Review Article DOI: http://doi.org/10.4038/jmj.v31i2.

72

Covid-19
N. Suganthan1
Department of Medicine, Faculty of Medicine, University of Jaffna.
1

Introduction they are positive-sense single-stranded RNA

viruses, they do not need to carry enzymes to
Coronaviruses infect both humans and animals.
initiate infection.(2) The virus genome has been
Since the 1960s, globally endemic human
coronaviruses have been identified as frequent sequenced and these results in conjunction with
causes of respiratory infections such as the common other reports show that it is 75-80% identical to
cold and responsible for all 10-20% of respiratory the SARS-CoV and even more closely related to
tract infection in adults. several bat coronaviruses.(3)

A novel coronavirus, designated 2019-nCoV, was Alpha and beta coronaviruses are found in
identified as the cause of a cluster of pneumonia cases both humans and animals. Gamma and delta
in Wuhan, a city in the Hubei province of China, coronaviruses have only been identified in animals.
at the end of 2019. Epidemiologic investigation Coronaviruses are widespread among birds and
in Wuhan identified an initial association with a mammals, with bats being host to the largest variety
seafood market where most patients had worked or of genotypes.
visited.(1) On January 30, 2020,  the World Health Human Coronaviruses
Organization declared the outbreak a “public health
emergency of international concern” (PHEIC). Following four viruses have been identified as
The current outbreak of this novel coronavirus common causes for respiratory tract diseases in
researched an unfortunate milestone record with human after initial detection coronavirus in 1960.
the death count officially exceeding that of the
SARS outbreak. As of Monday (09.02.2020), latest • 229E (alpha coronavirus)
data indicate this novel coronavirus has killed 910 • NL63 (alpha coronavirus)
people in about a month and a half, with 40573 • OC43 (beta coronavirus)
cases worldwide. As number of confirmed cases
and deaths have been raising continuously, details • HKU1 (beta coronavirus)
of the novel coronavirus in several aspects are still As a result of genetic recombination occurs between
not very clear. Very recently, WHO has named the members of the same or different coronavirus
disease COVID-19, short for “coronavirus disease groups, new viruses emerge from the animal
2019.” reservoirs and subsequently jump to human. There
are three new coronaviruses have been emerged as
Epidemiology
a result of this genetic recombination up to now.
Currently, it has been reported in all provinces in
China and 25 countries worldwide. • MERS-CoV (beta coronavirus) - Middle
East Respiratory Syndrome (MERS)
Virology
• SARS-CoV (beta coronavirus) - severe
Coronaviruses are large enveloped, positive single-
stranded RNA viruses that can be divided into four acute respiratory syndrome (SARS)
genera, namely alpha, beta, delta and gamma. A • 2019-nCoV (beta coronavirus) - 2019 novel
host-derived membrane surrounds the genome,
which is encased in a helical nucleocapside. As coronavirus acute respiratory disease

Corresponding author: N Suganthan, email: [email protected], https://orcid.org/0000-0001-7905-6709, Invited review

article by the editorial team
This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted
use, distribution and reproduction in any medium provided the original author and source are credited

Vol.31, No.2, December 2019 -3-

Experience learnt from SARS and MERS Routes of transmission
SARS It is transmitted by the direct contact with infected
secretions or large aerosol droplets.
SARS was first reported in 2003, when it emerged
in China. The illness spread by close person-to- Where did it start?
person contact to countries in North America,
South America, Europe, and greater Asia before Both SARS and MERS are thought to have
the global outbreak was contained later in 2003. originated from bats, then spread through civets
Common symptoms of SARS included fever, and camel respectively, to humans. Even though the
initial source of2019-nCoV is still not known, but
cough, dyspnea, and occasionally watery diarrhea.
first cases were linked to a seafood or wet market
A viral pneumonia that rapidly progresses to
in the city of Wuhan, capital of the central Hubei
respiratory failure. Of infected patients, 20% to
province.(10)
30% required mechanical ventilation and 9.6%
died, with higher fatality rates in older patients and Case definitions for surveillance
those with medical comorbidities. 8098 individuals
were infected and 774 died. There have been no The case definitions are based on the information
reported cases since 2004.(4,5,6) currently available and might be revised as new
information accumulates. Countries may need
MERS to adapt case definitions depending on their own
epidemiologic situation.(11)
An acute viral respiratory tract infection caused
by the novel beta coronavirus MERS-CoV, first Suspect case 
identified in Jordan and Saudi Arabia in 2012. Cases
have been limited to the Arabian Peninsula and its A. Patient with severe acute respiratory infection
surrounding countries, and to travelers from the (fever, cough, and requiring admission to hospital),
Middle East or their contacts. MERS shares many AND with no other etiology that fully explains the
clinical features with SARS such as severe atypical clinical presentation AND a
pneumonia. Patients with MERS have prominent history of travel to or residence in China during the
gastrointestinal symptoms and often acute kidney 14 days prior to symptom onset, 
failure. November 2019, MERS-CoV has caused
a total of 2494 cases and 858 deaths, the majority OR 
in Saudi Arabia. MERS necessitates mechanical B. Patient with any acute respiratory illness AND at
ventilation in 50% to 89% of patients with a case least one of the following during the 14 days prior
fatality rate of 36%.(7,8,9) to symptom onset:
Transmission and incubation period of a. a) contact with a confirmed or probable case
2019-nCoV of 2019-nCoV infection, or
Coronaviruses are zoonotic and rarely, animal b. b) worked in or attended a health care
coronaviruses can infect people and then spread facility where patients with confirmed or
between people such as with MERS, SAR and now probable 2019-nCoV acute respiratory
with 2019-nCoV. Human-to-human transmission disease patients were being treated.
has been confirmed and transmission from
asymptomatic individuals during the incubation Probable case 
period may occur. Ro (reproduction number) Probable case: A suspect case for whom testing for
estimate is 1.4 to 2.5, meaning that every person 2019-nCoV is inconclusive or is tested positive
infected could infect between 1.4 and 2.5 people. using a pan-coronavirus assay and without
In comparison, measles has an RO of 12-18 and laboratory evidence of other respiratory pathogens.
SARS had a similar RO as the 2019-nCoV. The
viral incubation period is estimated at ~5 days Confirmed case 
(95% confidence interval, 4 to 7 days). Chinese
A person with laboratory confirmation of 2019-
authorities have reported that the incubation period
nCoV infection, irrespective of clinical signs and
may be longer (up to 14 days).(8)
symptoms. (11)
-4- Jaffna Medical Journal
Clinical features of Covid-2019 2019-nCoV is not detected by standard respiratory
viral panels. Lower respiratory specimens
The 2019 coronavirus (2019-nCoV) infection likely have a higher diagnostic value than upper
may be asymptomatic or may result in an acute respiratory tract specimens for detecting 2019-
respiratory disease. Covid-19 may present with nCoV infection. WHO recommends that lower
mild, moderate, or severe illness; the latter includes respiratory specimens such as sputum, endotracheal
severe pneumonia, ARDS, sepsis and septic shock. aspirate, or bronchoalveolar lavage be collected
Early recognition of suspected patients allows for 2019-nCoV testing where possible. If it is
for timely initiation of infection prevention and not possible, upper respiratory tract specimens
control. Males are more commonly affected, and such as a nasopharyngeal aspirate or combined
the median age range of patients is 49 to 59 years. nasopharyngeal and oropharyngeal swabs should
Nearly all reported cases have occurred in adults be collected. Specimen testing is performed using
(median age 59 years). a real time reverse transcription PCR (rRT-PCR)
assay for 2019-nCoV. Turnaround time for the PCR
Frequently reported signs and symptoms at the assay testing is about 24-48 hours.
illness onset include fever (83-98%), cough (76-
Treatment
82%), and myalgia or fatigue (11-44%). Less
commonly reported symptoms include sputum There is no specific anti-viral treatment
production, headache, haemoptysis and diarrhea. recommended. Main stay of treatment consists of
The fever course among the patients with 2019- promptly implement infection control measures,
nCoV infection is not fully understood. It could be supportive care to relieve symptoms and support
prolonged and intermittent. There are no specific organ function.
signs or symptoms that would suggest Covid-19 Infection prevention and control (IPC) measures is
compared symptoms and signs of respiratory a critical and integral part of clinical management
illnesses caused by other viruses.(12,13) of patients and should be initiated at the point
Investigations and confirmation of the diagnosis of entry of the patient to hospital. Standard
precautions should always be routinely applied
In the FBC, lymphopenia (63%) appears as a in all areas of health care facilities. Standard
prominent laboratory abnormality along with precautions include hand hygiene; use of PPE to
leukopenia in 9-25% , leukocytosis in 24-30% and avoid direct contact with patients’ blood, body
thrombocytopenia in 12%. Elevated transaminases fluids, secretions (including respiratory secretions)
were noted in 37% of whom extreme elevations are and non-intact skin. Standard precautions also
rare. Inflammatory markers are elevated in majorly include prevention of needle-stick or sharps injury;
(CRP- 68%, ESR-84%) and procalcitonin is normal safe waste management; cleaning and disinfection
in most. Chest X-ray and CT findings show bilateral of equipment; and cleaning of the environment.
infiltrate in 75% and unilateral involvement in 25%. (see table 1)(14)

Table 1: IPC measures

At triage • Give suspect patient a medical mask
• Direct patient to separate area, an isolation room if
available
• Keep at least 1meter distance between suspected patients
and other patients.
• Instruct all patients to cover nose and mouth during
coughing or sneezing with tissue or flexed elbow for
others.
• Perform hand hygiene after contact with respiratory
secretions

Vol.31, No.2, December 2019 -5-

 • Use a medical mask if working within 1-2 meters of the
patient.
• Place patients in single rooms, or group together those
with the same etiological diagnosis.
• If an etiological diagnosis is not possible, group patients
Apply droplet precautions with similar clinical diagnosis and based on epidemiological
risk factors, with a spatial separation.
• When providing care in close contact with a patient with
respiratory symptoms (e.g. coughing or sneezing), use eye
protection (face-mask or goggles)
• Limit patient movement within the institution

• Use PPE (medical mask, eye protection, gloves and gown)

when entering room and remove PPE when leaving.
• If possible, use either disposable or dedicated equipment
(e.g. stethoscopes, blood pressure cuffs and thermometers).
• If equipment needs to be shared among patients, clean and
disinfect between each patient use.

Apply contact precautions • Ensure that health care workers refrain from touching
their eyes, nose, and mouth with potentially contaminated
gloved or ungloved hands.
• Avoid contaminating environmental surfaces that are not
directly related to patient care (e.g. door handles and light
switches).
• Ensure adequate room ventilation. Avoid movement of
patients or transport. Perform hand hygiene.

• Ensure that healthcare workers performing aerosol-

generating procedures (i.e. open suctioning of respiratory
tract, intubation, bronchoscopy, cardiopulmonary
resuscitation) use PPE, including gloves, long-sleeved
gowns, eye protection, and fit-tested particulate respirators
(N95 or equivalent, or higher level of protection).
• Whenever possible, use adequately ventilated single
Apply airborne precautions rooms when performing aerosol-generating procedures,
during aerosol generation
meaning negative pressure rooms with minimum of 12
procedures
air changes per hour or at least 160 litres/second/patient
in facilities with natural ventilation.
• Avoid the presence of unnecessary individuals in the room.
• Care for the patient in the same type of room after
mechanical ventilation commences.

-6- Jaffna Medical Journal

Provide standard supportive management for Table 2: Case fatality rate of selected viral diseases
respiratory disease and complications, including
advanced organ support if indicated.(14) Disease Case fatality rate
pH1N1 0.02-0.4%
• Supplementary Oxygen Therapy (target
Cocid-19 2-3%
SpO2 ≥90% in non-pregnant adults and
SARS 10%
SpO2 ≥92-95 % in pregnant patients)
MERS 37%
• Conservative fluid management Ebola virus 63%
• Antipyretics and /or Analgesics Prevention
• A d m i n i s t e r a p p r o p r i a t e e m p i r i c There is no vaccine available currenlty. It has begun
antimicrobials within ONE hour of developing a vaccine and hope to begin a phase 1
identification of sepsis trial within 3 months. So, spread of 2019-nCoV
infection can be controlled or reduced from person-
• Empiric therapy includes a neuraminidase to-person by doing the following
inhibitor for treatment of influenza when
there is local circulation or other risk factors • Wash hands often with soap and water for at
least 20 seconds. If soap and water are not
• Other supportive care such as intubation,
available, use alcohol-based hand sanitizer
mechanical ventilation, non-invasive containing at least 60% alcohol.
ventilation etc)
• Avoid touching your eyes, nose, or mouth
• Close monitoring for signs of deterioration. with unwashed hands.
• Do not routinely give systemic • Avoid close contact with people who are
corticosteroids for treatment of viral sick.
pneumonia or ARDS outside of clinical
trials unless they are indicated for another • Stay home when you are sick.
reason septic shock or other disease
• Cover your cough or sneeze with a tissue,
processes (acute exacerbation of COPD,
then throw the tissue in the trash.
etc).(13)
• Clean and disinfect frequently touched
• Managing sepsis and septic shock – follow
objects and surfaces.(16,17)
surviving sepsis guideline
Masks are Not Routinely Advised for public
Anti-viral drugs
for a healthy person, routinely wearing a mask
Potential treatments against the novel coronavirus while out in public is unlikely to be helpful. In
include remdesivir, which was tested against addition, masks have to be changed every 20
Ebola, and Kaletra, a combination of the antivirals minutes and they become moist and ineffective
lopinavir and ritonavir. First case of covid-19 in when worn through the day. Masks should instead
USA was treated with intravenous remdesivir with be reserved to be worn if you have symptoms of
favorable outcome.(15) However, it needs further respiratory tract infection to reduce transmission
studies to recommend these drugs to prescribe of virus.
routinely for this condition.
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