Covid 19 viral disease

1. CORONA VIRUS DISEASE
2019
(COVID -19)
PRESENTED BY
ALL OF US
SUPERVISOR
Dr. JOHN

2. Ethical Consideration- Fairness
• Distributive justice relates to fairness in the allocation of resources
and to the physician's obligations to patients.
• In other words, society's comparable individuals and groups should
share similarly in the society's benefits and burdens.
• In emergency medical practice, the most direct application of
distributive justice is in triage.
• The function of the triage in a hospital is to identify and prioritize
those with the most urgent needs to use the emergency service first .
An accurate triage decision is a correct allocation for patients to
receive emergency service in the best suitable time according to the
severity of their condition.

3. Outline
• Definition & Introduction
• Epidemiology / History
• Virology / Variants
• Transmission
• Pathophysiology
• Clinical features
• Risk factors
• Diagnosis (Investigations)
• Treatment
• Prevention
• Complications

4. Background
• Severe Acute Respiratory Syndrome (SARS) is caused by SARS-
associated coronavirus (SARS-CoV). This virus belongs to the
coronaviridae family grouped together in 1968 due to existence of
crown-like appearances on their cell membrane
• SARS-CoV emerged about two decades ago in China and spread
rapidly to other countries. Fortunately, it was successfully
contained and no new cases have been reported since.
• MERS (Middle East Respiratory Syndrome) is caused by MERS-
coronavirus (MERS-CoV) which emerged in 2012 in Saudi Arabia
and circulated throughout the Middle East and was carried by
travelers to other parts of the world including the United States,
Europe, Africa, and Asia. The rate of new infections has since
dropped significantly.

5. Background ctd..
• Late in 2019, a third member of the coronavirus family capable of
causing severe disease arose. The new virus, emerging in Wuhan,
China, is called SARS-CoV-2 and is responsible for the disease known
as COVID-19. SARS-CoV-2 spread quickly around the globe. Unlike
SARS-CoV or MERS-CoV, SARS-CoV-2 was not able to be controlled,
resulting in a worldwide pandemic.
• The SARS-CoV-2 previously had a provisional name; 2019 novel
coronavirus (2019-nCoV) and also has been called human
coronavirus 2019.

6. Introduction
• Coronavirus disease 2019 (COVID-19) is an infectious respiratory
disease caused by a novel coronavirus called severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2).
• First identified in the city of Wuhan, China, the WHO declared the
outbreak a Public Health Emergency of International Concern on 30th
January 2020, and a pandemic on 11th March 2020
• Available evidence indicates that it is most likely of zoonotic origins
and has close genetic similarity to bat coronaviruses, suggesting that
it emerged from a bat-borne virus.

7. Epidemiology
• Globally, as of 11:43pm CEST, 9 August 2023, there have
been 769,369,823 confirmed cases of COVID-19,
including 6,954,336 deaths, reported to WHO. As of 7 August
2023, a total of 13,492,264,486 vaccine doses have been
administered.
• In Uganda, from 3 January 2020 to 11:43pm CEST, 9 August 2023,
there have been 171,729 confirmed cases of COVID-19
with 3,632 deaths, reported to WHO. As of 27 May 2023, a total
of 26,406,936 vaccine doses have been administered.

8. Epidemiology
• The first confirmed case of the disease was confirmed in
Uganda on March 21st 2020, and a country-wide lockdown
was declared a day later.
• The first disease-related death was reported on July 23rd
2020 and was a 34-year-old Ugandan female, resident of
Namisindwa District.
• Highest number of new confirmed cases were reported on
August the 16th 2021 with 21,653 people testing positive for
the disease on that day only.

9. Virology
• Coronaviruses are enveloped positive sense single-stranded
RNA viruses. 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).
• The closest RNA sequence similarity is to two bat
coronaviruses, and it appears likely that bats are the primary
source; whether COVID-19 virus is transmitted directly from
bats or through some other mechanism (eg, through an
intermediate host) is unknown

10. Cont. on Virology…
• Like other coronaviruses, SARS-CoV-2 has four structural
proteins, known as the S (spike), E (envelope), M
(membrane), and N (nucleocapsid) proteins.
• The N protein holds the RNA genome, and the S, E and M
proteins together create the viral envelope.
• The spike protein is the protein responsible for allowing the
virus to attach to and fuse with the membrane of a host cell.

11. Variants
• Alpha (B.1.1.7)
• Beta (B.1.351)
• Gamma (P.1)
• Delta (B.1.617.2)
• Omicron (B.1.1.529)
• And others….

12. Transmission
• Direct person-to-person respiratory transmission is the
primary means of transmission of severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2). It is thought to occur
mainly through close-range contact (ie, within approximately
six feet or two meters) via respiratory particles.
• Environmental contamination — Virus present on
contaminated surfaces may be another source of infection if
susceptible individuals touch these surfaces and then
transfer infectious virus to mucous membranes in the
mouth, eyes, or nose. Preliminary research indicates that the
virus may remain viable on plastic and stainless steel for up
to 3 days.

13. • Risk of animal contact — SARS-CoV-2 infection is thought to
have originally been transmitted to humans from an animal
host, but the ongoing risk of transmission through animal
contact is uncertain.
• SARS-CoV-2 infection has been described in animals in both
natural and experimental settings but there have been rare
reports of animals with SARS-CoV-2 infection (including
asymptomatic infections in dogs and symptomatic infections
in felines)

14. Pathophysiology

16. Clinical Features
• The incubation period for COVID-19 is generally within 14 days following
exposure with most cases occurring approximately four to five days after
exposure.
• Asymptomatic ;- One review performed prior to the introduction of COVID-
19 vaccination estimated that 33 percent of people with severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) infection never develop
symptoms.

17. Symptomatic Infection;
Mild - Moderate ; Cough , headache, myalgia, nasal congestion ,
sneezing , diarrhea , sore throat, and loss of taste or smell.
Severe ; -fever, cough, dyspnea, and bilateral infiltrates on chest
imaging.
Critical; -respiratory failure, shock, or multiorgan dysfunction
which was reported in 5 percent.

18. Differentials
1. Community Acquired Pneumonia
2. Respiratory Syncitial Virus
3. MERS
4. Pulmonary TB
5. Common cold
6. Influenza infection
7. Etc etc

19. Risk Factors for Severe Illness
•Increasing age i.e >60 years which are likely to have
severe illness and also associated with increased
mortality.
•Comorbidities — Multiple comorbidities and
underlying conditions have been associated with
severe illness (ie, infection resulting in
hospitalization, admission to the ICU, intubation or
mechanical ventilation, or death).
•Include ;- Cancer, CVA, CKD, DM, HIV ,Lung diseases,
liver diseases, severe acute malnutrition. etc

20. • Socioeconomic background and sex — Certain demographic
features have also been associated with more severe illness.
• Males have comprised a disproportionately high number of
critical cases and deaths in multiple cohorts worldwide.
• Black, Hispanic, and Southern Asian individuals comprise a
disproportionately high number of infections and deaths due
to COVID-19 in the United States and United Kingdom, likely
related to underlying disparities in the social determinants of
health

21. • Viral factors — Patients with severe disease have also been
reported to have higher viral RNA levels in respiratory
specimens than those with milder disease.
• Genetic factors — Host genetic factors are also being evaluated
for associations with severe disease. As an example, one
genome-wide association study identified a relationship
between polymorphisms in the genes encoding the ABO blood
group and respiratory failure from COVID-19 (type A associated
with a higher risk). Type O has been associated with a lower
risk of both infection and severe disease .

23. Investigations
• Nucleic acid amplifications tests (NAATs; eg, reverse transcription
polymerase chain reaction [RT-PCR]) – RT-PCR for SARS-CoV-2 is
the primary test used to diagnose active COVID-19. The test is
performed primarily on upper respiratory specimens (including
nasopharyngeal swabs, nasal swabs, and saliva) but can also be
performed on lower respiratory tract samples. Sensitivity and
specificity are generally high, although performance varies based
on the specific assay used, specimen quality, and duration of
illness.
• Antigen tests – Antigen tests can also be used to diagnose active
infection. Antigen tests are less sensitive than NAATs, and their
performance varies by the specific antigen test. These tests are
typically performed on nasopharyngeal or nasal swabs.

24. • Serology - serologic tests measure antibodies to SARS-CoV-2
and are primarily used to identify patients who have had
COVID-19 in the past as well as patients with current
infection who have had symptoms for three to four weeks.
Sensitivity and specificity are highly variable, and cross-
reactivity with other coronaviruses has been reported.
• Pulse oximetry may reveal hypoxia/hypoxemia (i.e., oxygen
saturation <94%, or <88% in the presence of chronic lung
disease). Clinicians should be aware that patients with
COVID-19 can develop "silent hypoxia": their oxygen
saturations can drop to low levels and precipitate acute
respiratory failure without the presence of obvious
symptoms of respiratory distress.

25. Treatment
• There’s currently no cure for an infection caused by the 2019 coronavirus.
Treatment is generally supportive unless symptomatic.
• According to MoH Uganda Guidelines;
• Mild : For Adults and Children >12 yrs ; Paracetamol 1 gm TDS for 3 days ,
vitamin D 1200mg daily for 1 month, Tabs Zinc 20mg OD for 14 days.
• Moderate : -For Adults and Children >12 yrs ; tabs Azithromycin 500mg OD for
5 days, Tabs Zinc 20mg OD for 14 days, Vitamin D 800 IU OD for days.
• Children 6-11 years ; Amoxicillin 500mg TDS for 5 days , Tabs Zinc 20mg OD for
14 days, Vitamin D 800IU OD for 1 month.

26. Children < 5 yrs ; Oral amoxicillin 40mg/kg/dose BD for 5 days,
Vitamin D 400IU OD for 1 month.
• Severe : -Adults and Children >12 yrs ; Oxygen therapy , Tabs
co-amoxiclavulanic acid 625mg BD for 1 week or IV
ceftriaxone 2g OD for 1 week, Zinc 20mg OD for 14 days ,IV
dexamethasone 6-10mg OD for 10 days, Vitamin D 1200mg
OD for 1 month.
• -Children < 12 yrs ; IV ampicillin and gentamycin (50mg/kg 6
hourly for 5 days and 7.5mg/kg OD for 5 days respectively),
Zinc 20mg OD for 14 days.
• Critical : ARDS should be managed in ICU with appropriate
facility and medical expertise.

27. COVIDEX
• COVIDEX ™ is a prepared plant extract of Zanthoxylum and Warbugia
species that is reported to have antiviral agents with in vitro activity
against SARS COV-2, the causative agent for COVID-19 disease. Other
constituents in COVIDEX include alkaloids, sponins, reducing sugars
and acidic compounds. IT is given either 2 drops nasally plus 6 drops
orally or 6 oral drops only of COVIDEX three times daily for 7 days.

28. Home based care
• In a study on outcomes and experiences of COVID-19 patients under
home-based care in Kapelebyong district in Uganda, almost all (96%)
COVID-19 patients under home-based care had a good outcome. This
could be because most of the cases managed at home were of milder
COVID-19. The study findings are similar to those observed among
home quarantined patients with COVID-19 in China, where 91.9% of
COVID-19 patients had a good treatment outcome.

29. Prone Positioning
• Prone positioning is a conventional method to enhance oxygenation
in Acute Respiratory Distress Syndrome (ARDS) patients who need
mechanical ventilator.
• It is proven that oxygenation is significantly more beneficial in prone
position compared to the supine position.
• Furthermore, numerous lines of evidence have confirmed that prone
positioning could prevent lung injuries caused by ventilators.

30. Remdesivir
• Remdesivir is a nucleotide prodrug of an adenosine analog. It binds
to the viral RNA-dependent RNA polymerase and inhibits viral
replication by terminating RNA transcription prematurely.
• Remdesivir was approved by the US FDA for treatment of COVID-19
in adult and paediatric patients aged over 12 years and weighing over
40kg with mild to moderate COVID-19 and high risk of progressing to
severe COVID-19.
• Others: nirmatrevir plus ritonavir (paxlovid), sotrovimab and
molnupiravir

31. • Monoclonal antibodies are synthetically derived proteins that help the
body develop an immune response against foreign-made substances
such as viruses by binding to the spike protein on its surface and
preventing multiplication.
• Used in mild to moderate disease.
• These medications include:
• bamlanivimab,
• casirivimab and imdevimab.
• Molnupiravir ( Anti viral )

32. Monitoring
• Regularly monitor the following in hospitalized patients to facilitate
early recognition of deterioration and monitor for complications;
• Vital signs (temperature, respiratory rate, heart rate, blood pressure,
oxygen saturation)
• Hematologic and biochemistry parameters (CBC, LFTs, RFTs)
• Coagulation parameters (D-dimer, fibrinogen, platelet count,
prothrombin time)
• ECG
• Chest imaging
• Signs and symptoms of venous or arterial thromboembolism.

33. Post-discharge follow-up
• Patients who have had suspected or confirmed COVID-19 (of any
disease severity) who have persistent, new, or changing symptoms
should have access to follow-up care.
• More than half of patients discharged from hospital had lung
function and chest imaging abnormalities 12 weeks after symptom
onset.
• Pulmonary function tests may reveal altered diffusion capacity, a
restrictive pattern, or an obstructive pattern. Impaired diffusion
capacity was more severe and recovered slower in females compared
with males, and the first 3 months was the critical recovery period for
diffusion capacity. (Chen M, Liu J, Peng P, et al. Dynamic changes of
pulmonary diffusion capacity in survivors of non-critical COVID-19
during the first six months. EClinicalMedicine. 2022 Jan;43:101255.)

34. Prevention
•The best way to prevent the transmission of the
virus is to avoid or limit contact with people who
are showing symptoms of COVID-19 or any
respiratory infection.
•The next best thing is to practice good hygiene and
physical distancing to help prevent bacteria and
viruses from being transmitted.

35. Prevention tips
• Wash your hands frequently for at least 20 seconds at a time with
warm water and soap. How long is 20 seconds? About as long as it
takes to sing your “ABCs.”
• Do not touch your face, eyes, nose, or mouth when your hands are
dirty.
• Do not go out if you’re feeling sick or have any cold or flu symptoms.
• Stay at least 6 feet (2 meters) away from people. Avoid crowds and
large gatherings.
• Cover your mouth with a tissue or the inside of your elbow whenever
you sneeze or cough. Throw away any tissues you use right away.
• Wear a mask or face covering in public places.
• Clean any objects you touch a lot. Use disinfectants on objects like
phones, computers, and doorknobs

36. Vaccines
• Pfizer
• Moderna
• Johnson and Johnson
• AstraZeneca

37. Complications
Researchers have seen the following complications in
people who have developed COVID-19:
acute respiratory distress syndrome (ARDS)
blood clots
irregular heart rate (arrhythmia)
cardiogenic shock

38. •kidney injury or kidney failure (including needing
dialysis)
•severe muscle pain
•heart damage or heart attack
•multisystem inflammatory syndrome in children
(MIS-C); this is also known as pediatric multisystem
inflammatory syndrome (PMIS) [features of fever,
skin rash, conjunctivitis, generalized inflammation
of body]

39. References
• Uganda National Guidelines for management of COVID-19
• WHO treatment guidelines
• covid19.who.int
• James, E., Wanume, B., Musaba, M.W. et al. Characteristics,
treatment outcomes and experiences of COVID-19 patients under
home-based care in Kapelebyong district in Uganda: a mixed-
methods study. Trop Med Health 50, 93 (2022).
• Berthier F, Pili-Floury S, Besch G. Prone positioning combined with
high-flow nasal or conventional oxygen therapy in severe Covid-19
patients. Crit Care. 2020;24:256