SPECIAL ARTICLE

Novel Coronavirus 2019 (2019-nCoV) Infection: Part I - Preparedness and

Management in the Pediatric Intensive Care Unit in Resource-limited
Settings
NAMITA RAVIKUMAR1, KARTHI NALLASAMY1, ARUN BANSAL1, SURESH KUMAR ANGURANA1, BASAVARAJA GV2, MANU
SUNDARAM3, RAKESH LODHA4, DHIREN GUPTA5, AND MURALIDHARAN JAYASHREE1 FOR THE INTENSIVE CARE CHAP-
TER OF INDIAN ACADEMY OF PEDIATRICS
From Division of Pediatric Critical Care, Departments of Paediatrics, 1Advanced Paediatrics Centre, Postgraduate Institute of
Medical Education and Research (PGIMER), Chandigarh, India; 2Paediatric Intensive Care Unit, Indira Gandhi Institute of Child
Health, Bangalore Karnataka, India; 3Division of Critical Care Medicine, Sidra Medicine, Doha, Qatar; 4Department of
Pediatrics, All India Institute of Medical Sciences, New Delhi, India; and5Pediatric Intensive Care Unit, Sir Ganga Ram Hospital,
New Delhi, India.
Correspondence to:Dr Arun Bansal, Professor, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of
Medical Education and Research, Chandigarh, India. drarunbansal@gmail.com
Received: March 26, 2020; Initial review: March 28, 2020; Accepted: March 31, 2020.
First reported in China, the 2019 novel coronavirus has been spreading across the globe. Till 26 March, 2020, 416,686 cases have been
diagnosed and 18,589 have died the world over. The coronavirus disease mainly starts with a respiratory illness and about 5-16% require
intensive care management for acute respiratory distress syndrome (ARDS) and multi-organ dysfunction. Children account for about
1-2% of the total cases, and 6% of these fall under severe or critical category requiring pediatric intensive care unit (PICU) care. Diagnosis
involves a combination of clinical and epidemiological features with laboratory confirmation. Preparedness strategies for managing this
pandemic are the need of the hour, and involve setting up cohort ICUs with isolation rooms. Re-allocation of resources in managing this
crisis involves careful planning, halting elective surgeries and training of healthcare workers. Strict adherence to infection control like
personal protective equipment and disinfection is the key to contain the disease transmission. Although many therapies have been tried
in various regions, there is a lack of strong evidence to recommend anti-virals or immunomodulatory drugs.
Keywords: COVID-19, Guideline, Pandemic, SARI, Treatment.

Published online: March 29, 2020; PII: S097475591600151

T
he year 2020 started with the emergence of the BURDEN
2019 novel corona virus (2019-nCoV) as a
Global: Till March 26, 2020, a total of 416,686
threat to the world; shortly afterwards the
confirmed cases from 197 countries with 18,589 deaths
World Health Organization (WHO) declared it
have been reported by WHO. China has reported the
a pandemic. Having begun in China, globalization and
maximum cases with a total of 81,869, followed by Italy
travel led its spread all over the globe, overwhelming the
with 69,176 cases. However, mortality is more in Italy
healthcare resources and resulting in high mortality and
with 6,820 (9.9%) deaths followed by China having
morbidity. About 5% of adults, especially those with co-
3,287 (4%) deaths. The United States of America has
morbidities, were critically ill and required intensive care
surpassed Spain and Germany over the last few days with
unit (ICU) care [1]. People of all ages were found to be
51,914 cases and 673 deaths [3].
susceptible but severe illness was rare in children [2].
Most of the experience of critical care management of Indian scenario: A total of 606 cases with 10 deaths have
pediatric patients with coronavirus disease 2019 been reported from India as on March 26, 2020 as
(COVID-19) is derived from the affected children of reported by the WHO. Among these cases, only one child
present epidemic in China, as well as from the previous from Kerala has been tested positive.
coronaviral outbreaks viz. Severe acute respiratory
EPIDEMIOLOGY
syndrome (SARS) and Middle East respiratory syndrome
(MERS). We write this review as a guidance statement for The 2019-nCoV belongs to a group of enveloped
preparedness and managing children with suspected or positive-sense RNA viruses in the family, Coronaviridae
confirmed COVID-19 requiring intensive care in a with 4 genera viz., alpha, beta, gamma and delta. Human
resource-limited setting like India. coronaviruses (HCoV) belong to alpha and beta genus

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and are mostly implicated in endemic respiratory (63%), malaise (35%), myalgia, headache, nausea,
infection with mild severity [4]. However, the novel vomiting and diarrhea [12]. A prospective study from
coronaviruses infecting humans namely, SARS-CoV, China involving 171 children with confirmed COVID-19
MERS-CoV and SARS-CoV-2 are believed to have reported fever (41%) with a median duration of 3 days (1-
originated from bats with few intermediate hosts like 16), cough (48%), pharyngeal erythema (46%) tachypnea
civet cats, camels and pangolins [5]. RNA viruses mutate (28%) and diarrhea (8.8%). The cohort had 15%
faster than DNA viruses, single-stranded viruses mutate asymptomatic, 19% upper respiratory infection, and 65%
faster than double-strand virus, and genome size appears pneumonia. Only 3 children (1.7%) required care and
to correlate negatively with mutation rate. mechanical ventilation. All three of them had
comorbidities, and one died [7].
Transmission Characteristics
ICU Requirements in COVID
It is speculated that it originated in bat (genetic character
matches to bat corona virus) then it got transmitted to The severe and critical categories require admission and
pangolins, or scaly anteaters. Humans seem to be management in ICU. Among adults, 7% of patients
accidental host who got this virus from pangolins in admitted with SARS-CoV-2 pneumonia required ICU
Wuhan seafood market. Human to human transmission of care. The mean age of these ICU patients was 60 years
COVID-19 started in Wuhan city, Hubei Province of with male: female ratio of 2:1 and 50% had chronic
China where it was initially labelled as ‘Pneumonia of illness. Majority had Multi-organ dysfunction syndrome
unknown etiology’. Epidemiological investigation of (MODS) with ARDS (67%), acute kidney injury (29%),
early transmission dynamics revealed that 55% of the liver dysfunction (29%) and cardiac injury (23%). Of the
cases of COVID-19 during December, 2019 were linked ICU admissions, 71% required mechanical ventilation,
to the hunan seafood wholesale market. The mean 35% vasoactive support, 17% renal replacement therapy
incubation period has been reported to be 5.2 days with and 11% ECMO. Mortality was as high as 61% among
the 95th centile being 12.5 days. The main modes of the critically ill [12]. As per unpublished data from Italy,
transmission include droplet and fomites followed by 16% of admitted patients with COVID-19 needed ICU
airborne transmission. Reproduction number of nCoV-19 care [13]. In the Chinese pediatric cases, 5.9% of all
is between 2.2 to 3.6, which is comparable to SARS-CoV pediatric cases belonged to the severe or critical
but higher than MERS-CoV[6]. categories. Based on the experience in managing
community-acquired pneumonia, high-risk pediatric
Less severe affection in children: Children less than 10
population includes children with underlying conditions
years of age accounted for 1% of the total cases [1]. The
such as congenital heart disease, broncho-pulmonary
median age among pediatric cases was 6.7 years [7]. The
hypoplasia, airway/lung anomalies, severe malnutrition,
lesser proportion of severe cases among children has
and immunocompromised state; however, more
been attributed to lesser opportunities for exposure and
information is needed in the setting of COVID-19 [2].
immaturity of angiotensin converting enzyme 2 receptors,
which are proposed to be the binding sites for DIAGNOSIS
coronaviruses [8,9].
Case definitions for suspected, probable and confirmed
Case Fatality Rate COVID-19 cases as given by WHO are in Box I [16]. The
largest series on children analyzing suspected and
The overall case fatality rate as per China Centre for
confirmed COVID cases is from the electronic data base
Disease Control and Prevention (CDC) is 2.3%, which is
of Chinese CDC [17]. Cases were suspected based on the
much lower compared to SARS (9.6%) and MERS (34%)
presence of clinical features and exposure history. They
but significantly higher compared to the latest H1N1
also identified high-risk cases and categorized into
influenza pandemic (0.001 – 0.007%)[1]. However, as
groups based on severity (Box II).
per WHO, the global case fatality rate is as high as 4.4%
with absolute number of deaths already higher than the Laboratory testing of suspected cases is based on
total fatality of SARS and MERS combined [10]. The clinical and epidemiological factors. Screening protocol
case fatality reported from Italy is 7.2% which has gone should be adapted to local situation and may change with
up to 9.8% as per WHO (as on March 26, 2020) [11]. the evolution of the outbreak scenario in the local
CLINICAL MANIFESTATIONS population. Recent testing strategy in India (as on March
20, 2020) given by ICMR is as per algorithm in Fig.
The common clinical features reported in the critically ill 1[18]. Specimen handling for molecular testing would
patients include fever (98%), cough (77%), dyspnea require Biosafety 2 (BSL-2) or equivalent facilities.

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BOX I World Health Organization Case Definitions for Coronavirus Disease 19 (COVID-19)
Suspect case
A. A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease (e.g., cough,
shortness of breath), AND with no other etiology that fully explains the clinical presentation AND a history
of travel to or residence in a country/area or territory reporting local transmission (See situation report) of
COVID-19 disease during the 14 days prior to symptom onset.
OR
B. A patient with any acute respiratory illness AND having been in contact with a confirmed or probable COVID-
19 case (see definition of contact) in the last 14 days prior to onset of symptoms
OR
C. A patient with severe acute respiratory infection (fever and at least one sign/symptom of respiratory disease
(e.g., cough, shortness breath) AND requiring hospitalization AND with no other etiology that fully explains
the clinical presentation.
Probable case
A suspect case for whom testing for COVID-19 is inconclusive. Inconclusive being the result of the test reported
by the laboratory
Confirmed case
A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms
Source: World Health Organization [16].

BOX II Risk Stratification and Severity Categorization for Coronavirus Disease-19 (COVID-19)
High risk cases
Clinical features Fever, respiratory/ digestive symptoms, fatigue
Laboratory tests Leukopenia, lymphopenia, high C-reactive protein
Radiology Abnormal chest ray
Severity categorization
Asymptomatic infection No clinical or radiological features but tested positive
Mild Upper respiratory or gastrointestinal symptoms and signs
Moderate Clinical/radiological features of lower respiratory involvement
Severe Presence of dyspnea or hypoxemia requiring oxygen, refusal to feed, altered sensorium
Critical Organ dysfunction including Acute respiratory distress syndrome (ARDS), shock,
encephalopathy, myocardial dysfunction, coagulation dysfunction and acute kidney injury
Modified From Dong, et al. [17].

Attempts to culture the virus require minimum of BSL-3 Confirmatory Tests

facilities [19].
(a) Respiratory tract or blood samples tested positive for
Type of Sample 2019-nCoV nucleic acid using Real-time Reverse
Transcriptase – Polymerase Chain Reaction (RT-PCR)
Upper respiratory specimens: nasopharyngeal and
oropharyngeal swabs; both swabs are placed together in a (b) Genetic sequencing of respiratory tract or blood
viral transport medium and transported to the laboratory samples is highly homologous with the known 2019-
in ice. nCoV, but this is not done routinely.
Lower respiratory specimens: sputum and/or Serological tests may help in epidemiological
endotracheal aspirate or bronchoalveolar lavage in investigation but there could be cross reactivity with
patients with more severe respiratory disease (obtained other coronaviruses. Viral isolation is not done routinely
with aerosol precautions) for diagnosis. Rapid diagnostic test kits like Xpert Xpress

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History of international travel or contact

with positive case

↓
↓ ↓
Yes No
↓ ↓
↓ ↓ Test if
Asymptomatic Sypmtomatic cases
(fever, cough, Symptomatic
Home quarantine dyspnea) → HCW
→ x14 days ↓
Test for COVID-19 Patients admitted
All family members (RT-PCR) → with SARI
→ under home quarantine

Direct and high-risk contacts

→ tested once between day 6 & 14

Fig. 1 Testing strategy for suspected cases as per Indian Council of Medical Research.

SARS-CoV-2 by Cepheid has been approved by the US- Laboratory markers of organ dysfunction: Elevation of
FDA (United States Food and Drug Administration) for transaminases is seen in 12-14% and d-Dimer in 14%
Emergency Use Authorization (EUA) and RealStar cases [7].
SARS-CoV-2 RT-PCR kit 1.0 by Altona Diagnostics and
PREPAREDNESS AND ADMINISTRATIVE
Patho Detect by MY LAB have been approved by
CONCERNS FOR ICU
ICMR[20,21].
A phased and tiered plan for ICU during the pandemic
Ancillary Investigations
needs to be made based on the assessment of healthcare
Complete blood count: Lymphopenia was seen in 85% of burden and resource utilization [13,22,23].
critically ill adults, suggesting it a marker of severe
Intensive care units: Create cohort intensive care units
disease while among the overall pediatric cases, it was
where critically ill confirmed COVID-19 patients will be
seen in 3.5% [7,12].
managed. This would be a different area from where other
Infection markers: Elevation of C-reactive protein (CRP) PICU patients are being managed in order to reduce
was reported in 20% and procalcitonin in 64% of cases transmission within the hospital. In addition, a separate
[7]. area should be developed where suspected COVID-19
patients will be managed. With increasing burden of
Radiological findings: Chest radiography (CXR) or
patients, general beds may have to be converted to ICU
computed tomography (CT) are not recommended as a
beds and provided with suitable infrastructure. Predictive
routine for children but only in specific cases presenting
models based on local epidemic need to be developed for
with pneumonia and/or acute respiratory distress
expected number of patients as well as need of
syndrome (ARDS). Parenchymal abnormalities with
equipment.
peripheral consolidations on CXR have been reported in
a small case series from Korea [14]. Ground glass Setting up of isolation rooms : Negative pressure
opacities (32%), local patchy shadows (18%) and isolation is the standard recommendation for
bilateral patchy shadows (12%) on CT chest were the management of a suspected or proven COVID-19 patient.
common findings in children [7]. Bilateral pneumonia However, in case of non-availability of these rooms, use
(75%), unilateral pneumonia (25%) and multiple single rooms with separate air outlet/exhaust, preferably
mottling and ground-glass opacity (14%) were reported on the higher floor of the building. These rooms should be
based on CXR and CT findings from adult patients in equipped with resuscitation trolley, essential drugs,
Wuhan, China [15]. multipara monitor and ventilator. Positive pressure rooms

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like operation theatres are not suitable for airway Severe acute respiratory illness (SARI): SARI is defined
management as aerosol generation is higher. by the presence of cough and fast breathing plus at least
one of the following [25]:(i) Oxygen saturation (SpO2)
Reducing the ICU burden: All elective non-urgent <90%, (ii) severe chest indrawing and grunting, and (iii)
admissions and surgeries need to be halted during the altered mental status.
outbreak in order to rationalize resource-utilization, and
ensure adequate back-up to handle the crisis. SARI is the most common indication for ICU transfer
and most guidelines are similar to management of any
Re-allocation of staff: During the crisis, there may be viral pneumonia with ARDS with an emphasis on
acute shortage of critical care specialists and nursing minimizing risk of transmission to others, especially
staff. It is essential to identify staff from respiratory healthcare workers [26,27]. The details on the
medicine, infectious disease and other units who may be management of SARI are given in Part II of this write-up
trained in infection control, personal protective and Table I.
equipment (PPE) use and management of critically ill
patients. Septic shock: Management of septic shock in COVID is
not very different from the routine. However, the
Rotation of staff and reserve for back-up: Adequate Surviving Sepsis Campaign (SSC) guidelines for
reserve of healthcare providers needs to be ensured as a COVID-19 recommend conservative fluid strategy,
back-up in case of emergencies or healthcare avoiding colloids as resuscitation fluid, and to use low
professionals falling sick. The team members should be dose steroids in catecholamine refractory shock [28]. In
working on rotation (in a shift of 4-7 days) with adequate children, epinephrine is the first vasoactive of choice for
rest in between. septic shock.
Training of all staff: All those who are likely to come in Co-infections: Co-infections like secondary bacterial
close contact with the patient or are handling equipment, pneumonia are common, especially in children (50%) and
surroundings, and waste management should receive addition of broad spectrum antibiotic to cover gram
training regarding infection control including correct positive, gram negative, and staphylococcal infection is
technique of donning and doffing of PPE and disinfection recommended [29].
of surfaces and equipments. Proper training and a written
plan (Standard Operating Procedure) should be there for Myocarditis: Cardiogenic shock with elevations in
waste disposal. hypersensitive Tropnonin-I have been seen in 12% of
patients. Management includes inodilators like milrin-
Rational use of PPE: In view of current global shortage, one, diuretics, immunomodulators (methylprednisolone
WHO has formulated guidelines for the rational use of and IVIG) and circulatory support with ECMO (extra-
PPE. This includes co-ordination of PPE supply chain corporeal membrane oxygenation) have also been used in
management mechanism, appropriate PPE use based on a few cases [30,31].
indication, minimizing the need of PPE by bundling
Acute kidney injury : This has been reported in 7% and
activities, using physical barriers and telemedicine where
renal replacement therapy may be necessary [32].
appropriate, and restricting visitors [24].
Supportive care: This includes conservative fluid
MANAGEMENT IN RESOURCE-LIMITED management, nutrition, appropriate sedo-analgesia, and
SETTINGS prevention and treatment of healthcare associated
Triage andTransport infections.

A dedicated area for screening and triaging of patients Specific Therapy

with suspected COVID-19 is essential. Once the patient Although no definitive therapy till date has proven
fits to the case definition and requires admission, benefit for SARS-CoV2, antiviral drugs like Remdesivir,
unnecessary movement must be avoided and minimum Lopinavir/Ritonavir are being used in over 50% of the
staff should accompany the patient. Ensure that the critically ill adults based on in vitro viral inhibition and
patient (if self-breathing) and the accompanying persons recovery in SARS and MERS but there is no strong
should be on a 3-ply surgical mask. evidence [33–36]. Chloroquine has been found to
ICU Management increase endosomal pH and hinder virus cell fusion and
also interfere with ACE2, a receptor for binding of
Severe and critical cases need ICU care for monitoring, SARS-CoV2 [37]. A combination of hydroxychloroquine
ventilation and organ support therapy. and azithromycin showed reduction in viral load [38].

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Table I Treatment Based on Severity of Disease in Proven Coronavirus Disease-19 (COVID-19)

Symptomatic Admit in Treatment Discharge
proven case
Mild Designated COVID Symptomatic treatment Discharge if 72 h afebrile or 7d after symptom
isolation room onset and two samples negative 24 h apart
followed by home quarantine for total 14 d
Moderate Designated COVID Supportive care, oxygen Clinical improvement and two negative
isolation room Oseltamivir nCoV PCR tests 24 h apart
Severe COVID ICU Provide nasal prong oxygen Clinical improvement and two negative
Escalate to invasive ventilation nCoV PCR tests 24 h apart
if worsening
Avoid HFNC/NIV
Oseltamivir Ritonavir/Lopinavir
OR Hydroxychloroquine
Supportive care
Critical COVID ICU In addition to the above: Clinical improvement and two negative
Intubate based on clinical/blood nCoV PCR tests 24 h apart
gas/radiological features
Use all airborne precautions
Ventilation ARDS protocol
Other organ support
Once improving, wean from
ventilator and extubate as per
protocol
HFNC: High-flow nasal cannula, NIV: Non-invasive ventilation, ICU: intensive care unit,ARDS: Acute respiratory distress syndrome.

Interferons, IVIG, and convalescent plasma from or ethyl alcohol 70%) can be used to wipe down surfaces
recovered SARS patients are other tested treatment where the use of bleach is not suitable for e.g. Mobiles,
options [39]. Vaccination for RNA viruses (measles, laptops, keys, pens etc.
influenza, polio) has shown higher titers of neutralizing
Disinfection: Freshly prepared1% sodium hypochlorite
antibodies against SARS-CoV [40] (Table II). Based on
should be used as a disinfectant for cleaning and
the current experience, we may use broad spectrum
disinfection with at least 10 minute contact period.
antibiotics, oseltamivir, protease inhibitors, hydro-
xychloroquine and azithromycin. Lopinavir/Ritonavir Aerosol: Ensure room disinfection within 20 minutes of
along with Chloroquine should be avoided in any procedure generating aerosol.
combination.
Social distancing: Maintain at least 1 meter distance
Course and Recovery unless required for examination or procedure.
In adult patients with COVID-19 pneumonia, onset of Contact and droplet precautions: minimize direct
symptoms to respiratory failure takes an average of 7 contact, ensure hand hygiene, and cough etiquette.
days with peak severity at 10 days. Signs of improvement
starts occurring by day 14. However, at the time of Healthcare Worker (HCW) Risks
reporting of most studies, many patients were still
Apart from risks related to droplet spread and from
admitted and their course needs to be followed to know
contaminated surfaces, ICU professionals face the
the exact prognosis [40].
challenge of acquiring infection during aerosol
INFECTION PREVENTION AND CONTROL generating procedures (see table in Part II). HCW should
wear a medical mask and gown when entering a room
In the intensive care setting, disinfection of high–touch
where patients with suspected or confirmed COVID-19
surfaces like monitors, ventilator screen, other
are admitted and use full personal protective equipment
equipment, resuscitation trolleys etc are essential and
(PPE), which includes N95 mask, goggles or face shield,
need to be carried out every 4 hours.
cap, full sleeve gown and shoe cover, when performing
Surface decontamination: Alcohol (e.g. isopropyl 70% aerosol-generating procedures [41]. The entire PPE is

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 TABLE II Pharmacotherapy in COVID-19
Drug class Drug name; Mechanism Dose Additional points Evidence
stage
Antiviral drugs
Nucleoside analogue Ribavarin; Inhibits RNA IV 8 mg/kg 8 hourly × 14 d Side effects: In vitro studies
RAVIKUMAR, ET AL.

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Pneumonia synthesis and Hemolyticanemia, SARS data
viral replication Hypocalcemia, Not recommended
Hypomagnesemia
May increase viral load in
combination with steroid
Neuraminidase inhibitor Oseltamivir; Reduces viral <12 mon: 6 mg/kg/ dose BD If co-infection with influenza MERS-CoV data
Pneumonia replication >12 mon: suspected
<15 kg: 60 mg/d
15-23 kg: 90 mg/d
23-40 Kg:120 mg/d
>40 kg: 150 mg/d
Given PO /BD for 5 d
(max dose 150 mg)
Protease inhibitor Lopinavir/ Inhibit CoV main Low dose: 200/100 mg BD In-vitro studies
Ritonavir; protease required High dose: BD for 6-15 d SARS data [33]

330
Early ARDS in replication 14 d-12 mon: 16 mg/kg/dose Weak recommendation [44]
< 15 kg: 12 mg/kg/dose
15-40 kg: 10 mg/kg/dose
(Based on Lopinavir)
>40 kg: 400/100 mg
Given PO/BD for 5-14 d
(Max dose Lopinavir 400 mg /
ritonavir 100 mg)
Adenosine analogue Remdesivir; Incorporates into Adult dose: 200 mg IV on d 1 Avoid in children, pregnant, In vitro studies [35]
Pneumonia viral RNA and leads followed by 100 mg daily renal and hepatic impairment Case report in US [36]
to premature chain ×5-10 d On-going trials termination
Aminoquinoline Chloroquine Increases endosomal CQ: 10 mg/kg base stat Inhibits pneumonia Unpublished data [45]
Hydroxy- pH and hinder virus followed by 5 mg/kg base BD exacerbation Ongoing phase III trial for
chloroquine; cell fusion HCQ: 8 mg / kg/ loading dose, Negative conversion prophylaxis and reducing
Pneumonia Inhibits viral binding then 4 mg/Kg / dose Shortens disease transmission
to ACE-2 PO /BD/ 5 d ICMR recommendation for
Immunomodulatory effect (max dose 400 mg) prophylaxis
Prophylaxis 400 mg BD on d
1 then 400 mg weekly

Contd....
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 Table 1 Contd....

Drug class Drug name; Mechanism Dose Additional points Evidence

stage

Immuno-modulators
RAVIKUMAR, ET AL.

Corticosteroids Methylpre- To suppress cytokines 1-2 mg/kg/day × 5-7 d Delays clearance of viral Reduced duration of supplemental

INDIAN PEDIATRICS
dnisolone; storm, HLH RNA oxygen and radiological
Pneumonia improvement [46]
ARDS SSC guidelines recommend use in
ARDS but meta-analysis in viral
pneumonia- harm > benefit [28]

Immunoglobulin IVIG/Convale- Immunomodulator 1-2 g/kg over 2-5 d After all therapies failed Critically ill SARS
scent plasma; [47]
Critical stage
Immuno-modulator and antiviral
Immunomodulator Interferon-α; Reduces viral load Nebulization of 200,000 Weak recommendation [48]
& antiviral Early phase of - 400,000 IU/kg (2-4 µg/kg)
URTI, in 2 mL sterile water BD for
Pneumonia 5-7 d
Interferon-α2b Reduces viral load 1-2 sprays (8000 IU/spray)

331
spray; Close on each side of the nasal cavity,
contacts 8-10 sprays on the oropharynx,
URTI once every 1-2 hrs for 5-7 d
Immunotherapy
Interleukin -6 inhibitor Tocilizumab; Immunosuppression <30 kg - 12 mg/kg/dose For HLH and cytokine storm On-going clinical trials
Cytokine release >30 kg - 8 mg/kg/dose IV BD
syndrome as infusion 1-2 d
(max dose 800 mg)
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recommended to be used for 4-6 hours and changed of the work in ensuring that questions related to the accuracy or
earlier if there is any soiling. Team should not include integrity of any part of the work are appropriately investigated
staff vulnerable to infection like immunocompromised and resolved.
person, pregnant ladies, age >60 years or those with co- Funding: None; Competing interests: None stated.
morbidities. In the event of exposure and manifestation
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