Jia-Yia Liu, MD
Dr. Liu is currently President of AMPSAA and practices Internal Medicine/Infectious Diseases @ Cedars-Sinai Medical Center. She is also an Assistant Professor @ Loma Linda University Medical Center, School of Medicine.
On December 31, 2019, WHO was notified of unknown origin of viral pneumonia cases in Wuhan, China. The index cases were all associated with a seafood and live animal market in Wuhan, China. Subsequent identification confirmed the etiology to be a zoonotic Coronavirus, which on February 11 was named COVID-19. The case models reported in Lancet predicted that by January 25, 2020, over 75,815 individuals were infected in Wuhan, China with a doubling time of 6.4 days. (1) Since then, COVID-19 is proven to be transmitted from human-to-human by symptomatic and asymptomatic carriers. The people highest at risk are those in close contact with live infected animals and caregivers for the ill. (2) Currently, the US has 15 confirmed cases with 12 of those having direct travel to China. (3)
As of February 13, 2020, the numbers infected rose sharply because cases are no longer required to have pcr-confirmation due to the shortage of test kits. (4) As of February 19, there are over 70,000 cases, which is still considered to be an underestimate. (3) COVID-19’s genetic structure is 82% similar to SARS. Both are large RNA beta coronavirus, discovered to have likely originated from Chinese chrysanthemum head bats with possible endangered pangolins as the vector of transmission to humans. (5-7) COVID-19 mortality rate is roughly 2.38%, with the majority of infected patients being asymptomatic or having only mild symptoms. (7) To date, nearly 1,400 deaths have been reported in China. (8) In comparison, the mortality of SARS (2002) and MERS (2013) were 9% and 36% respectively. As a reference, the current mortality of influenza is 0.1%. (8) CT scans of 63 confirmed COVID-19 patients between the ages of 29-60 demonstrate intense pulmonary inflammation with punctate ground glass opacities; 44% of patients had 5 or more lobes involved. (6) On February 15 the first death outside of Asia was confirmed by France in an 80-year-old Chinese tourist. To date only four people have died outside of China from COVID-19. (2)
Despite having a global travel band to China and self-imposed travel restrictions within China, new cases of COVID-19 continue to emerge around the world. As of Feb 13, 2020, 447 cases have been reported outside of China. Of those,170 cases had a history of travel to China. The majority of those cases have not resulted in ongoing transmission with the exception of 19 cases. To date clusters of human-to-human transmissions have occurred in Europe and Asian countries outside of China, with the largest outbreak involving 355 passengers of the Diamond Princess Cruise Ship, which is currently docked in Japan. (2,9)
Currently, COVID-19 is believed to have an average of 5.2 days and up to a 2 week incubation period with a high sputum viral load in the convalescent period. (3) This correlates with previous reports of reduced viral shedding with SARS-CoV when patients had severe symptoms. (6) Therefore as a protective public health measure, the CDC has enacted a mandatory quarantine law in which all travelers coming to the United States, who have visited China, will be placed on a 14-day quarantine. Recently, 195 American evacuees from Wuhan, China who were placed under 14-day mandatory quarantine at March Air Force Base in Riverside, California were declared risk free and released. Currently, on the quarantined Diamond Princess Cruise Ship, 44 Americans contradicted COVID-19. As of Sunday, February 16, another 400 U.S. asymptomatic citizens will be offered evacuation to the United States and placed on a 14-day mandatory quarantine; those ill will remain in Japan for treatment. (9)
Why is COVID-19 a Big Deal?
The world is bracing for the worst and hoping for the best. The fear is in the unknown: unknown victims, unknown treatments and unknown mortality rates. To date, it appears the majority of serious illnesses occur in men with underlying chronic diseases including heart disease, diabetes and chronic lung diseases, especially caused by tobacco. (7,10) With China being the largest tobacco consumer in the world, roughly 315 million Chinese smokers or ⅓ of its population are of high risk. (11) To-date the US has 15 confirmed cases but there have been 443 total cases of “PUI” or Persons Under Investigation, of which 81 cases are still pending. The risk is considered LOW to the American public. Source control is all about preventing “Sustained Transmission”, which occurs when an infection is transmitted from human-to-human. Outbreaks are fueled by superspreaders, in which all cases can be traced back to an index case, and clusters can exceed 100 people. Hence the necessity for a 14-day mandatory quarantine. (2)
This epidemic has reminded the world of the deadly 1918 Pandemic H1N1 avian flu virus in which 50 million people or 3% of the world’s population died, 2003 SARS-CoV outbreak in China claiming 9% mortality, 2013-2014 MERS-CoV claiming 36% mortality predominantly in healthcare workers, 2015-2016 Ebola virus outbreak in West Africa which affected 28,600 people and had a 40% mortality rate, and in 2015 the Zika Virus Brazilian outbreak causing an alarming high rate of microcephalic babies. (2) Hence, we are all reminded of the importance of communication and cooperation across nations to solve global crises.
As a direct result of the COVID-19 epidemic, personal protective equipment from N-95 masks, googles and coverall gowns have been raided and rationed in the US. Ironically, Wuhan, China is a pivotal supplier of the worlds’ masks and gowns. Unfortunately, a series of culminating events occurred resulting in shutting down China’s production of personal protective equipment and they only recently resumed operations. The world, including AMPSAA have been diligently searching for personal protective equipment to send back to help our friends in their time of need. The United States has donated 17.8 tons of medical supplies to China and recently pledged an additional $100 million to China and other impacted countries. (12) AMPSAA has secured 8,250 protective coverall gowns, which should arrive in China by the end of this week.
Hope is on the Horizon.
Currently there is no antiviral or vaccine against any coronavirus. However, a number of US drug manufacturers have sent antivirals or money to buy supplies to help China’s battle to contain the COVID-19. Among the drug donors are AbbVie Inc. and Gilead Sciences. (13-15)
AbbVie Inc makes Kaletra (lopinavir/ritonavir), an HIV protease inhibitor released in 2005, shown to have some activity against MERS-CoV in 2015. It has also been used recently by a high profile victim of the COVID-19, Dr. Guangfa Wang, the leader of Peking University First Hospital’s Pulmonary and Critical Care Medicine. He was part of a national team of experts sent to Wuhan China and subsequently contracted COVID-2019. However, he recovered after receiving Kaletra. AbbVie China will donate $1.5 million of Kaletra to Wuhan to treat infected patients. (14)
Gilead Sciences sent an unapproved Ebola drug, remdesivir to China. Remdesivir has shown some effectiveness against other coronaviruses (murine hepatitis virus and Middle East Respiratory Syndrome (MERS), Marburg, RSV, Nipah virus and Hendra virus). Remdesivir is an antiviral nucleotide prodrug that is suspected to cause premature termination of viral RNA transcription. It has been shown to also reduce pulmonary pathology in human epithelial cell lines. (15)
Other drugs undergoing clinical trials include, an old malaria drug, chloroquine phosphate, which showed promising inhibitory in vitro antiviral properties. An overseas anti-influenza drug favipiravir appears also to have anti-coronavirus activity. Inflammatory modulators are also being tested due to the overwhelming inflammatory pulmonary cascade caused by COVID-19. Even plasma from survivors, stem cell therapy and traditional Chinese herbal medicine are being tested. In all, there are over 80 clinical trials launched to find a treatment for COVID-19. (16)
Beware of Misinformation
The world has dramatically changed since the 2003 SARS epidemic in China. Within China, social media, including WeChat has significantly connected the globe instantaneously. Unfortunately misinformation is also easily spread. So much is still unknown about COVID-2019. Misinformation has fueled our emotions leading to irrational behavior. Even a highly respected Harvard statistics professor succumbed to his emotions and started a panic on twitter. Add to social media a huge language barrier, you can imagine how easily misinformation can be spread. (17)
How to Protect Yourself
Wash your hands. If soap and water is not available, use 60-90% alcohol based hand sanitizers. However, organic material will decrease the effectiveness of alcohol. (3,4, 18) It is currently unclear how long COVID-19 can survive in the environment. Around an infected person, wearing only a mask, even N-95 NIOSH certified, cannot protect you. To prevent contracting COVID-19, healthcare workers must be fully gowned, googled and masked since airborne spread is a main mechanism of viral transmission. A typical surgical mask can reduce the amount of virus spread by the superspreader, but it won’t do a whole lot for people around them. 3 feet is the distance you need to stay away from a superspreader unprotected. (3,4) As a general rule, the best protection is to wash your hands and keep a healthy immune system through diet, exercise, adequate sleep and by maintaining low physical and mental stress levels.