also not confirmed.(WHO)

6. PRESENTING SYMPTOMS: • fever, tiredness, and dry cough. • aches and pains. • nasal congestion, runny nose, sore throat. • diarrhea. • Anosmia may appear early in these individuals. • Difficulty in breathing at later stages. • symptoms are usually mild and begin gradually. • Most people (about 80%) recover from the disease without needing special treatment.

7. AT RISK PATIENTS: • Around 1 out of every 6 people who gets COVID-19 becomes seriously ill and develops difficulty breathing . • Elderly and children • Hypertensive • Diabetic • Cardiac patients • Asthma • Immunosuppressed/immunocompromised

8. COMPLICATIONS: • Pneumonia(8-9days) • ARDS(8-9 days) • cardiac injury, arrhythmia. • Secondary infection,septic shock . • liver dysfunction, • acute kidney injury, • and multi-organ failure.

9. MYTHS – REALITY CHECK! • Affects only elderly. • Hot and humid climate kills the virus • Snow and cold climate kills the virus • Hot water bath is the solution. • Mosquito bite transmits the disease. • Pets transmit the disease. • ayurvedic/herbal medicine is effective. • Saline nasal wash is going to reduce transmission • Antibiotics will kill the virus. • UV rays,hand dryers kill the virus

10. PREVENTIVE MEASURES: • Regularly and thoroughly clean your hands with an alcohol-based hand rub or wash them with soap and water. • Maintain at least 1 metre (3 feet) distance between yourself and anyone who is coughing or sneezing. • Avoid touching eyes, nose and mouth. • follow good respiratory hygiene • cover your mouth and nose with your bent elbow or tissue when you cough or sneeze. • dispose of the used tissue immediately.

11. FOR PATIENTS WITH TRAVEL HISTORY • 14 days to 1 month travel history should be enquired. • Self-isolation and home quarantine. Avoid contact. • mild symptoms such as headache, low grade fever (37.3 C or above) and slight runny nose-wait and watch. • medical mask should be used; worn for as long as possible, if it can be tolerated, and changed at least once daily. • Persons who cannot tolerate a medical mask should rigorously apply respiratory hygiene . • Improve airflow in their living space by opening windows and doors as much as possible. • If symptoms worsen- patient develops fever, cough and difficulty breathing, medical help needed.

12. COVID-19 and PREGNANCY • No evidence to say pregnant ladies are at higher risk. • To be tested only if symptoms are present. • WHO advice is that caesarean sections should only be performed when medically justified in a pregnant COVID-19 patient. • The mode of birth should be individualized and based on a woman’s preferences alongside obstetric indications. • Can and should breastfeed the baby; adequate precautions like hand- hygiene should be maintained. • If too unwell to breastfeed the baby due to COVID-19 : provide baby with breastmilk in a way possible, available, and acceptable to the mother. (Expressing milk/Relactation/Donor human milk)

13. WHO guidelines on PPE for healthcare workers: • wear disposable gloves to protect hands, • clean, long-sleeve gown to protect clothes from contamination. • medical masks to protect nose and mouth, • and eye protection (e.g., goggles, face shield), • before entering the room where suspected or confirmed 2019-nCoV acute respiratory disease patients are admitted. • Respirators (e.g. N95) are only required for aerosol generating procedures.

14. CORRECT USE OF MEDICAL MASKS: • Place the mask carefully, ensuring it covers the mouth and nose, and tie it securely to minimize any gaps between the face and the mask. • Avoid touching the mask while wearing it. • do not touch the front of the mask but untie it from behind. • After removal or whenever a used mask is inadvertently touched, clean hands using an alcohol-based hand rub or soap and water if hands are visibly dirty. • Replace masks as soon as they become damp with a new clean, dry mask. • Do not re-use single-use masks. • Discard single-use masks after each use and dispose of them immediately upon removal. • Cloth (e.g. cotton or gauze) masks are not recommended under any circumstances.

15. ISOLATION OF CASES: • Prioritise the patient. Triage needed. • All suspected cases to be isolated. Preferably with designated attached washrooms. • should be housed in the same room for the duration of their stay in the facility (e.g., minimize room transfers). • Patients should wear a facemask to contain secretions during transport ,if to be shifted. • If patients cannot tolerate a facemask or one is not available, they should use tissues to cover their mouth and nose. • Notify the authorities immediately

16. • Personnel entering the room should use PPE as described above. • Ideally, suspected and confirmed 2019-nCoV acute respiratory disease patients should be isolated in single rooms. • However, when this is not feasible (e.g., limited number of single rooms), cohorting is an acceptable option. • A minimum of 1-meter distance between beds should be maintained at all times. • Once the patient has been discharged or transferred, should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles. • Time for reusing the room- not specified.

17. CURRENT TESTING STRATEGY: (ICMR GUIDELINES) • i) All asymptomatic people who have undertaken International travel: - They should stay in home quarantine for 14 days. - They should be tested only if they become symptomatic (fever, cough, difficulty in breathing etc.). - If test result is positive, then they should be isolated and treated as per the standard protocol.

18. • ii) All contacts of laboratory confirmed positive cases: - They should stay in home quarantine for 14 days. - They should be tested only if they become symptomatic (fever, cough, difficulty in breathing etc.). - If test result is positive, then they should be isolated and treated as per the standard protocol. • iii) Health care workers - managing respiratory distress / Severe Acute Respiratory illness should be tested when they are symptomatic.

19. HOW TO COLLECT NASAL/ OROPHARYNGEAL SWAB? • Doctor should wear a clean, long-sleeve gown, a medical mask, eye protection and gloves. • Procedure should be conducted in a separate/isolation room • request the patients to cover their mouth with a medical mask or tissue. • As the procedure has potential to induce fits of coughing from the patient • there is no currently available evidence that cough generated via NP/OP specimen collection leads to increased risk of COVID-19 transmission via aerosols.

20. INVESTIGATIONS REVEALED: (as per CDC)  leukopenia (9–25%),  leukocytosis (24–30%),  lymphopenia (63%), and  elevated alanine aminotransferase and aspartate aminotransferase levels (37%).  Multiple areas of consolidation and ground glass opacities are typical findings on Xray or CT chest.

21. TESTING GUIDELINES- ICMR RECOMMENDATION: • Only real time PCR assays for RNA viruses • In govt approved centres • And lab which has NABL accreditation. • Commercial kits should be US- FDA approved or European –CE certified or both –under emergency use- only under intimation to DCGI, MOH&FW. NOT RECOMMENDED: • Conventional PCR • In-house real time PCR • Ag-Ab tests

22. TREATMENT • As per symptoms and general condition of the patient. • Antibiotics-to prevent secondary infection. • Corticosteroids contraindicated. • No specific protocol advised. • Intubation and ventilator support as and when required. • No vaccines developed yet.

23. PROPHYLAXIS:

24. DISINFECTION: • WHO recommendations include the use of: • 70% Ethyl alcohol to disinfect reusable dedicated equipment (e.g., thermometers) between uses • Sodium hypochlorite at 0.5% (equivalent 5000ppm) for disinfection of frequently touched surfaces.

25. BIOMEDICAL WASTE MANAGEMENT: • According to National Health guidelines. (ICMR website) • Disposal in a biohazard bag containing 2% Lyzol or 55 freshly prepared sodium hypochlorite solution. • Bag should be sealed and disposed according to guidelines.

26. CONTAMINATED SOILED LINEN DISINFECTION: • All individuals dealing with soiled bedding, towels and clothes from patients with COVID-19 should wear appropriate personal protective equipment. • heavy duty gloves, mask, eye protection (face shield/goggles), long-sleeved gown, apron (if gown is not fluid resistant), boots or closed shoes before touching any soiled linen. • Never carry soiled linen against body; place soiled linen in a clearly labelled, leak-proof container (e.g. bag, bucket) • If there is any solid excrement on the linen, scrape it off carefully with a flat, firm object and put it in the designated toilet before putting linen in the designated container.

27. • If the latrine is not in the same room as the patient, place soiled excrement in covered bucket to dispose of in the toilet . • Wash and disinfect linen: washing by machine with warm water (60- 90°C) and laundry detergent is recommended for cleaning and disinfection of linens. • If machine washing is not possible, linen can be soaked in hot water and soap in a large drum, using a stick to stir, avoiding splashing. • If hot water not available, soak linen in 0.05% chlorine for approximately 30 minutes. • Finally, rinse with clean water and let linen dry fully in the sunlight.

28. REFERENCES: as per information available on 25.3.2020. • https://www.icmr.nic.in/ • https://www.who.int/ • https://www.cdc.gov/ • NOTE- Not based on whatsapp formats/news/protocols. • Content is subjective to change daily.so KEEP UPDATED FROM THESE SITES . • #INDIA fights Corona.Let’s do our part!