Coronavirus Disease (COVID-19)

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Introduction to COVID-19

The World Health Organisation (WHO) has declared the coronavirus disease 2019 (COVID-19) a pandemic. A global coordinated effort is needed to stop the further spread of the virus. A pandemic is defined as a “occurring over a wide geographic area and affecting an exceptionally high proportion of the population” The last pandemic reported in the world was the H1N1 flu pandemic in 2009.

On 31 December 2019, a cluster of cases of pneumonia of unknown cause, in the city of Wuhan, Hubei province in China, was reported to the World Health Organisation. In January 2020, a novel coronavirus was identified and samples obtained from cases and analysis of the virus’ genetics indicated that this was the cause of the outbreak. This novel coronavirus was named Coronavirus Disease 2019 ( COVID-19) by WHO in February, 2020. The virus is referred to as SARS-CoV-2 and the associated disease is COVID-19.

As of 15 March 2020, over 156,000 cases have been identified globally in 123 countries with a total of over 5,000 fatalities.  Live data can be accessed here.

Novel Coronavirus (2019-nCoV) by World Health Organisation, published on 31 January 2020:

WHO: Coronavirus - Questions and Answers by World Health Organisation published on 16 January 2020

What is Coronavirus?

Coronaviruses are a family of viruses that cause illness such as respiratory diseases or gastro-intestinal diseases. Respiratory diseases can range 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 identified in humans previously. Once scientists determine exactly what coronavirus it is, they give it a name (as in the case of COVID-19, the virus causing it is SARS-CoV-2).

Coronaviruses got their name from the way that they look under a microscope. The virus consists of a core of genetic material surrounded by an envelope with protein spikes. This gives it the appearance of a crown. The word Corona means “crown” in latin.

Coronaviruses are zoonotic, meaning that the viruses are transmitted between animals and humans. It has been determined that MERS-CoV was transmitted from dromedary camels to humans and SARS-CoV from civet cats to humans.  The source of the SARS-CoV-2 (COVID-19) is yet to be determined, but investigations are ongoing to identify the zoonotic source to the outbreak.

Clinical Presentation

Among those who will become infected, some will show no symptoms. Those who do develop symptoms may have a mild to moderate, but self limiting disease with symptoms similar to the seasonal flu. Symptoms may include: 

• Respiratory symptoms
• Fever
• Cough
• Shortness of breath
• Breathing difficulties
• Fatigue
• Sore throat
• Pneumonia in more severe cases

A minority group of people will present with more severe symptoms and will need to be hospitalised, most often with pneumonia, and in some instances the illness can be so severe that it can lead to death.  Emergency warning signs where immediate medical attention should be sought include:

• Difficulty breathing or shortness of breath
• Persistent pain or pressure in the chest
• New confusion or inability to arouse
• Bluish lips or face

High Risk Population

The virus that causes COVID-19 infects people of all ages. The risk of severe disease gradually increases from 40 years of age. However, evidence to date suggests that two groups of people are at a higher risk of getting severe COVID-19 disease:

• Older people (people over 60 years of age)
• People with serious chronic illnesses such as:
  • Diabetes
  • Cardiovascular disease
  • Chronic respiratory  disease
  • Cancer

The World Health Organisation has issued and published advice for these high risk groups and community support. This is to ensure that these high risk populations are protected from COVID-19 without being isolated, stigmatised, left in positions of increased vulnerability or unable to have access to basic provisions and social care.

The WHO has issued advice for high risk populations:

• When having visitors at your home, extend  “1m greetings”, like a wave, nod or bow.
• Request that visitors and those who live with you, wash their hands
• Clean and disinfect surfaces in your home (especially those that people touch a lot) on a regular basis
• Limit shared spaces if  someone you live with is not feeling well (especially with possible COVID-19 symptoms)
• If you show signs and symptoms of COVID-19 illness, contact your healthcare provider by telephone, before visiting your healthcare facility
• Have an action plan in preparation for an outbreak of COVID-19 in your community
• When you are in public, practice the same preventative guidelines as you would at home
• Keep updated on COVID-19 through obtaining information from reliable sources

Transmission of COVID-19

The incubation period of COVID-19 is between 2 to 14 days This means that if a person remains well after 14 days after being in contact with a person with confirmed COVID-19, they are not infected.

Evidence is still emerging, but current information is indicating that human- to- human transmission is occurring. The routes of transmission of COVID-19 remains unclear at present, but from evidence from other coronaviruses and respiratory diseases it can be postulated that the disease may spread through large respiratory droplets and direct and indirect contact with infected secretions.

https://www.youtube.com/watch?v=1APwq1df6Mw

Diagnostic Procedures

A COVID-19 diagnostic testing kit has been developed and is available in clinical testing labs. The CDC recommends that any person who may have had contact with a person who is suspected of having COVID-19 and develops a fever and respiratory symptoms listed above are advised to call their healthcare practitioner to determine the best of course of action.  The main criteria for testing are:

• Location.
• Age.
• Medical history and risk factors.
• Exposure to the virus and contact history.
• Duration of symptoms.

If the above criteria are met it is advised that the following testing procedure is followed:

• Collect and test upper respiratory tract specimens, using a nasopharyngeal swab.
• If available testing lower respiratory tract specimens.
• If a productive cough is evident then a sputum specimen should be collected.
• For patients who are receiving invasive mechanical ventilation a lower respiratory tract aspirate or broncho-alveolar lavage sample should be collected.

Protective Measures

The WHO suggests the following basic preventative measures to protect against the new coronavirus:

1. Stay up to date with the latest information on the COVID-19 outbreak through WHO updates or your local and national public health authority.
2. Perform hand hygiene frequently with an alcohol-based hand rub if your hands are not visibly dirty or with soap and water if hands are dirty
3. Avoid touching your eyes, nose and mouth.
4. Practice respiratory hygiene by coughing or sneezing into a bent elbow or tissue and then immediately disposing of the tissue.
5. Wear a medical mask if you have respiratory symptoms and performing hand hygiene after disposing of the mask.
6. Maintain social distancing (a minimum of 1 m) from individuals with respiratory symptoms.
7. If you have fever, cough and difficulty breathing seek medical care.
   

https://www.youtube.com/watch?v=bPITHEiFWLc

Management / Interventions

Case Definitions

The definitions used by the WHO in COVID-19 [REF]

Suspect case:

Patient with acute respiratory illness (fever and at least one other symptom such as cough or difficulty breathing (shortness of breath) AND with no other aetiology that explains symptoms AND a history of travel to a country/area that reported transmission of SARS-CoV-2 virus

OR

Patient with acute respiratory illness AND who have been in contact with a confirmed or probable COVID-19 case in the last 14 days prior to onset of signs and symptoms

OR

Patient with severe respiratory illness (fever and at least one other symptom such as cough or difficulty breathing (shortness of breath) AND that requires hospitalisation AND with no other aetiology that explains clinical picture/presentation of the patient

Probable case:

A probable case is a suspected case for whom the report from laboratory testing for the COVID-19 virus is inconclusive.

Confirmed case:

A confirmed case is a person with laboratory confirmation of infection with the COVID-19 virus, irrespective of clinical signs and symptoms.

Differential Diagnosis

add text here relating to the differential diagnosis of this condition

Resources

Physiotherapy Member Organization by Country: Best Practices for Coronavirus

1. http://www.apta.org/Blogs/PTTransforms/2020/3/10/CoronaBestPractices/ (US)
2. https://physiotherapy.ca/cpas-statement-coronavirus-covid-19 (Canada)
3. https://www.iscp.ie/events-and-news/iscp-blog/member-update-covid-19-coronavirus-0 (Ireland)
4. https://www.csp.org.uk/news/coronavirus-resources-csp-members (UK)
5. https://australian.physio/coronavirus (Australia)
6. https://www.wcpt.org/news/Novel-Coronavirus-2019-nCoV - WCPT list of links to various global organizations and resources

Governmental Information for Health Professionals

1. https://www.gov.uk/government/collections/wuhan-novel-coronavirus (UK)
2. https://www.health.qld.gov.au/news-events/news/novel-coronavirus-covid-19-sars-queensland-australia-how-to-understand-protect-prevent-spread-symptoms-treatment (Australia)
3. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html - CDC (US)
4. https://www.who.int/emergencies/diseases/novel-coronavirus-2019 - WHO
5. https://www.un.org/coronavirus (United Nations)
6. https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html - CDC resource - Prevent in LTC facilities

Overview Resources and Factsheets

1. https://www.cdc.gov/coronavirus/2019-ncov/communication/factsheets.html
2. https://www.cochrane.org/news/special-collection-coronavirus-covid-19-evidence-relevant-critical-care - Evidence Relevant to Critical Care (Cochrane)
3. https://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm - Infection Control Respiratory Hygiene
4. https://www.thelancet.com/coronavirus?dgcid=etoc-edschoice_email_tlcoronavirus20 - The Lancet COVID-19 Resource Center
5. https://www.coursera.org/learn/covid-19?#syllabus - This is a current online course offered through Imperial College London, which may have some good resources
6. https://coronavirus.jhu.edu/ - the Johns Hopkins University & Medicine Coronavirus Resource Center (“Johns Hopkins experts in global public health, infectious disease, and emergency preparedness have been at the forefront of the international response to COVID-19.”)
7. Link to a real time map of global cases by Johns Hopkins University
   1. This article explains it further https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30120-1/fulltext