Coronavirus SARS-CoV2 infection (COVID-19)

Essential Evidence

Last Updated on 2020-09-28 © 2020 John Wiley & Sons, Inc.

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Authors:
Mark H. Ebell, MD, MS, Professor, College of Public Health, University of Georgia
Mindy A. Smith, MD, MS, Clinical Professor, Department of Family Medicine, Michigan State University
Henry C. Barry, MD, MD, MS, Professor Emeritus, Michigan State University
Pete Yunyongying, MD, FACP, Associate Professor , Carle-Illinois College of Medicine, University of Illinois
John Hickner MD, MS, Professor Emeritus, University of Illinois-Chicago

Editor:
Mark H. Ebell, MD, MS, Professor, College of Public Health, University of Georgia

Overall Bottom Line

  • EDITOR'S NOTE: This topic has been made freely available and is being updated regularly. We are at times linking to preprint servers and providing direct links to articles where possible, and most of this literature has been made freely available. As preprint work becomes peer reviewed and formally published, we will update the citations. Since preprint servers have not been peer-reviewed, and the data and conclusions may change, information from them should be used with great caution if at all.
  • Suspect COVID-19 when the virus is circulating in the population and a patient reports signs and symptoms of respiratory tract infection, or less commonly fever and neurologic symptoms or thrombosis. Most common symptoms are fever, cough, myalgias, and dyspnea; loss of taste and smell are also common. Approximately 40% of all patients are asymptomatic but appear to be as infectious as symptomatic patients. B
  • Preventive measures include hand washing, surface cleaning, case isolation, quarantine of contacts for 14 days, school and university closures, and general social distancing/sheltering at home. Modeling indicates that only by doing all of these measures can the number of severe cases requiring ventilation not overwhelm hospitals.B
  • Mask and isolate patients on presentation to a healthcare facility and obtain PCR from nasopharynx and oropharynx. Also test for influenza and strep throat if clinically suspected. C
  • The combination of age and CRP can be used to identify patients at low, moderate and high risk of severe illness (see Prognosis section below).B
  • Patients can be considered cured using a test-based strategy (recovery from fever without antipyretics and without respiratory symptoms plus 2 negative PCR tests 24 hours apart). For outpatients in settings where tests are not widely available, the CDC recommends that isolation be maintained for at least 10 days after illness onset and at least 3 days (72 hours) after recovery, defined as: at least 3 days free of fever without antipyretics, 3 days without respiratory symptoms, and at least 7 days after onset of symptoms. C
  • Treatment is primarily supportive and includes monitoring oxygen saturation.
  • Remdesivir shortens the duration of hospitalization (11 vs. 15 days) and may reduce mortality slightly. 108B
  • Corticosteroids have been shown in a large UK trial with 6425 patients to be highly effective at reducing mortality in patients with COVID-19 who are mechanically ventilated (NNT = 7) or who are on oxygen (NNT = 20) but not in hospitalized patients not requiring oxygen. 161 Their use also decreases the likelihood of requiring mechanical ventilation. 171B
  • Multiple randomized controlled trials have confirmed that hydroxychloroquine is not effective for severe disease, mild disease, early disease, or as post-exposure prophylaxis, and is associated with a higher risk of adverse events. 173 105A
  • The overall infection fatality rate is estimated to be 0.5% to 0.9% and is higher in older patients and those with comorbidities. 65 As of September 24th, the Johns Hopkins Center for Health Security reports that there have been 984,813 deaths and 32,356,829 confirmed cases worldwide, 203,147 deaths and 6,997,468 confirmed cases in the US (2.9% case fatality ratio), 9,304 deaths and 151,982 confirmed cases in Canada (6.1% case fatality ratio), and 42,025 deaths and 425,765 confirmed cases in the UK (9.9% case fatality ratio). Mortality rates per 100,000 are 62.0 in the US, 25.1 in Canada, and 63.2 in the UK. These rates are higher than the true case and infected fatality rates due to the large number of undiagnosed mild and asymptomatic cases. B

Practice Guidelines

  1. Balboni A, Battilani M, Prosperi S. The SARS-like coronaviruses: the role of bats and evolutionary relationships with SARS coronaviruses. New Microbiol 2012 Jan;35(1):1-16.
  2. Centers for Disease Control. (n.d.) Appendix B1: Revised CSTE SARS Surveillance Case Definition. Retrieved from Severe Acute Respiratory Syndrome (SARS). https://www.cdc.gov/sars/guidance/b-surveillance/app1.html
  3. Centers for Disease Control. (n.d.) Appendix F4: Guidelines for Collecting Speciments from Potential SARS Patients. Retrieved from Severe Acute Respiratory Syndrome. https://www.cdc.gov/sars/guidance/f-lab/app4.html
  4. Centers for Disease Control. (n.d.) Clinical Guidance on the Identification and Evaluation of Possible SARS-CoV Disease among Persons Presenting with Community-Acquired Illness. Retrieved from Severe Acute Respiratory Syndrome: Clinical Evaluation and Diagnosis. https://www.cdc.gov/sars/clinical/fig2.html
  5. Centers for Disease Control. (2012, July 07) Clinicial Guidance on the Identification and Evaluation of Possible SARS-CoV. Retrieved from https://cdc.gov/sars/clinical/guidance.html
  6. Chan KS, Lai ST, Chu CM, Tsui E, Tam CY, Wong MM, Tse MW, Que TL, Peiris JS, Sung J, Wong VC, Yuen KY. (2003) Treatment of Severe acute respiratory syndrome with lopinavir-ritonavir: a multicentre retrospective matched cohort study. Hong Kong Med J 2003 Dec;9(6):399-406.
  7. Chiou HE, Liu CL, Buttrey MJ, Kuo HP, Liu HW, Kuo HT, Lu YT. Adverse effects of ribavirin and outcome in severe acute respiratory syndrome: experience in two medical centers. Chest 2005 Jul;128(1):263-272.
  8. Christian MD, Poutanen SM, Loutfy MR, Muller MP, Low DE. Severe acute respiratory syndrome. Clin Infect Dis 2004;38(10):1420–1427
  9. Cowling BJ, Muller MP, Wong IO, Ho LM, Lo SV, Tsang T, Lam TH, Louie M, Leung GM. Clinical prognostic rules for severe acute respiratory syndrome in low- and high-resource settings. Arch Intern Med 2006;166(14):1505-1511.
  10. Grant PR, Garson JA, Tedder RS, Chan PK, Tam JS, Sung JJ. Detection of SARS coronavirus in plasma by real-time RT-PCR. N Engl J Med 2003;349(25):2468-2469.
  11. Hui DS, Chan MC, Wu AK, Ng PC. Severe acute respiratory syndrome (SARS): epidemiology and clinical features. Postgrad Med J 2004;80(945):373-381.
  12. Ksiazek TG, Erdman D, Goldsmith CS, Zaki SR, Peret T, Emery S, Tong S, Urbani C, Comer JA, Lim W, Rollin PE, Dowell SF, Ling AE, Humphrey CD, Shieh WJ, Guarner J, Paddock CD, Rota P, Fields B, DeRisi J, Yang JY, Cox N, Hughes JM, LeDuc JW, Bellini WJ, Anderson LJ; SARS Working Group. A novel coronavirus associated with severe acute respiratory syndrome. N Engl J Med 2003;348(20):1953-1966.
  13. Lee N, Hui D, Wu A, Chan P, Cameron P, Joynt GM, Ahuja A, Yung MY, Leung CB, To KF, Lui SF, Szeto CC, Chung S, Sung JJ. A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med 2003;348(20):1986-1994.
  14. Mahony JB, Richardson S. Molecular diagnosis of severe acute respiratory syndrome: the state of the art. J Mol Diagn 2005;7(5):551-559.
  15. Mazzulli T, Farcas GA, Poutanen SM, Willey BM, Low DE, Butany J, Asa SL, Kain KC. Severe acute respiratory syndrome-associated coronavirus in lung tissue. Emerg Infect Dis Emerg Infect Dis 2004;10(1):20-24.
  16. Peiris JSM, Yuen KY, Osterhaus ADME, Stöhr K.The severe acute respiratory syndrome. N Engl J Med 2003;349:2431-2441
  17. Vijay R, Perlman S. Middle East respiratory syndrome and severe acute respiratory syndrome. Curr Opin Virol 2016;16:70-76.
  18. World Health Organization. (2003) Summary of Probable SARS Cses With Onset of Illness from 1 November 2002 to 31 July 2003. Retrieved from Emergenceis preparedness, response: http://www.who.int/csr/sars/country/table2004_04_21/en/