26 March 2020 COVID-19  - PowerPoint Presentation

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26 March 2020

COVID-19 The BasicsPablo PerelJean Luc Eiselé Kate RalstonWelcome Everyone!Make sure your microphone is set to mutePlease ask any questions through ‘Chat’

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Outline

CoronavirusCOVID-19 PandemicCharacteristics of COVID-19DiagnosticClinical ManagementQ & A

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Viruses

The smallest known infectious agentsReplicate in living cells (use the cellular machinery to synthesize new virus particles for the transfer of the viral genomes to uninfected cells)

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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 deathsCOVID-19 is an emerging viral disease due to a new strain (SARS-CoV-2)

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?

SARS-

CoV

MERS-

CoV

SARS-CoV-2

HCoV

- 229E

HCoV

- NL63

HCoV

- OC43

HCoV

- HKU1

URTI

Zoonoses

Human

Coronaviruses

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COVID19 Pandemic

Originated in Wuhan, Hubei province

Zoonotic origin

Hypothesis

: animals in Wuhan market?

Person to person transmission

By March 25

th

416,686 confirmed cases

18,589 deaths

197 countries or territories

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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.

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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.

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Transmissibility 

R0 is > 1 case numbers would increaseR0 = 0 case numbers are stableR0 < 1 case numbers decrease.Depends on 3 factorshow long people are infectious, the probability of transmission per contact between susceptible and infected individuals, and the average rate of such contactsIn Wuhan: between 2-3

R0: Average number of successful transmissions per case when everyone in the population is susceptible.

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Prognosis or clinical outcomes

for infectious diseases

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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)

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Clinical presentation at onset

https://www.ncbi.nlm.nih.gov/pubmed?term=32031570

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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

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Viral

respiratory infectionsThe virus enters the respiratory tract (mouth and nose)The virus enters the mucous membrane and starts replicating   the respiratory tract swells and

is

inflamed

The virus

enters

the

lungs

and

surrounding

cells



more

symptoms

begin to show

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Isolation and identification of the virus

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Isolation and identification of the virus

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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

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Normal

cell

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ACE2

receptor

Virus

attachment

,

penetration

,

replication

, release

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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

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Direct virus

detection Polymerase Chain Reaction (PCR)

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Direct virus

detection Polymerase Chain Reaction (PCR)

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Direct virus

detection Polymerase Chain Reaction (PCR)

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Antibodies

are a trace of previous infection

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Clinical management

Two distinct situations:1. Non serious presentation, outpatient setting2. Unwell patients, requiring hospitalisation: pneumonia, respiratory failure +/- acute respiratory distress most common serious complications

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Clinical management

Non serious presentation, outpatient settingSelf isolate - Look out for deterioration and signs of gravityFace mask (if available)Disinfect surfaces regularly No Covid test required (depends on capacity and local recommendations)

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Clinical management

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

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Clinical management

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

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Infection control

Prompt testing and presumption of Covid19 contamination until test proves negativeStrict infection control measures to protect patients and staff

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Infection control

Separate Covid patient work streams to minimise spread to other services in the hospital and other patient presenting to the Emergency room

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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 bloodability of the blood to circulate to deliver oxygen to the tissues i.e. circulatory failure or shock

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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 bloodstreamThis leads to impaired oxygenation of the blood called hypoxia (mild to severe)

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Signs and symptoms of respiratory compromise

Shortness of breath Rapid, shallow breathing CoughingUsing accessory muscles to breathNot being able to talk in sentencesBlueish tinge to extremities or lips/tongue

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Managing respiratory failure

Requires complex and skilled medical and nursing personnelSupplemental Oxygen. Depending on the severity of deoxygenation:Mild support e.g. Oxygen via nasal prongs or mask: regular hospital wardCpap/bipap (invasive but an external mask): High dependency unitVentilator 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.

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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.

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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.

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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.

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Essential elements in the healthcare system

Adequate covid 19 testsAdequate 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

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Hope on the horizon...

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Questions & Answers

Make sure your microphone is set to mutePlease ask any questions through ‘Chat’

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Thank you very much

Pablo PerelKate RalstonMihela KraljPaula OrriteCliff HannanJean-Luc EiseléFor enquiries, please contact:communications@worldheart.org