SARS Coronavirus-2, beginning in 2019, a physician
and then several physicians in Wuhan, China
began to notice the emergence
of a fairly severe respiratory illness
beginning with mild upper
respiratory tract infection signs,
but rapidly progressing to severe
underlying or lower respiratory tract disease.
This illness was also characterized by
high infectivity and incredibly high case load.
Because of that high infectivity
and the impact on healthcare systems
and certainly on patients with
severe lower respiratory disease,
that virus or that infection
began to gain notice internationally
as the cause of a potential
In fact, ultimately, the virus identified causing this
infection process was a member of the coronavirus family
and aligned very closely with former outbreak viruses
including Middle East Respiratory Syndrome (MERS virus)
and Severe Acute Respiratory
Syndrome (SARS virus)
And to that end, the virus has now been named Severe
Acute Respiratory Syndrome or SARS Coronavirus-2,
the second one in the lineage of
SARS respiratory type illnesses.
The disease associated with SARS Coronavirus-2
is coronavirus infectious disease 2019 or COVID-19
as it is has been nicknamed.
And it is characterized again by that high
infectivity, high attack rate in a population
and potential progression to severe pneumonia
including acute respiratory distress syndrome
and multiorgan dysfunction failure
and severe acute respiratory syndrome.
The initial COVID-19 process began as I noted in Wuhan,
China would rapidly spread in nearby provinces in China
followed by spread to other areas and
countries in Asia including South Korea and Japan.
And then unfortunately and now, to the rest of
the world where nearly every country in the world
has checked in with cases.
An incredibly unfortunate
inclusion in this are cruise ships
which are floating hotels in which
multiple patients in a closed space
can be and have been infected
and then must undergo quarantine.
In March 2020, the World Health Organization
named the COVID-19 as a pandemic.
In large part to stimulate all countries around the
world to create and implement intense global response
with a goal of limiting internal spread and
hopefully even limiting further global spread.
The clinical aspects of COVID-19 :
First of all, high infectivity, high attack rate, very easy
through respiratory droplets to be infected with the disease.
Majority of cases are mild as noted.
In fact, at least 80 if not more,
85% of cases are already mild
those occurring in children, young
adults, even some older adults.
But severe disease can and does
occur most especially in patients
with some risk factors including those
of older age - so age 60 and higher,
those patients we have some degree
of immunodeficiency whether they are
immunosuppressed, or something like that.
Certainly those patients who have
preexisting lung or even other organ disease,
including those with type 1
insulin dependent, diabetes mellitus.
The mortality rate's estimated at 1-6%
although this is only an estimate as of this point
because the N - the
denominator is not yet known.
The virus testing is so far not complete and so the number
of mild cases who are not coming to testing are not known,
hence it's hard to predict exactly
what the true mortality rate is.
That said, comparing mortality
rates of COVID-19 with influenza,
it is estimated to be at least
10-fold higher, if not more.
Those areas of either the world or patients
who have the mortality rates of 6%
typically are those with an older average age or
those who are in a close unprotected environment
such as an extended care facility or
a cruise ship or a nursing home, etc.
Clinically, the incubation period for
COVID-19 is thought to be 2 days to 14 days
with a tail end however of at least 21 days.
Concerning evidence just emerging is
that the virus itself, SARS-Coronavirus-2
may persist in an infectious state
for at least 3-4 days and not longer
on environmental surfaces including counter
tops, utensils, doorknobs, etc. and so forth
After the incubation period,
most patients present with fever.
over 60% may have a dry cough and
myalgias so. so far a very influenza-like illness.
so far a very influenza-like illness.
However, shortness of breath occurring in over
30% so far is emerging as a symptom or a complaint
which may be more specifically predictive of infection with
COVID-19 versus influenza, rhinovirus, parainfluenza, etc.
As noted, those patients who had the severe
disease, do so by entering into respiratory failure
followed by hypotensive
shock, multiorgan dysfunction, etc
Well first and foremost, as one way to anticipate given that
COVID-19 occurs simultaneously with other respiratory illnesses,
it is important to evaluate for and hopefully exclude
other such illnesses, such as influenza, parainfluenza,
rhinovirus, even other coronaviruses
causing upper respiratory tract infection
and even including bacterial pathogens
such as pertussis and Mycoplasma.
However, to specifically evaluate or screen for
COVID-19 infection and the SARS Coronavirus-2,
one can send a nasopharyngeal
or oropharyngeal specimen, a swab
for a nucleic acid amplification
testing which can be done
fairly rapidly both commercially as
well as by country-held department labs.
Other diagnostics are emerging
and also, a blot spot testing for Immunoglobulin
M/G for presence of SARS Coronavirus-2.
It remains to be seen the utility of these
testing strategies in a screening process
versus a reserve in the
use of confirmatory testing.
Treatment unfortunately as with
many other viral infections, is scant.
There are no confirmed yet antiviral therapy agents
with known effect in this against SARS Coronavirus-2
although multiple agents
are being evaluated.
There is emerging evidence
that some antiretroviral therapies
may, such as what we see used in
HIV infection, may have some impact.
Passive immunotherapy including treatment with
monoclonal antibodies is also being evaluated for impact.
This is very similar to interventions
used in Ebola virus disease,
initially in West Africa and currently
in the Democratic Republic of Congo.
This is a concern.
Whether it's because patients are progressing into
severe disease despite initial support of care,
or for those patients who appear to have been
clinically improving and then apparently relapse
who enter into respiratory
failure and shock.
There is a suggestion in a manuscript
just published in clinical infectious diseases
that patients who are male, who
present with anorexia and absence of fever
may have high risk of
developing refractory cases.
Ultimately, the best treatment
is prevention and to that end,
at least six vaccine products separately
are being developed as I speak,
at least one of those has been administered
to live human volunteers in California in the States.
There remains to be seen the utility
or efficacy of the vaccine products,
until a day in which vaccines can be
appropriately developed and are effective,
then social distancing and quarantine are
the two most robust interventions possible.
Social distancing - a limiting contact
with other human beings within at least 6 feet,
avoiding large gatherings, practicing
of course good cough etiquette, etc.
And then the more invasive, if you will,
intervention that would be quarantine
and this involves closing borders, closing
restaurants, pubs, concerts, sports events,
any area in which humans may be too
close to violate that 6-foot distance rule.
Quarantine and that degree of intervention was
ultimately used very successfully in Wuhan, China.
And it is hopefully being rolled out
around the rest of the world as I speak.
It remains to be seen, if this
is too little too late however.
The two challenges that are anticipated and
one is attempting to avoid via quarantine:
Number 1 - is limit the number of patients at risk who
progress into severe disease with COVID-19.
This is a fear because the sheer number of
patients who might develop this progression
have high potential to overwhelm the
healthcare system of any country in the world
and certainly overrun the use of ventilators
and healthcare providers, hospital beds,
even hospitals available to care for them.
This was found to be a major challenge
in the initial province in China, in Wuhan
which experience exactly
The other concern that's being addressed with quarantine
is to try and limit the insertion of SARS Coronavirus-2
into the viral milieu of humans in the world
such as has happened with influenza both A and B
Viruses that are so inserted has
the potential for seasonal recurrence
and the same impact in
terms of morbidity and mortality
as recurrently seen with COVID-19 and see
many times in a decade with Influenza A and B.
So, the more that once we're
effective in preventing COVID-19,
the more successfully we'll see
our way through this particular pandemic
but this is just one of the
many many many more to come,
So until then, continue to
support vaccine development,
continue to develop antiviral
and WASH THOSE HANDS!