Halodoc COVID-19 Update from UFH, China:

Clinical Basics with Q&A

2020, March 21
0830: London
15:30 Jakarta
16:30 Beijing

United Family Healthcare

Dr DJ Hamblin-Brown
Dr Penny Wilson
Dr Katheine Bi
Dr. Jingjing Lu
2020.03.21
 Introductions and Agenda

Dr. DJ Hamblin-Brown

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Agenda – All times in JAKARTA
Start End Subject Presenter

Dr Irwan Heriyanto +
15:30 15:40 Introductions
Dr DJ Hamblin-Brown

Basic epidemiology and virology + public

15:40 16:00 Dr Penny Willson
health measures (“flattening the curve”)

Physiology of the disease, presentation, Dr Katherine Bi

symptomology + Treatment options
16:00 16:40
Radiological findings on X-Ray and CT Dr Lu LingJing

Dr Amanda
16:40 17:00 Questions and answers
Dr DJ Hamblin-Brown
 Coronavirus
Dr Penny Wilson

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Epidemiology - what you probably already know…
Cases in Indonesia as of Friday 20th March 2020

Total New Total Total Total

case cases deaths recovere active
s in 24 h d cases
369 +60 32 17 320

• Confirmed cases in 17 provinces

• 60 new cases in 24 hours
• Doubling time approx. 3 days
• Likely to be much more than this
• Limited testing

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 Epidemiology – the spread

• Droplet
• Droplets containing microorganisms can be generated when an
infected person coughs, sneezes, or talks.
• Droplets are too large to be airborne for long periods of time, and
quickly settle out of the air.

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 • Contact
• Direct contact: physical contact between an infected person and a
susceptible person, and the physical transfer of microorganisms.
Usually close household contacts. May also be relevant in
hospitals
• Indirect contact: a susceptible person is infected from contact with
a contaminated surface

• Viruses can survive for some time on surfaces.

• For Coronavirus, estimates of 24 hours on cardboard, 2-3 days on
plastic and stainless steel
• Likely to be shorter times on clothing, as thought that the virus will
desiccate quickly[1]
1. USA National Institute for Health – not yet formally published. Pre-print format Accessed 2020/3/17:
https://www.medrxiv.org/content/10.1101/2020.03.09.20033217v1.full.pdf?__cf_chl_jschl_tk__=6037568e0eb9046a5a80dc40e0f49ef0e1fbe816-1584455483-0-AX4Ir0Zadi4oW
ccv0Xehnz9aC0tL4SFYpo7S3-Nl3mjPurIm0s_6vfQCAJFRd0HKRa1vAVXCWiGHJXpyG1s2ATRG9JKPI-OgjUDeV8B4BMu23isJsTIIegzBlZphpm_21DKLw7PtYHw_rMSK7_Cn
wSGnDLTWFI5CqFSAgrIfBJAGx1YkdcLhEiENc8dY7AYmSOZmFigOFfq78qfINndB_q4FmWXjGQGBmL0Rn6mNmhVOIh4onEuLOcx-OKL4LCVU-5bk6A7bQP4b6p-NfDlzaxEV
Ax3KEyx0nWjpGHI7irCZUztiwsIDIlpdqtUmp4B8kquk0g-lvhL9hM9KpA5liVI

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 • Airborne (or aerosol) transmission
• Clearly a risk if procedures that produce aerosols are performed
• Tracheal intubation
• Non-invasive ventilation
• Tracheotomy
• Cardiopulmonary resuscitation
• Manual ventilation
• Bronchoscopy
• Dental treatments without the use of a dam
• Increasing evidence there may be some aerosol transmission in
general circumstances, but probably not the primary mode of
transmission

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 Testing…

• Relatively limited testing availability in Indonesia

• To be honest, fairly limited testing being done here in the UK!
• USA CDC has suggestions for prioritising testing[2]:
• Hospitalised patients with symptoms
• At risk patients with symptoms
• Healthcare workers
• Examples of the Benefits of testing:
• Better epidemiological data
• Possibly more certainty as to the real situation
• Examples of the Disadvantages of testing:
• Risks of false negatives (especially – false reassurance)
• Need for people to travel – thus increasing exposure risk

2. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html
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 …. or Telemedicine?

• Current UK guidance is that

• Those with mild symptoms do not need to be tested.
• They should continue to stay at home for seven days and only
contact their GP if their condition worsens.

• The director of the CDC’s National Center for Immunization and

Respiratory Diseases, recently suggested that hospitals and other
healthcare facilities use telehealth in dealing with COVID-19

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 Potential advantages of telemedicine
1. decreasing exposure risk – especially for vulnerable patients
• Australia is doing this with a new Temporary Medicare Benefits Schedule[3]
• People isolating themselves at home on the advice of a medical
practitioner,
• people aged over 70
• At risk groups
• Parents with new babies and people who are pregnant.
2. Decreased burden on healthcare facilities
• The reality is that the majority of patients who have coronavirus will be
able to be managed at home
• Decreasing the number of these people who come to hospital will help
to conserve valuable resources, without significant risk to the patient

• This Does need a clear plan of triage and advice for the telemedicine
3.team
https://www.health.gov.au/sites/default/files/documents/2020/03/covid-19-national-health-plan-primary-care-bulk-billed-mbs-telehealth-ser
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vices_0.pdf
 Standard
precautions!

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 Summary of standard precautions

• Hand Hygiene
• Respiratory hygiene
• Use of appropriate personal protective equipment (PPE) (according to risk
assessment)
• Injection safety practices
• Safe waste management
• Environmental cleaning
• Sterilization of patient-care equipment
• Proper management of linens

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 Hand Hygiene – the first, and most important part of standard
precautions
• Hand Hygiene
• 100% compliance, 100% of time
• Soap and water, or alcohol gel both effective
• If gel, please make sure you still follow all the steps to cover whole hand

“bare below the elbows”

• Risk of sleeves being contaminated by environment, and re-transferring
to hands
• Obviously this does not count if wearing full gown protection
• UFH is working on providing appropriate clothing, that will keep you
warm enough!

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 Reminder of the 5 moments for Hand Hygiene

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 Other moments to remember:

• Any time you remove gloves/other PPE

• Always perform hand hygiene immediately after removing, and before
putting on new PPE
• Hand gel is readily available in all areas

• Perform hand hygiene after contact with respiratory secretions.

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 Respiratory hygiene

• Ensure that all patients cover their nose and mouth with a tissue or elbow
when coughing or sneezing;

• Offer a medical mask to patients with suspected 2019-nCoV infection

while they are in waiting/public areas or in cohorting rooms;

• Perform hand hygiene after contact with respiratory secretions.

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 Use of appropriate personal protective equipment (PPE)
(according to risk assessment)
The key things to notice here are:

1. Appropriate
• To keep you and others safe
• To not be excessive, and thus use resources without benefit to you

2. According to risk assessment

• Not all situations have the same risk
• You will therefore see different staff wearing different levels of PPE at
different times

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 USA CDC on PPE[4]

Basically say that if entering a room with a suspected case, should wear:
• Gloves
• Gowns
• Respiratory protection with N95 mask
BUT – updated information published a few days ago says facemasks
are an acceptable alternative when the supply chain of respirators
cannot meet the demand
• Goggles or face-shield

4. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html Accessed
2020/3/17

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 Masks – to N95 or not to N95, that is the question…

• Mode of transmission
• Risk/benefit of each type of mask

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 Masks – to N95 or not to N95, that is the question…
• Mode of transmission
• Primarily droplet
• Possibility of contact spread
• Occasionally aerosol, if aerosol generating procedures are done

• Surgical masks significantly decrease the risk of spread for both droplet and
contact
• Stop the physical contact of droplets with nose and mouth
• Studies show they significantly decrease hand contact with nose and mouth
• One well done, randomized study in JAMA (2019) showed no signicant
difference in the incidence of laboratory-conrmed inuenza among health care
personnel with the use of N95 respirators (8.2%) vs medical masks (7.2%).
• Another study from SARS in Hong Kong showed the use of any mask (surgical
or N95) significantly decreases the risk of infection

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 Masks – to N95 or not to N95, that is the question…

• Mode of transmission
• Risk/benefit of each type of mask
Mask Benefits Risks
N95 • Droplet and aerosol • Limited benefit if poorly fitted
protection • Uncomfortable for many – leads to fiddling
• Filters out very small and increased risk for contact transmission
particles • If damp will transmit organisms
Surgical mask • Droplet protection • Not considered adequate protection for
• Decreased risk of aerosolized particles
mucous membrane
contact transmission
• Easy to use
• Relatively comfortable

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 Coronavirus disease (COVID19)
Diagnosis and Treatment Guidance

Dr Katherine Bi, MD,PhD

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 Reference

• Chinese CDC

• WHO

• CDC

• PubMed published papers

• Uptodate

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 Source of infection

• COVID 19 confirmed patients

• Asymptomatic COVID19 infection person

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 EPIDEMIOLOGY

Over past 14 days,

• Closely contact confirmed COVID patients

• Cluster

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 Closely Contact or Exposure

Confirmed COVID Patients, without effective prevention

1. Family members, coworkers, roommates, students, office,

- In one room or class room or working office

Healthcare workers

On Transportation

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 Update on the epidemiological characteristics

• The virus is believed transmitted mostly via droplets or contact.

• The average incubation period was 5.2 days,
• the basic reproductive number R(0) was 2.2 at the onset of the outbreak.
• clinically mild cases.
• fatality rate was 2.38%, and elderly men with underlying diseases were at
a higher risk of death

Zhonghua Liu Xing Bing Xue Za Zhi. 2020 Feb 14;41(2):139-144

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 Clinically Course

• Patients with a mild clinical presentation may not initially require

hospitalization

• clinical signs and symptoms may worsen with progression to lower

respiratory tract disease in the second week of illness

• multilobular infiltration, lymphopenia, bacterial co-infection fatal respiratory

diseases such as ARDS,

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 Epidemiological and clinical characteristics of 99 cases of 2019
novel coronavirus pneumonia in Wuhan, China
• the average age was 55·5 years (SD 13·1) and 50 (51%) patients had
chronic diseases.
• fever (82 [83%] patients),
• cough (81 [82%] patients),
• shortness of breath (31 [31%] patients),
• muscle ache (11 [11%] patients),
• confusion (nine [9%] patients),
• headache (eight [8%] patients),
• sore throat (five [5%] patients), rhinorrhoea (four [4%] patients), chest
pain (two [2%] patients), diarrhoea (two [2%] patients), and nausea and
vomiting (one [1%] patient)

Chen, Nand Zhang, L. (2020). : a descriptive study. The Lancet.

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 Clinical Characterization

• fever, cough, malaise,

• shortness of breath or difficulty in breathing

• gastro-intestinal symptoms such as nausea, vomiting, and/or diarrhea

• rhinorrhoea, sore throat,

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 Clinical Characterization

• Mild, low grade fever or fatigue, without “pneumonia”

• Moderate,

• Severe, progressive hypoxemia, CURB-65 >1, qSOFA >=2

• Very severe, with ARDS, septic shock, ICU admission criteria

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 Diagnostic Testing

• Use of real-time RT PCR assays for the in vitro qualitative detection of

2019-Novel Coronavirus

• Labs Features
✔ normal WBC
✔ lymphocytopenia
✔ Normal PCT
✔ Elevated CRP, ESR, LDH

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 Acceptable Specimens

• Nasopharyngeal or oropharyngeal aspirates or washes,

• Nasopharyngeal or oropharyngeal swabs,

• Broncheoalveolar lavage,

• Tracheal aspirates,

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 Imaging findings of COVID-19

Dr. Jingjing Lu

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D1 D5 D6

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• The hallmarks of COVID-19 on imaging were bilateral and peripheral
ground-glass and consolidative pulmonary opacities.
• Preponderance of ground-glass abnormality is noted in early disease,
followed by development of crazy paving, and finally increasing
consolidation later in the disease course.

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 F 63, Fever and fatigue

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 武汉2019新型冠状病毒（2019-nCoV）肺炎的临床影像学特征初探。《放射学实践》
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Sensivity & Specificity of chest CT in COVID

Highly sensitive but not very specific,

because the key findings can also be seen
with other causes of viral pneumonia

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Summary

• Chest X ray is not sensitive at early stage

• Chest CT may show characteristic findings
• GGO or consolidation, Bilateralism, Peripheral distribution, Multifocal
• Imaging serves as monitoring in progress stage or severe stage
• Clinical correlation always advised
• Epidermiology；
• Symptoms：Fever, Cough；
• Lab：WBC，lymphocytes，ESR，CRP，PCT；screening for other pathogens；Ig
G&M；
• Final diagnosis：RT-PCR

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 Initial CT findings and temporal changes
63 cases
• The imaging manifestations of the new coronavirus pneumonia are similar
to common viral pneumonia
• 30.2% of 21 patients had only one lobe involved, and 44.4% had all lobes
involvement.
• patchy/punctate ground glass opacities(85.7%), patchy
consolidation(19.0%), and mainly distributed in a sub-pleural area
• When patients' condition would improve, a little fibrous stripe may appear

Eur Radiol. 2020 Feb 13.

Department of radiology, Tongji hospital, Huazhong University of Science and Technology, Wuhan

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 21 patients signal center

• Figure 2: Chest CT findings of COVID-19 pneumonia on transaxial images. (a) GGO; (b)
crazy-paving pattern (GGO with superimposed inter- and intralobular septal thickening); (c)
Consolidation.
Eur Radiol. 2020 Feb 13.
Department of radiology, Tongji hospital, Huazhong University of Science and Technology, Wuhan
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 • lung abnormalities on chest CT showed greatest severity approximately
10 days after initial onset of symptoms.

Eur Radiol. 2020 Feb 13.

Department of radiology, Tongji hospital, Huazhong University of Science and Technology, Wuhan

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 Primary findings on CT

• ground glass opacities (GGO) in all hospitalized patients

• crazy paving appearance (GGOs and inter-/intra-lobular septal thickening)

• air space consolidation

• No mediastinal lymphadenopathy has been seen

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 Recovering with four Stages on Chest CT

• early stage (0-4 days);

• progressive stage (5-8 days);
• peak stage (10-13 days);
• and absorption stage (≥14 days).

Radiology. 2020 Feb 13:200370.

From the Department of Radiology, Union Hospital, Tongji Medical College

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 Radiographic Findings

• Chest CT images have shown

• bilateral involvement in most patients.

• Multiple areas of consolidation and ground glass opacities are typical

findings reported to date.

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 Treatment considerations

Dr Katherine Bi, MD,PhD

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 Case definitions - suspected cases
1. key epidemiological transmission features
• Traveling or living in HuBei
• Contact to people from HuBei
• Exposure to confirmed COVID patients
• Community or campus where having confirmed COVID
• Cluster
2. Clinical features
• Fever and/or respiratory symptoms
• Typical Pneumonia features in images of lung - Viral Pneumonia Features
• Labs show normal WBC or lymphocytopenia

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 Confirmed COVID

Suspected cases, +
• coronavirus RT-PCR positive,
• or positive to NGS
• Or COVID IgM / IgM+IgG positive

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 Important – Differential Diagnosis
• Acute seasonal Respiratory Disease
- Flu, Common Cold, Acute bronchitis, CAP
- Viral Pneumonia, Mycoplasma Pneumonia
• OP
• Underline Medical Condition, cancer with metastasis
• Tuberculosis

• Other medical illness related to Fever & Fatigue, UTI, abscess, cholecystitis.

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 Key Medical Information
• Epidemiology
• Time course
• Clinical features
• Labs – normal WBC, lymphocytopenia (NOT percentage of lymphcytes)
• Typical features of Images CT

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 Questions
• Leukocytopenia or normal WBC
• Normal PCT or slightly elevated
• CRP mildly elevated
• Lymphocytopenia
• Lymphocytosis

Viral ?

Bacteria ? - mycoplasma

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Viral Pneumonia

• Chest radiography usually demonstrates bilateral lung involvement, but

none of the viral etiologies of pneumonia result in pathognomonic findings

with this modality

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 Probable and Confirmed Patients Report
• Recognize Suspected Patients
• Isolation Immediately
• Hospital Specialists MDT
• Coronavirus RTPCR test
• Transfer suspected and confirmed patients to COVID Infectious Hospital
• Once Suspected cases can NOT be transferred out immediately, or the first
times virus RTPCR test is negative, second time of virus test in CDC is
needed, interval 24 hours
• Closely contact person - need Coronavirus screening test even though Flu is
positive

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 Where should suspected or confirmed patients be treated
• suspected - should be isolated in single rooms

• Confirmed – ideally, should be isolated in single rooms, or shared in one

treating room

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 Discharge and Release – China CDC
• Confirmed COVID patients

• No fever for 3 days

• Respiratory symptoms have been improving
• Two times negative to coronavirus RNA by rT-PCR, interval 24 hours

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 Clinical Management and Treatment
• No specific treatment for COVID 19
• prompt implementation of recommended infection prevention and control
measures
• supportive management of complications, including advanced organ support if
indicated.
• Corticosteroids should be avoided unless indicated for other reasons (for
example, chronic obstructive pulmonary disease exacerbation or septic shock

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 Antiviral Treatment – COVID19
• Effective treatment
• None
• Tentative treatment for severe cases (Level of evidence: Low)
• Adults
• Interferon alpha-2a 5 MU Nebulization for 10 minutes BID (mix with 2 mL of SWI)
+
• Lopinavir/ritonavir 400mg/100mg BID
• Pediatrics
• Interferon alpha-2a 3 MU Nebulization for 10 minutes BID (mix with 2 mL of SWI)
+
• Lopinavir/ritonavir
• <15 kg: Lopinavir 12 mg/kg/dose twice daily
• 15 to 40 kg: Lopinavir 10 mg/kg/dose twice daily
• >40 kg: Lopinavir 400 mg twice daily

国卫办 国家卫生健康委办公厅关于印发新型冠状病毒感染的肺炎诊疗方案（试行第二版） 号

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 Pharmacotherapeutics for the New Coronavirus Pneumonia
• Combination of Ribavirin and Interferon-α is recommended by National Health
Commission's Regimen (Revised Edition) because of the effect on MERS

• the effectiveness of Lopinavir/Ritonavir and Remdisivir needs to be confirmed

by randomized controlled trial (RCT),

Zhonghua Jie He He Hu Xi Za Zhi. 2020 Feb 14;43(0):E012.

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Antiviral Treatment

• Chloroquine diphosphate, 18-65yo, more than 50kg,

• 500mg twice daily, maximal 7 days

• Ribavirin,
• 500mg twice daily, maximal 10 days

• Abidore
• - 200mg three times daily, maximal 10 days

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SARS treatment - uptodate
• No specific treatment is currently recommended except for meticulous
supportive care.
• Antibacterial agents are ineffective.
• No antiviral agents have been found to provide benefit for treating SARS.
• During the epidemic, most patients were treated with high-dose glucocorticoids
and ribavirin, but most experts now agree that neither treatment had a clear
beneficial effect, and immediate and late toxicities were common.
• Lopinavir-ritonavir may have some activity against the virus in vitro, but its
clinical efficacy has not been established.
• Remdesivir (GS-5734), an experimental agent whose development was
accelerated because of its activity against Ebola virus, has activity against the
SARS and MERS coronaviruses

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 MERS treatment - uptodate

• No specific treatment is currently recommended except for meticulous

supportive care.
• Antibacterial agents are ineffective.
• No antiviral agents have been found to provide benefit for treating MERS.
• In cell culture and animal experiments, combination therapy with interferon
(IFN)-alpha-2b and ribavirin appears promising
• Lopinavir-ritonavir may have some activity against the virus in vitro, but its
clinical efficacy has not been established.
• Remdesivir (GS-5734), an experimental agent whose development was
accelerated because of its activity against Ebola virus, has activity against
the SARS and MERS coronaviruses

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 • Clinical management of severe acute respiratory
infections when novel coronavirus is suspected: What
to do and what not to do

severe acute respiratory infections when novel coronavirus is

suspected – WHO recommendation

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 • Early recognition and management

severe acute respiratory infections when novel coronavirus is

suspected – WHO recommendation

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Give empiric antimicrobials to treat suspected pathogens,
including community acquired pathogens

• Although the patient may be suspected to have novel coronavirus

infection, administer appropriate empiric antimicrobials as soon as
possible for community-acquired pathogens based on local
epidemiology and guidance until the diagnosis is confirmed

severe acute respiratory infections when novel coronavirus is

suspected – WHO recommendation

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Use conservative fluid management in patients with SARI when
there is no evidence of shock

• Patients with SARI should be treated cautiously with intravenous fluids,

because aggressive fluid resuscitation may worsen oxygenation

severe acute respiratory infections when novel coronavirus is

suspected – WHO recommendation

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Use conservative fluid management in patients with SARI when
there is no evidence of shock

• Do not give high-dose systemic corticosteroids or other adjunctive

therapies for viral pneumonitis outside the context of clinical trials

• Closely monitor patients with SARI for signs of clinical deterioration,

such as severe respiratory distress/respiratory failure or tissue
hypoperfusion/shock, and apply supportive care interventions

severe acute respiratory infections when novel coronavirus is

suspected – WHO recommendation

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Management of septic shock

• Recognize sepsis-induced shock when patient develops hypotension

(SBP < 90 mm Hg) that persists after initial fluid challenge or signs of
tissue hypoperfusion (blood lactate concentration > 4 mmol/L) and
initiate resuscitation by protocol

severe acute respiratory infections when novel coronavirus is

suspected – WHO recommendation

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Give early and rapid infusion of crystalloid intravenous fluids for
septic

• Overly aggressive fluid resuscitation may lead to respiratory

impairment. If there is no response to fluid loading and signs of volume
overload appear (i.e. crackles on auscultation, pulmonary edema on
chest X-ray) then reduce or discontinue fluid administration. This is
particularly important in resource-limited settings where mechanical
ventilation is not available. shock

severe acute respiratory infections when novel coronavirus is

suspected – WHO recommendation

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 • Use vasopressors when shock persists despite liberal fluid resuscitation

• Consider administration of intravenous hydrocortisone (up to 200

mg/day) or prednisolone (up to 75 mg/day) to patients with persistent
shock who require escalating doses of vasopressors

severe acute respiratory infections when novel coronavirus is

suspected – WHO recommendation

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