2. Coronaviruses are important human and animal pathogens that can cause
diseases ranging from the common cold to more severe and even fetal
respiratory infections.
At the end of 2019, a novel coronavirus was identified as the cause of a
cluster of pneumonia cases in Wuhan, a city in the Hubei Province of China.
It rapidly spread, resulting in an epidemic throughout China, followed by an
increasing number of cases in other countries throughout the world.
3. Evidence indicates that substantial similarities exits between severe acute
respiratory syndrome and covid-19.A recent study reported a 79.5%
genome sequence identity between SARS-cov-2 and SARS COV-1.
6. In February 2020, the World Health Organization designated the disease
COVID-19, which stands for coronavirus disease 2019 . The virus that
causes COVID-19 is designated severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2); previously, it was referred to as 2019-nCoV.
7. EPIDEMIOLOGY
Geographic distribution — Since the first reports of cases from Wuhan, a
city in the Hubei Province of China, at the end of 2019, more than 80,000
COVID-19 cases have been reported in China.
Increasing numbers of cases have also been reported in other countries
across all continents except Antarctica, and the rate of new cases outside
of China has outpaced the rate in China.
These cases initially occurred mainly among travelers from China and
those who have had contact with travelers from China . However,
ongoing local transmission has driven smaller outbreaks in some
locations outside of China, including South Korea, Italy, Iran, and Japan,
and infections elsewhere have been identified in travelers from those
countries .
8. Transmission
Person-to-person spread of severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) is thought to occur mainly via respiratory
droplets, resembling the spread of influenza.
9. With droplet transmission, virus released in the respiratory secretions when
a person with infection coughs, sneezes, or talks can infect another person
if it makes direct contact with the mucous membranes; infection can also
occur if a person touches an infected surface and then touches his or her
eyes, nose, or mouth.
Droplets typically do not travel more than six feet (about two meters) and
do not linger in the air
10. Viral RNA levels appear to be higher soon after symptom onset compared
with later in the illness [15]; this raises the possibility that transmission
might be more likely in the earlier stage of infection, but additional data
are needed to confirm this hypothesis.
11. VIROLOGY
Full-genome sequencing and phylogenic analysis indicated that the
coronavirus that causes COVID-19 is a betacoronavirus in the same
subgenus as the severe acute respiratory syndrome (SARS) virus (as well as
several bat coronaviruses).
Positive sense,single strandard RNA virus
12. The structure of the receptor-binding gene region is very similar to that of
the SARS coronavirus, and the virus has been shown to use the same
receptor, the angiotensin-converting enzyme 2 (ACE2), for cell entry .
The Coronavirus Study Group of the International Committee on
Taxonomy of Viruses has proposed that this virus be designated severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
13. Spectrum of illness severity
In a study describing 138 patients with COVID-19 pneumonia in Wuhan
Mild (no or mild pneumonia) was reported in 81 percent.
Severe disease (eg, with dyspnea, hypoxia, or >50 percent lung
involvement on imaging within 24 to 48 hours) was reported in 14
percent.
Critical disease (eg, with respiratory failure, shock, or multiorgan
dysfunction) was reported in 5 percent.
The overall case fatality rate was 2.3 percent; no deaths were reported
among noncritical cases.
14. Impact of Age
In several cohorts of hospitalized patients with confirmed COVID-19, the
median age ranged from 49 to 56 years .
In a report from the Chinese Center for Disease Control and Prevention
that included approximately 44,500 confirmed infections, 87 percent of
patients were between 30 and 79 years old .
Older age was also associated with increased mortality, with a case fatality
rate of 8 and 15 percent among those aged 70 to 79 years and 80 years or
older, respectively.
15. Clinical manifestations
Initial presentation — Pneumonia appears to be the most frequent
serious manifestation of infection, characterized primarily by fever, cough,
dyspnea, and bilateral infiltrates on chest imaging . There are no specific
clinical features that can yet reliably distinguish COVID-19 from other viral
respiratory infections.
16. In a study describing 138 patients with COVID-19 pneumonia in Wuhan, the
most common clinical features at the onset of illness were
Fever in 99 percent
Fatigue in 70 percent
Dry cough in 59 percent
Anorexia in 40 percent
Myalgias in 35 percent
Dyspnea in 31 percent
17. Other, less common symptoms have included headache, sore throat,
anosmia and rhinorrhea. In addition to respiratory symptoms,
gastrointestinal symptoms (eg, nausea and diarrhea) have also been
reported in some patients, but these are relatively uncommon.
18.
19. Acute respiratory distress syndrome (ARDS) is a major complication in
patients with severe disease.
In the study of 138 patients described above, ARDS developed in 20
percent after a median of eight days, and mechanical ventilation was
implemented in 12.3 percent .
In another study of 201 hospitalized patients with COVID-19 in Wuhan, 41
percent developed ARDS; age greater than 65 years, diabetes mellitus, and
hypertension were each associated with ARDS .
Other complications have included arrhythmias, acute cardiac injury, and
shock. In one study, these were reported in 17, 7, and 9 percent,
respectively .
20. Laboratory findings
In patients with COVID-19, the white blood cell count can vary.
Leukopenia, leukocytosis, and lymphopenia have been reported,
although lymphopenia appears most common .
Elevated lactate dehydrogenase and ferritin levels are common, and
elevated aminotransferase levels have also been described.
High D-dimer levels and more severe lymphopenia have been associated
with mortality
21. Imaging findings
Chest CT in patients with COVID-19 most commonly demonstrates
ground-glass opacification with or without consolidative abnormalities,
consistent with viral pneumonia .
Case series have suggested that chest CT abnormalities are more likely
to be bilateral, have a peripheral distribution, and involve the lower lobes.
Less common findings include pleural thickening, pleural effusion, and
lymphadenopathy
22. 79-year-old woman who presented with fever, dry cough, and chest pain for 3 days. Her husband and daughter-in-law
had been recently diagnosed with coronavirus disease 2019 (COVID-19). Patient expired 11 days after admission
(Courtesy of Song F, Shanghai Public Health Clinical Center, Shanghai, China)
A, Axial (A) and coronal (B) CT images show multiple patchy, peripheral, bilateral areas of ground-glass opacity.
23. 79-year-old woman who presented with fever, dry cough, and chest pain for 3
days. Her husband and daughter-in-law had been recently diagnosed with
coronavirus disease 2019 (COVID-19). Patient expired 11 days after admission
(Courtesy of Song F, Shanghai Public Health Clinical Center, Shanghai, China)
B, Axial (A) and coronal (B) CT images show multiple patchy, peripheral, bilateral
24. 47-year-old Chinese man with 2-day history of fever, chills, productive cough, sneezing, and fatigue who presented to
emergency department. (Courtesy of Liu M, China-Japan Friendship Hospital, Beijing, China)
A, Initial CT images obtained show small round areas of mixed ground-glass opacity and consolidation (rectangles) at
at level of aortic arch (A) and ventricles (B) in right and left lower lobe posterior zones.
25.
26. EVALUATION AND DIAGNOSIS
At present, the possibility of COVID-19 should be considered primarily in
patients with fever and/or respiratory tract symptoms (eg, cough,
dyspnea) who have had any of the following in the prior 14 days:
27. Close contact with a confirmed or suspected case of COVID-19, including
through work in health care settings. Close contact includes being within
approximately six feet (about two meters) of a patient for a prolonged
period of time while not wearing personal protective equipment or having
direct contact with infectious secretions while not wearing personal
protective equipment.
28. Residence in or travel to areas where widespread community transmission
has been reported (eg, China, South Korea, most of Europe [including
Italy], Iran, Japan).
●Potential exposure through attendance at events or spending time in
specific settings where COVID-19 cases have been reported
29. In the United States, the CDC recommends collection of a nasopharyngeal
swab specimen to test for SARS-CoV-2 [64]. An oropharyngeal swab can
be collected but is not essential; if collected, it should be placed in the
same container as the nasopharyngeal specimen. Sputum should only be
collected from patients with productive cough; induction of sputum is not
indicated.
30. SARS-CoV-2 RNA is detected by reverse-transcription polymerase chain
reaction (RT-PCR).
A positive test for SARS-CoV-2 confirms the diagnosis of COVID-19. If
initial testing is negative but the suspicion for COVID-19 remains, the WHO
recommends resampling and testing from multiple respiratory tract sites .
The accuracy and predictive values of SARS-CoV-2 testing have not been
systematically evaluated. Negative RT-PCR tests on oropharyngeal swabs
despite CT findings suggestive of viral pneumonia have been reported in
some patients who ultimately tested positive for SARS-CoV-2
33. MANAGEMENT
Site of care
Home care — Home management is appropriate for patients with mild
infection who can be adequately isolated in the outpatient setting .
Management of such patients should focus on prevention of
transmission to others and monitoring for clinical deterioration, which
should prompt hospitalization.
34. Hospital care — Some patients with suspected or documented COVID-19
have severe disease that warrants hospital care. Patients with severe
disease often need oxygenation support. High-flow oxygen and
noninvasive positive pressure ventilation have been used, but the safety
these measures is uncertain, and they should be considered aerosol-
generating procedures that warrant specific isolation precautions.
Some patients may develop acute respiratory distress syndrome and
warrant intubation with mechanical ventilation; extracorporeal membrane
oxygenation may be indicated in patients with refractory hypoxia
35. Supportive therapy
Vitals signs and oxygen saturation should be monited regularly,supportive
treatment strengthened , sufficient calories provided, and the stability of
the internal environment,such as water ,electrolyte and acid-base balance
maintained.The intake and output volumes should be strictly balanced.
36. Limited role of glucocorticoids
The WHO and CDC recommend glucocorticoids not be used in patients
with COVID-19 pneumonia unless there are other indications (eg,
exacerbation of chronic obstructive pulmonary disease) .
Glucocorticoids have been associated with an increased risk for mortality
in patients with influenza and delayed viral clearance in patients with
Middle East respiratory syndrome coronavirus (MERS-CoV) infection.
Although they were widely used in management of severe acute
respiratory syndrome (SARS), there was no good evidence for benefit,
and there was persuasive evidence of adverse short- and long-term harm
38. Remdesivir – Several randomized trials are underway to evaluate the
efficacy of remdesivir for moderate or severe COVID-19 .
Remdesivir is a novel nucleotide analogue that has activity against severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in vitro and
related coronaviruses (including SARS and MERS-CoV) both in vitro and in
animal studies
Any clinical impact of remdesivir on COVID-19 remains unknown.
39. Compassionate Use of Remdesivir for
Patients with Severe Covid-19
In this cohort of 61 patients hospitalized for severe Covid-19 who were
treated with compassionate-use remdesivir, clinical improvement was
observed in 36 of 53 patients (68%). Measurement of efficacy will require
ongoing randomized, placebo-controlled trials of remdesivir therapy.
(Funded by Gilead Sciences.)
40. Chloroquine/hydroxychloroquine – Both chloroquine and
hydroxychloroquine inhibit SARS-CoV-2 in vitro, although
hydroxychloroquine appears to have more potent antiviral activity [78]. A
number of clinical trials are underway in China to evaluate the use of
chloroquine or hydroxychloroquine for COVID-19
41. Lopinavir-ritonavir – This combined protease inhibitor, which has primarily
been used for HIV infection, has in vitro activity against the SARS-CoV and
appears to have some activity against MERS-CoV in animal studies . The
use of this agent for treatment of COVID-19 has been described in case
reports , but its efficacy is unclear. In one report of five patients who were
treated with lopinavir-ritonavir, three improved and two had clinical
deterioration; four had gastrointestinal side effects. It is being evaluated in
larger randomized trials.
42. A Trial of Lopinavir–Ritonavir in Adults
Hospitalized with Severe Covid-19
In hospitalized adult patients with severe Covid-19, no benefit was
observed with lopinavir–ritonavir treatment beyond standard care. Future
trials in patients with severe illness may help to confirm or exclude the
possibility of a treatment benefit
43. Tocilizumab – Treatment guidelines from China's National Health
Commission include the IL-6 inhibitor tocilizumab for patients with severe
COVID-19 and elevated IL-6 levels; the agent is being evaluated in a
clinical trial
46. Coronavirus in Singapore,Hong kong and Japan Lessons
from highly functioning health system
Rapid adaptation of surveillance system; rapid test
Selective use of travel restriction
Early effective inter-governmentalcordination
Shifted costs of treatment to government
Develped lans for sustaining health care system
Actively managed supply chain
Emphasized infection prevention and protection HCW.
47. Preventing exposure in the
community —
The following general measures are recommended to reduce
transmission of infection:
Diligent hand washing, particularly after touching surfaces in public. Use
of hand sanitizer that contains at least 60 percent alcohol is a reasonable
alternative if the hands are not visibly dirty.
Respiratory hygiene (eg, covering the cough or sneeze).
48. ●Avoiding touching the face (in particular eyes, nose, and mouth).
●Avoiding crowds (particularly in poorly ventilated spaces) if possible and
avoiding close contact with ill individuals.
●Cleaning and disinfecting objects and surfaces that are frequently
touched.
49. REFERENCES
Centers for Disease Control and Prevention. 2019 Novel coronavirus, Wuhan, Chi
. Information for Healthcare Professionals. https://www.cdc.gov/coronavirus/2019
nCoV/hcp/index.html (Accessed on February 14, 2020).
World Health Organization. Novel Coronavirus (2019-nCoV) technical guidance.
tps://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guida
nce (Accessed on February 14, 2020).
Gorbalenya AE, Baker SC, Baric RS, et al. Severe acute respiratory syndrome-relat
coronavirus: The species and its viruses – a statement of the Coronavirus Study G
oup. bioRxiv 2020. https://www.biorxiv.org/content/10.1101/2020.02.07.937862v1 (
Accessed on February 12, 2020).
Zhu N, Zhang D, Wang W, et al. A Novel Coronavirus from Patients with
Pneumonia in China, 2019. N Engl J Med 2020; 382:727.
Lu R, Zhao X, Li J, et al. Genomic characterisation and epidemiology of 2019
coronavirus: implications for virus origins and receptor binding. Lancet 2020;
395:565.
ACE Inhibitors and ARBs During the COVID-19 Pandemic
Convalescent plasma as a potential therapy for COVID-19
Long Chen,Jing Xiong,Lei Bao,Yuan Shi
