To prevent the spread of COVID-19: Clean your hands often. Use soap and water, or an alcohol-based hand rub. Maintain a safe distance from anyone who is coughing or sneezing. Wear a mask when physical distancing is not possible. Don’t touch your eyes, nose or mouth. Cover your nose and mouth with your bent elbow or a tissue when you cough or sneeze. Stay home if you feel unwell. If you have a fever, cough and difficulty breathing, seek medical attention. Calling in advance allows your healthcare provider to quickly direct you to the right health facility. This protects you, and prevents the spread of viruses and other infections. Masks Masks can help prevent the spread of the virus from the person wearing the mask to others. Masks alone do not protect against COVID-19, and should be combined with physical distancing and hand hygiene. Follow the advice provided by your local health authority.

1. 26 March 2020
COVID-19
The Basics
Pablo Perel
Jean Luc Eiselé
Kate Ralston
Welcome Everyone!
• Make sure your microphone is set to mute
• Please ask any questions through ‘Chat’

2. Outline
• Coronavirus
• COVID-19 Pandemic
• Characteristics of COVID-19
• Diagnostic
• Clinical Management
• Q & A

3. Viruses
• The smallest known infectious agents
• Replicate in living cells (use the cellular machinery to synthesize new
virus particles for the transfer of the viral genomes to uninfected cells)

4. Coronaviruses
• Coronaviruses are viruses that are causative agent
of common colds
• Two previous recent outbreaks due to
coronaviruses:
 SARS (2002-03) in Asia ~8000 cases & 800
deaths,
 MERS (2012-2019) in Saudi Arabia and 27
countries: ~2500 cases and ~800 deaths
• COVID-19 is an emerging viral disease due to a
new strain (SARS-CoV-2)

5. ?
SARS-CoV MERS-CoV SARS-CoV-2
HCoV- 229E
HCoV- NL63
HCoV- OC43
HCoV- HKU1
URTI
Zoonoses
Human
Coronaviruses

6. COVID19 Pandemic
• Originated in Wuhan, Hubei
province
• Zoonotic origin
– Hypothesis: animals in
Wuhan market?
• Person to person transmission
• By March 25th
– 416,686 confirmed cases
– 18,589 deaths
– 197 countries or territories

7. Ways of contagion
Droplets particles from the nose or
mouth which are spread when a
person coughs or exhales.
These droplets land on objects and
surfaces around the person.
This is why it is important to stay
more than 1 meter away from a
person who is sick.

8. Characteristics of COVID19
Incubation period: The time elapsed between exposure to the
virus, and when symptoms and signs are first apparent.
The incubation period for COVID-19 is thought to be within 14 days
following exposure, with most cases occurring approximately four to
five days after exposure.

9. Transmissibility
R0 is > 1 case numbers would increase
R0 = 0 case numbers are stable
R0 < 1 case numbers decrease.
Depends on 3 factors
how long people are infectious,
the probability of transmission per
contact between susceptible and
infected individuals,
and the average rate of such contacts
In Wuhan: between 2-3
R0: Average number of successful transmissions per
case when everyone in the population is susceptible.

10. Prognosis or clinical outcomes
for infectious diseases

11. COVID 19
Clinical presentation
• Mild (no or mild pneumonia)
reported in about 80 percent.
• Severe disease (eg, with
dyspnea, hypoxia, or >50 percent
lung involvement on imaging
within 24 to 48 hours) reported in
about 15 percent.
• Critical disease (eg, with
respiratory failure, shock, or
multiorgan dysfunction) reported
in 5 percent (these complications
mainly in elderly and those
with other health problems)

12. Clinical presentation at onset
https://www.ncbi.nlm.nih.gov/pubmed?term=32031570

13. Mortality
Case fatality risk is a measure of how serious a disease is, as it tells
you the proportion of people who die from the disease out of those
who have it (death/all cases)
• For MERS over a third
• SARS one in 10
• COVID-19 (2%) which is 1 in 50 people with the disease dying

14. Viral respiratory infections
1. The virus enters the respiratory
tract (mouth and nose)
2. The virus enters the mucous
membrane and starts
replicating  the respiratory
tract swells and is inflamed
3. The virus enters the lungs
and surrounding cells  more
symptoms begin to show

15. Isolation and identification of the virus

16. Isolation and identification of the virus

17. Isolation and identification of the virus
Analysis of the viral genome
confirmed this is a
coronavirus
Electron microscopy provides
access to 3D structure of the
virus at the atomic level

18. Normal cell

19. ACE2
receptor
Virus attachment, penetration,
replication, release

20. Detection of coronavirus
Gene detection = Direct virus detection
From Day 0 and only during infection
Serological detection = footprint of the virus
From Day 5-10 and for months/years
Immune
response

21. Direct virus detection
Polymerase Chain Reaction (PCR)

22. Direct virus detection
Polymerase Chain Reaction (PCR)

23. Direct virus detection
Polymerase Chain Reaction (PCR)

24. Antibodies are a trace of previous
infection

25. Clinical management
Two distinct situations:
1. Non serious presentation, outpatient setting
2. Unwell patients, requiring hospitalisation: pneumonia,
respiratory failure +/- acute respiratory distress most common
serious complications

26. Clinical management
1. Non serious presentation, outpatient setting
- Self isolate
- Look out for deterioration and signs of gravity
- Face mask (if available)
- Disinfect surfaces regularly
- No Covid test required (depends on capacity and local
recommendations)

27. Clinical management
How long to self isolate? (non test setting)
At least 7 days have passed since symptoms first appeared
AND
At least 72 hours have passed since recovery of symptoms (defined as
resolution of fever without the use of fever-reducing medications)
PLUS
improvement in respiratory symptoms (e.g., cough, shortness of breath)

28. Clinical management
2. Unwell patients, requiring hospitalisation : bilateral
pneumonia +/-respiratory failure or acute respiratory
distress
Cornerstones of management:
Infection control
Supportive care

29. Infection control
• Prompt testing and
presumption of
Covid19 contamination
until test proves
negative
• Strict infection control
measures to protect
patients and staff

30. Infection
control
• Separate Covid
patient work
streams to minimise
spread to other
services in the
hospital and other
patient presenting to
the Emergency
room

31. Supportive Measures
Measures which support the body against the consequences of the
infection, but do not fight the infection itself.
Covid 19 (and other infective agents causing pneumonia) can cause
disruption of two of the most vital necessities of the human body:
• oxygen transfer in the lungs into the blood
• ability of the blood to circulate to deliver oxygen to the tissues i.e.
circulatory failure or shock

32. Disruption of
oxygen
transfer in the
lungs
During lung infections (or
pneumonia) the mucous
and secretions produced
by the infective agent
and the bodies response
to it can impair the
alveoli’s ability to transmit
oxygen into the
bloodstream
This leads to impaired
oxygenation of the blood
called hypoxia (mild to
severe)

33. Signs and symptoms of respiratory
compromise
• Shortness of breath
• Rapid, shallow breathing
• Coughing
• Using accessory muscles to breath
• Not being able to talk in sentences
• Blueish tinge to extremities or lips/tongue

34. Managing respiratory failure
• Requires complex and skilled medical and nursing personnel
• Supplemental Oxygen. Depending on the severity of deoxygenation:
Mild support e.g. Oxygen via nasal prongs or mask: regular hospital
ward
Cpap/bipap (invasive but an external mask): High dependency unit
Ventilator support incl. intubation, sedation, continuous blood gas
monitoring: managed in the ICU
Aim is to assist the patient to keep up with the bodies need for oxygen
while the patient mounts an immune response which will improve the
situation so the patient is well enough to take over breathing again in
an adequate manner which delivers an adequate supply of oxygen.

35. Managing circulatory failure
• Severe infection can lead to a decrease in circulating blood volume
and blood pressure called shock.
• This is due to a number of complex factors involving both the
infectious agent itself and the body's own immune response.
• When the blood volume and blood pressure decrease so does the
body's ability to provide oxygen to every cell in the body.
• In order to support the bodies blood circulating volume there are a
number of supportive measures that can assist.

36. Managing circulatory failure
• Fluid resuscitation : increasing the circulating volume of the blood by
giving the patients fluids (direct in to veins via a catheter) which can
boost the volume of blood going through the system.
• Drug treatments : can act on different mechanisms in the body to
increase blood pressure e.g. increase the output of the heart, cause
veins to constrict to increase blood pressure, etc.
• Treat underlying cause : not possible in this case but in bacterial
pneumonia – antibiotics.
Aim is to assist the patient to sustain an adequate volume of
circulating blood at an adequate pressure until an immune response is
mounted which will improve the situation and the body can take over
and manage this on its own.

37. Managing organ failure
• As a result of the infective agent in the blood stream, the body's own
response to it and a situation of ‘shock’ the bodies organs can also stop
working effectively (= very bad news)
• This includes: kidneys, liver, heart, etc.
• There are a number of measures to counteract and mitigate the effects
on different organs and this is almost always within the ICU setting.
• Correcting circulatory failure and treating the underlying cause are key
to stopping this rapidly deteriorating situation.
• These patients are very unwell.

38. Essential
elements in the
healthcare
system
• Adequate covid 19 tests
• Adequate staff (with
appropriate training)
• Adequate protection for staff
(and patients)
• Adequate number of beds
for the very unwell (ICU) and
equipment (ventilators, etc.)
• Adequate capacity to keep
treating other medical
problems because although
attention is focused on covid
people don’t stop getting
sick for a variety if other
reasons

39. Hope on the horizon...

40. Questions & Answers
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• Please ask any questions through ‘Chat’

41. Thank you very much
Pablo Perel
Kate Ralston
Mihela Kralj
Paula Orrite
Cliff Hannan
Jean-Luc Eiselé
For enquiries, please contact:
communications@worldheart.org