COVID-19 What do we know so far?

Here are our #TakeVisually infographics on COVID-19 and tips on how to keep the virus at work.

All information correct at 30/3/20.

What is it?

Coronaviruses are a type of virus found in animals and people. At the end of 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, a city in the Hubei Province of China. It rapidly spread, resulting in an epidemic throughout China, followed by an increasing number of cases in other countries throughout the world. In February 2020, the World Health Organization designated the disease COVID-19, which stands for coronavirus disease 2019

How is it spread?

Person-to-person spread is thought to occur mainly via respiratory droplets.

With droplet transmission, virus released in the respiratory secretions when a person with infection coughs, sneezes, or talks can infect another person if it makes direct contact with the mucous membranes; infection can also occur if a person touches an infected surface and then touches his or her eyes, nose, or mouth.

Droplets typically do not travel more than six feet (about two meters) and do not linger in the air

What are the symptoms?

The incubation period for COVID-19 is thought to be within 14 days following exposure, with most cases occurring approximately four to five days after exposure

Fever in 99%

Fatigue in 70%

Dry cough in 59%

Loss of appetite in 40%

Myalgias (muscular pains) in 35%

Dyspnea (shortness of breath) in 31%

Sputum production in 27%

How serious is it?

Mild (no or mild pneumonia) 81%

Severe disease (eg, with dyspnea, hypoxia, or >50 percent lung involvement on imaging within 24 to 48 hours) 14%

Critical disease (eg, with respiratory failure, shock, or multi-organ dysfunction) 5%

Overall case fatality rate 2.3%

Prevention

The following general measures are recommended to reduce transmission of infection:

Diligent hand washing, particularly after touching surfaces in public

Use of hand sanitizer that contains at least 60 percent alcohol is a reasonable alternative if the hands are not visibly dirty

Respiratory hygiene (eg, covering the cough or sneeze)

Avoiding touching the face (in particular eyes, nose, and mouth)

Avoiding crowds

Cleaning and disinfecting objects and surfaces that are frequently touched

Self-isolation

If you live alone and you have symptoms of coronavirus illness (COVID-19), however mild, stay at home for 7 days from when your symptoms started

If you live with others and you are the first in the household to have symptoms of coronavirus, then you must stay at home for 7 days, but all other household members who remain well must stay at home and not leave the house for 14 days. The 14-day period starts from the day when the first person in the house became ill

For anyone else in the household who starts displaying symptoms, they need to stay at home for 7 days from when the symptoms appeared, regardless of what day they are on in the original 14 day isolation period

Personal Protective Equipment (PPE)

Any personnel entering the room of a patient with suspected or confirmed COVID-19 should wear the appropriate personal protection equipment: gown, gloves and a face mask

Respirators (FFP3) should be worn during aerosol-generating procedures

Aerosol-generating procedures include tracheal intubation, noninvasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, upper endoscopy, and bronchoscopy

Nasopharyngeal or oropharyngeal specimen collection is not considered an aerosol-generating procedure

Testing

The virus is detected by reverse-transcription polymerase chain reaction

A positive test confirms the diagnosis of COVID-19

If initial testing is negative but the suspicion for COVID-19 remains, the WHO recommends resampling and testing from multiple respiratory tract sites

The accuracy and predictive values of testing have not been systematically evaluated. Negative RT-PCR tests on oropharyngeal swabs despite CT findings suggestive of viral pneumonia have been reported in some patients who ultimately tested positive

Radiological Findings

Chest CT in patients with COVID-19 most commonly demonstrates ground-glass opacification with or without consolidative abnormalities, consistent with viral pneumonia

Case series have suggested that chest CT abnormalities are more likely to be bilateral, have a peripheral distribution, and involve the lower lobes

Less common findings include pleural thickening, pleural effusion, and lymphadenopathy

In Pregnancy

In two reports including a total of 18 pregnant women with suspected or confirmed COVID-19 pneumonia, there was no laboratory evidence of transmission of the virus to the neonate

However, neonatal cases of infection have been documented

What are the risks of COVID-19 infection in pregnant women?

The approach to prevention, evaluation, diagnosis, and treatment of pregnant women with suspected COVID-19 should be similar to that in nonpregnant individuals

It is unknown whether the virus can be transmitted through breast milk. The only report of testing found no virus in the maternal milk of six patients

However, droplet transmission could occur during breastfeeding. Mothers with confirmed COVID-19 or with suspected COVID-19 should take precautions to prevent transmission to the infant during breastfeeding (including hand hygiene and use of a face mask)

Medications

Patients receiving angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) should continue treatment with these agents

Stopping these agents in some patients may exacerbate cardiovascular or kidney disease and lead to increased mortality

The decision to discontinue prednisone, biologics, or other immunosuppressive drugs in the setting of infection must be determined on a case-by-case basis. Glucocorticoids should not be used in patients with COVID-19 pneumonia unless there are other indications (eg, exacerbation of chronic obstructive pulmonary disease)

The European Medicines Agency (EMA) and the WHO do not recommend that NSAIDs be avoided when clinically indicated

How Good is the Test?

The polymerase chain reaction (PCR) test works by multiplying and then identifying viral DNA.

No test is perfect and swabs from the nose have a false negative (a negative result when the patient actually has COVID-19) rate of 37%

Throat swabs have a false negative rate of 68%

This means in patients with strong clinical suspicion of COVID-19 but a negative swab repeat testing is recommended. In patients with mild symptoms who do not require hospital admission testing with a high risk of a false negative result might be falsely reassuring

Antibody testing, currently in development, would look for antibodies to COVID-19 showing that someone has had the virus and recovered.

Is the NHS being denied personal protective equipment?

Public Health England guidance on PPE follows that of the World Health Organisation (WHO) a non-partisan specialised agency of the United Nations responsible for international public health. WHO guidance is based on all available evidence

Unfortunately, there has been a lot of media coverage stating that this guidance is not adequate. This is personal opinion being presented as fact. As with all healthcare equipment PPE is a finite resource and meeting demand will be a challenge

It is worth mentioning that even with PPE special care must be take especially during donning (putting on) and doffing (taking off). PHE have produced videos showing donning and doffing techniques

Is anosmia a symptom?

There is interest in whether anosmia (loss of sense of smell) is an important symptom of COVID-19.

There are reports of anosmia being the only symptom of infection

In Germany it is reported that more than 2 in 3 confirmed cases have anosmia. In South Korea, where testing has been more widespread, 30% of patients testing positive have had anosmia as their major presenting symptom in otherwise mild cases

However, 40% of all cases of anosmia are due to viral infections so this is not surprising. The olfactory bulb has stem cells and so regenerates in 7 to 10 days

Why is it so bad in Italy?

In Italy in mid-March the estimated fatality rate was 7.2% compared to 0.9% in South Korea at the same time. What is different about Italy?

We know that risk of mortality due to COVID-19 increases with age

Certain co-morbidities also increase mortality:

Cardiovascular disease

Diabetes mellitus

Hypertension

Chronic lung disease

Cancer

Chronic kidney disease

In Italy, the median age of patients with infection was 64 years, whereas in South Korea the median age was in the 40s. In a subset of 355 patients who died with COVID-19 in Italy, the mean number of pre-existing co-morbidities was 2.7, and only 3 patients had no underlying condition

So it seems that Italy's higher mortality rate is due to the disease's prevalence in an older population with more co-morbidities

Does Anti-Malaria Medication Cure it?

There has been discussion about anti-malarial drugs, Chloroquine and Hydroxychloroquine being used to treat COVID-19. The theory is that although these aren't anti-viral agents they affect the acidity of a part of cells called the Golgi apparatus which the COVID-19 virus hijacks to replicate. By changing the pH of the Golgi apparatus they could slow the virus replication. It is important to point that a lot of evidence for this comes from an in vitro (cells in a petri dish) study, not in human beings

The study which is often being quoted as 'proving' that Hydroxychloroquine works in combination with an antibiotic Azithromycin is Gautret et al. (2020). This study compared treatment with Hydroxychloroquine and Azithromycin, treatment with Hydroxychloroquine alone and standard treatment. This study found that Hydroxychloroquine increased elimination of COVID-19 by day 6 and the effect was improved if Azithromycin was used as well

All studies have their limitations and this one has a few. It is a small study (42 patients) with 26 patients in the treatment arm. Of those treatment patients 6 dropped out and so weren't included in the results. Of these 3 patients went to intensive care, 1 died and 1 dropped out due to nausea from the Azithromycin. These 5 patients could all be considered failures and yet were not included in the results. This made it more likely to find that treatment worked. The study also used nasopharyngeal swabs to detect the virus which we know have a high false negative rate

Basically, more high quality research is needed. Moreover, both Hydroxychloroquine and Azithromycin can cause heart arrhythmia and shouldn't be taken without medical advice anyway. On top of this Hydroxychloroquine is often taken by patients with conditions such as lupus and rheumatoid arthritis who rely on there being a stock

Another drug being investigated is Remdesivir for cases of moderate or severe COVID-19. This drug was developed during the Ebola epidemic on 2014-2016. Both Ebola and COVID-19 use RNA rather than DNA as their genetic material. Remdesivir is designed to interfere with the action of RNA-dependent RNA polymerase, the enzyme RNA viruses use during their replication

Should I Wear a Surgical Mask and Gloves When I’m Outside?

The large respiratory droplets which spread COVID-19 do not typically spread beyond 2 metres and so a surgical mask is only of benefit if you are within 2 metres of someone who is symptomatic.

Using a scarf or homemade mask is of no benefit. Medical gloves do not repel COVID-19 so if you wear them and touch your face they can transmit the virus. If you do wear them you need to either change them regularly or wash them as you would your own hands

How Long is the Lockdown Going to Be?

The UK lockdown is due to be reviewed on April 13th. However, it is very likely that the lockdown will be extended. Wuhan was in lockdown from 23rd January to 27th March. It's estimated that the decision to maintain the lockdown until the end of March and not the beginning prevented 24% infections by the end of the year

References

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KCDC. Updates on COVID-19 in Korea. March 14, 2020. https://www.cdc.go.kr/board/board.es?mid=a30402000000&bid=0030 (Accessed on March 14, 2020).

Centers for Disease Control and Prevention. Interim Clinical Guidance for Management of Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) Infection, Updated February 12, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html (Accessed on February 14, 2020

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