World Health Organization declares Global Emergency: A review of the 2019 Novel Coronavirus (COVID-19

 

World Health Organization declares Global Emergency: A review of the 2019 Novel Coronavirus (COVID-19

On 31st December 2019, 27 cases of pneumonia of unknown aetiology were identified in Wuhan City, Hubei province in China.[1] Wuhan is the most populous city in central China with a population exceeding 11 million. These patients most notably presented with clinical symptoms of dry cough, dyspnea, fever, and bilateral lung infiltrates on imaging. Cases were all linked to Wuhan's Huanan Seafood Wholesale Market, which trades in fish and a variety of live animal species including poultry, bats, marmots, and snakes.[1] The causative agent was identified from throat swab samples conducted by the Chinese Centre for Disease Control and Prevention (CCDC) on 7th January 2020, and was subsequently named COVID-19 by the World Health Organization (WHO).[2] To date, most COVID-19 infected patients have developed mild symptoms such as dry cough, sore throat, and fever. The majority of cases have spontaneously resolved. However, some have developed various fatal complications including organ failure, septic shock, pulmonary oedema, severe pneumonia, and acute respiratory distress syndrome (ARDS).[3] 54.3% of those infected with COVID-19 are male with a median age of 56 years old. Notably, patients who required intensive care support were older and had multiple comorbidities including cardiovascular, cerebrovascular, endocrine, digestive, and respiratory disease. Those in intensive care were also more likely to report dyspnoea, dizziness, abdominal pain, and anorexia.[4] 

WHO Global Health Emergency 

On  30th  January  2020,  the  WHO  declared  the  Chinese outbreak  of  COVID-19  to  be  a  Public Health Emergency of International Concern, posing a high risk to countries with vulnerable health systems. The emergency committee have stated that the spread of COVID-19 may be interrupted by early detection, isolation, prompt treatment, and the implementation of a robust system to trace contacts.[5] Other strategic objectives include a means of ascertaining clinical severity, the extent of transmission and optimising treatment options. A key goal is to minimise the economic impact of the  virus  and  to  counter  misinformation  on  a  global  scale.[5]In  light  of  this,  various  bodies  have committed  to  making  articles  pertaining  to  COVID-19  immediately  available  via  open  access  in order to support a unified global response.[6]  

Global response 

Efforts aimed at deciphering the pathophysiology of COVID-19 have led to the EU mobilising a €10,000,000 research fund to “contribute to more efficient clinical management of patients infected with the virus, as well as public health preparedness and response”.[7] Regarding diagnostic testing, US-based  companies such as Co-Diagnostics and the Novacyt’s molecular diagnostics division Primerdesign have launched COVID-2019 test kits for use in the research setting.[8, 9] The United Kingdom (UK) government have also invested £20,000,000 to help develop a COVID-
219-specific vaccine.[10] Additionally, the United States (US) have suspended all entry of immigrants and non-immigrants who have travelled to high risk zones with the intention of halting further spread of COVID-19.[11] Hong Kong has also suspended several public transport services across the border and many hospital workers and civil servants are currently on strike.  Strikers are demanding that the border to mainland China be closed completely to prevent further spread of COVID-19. However, Hong Kong authorities have to date resisted these requests, stating that “closing the border completely would go against advice from the WHO”.[12] In addition, growing fears regarding China’s economy has led the Chinese central bank to invest ¥150 billion to support the stability of the currency market

Confirmed UK cases and British response 

As  of  14th  February  2020,  a  total  of  2,955  tests  for  COVID-19  have  been  conducted  across  the UK.  To  date,  9  individuals  have  tested  positive  resulting  in  the  UK  public  health  risk  for  viral infection being raised from low to moderate.[14] To prevent transmission, the UK government are following  direct  guidelines  from  the  Department  of Health  (DoH)  for  encountering  overseas travellers  with  respiratory  infections,  particularly  for  those  who  have  travelled  to  Wuhan.[15–17] The UK National Health Service (NHS) have stressed the importance of using personal protective equipment  (PPE),  taking  a  thorough  travel  history, and  escalating  suspected  cases  immediately with  a  view  to  isolating  patients.  Any  detected  cases  of  COVID-19  should  be  transferred  to  an Airborne High Consequence Infectious Diseases (HCID) centre, including the two principal centres in England (the Royal Free Hospital in London and the Newcastle Royal Victoria Infirmary). The DoH and UK Chief Medical Officers have also advised individuals having visited Wuhan and the  Hubei  Province  in  the  last  14  days  to  remain  indoors  and  to  call  NHS  111.  This  advice  also applies to individuals that have visited mainland China, Thailand, Japan, Republic of Korea, Hong Kong,  Taiwan,  Singapore,  Malaysia,  and  Macau.  The  British  Foreign  and  Commonwealth  Office have  advised  British  citizens  to  avoid  all  travel  to  the  Hubei  Province,  and  to  avoid  unnecessary travel  to  Mainland  China.[18]  More  recently,  200  British  citizens  were  quarantined  following  an evacuation  flight  from  Wuhan  on  the  30January  2020.  All  other  flights  arriving  to  the  UK from Hubei    Province    have    since    been    suspended.[19]    However,    in    keeping    with    WHO recommendations,  no  travel  restrictions  have  been  placed  on  individuals  who  have  travelled  to China within the last two weeks and are free to enter the UK.

Viral transmission and spread

 There are currently few studies that define the pathophysiological characteristics of COVID-19, and there is great uncertainty regarding its mechanism of spread. Current knowledge is largely derived from  similar  coronaviruses,  which  are  transmitted  from  human-to-human  through  respiratory fomites.[20]  Typically,  respiratory  viruses  are  most  contagious  when  a  patient  is  symptomatic. However,  there  is  an  increasing  body  of  evidence  to  suggest  that  human-to-human  transmission may  be  occurring  during  the  asymptomatic  incubation  period  of  COVID-19,  which  has  been estimated to be between 2-10 days.[20–22]  As of 15th February 2020, 50,580 cases of COVID-19 have been confirmed, 50,054 of which are confined  to  China.  Of  the  Chinese  cases,  37,884  were  confirmed  in  the  Hubei  Province  with  the remainder  being  reported  in  33  provinces,  regions  and  cities  in  China  (Figure  1).[23]  The remaining 526 cases were identified in 25 countries including Japan, the US, and Australia. Two of these  cases  were  fatal  (the  Philippines  and  Japan).  170  individuals  with  COVID-19  reported outside  of  China  had  travelled  to  the  country,  and 127  cases  were  associated  with  possible  or confirmed transmission outside of China. It is important to note that these figures are likely to be an underestimate, since the data presented depicts laboratory-confirmed diagnoses only

Prevention

Various  bodies  including  the  WHO  and  US  Centers  for  Disease  Control  and  Prevention  (CDC) have issued advice on preventing further spread of COVID-19.[20, 25] They recommend avoiding travel  to  high-risk  areas,  contact  with  individuals  who  are  symptomatic,  and  the  consumption  of meat  from  regions  with  known  COVID-19  outbreak.  Basic  hand  hygiene  measures  are  also recommended,  including  frequent  hand  washing  and  the  use  of  PPE  such  as  face  masks. Japanese-based  company  Bespoke  Inc  has  also  launched  an  artificial  intelligence-powered chatbot   (Bebot)   that   provides   up   to   date   information   regarding   the   coronavirus   outbreak, preventative measures that one can take, as well as a symptom checker.

Diagnosis

Clinical features of COVID-19 include dry cough, fever, diarrhoea, vomiting, and myalgia. Individuals with multiple comorbidities are prone to severe infection and may also present with acute kidney injury (AKI) and features of ARDS.[3, 27] The WHO and CDC have both issued guidance on key clinical and epidemiological findings suggestive of a COVID-19 infection (] Extensive laboratory tests should be requested for patients with suspected infection. Patients may present with an elevated C-reactive protein, erythrocyte sedimentation rate, lactate dehydrogenase, creatinine, and a prolonged prothrombin time

TreatmentAt 

 present,  no  effective  antiviral  treatment  or  vaccine  is  available  for  COVID-19.  However,  a randomized  multicentre  controlled  clinical  trial  is  currently  underway  to  assess  the  efficacy  and safety  of  abidole  in  patients  with  COVID-19  (ChiCTR2000029573).  First-line  treatment  for  fevers include antipyretic therapy such as paracetamol, whilst expectorants such as guaifenesin may be used  for  a  non-productive  cough.[4]  Patients  with  severe  acute  respiratory  infection,  respiratory distress,  hypoxaemia  or  shock  require  the  administration  of  immediate  oxygen  therapy.  This should be at 5 L/min to reach SpO2 targets of ≥90% in non-pregnant adults and children, and ≥92-95%  in  pregnant  women.[31–33]  In  the  absence  of  shock,  intravenous  fluids  should  be  carefully administered.[34]  Renal  replacement  therapy  (RRT)  should  be  initiated  for  patients  with  an  AKI. Renal  function  and  fluid  balance  should  be  used  to identify  patients  that  may  require  RRT.[4] Broad   spectrum   antibiotic   therapy   should   also   be   administered   within   one   hour   of   initial assessment  for  sepsis.[35]  It  is  important  to  note that  patients  can  develop  further  bacterial  and fungal  infections  during  the  middle  and  latter  stages  of  the  disease.  Therefore,  conservative  and rational antibiotic regimens must still be followed.[36] The National Health Commission of the People's Republic of China recommends the use of IFN-αand  lopinavir/ritonavir.  This  advice  is  based  on  prior  research  showing  that  these  medications lower mortality rates in patients infected with SARS.[37]. Oseltamivir, a neurominidase inhibitor, is currently  being  used  by  medical  staff  in  China  for suspected  infections  despite  the  lack  of  any conclusive  evidence  regarding  its  effectiveness  on COVID-19.  Glucocorticoids  may  also  be considered  for  patients  with  severe  immune  reactions.  In  children,  methylprednisolone  should  be limited to 1-2 mg/kg/day for a maximum of 5 days.[4, 36] Prognosis As of 15th February 2020, a total of 1,526 deaths have been reported worldwide. Outside of China, two of these deaths have been reported in the Philippines and Japan.[23] However, the number of positive cases and deaths continues to rise. The current reported mortality for COVID-19 is approximately 3.0% compared with 9.6% for SARS[38] and 34.4% for MERS.[39] The clinical features of COVID-19 versus its distance relative SARS are summarised in Table 2. To date, COVID-19 has been shown to have a mean incubation period of 5.2 days and a median duration from the onset of symptoms to death of 14 days,[22, 40] which is comparable to that of MERS.[41]  Patients ≥70 years of age have a shorter median duration (from the onset of initial symptoms to death) of 11.5 days, highlighting the vulnerability of this particular patient cohor 

orld Health Organization declares Global Emergency: A review of the 2019 NovelCoronavirus (COVID-19)Catrin Sohrabi, Zaid Alsafi, Niamh O’Neill, Mehdi Khan, Ahmed Kerwan, Ahmed Al-Jabir, Christos Iosifidis, Riaz AghaPII:S1743-9191(20)30197-7DOI:https://doi.org/10.1016/j.ijsu.2020.02.034Reference:IJSU 5293To appear in:International Journal of SurgeryReceived Date:3 February 2020Revised Date:17 February 2020Accepted Date:24 February 2020