Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new coronavirus that emerged in 2019 and causes coronavirus disease2019(COVID-19).1,2 SARS-CoV-2ishighlycontagious.Itdiffers from other respiratory viruses in that it appears that human-tohuman transmission occurs approximately 2 to 10 days prior to the individual becoming symptomatic.2–4 The virus is transmitted from person to person through respiratory secretions. Large droplets from coughing, sneezing or rhinorrhoea land on surfaces within 2 m of the infected person. SARS-CoV-2 remains viable for at least 24 hours on hard surfaces and up to 8 hours on soft surfaces.5 The virus is transferred to another person through hand contact on a contaminated surface followed by touching the mouth, nose or eyes. Aerosol airborne infected particles created during a sneeze or cough remain viable in the air for3 hours.5 These airborne particles of SARS-CoV2 can then be inhaled by another person or land on the mucosal membranes of the eyes.

1. Coronavirus Disease
(COVID-19)
DR. NIRAJ KUMAR , PT
BPT, MPT (ORTHO), MHA,
PH.D. PHYSIOTHERAPY (ORTHOPEDICS)*
ASSOCIATE PROFESSOR PHYSIOTHERAPY DEPT.
SHRI GURU RAI INSTITUTE OF PARAMEDICAL SCIENCES , DEHRADUN

2. COVID-19
 Current outbreak of an infectious disease throughout the world.
 Outbreak was declared a Public Health Emergency of
International Concern on 30 January 2020.
 WHO has officially named it Coronavirus Disease 2019 (COVID-
2019)

3. As on 7th March, 2020
 More than 90 countries affected
 Worst affected: China (>80,000 cases)
 South Korea: >5,000 cases
 Italy and Iran: around 3,000 cases
 More than 1 lakh infected
 More than 3,000 deaths
 Travel advisory for China, South Korea, Italy, Iran, and Japan

4. What causes COVID-19?
 A virus
 Virus was initially called 2019 novel coronavirus (2019-nCoV)
 Later renamed by WHO as severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2)
 SARS-CoV-2 belongs to a group of viruses called Coronaviruses
 Corona (Latin=crown)

6. What are the infections caused by
Coronaviruses?
 Respiratory: Common cold, sore throat, pneumonia, etc.,
 Gastro-intestinal: diarrhea
 Most cause mild disease
 Severe disease were earlier caused by:
1. SARS-CoV: China (2003) [CFR:9.6%]
2. MERS-CoV: Saudi Arabia (2012) [CFR: 34.4%]

7.  Coronaviruses infect both
humans and animals

8. How did COVID-19 start?
 In December, 2019, a cluster of pneumonia
cases was reported in a live animal (even
selling wild animals) market in Wuhan,
China
 However, person to person transmission
has resulted in a large number of cases
worldwide

9. What is the source?
 COVID-19 is a
zoonotic disease
 Animal reservoir of
COVID-19 are
probably bats
 Intermediate host is
probably pangolin
Pangolin

10. Why did the virus infect
humans?
 Probably the virus mutated to adapt in
humans (host adaptation)
OR
 Increased contact between humans and
animals containing the mutated virus

11. What are the important modes of
transmission?
 Primarily through droplets containing virus during coughing,
sneezing (upto 1 meter) [DROPLET ROUTE]
 Also, contact of droplets with eyes, nose, and mouth with
contaminated hands/fomites [CONTACT ROUTE]

12. What are the other modes
of transmission?
 Rarely airborne route, but this does not seem an important route
 Virus is isolated in stool, but feco-oral route does not seem important
route
 Additionally, from/to animals???

15. How long does the virus survive
on surfaces?
 Probably from a few hours upto several days depending
on the type of surface (based on data on SARS-CoV)
 Probably for 20-30 minutes on hand

16. What is the incubation period?
 For most cases: 2-14 days
 Average: 5 days

17. When are the patients infectious?
 Some in the incubation period may shed the shed the virus, but their
impact on the spread is minimal
 Asymptomatic persons can also shed the virus, but asymptomatic
patients are rare
 Virus shedding is maximum in patients exhibiting severe symptoms
 Virus shedding may occur after resolution of symptoms

19. How does the virus cause
disease?
 Protein S-spikes of the virus bind to Angiotensin Converting
Enzyme-2 (ACE-2) receptors
 ACE-2 receptors are present in lungs, heart, kidneys, stomach,
intestines, and other organs

20. Pathogenesis…cont’d
 Virus may spread to different organs through blood (viremia)
 Virus multiplies intracellularly and causes cell death by
diverting the cell’s protein synthesis apparatus for its own
use

22. How does the virus kill?
 Atypical Pneumonia Acute Respiratory Distress
Syndrome (most common)
 Kidney failure
 Cardiac failure
 Secondary bacterial pneumonia and sepsis

23. What are the specimens used for
diagnosis of COVID-19?
1. Nasal or throat swabs,
2. Sputum,
3. Broncho-alveolar lavage, etc.,

24. How is COVID-19 diagnosed?
 Reverse Transcriptase-Polymerase Chain Reaction (RT-
PCR) [Sensitivity of upto 70%, but high specificity]
 No serological test available so far

25. COVID-19 testing centers in India

26. Is there a more sensitive test than RT-PCR?
 Yes!
 Chest CT (Sensitivity of >95%, but less
specificity than RT-PCR)
 CT findings: Scattered bilateral ground glass
opacities consolidation crazy paving
pattern
 Chest X-ray not so sensitive as CT, but useful in
resource poor settings

27. Ground glass opacities in Chest CT

28. How many develop severe disease?
 Mild to moderate: 80%
 Severe (requiring admission and oxygen): 14%
 Critical (requiring ICU admission and life support): 6%
 Most cases are mild less reporting disease more widespread than
actual figures.

29. What is the case fatality/death rate (CFR)?
 Death rate=Number of deaths/Number of cases
 Crude fatality rate: 3.4%
 <0.4% (< 50 years) to 14.8% (>80 years)
 Disease in children: relatively rare and mild (CFR:0.2%)
 Note: This is very early data from China

30. CFR of COVID-19 based on age

31. What is the death rate in different comorbid
conditions?
Pre-existing condition Death rate of all cases
Cardiovascular disease 13.2%
Diabetes 9.2%
Chronic respiratory
disease
8.0%
Hypertension 8.4%
Cancer 7.6%
None 1.4%

32. When can patients be discharged from
the hospital?
 Absence of fever without use of anti-pyretics
 Absence of any other symptoms like cough
 Negative test for virus (RT-PCR) from respiratory
specimens taken atleast 24 hours apart

33. Is there a specific vaccine or treatment?
 Not yet!
 However, vaccines and treatment are in development,
and may be available in a few months
 Some early candidate drugs: Hydroxy Chloroquine,
Favipiravir (anti-Influenza), and Remdesivir (anti-Ebola)

34. How are patients managed in the
hospital?
 Only supportive care is given:
1. fluids,
2. oxygen,
3. ventilator,
4. dialysis,
5. inotropes, etc.,

35. How can we prevent the transmission?
 Avoid close contact with cases
 Maintain social distancing (> 1 meter)
 Do frequent (every 30 minutes) hand hygiene (wash/rub), and
avoiding touching of eyes, nose, and mouth
 Avoid gatherings unless absolutely necessary
 Avoid close contact with animals
 Cook animal products thoroughly

36. Hand Hygiene
Hand Wash (when soiled)Hand Rub

37. What is Cough Etiquette?
 During coughing or sneezing, cover the mouth and nose with
disposable tissue (inner side of elbows if tissue is not available) and
immediately discard the tissue
 Hand hygiene after coughing or sneezing
 It should be practiced by everyone, irrespective of having COVID-19
or not

39. Should everyone wear masks?
Which are better, face masks or N95 masks?
 No!
 Masks are very effective for halting spread of virus from
sick patients (not only of COVID-19)
 Masks are not advised for general population
 However, masks offer some protection and are advised
for health care workers and for close contacts

40. What are N95 masks and HAZMAT
suits?
 N95 masks are more effective than face masks for the
exposed, but require training to wear
 HAZMAT (Hazardous Materials) suit offer best protection to
Health Care Workers

41. N95 masks

42. HAZMAT Suits

43. What should I do if I develop
respiratory symptoms?
 If fever, cough, and shortness of breath, contact a doctor
 The advisory of eliciting a history of travel to countries having the
epidemic and close contacts may become less important once
declared a pandemic

44. Is it an epidemic or a pandemic?
 Declared a pandemic on 11th March, 2020
 Goal will now shift from containment of spread to
mitigation of effects

45. Flattening the epidemic curve

46. What is the possible outcome of COVID-19?
 The pandemic may infect the majority of population (60-
70%) until herd immunity develops, before dying out
 Mortality will be seen in a small proportion
 If a vaccine/treatment becomes available, mortality will be
much lower

47. Recommendations regarding Personal protective
equipment( PPE) for physiotherapists.
 It is imperative that physiotherapists understand the measures in
place to prevent transmission of COVID-19.
 Recurrent use of shoe covers is not recommended, as repeated
removal is likely to increase the risk of staff contamination.12
 PPE must remain in place and be worn correctly for the duration of
exposure to potentially contaminated areas. PPE (particularly
masks) should not be adjusted during patient care.
 All personal items should be removed before entering clinical areas
and donning PPE. This includes earrings, watches, lanyards, mobile
phones, pagers, pens, etc.
 Stethoscope use should be minimised. If required, use dedicated
stethoscopes within isolation areas.

48. Physiotherapy management
Airway clearance techniques:-
Airway clearance techniques include
 Positioning,
 Active cycle of breathing,
 Manual and/or ventilator hyperinflation,
 Percussion and vibrations,
 positive expiratory pressure therapy (pep) and
mechanical insufflation-exsufflation.
Non-invasive ventilation and inspiratory positive pressure
breathing physiotherapists may use inspiratory positive
pressure breathing. non-invasive ventilation may be
applied as part of airway clearance strategies in the
management of respiratory failure or during exercise.

49. Techniques to facilitate secretion clearance Techniques to facilitate secretion clearance
include assisted or stimulated cough manoeuvres and airway suctioning.
Other
Physiotherapists prescribe exercise and assist patients to mobilise. Physiotherapists
also play an integral role in the management of patients with a tracheostomy. COVID-19
poses significant considerations for respiratory physiotherapy interventions due to their
aerosol-generating procedures.
Physiotherapy management principles – mobilisation, exercise and rehabilitation
interventions
Physiotherapists are responsible for providing musculoskeletal, neurological and
cardiopulmonary rehabilitation tasks, as outlined below.
Range of motion exercises
Passive, active-assisted,
active or resisted joint range of motion exercises may be performed to maintain or
improve joint integrity,
range of motion and muscle strength.
Mobilisation and rehabilitation Examples of mobilisation and rehabilitation include bed
mobility, sitting out of bed, sitting balance, sit to stand, walking, tilt table, standing
hoists, upper/lower limb ergometry and exercise programs. Box 4 outlines
recommendations for implementing these activities in patients with COVID-19.

50. Summary
 COVID-19 is a disease with high transmission, but
relatively low mortality
 Spreads by droplet and contact route
 Patients primarily develop fever and respiratory symptoms
 Most recover on their own, and few require special care
 Masks are advised for sick patients and close
contacts/care givers only
 Frequent hand hygiene and cough etiquette should be
practised by everyone
 Close contact with cases, and gatherings should be
avoided, especially by the vulnerable population (elderly
and with underlying conditions)
 Vaccines and treatment may be available in a few months

51. THANK YOU