News & Perspective

Fighting the novel coronavirus with latest evidence from literature

Infectious Diseases
2 months ago, OP Editor

The novel coronavirus (COVID-19) outbreak, which began in China, December 2019, has now spread to many countries around the world, with an increasing number of confirmed cases every day. The World Health Organization (WHO) declared a public health emergency of international concern on 30 January 2020. With a death toll exceeding that of the previous SARS-CoV outbreak, there is an urgent need to fully understand its transmission and disease mechanisms to implement effective control measures in place as well as generating appropriate treatments and vaccines. Herein, an overview of the currently available literature on the epidemiology, clinical presentation, diagnosis, and treatment of this virus is presented.

A retrospective, single-center case series involving 138 consecutive hospitalized patients with confirmed COVID-19 was carried out at Zhongnan Hospital of Wuhan University in Wuhan, China, from 1 January to 3 February 2020.1 The median age was 56 years (range, 22-92 years) and 75 patients (54.3%) were men. Hospital-associated transmission was suspected for 29% of affected healthcare professionals and 12% of hospitalized patients. Common symptoms included fever (98.6%), fatigue (69.6%) and dry cough (59.4%).1 Less common symptoms were headache, dizziness, abdominal pain, diarrhea, nausea, and vomiting. 10.1% of patients initially presented with diarrhea and nausea, which progressed to fever and dyspnea in 1-2 days.1 This study paved the discovery of secondary transmission through fecal matter, in addition to primary transmission by virus-laden droplets from an infected person’s cough.

Lymphopenia occurred in 70.3% patients, prolonged prothrombin time was observed in 58% of patients, and lactate dehydrogenase was elevated in 39.9%. Chest computed tomographic scans of all patients showed bilateral patchy shadows or ground glass opacity in the lungs.1 Due to complications, 26.1% of the patients were transferred to the intensive care unit (ICU). 61.1% of ICU-transferred patients had acute respiratory distress syndrome (ARDS), 44.4% had arrhythmia, and 30.6% experienced shock. The median time from first symptom to dyspnea was 5.0 days, to hospital admission was 7.0 days, and to ARDS was 8.0 days.1 Patients treated in the ICU compared with those who were not, tended to be older (median age, 66 years vs. 51 years), more likely to have underlying comorbidities (72.2% vs. 37.3%), dyspnea (63.9% vs. 19.6%), and anorexia (66.7% vs. 30.4%).1 As of 3 February 2020, 47 patients had been discharged and 6 had died (4.3%), whilst the rest remained hospitalized. Among those who were discharged (n = 47), the median hospital stay was 10 days.1

According to the recommendation guidelines published by the Zhongnan Hospital of Wuhan University Novel Coronavirus Management and Research Team, the affected patients should rest in bed, be monitored for vital signs (heart rate, pulse oxygen saturation, respiratory rate, and blood pressure) and be given supportive treatment to ensure sufficient energy intake and balance for water, electrolytes, acid base levels and other internal environmental factors.2 They should also be monitored for blood routinely, C- reactive protein levels, organ function (liver enzyme, bilirubin, myocardial enzyme, creatinine, urea nitrogen, and urine volume, etc.), coagulation function, arterial blood gas analysis and chest imaging.2 Effective oxygen therapy, including nasal catheter, mask oxygen, high flow nasal oxygen therapy (HFNO), non-invasive ventilation (NIV) or invasive mechanical ventilation, should be provided. Extracorporeal Membrane Oxygenation (ECMO) should also be considered for the patients with refractory hypoxemia that is difficult to be corrected by protective lung ventilation.2

At present, there is no evidence from randomized controlled trials to support the use of specific drug treatment against this new coronavirus in suspected or confirmed cases. The α-interferon atomization inhalation is considered to relive respiratory symptoms (5 million U per time for adults in sterile injection water, twice a day) and lopinavir/ritonavir (orally, 2 capsules each time, twice a day) has also been used.2

Depending on the clinical manifestations of patients, if accompanying bacterial infection cannot be ruled out, less-symptomatic patients could consider antibacterial drugs indicated for community-acquired pneumonia.2 Other possible therapies include symptomatic treatment of fever, nutrition support treatment, reducing the incidence of stress ulcers and gastrointestinal bleeding, minimizing the secretion of lung glands to improve respiratory function, and lowering the incidence of venous embolism.2

The case fatality rate of COVID-19 projected by WHO is 2%, which is significantly lower than that of 10% by SARS-CoV.3 As of 11 February 2020, out of the 42,638 confirmed cases, 1,016 deaths and 3,996 recoveries have been reported by the National Health Commission of China.3 Among the 27 countries affected outside China, there are 464 confirmed cases and 2 deaths, giving the fatality rate out of China only 0.43%, which is similar to influenza.4 Although COVID-19 is more contagious than other reported coronavirus infections, the fatality rate is comparatively low. Multiple international health agencies, country-wise health departments, and other partners are implementing aggressive measures to slow the global transmission of COVID-19. These measures require the identification of cases and their contacts, and the appropriate assessment and care of travelers arriving from mainland China.5 Although these measures might not prevent the eventual establishment of ongoing and widespread transmission of the virus, they are being implemented to 1) slow the spread of illness; 2) provide time to better prepare health care systems and the general public to be ready if widespread transmission with substantial associated illness occurs; and 3) better characterize COVID-19 infection to guide public health recommendations and the development of medical countermeasures including diagnostics, therapeutics, and vaccines.5 With the current global concerted efforts to contain the disease and find a cure, the outlook for defeating the COVID-19 remains positive.

1. Wang D et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. February 2020.

2. Jin Y-H et al. A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version). Mil Med Res. 2020;7(1):4.

3. Coronavirus Update (Live): 40,614 Cases and 910 Deaths from the Wuhan China Virus Outbreak – Worldometer. https://www.worldometers.info/coronavirus/. Accessed February 10, 2020.

4. CDC: Influenza, pneumonia related deaths reach epidemic level. masslive. https://www.masslive.com/news/2018/02/cdc_statistics_show_influenza_
pneumonia_related_deaths_epidemic.html
. Published February 5, 2018. Accessed February 11, 2020.

5. Patel A et al. Initial Public Health Response and Interim Clinical Guidance for the 2019 Novel Coronavirus Outbreak – United States, December 31, 2019-February 4, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(5):140-146.

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