Several coronaviruses can infect humans, the globally endemic human coronaviruses HCoV-229E, HCoV-NL63, HCoV-HKU1 and HCoV-OC43 that tend to cause mild respiratory disease, and the zoonotic Middle East respiratory syndrome coronavirus (MERS-CoV) and severe acute respiratory syndrome coronavirus (SARS-CoV) that have a higher case fatality rate. COVID-19 is the infectious disease caused by the most recently discovered coronavirus. This new virus and disease were unknown before the outbreak began in Wuhan, China, in December 2019.
•The virus can spread from an infected person’s mouth or nose in small liquid particles when they cough, sneeze, speak, sing or breathe heavily. These liquid particles are different sizes, ranging from larger ‘respiratory droplets’ to smaller ‘aerosols’.
•Other people can catch COVID-19 when the virus gets into their mouth, nose or eyes, which is more likely to happen when people are in direct or close contact (less than 1 metre apart) with an infected person.
•Current evidence suggests that the main way the virus spreads is by respiratory droplets among people who are in close contact with each other.
•The virus can also spread after infected people sneeze, cough on, or touch surfaces, or objects, such as tables, doorknobs and handrails. Other people may become infected by touching these contaminated surfaces, then touching their eyes, noses or mouths without having cleaned their hands first.
•Aerosol transmission can occur in specific settings, particularly in indoor, crowded and inadequately ventilated spaces, where infected person(s) spend long periods of time with others, such as restaurants, choir practices, fitness classes, nightclubs, offices and/or places of worship. More studies are underway to better understand the conditions in which aerosol transmission is occurring outside of medical facilities where specific medical procedures, called aerosol generating procedures, are conducted.
The incubation period for COVID-19, which is the time between exposure to the virus (becoming infected) and symptom onset, is, on average, 5–6 days, but can be up to 14 days. This period is also known as the pre-symptomatic period.
Some infected persons can be contagious, from 1–3 days before symptom onset. It is important to recognize that pre-symptomatic transmission still requires the virus to be spread via infectious droplets or by direct or indirect contact with bodily fluids from an infected person.
• Presenting signs and symptoms of COVID-19 vary. Most persons experience fever (83–99%), cough (59–82%), fatigue (44–70%), anorexia (40–84%), shortness of breath (31–40%), myalgias (11–35%). Other non-specific symptoms, such as sore throat, nasal congestion, headache, diarrhoea, nausea and vomiting, have also been reported. Loss of smell (anosmia) or loss of taste (ageusia) preceding the onset of respiratory symptoms has also been reported.
• Older people and immunosuppressed patients in particular may present with atypical symptoms such as fatigue, reduced alertness, reduced mobility, diarrhoea, loss of appetite, delirium, and absence of fever.
• Symptoms such as dyspnoea, fever, gastrointestinal (GI) symptoms or fatigue due to physiologic adaptations in pregnant women, adverse pregnancy events, or other diseases such as malaria, may overlap with symptoms of COVID-19. Children might not have reported fever or cough as frequently as adults.
While most people with COVID-19 develop only mild (40%) or moderate (40%) disease, approximately 15% develop severe disease that requires oxygen support, and 5% have critical disease with complications such as respiratory failure, acute respiratory distress syndrome (ARDS), sepsis and septic shock, thromboembolism, and/or multiorgan failure, including acute kidney injury and cardiac injury.
Adults of any age with the following conditions ARE AT INCREASED RISK OF SEVERE ILLNESS from the virus that causes COVID-19:
• Chronic kidney disease
• COPD (chronic obstructive pulmonary disease)
• Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
• Immunocompromised state (weakened immune system) from solid organ transplant
• Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
• Severe Obesity (BMI ≥ 40 kg/m2)
• Sickle cell disease
• Type 2 diabetes mellitus
Based on what we know at this time, adults of any age with the following conditions MIGHT BE AT AN INCREASED RISK FOR SEVERE ILLNESS from the virus that causes COVID-19:
• Asthma (moderate-to-severe)
• Cerebrovascular disease (affects blood vessels and blood supply to the brain)
• Cystic fibrosis
• Hypertension or high blood pressure
• Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines.
• Neurologic conditions, such as dementia
• Liver disease
• Overweight (BMI > 25 kg/m2, but < 30 kg/m2)
• Pulmonary fibrosis (having damaged or scarred lung tissues)
• Thalassemia (a type of blood disorder)
• Type 1 diabetes mellitus
COVID-19 is associated with mental and neurological manifestations, including delirium or encephalopathy, agitation, stroke, meningo-encephalitis, impaired sense of smell or taste, anxiety, depression and sleep problems. In many cases, neurological manifestations have been reported even without respiratory symptoms. Anxiety and depression appear to be common amongst people hospitalized for COVID-19, with one hospitalized cohort from Wuhan, China, revealing over 34% of people experiencing symptoms of anxiety and 28% experiencing symptoms of depression. An observational case series from France found that 65% of people with COVID-19 in intensive care units (ICUs) showed signs of confusion (or delirium) and 69% experienced agitation. Delirium, in particular, has been associated with increased mortality risk in the context of COVID-19 (22). Moreover, there have been concerns related to acute cerebrovascular disease (including ischaemic and haemorrhagic stroke) in multiple case series from China, France, the Netherlands, and the United States of America. Case reports of Guillain-Barré syndrome and meningo-encephalitis among people with COVID-19 have also been reported.
Reduce chances of being infected or spreading COVID-19 by taking some simple precautions:
• Regularly and thoroughly clean your hands with an alcohol-based hand rub or wash them with soap and water
Why? Washing your hands with soap and water or using alcohol-based hand rub kills viruses that may be on your hands
• Maintain at least 1 metre (3 feet) distance between yourself and anyone who is coughing or sneezing
Why? When someone coughs or sneezes they spray small liquid droplets from their nose or mouth which may contain virus. If you are too close, you can breathe in the droplets, including the COVID-19 virus if the person coughing has the disease
• Avoid touching eyes, nose and mouth
Why? Hands touch many surfaces and can pick up viruses. Once contaminated, hands can transfer the virus to your eyes, nose or mouth. From there, the virus can enter your body and can make you sick
• Make sure you, and the people around you, follow good respiratory hygiene. This means covering your mouth and nose with your bent elbow or tissue when you cough or sneeze. Then dispose of the used tissue immediately.
Why? Droplets spread virus. By following good respiratory hygiene, you protect the people around you from viruses such as cold, flu and COVID-19
• Stay home if you feel unwell. If you have a fever, cough and difficulty breathing, seek medical attention
• Keep up to date on the latest COVID-19 hotspots (cities or local areas where COVID-19 is spreading widely). If possible, avoid traveling to places – especially if you are an older person or have diabetes, heart or lung disease.
Why? You have a higher chance of catching COVID-19 in one of these areas.
• Advice to download and use Aarogya Setu app
Instructions for patients
• Ask the suspected patient to wear a medical mask and direct the patient to a separate area, ideally an isolation room/area if available. Keep at least 1 m distance between patients.
• Instruct all patients to cover nose and mouth during coughing or sneezing with tissue or flexed elbow, dispose of tissues safely immediately after use in a closed bin and perform hand hygiene after contact with respiratory secretions.
Apply standard precautions
• Apply standard precautions according to risk assessment for all patients, at all times, when providing any diagnostic and care services.
• Standard precautions include hand hygiene and the use of personal protective equipment (PPE) when risk of splashes or in contact with patients’ blood, body fluids, secretions (including respiratory secretions) and non-intact skin.
• Standard precautions also include appropriate patient placement; prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment.
• Best practices for safely managing health care waste, including waste related to surgeries and obstetric care, should be followed.
Apply contact and droplet precautions
• For suspected and confirmed COVID-19 patients, contact and droplet or airborne precautions should be applied
• Contact precautions prevent direct or indirect transmission from contact with a suspect or confirmed COVID-19 patient and/or contaminated surfaces or equipment (i.e. contact with contaminated oxygen tubing/interfaces).
• Contact precautions include gloves and disposable gown.
• Droplet precautions prevent large droplet transmission of respiratory viruses, and include medical mask and eye protection. Use a medical mask if working within 1 m of the patient. When providing care in close contact with a suspect or confirmed COVID-19 patient use eye protection (face mask or goggles), because sprays of secretions may occur. In particular, use a combination of PPE for contact and droplet precautions (medical mask, eye protection, gloves and gown) when entering room and remove PPE when leaving.
• Carefully practise hand hygiene using an alcohol-based hand rub if hands are not visibly dirty or soap and water and disposable towels, before PPE use and after PPE removal, and when indicated while providing care, according to the WHO Five Moments for hand hygiene.
• If possible, use either disposable or dedicated equipment (e.g. stethoscopes, blood pressure cuffs, pulse oximeters and thermometers). If equipment needs to be shared among patients, clean and disinfect between each patient use.
• Ensure that health care workers avoid contaminating environmental surfaces that are not directly related to patient care (e.g. door handles and light switches) and refrain from touching their eyes, nose and mouth with potentially contaminated gloved or ungloved hands.
• Place all cases in single rooms, or separately group together those with same etiologic diagnosis, such as suspect cases with suspects; probable cases with probable; and confirmed cases with confirmed. In other words, if an etiological diagnosis is not possible, group patients with similar clinical diagnosis and based on epidemiological risk factors. Keep at at least 1m spatial separation between cases. Suspected or probable cases should not be cohorted together with confirmed cases. Limit patient movement within the institution and ensure that patients wear medical masks when outside their rooms.
Apply airborne precautions when performing aerosol-generating procedures
• When performing aerosol-generating procedures (tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation and bronchoscopy) and in settings where aerosol-generating procedures are frequently in place, airborne instead of droplet precautions should be used, in combination with contact precautions.
• Use the appropriate PPE, including gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or equivalent, or higher level of protection).
• A scheduled fit test should not be confused with a user’s seal check before each use. Whenever possible, use adequately ventilated single rooms when performing aerosol-generating procedures, meaning negative pressure rooms with a minimum of 12 air changes per hour or at least 160 L/second/patient in facilities with natural ventilation.
• Avoid the presence of unnecessary persons/individuals in the room during procedure.
• Care for the patient in the same type of room after mechanical ventilation begins.
• Because of uncertainty around the potential for aerosolization, high-flow nasal oxygen (HFNO), NIV, including bubble CPAP, should be used with airborne precautions until further evaluation of safety can be completed. There is insufficient evidence to classify nebulizer therapy as an aerosol-generating procedure that is associated with transmission of COVID-19. More research is needed.
• It is recommended that for all suspect cases, collection of upper respiratory tract (URT) specimens (nasopharyngeal and oropharyngeal) for testing by reverse transcription polymerase chain reaction (RT-PCR) and, where clinical suspicion remains and URT specimens are negative, to collect specimens from the lower respiratory tract (LRT) when readily available (expectorated sputum, or endotracheal aspirate/bronchoalveolar lavage in ventilated patient). In addition, testing for other respiratory viruses and bacteria should be considered when clinically indicated.
• SARS-CoV-2 antibody tests are NOT recommended for diagnosis of current infection with COVID-19.
• Depending on local epidemiology and clinical symptoms, test for other potential etiologies (e.g. malaria, dengue fever, typhoid fever) as appropriate.
• For COVID-19 patients with severe or critical disease, also collect blood cultures, ideally prior to initiation of antimicrobial therapy.
According to a recent literature review, the most frequent laboratory abnormalities encountered in patients with COVID-19 encompass:
• Lymphopenia (35-83%)
• Thrombocytopenia (5-36%)
• Increased CRP (75-93%)
• Increased LDH (27-92%)
• Increased ESR (up to 85%)
• Increased D-dimer (36-43%)
• Decreased serum albumin (50-98%)
• Decreased Hb (41-50%).
Risk factors associated with higher odds of in-hospital death were:
• Older age,
• D-dimer levels greater than 1 μg/mL
• Higher SOFA score on admission
Elevated levels of blood IL-6, high-sensitivity cardiac troponin I, lactate dehydrogenase, ALT and ferritin & lymphopenia were more commonly seen in severe COVID-19 illness.
Lymphopenia is one of the hallmarks of COVID-19 and is also an unfavourable prognostic indicator. In general, counts of peripheral CD4 and CD8 T cells are found to be substantially reduced. CD8 T cells are also found to contain a considerable number of cytotoxic granules.
Increased high-sensitivity cardiac troponin I during hospitalisation was found in more than half of those who died.
SGOT, SGPT are increased and indicate liver injury or wide spread organ damage, and elevated creatinine which indicates kidney injury.
Although less than 20% of COVID-19 patients present with increased procalcitonin, results of a recent meta-analysis suggest that serial procalcitonin measurement may play a role for predicting evolution towards a more severe form of disease and for defining the risk of developing severe bacterial co-infections. Increased procalcitonin values are associated with a nearly 5-fold risk of more severe forms of COVID-19.
In patients with severe COVID-19, histological examination of lung tissue shows diffuse alveolar damage characterized by the presence of cellular fibromyxoid exudates, desquamation of pneumocytes and hyaline membrane formation. This is consistent with ARDS.
Chest radiographs may show bilateral infiltrates. The most common patterns on chest CT were found to be ground-glass opacity (56.4%) and bilateral patchy shadowing (51.8%).
The age distribution of infected patients is as follows (data from 44,672 patients laboratory confirmed cases):
• <10 years: <1%
• 10-19 years: 1%
• 20-29 years: 8%
• 30-79 years: 87%
• ≥ 80 years: 3%
No. As per the latest revised discharge policy, there is no need for testing prior to discharge all presymptomatic/very mild/mild confirmed cases of COVID-19 after 10 days of symptom onset and no fever for 3 days. Therefore, it stands to reason, that no testing is also needed for patients undergoing home isolation (pre-symptomatic/very mild/mild confirmed cases) after the home isolation period is over.
The latest guidelines for discharge are summarised in the flowchart below (Source: MoFHW, Govt of India):
Suburban Diagnostics is amongst the very first list of 4 labs approved by ICMR on March 22,2020 for Covid-19 testing across the country. Suburban Diagnostics has Exclusive collection centres and drive thru collection points.
WHO website, https://www.who.int/news-room/q-a-detail/q-a-coronaviruses,
WHO reference number: WHO/COVID-19/laboratory/2020.4
WHO reference number: WHO/nCoV/Clinical/2020.3
WHO reference number: WHO/nCov/IPC/HomeCare/2020.2
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