GatutPriyonugroho

RumahSakitUniversitasIndonesia
20 Mei 2020

Pengantar COVID–19
Coronavirus Disease

Biodata
Sekretaris Perhimpunan Dokter Paru Indonesia (PDPI cabang Jakarta)
Work General physician, clinic for industrial area (2009-2011). Pulmonary
physician, Permata Bekasi hospital (2017-now). Staf, division of Pulmonary
Infectious Disease, departement of Pulmonology & Respiratory Medicine,
Faculty of Medicine, Universitas Indonesia (2017-2018). Pulmonologist, RS
Mitra Kalideres (2017-now). Managing Assistant of Non-Communicable and
Geriatry Cluster (April-September 2019). Staff, KSM Paru (Pulmonology
medical staff group), RS Pendidikan Universitas Indonesia (Universitas
Indonesia Teaching Hospital), Universitas Indonesia (2019-now)
Rumah Sakit Universitas Indonesia
Dosen Asisten Ahli, Universitas Indonesia
Research
• As investigator: Priyonugroho G, Zaini J, Samoedro E, Firmansyah I, Nurwidya F, Antariksa B, et
al. Corrrelation between urinary cotinine, exhaled carbon monoxide, and nicotine dependence
among Indonesian individuals in the national narcotics and illicit drug rehabilitation center. J
Nat Sc Biol Med 2018;9:268-72
• As research assistant: Nguyen VN, Yunus F, et all. The prevalence and patient characteristics of
chronic obstructive pulmonary disease in non-smokers in vietnam and Indonesia: an
observational survey. Respirology. 2015 May;20(4):602-11
Others
• Workshop of Interventional Pulmonology; Bronchoscopy and Pleural Procedures. PIPKRA (2019)
• Basic Life Support, American Heart Association (2018)
• endTB regional workshop of new and repurposed drugs for durg-resistant TB (Ho Chi Minh,
Vietnam, 11-16 September 2017)
• Poster: Microbial pattern of bronchial washing in patient with lung cancer World congress of
bronchology and interventional pulmonology (World Congress of Bronchology and Interventional
Pulmonology, Kyoto, 2014)
• Workshop trainer: Diagnosis of DS TB & DR TB in adult, workshop of TB for District-based Public-
Private Mix (2-6 October 2017)
• Workshop trainer: Antibiotic strategy in sepsis, workshop of sepsis (26 October 2017)
• Workshop trainer: PIPKRA - Pulmonary Emergency and Respiratory Life Support - Oxygen Therapy
session (8 February 2017, Persahabatan hospital)
• Good clinical practice (Jakarta, 10-12 August 2017)
• Diagnosis of TB and NTM using GenoScholar (Jakarta 5-6 December 2017)
• National facilitator of TB for district-based public-private mix in primary care and hospital
(Yogyakarta, 21-24 August 2017)
• Clinical teacher (Jakarta, 12-15 December 2017)
• Basic and Advance Life Support, Training on Trainers for in-House Training, RSUI (2019)
Desember 2019, muncul serangkaian
pneumonia tanpa penyebab yang jelas di
Wuhan, Hubei, Cina.

Gejala klinis mirip pneumonia virus. Hasil

sekuensing mengindikasikan coronavirus
yang baru, sehingga dinamakan 2019
novel coronavirus (2019-nCOV)

1. Menyebar dengan cepat

2. Menyebabkan kematian
 https://covid19.who.int/
Laporan situasi
 https://covid19.who.int/
Laporan situasi
 Perbandingan

Angka kematian Angka kematian H5N1 Flu Burung COVID di Cina :

2003: 31 Desember 2019

44 kasus

SARS-CoV 10% 2019: 861 kasus

MERS-CoV 37% COVID19 = 90.955 kasus
KEMATIAN
H5N1 60-78% 2 %  6,89 % Dunia : 53% 11 Maret 2020
IDN : 84%

Dunia : 118.162 kasus COVID-19

.
1. https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd
2. www.who.int
 Apa itu CoV ?

• Virus RNA, biasa menginfeksi

mamalia & burung.
• Awal: SARS Cina 2003, MERS
2012 : MERS Saudi 2012
• Kelelawar  musang, anjing
rakun, dan unta  manusia.

1. Chappel JD, Terence SD. Biology of viruses and viral diseases. In: Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 8th ed. 2015
2. McIntosh K, Perlman S. Coronaviruses, including SARS and MERS. In: Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 8th ed. 2015
3. https://www.cdc.gov/coronavirus/2019-ncov/summary.html
4. Jia Y, et al. Analysis of the mutatioan dynamics of SARS-CoV2 reveals the spread history and emergence RBD mutant with lower ACE2 binding affinity. bioRxiv 2020
 Patofisiologi

1. Shereen MA, et al. COVID-19 infection: origin, transmission, and characteristics of human coronaviruses. J Adv Res 2020;24:91–98
2. Totura AL, Baric RS. SARS coronavirus pathogenesis: host innate immune responses and viral antagonism of interferon. Cur Opin Virol 2012;2(3):264-75 2
3. Kindler E, et al. Early endonuclease-mediated evasion of RNA sensing ensures efficient coronavirus replication. PLoS Pathog 2017.
4. Jaafar ZA, Kieft JS. Viral RNA structure-based strategies to manipulate translation. Nat Rev Microbiol 2019.
5. Li G, et al. Coronavirus infections and immune responses. J Med Virol 2020
6. Li X, et al. Molecular immune pathogenesis and diagnosis of COVID-19. J Pharm Anal 2020
 Patofisiologi

3
4
1. Shereen MA, et al. COVID-19 infection: origin, transmission, and characteristics of human coronaviruses. J Adv Res 2020;24:91–98
2. Totura AL, Baric RS. SARS coronavirus pathogenesis: host innate immune responses and viral antagonism of interferon. Cur Opin Virol 2012;2(3):264-75
3. Kindler E, et al. Early endonuclease-mediated evasion of RNA sensing ensures efficient coronavirus replication. PLoS Pathog 2017.
4. Jaafar ZA, Kieft JS. Viral RNA structure-based strategies to manipulate translation. Nat Rev Microbiol 2019.
5. Li G, et al. Coronavirus infections and immune responses. J Med Virol 2020
6. Li X, et al. Molecular immune pathogenesis and diagnosis of COVID-19. J Pharm Anal 2020
 Patofisiologi

1. Shereen MA, et al. COVID-19 infection: origin, transmission, and characteristics of human coronaviruses. J Adv Res 2020;24:91–98
2. Totura AL, Baric RS. SARS coronavirus pathogenesis: host innate immune responses and viral antagonism of interferon. Cur Opin Virol 2012;2(3):264-75
3. Kindler E, et al. Early endonuclease-mediated evasion of RNA sensing ensures efficient coronavirus replication. PLoS Pathog 2017.
4. Jaafar ZA, Kieft JS. Viral RNA structure-based strategies to manipulate translation. Nat Rev Microbiol 2019.
5. Li G, et al. Coronavirus infections and immune responses. J Med Virol 2020
6. Li X, et al. Molecular immune pathogenesis and diagnosis of COVID-19. J Pharm Anal 2020
 Patofisiologi

6 7

1. Shereen MA, et al. COVID-19 infection: origin, transmission, and characteristics of human coronaviruses. J Adv Res 2020;24:91–98
2. Totura AL, Baric RS. SARS coronavirus pathogenesis: host innate immune responses and viral antagonism of interferon. Cur Opin Virol 2012;2(3):264-75
3. Kindler E, et al. Early endonuclease-mediated evasion of RNA sensing ensures efficient coronavirus replication. PLoS Pathog 2017.
4. Jaafar ZA, Kieft JS. Viral RNA structure-based strategies to manipulate translation. Nat Rev Microbiol 2019.
5. Li G, et al. Coronavirus infections and immune responses. J Med Virol 2020
6. Shi Y, et al. COVID-19 infection: the perspectives on immune responses. Cell Death & Differentiation 2020
 Manifestasi Klinis

• Gejala • Ringan-sedang 81% (asimtomatik /

- Demam (83-99%). prasimtomatik 13%).
- Batuk (59-82%). • Sakit berat 14%
- Lemas (44-70%). • Faktor risiko sakit berat: usia >65,
- Anorexia (40-84%). komorbid KV, DM, respirasi kronik, HT,
- Sesak / napas pendek (31-40%). kanker, jantung, stroke, CKD.
- Berdahak (28-33%). Batuk darah (5%).
- Myalgia (11-35%). Sakit kepala (8%).
- Diare (5%). Mual/muntah (4%).
- Saat datang ke RS, yang demam hanya 44%.

1. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
2. Zhou F, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a restrospective cohort study. The Lancet 2020.
3. Huang C, et al. Clinical features of patinets infected with 2019 novel coronavirus in Wuhan, China. The Lancet 2020
 Manifestasi Klinis

1. Kementerian Kesehatan RI. Pedoman pencegahan dan pengendalian Coronavirus Disease (COVID-19) 4th ed. 2020.
 Manifestasi Klinis

• Klasifikasi
- OTG
- ODP
- PDP
- Probable
- Terkonfirmasi

1. Hassan SA, et al. Coronavirus (COVID-19): A review of clinical features, diagnosis, and treatment. Cureus 2020;12(3):e7355.
 Timeline

• Hari ke-1 : demam dan

batuk. Pemeriksaan
molekular sudah
memberi hasil positif
• Hari ke-7: sesak
• Hari ke-10: infeksi berat

• Hari ke-12: kerusakan berat paru

• Hari ke-15: kerusakan berat jantung dan ginjal. Hari ke-17: tambahan infeksi bakteri
• Hari ke-19: meninggal
• 98% pasien selamat, hari ke-22 bisa pulang ke rumah.
1. Zhou F, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a restrospective cohort study. The Lancet 2020.
2. Huang C, et al. Clinical features of patinets infected with 2019 novel coronavirus in Wuhan, China. The Lancet 2020
 Penunjang

1. https://www.kyvobio.com/lees/newsletter-26/sars-cov-2-covid-19-diagnosis-by-2264.html
2. https://m.facebook.com/story.php?story_fbid=3141649285926435&id=803774136380640
3. Jin Y, et al. Diagnostic value and dynamic variance of serum antibody in coronavirus disease 2019. Int J Infect Dis 2020. pii: S1201-9712(20)30198-3
 Penunjang

• Pada fase awal: CD4 dan CD8 ↓

• Leukosit rendah (17%), normal (62%), tinggi (21%).
Neutrofil dan PCT normal. Limfo↓ 83%.
• Pada kondisi lebih berat: Limfo↓, Neu↑, SGOT
SGPT ↑, CRP ↑, d-dimer ↑

1. Hassan SA, et al. Coronavirus (COVID-19): A review of clinical features, diagnosis, and treatment. Cureus 2020;12(3):e7355.
2. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html
3. Zhou F, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a restrospective cohort study. The Lancet 2020.
4. Huang C, et al. Clinical features of patinets infected with 2019 novel coronavirus in Wuhan, China. The Lancet 2020
 Diagnosis

• RT PCR
• Rapid antibody
• Radiologi (CTsensitivitas 97% vs RT PCR 59%)

INTEGRASI DATA
 Laki-laki (47) Demam 3 hari, sesudah itu tak ada keluhan.

• TSB, CM. TD 129/85. HR 106x. RR • Leu 2700. Trb 68000.

20x. Temp 36.5. SpO2 97% dgn NK SGOT 52. SGPT 46.
3 lpmMata CA -/- SI -/-. Thorax • Anti-Dengue IgG
gerak bentuk simetris. Cor S1 S2 pos, IgM pos
reg murmur - gallop -. Pulmo sn
ves +/+ wh -/- rh -/-. Abdomen
supel datar BU (+) NTE(+).
Ekstremitas akral hangat CRT < 2

PCR SARS-CoV2 selalu negatif (2x)

 Perempuan (27)

• Batuk dan sakit kepala.

• Satu-satunya kontak
kasus positif yang
diketahui 29 Februari
2020
• PF normal.
• Lab normal.

PCR SARS-CoV2 4x positif. Sesudah 70 hari baru negatif.

 • HFNOT
Tatalaksana
• Ventilasi mekanis lung protective strategy
• Definitif belum ada • Tatalaksana syok sepsis
• Asimtomatik atau Ringan: isolasi mandiri • Hydroxychloroquine atau Chloroquine
di rumah • Lopinavir/ritonavir, Oseltamivir, Remdesivir,
• Sedang atau berat: rawat Favipiravir
• Suportif • Tocilizumab
• Terapi oksigen • NAC
• Terapi cairan • Azitromisin
• Antibiotik empiric • Vitamin C
• Steroid sistemik rutin tidak dianjurkan • Zinc

1. IDSA. Guideline n the treatment and management of patients with COVID-19.

• Plasma konvalesen
2. Kemkes RI. Pedoman kesiapsiagaan menghadapi COVID-19 revisi 4
3. Perhimpunan Dokter Paru Indonesia. Pneumonia COVID-19: Diagnosis dan penatalaksanaan di Indonesia. 2020
4. WHO. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. 2020
Tatalaksana
 Penularan

Dari Hewan
• Pejamu asli : kelelawar
• Pejamu antara : musang, anjing rakun, unta
• Hewan liar di pasar Huanan, Wuhan

Dari Manusia
• Batuk
• Cairan tubuh lain
• Droplet
 Penularan secara Droplet /
percik renik / tetesan

3. Permukaan
benda-benda Turun
mengikuti
gravitasi dan
menempel
1. Tangan di benda

2. lantai
1 meter
 Infection Prevention Control for novel acute respiratory
infections with potential for high public health impact
Prinsip Personal protective equipment
• Early recognition and source control • Hanya mengurangi risiko tertular, tidak
• Administrative control menyingkirkan bahaya

• Environmental and engineering control • Minimal masker bedah/medis

• Personal protective equipment • Pada aerosol-generating procedures, harus: N95

/ FFP2 / setara, gloves, gowns, eye protection

Pastikan sebelum melakukan kegiatan: • Coverall / hazardous material suit

1. Identifikasi bahaya
2. Pahami performa masing-masing APD
3. Apakah APD memadai untuk menghadapi
bahaya tsb Sesudah pekerjaan yang high risk, mandi
4. Pakai dengan benar
 Infection Prevention Control for novel acute respiratory
infections with potential for high public health impact
Personal protective equipment
Respirator
• N95 ini didesain untuk memfilter minimal 95% • N95 jika belum dipakai, disimpan 10 tahun,
partikulat berukuran sampai 0,3 mikron. N kalau kondisi masih baik
tidak tahan minyak dan air, R kalau kebal, P
• Sesudah dipakai, performa menurun 1%/hari.
(proof) kalau anti. Disertifikasi NIOSH. FFP2 oleh
Eropa • Jika langka atau terpaksa, disinfeksi dengan:
 UVGI
• CoV ukurannya 0,08-0,1 mikron.
 VHP
• Saat diuji dengan partikel virus MS2 yang  Moist heat
ukurannya 0,02 mikron. Pada aliran udara 2 siklus
85L/menit dan 135L/menit kebocorannya 2-4%.
• N95 diuji di kelembaban 40%, cukup kering

1. Gardner PD, et al. Viable viral efficiency of N95 and P100 respirator filters at constant and cyclic flow. J Occup Envir Hyg 2014
2. Eninger RM, et al. Filter performance of N99 and N95 facepiece respirators against viruses and ultrafine particles. Ann Occup Hyg 2008
 Infection Prevention
Control for novel
acute respiratory
infections with
potential for high
public health impact

Personal protective
equipment - Respirator
 Infection Prevention Control for novel acute respiratory
infections with potential for high public health impact
Personal protective equipment
Coverall
• ISO 16603 class 3 exposure pressure tahan • EN 13034 standard offers sufficient protection
penetrasi darah dan cairan tubuh against all acids and alkalis (also called bases)
• ISO 16604 class 2 exposure pressure tahan blood that are dissolved in water.
borne pathogen penetraton • EN 1149-5: 2008 Protection against electrostatic
• ISO 13982-1:2004 Protective clothing for use charges
against solid particulates — Part 1: Performance • EN 1073-2 : 2002 Protective clothing against
requirements for chemical protective clothing rafdioactive contamination – Part 2 :
providing protection to the full body against Requirements and test methods for non-
airborne solid particulates (type 5 clothing) ventilated protective clothing against particulate
radioactive contamination
 Virus Corona
• Suhu panas (>30˚C) dan lembab (>95%)
― Dalam 1 hari, hampir semua inaktif.
Jangan mengandalkan
• Suhu sejuk (22-25˚) dan agak kering suhu dan kelembaban
(40%) / serupa ruangan ber-AC
― Virus bertahan 5 hari.

• Di udara dingin (4˚C) dan kering (20%) Bersihkan / barang

― Virus bisa bertahan 1 bulan.
cuci tangan !!!
 Health Advice (WHO)
Cegah diri sendiri dari penyakit Cegah orang lain tertular/sakit
Tutup mulut dan hidung
dengan tissue atau siku Hindari bepergian
Hindari kontak ketika batuk atau bersin
jika sakit atau
langsung tanpa bepergian ke
terproteksi dengan Terapkan Buang tissue ke tempat sampah tempat outbreak
orang sakit saluran tertutup
napas dan hewan
hand hygiene
peliharaan ataupun Gunakan masker
Cuci tangan setelah batuk atau
hewan liar bersin atau kontak orang sakit jika sakit

Makanan yang aman Ketika berbelanja di Pasar Ketika bekerja di Pasar

Cuci tangan setelah menyentuh

hewan atau produk hewan Gunakan proteksi tubuh, sarung
tangan dan wajah ketika Sering cuci tangan, terutam
Masak matang dan memegang produk hewan setelah memegang produk
higienis Hindari menyentuh hewan

Hindari kontak hewan Lepaskan baju pelindung setelah

sakit dan spoil meat bekerja, cuci setiap hari
Desinfektan tempat
Hindari kontak stray animal Hindari keluarga terpapar pakaian kerja, sehari sekali
dan sampah atau cairan kerja
 Edukasi

Sudah ada pedoman yang

dapat dipertanggung-
jawabkan dari:
1. Perhimpunan profesi
kedokteran dalam dan
luar negeri
2. Kementerian
Kesehatan
3. Pemerintah daerah
4. WHO, CDC, IDSA
7 Langkah Sederhana untuk Melindungi Diri
Kita dari Penyebaran COVID-19:
1. Sering mencuci tangan
2. Hindari menyentuh mata, mulut dan hidung
3. Tutup mulut saat batuk dengan ujung siku atau tisu
4. Hindari tempat kerumunan
5. Istirahat di rumah jika merasa tidak enak badan, walaupun hanya
sedikit demam atau batuk
6. Jika mengalami demam, batuk dan sulit bernapas, segera cari
tempat pelayanan kesehatan, namun hubungi terlebih dahulu via
telepon
7. Tetap waspada dengan terus memantau informasi dari WHO
Terima
kasih