COVID – 19 VIRUS VARIANTS

• As SARS-CoV-2 virus mutates, or changes,

constantly, variants of the virus develop.
• Variants are monitored and studied.
• Scientists look to see which ones may change in a
way that allows them to spread easily, or makes
them harder to treat or prevent with vaccines.
• COVID-19, testing, treatment, and vaccinations
may be adjusted as variants appear.

Severe acute respiratory syndrome coronavirus 2

(SARS-CoV-2) causes COVID-19
• The first cases were identified in people with
pneumonia in Wuhan, China, in late December
2019.
• The first cases were identified in people with
pneumonia in Wuhan, China, in late December
2019.
o Widespread human to human spread
o Large number of affected countries

COVID-19 pandemic is ongoing; the situation remains

dynamic.

In the Philippines
From 3 January 2020 to 5:18pm CET, 21 March 2022:
• 3,674,286 confirmed cases of COVID-19
• 58,263 deaths, reported to WHO
• As of 9 March 2022, a total of 138,008,339
vaccine doses have been administered

How is it spread?
1. Droplet transmission:
• Occurs when people come in close contact
(within 2 metres or 6 feet) of an infected person ACE 2 RECEPTORS
• Droplets containing the virus can land in the • Upper airway
nose, eyes or mouth directly o The cells lining the nose are rich in ACE 2
(angiotensin converting enzyme)
2. Airborne Transmission o The virus requires this receptor to enter the
• Virus spread to people more than 2 metres (6 cell
feet) away if they inhale air carrying very small • Lungs
particles that contain virus • Heart
• More likely in poorly ventilated and/or crowded • Kidneys
indoor settings where people spend longer • Intestines
periods of time

3. Through Contaminated Objects

• Touching contaminated objects puts the droplets
onto your hands
• If you touch your face the droplets can enter your
nose / eyes / mouth

Remember: Infected people with minimal or no

symptoms can spread COVID-19.
• The virus then hijacks the cell’s machinery to
produce new viruses. If the immune system does Signs and Symptoms in
Percentages
not fight back, the virus goes down the respirator children
tree and attacks the lungs, which are rich in ACE2.
To fight the virus, the body stimulates the WBC to Fever 71
release inflammatory cytokines. These bring in
more cells which will release more inflammatory Cough 80
mediators.
Headache 58

Sore throat 35

Myalgia 61

Shortness of breath 43

Diarrhea 31

Nausea and vomiting 16

Runny nose 7

Abdominal pain 12

COMMON SYMPTOMS IN CHILDREN INCLUDE

• Fever
• Cough
• Sore throat
• Fatigue
• Shortness of breath
• LBM
• Headache/ muscle aches
• Sudden loss of smell and taste
• Runny/stuffy nose
• Nausea, vomiting, diarrhea
 • Rash
• Conjunctivitis
Symptoms start about one day after exposure but can
be as long as 14 days. Most people develop symptoms
within 5-6 days.
Some people have no symptoms, most have a mild
illness and recover in about 2 weeks.
People who have recovered may become infected
again (re-infection).
DERMATOLOGIC MANIFESTATIONS
• Covid toe
o Acral eruption of erythematous-
violaceous papules and macules
with bullous evolution or digital
swelling
• Erythematous rash
• Urticaria or hives
• Chicken pox like blisters
• Livido reticularis (mottling)
o The American Academy of Dermatology
(AAD) has established a COVID-19 registry
for physicians and health care professionals
treating COVID-19 patients who develop
dermatologic manifestations, or patients
with an existing dermatologic condition
who develop COVID-19.
COMORBIDITIES
• Severe and fatal disease can occur at any age
• Higher risks for death:
o Older people
o Underlying heart disease
o High blood pressure
o Cancer
o Diabetes
o Obesity
DIAGNOSIS
The Polymerase Chain Reaction (PCR)
• Most accurate and widely used
• Swab is collected from the nose and throat
• Done in specialised labs
• Results can take hours or days
• For current, active infections
• Determines contagiousness
Rapid Diagnostic Test (RDT)
• Less accurate than PCR
• Result available within minutes.
• Tests can be done at the “point of care”, at work,
or at home.
• Swab is taken from the nose, or a sample of saliva
is used
• At the early phase ( < 7 days from onset of
symptoms)
• Better at identifying those with symptoms
• Sensitivity is 33-80% ( meaning: if it is negative, it
does not mean anything)
Serological Tests
• Detects IgG, IgM, or IgA that the body produces
during an infection
• Body needs time to respond to viral invasion
• Does not achieve same detection rate as viral
genome diagnosis
• Immune status and the status of a given
population related to their ability to contract or
resist infection will be based on their antibody
status
• IgM: early phase reactants during acute infection
and is detected 6-7 days after symptom onset
• IgG: developed around 2 weeks after the disease

CASE DEFINITION 1
CATEGORY CRITERIA
A. A person who meets the clinical
and epidemiological criteria
SUSPECT B. A patient with severe acute
CASE respiratory illness (SARI) with
history of fever of > 38 degrees C
and cough within the last 10 days
Clinical Criteria
1. Acute onset of fever and cough
2. Acute onset of any 3 of the ff:
> fever cough, general weakness, fatigue,
headache, myalgia, sore throat, coryza,
dyspnea, anorexia/nausea, vomiting,
diarrhea, altered mental status
Epidemiological Criteria
• Residing or working in an area with high risk
transmission of the virus within 14 days of onset
of symptoms
• Residing or travel to an area with community
transmission anytime within 14 days prior to
onset of symptoms
• Working in any health care settings, within 14
days of onset of symptoms
CATEGORY CRITERIA
A person who meets the clinical
criteria and is a contact of a
probable or confirmed case, or
linked to a covid cluster
A suspect case with chest imaging
showing findings suggestive of
COVID 19
PROBABLE
CASE
A person with recent onset of
anosmia or ageusia in the absence
of other identified cause
Death not otherwise explained
with respiratory distress preceding
death AND was in contact with
probable or confirmed case or
COVID cluster
CATEGORY CRITERIA
A person with positive Nucleic
Acid Amplification TEST (NAAT)
A person with positive SARS-COV-
2 Antigen RDT and meeting
CONFIRMED either probable case definition or
CASE suspect criteria
An asymptomatic person with
positive SARS-COV2 Ag RDT who
is a contact of probable or
confirmed case
Severity (Children): MODERATE
• Clinical signs of non-severe pneumonia
o Cough
o Difficulty in breathing
o Chest indrawing
• SpO2 > 95% on room air
• While diagnosis can be made on clinical grounds,
chest imaging (chest Xray, CT scan, ultrasound)
assist in the diagnosis
Severity (Children): SEVERE
• Children with clinical signs of pneumonia with at
least one of the ff:
o Central cyanosis or SpO2 < 95% and severe
respiratory distress
o General danger signs: inability to breastfeed
or drink, lethargy or unconsciousness,
convulsions
o Tachypnea
Severity (Children): CRITICAL
• ARDS
• Onset within one week of known clinical insult
• Origin is pulmonary infiltrates

IMAGING STUDIES
When to do an initial image
• Not recommended
o As a screening tool for asymptomatic or
symptomatic patients
o With mild symptoms unless patient has a
health condition or worsens clinically
• Recommended
o Chest x – ray for moderate/sever symptoms
regardless of COVID – 19 infection status:
chest CT if results might impact patient
management
o As an initial work – up health resource
constrained environments to assist with
triage

Chest X – ray Findings

• May be normal
• Most suggestive imaging pattern for COVID-19 in
Chest CT Scan
children:
Most typical pattern includes:
o Bilateral peripheral predominant ground
• Bilateral GGO
glass opacities, or consolidation in the mid
• Consolidation
and lower lung zones
o Peripheral distribution not distinctive in • Peripheral subpleural location
children • Predominantly in the mid and lower lung zones

Ground glass opacities in the periphery

Halo Sign TREATMENT PLAN
• Characteristic findings in Covid in children At high risk of progressive COVID or hospitalization:
• The “halo” sign also appears in infectious • Cardiovascular disease
aspergillosis or other fungal infections, • Chronic metabolic disease
particularly in immunocompromised children, so • Chronic kidney disease
care should be taken when making a diagnosis. • Chronic liver disease
• 2 parts: • Immunocompromised conditions
o Central opacity (consolidation)
o Ring-like surrounding hazy area Nutritional Support
referred to as ground-glass
opacity (GGO). VITAMINS/ MINERALS DOSAGES

2 months-5 yrs: 15 mg
Zinc sulfate BID
> 5yrs: 20 mg BID

Vitamin D < 2yrs: 1,000 IU/day

(cholecalciferol) >2 yrs: 2,000 IU/day

Experimental Rx for Mild-Moderate COVID

• Indications
o Child non-hospitalized AND laboratory
confirmed
o Mild to mod COVID 19
o Within 10 days of symptom onset
o High risk of progressing to severe covid or
hospitalization
• Bamlanivimab + Etesevimab: given as single IV
infusion
• Casirivimab + Imdevimab: given as single IV
infusion

Severe and Critical Covid

• Steroid:
A. halo sign o Dexamethasone: 0.15 mg/kg IV once a day
• Early phase covid 19 axial lung window CT image for 10 days
shows a rounded ground-glass opacity (arrow) o Alternatives:
with subtle area of central consolidation in ▪ Methylprednisolone 0.8 mg/kg once a
keeping with the “halo” sign day IV ( max: 32 mg)
▪ Hydrocortisone
B. rounded ground glass appearance • < 1 month: 0.5 mg/kg IV q 12
• Progressive phase of pediatric COVID-19 hrs x 7 days, followed by
pneumonia in a 15-year-old female. Axial lung 0.5mg/kg IV od for 3 days
window CT image demonstrates rounded ground • > 1 month: 1.3 mg/kg IV q 8 hrs
glass opacities (arrows) with subtle area of • Tocilizumab
central consolidation. Between these areas, o in combination with steroid
ground-glass opacities (asterisks) start to fill the o < 30 kg: 12 mg/kg
lung parenchyma. o 30 kg: 8 mg/kg
o Give as a single dose
C. confluent consolidation
• Developed phase of pediatric COVID-19
pneumonia in a 16-year-old female with positive
COVID-19 RT-PCR test. Axial lung window CT
image shows predominantly confluent
consolidation (arrow) in the posterior left lower
lobe
 AEROSOL GENERATING PROCEDURE (AGP)
• Procedures performed on patients that are more
likely to generate higher concentrations of
infectious respiratory aerosols than coughing,
sneezing, talking, or breathing.
In the background of COVID 19:
Avoid nebulizers where possible
• Increase risk of viral spread to other patients AND
to health care professionals
• Use pressurized metered dose inhaler via a
spacer
• With a mouthpiece or tightly fitting face mask if
required
• With a mouthpiece or tightly fitting face mask if
required
• Need to nebulize medication in a location that
minimizes exposure to others
• Nebulize in garage, porch, patio
Recommendation On Aerosol Therapy on COVID 19 or
Suspected COVID Patients
Limited indications of nebulization include the
following:
• Severe, life threatening respiratory distress
• Patients with compromised ventilation
• Uncooperative patients
• History of poor response to pMDI
Does steam inhalation relieve signs & symptoms of
cough and colds?
• as early as 2000, a Cochrane systematic review
evaluated effects of inhalation of heated
humidified air. This is continuously updated and
the most recent review in 2017m wherein 6 RCTs
were included. Results have been inconsistent, In
BMJ, the review found that in patients 3 years
and before, steam inhalation did not reduce
symptoms of respiratory infections. WHO stand
suggest that neither steam or cool mist be
encouraged due to lack of data.
• Inconsistent results
• Steam inhalation did NOT reduce symptoms of
acute respiratory infection
• Neither steam nor cool mist therapy be
encouraged in the management of a cough or
cold
Does it kill the virus?
• It will kill the host first before it kills the virus
Steam inhalation and asthma
Inhalation of steam (hypotonic solution) →
bronchospasm → asthma attack

Steam Inhalation Therapy

• Application of warm moist vapor to the
respiratory passage which is done by putting
one’s head over a bowl of steaming water and
covering it with a towel
• Traditionally used to relieve symptoms of cold or
sinus. It is believed that when you inhaler warm
moist air, it loosens the mucus and decongest
snasal passages thereby providing temporarily
relief from symptoms of cold/. There are theories
that increasing nasal temperature can potentiate
anti-viral activity of interferon, inhibits release of
mast cdll mediators, and limits viral replication
tus decreasing duration of symptoms.

Theories
• Increase intranasal temperature potentiates anti-
viral activity of interferon
• Inhibits release of mast cell mediators
• Limits viral replication
 PNEUMONIA IN CHILDREN
Pneumonia
• An inflammation in the lung caused by an
infectious or non-infectious agents that stimulate
a response resulting in damage to the lung

Infectious Pneumonia:
• Leading single cause of mortality in children
younger than 5 years of age
• 4 to 5 million deaths in children younger than 5
years of age annually Chest indrawing → predicts hypoxemia
• Over 13 million new cases of pneumococcal • A single clinical index that suggests need for
pneumonia were estimated admission is chest indrawing

Etiology according to Age group Physical Findings To Look For

• According to WHO
o Tachypnea and lower chest indrawing
• Danger signs
o Inability to drink
o Persistent vomiting
o Convulsions
o Lethargy
o Impaired level of consciousness
o Stridor
Pathophysiology o Severe malnutrition

RR
Age
Cut-off point
< 2 months old 60

2-12 months 50

1-5 years old 40

How do you diagnose pneumonia? PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

• Tachypnea is still the best predictor for (PCAP)
pneumonia (WHO) • 3 months of age or older
• Tachypnea and chest indrawing gives a higher • pneumonia from the community
probability of the presence of pneumonia
• RR depends on the child’s age: Pneumonia Diagnosis
o 0-2 months: 60/min • 3 months to 5 years
o 2 mo-12 mo: 50/min o Cough + tachypnea and chest indrawing
o 12 mo-5 yrs: 40/min • 5 years to 12 years
o 5 yrs-12 yrs: 30/min o Cough + tachypnea, fever, crackles
o ≥ 12 yrs: 20/min • More than 12 years old
o fever, tachypnea, tachycardia
o at least one abnormal chest
finding: decreased breath sounds, rhonchi,
crackles or wheeze

Note: The absence of age specific tachypnea or chest

indrawing does not rule out pneumonia
The absence of cough does not imply absence of the
disease
Cough is not the initial presentation in 24% with
radiographic pneumonia
PCAP Classification

In short….
• PCAP A : tachypnea only
• PCAP B : tachypnea plus a co-morbidity
• PCAP C: tachypnea plus co-morbidity plus
intercostal/ subcostal retractions
• PCAP D: with signs and symptoms of respiratory
failure

NON – SEVERE PCAP (LOW RISK PCAP)

• Treated in the OPD
• Return for admission for admission within 48
hours if:
o No clinical improvement
o Signs of deterioration
▪ Hypoxemia
▪ chest indrawing
▪ retractions
▪ grunting
▪ altered sensorium
▪ pallor
• Unable to feed, drink, take medication
• Underlying medical condition that can aggravate
clinical status

SEVERE PCAP (HIGH RISK PCAP)

• Admitted
• Immediate institution of recommended
management plan
When should you get a chest xray for diagnosis?
• None for PCAP A or B in the ambulatory setting
• Definitely, for those with severe (high risk) PCAP
• Initial diagnostic aid of choice for severe PCAP

High index of suspicion

• Dehydration in those 3 months to 5 years old
• Severe malnutrition especially < 7years old
• High grade fever and leukocytosis in those
3-24 months old even without respiratory
Symptoms
• Occult pneumonia identified on chest Xrays of Other Diagnostics for Severe Pneumonia
infants with fever and leukocytosis even in the
absence of respiratory symptoms

Chest ultrasonography Severe PCAP

Procalcitonin Severe PCAP

Sputum gram stain Not done

Sputum culture Not done

Procalcitonin
• Biomarker for bacterial infection
• Determination of disease severity
• Evaluation of patient’s response to treatment
• Chest PAL for children able to stand upright
• Chest APL for younger infants Other Imaging Modalities
• Bedside lung ultrasound
Diagnostics
• CT scan
• WHO criteria (Chest X-ray)
o not routinely done unless another
o Consolidation: a dense opacity that may be
underlying diagnosis is suspected
a fluffy consolidation of a portion or whole
• MRI
of a lobe or the entire lung, often
o Greater sensitivity for complications such as
containing air bronchograms
abscess and necrosis
o Pleural effusion
o Radiation-free procedure
o More expensive
Radiologic Findings
• Alveolar or lobar pneumonia
Etiologic Diagnosis
• Typical bacteria
• Antigen and Serologic tests
o Urine
o Plasma
• Polymerase chain reaction
o Respiratory secretions
o Pleural effusions
o Lung aspirate samples
o Blood

Management
• Empiric antibiotic is considered
• Signs and symptoms of PCAP with ANY of the ff
suggestive of bacterial etiology ( for both severe
and non-severe PCAP)
o Elevated WBC
o Elevated C-reactive protein
o Elevated procalcitonin
 o Imaging showing: What treatment should be initially given if influenza
▪ Alveolar infiltrates on chest Xray virus is strongly considered?
▪ Unilateral solitary lung consolidation • Oseltamivir 2x a day for 5 days
and/or air bronchogram and/or o Less than 1 year: 3 mg/kg/dose
plural effusion o More than 1 year old:
▪ 15 kg or less: 30 mg
What empiric treatment should be administered if a ▪ > 15 – 23 kg: 45 mg
bacterial etiology is strongly considered? ▪ > 23 kg: 60 mg
• For non- severe PCAP w/out previous antibiotic, ▪ > 40 kg: 75 mg
regardless of immunization status • Doses to be started w/in 48 hours of onset of
o Amoxicillin trihydrate influenza-like symptoms
▪ 40-50 mg/kg/day, max of 1500
mg/day in 3 divided doses in areas What is a good clinical response?
with proven low antibiotic resistance • Cough has improved
to amoxicillin • Body temperature has returned to normal
▪ 80-90 mg/kg/day given bid in areas • Good clinical response: clinical stability that is
with proven high amoxicillin sustained for the immediate past 24 hours
resistance
▪ May be given for a minimum of 5-7 SWITCH THERAPY
days Meets ALL of the following:
o If with known hypersensitivity to Amoxicillin • Current antibiotic given for at least 24 hours
or suspicion of atypical organisms • Afebrile for at least 8 hours without any
particularly Mycoplasma pneumoniae antipyretic
▪ Azithromycin at 10mg/kg/day OD x 3 • Able to feed without vomiting and diarrhea
days, or 10 mg/kg/day at day 1, then • Clinical improvement:
5 mg/kg/day for day 2 to 5, max dose o no hypoxia
of 500 mg/day OR o no danger signs
▪ Clarithromycin at 15 mg/kg/day, max o no tachypnea
dose of 1000 mg/day in 2 divided o no fever
doses for 7 days o no tachycardia
• For severe PCAP w/out previous antibiotic
o Completed primary immunization against Adjunctive therapy that works:
Hib: • Vitamin A recommended for measles pneumonia
▪ Penicillin G at 200,000 units/kg/day • Bronchodilators for PCAP with wheezing
in 4 divided doses
o Not completed primary immunization or What doesn’t work
unknown immunization status:
• Zinc during active pneumonia
▪ Ampicillin at 200 mg/kg/day in 4
• Vitamin D
divided doses
• Mucokinetic and mucolytic
o Alternatives
• Probiotics
▪ Cefuroxime 100-150 mg/kg/day
▪ Ceftriaxone 75-100 mg/kg/day • Vitamin C
• If highly suspicious of Staph aureus • Virgin coconut oil
o Add Clindamycin 20-40 mg/kg/day • Nebulization with saline
o If with severe and life threatening • Steam inhalation
conditions (sepsis or shock):
▪ Vancomycin 40-60 mg/kg/day

VIRAL ETIOLOGY
• If a non-influenza virus is suspected, antiviral drug
therapy may not be beneficial