WHEN THE SUN RISES WE WORK HARD TO DELIVER COVID-19 Basic training for doctors
Thank YOU for your dedication to our people 2
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Novel Coronavirus CASE FATALITY RATE CIVET SARS 800 8 000 X 100 = 10% mutates mutates 2002 CAMEL 850 MERS 2 500 X 100 = 39% mutates mutates 2012 Potentially PANGOLIN 132 922 mutates mutates 2 052 508 X 100 = 6.48% COVID-19 4
R 0 - Reproductive Ratio Degree of ‘ spreadability ’ How many people can one person infect R 0 = 2-3 1 3 R 0 9 1 27 5
R 0 of Influenza 1 R 0 = 1.3 1 R 0 1 1 1 6
How do we make the R 0 drop? COVID-19 R 0 >1 - Quarantining - Physical distancing R 0 - PREVENTING SPREAD Influenza 1 R 0 = 1 Target: R 0 <1 7
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How does COVID-19 spread? Respiratory droplets Mother-to- Fecal-oral child Airborne ± 3 hours 9
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Pathophysiology of SARS-CoV-2 11
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S-spike protein ACE-2 ACE-2 receptor receptor RNA-dependant RNA polymerase + ss-RNA Ribosome mRNA Translation Type 2 pneumocyte Protease 14
IL-1 IL-6 Macrophages TNF- α 15
IL-1 IL-6 TNF- α 16
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Macrophage IL-1 IL-6 TNF- α Reactive oxygen species Proteases Neutrophil 18
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Complications of COVID-19 • Inflammatory response spills ARDS over into bloodstream Systemic • ↓ blood volume inflammatory • ↓ peripheral resistance response • Decreased perfusion of Hypotension patients organs Multi-organ failure 21
Incubation period 2 days 14 days 27 days 5 days Self-quarantine for 14 days 22
Signs and Symptoms 23
Some patients can be asymptomatic 24
Person Under Investigation: Apply the latest case definition from the NICD : http://www.nicd.ac.za/diseases-a-z-index/covid-19/ Persons with acute respiratory illness with sudden onset of at least one of the following: • Cough 38˚C • Sore throat • Shortness of breath, • Fever [≥ 38 °C or subjective history of fever] 25
HIGH RISK persons: Patients with any one of the previous symptoms WITH the following are then considered to be HIGH RISK : In the last 14 days: Close contact with a confirmed or probable case of COVID-19 OR Live in or travel to areas with local transmission of Coronavirus (the list of these countries/provinces will change with time – consult the NICD website) OR Worked in, or attended a health care facility where patients with COVID-19 were being treated without PPE 26
Example of a screening tool: 27
Who needs to be tested? Prioritise HIGH RISK All Persons Under Investigations 28
Differential Diagnoses Rx Ix Diff Dx Sputum MCS +/- MTB • Flu GXP CAP e.g. coamoxyclav TB Urine LAM Atypical pneumonia e.g. Bacterial FBC and diff azithromycin pneumonia Blood cultures Severe Influenza or with If low immunity: NP or OP swabs for risk factors: oseltamivir PJP viral /atypical TB: RHZE pathogens CXR PJP e.g. cotrimoxazole Urine Legionella Ag 29
LOOK OUT FOR TB Remember, COVID-19 may have a similar presentation to TB. We must not forget to screen AND test for TB. 30
Choosing the correct PPE: If you are EDUCATING and SCREENING patients, you only need to wear a medical/surgical mask . You should also try to keep 1-2 metres between you and the patient at all times 2 metres 31
How do I know what PPE to wear? Goggles or face shield If you are ASSESSING patients, you need to Medical/surgical facemask wear: Gown or plastic apron Non-sterile gloves 32
How do I know what PPE to wear? If you are TESTING patients, you need to wear: Goggles or face shield N95 respirator Gown or plastic apron Non-sterile gloves 33
How do I know what PPE to wear? If you are conducting an AUTOPSY , you need to wear: Conducting an autopsy with Scrub suit aerosol-generating procedures Long-sleeved, fluid scrub suit resistant gown Gloves Goggles or face shield (long sleeved, N95 respirator fluid resistant) 34
N95 respirator Write your name on it Reusable for 1 week Hang up after each use 35
N95 respirator Putting on and taking off mask Re-usable for up to 1 week How to keep it between use • UNLESS IT GETS: • Hang it up on a • Never touch the hook front of the mask • Wet • OR • Soiled • Damaged • Keep in a brown • Elastics become bag loose • Use the elastics • Use gloves to to put on and insert and remove take off 36
N95 respirator 37
How to test COVID-19 suspects Don PPE Assess patient Clinically triage Conduct testing 38
PPE: patient assessment 39
Patient assessment: Assess the patient: Ability to Risk of Symptoms self-quarantine deterioration 40
Triage patient: Triage the patient according to assessment: Mild Severe disease disease 41
Mild disease Mild disease • SpO2 ≥95% • Respiratory rate <25 • Heart rate <120 • Temperature 36 – 39˚C • Normal mental status Able to safely self-quarantine • Separate bedroom available for patient to home-quarantine in • Patient able to contact, and return to, healthcare facility in case of deterioration Not at high risk of deterioration • Age <65 years • No cardiac or pulmonary comorbidities • No other debilitating comorbidities (e.g. cancer)
Underlying comorbidities: U NDE YING M EDIC AL C ON OF COVID-19 19 IN IN C HIN NDERL RLYING DICAL ONDIT DITION IONS OF HINA 60 Mild Severe Critical HIV Hypertension TB Proportion of cases (%) 40 malnutrition Diabetes Heart Immuno- 20 disease Lung deficiency disease Liver Kidney disease disease disease 0 Hypertension Other Diabetes Cardiovascular Lung disease Chronic liver Chronic kidney Immunodeficiency disease disease disease diseases China CDC/NHC 2020 43 19230 Confirmed cases with detailed epidemiological investigation information
Mild disease • SpO2 ≥95% • Respiratory rate <25 • Heart rate <120 • Temperature 36 – 39˚C • Normal mental status Able to safely self-quarantine • Separate bedroom available for patient to home-quarantine in • Patient able to contact, and return to, healthcare facility in case of deterioration Not at high risk of deterioration • Age <65 years • No cardiac or pulmonary comorbidities • No other debilitating comorbidities (e.g. cancer) Mild disease Mild disease AND AND Severe disease Able to self-quarantine Low risk OR AND BUT High risk Low risk Unable to self-quarantine Home-quarantine Refer to quarantine site Require hospitalisation 44
Testing: Nasopharyngeal swab Sputum Oropharyngeal swab Patient Specimen Documentation Notification forms completion Register 45
Don PPE: 46
2 types of swabs can be used: Swab with Universal Transport Medium 47
3 types of swabs can be used: Dry swab 48
Anatomy of the naso- and oropharynx 49
Anatomy of the oropharynx and tonsils Oropharynx 50
How to take a nasopharyngeal swab: • Measure the distance from the nose to the ear • This is how far you need to insert the swab into the nose 1. • Gently insert swab into one nostril, aiming backwards, along the floor of the nasal cavity, until the nasopharynx is reached 2. • If resistance is encountered during insertion of the swab, remove it and try the other nostril Gently rotate the swab and hold in place for a few seconds, then slowly withdraw the swab 3. If you have the universal transport medium, unscrew the cap and insert the swab directly into the vial Break plastic shaft at the break point so that it can fit in the tube 4. If you are using a dry swab, insert the swab into the plastic swab container 5. 51
Nasopharynx 52
How to take a oropharyngeal swab: • Ask the patient to tilt their head back and open mouth wide • Hold the tongue down with a tongue depressor, and ask the patient to say “AHHHH” 1. • Using a new swab (separate to the nasopharyngeal swab), swab each tonsil first, then the posterior pharynx in a “figure 8” movement 2. Avoid swabbing the soft palate Do not touch the tongue with the swab tip as this procedure can induce the gag reflex 3. If you have the universal transport medium, insert the swab directly into the same vial 4. containing the nasopharyngeal swab If you are using a dry swab, insert the swab into its own plastic swab container 5. 53
Posterior pharynx 54
Sputum If the patient has a productive cough, it is useful to also collect a sputum sample for COVID-19 testing DO NOT induce sputum 55
Storage and Transport • Close the lid of the tube or plastic container 1. •Label the tube/plastic container with patient’s details 2. • Place an NHLS barcode sticker on the specimen 3. Place the specimen into the plastic bag and seal it 4. 56
Other testing modalities: Broncho-alveolar lavage Fibro-bronchoscope brush biopsy Blood Coming soon: RAPID TESTS 57
Review of testing modalities: 58
Complete forms You need to complete the following forms to send with the specimen to NHLS: 1. • NHLS requisition form • Specimen submission 2. form 59
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