COVID 19

I thought this might be a good time to review COVID 19 and coronaviruses.

Intro:

Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). A novel coronavirus (nCoV) is a new strain that has not been previously identified in humans.  

Coronaviruses are zoonotic, meaning they are transmitted between animals and people.   SARS-CoV was transmitted from civet cats to humans and MERS-CoV from dromedary camels to humans. Several known coronaviruses are circulating in animals that have not yet infected humans. 

Best preventative strategies are: WASH YOUR HANDS; stay 1-3m away from people in social situations; cover your mouth with your elbow if you cough or sneeze; avoid touching your face,nose or eyes. Avoid close contact with people who are sick; stay home when you are sick; and clean and disinfect frequently touched objects and surfaces. Coronavirus is spread by DROPLET transmission and these steps above minimize exposure to droplets.

What about masks?

• If you are healthy, you only need to wear a mask if you are taking care of a person with suspected 2019-nCoV infection.
• Wear a mask if you are coughing or sneezing.
• Masks are effective only when used in combination with frequent hand-cleaning with alcohol-based hand rub or soap and water.

What about Canada? To date there are 77 confirmed cases in Canada, 34 in Ontario. That number will go up.

How infectious is COVID 19?

It looks like it is more infectious that influenza. The R0 is a measure of how readily a virus is transmitted. The R0 for influenza ia 1-2-1.4 and the estimates for COVID 19 are around 3. This means for every one person infected they will pass it along to three other people.

What is the case fatality rate of COVID 19?

This is a moving target. Early in the outbreak when only the sickest patients were being identified, the case fatality rate (CFR) was over 10%. That number is steadily decreasing as more cases are being diagnosed and more testing is being done. The denominator now will include the MANY people who have mild symptoms. Still, the most current estimates have the CFR at 2-3%. A study in the NEJM had the mortality rate estimated at 1.4%. Some areas are reporting mortality rates of less than 1%. We won’t know for a while longer the best estimate for mortality rate but for now it looks to be more serious than seasonal influenza. On average seasonal influenza has a mortality rate of about 0.1%.

Your age matters when estimating mortality rate!

Under the age of 40, the death rate so far is only 0.2%; 0.4% for ages 40-49; 1.3% for 50-59, 3.6% for 60-69; 8% for 70-79 and 15% for 80-89.

Comorbidities Matter:

Death rate higher if you have cardiovascular disease (10.5%), respiratory disease (6.3%) , diabetes (7.3%), hypertension (6%) or cancer (5.6%). The death rate fwith no known conditions is aorund 0.9% currently.

What is the clinical spectrum of the disease?

So far, it seems that fever, dry cough and dyspnea are the commonest symptoms. However, influenza-type symptoms including sore throat, headache and myalgia have also been described in some). So far, about 80% of cases have been classified as mild, 14% severe (dyspnea, pneumonia) and 5% critical (respiratory failure, septic shock, and/or multiple organ dysfunction/failure). Sympotms can atake up to 14 days after exposure to develop.

What should you do if you see a patient with severe acute respiratory illness (SARI) and possible exposure to COVID 19?

Take precautions mentioned previously. Mask on patient. Mask on providers. Gown and eye protection on provider.

Early supportive therapy and monitoring. Give supplemental oxygen therapy immediately to patients with SARI and respiratory distress, hypoxia, or shock.

Use contact precautions when handling contaminated oxygen interfaces of patients with nCoV infection.

Use conservative fluid management in patients with SARI when there is no evidence of shock. Remarks: Patients with SARI should be treated cautiously with intravenous fluids, because aggressive fluid resuscitation may worsen oxygenation, especially in settings where there is limited availability of mechanical ventilation.

Give empiric antimicrobials to treat all likely pathogens causing SARI. Give antimicrobials within one hour of initial patient assessment for patients with sepsis. Although the patient may be suspected to have nCoV, administer appropriate empiric antimicrobials within ONE hour of identification of sepsis. Empiric antibiotic treatment should be based on the clinical diagnosis (community-acquired pneumonia, health care-associated pneumonia [if infection was acquired in healthcare setting], or sepsis), local epidemiology and susceptibility data, and treatment guidelines. Empiric therapy should be de-escalated on the basis of microbiology results and clinical judgment.

Do not routinely give systemic corticosteroids for treatment of viral pneumonia or ARDS outside of clinical trials unless they are indicated for another reason. A systematic review of observational studies of corticosteroids administered to patients with SARS reported no survival benefit and possible harms (avascular necrosis, psychosis, diabetes, and delayed viral clearance). A systematic review of observational studies in influenza found a higher risk of mortality and secondary infections with corticosteroids; the evidence was judged as very low to low quality due to confounding by indication. A subsequent study that addressed this limitation by adjusting for time-varying confounders found no effect on mortality. Finally, a recent study of patients receiving corticosteroids for MERS used a similar statistical approach and found no effect of corticosteroids on mortality but delayed lower respiratory Clinical management of severe acute respiratory infection when Novel coronavirus (2019-nCoV) infection is suspected:

Application of timely, effective, and safe supportive therapies is the cornerstone of therapy for patients that develop severe manifestations of 2019-nCoV. Understand the patient’s co-morbid condition(s) to tailor the management of critical illness and appreciate the prognosis. Communicate early with patient and family.

References

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Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:753-71. © World Health Organization 2020. All rights reserved. This is a draft. The content of this document is not final, and the text may be subject to revisions before publication. The document may not