Head of the department Professor - PowerPoint Presentation

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Head of the department Professor Ryabokon O.V.,Associate Professor Furyk O.O.

Zaporizhzhia State Medical UniversityDepartment of Infectious Diseases

Acute respiratory infection caused by

coronavirus 2019-nCoV(etiopathogenetic patterns, clinic, treatment, prevention)

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CoronavirusesCoronaviruses are a large family of viruses that cause diseases from common acute respiratory infection to more severe conditions, such as:Severe Acute Respiratory Syndrome (SARS)Middle Eastern Respiratory Syndrome (

MERS)the new

coronavirus is named 2019-nCoV (COVID-19).WHO, 2020 “Emerging respiratory viruses, including nCoV”

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How do new viruses appear?Human health, animal health and the state of ecosystems are inextricably linkedIt is known that 70-80% of infectious diseases that occur in humans for the first time and again have zoonotic origin, i.e. they can be transmitted between animals and humans (Jones et al. (2008) Nature)Population growth, climate change, increased urbanization, international travel and migration all increase the risk of respiratory pathogens

WHO

, 2020 “Emerging respiratory viruses, including nCoV”

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2002: Coronavirus causing severe acute respiratory syndrome (SARS-CoV). 8096 people were ill, fatality rate – 9,6%.2012: Coronavirus causing Middle Eastern Respiratory Syndrome (MERS-CoV). 2494 people were ill, fatality rate – 34,4%.2019: New

Coronavirus (2019-nCoV). 128343 people became ill, fatality rate was 3,7% (as of 03/13/20).

Chronology appear new coronavirusesWHO, 2020 “Emerging respiratory viruses, including nCoV”

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On-line information on the spread of COVID-19 coronavirus infection as March 17, 2020 https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd More than 63 268 COVID-19 cases have been reported in the European Region(confirmed deaths of 2,755 people )Italy

27980Spain 9191France 5380Germany 4838Switzerland 2200

United Kingdom1547The Netherlands1413

Norway 1169Sweden 1059Belgium 1058Austria 959Denmark 898Greece 331Czech Republic 298

Finland 272

Slovenia- 253

Israel 250

Portugal 245

Estonia – 205

Ireland 169

Iceland 161

Romania - 158

Poland 150, San Marino – 102, Russian Federation - 93, Luxembourg - 81, Slovakia - 72, Serbia - 62, Bulgaria - 62, Albania - 51, Croatia-49, Hungary - 39, Belarus - 36, Latvia - 34, Georgia - 33, Cyprus - 33, Armenia - 30, Malta - 30, Republic of Moldova - 23, Azerbaijan - 21, Bosnia and Herzegovina - 21, Northern Macedonia - 19, Lithuania - 17, Andorra - 14, Turkey – 12, Monaco – 9, Liechtenstein - 7, Kazakhstan-6,

Ukraine - 5,

Holy See - 1.

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Online information on the spread of COVID-19 coronavirus infection in Ukraine as of March 16, 2020 There are 5 laboratory confirmed COVID-19 cases in Ukraine. In Chernivtsi region - 4, in Zhytomyr - 1 (lethal) in a 71-year-old woman.Since the beginning of 2020, the Public Health Center has received 94 reports of suspicion of COVID-19 (5 cases have been laboratory confirmed, 80 are negative, 9 are being investigated

). The Virology Reference Laboratory of the Public Health Center has tested on COVID-19 about 500 samples.https://moz.gov.ua/article/news/operativna-informacija-pro-poshirennja-koronavirusnoi-infekcii-2019-ncov-

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WHO has identified four scenarios for COVID-19 in the countries: Countries without cases (0 cases);Countries with 1 or more cases, imported or detected locally (sporadic cases);Countries in which case clusters are observed in time, territory, or overall impact (Case clusters);Countries where large outbreaks with local transmission occur (community broadcast).

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Features of the infection caused by COVID-19COVID-19 causes ARD, which is a wide range of diseases from asymptomatic or mild to severe disease with the risk of death. 80% of cases are mild or asymptomatic, 15% are severe infections requiring oxygen therapy, and 5% are critical cases requiring artificial lung ventilation.The virus is transmitted through contact with the patient, that is, public health measures such as hand hygiene and respiratory etiquette are important actions that can prevent infection.Older age and existing comorbidities increase the risk of developing a serious infection. Children suffer less than adults, the incidence rate in the 0-19 age group is low.

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Problems associated with preventing the spread of COVID-19 infection the COVID-19 virus has never been detected in a population of humans before, the occurrence is associated with a mutation that made it possible to overcome the interspecific barrier. the virus proved to be persistent in the environment. a large number of mild and asymptomatic forms of infection.

 the COVID-19 virus genome is the longest among the Coronaviruses, which is explained by the virus mutations (2 mutations per month in average ).

 weak epidemiological surveillance systems in many countries. based on epidemiological studies in China, it has been shown that in the presence of personal direct contact with an infected person, the likelihood of contact infection is between 1% and 5%.

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Pathogenesis upon penetration into the human body COVID-19 virus binds to angiotensin converting enzyme 2 (ACE2) receptors, which is necessary for its penetration into the cell and subsequent replication.  in the lungs, ACE2 receptors are mainly expressed by type II alveolar epithelial cells (83%) and partly by type I, partly by endothelial cells.   ACE2 receptors are also expressed by gastric epithelial cells, the 12th cavity, the rectum, which also supports the penetration of the virus.

http://www:medpagetoday.com/infectiousdisease/covid19/

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Pathogenesis the COVID-19 virus binds more easily to ACE2 receptors than the SARS-CoV virus, that explains the higher rate of human-to-human transmission of the virus.   ACE2 receptor expression is associated with age, and the number of cells in the lungs expressing this receptor is much higher in men.

   the number of ACE2 receptor expressing cells is more prevalent in Asian individuals than in African American and European people.http://www:medpagetoday.com/infectiousdisease/covid19/

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Signs and symptomsfeverchillscoughshortness of breathpossible intestinal manifestations (nausea, diarrhea, abdominal discomfort)

Rapid progression to severe pneumonia and respiratory failure usually occurs within 1 week

Threatening for life manifestations of respiratory infection:Severe pneumoniaAcute respiratory distress syndromeEarly recognition of these clinical syndromes allows timely initiation of supportive therapies.

https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

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Frequency of clinical manifestations in patients hospitalized with COVID-19 infection temperature 98-98,6%  dry cough 76-82%  shortness of breath 43%  weakness, myalgia 44%  wet cough 28-37%  headache 9%  hemoptysis 5%

  diarrhea 14%  nausea 14%  vomiting 5%

The time from onset of the first symptoms of infection to onset of shortness of breath was on average 5-7 dayshttp://www:medpagetoday.com/infectiousdisease/covid19/

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Case definition for COVID-19 epidemiological surveillance in the EU as of 02/25/2020SUSPECTED CASE - requires diagnostic testing (not reported to European level).Patients with acute respiratory infection who require or do not require hospitalization if, 14 days before the onset of these symptoms, they met one of the epidemiological criteria:  close contact with a confirmed or suspected COVID-19 infection case  OR  were in areas with possible (expected) transmission of the pathogen.

CONFIRMED CASE -

a person with laboratory confirmation of a virus that causes COVID-19 infection, regardless of clinical symptoms

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Etiotropic therapy for COVID-19 infectionIn China, attempts have been made to treat COVID-19 infection with various existing antiviral agents: ritonavir + lopinavirinhalation IFNoseltamivirzanamivirparamivirballoxavir

were not effective

REMDEZIVIR – a broad-spectrum antiviral developed by Gilead has shown in vitro activity against Ebola virus and coronaviruses. Today, the drug is undergoing clinical trials with a previous efficiency of 50%.

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Order of the Ministry of Health of Ukraine № 552 of February 25, 2020 Standard 1. Organization of monitoring and measures in the SARS-CoV-2 infection cellThe doctor who detected the COVID-19 in patient, registers the case in the form of primary accounting records No. 058 / o "Emergency notification of infectious disease, food, acute occupational poisoning, unusual response to vaccination" approved by the order of the Ministry of Health of Ukraine from 10.01.2006 No. 1, registered with the Ministry of Justice of Ukraine under No. 686/12560 on June 8, 2006, and informs the administration of the healthcare institution for the organization of further clinical observation, timely medical care and anti-epidemic measures, individual and community level. Contact investigation and follow-up of persons who have had contact with COVID-19 patients (Annexes 1, 2) are carried out.

 All healthcare providers who directly provide medical care are in contact with the biological materials of patients infected with SARS-CoV-2, using personal protective equipment against infectious disease (Annex 3). Health monitoring of health care providers directly providing care to patients infected with SARS-CoV-2, contacting biological samples and materials of patients infected with SARS-CoV-2 is performed within 14 days after the last contact, and includes temperature measurement, evaluation complaints and physical examination, serological and laboratory testing. The healthcare providers referred to in paragraph 3 of Standard 1 are recognized as contact for infection with SARS-CoV-2 and are subject to paragraph 2 of Standard 1.

 Persons suspected of being infected with SARS-CoV-2 are tested by laboratory testing. Based on clinical need, testing can be applied to a group of acute respiratory diseases among healthcare providers working at the infection center. Samples of laboratory test material for SARS-CoV-2 are collected from the lower respiratory tract (such as sputum, endotracheal aspirate, or bronchoalveolar lavage (hereinafter - BAL)). If patients do not have symptoms of lower respiratory tract disease, or have clinical signs of this, but collection of lower respiratory tract material is not possible, upper respiratory tract samples (nasopharyngeal aspirate or combined nasopharyngeal and oropharyngeal swabs) should be collected. If the initial test results are negative in a patient suspected of COVID-19, samples from different areas of the respiratory tract (nose, phlegm, endotracheal aspirate) are re-collected in that patient, such as blood, urine and defecation may also be collected, to control the presence / extraction of SARS-CoV-2 virus.

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The decision regarding home health care is made after assessing the safety of the patient's home environment and a thorough clinical assessment of the patient's condition. The mild symptoms are low fever up to 38oC, cough, malaise, rhinorrhea, sore throat without any serious symptoms (such as dyspnea or shortness of breath, rapid breathing, presence of sputum while coughing or hemoptysis), gastrointestinal symptoms (such as gastrointestinal nausea, vomiting and / or diarrhea) and without changes in mental state (i.e. without light headed state, lethargy). The rationale for an outpatient decision is included in the patient's medical records.The healthcare facility responsible for the organization of medical care in the region will contact the health care provider who provides home health care for the full recovery of the patient.Medical staff are involved in monitoring the current state of health of the patient and the contact person through regular (such as daily) visits, conducting diagnostic tests as needed. If visits are not possible, the current health status is monitored in distant mode. Patients and cohabitants are informed about: personal hygiene, basic disease prevention measures, how to safely care for a suspected infected family member, and prevent the spread of the disease through household contact.Patient and family members are provided with ongoing support and health monitoring. The adherence to the COVID-19 patient placement and care guidelines (Annex 4) is followed.Home-based healthcare providers independently carry out a risk assessment to select and apply the appropriate personal protective equipment (PPE).Keeping in touch involves monitoring your health for 14 days from the last day of contact.To persons (including health care providers) who may have contacted persons suspected of having COVID-19:a constant communication with the health care provider during the observation period is ensured;current health surveys through regular (such as daily) visits is assigned, conducting diagnostic tests if needed. In the case when visits are not possible - control of the current state of health is carried out by telephone;information on where to go for help if the contact's health is deteriorating and what safety measures to follow is provided, as well as the most appropriate mode of transportation, designated time and place of entry to a designated healthcare facility (Annex 5).

Order of the Ministry of Health of Ukraine No 552 of February 25, 2020 Standard 2. Outpatient care for patients suspected of having SARS-CoV-2 with mild disease and contact management

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Order of the Ministry of Health of Ukraine of No. 552 February 25 Standard 3. Clinical treatment of severe acute respiratory infection for suspected SARS-CoV-2When a patient is admitted to a healthcare facility, sorting is carried out, namely: early identification of patients with SARI (severe acute respiratory infection) associated with SOUGO-19 (Appendix 6), the severity of the disease, and, if necessary, medical assistance (Appendix 7).Standard safety measures include hand hygiene; use of Individual protection measures (IPM) to avoid direct contact with blood, body fluids, secretions (including respiratory secretions) and intact skin, prevention of needle or sharp objects injury; safe waste management; cleaning and disinfection of equipment (Annex 8).Patients with SARI and acute respiratory distress syndrome (hereinafter referred to as ARDS, hypoxemia, or shock are given early supportive care and monitoring immediately (Annex 9). All areas where SARI patients are cared for are equipped with pulse oximeters, functioning oxygen systems and disposable oxygen interfaces (nasal cannulas, simple face masks and reservoir mask).Patients with SARI are monitored and corrected for treatment interventions based on concomitant abnormalities, values, and patient preferences for intervention to ensure viability through active communication with patients and families, and support and prognostic information.Samples for laboratory diagnostics are collected taking into account the clinical picture using IPM (Annex 10).

Patients with COVID-19 with ineffective SaO2 oxygen therapy <90%) are evaluated for ARDS and hypoxemic respiratory failure and, if necessary, appropriate treatment (Annex 11).Signs of septic shock in patients with COVID-19 are detected in a timely manner and, if necessary, appropriate treatment is given (Annex 12).All patients with severe disease are prevented from general complications (Annex 13).Pregnant women with suspected or confirmed COVID-19 are treated as described in criterion 3, taking into account pregnancy standards. The use of investigational therapies outside of clinical trial is considered on the basis of individual risk and benefit analysis based on the potential benefit to the mother and the safety of the fetus, with the advice of experienced obstetricians and the decision of a consultant. Emergency birth and termination decisions are considered and based on many factors: gestational age, maternal condition, and fetal stability following multidisciplinary consultations with obstetricians, neonatologists, and intensive care professionals.

Therapies are being sought and COVID-19 clinical trials are being conducted. Due to the lack of specific treatment for patients with suspected or confirmed COVID-19, unlicensed intervention methods are used, including out-of-instructions treatment by decision of the consultant.

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Key message for healthcare professionals - 1http://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf Support hand hygieneWash hands with soap and water or alcohol-based antiseptic for at least 20 seconds:Before and after touching any patient

Before aseptic procedureAfter contact with biological fluids

After touching the things the patient is contactingBefore and after wearing any personal protective equipmentPerform hand hygiene after contact with contaminated respiratory tract

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Key message for healthcare professionals - 2Support respiratory etiquetteCover your face when coughing or sneezing with a napkin, then through it in a bucket. If you don't have a napkin, cough or sneeze into the top of your sleevePeople with respiratory symptoms should be asked to wear masks to protect othersMake sure your healthcare facility has napkins and buckets for placing napkins in patient waiting areas

Caution should be exercised about drips, such as wearing a mask when examining patients with respiratory symptomsWHO

, 2020 “Emerging respiratory viruses, including nCoV”

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Infection prevention and infection control for the general public To avoid transmissions, you must:avoid crowds and frequent indoor overcrowding maintain a distance of at least 1 meter (preferably 2 meters) from any person with respiratory symptoms (eg, coughing, sneezing)

clean your hands often with an alcohol-based antiseptic if your hands are not dirty (20-30 seconds) or soap with water when your hands are dirty(40-60 sec)if you cough or sneeze, cover your nose and mouth with a bent elbow or paper towel, dispose of the tissue immediately after use and have a hand hygiene treatmentrefrain from touching your mouth and nose

People with respiratory symptoms should:wear a medical mask and seek medical help as soon as possible if you experience fever, cough and shortness of breath

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The in vitro virucidal activity of decamethoxin at a concentration of 41.8-62.5 µg / ml (0.004-0.006%) against coronaviruses was established

Recommendation for the use of decamethoxin for the prevention

of coronavirus infection in adults

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Prevention of coronavirus infection using 0.2 mg / ml decamethoxin solution during epidemic risk:To protect the mucous membrane of the eye from the penetration of coronaviruses: instill in a conjunctival sac 2-3 drops of decamethoxin solution 4-6 times a day.

To protect the nasal mucosa and

oropharynx

from penetration of coronaviruses: rinse the mouth and throat 25-50 ml with a solution of decamethoxine 2-3 times a day. After rinsing for 1 hour, refrain from eating and drinking.

To protect the respiratory tract

from the penetration of

coronaviruses

: inhalation with a nebulizer 2 ml 2-3 times a day.

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The following resources were used in the preparation of the lecture: WHO " Curriculum Adapted Respiratory Viruses Emerging, Including New Coronavirus (nCoV) " http://bit.do/covid19_basic Adapted materials from the WHO training course "Emergency Assistance for Severe Acute Respiratory Viral Infection" http://bit.do/covid19_clinical Standards of medical care for coronavirus MOH http://bit.do/covid19_moz https://www.cdc.gov/coronavirus/2019-nCoV/https://www.uptodate.com/home/covid-19-access

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Thank you   for attention !