RICARDO S.

GUANZON, MD, EdD, PhD, DFM, RGC, RPy, LPT, FPAFP

Dean, College of Medicine, Mariano Marcos State U, Batac City, Ilocos Norte
Board of Director, Phil Guidance Counseling Association
Board of Trustees, Phil Academy of Family Physicians
Chi Sigma Iota, (Iota Phi, Counseling Academic and Professional
Honor Society International
Member, Phil Society of Microbiology and Infectious Diseases
June 4, 2020 6pm
 INFECTION AND DISEASE
• "infection" and "disease" are not synonymous.
• An infection results when a pathogen invades and begins growing
within a host.
• Disease results only if and when, as a consequence of the invasion
and growth of a pathogen, tissue function is impaired.

• Our bodies have defense mechanisms to prevent infection and,

should those mechanisms fail, to prevent disease after infection
occurs.
Microbes That Cause Infectious Diseases
• There are five major types of infectious agents:
• Bacteria – Ex. Strep pneumonia causing pneumonia
• Viruses – Ex. Influenza A, SARS-CoV-2 (causing Covid-19)
• Fungi – Candida (oral thrush), Histoplasma (pneumonia)
• Protozoa – Entamoeba histolytica causing amebiasis
• Helminths – Schistosoma

• Prions – Proteins only, Creutzfeldt-Jakob Disease

Coronaviruses (CoV) are a family of viruses that cause illness ranging from
the common cold to more severe diseases such as
Middle East Respiratory Syndrome (MERS-CoV) and
Severe Acute Respiratory Syndrome (SARS-CoV).

A novel coronavirus (nCoV) is a new strain that has not been previously
identified in humans. (WHO)

Coronaviruses are zoonotic infections, meaning transmitted between

animals and people.
 Coronaviruses
• Detailed investigations found that SARS-CoV1 was transmitted from civet
cats to humans in SARS-Cov1
• From bats mediated by snakes or pangolins to humans in SARS-Cov2
- (but still continues to be investigated)
• and MERS-CoV from dromedary camels to humans.
• Several known coronaviruses are circulating in animals that have not yet
infected humans. (WHO
The disease caused by the Virus SARS-CoV2 has been designated
COVID-19 by the WHO
SARS-CoV2 (The novel coronavirus of 2019)
• The 2019 – 2020 China pneumonia outbreak, also known as Wuhan
pneumonia began as an outbreak of viral pneumonia, due to a new
coronavirus, the SARS-CoV2, that infected primarily stallholders who
worked at the Huanan Seafood Market in the city of Wuhan in central
China.

• The first cases were reported on 31 December 2019, with the earliest
symptoms appearing just over three weeks earlier on 8 December 2019,
and by 5 January 2020 there were 59 suspected cases in China
 MODE OF TRANSMISSION
Infectious agents may be transmitted through either direct or indirect contact.

I. Direct contact occurs when an individual is infected by contact with the

reservoir, for example, by touching an infected person, ingesting infected meat,
or being bitten by an infected animal or insect.

• Transmission by direct contact also includes inhaling the infectious agent

(aerosolize) in droplets emitted by sneezing or coughing and contracting the
infectious agent through intimate sexual contact.

• Ex. Ringworm, AIDS, influenza, rabies, and malaria, COVID-19.

II. Indirect contact occurs when a pathogen can withstand the environment
outside its host for a long period of time before infecting another individual.

• Inanimate objects that are contaminated by direct contact with the reservoir
• a tissue used to wipe the nose of an individual who has a cold
• a toy that has been handled by a sick child may be the indirect contact for a susceptible
individual.
• Door knob, face mask, endotreacheal tube, etc (seen in Covid19) where virus lodged
(The reason for disinfecting these objects, throwing away contaminated)

• Ingesting food and beverages contaminated by contact with a disease reservoir is another
example of disease transmission by indirect contact.
 Important Data/Issues
• SARS virus = 100 nanometers
• FLU virus = 80 120 nanometers
• Usual human coronavirus = 0.1 to 0.2 microns* (around 125 nm)
• SARS-CoV2 is characterized is at 400 -500 nm (.4- .5 u)(Wuhan)
• (UK studies report they are also around 100-200 nm)
• (NY studies 70 -90 nm)

• 1 nanometer = 0.001 micrometer = 1 billionth of a meter

• Human hair = on the average, 100 microns
• The n95 mask = Filter out 0.3 microns 95 % of the time
(not guaranteed depending on producer)*
• Micron = 1/1,000th of a millimeter
• 125 nm = 0.125 microns (divide by 1,000)
 How Big Are Coronavirus Particles?
Coronavirus particles (fancy scientific name “virions”) are spheres with diameters of approximately
0.125 microns (125 nm). The smallest particles are 0.06 microns, and the largest are 0.14 microns.
This means coronavirus particles are smaller than the PM2.5 cutoff, but bigger than some dust particles
and gases.
 Respiratory virus shedding in exhaled breath and
efficacy of face masks
Nancy H Leung, Daniel KW Chu, Eunice YC Shiu, Kwok-Hung Chan, James J McDevitt Et a

• On average, viral shedding is higher in nasal swab compared to throat

swabs
• (Must clean our noses and gurgle with solution)
Surgical face mask significantly reduced detection of influenza
virus RNA in respiratory droplets and coronavirus RNA in aerosols
with a trend towards reduced detection of coronavirus RNA in
respiratory droplets.
“Surgical face mask could prevent transmission of
human coronaviruses and influenza viruses in
symptomatic individuals”
(Paddy Robertson, 2020) https://smartairfilters.com/en/blog/can-masks-capture-coronavirus/
(Paddy Robertson, 2020) https://smartairfilters.com/en/blog/can-masks-capture-coronavirus/
In another study, researchers shot actual virus particles at N95 masks. The masks captured
over 95% of virus particles (Paddy Robertson, 2020).

https://smartairfilters.com/en/blog/can-masks-capture-coronavirus/
Even poorly performing masks captured over 90% of viruses. The researchers chose two N95 masks that scored
poorly in an earlier study, yet even these poor-performers still blocked 94% of particles under the heaviest air
flow rate.

Conclusion: Masks
– including surgical
masks and N95
masks – can
capture viruses
and even particles
over 10 times
smaller (Paddy
Robertson, 2020)

https://smartairfilters.com/en/blog/can-masks-capture-coronavirus/
Several 3M masks were able to capture over 99% of tiny 0.01 micron particles (10 times smaller than the
coronavirus), even while on people’s face. What’s more, surgical masks were surprisingly effective,
capturing 63% of the tiny virus-sized particles (Paddy Robertson, 2020)
https://smartairfilters.com/en/blog/can-masks-capture-coronavirus/
 Can Masks Protect People From The Coronavirus?

Bottom line: Masks can filter particles as small as 0.007 microns – 10 times smaller than
viruses, and much, much smaller than the PM2.5 cutoff. What’s more, they work
surprisingly well, even while people are wearing them. Surgical masks don’t work as well
as N95 masks, but they are cheaper and more readily available. This makes them useful
alternatives when other masks aren’t available (Paddy Robertson, 2020)

https://smartairfilters.com/en/blog/can-masks-capture-coronavirus/
 American Journal of Infection Control
June 2, 2020
Jonathan Carnino, Department of Pulmonology
Boston University School of Medicine
• Salt treatment of surgical masks improved the abilty to block various strains of
the flu virus (in a previous study)

• Paper towels soaked in saline solution and then allowed to dry, effectively
filter out particles comparable to the size of coronavirus, SARS-CoV-19

• Salt in water forms in a molecular bond creating a lattice; when a nanoparticle

hits the treated paper towel, the salt dissolves for a second, when it dries up,
it creates lattice again encapsulating the virus
What happens when we cough or sneeze?
COVID-19 transmission infographic
 Persistence of Coronaviruses on Surfaces
(Indirect contact)
• 2 – 8 Hours : Aluminum
• 8 hours : Surgical Gloves
• 9 hours : Attached - shoes, cemented road, pavement
• 48 hours : Steel
• 4 days : Glass
• 4 days : Wood
• 4 – 5 days : Paper
• 5 days : Plastic
• 7 days : Face mask
 SARS-CoV2
• 81 % are MILD

• 14 % are MODERATE

• 5 % are CRITICAL
 Manifestations/Diagnosis
• Fever, headache, dry cough, myalgias, abdominal discomfort, difficulty of
breathing, diarrhea, loss of smell, anorexia, fatigue

• 2 – 11 days after exposure flu-like symptoms appear

• Day 5 – bilateral pneumonia
• Day 10 – Cytokine storm (elevated Interleukin-6) leading to ARDS and multi-organ failure
(very fast)

• Mean Incubation Period was 6.4days

 Incubation Period
• A pooled analysis of 181 confirmed COVID-19 cases reported outside
Hubei province, China between January to February 2020 showed
that the median
- incubation period was estimated to be
5.1 days (95% CI, 4.5-5.8 days), with almost
98% of patients manifesting within 11.5 days (CI 8.2-15.6 days) of
infection(20). The estimated mean incubation period of 5.5 days.
5th day - 11th day: Almost 100 % symptoms manifest
 Signs and Symptoms
• In a meta-analysis comprised of 10 studies from China (n= 50,466) (16), the
incidence of fever was 89.1%, cough occurred in 72.2%, and the incidence of
muscle soreness or fatigue was 42.5%. Diarrhea, hemoptysis, headache, sore
throat, shock, and other symptoms occurred only in a small number of patients
European Union data on presenting symptoms among 29 of first cases
Table 3. Clinical signs and symptoms of patients with COVID-19 infection
Clinical Course from admission to discharge
Median Duration/Time Symptoms Median day developmnt Condition develop
13·0 days (9·0–16·5) from illness onset to 9·0 days (7·0–13·0) Sepsis developed
dyspnea after illness onset
12·0 days (IQR 8·0–13·0 Fever (12·0 days [8·0–15·0]), ARDS
19·0 days (IQR 12·0–23·0) cough (15·0 days [10·0–17·0]), acute cardiac injury
(15·0 days [13·0–19·5] acute kidney injury
17·0 days [13·0–19·0]). Secondary infection
Survivors 45 % (62) with cough
Non-survivors 72 % (39) with cough
Figure 1: Clinical Course of COVID-19 Patients Among Survivors vs. Non-Survivors (6)
 DIAGNOSIS
1. RT-PCR (Reverse Transcriptase – Polymerase Chain Reaction
• Requires BSL-2; can have false negative even after 3 weeks (Zhang et al)

2. Rapid flow assays of IgG and IgM

• It takes 5 – 10 days to make IgM antibodies – thus can have false negative
• (sometimes used to monitor response to treatment)
• Ab appears on D11 post infection ( IgM on D11, IgG on D14) (MedRxiv)
1. Polymerase Chain Reaction (RT-PCR) tests
• Cepheid gives results in 45 minutes

• Thermofisher gives results in 1.5 hours

• Abbott rapid gives results in 5 – 15 minutes

1. Real Time - Polymerase Chain Reaction (RT-PCR)
• Day 1 - of exposure: 0 %
• Day 5 - of exposure: 1st day of symptoms: 62 %
• Day 8 - of exposure: 3rd day of symptoms: 80 %
• Day 21 - of exposure: no more symptoms: 34 %

• Best day to test is 5 days to 8 days post-exposure

https://www.acpjournals.org/doi/10.7326/M20-1495
Variation in False-Negative Rate of Reverse Transcriptase Polymersae
Chian Reaction
 Contagion/PCR
• Almost all Covid-19 patients are not contagious by the 11th day of
illness (Dr. Edsel Maurice Saldana, PSMID, UP-PGH
• Implication: Time-based testing rather than test-based clearance
• RT-PCR CAN REMAIN POSITIVE FOR UP TO 8 WEEKS
• BUT PEOPLE ARE NO LONGER CONTAGIOUS BY THE 2ND WEEK.
• Record more recoveries much faster (the need for 2 negative PCR
• for clearance

*8 – 10 days there is no longer culturable virus (viable) even if RT-PCR remains

positive, they are detecting RESIDUAL virus genetic material or pieces of the
virus, not the infectious virus (UP=NIH)
** TIME WINDOW UNTIL INFECTION TESTS POSITIVE –
3 DAYS by PCR test - using swabbing of nasopharyngeal or
oropharyengeal area (<62 %)
7 DAY S by Serology - blood sample

(Dr Wen Hong Zhang, “Shanghai” China Experience with Covid-19

Zoom Session, 3/24/20)
 2. Rapid flow assays of IgG and IgM
(RAT- rapid antibody test)

• It takes 5 – 10 days to make IgM antibodies – thus can have false negative
(sometimes used to monitor response to treatment)

• Covid rapid testing may not work if done within 11 days of infection because
Ab appears on D11 post infection (IgM on Day 12, IgG on Day 14)

(https; www. Medrxiv.org/content/10.1101/2020.03,02,20030189v1

Juanjuan Zhao Jr et al (not peer-reviewed)
 Rapid Antibody Test

Sensitivity Specificity
• 90 % • 95 %
• The ability to label a person • The ability to label a person who
• who has the disease positive does not have a disease negative
 Prognostication
• Age and Co-morbidities – (DM, COPD, CVD)
Prevention (Non-pharmaceutical interventions)

1. Physical Distancing at least 1 meter or more

decreases risk of infection by 80 %

2. Wearing a face mask reduces risk of infectionby 85 %

Drugs used for Covid-19 - majority are used as
investigational, off-label, compassionate
• chloroquine, hydroxychloroquine - antimalarial
• azithromycin- antimicrobial
• Remdesivir - antiviral
• lopinavir-ritonavir- antiviral
• favipiravir - antiviral
• ribavirin - antiviral
• interferon - antiviral
• convalescent plasma - source of antibodies
• steroids - anti-iinflammatory
• anti–IL-6 inhibitors - Tociluzumab - immunomodulators
Serious Side Effects/Adverse Reactions
• including QT prolongation in the EKG
• torsades de pointes - can lead to serious arrhythmias and sudden - -
death,ventricular arrythmia and ventricular fibrillation
• hepatitis,
• acute pancreatitis,
• neutropenia, and
• anaphylaxis
 Hydroxychloroquine
• Hydroxychloroquine is an arthritis medicine (to treat acute and
chronic rheumatoid arthritis), that can be used to treat malaria, also
used to treat discoid lupus erythematosus and systemic lupus
erythematosus.
• It controls lupus by decreasing the immune system’s activity without
predisposing it to infection. (Johns Hopkins Lupus Center)

• It can also protect against UV light and sometimes even improve skin
lesions that don't respond to ointments.
Hydroxychloroquine and chloroquine
• chloroquine 500 mg twice daily and hydroxychloroquine 400–600 mg
twice a day loading followed by 400–600 mg blocked SARS-CoV-2 cell
entry in vitro.

• In addition, an early study suggested clinical benefit in patients with

COVID-19, showing reduction in pneumonia severity, length of
hospitalization, and viral shedding.
 Azithromycin
• High tissue concenrtration - 500 mg OD

• Azithromycin can also have serious side effects, including the risk of
potentially fatal heart rhythms
 REMDESIVIR
• The drug impairs the ability of the virus to replicate

• is an experimental antiviral drug from the American biotech firm

Gilead Sciences.

• It was originally tested as a treatment for Ebola and other

coronaviruses including SARS and is now being tested as a possible
COVID-19 treatment. T
 (Tocilizumab) IL- 6 Inhibitor
• also known as atlizumab (Actemra) , is an immunosuppressive drug,
mainly for the treatment of rheumatoid arthritis and systemic juvenile
idiopathic arthritis, a severe form of arthritis in children.

• It is a humanized monoclonal antibody against the interleukin-6

• Indicated for adults with moderate-to-severe active rheumatoid
arthritis with inadequate response to 1 or more disease modifying
antirheumatic drugs (DMARDs)

• anti-cytokine syndrome storm - 4 mg/kg IV q4Weeks initially

 Adverse events associated with
Hydroxychloroquine
• dry cough,
• hoarseness,
• fever, skin rash, itching
• difficulty breathing, and
• increased incidence of cardiac arrhythmia
• nausea and vomiting, nervousness
• stomach pain or cramps,
• loss of appetiteor weight loss,
• diarrhea, hair loss,ringing in your ears,
• dizziness, spinning sensation,headache
 COPING WITH THE PANDEMIC
(After understanding Covid-19)
• COPING MECHANISM
• an adaptation to environmental stress that is based on conscious or
unconscious choice and that enhances control over behavior or gives
psychological comfort

• Coping is investing one's own conscious effort, to solve personal and

interpersonal problems, to try to master, minimize or tolerate stress and
conflict. The psychological coping mechanisms are commonly termed coping
strategies or coping skills
 FOUR TYPES OF COPING STRATEGIES
(Weiten)
• Appraisal-focused (adaptive cognitive) - challenging own
assumptions.
• modify thinking, distancing from the problem, alter goals/values, see humor
• Covid-19 can be prevented by quarantining, physical distancing, mask wearing

• Problem-focused (adaptive behavioral) - taking control of the stress;

remove source of stress, flight (removing oneself from
stressful condition) seeking info in handling the situation
• Emotion-focused, (Billings and Moos added avoidance coping as one
of the emotion-focused coping) - (reduce negative emotion due
to exposure to stressors) - ex. distraction (being busy), forgive,
mindfulness, prayers, emotional disclosure, drugs/alcohol
• Communicating with others, telling your story

• Occupation-focused coping - change occupation itself

Principle of Psychological Uncertainty
it causes the brain to propose untested conclusions
• It redirects the brain to concoct conditions to shift to certainty
• Anticipating uncertainty may torture you
• The brain prefers an outcome which is more definite
• If your knew what's going to come rather than an uncertainty, then
you become calmer
• uncertainty causes anxiety - stress response goes haywire
Mental Health Conditions arising from Uncertainty
• Addiction
is when a person compulsively persists in certain behaviours
regardless of the consequences. A person can be addicted to
substances (drugs or alcohol) or activities (gambling, sex, the Internet)

• Anxiety
is a common emotion when dealing with daily stresses and
problems. But when these emotions are persistent, excessive and
irrational, and affect a person’s ability to function, anxiety becomes a
disorder.
• Bipolar

• formerly referred to as manic depressive illness, is a mood disorder with two

extremes: depressed (“low”) and manic (“high”).

• Depression

• Psychosis and Schizophrenia

• distortions in thinking, perception, emotions, language, sense of self and
behaviour. During a psychotic episode, a person may experience hallucinations and
delusions.
 Negative Coping Mechanism

• Negative coping includes the

• use of alcohol,
• drugs,
• overeating and;
• other risky or aggressive behaviours to cope with stress or anxiety
 Stress- is a biological and psychological response
experienced on encountering a threat that we feel we
do not have the resources to deal with.
• A stressor is the stimulus (or threat) that causes stress, e.g. exam,
divorce, contraction of Covid-19, death of loved one, loss of job.

• Sudden and severe stress generally produces:

- Increase in heart rate
- Increase in breathing (bronchodilate)
- Decrease in digestive activity (do not feel hungry)
- Liver released glucose for energy (glycogenolyss)
 Stress
• Firstly, our body evaluates a situation and decides whether or not it is
stressful. This decision is made based on sensory input and processing
(there might be alteration we have to be careful) and also on stored
memories (i.e. our previous response the last time we were in a similar
situation) (This is where perspective is very important)

• If the situation is judged as being stressful, the hypothalamus is activated.

• The hypothalamus in the brain is in charge of the stress response. When a

stress response is triggered, it sends signals to two other structures: the
pituitary gland, and the adrenal medulla.
• These short term responses are produced by The Fight or
Flight Response via the Sympathomedullary Pathway (SAM).
• Long term stress is regulated by the Hypothalamic Pituitary-
Adrenal (HPA) system.
The Hypothalamic Pituitary-Adrenal (HPA) System
• The stressor activates the Hypothalamic Pituitary Axis
The hypothalamus stimulates the pituitary gland
The pituitary gland secretes adrenocorticotropic hormone (ACTH)

Cortisol enables the body to maintain steady supplies of blood sugar

Cortisol enables the body to maintain steady supplies of blood sugar

• Adequate and steady blood sugar levels help a person to cope with
prolonged stressor, and helps the body to return to normal

The adrenal cortex releases stress hormones called cortisol releasing

stored glucose from the liver (for energy) and controllling swelling
after an injury.

There is immune suppression

• The stressor activates the Hypothalamic Pituitary Axis

• The hypothalamus stimulates the pituitary gland

• The pituitary gland secretes adrenocorticotropic hormone (ACTH)

• ACTH stimulates the adrenal glands to produce the hormone corticosteroid

• Cortisol enables the body to maintain steady supplies of blood sugar

 STRESS RESPONSE
• Adequate and steady blood sugar levels help a person
to cope with prolonged stressor, and helps the
body to return to normal

• The adrenal cortex releases stress hormones, called cortisol. This has
a number of functions including releasing stored glucose from the
liver (for energy) and controlling swelling after an injury.

• The immune system is suppressed while this happens. (ALWAYS SICK)

 The hypothalamus also activates the adrenal
medulla
• The adrenal medulla secretes the hormone adrenaline. This hormone
gets the body ready for a fight or flight response. Physiological
reaction includes increased heart rate.

• Adrenaline creates changes in the body such as decreases (in

digestion) and increases (sweating, increased pulse and blood
pressure).
 COPING STRATEGIES
• Take a time-out. ...
• Eat well-balanced meals. ...
• Limit alcohol and caffeine, which can aggravate anxiety and trigger
panic attacks.
• Get enough sleep. ...
• Exercise daily to help you feel good and maintain your health. ...
• Take deep breaths. ...
• Count to 10 slowly. ...
• Do your best
IBA ANG MAY ALAM!
 Take Home Message
• 1. Be Realistic - Know yourself (Strength vs Weakness)
• 2. Be Purveyors of Truth - no Fake News
• 3. Learn to love yourself - Be kind to yourself
• 4. Be an Inspiration to people - learn to appreciaate frontliners
• 5. Live Life each moment, each day and enjoy
• 6. Learn to Leave with others - family, community, society
• 7. Be connected spiritually - What is the Message
 THE END

Thank you!