India is currently in the second stage of the coronavirus disease 2019 (COVID-19)
pandemic. It all started in December 2019 when there was a cluster of patients with
pneumonia in Wuhan, the capital of Hubei province in China. Investigators found that
it was caused by a new strain of coronavirus known as severe acute respiratory syndrome-coronavirus
2 (SARS-CoV-2). It has since been labeled as COVID-19. As of March 19, 2020, 230,588
cases have been reported and 9390 patients have died. In India, 173 patients were
diagnosed with COVID-19 with 4 deaths reported. On March 11, 2020, the World Health
Organization (WHO) has declared COVID-19 as a pandemic. In this issue of IJMPO, Tsang
et al. have appropriately reviewed the current knowledge about symptomatology, rapid diagnosis,
and treatment as well as prevention strategies for COVID-19.[1]
Here, we will summarize the current understanding and practical information to handle
this deadly menace. The COVID-19 is transmissible in a community setting, and clusters
of infection can be seen in people who return from countries with high infection.[2]
Etiology
Coronaviruses are a large family of viruses that cause illness ranging from the common
cold to more severe diseases such as Middle East respiratory syndrome-CoV and SARS-CoV.
SARS-CoV-2 is a single-stranded, RNA virus with a diameter of approximately 60–140
nm. It has a crown-like appearance under an electron microscope and is a Betacoronavirus. It has presumably originated from bats with an initial animal-to-human transmission
through an intermediary. Its subsequent spread is human to human, with infected people
as the most frequent source of its spread. The incubation time of SARS-CoV-2 is usually
3–7 days but could be up to 2 weeks. COVID-19 epidemic doubled about every 7 days,
with each patient transmitting the infection to an additional of 2.2 individuals.[3]
Mode of Spread
The SARS-CoV-2 spreads primarily through air by droplet infection from nose or mouth
from an infected person to another, usually within 6 feet. The other mode of spread
is by contact when the droplets land on the surfaces and spread if a person touches
the surface and then touches the eyes, nose, or mouth. One study has shown that SARS-CoV-2
is stable in aerosols (size <5 μm) for 3 h, plastic and stainless steel for up to
72 h, copper for 4 h, and cardboard for up to 24 h.[4] Disinfection practices need to be modified with due consideration to this information.
The virus is sensitive to ultraviolet rays, heat, ether, ethanol, chlorine-containing
disinfectants, peroxyacetic acid, and chloroform.[3]
Symptoms
The common symptoms are fever, cough, and shortness of breath. Some patients can have
rhinitis, sore throat, and diarrhea. Rarely, it can lead to SARS, kidney failure,
and death. A study from China among 1099 patients with laboratory-confirmed COVID-19
showed that fever and cough were present in 89% and 68%, respectively. Lymphocytopenia
was seen in 83% and ground-glass opacity of lung in 56%. Among these patients, 5%
needed intensive care unit (ICU) care, 2.3% needed invasive mechanical ventilation,
and 1.4 had died.[5]
High-Risk Patients
High-risk patients include elderly (>60 years); pregnant women; patients with renal
failure, cancer, uncontrolled diabetes or hypertension, chronic obstructive airway
disease, and coronary heart disease. A study from China reported that patients with
older age, high Sequential Organ Failure Assessment (SOFA) score, and d-dimer >1 μg/ml
had a higher risk of mortality.[6] Another study also showed that older patients with comorbidities and acute respiratory
distress syndrome had a high risk of mortality.[7] In contrast to adults, most children with COVID-19 infection have a milder course.[8] Patients on chemotherapy and those who are immunocompromised are susceptible to
various infections. There is no sufficient information on SARS-CoV-2 infection in
cancer patients. Limited evidence suggests that cancer patients, especially elderly,
are more prone to contract SARS-CoV-2 infection as well as severe complications (ICU
care, invasive ventilation, or death).[9]
Testing
High viral load is seen soon after symptom onset and in the nose than in throat secretions.[10] However, one study has shown that the viral load in asymptomatic patients is as
high as in symptomatic patients, leading to transmission by asymptomatic patients.[11] The Centers for Disease Control and Prevention recommends testing with COVID-19
reverse transcription-polymerase chain reaction. The Food and Drug Administration
approved rapid point-of-care SARS-Co-V-2 diagnostic test on March 21, 2020, where
results are available within an hour.[12] The specimen can be from either upper or lower respiratory tract (sputum, nasopharyngeal
swab, oropharyngeal swab, nasal aspirate, and lower respiratory tract aspirate) in
patients with suspected COVID-19 infection. Appropriate personal protective equipment
should be worn during collection and transportation of samples from suspected COVID-19
patients. A false-negative result is possible in the early stage of infection. In
addition, there is a rare possibility of a false-positive result. According to Tsang
et al., testing the sputum offers speedy diagnosis, is easy, and reduces the risk to health-care
workers (HCWs) significantly.[1]
Indian Council of Medical Research's Revised Testing Guidelines
Indian Council of Medical Research's Revised Testing Guidelines
-
All symptomatic patients (fever, cough, or shortness of breath) who have undertaken
international travel in the last 14 days
-
All symptomatic patients who have contact with COVID-19 laboratory-confirmed positive
cases
-
All symptomatic HCWs
-
All hospitalized patients with severe acute respiratory illness
-
Asymptomatic direct and high-risk contacts of a confirmed case should be tested once
between day 5 and day 14 of contact.[13]
Imaging
The most common lung findings on computed tomography scan are bilateral, peripheral,
and ill-defined ground-glass opacity involving both lower lobes.[14] COVID-19 pneumonia can be seen even in asymptomatic patients and can have rapid
evolution from focal unilateral to diffuse bilateral ground-glass lung opacities.[14]
Treatment
Isolation and symptomatic supportive care is the current recommended treatment.
A randomized controlled trial in hospitalized patients with severe COVID-19 (n = 199) from China has shown no benefit (clinical improvement, mortality, or reduction
in viral RNA load) when treated with antiviral drugs (lopinavir–ritonavir combination)
as compared to standard-of-care treatment. However, the patients recruited for the
study had advanced infection with considerable lung damage.[15] The Union Health Ministry of India currently recommends conditional use of these
drugs with informed consent.[16] A preclinical study showed that hydroxychloroquine (HCQ) inhibits COVID-19 by attenuating
the inflammatory response.[17] A non-randomized open-label study with small sample size (n = 20) from France showed that COVID-19-infected patients had reduction in viral load
when treated with HCQ and azithromycin. However, this study has been criticized for
significant limitations including small sample size and inadequate testing of viral
load in the controls.[18] A human monoclonal antibody that blocks SARS-CoV-2 is under evaluation.[19]
Prognosis
Nearly 80% of infections with COVID-19 are mild and recover within weeks. About 5%
need ICU care with a mortality rate of 1%–2%.[5]
Prevention and Control
To date, there is no proven vaccine to prevent infection with COVID-19. Social distancing
is recommended to decrease contact between infected and noninfected people and is
currently the most effective public health preventive measure.[20] A mathematical modeling study has suggested that contact tracing and case isolation
can help to control the COVID-19 within 3 months.[21] There is currently no evidence that traditional medications control or cure the
disease.
Suspected Contact With Coronavirus Disease 2019 Patients
Suspected Contact With Coronavirus Disease 2019 Patients
-
Home quarantine should be done for a duration of 14 days in case of close contact
with a confirmed case of COVID-19
-
Clean and disinfect frequently touched surfaces in the quarantined person's room (e.g.
bed frames and tables) daily with 1% sodium hypochlorite solution
-
Clean and disinfect toilet surfaces daily with regular household bleach solution/phenolic
disinfectants
-
Clean the clothes and other linen used by the person separately using common household
detergent and dry.
World Health Organization's Recommendation
World Health Organization's Recommendation
-
The WHO recommends “Test, Test, Test” to increase testing in all suspected COVID-19
infections so that patients diagnosed with COVID-19 and their contact can be quarantined
or treated if symptomatic. This may help to contain the epidemic rapidly.[22]
Do's
-
Increase the awareness of COVID-19 infection without increasing fear
-
In case of any symptoms such as fever, cough, or shortness of breath, contact your
local health-care authorities
-
Cover your nose and mouth with a tissue while coughing and sneezing and throw the
tissue into a closed bin immediately
-
Prefer social distancing and stay at home in a well-ventilated room
-
Wash hands frequently and thoroughly with soap and water for at least 20 s. If soap
and water is not available, use alcohol-based hand rub
-
Stay 1 m away from sick people
-
Wear N95 mask if you have symptoms (fever, cough, and shortness of breath), when caring
for a suspected/proven COVID-19 patient, or attending to any patient with respiratory
symptoms
-
Use hand sanitizers after using biometric attendance
-
Use hand sanitizers after touching or discarding a mask.
Don'ts
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Do not touch your eyes, nose, or mouth
-
Avoid touching mask while using it
-
Do not leave mask hanging from the neck
-
Do not use the mask after 6 h of use or after it becomes wet
-
Never reuse disposable masks
-
Avoid shaking hands or hugging
-
Avoid visiting crowded places or social/religious gathering
-
Avoid public transportation
-
Limit contact with pets and animals
-
Do not share personal household items such as glasses, cups, plates, towels, or bedding
with other people in your home.
