Apart but United: Fighting the Coronavirus Pandemic

Fighting the Coronavirus Pandemic Apart but United

by April Ingram

As we rang in 2020 — a new decade, full of optimism — few of us could have predicted the ways in which the world would change in just a couple months. Admittedly, I had never heard the term “social distancing” until a couple months ago.

At the time of writing, there aren’t many countries left untouched by the COVID-19 pandemic. However, this could also be a result of under-testing and under-reporting. And as of May 11, the number of cases in the United States surpassed that of all other nations... a tally that continues to change daily.

COVID-19: What We Need to Know

Let’s get the terminology correct: The novel coronavirus, referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was previously known by the provisional name 2019-nCoV. The highly contagious virus is what causes the severe respiratory disease known as COVID-19.

This is not our first global experience with a coronavirus — SARS and MERS (Middle East respiratory syndrome) are also types of coronaviruses. The current SARS-CoV-2 is an enveloped, single-stranded RNA virus — and although it appears to be not quite as fatal as the SARS or MERS coronaviruses, there have already been a significant number of global fatalities with more than 95,000 deaths worldwide at press time.

Currently, the primary intervention is preventing the spread of COVID-19 by controlling infections. Public health authorities are carefully monitoring the situation to learn more about this novel virus and its associated outbreaks, so that we can better respond to the situation.

For the most part, citizens are compliant with the social distancing guidelines. People have become diligent handwashers who stay at home when possible. Companies have established plans for teleworking, and the population has adapted to the cancellation of events.

A challenge is teasing the facts from the myths (and fears) — and as members of the medical community, finding the time to provide accurate information, while being overwhelmed by caring for those that need help.

Innovation and Solidarity Amid a Pandemic

The rapid spread of the virus has led to an extraordinary situation: Acute hospitals have been confronted with a massive influx of patients. Initially, this was absorbed by the restricting elective procedures and transferring patients to less intensive levels of care, to make ventilator-equipped beds available to those with the most dire need.

Some countries have not yet seen their infections peak and have insufficient resources. Rationing decisions have become necessary, placing considerable burdens on medical staff. As an example, ventilator sharing is becoming more common.

In an effort to address the lack of resources, companies that typically manufacture things like cars have transitioned their production lines into ventilator assembly. Manufacturers of sporting equipment are now making masks and gowns to protect front-line healthcare staff. And distilleries that were producing spirits for our favorite cocktails are making and distributing alcohol-based hand sanitizer. Be it necessity or desperate times that breed innovation, either way, these are important and valued initiatives. Symptoms can appear as soon as two days, or as long as 14 days, after exposure. Severe complications include pneumonia.

In a study published in the Annals of Internal Medicine on March 10 by Dr. Lauer and colleagues at Johns Hopkins, they found that the mean incubation period for SARS-CoV-2 was 5-7 days. More than 97% of those who developed symptoms did so within 11.5 days of exposure. This study further supports the current 14-day quarantine recommendations. 1

Current understanding about how COVID-19 spreads is based largely on what is known about other similar coronaviruses — primarily person-toperson, through respiratory droplets produced when an infected person coughs or sneezes. There is also evidence it can spread from surfaces touched by an infected person, then touched by another person who then touches their mouth, nose or eyes. Viral RNA has also been found in stool samples from infected patients, raising the possibility of transmission through the fecal/oral route.

As you wash your hands, consider a recent study from the New England Journal of Medicine, in which researchers detected viable SAR-CoV-2 in aerosols up to three hours postaerosolization. Although the study was performed in a laboratory Goldberg Asymptomatic transmission is also a real concern, as detailed in a Feb. 21, 2020 report in JAMA. They describe a case of an asymptomatic carrier who potentially infected 5 family members despite having a normal chest CT. 3

drum, which lacked ventilation and may not necessarily reflect virus behavior in the real-world, they found that the infectious virus survived up to 24 hours on cardboard, up to 4 hours on copper, and up to 2-3 days on plastic and stainless steel. 2

The U.S. Center for Disease Control (CDC) identified SARS-CoV-2 RNA (not necessarily indicating infectious virus) on various surfaces within cruise ship cabins of passengers who tested positive up to 17 days after they had disembarked from the ship.

Understanding COVID-19’s Symptoms, Incubation and Transmission

COVID-19 patients typically present with respiratory illness, including fever, cough and shortness of breath. Conjunctivitis has also been reported.

Notably, Dr. Li Wenliang, an ophthalmologist from Wuhan Central Hospital — who is recognized as the physician that originally sounded the alarm on the virus — believed that he was infected by a glaucoma patient who showed no symptoms. Dr. Li passed away on Feb. 7, 2020.

A Look at the Coronavirus’s Comorbidities

Lancet Respiratory Medicine recently published a review of studies of the most distinctive comorbidities of

patients hospitalized with COVID-19. 4 Xiaobo Yang and colleagues in Wuhan, China, reported that of 32 non-survivors (from a group of 52 intensive care unit patients), 22% had cerebrovascular diseases and 22% had diabetes. 5 Similarly, findings from Zhang et. al., also from Wuhan, noted that 30% of COVID-19 hospitalized patients had hypertension and 12% had diabetes. 6

Guan et. al. also published their study in the New England Journal of Medicine, which described 1,099 patients with confirmed COVID-19, 173 of whom had severe disease with comorbidities of hypertension (23.7%); diabetes (16.2%); coronary heart diseases (5.8%); and cerebrovascular disease (2.3%). 7

A Race Against Time to Develop Vaccines and Treatments

Currently, there is no vaccine to prevent infection. Trials for a mRNA coronavirus vaccine began enrolling patients on March 5, 2020 at Kaiser Permanente Washington Health Research Institute in Seattle, Washington, and at Emory Children’s Center in Decatur, Georgia, U.S.

At this time, there are no proven agents for prophylaxis or therapy for SARSCoV-2. Remdesivir, a novel antiviral, nucleotide analog, developed by Gilead Sciences as a treatment for Ebola and Marburg virus infections, has shown activity in vitro and is currently in clinical trials.

Chloroquine, approved for malaria, and hydroxychloroquine, approved for autoimmune disorders, are under investigation for the treatment of COVID-19. However, it is very important to understand that the proposed doses being studied exceed the maximum daily dose considered safe for long-term therapy, as described an Asia-Pacific Vitreo-retina Society working group.

Until more is learned about the toxicity associated with current regimens, decisions should be made on an individual basis, taking into consideration any pre-existing retinal disease. Unfortunately, members of the public have accessed chloroquine and/or hydroxychloroquine in efforts to self-medicate or prevent the virus, and several overdose-related fatalities have occurred since the conversation began. Also, shortages of these drugs have become apparent for patients that rely on them for prescribed treatment of autoimmune disorders.

Eye Safety: Coronavirus and Ophthalmology

Recommendations for ophthalmologists during this pandemic have been

published by the American Academy of Ophthalmology. They highlight several reports that suggest the virus can cause mild follicular conjunctivitis, otherwise indistinguishable from other viral causes, and possibly be transmitted via aerosol contact with conjunctiva.

Patients who present to ophthalmologists for conjunctivitis who also have fever and respiratory symptoms, including cough and shortness of breath, could represent cases of COVID-19.

Protection for the mouth, nose and eyes when caring for patients potentially infected with SARS-CoV-2 is highly recommended. Current evidence supports that the virus causing COVID-19 is very likely susceptible to the same alcohol- and bleach-based disinfectants that ophthalmologists commonly use to disinfect ophthalmic instruments and office furniture. Disinfection practices to prevent officebased spread of other viral pathogens are recommended before and after every patient encounter.

References:

Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, Azman AS, Reich NG, Lessler J. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020 March 10. van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, Tamin A, Harcourt JL, Thornburg NJ, Gerber SI, Lloyd-Smith JO, de Wit E, Munster VJ. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020 March 17. Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, Wang M. Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA. 2020 February 21. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med. 2020 March 11. Yang X, Yu Y, Xu J, et. al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020 February 24. Zhang JJ, Dong X, Cao YY, et. al. Clinical characteristics of 140 patients infected by SARS-CoV-2 in Wuhan, China. Allergy. 2020 February 19. Guan W, Ni Z, Hu Y, et. al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020 February 28.