March 1, 2020

COVID-19: The Novel Coronavirus 2019

The Novel Coronavirus 2019, was first reported on in Wuhan, China in late December 2019.  The outbreak was declared a public health emergency of international concern in January 2020 and on March 11th, 2020, the outbreak was declared a global pandemic.  The spread of this virus is now global with lots of media attention.  The virus has been named SARS-CoV-2 and the disease it causes has become known as coronavirus disease 2019 (COVID-19).  This new outbreak has been producing lots of hysteria and false truths being spread, however the data surrounding the biology, epidemiology, and clinical characteristics are growing daily, making this a moving target.  This post will serve as a summary of what is currently known, how to screen, when to test, and how to prevent spread of COVID-19.

This post has was getting to big to be useful, so we have broken each section up into its own post for easier use…

COVID-19 Facts

  • Betacoronavirus
  • Currently there are 7 known coronaviruses known to infect humans
  • COVID-19 is in the same family as SARS-CoV and MERS-CoV
  • Animal reservoir likely from bats

  • Evaluation of 103 SARS-CoV-2 genomes have shown there are two major types of the virus (i.e. COVID-19 is potentially mutating) [Link is HERE]:
    • L Type (70%): More prevalent; More aggressive & spreads more quickly; Often seen in patients in Wuhan China
    • S Type (30%): Less aggressive; Strain spreading in countries outside of China
    • There is a request to retract the paper on subtypes which can be found HERE
  • Overall case fatality rate is estimated to be between 0.2%  –  6.6%
  • Case fatality rate is estimated to be ≈8% in patients 70 – 79 years of age [1]
  • Case fatality rate is estimated to be ≈15% in patients ≥80 years of age [1]
  • 80% of mortality cases in patients ≥60 years of age [2]
  • Study out of Italy also showed similar numbers with mortality increasing with age[3]:

  • Binds with high affinity to the angiotensin-converting enzyme 2 (ACE2) receptor in humans. The ACE2 enzyme is expressed in type II alveolar cells in the lungs
  • Severe disease and poor outcomes (i.e. ICU level of care and mortality) currently appear to occur in patients with chronic pulmonary disease, smoking, chronic medical conditions (i.e. hypertension, diabetes, or cardiovascular disease), or advanced age while kids and healthy younger adults seem to have milder courses
    • The reasons for children having milder forms of illness are not clear at this time
    • Preliminary evidence suggests children are just as likely as adults to become infected but are less likely to be symptomatic or develop severe symptoms
    • Our focus should be on patient populations at high risk (i.e. Nursing homes & hospitals)
  • Two fact sheets from the CDC Website for the lay public:

COVID-19 Update – March 2020 with Dr. Anthony Fauci, MD from March 6th, 2020 (34:44min)

The Basics (Click on Image to go)

Screening, Testing, PUI, and Returning to Work (Click on Image to go)

Potential Workflows and Telemedicine (Click on Image to go)

Laboratory and Imaging Abnormalities (Click on Image to go)

Thrombosis & Hemoglobin (Click on Image to go)

Neurologic Manifestations (Click on Image to go)

Pediatrics and Pregnancy (Click on Image to go)

Prevention (Click on Image to go)

The Society of Critical Care Medicine/Surviving Sepsis Campaign Guidelines on the Management of Critically Ill Adults with COVID-19 (Click on Image to go)

Cardiovascular Considerations (Click on Image to go)

Airway Management (Click on Image to go)

Clinical-Therapeutic Staging Proposal and Treatment (Click on Image to go)

Critical Care Utilization for COVID-19 Outbreak in Lombardy, Italy (Click on Image to go)

Protecting Our Families and Patient Disposition (Click on Image to go)

Coronavirus Q&A with Anthony Fauci, MD April 8th, 2020 (Video Time 35:30min)

References:

  1. Wu Z et al. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72,314 Cases From the Chinese Center for Disease Control and Prevention. JAMA 2020. PMID: 32091533
  2. Yee J et al. Novel coronavirus 2019 (COVID-19): Emergence and Implications for Emergency Care. Infectious Disease 2020. [Link is HERE]
  3. Sorbello M et al. The Italian Coronavirus Disease 2019 Outbreak: Recommendations from Clinical Practice. Anaesthesia 2020. [Epub Ahead of Print]

For More Thoughts on This Topic Checkout:

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami) and Mizuho Morrison, DO (Twitter: mizuhomorrison)

Cite this article as: Salim Rezaie, "COVID-19: The Novel Coronavirus 2019", REBEL EM blog, March 1, 2020. Available at: https://rebelem.com/covid-19-the-novel-coronavirus-2019/.
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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of REBEL EM
51 Comments
  • M. Schmidt
    Posted at 16:22h, 01 March Reply

    ACE-2 receptors are upregulated by age and smoking – this seems well-established. However, I have not found a source for the popular claim that ACE2 receptors are *absent* in infants and very young children – which may explain why there have been no cOVID-19 deaths in young children. Source, anyone? I would appreciate the education.

    • Salim Rezaie
      Posted at 16:29h, 01 March Reply

      Hello Mary,
      Yes that is correct…upregulated as we get older and by smoking which why older patients and patients who smoke seem to have worse cases…I also have not found a source for the claim that infants and younger children have less or absent ACE2 receptors. From an epidemiological standpoint that seems to be playing out right before our eyes with the current COVID-19 outbreak we have seen…this however may be simply because we are not testing younger kids. Would also like to see a reference for this.

      Salim

  • Tracey Stanton
    Posted at 18:44h, 01 March Reply

    Shouldn’t the statistics be labeled case fatality rate rather than mortality rate?

    • Salim Rezaie
      Posted at 18:53h, 01 March Reply

      Hi Tracey,
      Yes you are correct. TY for the comment and this has been edited on the post to reflect that.

      Salim

  • Salim Rezaie
    Posted at 17:48h, 09 March Reply

    We received an email from a reader…I will share his email below.

    More of a practical question regarding management. The two scenarios listed for admit or discharge seem rather obvious. Those who need supportive resp care or have severe disease stay in the hospital. Young healthy people self isolate for 14 days.

    Has anyone run into the scenario yet where you have a PUI who you don’t think will self quarantine effectively? Not a lot of people can comfortably miss work for 2 weeks without consequence to them or their families.

    I worked with Swami as a resident and my first gig as an attending and know he has experience with high need populations at Bellevue (low financial resources or no sick time, undomiciled patients, persistent mental health disorders, etc.). I’d be interested in what others seem to be doing with cases like these.

    Your guidance and input are greatly appreciated

    Andrew Kopping

    My response:
    To be fair I have not had a patient with COVID-19, and this is a tough question all of us are having to deal with or will have to deal with. How much capacity do we have at hospitals for quarantine vs self quarantine at home. We have read reports all over the news about people showing up to public functions. I am not sure what the best answer is…

    We simply don’t have the physical space to take care of everyone and everything. If containment is what you are getting at, the cat is out of the bag. We give the same instructions to patients positive for flu. How many of them self quarantine?

    Let me put this another way…you recommend to a patient who has diabetes mellitus to change their diet and be compliant with their diet. That person doesn’t require admission necessarily, but how do I control what they eat and when they take their medications? I realize this is a bit different as they don’t affect the community at large, but hopefully you understand what I am getting at.

    When I was a hospitalist and we had Tb patients that were not following instructions we would admit them for DOTS therapy (Directly observed treatment, short-course). This was a strategy recommended by the World Health Organization and according to them this is the most cost-effective way to stop the spread of Tb in communities with a high incidence of disease…Unfortunately, at this time, there is no approved vaccine or treatment for COVID-19 and so this will not work in this situation.

    We will always do my best we can for our patients and the community. Give very specific instructions about self isolation, but at the end of the day, we can’t control peoples behavior. I would be interested to hear others thoughts on this.

    Salim

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  • Jamie Praslicka
    Posted at 08:50h, 12 March Reply

    Hello,

    Would you be willing to make some recommendations for 911 EMS responses? I have found little to no information on treatment plans for patients with suspected COVID -19. To include field intubation sand airway management.

  • Gary Heigel
    Posted at 13:27h, 12 March Reply

    Great consolidation of relevant information I will be sharing with all my students.
    Thanks Sal!

    • Salim Rezaie
      Posted at 19:49h, 12 March Reply

      TY so much Gary…will continue to update as I get new info. Glad you found it useful.

      Salim

  • Terry Folsom
    Posted at 14:31h, 12 March Reply

    First, the childrens susceptibility question, I can find no posted refference to the ACE2 not being present or having a lower presence in children. However, I thought this was interesting: https://www.researchgate.net/publication/339495268_Are_children_less_susceptible_to_COVID-19

    Regarding Healthy People, especially <50 working people self isolating as a precaution. This seems absurd on the face of it. If healthy people self isolate and use their personal of employer provided resources, what happens if/when the actually have the disease? Will they still have any or sufficient resources to see themselves and their dependents thru? In many cases not, I am thinking.

    Is the mortality rate of this disease (and I do mean the rate of mortality in the entire population) really so significant that the economic health of both individuals, countries and, it seems, the world should be sacrificed to prevent infection ? Mrs Merkel yesterday told Germans that they were 66% likely to become infected, that 98-99% would live and they should deal with it. I am not a native German speaker, but that is the very short version of her bottom line. Is the fear of this virus wagging the dog? Thank-you

    • Salim Rezaie
      Posted at 19:58h, 12 March Reply

      Hello Terry,
      Appreciate your comments…I actually have 5 papers, now 6 with yours to go through the pediatric issues with COVID-19…so be on the lookout for an update to this.

      As for the self isolation for 14days…I 100% agree with you on this…most people will not be able to survive without working. I am not sure there is a great answer for this. This is simply the policy as reported by the CDC recs. If you have any ideas on this, would love to hear them.

      Finally, the mortality rate of the disease and its effect on both individuals and economy is a controversial and complex one. There are countries like South Korea that went on complete lock down early on, and other countries like Italy that didn’t. How is it that the mortality rate in Italy is closer to 5% and in South Korea it is <1%. Its simple...flattening the curve of severely ill cases by social distancing to not overwhelm an entire healthcare system.

      These are very insightful comments and questions that I am not sure any of us have completely figured out and I suspect will be different in every country and every system that we each work in. TY so much for taking the time to write and I hope some of the above was helpful.

      Salim

  • Antonio Fernandez MD
    Posted at 03:30h, 14 March Reply

    Thanks for putting together such a comprehensive and excellent resource!
    I keep coming back to solve all my doubts.

    • Salim Rezaie
      Posted at 09:12h, 14 March Reply

      Hello Antonio,
      Glad you are finding it useful. Will continue to update as frequently as I can. TY for leaving your comment.

      Salim

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  • Felipe Salazar
    Posted at 09:52h, 18 March Reply

    Hi Salim, I am Felipe Salazar, an emergency doctor in Ecuador, my country has different populations above sea level, it would seem that covid19 spreads more slowly in populations over 2500 meters, do you have any information about this?
    one of the post of the comments is mine, but it is in Spanish, I did not upload it, but if you can check it it would be very helpful

    • Salim Rezaie
      Posted at 10:12h, 18 March Reply

      Hello Felipe,
      I have not been able to find anything on this. I suspect people in higher altitudes are most likely more spaced out and there for we see less spread. This is just a hypothesis as other factors like the altitude itself could have an effect. If I do come across anything I will be sure to update the post.

      Salim

  • Matthew J Streitz
    Posted at 11:41h, 20 March Reply

    Great info Salim! Thanks!

    • Salim Rezaie
      Posted at 11:43h, 20 March Reply

      TY Matt,
      Hope this information is helpful to others and stay safe…one day at a time…one patient at a time.

      Salim

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  • Gerald Diaz
    Posted at 13:36h, 21 March Reply

    GREAT resource.
    Curious- why is everyone so down on CPAP? I’m with Dr. Farkas- vents just don’t scale very well requiring ICU RNs/RTs/sedation, increased monitoring. CPAP you give em a facemask. Why are so many shops (like mine) jumping straight to intubation?
    The most recent Clinical Problem Solvers podcast, the italian intensivist Dr. Monti says 1/2 of their patients do well on CPAP (they don’t have HFNC there) and don’t require intubation. In addition he states it’s a good test for who needs intubation, as non-responders are usually obvious within 1-2 hours.
    We will eventually need COVID wards with full gear so the aerosolization issue should not be a problem.

    • Salim Rezaie
      Posted at 17:50h, 21 March Reply

      Hey Gerald,
      I don’t think people are down on it, as much as the concern of aerosolization from it. The CPAP that was used in Italy was CPAP helmets/hoods NOT masks which minimizes aerosolization. You hit the nail on the head…we will eventually need COVID wards with us in full PPE to care for these patients, because we will simply run out of vents if we go right to an intubation first strategy.

      Salim

      • Gerald Diaz
        Posted at 20:27h, 22 March Reply

        Actually Dr. Monti states he preferred facemask over helmet as they tried to monitor remotely as much as possible and in the event of a malfunction it’s easier for a patient to simply rip off the mask. But you’re right in all of the videos I see lots of helmets. Worried we will run out of ICU resources (particularly healthy bodies) and wondering as a hospitalist we can take more of the burden from them using NiV. Please be safe. (PS I think your CDC exposure table is duplicated?)

        • Salim Rezaie
          Posted at 20:30h, 22 March Reply

          Hey Gerald,
          TY for all that you do and comments. Working on partitioning post to make easier to navigate…so may see some duplicates as I am working on that. TY for looking out.

          Salim

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  • Shielah M Andersen
    Posted at 22:37h, 30 March Reply

    What about ACE inhibitors? Also, If I am making a physical model, how many of each type of protein as show in the above diagram are present on each unit of the virus? thanks for the info:)

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  • Phoebe
    Posted at 00:42h, 08 April Reply

    Nice posting. Thanks for your sharing!

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  • Epson Printer Offline
    Posted at 05:12h, 12 May Reply

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