Coronavirus outbreak 2019-2020. The current situation in India. Pediatric profile, management. Pictures are taken freely available on internet.

1. dddd
CORONAVIRUS
OUTBREAK
DR. DEEPAK KUMAR
Associate Professor
Pediatrics, MAMC
2019-2020

2. Corona = “Crown”

3. Coronavirus
• Enveloped RNA virus
Etiological agent for -
• COVID-19-Corona Virus Disease 2019
• SARS - Severe Acute Respiratory Syndrome,
2002-03
• MERS - Middle East Respiratory Syndrome,
2012-present
*Different strains

4. Origin
• Dec, 2019 novel coronavirus (2019-nCoV)
• First identified in Wuhan, China
• Huanan seafood market (a wet market)
• Large variety of animals, wild caught and farm
raised, are sold
• Spread from animals (? Bats)

7. Current Status
• Total cases- 119,225
• Deaths- 4299 {3,587 (in China) + 686(other)}
• Number of countries/areas/territories- 104
• Active cases- 48,357
• Closed- 66569
Situation Report 11th March, 2020, last updated 10:30 am

8. Country Total New Death Recovered Serious
China 80904 45 3123 61,493 4492
Diamond
Princess
696 7 10 35
S. Korea 7382 248 51 288 54
Italy 10149 1492 631 1004 877
Japan 488 33 7 23 7
Singapore 150 12 0 53 7
Iran 8042 743 291 2731 -
USA 1010 16 31 15 10
India 62 9 0 4

10. How many cases in India?
S.
No
Name of State/UT Total confirmed
cases (Indian)
Total confirmed
cases (Foreign)
1. Delhi 4 0
2. Haryana 0 14
3. Kerala 9 0
4. Rajasthan 0 2
5. Telangana 1 0
6. Uttar Pradesh 9 0
7. Union Territory of Ladakh 2 0
8. Tamil Nadu 1 0
9. Union Territory of Jammu and Kashmir 1 0
10 Punjab 1 0
11 Maharashtra 2 0
12 Karnataka 4 0
Total number of confirmed cases 34 16
Ministry of Health and Family Welfare, March 11, 2020

11. Pediatric Patients In India
1st case- 3 year/M
• Detected on 9th March
2020
• Diagnosed in Kochi,
Kerala
• Admitted in Ernakulum
Medical College, family
quarantined
• Had travelled to Italy,
returned on 7th March
2nd case- 13 years/F
• Detected on 11th March
2020
• Diagnosed in Bangalore,
Karnataka
• School quarantined
• Had returned from USA

12. • Elderly and those with underlying disease-
serious
• Symptoms in children are relatively mild
• Death cases - elderly and those with chronic
underlying diseases

13. Age-wise Fatality
AGE DEATH RATE
80+ years old 14.8%
70-79 years old 8.0%
60-69 years old 3.6%
50-59 years old 1.3%
40-49 years old 0.4%
20-39 years old 0.2%
10-19 years old <0.1%
0-10 years old NIL
Guan et al, China Medical Treatment Expert Group for COVID-19, NEJM, Feb2020

14. Pre-morbid conditions
PRE-EXISTING
CONDITION
DEATH RATE
(confirmed cases)
Cardiovascular disease 13.2%
Diabetes 9.2%
Chronic respiratory
disease
8.0%
Hypertension 8.4%
Cancer 7.6%
No pre-existing
conditions
0.9%
Guan et al, China Medical Treatment Expert Group for COVID-19, NEJM, Feb2020

15. Transmission
• Incubation period = 2 to 14 days
• Mean incubation period found- 5 days.
• Mode of transmission – droplet infection,
direct contact, close contact.
• Doesn’t transmit via air currents.
• Transplacental, Breast milk - not proven

16. Clinical Features
Common symptoms
•Fever
•Cough
•Breathlessness
•Myalgia
•Sore throat
Uncommon symptoms
•Diarrhea
•Vomiting
•Headache
•Chest pain
•Hemoptysis

17. Signs
• Mild symptoms - +/- signs
Severe condition-
• Tachypnea
• Crackles in lungs
• Decreased breath sounds
• Dullness on percussion

18. Pediatric Data
Parameter Number of patients affected (n=20)
Age- <1 month
1 month-1 year
1-6 years
>6 years
3 (15%)
6 (30%)
8 (40%)
3 (15%)
Positive contact history 13 (65%)
Fever 12 (60%)
Cough 13 (65%)
Tachypnea 2 (10%)
Diarrhoea 3 (15%)
Presence of comorbidities 7 (35%)
Xia et al, February 2020, Pediatric Pulmonology

19. Case Definition

20. SARI
• ARI with history of fever or measured temp. ≥38
C° and cough; onset within the last ~10 days; and
requiring hospitalization
CLOSE CONTACT
• Health care associated exposure
• Working together or sharing the same classroom
with nCoV patient
• Traveling together with nCov
• Living in the same household

21. When should I suspect COVID-19?
A patient with SARI AND
- History of travel to or residence in a high risk
region during the 14 days prior to symptom
onset
- OR in contact with a confirmed COVID-19
- OR requiring hospitalization with no other
etiology that fully explains the clinical
presentation

22. Confirmed case
• A person with laboratory confirmation of
2019-nCoV infection, irrespective of clinical
signs and symptoms.

23. Testing and Treatment Centers
Regional centers for Delhi state are-
Dr RMLH Safdarjung
• Samples are sent to NCDC or AIIMS, Delhi for testing.
• Test- RT PCR

24. Specimen type Collection materials Storage till testing
Nasopharyngeal and
Oropharyngeal swab
Dacron or polyester
flocked swabs
≤5 days: 4oC
>5 days: -70oC
Bronchoalveolar
lavage
Sterile container ≤48 hours: 4oC
>48 hours: -70oC
(Endo)tracheal
aspirate,
nasopharyngeal
aspirate or nasal wash
Sterile container ≤48 hours: 4oC
>48 hours: -70oC
Sputum Sterile container ≤48 hours: 4oC
>48 hours: -70oC
Serum (2 samples
acute and
convalescent possibly
2-4 weeks after acute
phase)
Serum separator tubes
(adults: collect 3-5 ml
whole blood)
≤5 days: 4oC
>5 days: -70oC

26. Other Investigations

27. Blood Investigations
• Leukopenia (80%)
• CRP – may be elevated
• Procalcitonin– normal in adults, raised in
children
• LDH elevated in 75% of patients (adults)
• CPK elevated in 33% of patients

28. Lab Parameters
PARAMETERS FINDINGS
TLC - <5500
5500-12200
>12200
4 (20%)
14 (70%)
2 (10%)
Lymphocyte percentage- <45
45-65
>65
7 (35%)
10 (50%)
3 (15%)
CRP>3 7 (35%)
PCT>0.05 16 (80%)
ALT>40 5 (25%)
CK-MB >25 5 (25%)
Xia et al, Feb 2020, Pediatric Pulmonology

29. Radiological findings
• Ground glass appearance (MC)
• Infiltrates
• Consolidation
• Mottling
• Pleural effusion is rare
None of them specific for COVID 19

33. “Halo Sign”

34. Radiological findings
Parameter Number of patients
Radiological findings-
• Ground glass
opacities ( X-ray)
• Consolidation with
Halo sign (X-ray & CT)
• Reticular opacities
• Tiny nodules
20 (100%)
12 (60%)
10 (50%)
4 (20%)
Xia et al, February 2020, Pediatric Pulmonology

35. TREATMENT

36. Principles
• Designated hospitals with effective isolation
and protection
• Suspected cases - single room
• All confirmed cases - same ward
• Critical cases- ICU as soon as possible

37. Treatment
• Bed Rest
• Monitor for vital signs
• Supportive treatment – energy intake and
balance for water, electrolytes
• Monitor for blood routine, CRP, PCT, organ
function, ABG analysis and chest imaging
• Effective oxygen therapy

38. Specific therapy??
• > 100 trials are being conducted in China
• Including – Antivirals, Antimalarials, Steroids,
Traditional chinese medications
• Earliest possible reports of RCT’s expected-
April 2020
• Most ?promising drugs – Remdesivir,
Lopinavir/Ritonavir (Few Case reports)

39. DRUGS
WHO
Recommendations Comments
Remdesivir For Research purposes Used in SARS, MERS
outbreak
Lopinavir/Ritonavir For Research purposes Used in prev.
outbreaks
Interferon-gamma NO Used in prev.
outbreaks
Oseltamivir NO
Chloroquine NO Inhibits SARS virus in
vitro
Steroids NO ? Role in ARDS
Ganciclovir NO

40. Remdesivir
- Broad spectrum antiviral
- Inhibits RNA polymerase
- Used for Ebola, MERS and SARS
- Safer to used compared to Lopinavir/Ritonavir
- WHO recommend its use for the research
purposes only
- Not available in India

41. Lopinavir/Ritonavir
• Protease inhibitor used in HIV
• Numerous trials being conducted
• No recommendations
• Can be used in Covid-19, severe pneumonia
• Twice a day, for 7 to 14 days (adults)

42. Supportive
• Antipyretics
• Nutritional
• Anti-ulcers

43. VACCINES
• Developed by Modern Pharmaceuticals
• Within 42 days of outbreak
• m- RNA vaccine
• Phase -1 trial on 100 healthy subjects
• Results- expected next year
• Other – CureVac and GlaxoSmithKline- in
preclinical stage

44. Preventive measures

45. Frequent hand washing
• Recommended for at least 20 seconds
• Using Soap and water – adequate
• Alcohol based Hand rubs can be used
• All the steps of hand washing has to be
followed each time
• Demonstrate the steps!!

46. Cough and sneezing etiquettes
• Use of disposable napkins- to be thrown after
every use.
• If not available, sneeze/cough in the elbow.

47. Should I use N 95 mask?
Indications for N-95 masks
• For health care workers handling positive patients
during
– Intubation
– Open suctioning
– Bronchoalveolar lavage
– Nebulization
– Non Invasive Ventilation
– In patients with Tracheostomy tube
– During CPR

48. Travel restrictions
China, South korea, Japan, Iran, Italy
Avoid non-essential travel!!
GOI- 06.03.20

49. TAKE HOME MESSAGE
• DO NOT PANIC
• Total number of cases in India-62
• Total number of deaths in India- 0
• Pediatric cases in India- only 1
• Community spread has not been reported
• Take all precautions
• Guidelines may change as the number
increases

50. Do not spread jokes, Covid-19 Kills!!!
PYAARHAI!!
THANK YOU
Helpline Number : +91-11-23978046
Email- ncov2019@gmail.com