RISK ASSESMENT AND MANAGEMENT

OF COVID-19

1 INTRODUCTION:
Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was first identified in
December 2019 in Wuhan, Hubei, China, and has resulted in an ongoing
pandemic.  As of 15 August 2020, more than 21.1 million cases have been reported
across 188 countries and territories, resulting in more than 765,000 deaths. More
than 13.2 million people have recovered.[1]
Common symptoms include fever, cough, fatigue, shortness of breath, and loss of
smell and taste. While most people have mild symptoms, some people
develop acute respiratory distress syndrome (ARDS) possibly precipitated
by cytokine storm, multi-organ failure, septic shock, and blood clots.[15][16]
[17]
 The time from exposure to onset of symptoms is typically around five days, but
may range from two to fourteen days.
The virus is spread primarily via small droplets produced by coughing,  sneezing,
and talking. The droplets usually fall to the ground or onto surfaces rather
than travelling through air over long distances. However, those standing in close
proximity may inhale these droplets and become infected.[2] People may also
become infected by touching a contaminated surface and then touching their
face. The transmission may also occur through smaller droplets that are able to stay
suspended in the air for longer periods of time in enclosed spaces, as typical
for airborne diseases. It is most contagious during the first three days after the
onset of symptoms, although spread is possible before symptoms appear, and from
people who do not show symptoms. The standard method of diagnosis is by real-
time reverse transcription polymerase chain reaction (rRT-PCR) from
a nasopharyngeal swab. Chest CT imaging may also be helpful for diagnosis in
individuals where there is a high suspicion of infection based on symptoms and
risk factors; however, guidelines do not recommend using CT imaging for routine
screening.
Recommended measures to prevent infection include frequent hand
washing, maintaining physical distance from others (especially from those with
symptoms), quarantine (especially for those with symptoms), covering coughs, and
keeping unwashed hands away from the face. The use of cloth face coverings such
as a scarf or a bandana has been recommended by health officials in public settings
to minimise the risk of transmissions, with some authorities requiring their
use. Health officials also stated that medical-grade face masks, such as N95 masks,
should be used only by healthcare workers, first responders, and those who directly
care for infected individuals.
There are no proven vaccines nor specific antiviral treatments for COVID-
19. Management involves the treatment of symptoms, supportive care, isolation,
and experimental measures. The World Health Organization (WHO) declared the
COVID-19 outbreak a public health emergency of international
concern (PHEIC) on 30 January 2020 and a pandemic on 11 March 2020. Local
transmission of the disease has occurred in most countries across all six WHO
regions.

2 MANAGEMENT:
People are managed with supportive care, which may include fluid therapy, oxygen
support, and supporting other affected vital organs. The CDC recommends those
who suspect they carry the virus wear a simple face mask.  Extracorporeal
membrane oxygenation (ECMO) has been used to address the issue of respiratory
failure, but its benefits are still under consideration.  Personal hygiene and a
healthy lifestyle and diet have been recommended to improve
immunity. Supportive treatments may be useful in those with mild symptoms at the
early stage of infection.
The WHO, the Chinese National Health Commission, and the United
States' National Institutes of Health have published recommendations for taking
care of people who are hospitalised with
COVID-19. Intensivists and pulmonologists in the US have compiled treatment
recommendations from various agencies into a free resource, the IBCC.

3 MONITORING:
  Vital signs (temperature, respiratory rate, heart rate, blood pressure, oxygen
saturation)
 Haematological and biochemistry parameters
 Coagulation parameters (D-dimer, fibrinogen, platelet count, prothrombin
time)
 ECG
 Chest imaging
 Signs and symptoms of venous or arterial thromboembolism.
Medical early warning scores
 Utilise medical early warning scores that facilitate early recognition and
escalation of treatment of deteriorating patients (e.g., National Early
Warning Score 2 [NEWS2], Paediatric Early Warning Signs [PEWS]) where
possible.[3]
 There are no data on the value of using these scores in patients with COVID-
19 in the primary care setting.
Pregnant women
 Monitor vital signs three to four times daily and fetal heart rate in pregnant
women with confirmed infection who are symptomatic and admitted to
hospital. Perform fetal growth ultrasounds and Doppler assessments to
monitor for potential intrauterine growth restriction in pregnant women with
confirmed infection who are asymptomatic. Perform fetal growth ultrasound
14 days after resolution of symptoms.

4 SURVEILLANCE:
COVID-19 surveillance involves monitoring the spread of the coronavirus
disease in order to establish the patterns of disease progression. The World Health
Organization (WHO) recommends active surveillance, with focus of case
finding, testing and contact tracing in all transmission scenarios. COVID-19
surveillance is expected to monitor epidemiological trends, rapidly detect new
cases, and based on this information, provide epidemiological information to
conduct risk assessment and guide disease preparedness.

4.1 Syndromic surveillance:

Syndromic surveillance is done based on the symptoms of an individual who
corresponds to COVID-19. As of March 2020, the WHO recommends the
following case definitions:
 Suspect case: "a patient with acute respiratory illness (fever and at least one
sign/symptom of respiratory disease, e.g. cough, shortness of breath), and a
history of travel to or residence in a location reporting community
transmission of COVID-19 disease during the 14 days prior to symptom
onset" OR " a patient with any acute respiratory illness and having been in
contact with a confirmed or probable COVID-19 case in the last 14 days
prior to symptom onset" OR "a patient with severe acute respiratory illness
(fever and at least one sign/symptom of respiratory disease, e.g. cough,
shortness of breath; and requiring hospitalization) and in the absence of an
alternative diagnosis that fully explains the clinical presentation"
 Probable case: "a suspect case for whom testing for the COVID-19 virus is
inconclusive" OR "a suspect case for whom testing could not be performed
for any reason"
 Confirmed case: "a person with laboratory confirmation of COVID-
19 infection, irrespective of clinical signs and symptoms"
 Contact: "a person who experienced any one of the following exposures
during the 2 days before and the 14 days after the onset of symptoms of a
probable or confirmed case
1. face-to-face contact with a probable or confirmed case within 1 meter and
for more than 15 minutes
2. direct physical contact with a probable or confirmed case
3. direct care for a patient with probable or confirmed COVID-19 disease
without using proper personal protective equipment
4. other situations as indicated by local risk assessments"
The WHO recommends reporting probable and confirmed cases of COVID-19
infection within 48 hours of identification. Countries should report on a case-by-
case basis as far as possible but, in case of limitation in resources, aggregate
weekly reporting is also possible. Some organizations have created crowdsourced
apps for syndromic surveillance, where people can report their symptoms to help
researchers map areas with concentration of COVID-19 symptoms.
4.2 Virological surveillance:
Virological surveillance is done by using molecular tests for COVID-19. WHO has
published resources for laboratories on how to perform testing for COVID-19. In
the European Union, laboratory confirmed cases of COVID-19 are reported within
24 hours of identification.
4.3 Digital surveillance:
At least 24 countries have established digital surveillance of their citizens. The
digital surveillance technologies include COVID-19 apps, location data and
electronic tags. The Center For Disease Control and Prevention in USA tracks the
travel information of individuals using airline passenger data.
Tracking wristbands can take the place of smartphone apps for users who either do
not own a smartphone, or who own a smartphone unable to support Bluetooth Low
Energy functionality. In the UK, as of 2020 more than ten percent of smartphones
lack this functionality. In addition, in South Korea, people found to be breaking
quarantine are issued tracking wristbands designed to alert authorities if the band is
removed. At least one jurisdiction in the U.S. has used existing ankle
bracelet technology to enforce quarantine on patients found to be in violation.
In Hong Kong, authorities are requiring a bracelet and an app for all travellers. A
GPS app is used to track the locations of individuals in South Korea to ensure
against quarantine breach, sending alerts to the user and to authorities if people
leave designated areas. In Singapore, individuals have to report their locations with
photographic proof. Thailand is using an app and SIM cards for all travelers to
enforce their quarantine. India is planning to manufacture location and
temperature-monitoring bands. Israel has used its existing surveillance tools to
track and send messages to those who are required to quarantine themselves.
Human rights organizations have criticized some of these measures, asking the
governments not to use the pandemic as a cover to introduce invasive digital
surveillanc.
REFERENCES:
1 "COVID-19 Dashboard by the Center for Systems Science and Engineering
(CSSE) at Johns Hopkins University (JHU)". ArcGIS. Johns Hopkins
University
2 "The continuing 2019-nCoV epidemic threat of novel coronaviruses to
global health—The latest 2019 novel coronavirus outbreak in Wuhan,
China". International Journal of Infectious Diseases. 91: 264–
266. doi:10.1016/j.ijid.2020.01.009. PMC 7128332. PMID 31953166.
3  "WHO Director-General's opening remarks at the media briefing on
COVID-19". World Health Organization (WHO) (Press release). 11 March
2020. Archived from the original on 11 March 2020. Retrieved 12
March 2020.  Furukawa NW, Brooks JT, Sobel J (July 2020). "Evidence
Supporting Transmission of Severe Acute Respiratory Syndrome Coronavirus 2
While Presymptomatic or Asymptomatic".