COVID-19 / SARS CoV2 disease

1. COVID-19 Presentation by : Dr. Shiva Kandel 1st year resident MD (GP & EM) JMCTH,TU June 9, 2021

2. Epidemiology brief

4. As of jestha 19 Total positive case- 571111 Total death :- 7555 (decreasing ) Recovery rate:- 80.8% ( increasing)

5. Virology brief • enveloped positive-stranded RNA viruses • is a beta coronavirus, same subgenus as the severe acute respiratory syndrome (SARS) virus &MERS • Proposed name- severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) • Primary Host :- Bat • intermediate animal host - could be a domestic food animal, a wild animal, or a domesticated wild animal not yet been identified. • Cell entry- by binding the angiotensin-converting enzyme 2 (ACE2) host receptor through the receptor-binding gene region of its spike protein

6. Variants 1. B.1.1.7– UK 2. P.1 japan/brazil 3. B.1.351 south Africa 4. B.1.427 and B.1.429 US-California 5. B.1.617 (includes 3 sub-lineages):†B.1.617.1 , B.1.617.2 B.1.617.3 india - Secondary wave was believed to be due to double mutant variant at first but Recently triple mutant variant (B.1.618) has been traced in west Bengal, INDIA

7. Transmission- • “Three C’s” (the risk of COVID-19 spreading is higher in places where these “3Cs” overlap): • -Crowded places with many people nearby; • -Close-contact settings, especially where people have conversations very near each other; within approx. 6 ft or 2 m • -Confined and enclosed spaces with poor ventilation.

8. Transmission Routes • large respiratory droplets • Airborne transmission • direct or indirect contact with infected secretions • non-respiratory specimens eg. stool, blood, ocular secretions, and semen (but the role of these sites in transmission is uncertain ) • The risk of transmission varies by • the type and duration of exposure, • use of preventive measures, • individual factors (eg, the amount of virus in respiratory secretions, symptomatic > asymptomatic)

9. Prevention • Hand washing/sanitization • Respiratory hygiene ( eg:- covering the cough or sneeze). • Avoiding touching the face (in particular eyes, nose, and mouth) • Cleaning and disinfecting objects and surfaces that are frequently touched. • Adequate ventilation of indoor spaces • using portable high-efficiency particulate air (HEPA) filtration systems

10. WHO: Mythbuster

11. Classification • The clinical spectrum SARS-COV-2 infection ranges from • asymptomatic infection • Symptomatic • mild • moderate and • severe(critical and fatal) illness (predominantly occurs in adults with advanced age or certain underlying medical comorbidities ) • The incubation period 4-5 days on average, but may be as long as 14 days.

14. Symptoms that may be seen in patients with COVID-19 • Cough – 50% • Fever (≥100.4°F) – 43% • Myalgias—36% • Headache—34% • Dyspnea (new or worsening over baseline)– 29% • Sore throat– 20% - Anosmia or other smell abnormalities - Ageusia or other taste abnormalities Reference:Centers for Disease Control and Prevention. nterim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19). Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html. Other •Diarrhea- 19% •Nausea/vomiting- 12 % •Rhinorrhea and/or nasal congestion •Chills/rigors •Fatigue •Confusion •Chest pain or pressure •new-onset pernio-like lesions (eg, "COVID toes") Clinical features

15. Investigations • Test for diagnosis • Nucleic acid amplification testing (NAAT)/RT-PCR – (gold standard) • Antigen testing • Antibody or serology testing • Supportive test • Laboratory • Imaging

16. Nucleic acid amplification testing (NAAT)/RT-PCR • A positive test confirms the diagnosis • Preferred Specimen site- from the upper respiratory tract • If initial test is negative but high suspicion– repeat test 24-48 hr after • the sensitivity depends on • the type and quality of the specimen obtained, • the duration of illness at the time of testing (best timing 2 days before and within 7 days after • the specific assay • sensitivity is estimated to be approximately 70% and specificity, 95% (Watson J., Whiting P.F., Brush J.E. Interpreting a COVID-19 test result. BMJ. 2020;369:m1808.https://www.bmj.com/content/369/bmj.m1808 ) • False positive results are most commonly related to errors in sample handling during or after swab collection

17. • Ct refers to the number of cycles needed to amplify viral RNA to reach a detectable level • Inversely proportional to amount of target nucleic acid/viral load • Ct values from viral RNA can vary depending on method of specimen collection, specimen source, transport, and the time from infection to collection to analysis • PCR Ct values may vary significantly between assays, even those using the same gene target • It’s unclear how Ct should be applied in clinical settings Cycle threshold value

18. CT value < 29 – suggest abundant target nucleic acid in sample CT value 30-37 -suggest moderate target nucleic acid in sample CT value 38-40- suggest minimal target nucleic acid in sample

19. Specimen collection site • Nasal or nasopharyngeal wash/aspirate - highest sensitivity • Nasal swab specimen from both anterior nares, • Nasal mid-turbinate swab, • Oropharyngeal swab specimen • Broncholoalveolar lavage in intubated patient • Saliva specimen (1 to 5 mL) collected by the patient while supervised

20. Priority IDSA guidance First/High priority •Critically ill patients with unexplained viral pneumonia or respiratory failure •Any individual with features of a lower respiratory tract illness and is close contact to COVID19 positive • Symptomatic immunosuppressed (including patients with HIV), older, or have underlying chronic health conditions •Symptomatic Individuals who are critical to the pandemic response, including health care workers, public health officials, and other essential leaders Second/Priority •Non-ICU hospitalized patients and long-term care residents with unexplained fever and features of a lower respiratory tract illness References:Infectious Diseases Society of America. COVID-19 Prioritization of Diagnostic Testing. Available at: http://www.idsociety.org/globalassets/idsa/public-health/covid-19-prioritization-of-dx-testing.pdf (Accessed on March 26, 2020). Suggested priorities for SARS-CoV-2 (COVID-19) testing

21. Third •Outpatients patient with respiratory symptoms plus comorbid conditions (diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, age >50 years, immunocompromising conditions); •testing of outpatient pregnant women and symptomatic children with similar risk factors is also included in this priority level* Fourth •Community surveillance as directed by public health and/or infectious diseases authorities References:Infectious Diseases Society of America. COVID-19 Prioritization of Diagnostic Testing. Available at: http://www.idsociety.org/globalassets/idsa/public-health/covid-19-prioritization-of-dx-testing.pdf (Accessed on March 26, 2020).

22. When to test in asymptomatic patient ? • If they :- • Are Close contact (immediate test and if negative repeat after 5-7 days of last exposure) • Are staff of health care facilities with identification of COVID19 in admitted patient • Screening Hospitalized patient in high prevalence area • Prior to surgical procedures or aerosol-generating procedures (endoscopy, bronchoscopy) • Prior to receiving immunosuppressive therapy (including prior to transplantation)

23. Counselling to close contact with covid19 positive patient • Give RT PCR • Daily monitoring for fever, cough, or dyspnea for 14 days • Those awaiting test results • should stay Self-quarantine at home, with maintenance of at least 6 feet (2 meters) from other people and animals in the household • Using masks, not sharing items such as dishes, towels, and bedding, and cleaning of shared/frequently touched surfaces

24. Other diagnostic tests:- Antigen testing- GeneXpert, lateral flow assays result within 45 min • the sensitivity of antigen tests is lower so negative antigen tests should usually be confirmed with NAAT Serology testing :- • for patients with symptoms for at least two weeks (IgM– 5-8 days onwards ,IgG 10-14 days onwards) • (ELISA) or chemiluminescence immunoassays (CLIA)-more sensitive • Sensitivity depends on duration and severity

26. Antibody test - Sensitivity and specificity varies according to kit manufacture company False positive tests in antibody test : • Because antibody tests may detect coronaviruses other than SARS-CoV-2, such as those that cause the common cold. • done in populations with higher rates of infection for Public health and research purpose

27. Supportive test • lymphopenia, eosinopenia, and neutrophil/lymphocyte ratio ≥ 3.13 are related to greater severity and worse prognosis • High values of C-reactive protein (CRP) • elevated D-dimer,fibrinogen, ferritin, LDH,procalcitonin,IL-6 • LFT • RFT

28. Imaging • Plain chest X-rays • sparse bilateral consolidations accompanied by ground glass opacities, • peripheral/subpleural images, predominantly in the lower lobes • CT chest :- greater sensitivity • Pulmonary ultrasonography – • good sensitivity; • the typical findings are B-lines, consolidations and pleural thickening

29. - multifocal, bilateral, peripheral/subpleural ground glass opacities, generally affecting the posterior portions of the lower lobes, with or without associated consolidations

30. Complications • Respiratory failure – Acute respiratory distress syndrome (ARDS) • Other complications of severe illness include • Cardiac and cardiovascular complications – arrhythmias, myocardial injury, heart failure, and shock • Thromboembolic complications – deep vein thrombosis (DVT) and pulmonary embolism (PE) , acute stroke and limb ischemia • Neurologic complications – Encephalopathy , Stroke, movement disorders, motor and sensory deficits, ataxia, and seizure • Inflammatory complications (eg, the multisystem inflammatory syndrome in children, SEPSIS,Septic shock ) • Secondary infections-- bacterial or fungal coinfections • Recovery and long-term sequelae- persistent symptoms include fatigue, dyspnea, chest pain, cough, and cognitive deficits

31. Persistent symptom¶ Proportion of patients affected by symptom Approximate time to symptom resolutionΔ Common physical symptoms Fatigue 15 to 87% [1,2,6,9,14] 3 months or longer Dyspnea 10 to 71% [1,2,6-9,14] 2 to 3 months or longer Chest discomfort 12 to 44% [1,2] 2 to 3 months Cough 17 to 34% [1,2,9,12] 2 to 3 months or longer Anosmia 10 to 13% [1,3-5,9,11] 1 month, rarely longer Less common physical symptoms Joint pain, headache, sicca syndrome, rhinitis, dysgeusia, poor appetite, dizziness, vertigo, myalgias, insomnia, alopecia, sweating, and diarrhea <10% [1,2,8,9,11] Unknown (likely weeks to months) Psychologic and neurocognitive Post-traumatic stress disorder 7 to 24% [6,10, 14] 6 weeks to 3 months or longer Impaired memory 18 to 21% [6,15] weeks to months Poor concentration 16% [6] Weeks to months Anxiety/depression 22 to 23% [2,7,8,10, 12,13, 14] Weeks to months Reduction in quality of life >50% [8] Unknown (likely weeks to months)

32. Myth busters

33. Staging of illness according to pathophysiology

34. TUTH guideline After PCR positive Mild Fever <6 days, No SOB spo2 >94 % No chest x ray changes • Home isolation • Contact/droplet precautions • Awake proning • Plenty of fluids • Adequate nutrition • Adequate sleep • Antipyretics /symptomatic Rx • NO STEROID Moderate Tachypnea (RR>24/min ) Hypoxia (spO2 <92% ) Shortness of breath ,Fever >100.4 dF for >6 days C xray findings • Investigations -CBC, RBS,CXR , LFT, RFT, CRP, LDH ferritin, d -dimer , serum albumin • Admission in isolation ward • O2 support to maintain spO2 >92% • Awake proning /positioning • Dexamathasone 8mg OD • LMWH prophylaxis (enoxaparin) • Consider remdesivir - if within 7-9 days of symptom onset (ALT/AST <5*ULN and egFR >30ml/minm2 • Optional :- CPT if within 7 days of symptoms

35. Severe • Tachypnea RR>30min • Hypoxia (sPO2 <90% in RA • Admission in HDU/IcU • Oxygen support via NRM /NIV/HFNC • Intubation if NIV not tolerated • iv dexamethasone 8mg OD/IV methylprednisolone 40mg BD • LMWH prophylaxis (enoxaprin) • Consider remdesivir if within 7-9 days of symptoms onset (AST/ALT <5 x ULN and eGFR >30ml/min/m2 • If sepsis/septic shock manage as per sepsis care protocol • Optional:- CPT if within 7 days of symptoms

36. Inpatient evaluation Daily: ●Complete blood count (CBC) with differential, with a focus on the total lymphocyte count trend ●Complete metabolic panel ●Creatine kinase (CK) ●C-reactive protein (CRP) • Alternate day (or daily if elevated or in the intensive care unit): ●Prothrombin time (PT)/partial thromboplastin time (PTT)/fibrinogen ●D-dimer

37. • Check baseline level and repeat them if abnormal or with clinical worsening: ●Lactate dehydrogenase, repeated daily if elevated ●Troponin, repeated every two to three days if elevated ●Electrocardiogram (ECG), with at least one repeat test after starting any QTc- prolonging agent - Daily portable chest x-ray for evaluation of extent of lung involvement - If suspicion of secondary bacterial infection we check two sets of blood cultures and sputum Gram stain and culture - Hep B, hep C, and HIV serology if not done previously

39. Source:- NMC guideline may 2021

40. Source:- NMC guideline may 2021 SpO2 <90 % in RA RR >30

41. -In selected patients with mild ARDS, if available HFNO (60l/min with fiO2 1.0) -non-invasive ventilation – continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) -If no improvement or deteriorates after 1 hr of NIV start mechanical ventilation delivery devices & appropriate flow rate -nasal cannula : up to 5 L/min -Venturi mask for flow rates 6– 10 L/min -face mask with reservoir bag for flow rates 10–15 L/min). Target:- Any patient with emergency sign SPO2 >94% In stable hypoxemic >90% COPD – 88-92 % Pregnant > 92-95%

42. Suggested dosing of standard thromboprophylaxis is as follows: -Enoxaparin 40 mg by subcutaneous injection every 24h Unfractionated heparin (UFH) 5000 units by subcutaneous injection every 8 or 12h: - Other drugs:- fondaparinux ,tinzaparin, dalteparin Enoxaparin - Prophylactic dosages (non-weight adjusted) in low body weight (women < 45 kg, men < 57 kg) may lead to a higher risk of bleeding. Careful clinical observation is advised. - If BMI > 40 kg/m2 or weight > 120 kg: enoxaparin 40 mg by subcutaneous injection every 12h. Unfractionated heparin (UFH) - - If BMI > 40 kg/m2 or weight > 120 kg: 7500 units q12h or 5000 units every 8h.

44. Therapeutcs and COVID-19: living guideline - World Health Organizaton (WHO)

45. NMC guideline, may 2021 Systemic corticosteroids :- oral dexamethasone 6mg OD or prednisolone 40mg OD or oral methylprednisolone 32 mg OD • When SpO2 <93% on room air • Follow up after 2-3 days to decide on duration of steroid therapy • Should not be started in mild to moderate disease when spo2>93% Inhaled corticosteroid -budesonide 800mcg twice daily • For adults with mild to moderate disease within 7 days from onset of symptoms • Discontinue on resolutions of symptoms or if patient started on steroid therapy Antibiotics :- in the absence of clear evidence of bacterial infection not recommended

46. Supportive medicine

47. *An international Guideline Development Group (GDG) WHO suggest against administering remdesivir in addition to usual care.

48. Therapeutcs and COVID-19: living guideline - World Health Organizaton (WHO)

49. Remdisivir • only for those with severe disease who are within the first 10 days from symptom onset but have rapidly progressing hypoxia inspite of systemic corticosteroid use or for immunocompromised patients requiring low flow oxygen or severe infection requiring ICU admission who are not on ventilators. • Only shown to decrease the length of hospitalization but not mortality • Has not been shown to improve outcome in patient who are on ventilators Toclizumab (IL-6 pathway inhibitor) -considered in patients with severe or critical covid-19 who have rapidly increasing oxygen needs and systemic inflammation(CRP>75mg/L) despite use of systemic steroids - single dose @8mg/Kg IV with 100ml NS over 1 hr . Not to be used in active TB, fungal infection, sepsis , pregnancy ,lactating mother NMC guideline for use of remdisivir and toclizumab

50. New drugs :- Baricitinib • Baricitinib is a Janus kinase inhibitor,has immunomodulatory plus antiviral effects through interference with viral entry • Option for patient progressing toward needing higher levels of respiratory support despite initiation of steroid • Not used in patient received toclizumab • Provide mortality benefit for critical patient • Authorized in US along with remdisivir Monoclonal antibody – -Trials of monoclonal antibodies that have been developed to neutralize SARS-CoV-2 by targeting the SARS-CoV-2 spike protein and preventing viral cell entry are also underway

51. -recommend for patients with suspected or confirmed severe COVID-19, -the use of empiric antimicrobials to treat all likely pathogens, based on clinical judgment, patient host factors and local epidemiology, - this should be done as soon as possible (within 1 hour of initial assessment if possible), ideally with blood cultures obtained first. -Duration of empiric antibiotic treatment should be as short as possible; generally 5–7 days.

52. Hydroxychloroquine was one candidate agent for either pre- or post-exposure prophylaxis, but available placebo-controlled trial data suggest it is not effective in preventing infection. https://www.uptodate.com/contents/covid-19-epidemiology-virology-and-prevention/abstract/296-301

53. -Ivermectin has demonstrated activity against SARS-CoV-2 in vitro, =-plasma levels high enough for antiviral activity cannot be achieved with safe drug doses https://www.uptodate.com/contents/covid-19-epidemiology-virology-and-prevention/abstract/306

54. Mental health and psychosocial support • measures to prevent delirium, an acute neuropsychiatric emergency in ICU patient • Help people address urgent needs and concerns, and help with decision-making, as necessary. • Help connect people with loved ones and social support, including through phone or internet as appropriate. • prompt identification and assessment for anxiety and depressive symptoms in the context of COVID-19 and psychosocial support

56. When to discontinue precaution or discharge from isolation? • Two strategies • non test based- For most immune-competent patients with COVID-19 positive result • test based - require two negative RT-PCR tests for SARS-CoV-2 on sequential respiratory specimens collected ≥24 hours apart

57. Non-test-based strategies for discharging patient :- Population Strategy Symptomatic mild to moderate patients •all of the following conditions must be met: 1. At least 10 days passed since symptoms first appeared ,Except in severely immunocompromised patients, extended for ≥20 days PLUS 2. At least 24 hours afebrile period without any antipyretics PLUS 3. improvement in symptoms (eg, cough, shortness of breath). Symptomatic severe or critical patient all of the following conditions must be met: 1. At least 10 -20 days have passed since symptoms first appeared PLUS (>20 days for severely immunocompromised patients) 2. At least 24 hours afebrile period without any antipyretics PLUS 3. improvement in symptoms (eg, cough, shortness of breath).

58. Asymptomatic patients with laboratory-confirmed COVID-19 Time-based (before discontinuing precautions, all of the following conditions must be met): 1.After 10 days of their first positive viral diagnostic test. (severely immunocompromised patients. extended for ≥20 days ) 2.No subsequent illness developed.  severe immunocompromised defined as combined primary immunodeficiency disorder, -receiving certain chemotherapy for cancer, -being within 1 year of receiving a hematopoietic stem cell or solid organ transplant, -HIV and a CD4 count <200 cells/microL, -receiving chimeric antigen receptor T (CAR-T) cell therapy or B cell-depleting therapies, -receipt of prednisone >20 mg/day for more than 14 days).

59. • Discharging prior to meeting criteria – • can be sent home with instructions to self-isolate until they meet the above criteria. • Once infection control precautions/home isolation are discontinued, all patients should still continue to follow public health recommendations for wearing face covers.

60. Test-based strategies in symptomatic patients • may discontinue infection control precautions specific for COVID-19 when there is • Resolution of fever without the use of fever-reducing medications; AND • Improvement in symptoms (eg, cough, shortness of breath); AND • Negative RT- PCR results from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens).

61. Test-based strategies in Asymptomatic patients • at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens). • if first test is positive- obtain a second test after 72 hours • If first test is negative, the second test after 24 hours later. • If the person continues to test positive, some clinicians have used the cycle threshold (Ct) to help assess infectivity; the higher the Ct, the fewer the RNA copies *Ct values can be affected by factors other than viral load (how the specimen was stored), and no clinical studies have validated use of Ct to guide management

62. Immunocompromised patients with confirmed infection • those with significant immunocompromise may shed viable virus for more than 20 days. • The following groups are considered to be at risk for prolonged viral shedding: • patients within one year of receiving a hematopoietic stem cell or solid organ transplant, • patients with cancer receiving certain chemotherapy, • patients with HIV and a CD4 count <200 cells/microL, • patients with combined primary immunodeficiency disorder, • patients receiving chimeric antigen receptor T (CAR-T) cell therapy or B cell-depleting therapies, and those receiving prednisone >20 mg/day for more than 14 days • regardless of disease severity isolation duration should be extended • Discontinuation criteria is similar to severe immunocompetent patient

63. Vaccination • WHO has listed the vaccine for emergency use, giving the green light for the vaccine to be rolled out globally to address the emergency, by considering known and potential benefits of the vaccine that outweigh the known and potential risks. • Pfizer/BioNTech- 95% efficacy against symptomatic covid19 , 2 dose 3 week apart • Moderna (spain)– efficacy 94% , 2 dose 4 week apart • SputnikV- efficacy 92% , 2 dose 3 weeks apart • Novavax – efficacy 89% 2 dose 3 weeks apart • AstraZeneca/Oxford COVID-19 vaccines/covishield – efficacy 70% (85% in 65 years or older) (produced by AstraZeneca-SKBio (Republic of Korea) and the Serum Institute of India) • Sinopharm vaccine – 2 dose 79% efficacy • Janssen/Johnson & Johnson(Belgium) – single dose 66% efficacy against moderate to severe COVID-19 : https://www.who.int/groups/strategic-advisory-group-of-experts-on-immunization/covid-19-materials

64. AstraZeneca/Oxford COVID-19 vaccines/covishield- vaccine • Age 18 years and above (Pfizer 12 years and above) • two doses (0.5 ml) given intramuscularly into the deltoid muscle • Interval of • 4 to 12 weeks apart (manufacturer recommendation) • 8 to 12 weeks apart (WHO recommendation) • 4 to 8 weeks ( NTAGI & NEGVAG, India0 • If 2 nd dose administered less than 4 weeks after 1 st , the dose does not need to be repeated. • If 2 nd dose is delayed beyond 12 weeks, it should be given at the earliest possible opportunity. • minimum interval of 14 days between administration of covishield and any other vaccine against other conditions

65. Precautions -A history of anaphylaxis Side effects • Local injection site reactions • Systemic symptoms (fevers, chills, fatigue, myalgia, headache) • Cerebral venous sinus thrombosis (169 of ≈ 34 million) • Splanchnic vein thrombosis (54 of ≈ 34 million) • very rare thrombosis with thrombocytopenia syndrome (TTS) - 4 to 20 days following vaccination In UK 4 cases per 1 million (1 case per 250 000) vaccinated adults, In the EU approximately 1 case per 100 000 COVID-19: coronavirus disease 2019; WHO: World Health Organization.

66. Populations for which limited or no data exist from the clinical trials of Covishield Children and adolescents below the age of 18 years - currently no efficacy or safety data for children or adolescents below the age of 18 years Pregnant women • Insufficient available data to assess vaccine efficacy or vaccine-associated risks in pregnancy • Preliminary reproductive toxicity studies in mice have not shown harmful effects of the vaccine in pregnancy. • In the interim, WHO recommends the use of ChAdOx1-S [recombinant] vaccine in pregnant women only if the benefits of vaccination to the pregnant woman outweigh the potential risks.

67. Lactating women • Vaccine efficacy is similar in lactating women as in other adults • no data on the effects of the vaccine on breastfed children. • according to the WHO Prioritization Roadmap a lactating woman is part of a group recommended for vaccination Immunocompromised person • recommended for vaccination (Although the immune response to the vaccine may be reduced, which may lower its clinical effectiveness)

68. Persons who previously had SARS-CoV-2 infection • recommended after 6 months (since reinfection is uncommon after natural infection in this period ) • If previously received convalescent plasma :- • Recommended After 90 days (to avoid interference of the antibody treatment with vaccine-induced immune responses) Persons with current acute COVID-19 • should not be vaccinated until recovery from acute illness and the criteria for discontinuation of isolation have been met (after 3 week) • The optimal minimum interval between a natural infection and vaccination is not yet known.

69. SARS-CoV-2 variants & vaccine • Preliminary analyses have shown a slightly reduced vaccine effectiveness against B1.1.1.7 (UK) • marked reduction in vaccine effectiveness against mild and moderate disease due to B 1.351 (south Africa) • WHO currently recommends the use of ChAdOx1-S [recombinant] vaccine according to the Prioritization Roadmap (4) even if variants are present in a country.

70. References • COVID-19 Clinical management, Living guidance ;25 January 2021 ; WHO • Update in COVID19 therapeutics, 59th update ; 18th may 2021 • Interim recommendations for use of the ChAdOx1-S [recombinant] vaccine against COVID-19 • UPtodate resources

71. THANK YOU !

COVID-19 / SARS CoV2 disease

COVID-19 / SARS CoV2 disease

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