GOVERNMENT OF KARNATAKA ‘No: HFW 403 ACS 2020 Kamataka Government Secretariat Vikasa Soudha, Bengaluru, Dated: 15.10.2020 CIRCULAR ‘Subject: Syndromic approach to covid-19 disease Viral infections manifest as varied elinieal syndrome, which cre similar to ‘many other pathogens. Hence, itis not possible to confirm the diagnosis of patients with COVID-19 or Influenza infection without a diagnostic test. And many times, in spite of clinical-radiological features suggestive of COVID-19 disease, the RT-PCR test, which is considered as Gold Standard ‘Test, may be negative. With sensitivity and specificity of RT-PCR tests for nasal & throat swab ranging between 60-70%, we may miss many positive cases, ic false negative reports. Standard Q COVID-19 Ag rapid antigen detection test, which is recommended by the ICMR has shown sensitivity (ie. ability to detect ‘rue positives) ranging from 50.6% to 84% and specificity (i.e. ability 0 detect true negatives) of 99.3 to 100%, afer two independent evaluations. Additionally, several retrospective studies have shown that CT Thorax has greater sensitivity (86%-98%) and lower false-negative rate than RT-PCR. With increase in the spread of COVID-19 disease in the country and state along with increase in the number of tests every day, the percentage of False [Negative Reports are increasing and it's expected to increase further in future. Hence, a proxy syndrome, called COVID-19 Like Syndrome (or) COVID- 19 Probable case, has to be used to identify such cases with correlation of clinical features, CT Thorax findings & laboratory investigations, so that we can initiate ‘treatment similar in lines to COVID-19 confirmed cases as early as possible, to reduce the spread of infection, morbidity & mortality. Page 10f 16 ee{Neseanee pred tom a ee he ase wns wit a = ‘atanat mes bec aie ‘etc mypa or tow coy bce, saeafnnmtfomsng Sun atte rea ae ete Seti irene hh ta ne i ne eve ts 36s caugh hose wn pan wo rogues ‘Assman oth ce my nd ete MD Tk nine COND 9 sn fn Br [ETE tet int te map ed Re ie te nat eet cn onl tre {Ape then oa anim ett a rg atthe ay heA. CLINICAL FEATURES OF COVID-19 DISEASE, 1 Any IL and SARI cases ‘LT is efined as one with scat respiratory infection with ever > 38° C (100.4) and cough ‘with onset within lst 10 days + SARI defined as one with ate respiratory infection with fever > 38” C (100.4), cough ‘ith onset within the ast 10 days and requiring hospitalization 2, Symptoms in detail 0 Jook for: a 7 eer B77), 7 CRIT, + Dry cough (677%), + Nausea or vomiting (5.0%) + Fatigue (38.1%). + Nasal congestion (4.8%), + Sputum production (33.4%), + Diana (3.7%), and + Shortness of breath (18.6%), + Memopysis (0.9%), and + Sore throat (139%), + Conjunctival congestin (0.8%) + Headache (13.6%), + Smell and tne disorders + Myalgia or arthralgia (148%), (ceanosminidysgeusia) 3, Extra Pulmonary manifestations to look for: TWeadache, Dizziness, Encepalopatiy, GH Syndrone, Agousa, Myalgi, Anosmia Strate Myocarits, Myocardial injury Tachema, Caron opal Arrythmias, Cardiogenie Sock, acute cor pulmonale Deep vein thrombosis, Pulmonary embolism, Catheter read thrombosis ‘cute king Tu poten Hema Flevated Aminotranserases, Elevated Biliabin Diana: nausealvoniing donna pain, Typerelyeemia, diabetic Ketoacidosis Derma tologieal Peiechaielivedo feticularis, ersthemaious ah, una, WESTOS perniontbe lesions ne cras tLB. RADIOLOGICAL EVIDENCE OF COVID-19 DISEASE: coral 7 ba that is used to assess the suspicion of For details please refer to ANNEXURE -1 es ro ta OAD aa As ens fe a eating Oa {Stat tg Yo 0 Tage fs Se eee ac aL stone Overview of CO-RADS Categories And The Corresponding Level Of Sespeion For ‘Pulmonary Tavolvement In COVID-19, Lede opine My CORMDSCgny een CODY Sony a Nie Sonn aca igagv we 1 Vey ‘Nome meiks 2 La Til ini ba COD 9 3 Epcltense Fees pei OVID Seat dis 4 Heh Srp eCOMD 5 Virb Tp ecOnD-8 ‘ Poe ECR pa i SH-C2 ‘Nee —CORADS = COMD 19 Resi oD pen, COMI = cen 2m, RETCR- enc ascn ree dni, SARS eric da i 2. ‘Typical Features for Pulmonary Involvement of COVID-19 kip Fs ‘Goud pic vida onion og gion die ice el wis ligewe plerd ilove ad el acl ein a ae Ged ge ‘Up eration, al nk age Sup deren. sing eg fap lc scm pnb Cay oing ci one wih omc pees “ced ec inp hvu a ray poets Page of 16‘Son Sion DO taal Sito North Aare Ep Cont Senet on pang hat CT Pgs ‘ina COND. Enkomdtyhe Socyef Tranche artan alee of ada nd ALA Type ‘Cammenga — | Pipl neal GGO™ ihr Greene | sae ‘eto mln ib atu | “Commo oe Seafeme | heer cern Eeovio.» utioou co tranfesmoniy | pene Ine Couey Op rn ch Reeoehabsignrateresaeot | uments ering Geeeementcniacinte | Ramet ‘ay ‘Serene ae Sir apg pt cost Thasersinte | Nowa ging | Aber ef pa etre AND Same | Rue “inane in bee sreowD.9 rane ‘tnt 9) prc, — ise atu pr, cana! | hugh eee sds CGO‘ orwstotsonalansn cng | aw svar of apclsedasbtan sue toneset | itr and wont ‘romper pose [Conn pulse samc ‘come Tena cee CTSEVERITY SCORE 25) (Chang YC, Yu Cl, Chang ea Palmonary seaeoe in orale patos fer ee te reat’ ‘yma vlaion wh dhivscton Cr Racy. 2005296 1087-1073) Page of 16 re‘THERE ARE TWO LUNGS. Right Lang an Let Lang Right lng is vided in thee ‘obs, UPPER ‘LOBE, MIDDLE LOBE, LOWER LOBE. Lef angi vided in two lobes, UPPER LOBE AND LOWER LOBE EACH LOBE IS GIVEN SCORE 1 TO 5 BASED ON LUNGINVOLVEMENT. Scoringsmstem(SINGLELOBE:, _*_Scorecalelation fs dane based on each abe Sc INFECTED: SCORE T imvohemen, 5.5% INFECTED: SCORE 2 ‘+ Each lobe as maximum sore S. Ang so $obes has 25-50% INFECTED : SCORE 3 ‘maximum sear of25 50-75 9 INFECTED : SCORE ‘+ Forexample sore 5 means tat lbeis > 75% 315% INFECTED: SCORE 5 involved or fected by COVID-19 SCORE cree & Mild o oder SIs See CHEST X RAY Interpretation in COVID-19 Suspect (a cto Rl of Chet adios ing COVE Pann St 2 ‘xp ef COVID-9 psc (A) Pate: Paseo tating aro Pate 2:Loner ins [Goafernsto tr oer: etl ea ee) () fan Maem ‘cn whe an) Poon ANSE. ahaha mor ‘Therepored seri of CXR in ages of COVID-9 ranges fom 33.3 1 9%. This sey slower ton ‘hatofCT sears (up 985), nd ofl RT-PCR. Its oweve bee Showa that CAR may be shal Page of 16|nsome patns, een when eal RE-PCR engi. Hence, ew ofthe various adnan tisk to ben ‘ef oo ing the pnd tren ‘Chest X Ray Reporting ‘steal pos we report the CXR th iso be viewed in pia viewing candor, refraby 00.2 ctu rv an orion sya (PACS) with propa ont ya aie belo, _NarmalCXB noel; COVID-19 m8 exci {Clonicprosele COVID19- Lower abe presooan a itr peina mil, br aes of “ndterminte: Does tio ison: COVIDpstrn ‘Naw-COVTD paner: Phew, lobar onion, peal von, palmar dena WHO recommendations for usage of chest imaging in diagnosis of COVID.19 Recommendations =a Remaris - Foray otc a pans wi COVIDT, WHO vga eto wend [RIE PCH sal Dede ‘ring rth apn sCOMID.D. | ent dag or smpomati pater with peed COVIDB, WHO aug ato we cht RERCR all Boe nr for ibe dings worap OF COVIDAD when RT-PCR icing arate | endrndapet heey ee or poms pan ih sped COVID9, WHO saps a chew mag orth ison erp of COVIDP he (DRTRCR eagr met sates este tt erie {@)RT-FCH etn abe bot re ard elie net (Shinn RT-PCR sng met ut ith gh cal efspiionfCOVED-9_| bored ‘Chest Imaging should not be used alone as diagnostic modality when RT-PCR facility is avallable, The absence of atiologcl sigs of COVID-19 pseamoni camel completly exlade a COVID- 19 infection Hence, mang shoul be wed es one clement fhe agnosie Workup tha ot evise cles linia and abort dala Laboratory Investigations: Tymphopenia 20) ‘CRP>IOI mg >a migra D.Dimer> 006mg D. RE-PCRof Ns ‘Negative Delayed reporting (nextel patent) 2 Notavallabte mera tree 1. Tyroat Swab for COVID-19 ~COVID-19 Like Syndrome (COVID-19 Probable Case) (modified from WHO definition) Any Suspect case who is RT-PCR Negative, but clinico- radiological evidence and laboratory values are suggestive of COVID-19 disease as per criteria mentioned below * c Radilogcal evidence ‘Blood investizatons (erTorax/Chestx Ray a cnrsioomg CCORAD 5 fr) Typist Sern 309 mero sppearence sper RSNA ‘io sso. (oneanaue statement. omer Doren a Glnical features > ovine Probable Case (covin19 ke Syndrome) A+B+C+D is suggestive of Probable COVID-19 Case (COVID-19 Like Syndrome) Nasal & Threat Swab RT-PCR s Negative suggestive of ‘covinis age 8016,recaint Seaxsesinrom at aed onc ee) ‘orcows > 30min ston Ginilans may be wsuspacting of COVID- 19 |» The wus sensi and specify of chen CT in aypieal presentations sreunknowa. Even pens wih @pomal + Ina RT-PCR may be negative, and sypieat hast CT a only atypia eatues may have festres may eneorage repel connate covip- 19 testing + Clinicians may fe tat having “COVID-I9 ‘+ Standardaed reporting language can improve report boxes the in ad its their report sity an lary by ering ‘options for patient magerent ‘onsen! erinlons Patients may be appreensive about ving Reporting data can be we for future taching, terminology like "COVID-1" or esearch, clinical quality improvemeat, nd coronas i heir repot and mca {inure management pathway records oe Behe tat teagan ouane mere a aches en's ey Wn ee ccs ee i nea ate a oy geen estes oe earners cel Tite Additional Chief Secretary to Government Departament of Health & Family Welfare To: 1. The Commissioner, BBMP, Bengaluru Page 5 of 16Copy for information t is 2 ‘The Deputy Commissioners , All Districts ‘The Chief Executive Officers, Zilla Panchayath, All Districts ‘The District Health Officer & District Surgeons ~ All Districts ‘The Dean cum Directors, All Medical Colleges ‘The President ~ IMA, IAP, PHANA, for circulation to all the members & Heads ofall Private Medical Establishments. ‘The Chief Secretary, Government of Kamataka, Bengaluru ‘The Principal Secretary to Government, Medical Education Dept., Bengaluru ‘The Commissioner, Health & Family Welfare Services, Bengaluru ‘The Mission Director, NHM, Bengaluru ‘The Director, Health & Family Welfare Services, Bengaluru ‘The Director, Medical Education Dept., Bengaluru Page 16.0416