What are the other Names for this Condition? (Also known as/Synonyms)

• 2019 Novel Coronavirus (2019-nCoV) Infection
• COVID-19 (Coronavirus Disease 2019)
• Wuhan Coronavirus Infection

What is Coronavirus Disease 2019? (Definition/Background Information)

• Coronavirus Disease 2019 (COVID-19) is described as an emerging airborne illness causing flu-like symptoms that can be severe in older adults and individuals with weak immune system. COVID-19 is declared a pandemic by World Health Organization (WHO), meaning that the disease is spread across several continents affecting many countries
• The first cases of human infection were reported in December 2019 from Wuhan, the capital city of Hubei province, China; thus, it was earlier called Wuhan Coronavirus Infection. The infection is caused by a “newly” identified strain of coronavirus namely, 2019 novel coronavirus (2019-nCoV), also known as Wuhan novel coronavirus (WN-CoV), from the place of its origin i.e., Wuhan city
• Current evidence indicates that Coronavirus Disease 2019 is a zoonotic infection, meaning it may have been transmitted from animals to humans. Based on recent research studies, the causative virus is now termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel strain of SARS-CoV that caused the severe acute respiratory syndrome (SARS), several years ago
• Coronaviruses (CoVs) are common pathogens that are known to cause nasal, sinus, and upper throat infections. Most of the viruses are not dangerous, but some strains have been responsible for deadly global epidemics such as the Middle East respiratory syndrome (due to MERS-CoV) and severe acute respiratory syndrome (due to SARS-CoV)
• Individuals with severe Coronavirus Disease 2019 present symptoms similar to pneumonia including high temperatures, coughing, and breathing difficulties. The incubation period is from anywhere between 2 days to 2 weeks. Individuals with poor immunity may develop complications including severe weaknesses and lung infections
• The treatment options are geared towards addressing the symptoms and providing supportive care. Currently, there are neither treatment protocols nor effective antiviral agents available for this new viral strain. Individuals with mild Coronavirus Disease 2019 are known to recover through an intake of sufficient fluids and adequate rest
• The prognosis of Coronavirus Disease 2019 is primarily dependent on the immune status and age of the individual, and the severity of the illness. A combination of old age and infections presenting complications including multiple organ failure have resulted in deaths. Over 80% of the fatalities reported are elderly adults, over 60 years of age

Who gets Coronavirus Disease 2019? (Age and Sex Distribution)

• Individuals with weak immune systems and elderly adults are more susceptible to Coronavirus Disease 2019; however, individuals of any age category may be affected. Based on the recorded number of cases, infections in young children is very infrequent
• Both males and females are susceptible to this viral infection
• The infection is known to affect individuals of all races and ethnicity

According to current reports, COVID-19 has been reported from over 150 countries/regions, apart from mainland China (and special areas), where over 30% of the cases are recorded. These include countries in Asia, Africa, Europe, Australia, and America (both south and north); over 40% of the cases are from European nations. New cases are being increasingly reported from various nations and regions that did not previously harbor the infection.

What are the Risk Factors for Coronavirus Disease 2019? (Predisposing Factors)

Coronavirus Disease 2019 is believed to spread through direct contact with infected animals or humans, and by consuming infected animal products. The following may be some of the risk factors for contracting the virus:

• Direct contact with infected animals and marine creatures: The origin of the infection is reportedly from the Wuhan seafood and meat market (that had both live and slaughtered animals on sale)
• Direct contact with infected individuals: Coronaviruses generally spread through coughing or sneezing; the transmission can be airborne or via direct touching of infected surfaces
• Living in areas of active outbreaks
• Working in a healthcare facility in direct contact with COVID-19 infected patients; caring for people who are ill
• Working in farms with infected animals (unknowingly)
• Having a weakened immune system, such as due to HIV infection/AIDS, cardiovascular diseases (CVDs), or unchecked diabetes
• Elderly adults have a high risk for the condition
• Individuals with cancer, chronic respiratory illnesses, or uncontrolled diabetes may have an elevated risk
• Traveling to parts of the world known to harbor the virus and not practicing proper hygiene

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Coronavirus Disease 2019? (Etiology)

Coronavirus Disease 2019 (COVID-19) is a respiratory infection that is caused by the newly-labelled virus, called 2019 novel coronavirus (2019-nCoV) or Wuhan novel coronavirus (WN-CoV). Genetic analysis have revealed its close similarity to SARS-CoV; hence, the novel virus is now designated as the "severe acute respiratory syndrome coronavirus 2 (or SARS-CoV-2)".

• Coronaviruses generally infect warm-blooded animals causing a variety of conditions but are known to change their hosts by undergoing mutations; thus, transmission to humans can occur from animals. The virus has been detected in respiratory secretions, blood, urine, and feces
• Presently, the animal species (or animals) responsible for COVID-19 is unknown; the actual transmission route is also unclear. It is believed that the spread may occur through close human contact with infected animals (possibly bats) and their secretions, or by consuming improperly cooked or undercooked meat, milk, and other products of such infected animals (primary or intermediate hosts)
• Human to human transmission of coronavirus is known to take place via infected respiratory droplets that are produced when an individual sneezes or coughs. Current reports indicate that the virus is highly infectious and spreads faster than initially believed. Touching surfaces that are contaminated by such droplets may accelerate the transmission; the virus is known to survive for a few hours outside the host on surfaces. The virus can also spread through kissing (contact through saliva)
• The contagion may easily spread in urban/rural crowded spaces, marketplaces, transportation facilities, and within healthcare settings (while caring for individuals with the sickness). Individuals, who are old or have poor immune systems, are easily prone to contracting COVID-19

With the identification of 2019-nCoV coronavirus, the number of strains of coronaviruses that cause infections in humans has risen to seven. Current research studies have established the ease of viral transmission; most reports confirm that the 2019-nCoV is indeed highly-contagious.

What are the Signs and Symptoms of Coronavirus Disease 2019?

Individuals infected with Coronavirus Disease 2019 may or may not show symptoms; this may depend upon the severity of the illness and immune status and age of the individual. The time between exposure to the virus and presentation of symptoms is reportedly anywhere from 2 days to 10-14 days (mean period 5 days).

Among those presenting signs and symptoms, the following flu-like symptoms have been observed:

• Fever and chills, observed in a vast majority of cases
• Dry cough, observed in 4 in 5 individuals
• Sore throat
• Runny nose and sneezing are uncommon
• Shortness of breath; shallow breathing
• Muscle and joint pain
• Other symptoms may include cough producing phlegm, chest pain, loss of appetite, fatigue, nausea and vomiting
• Blood in sputum
• Diarrhea

Preliminary data shows that COVID-19 infects children less severely than adults.

How is Coronavirus Disease 2019 Diagnosed?

The World Health Organization has provided certain diagnostic guidelines to facilitate testing and identification of the pathogen. However, presently, the information on the testing protocols is limited.

In general, Coronavirus Disease 2019 may be diagnosed through the following tests and exams:

• A complete physical examination and assessment of the presenting signs and symptoms
• Evaluation of the affected individual’s medical history and recent travel history
• Blood tests including complete blood count (CBC) and blood culture; decreased white blood cell count is noted
• Nucleic acid test (NAT) for infections
• Sputum culture
• Chest X-rays and other imaging studies, such as chest CT scans, are important
• Bronchoscopy: A technique for visualizing the insides of the airways for diagnostic purposes
• Real-time reverse transcription-polymerase chain reaction (rRT-PCR) test: A molecular test for individuals with active infection, performed on respiratory or blood samples
• Kidney function test

The US Centers for Disease Control and Prevention (CDC) has proposed the following “Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for 2019 Novel Coronavirus (2019-nCoV)”, according to which, if testing is recommended, the following specimens should be collected:

• Lower respiratory tract: Bronchoalveolar lavage, tracheal aspirate, or sputum
• Upper respiratory tract: A nasopharyngeal (NP) swab AND oropharyngeal swab (OP)
• Serum

Reference: https://www.cdc.gov/coronavirus/2019-nCoV/guidelines-clinical-specimens.html

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Coronavirus Disease 2019?

Coronavirus Disease 2019 may result in the following complications:

• Debilitating weakness
• Severe pneumonia
• Acute respiratory distress syndrome (ARDS); severe lung infection causing respiratory distress
• Organ failure; kidney failure
• Septic shock: It is a condition in which many body organs can fail, causing a life-threatening situation
• Public and community health threat; due to the outbreak of an epidemic with grave consequences, especially if the virus is not identified early and contained appropriately

Severe cases of COVID-19 infection that present complications are known to result in death.

How is Coronavirus Disease 2019 Treated?

Presently, there are no established protocols or standard guidelines for the treatment of Coronavirus Disease 2019. The treatment is largely symptomatic to relieve pain and offer suitable support. It is reported that antiviral medications currently available are ineffective against this novel virus.

The following measures may be considered towards managing COVID-19:

• Symptomatic treatment for mild cases includes plenty of rest, lots of warm fluids, and flu medications, if any, prescribed by the healthcare professional
• Hospitalization of individuals having severe infections; stabilization of the condition, administration of intravenous fluids, oxygen therapy, and providing other supportive measures
• Admission to an ICU or ventilator assistance, in case of complications such as organ failure
• Isolation of the affected individuals, to minimize transmission risk

How can Coronavirus Disease 2019 be Prevented?

Coronavirus Disease 2019 is a recently emerging infection with a potential for developing into a global epidemic. Even though the exact source of transmission of this infection is unidentified, there are well-established preventative measures available for viral respiratory illnesses that are published by public health bodies and governmental organizations such as the UK’s National Health Service (NHS), US Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO).

Recommendations for the patients, their family members, caretakers, and the general public:

• Seeking immediate medical attention if any flu-like signs and symptoms are noted, particularly in the endemic areas, or where an episode or breakout has been reported
• To avoid human to animal transmission:
  • Avoiding direct contact with infected animals that may be hosts for the virus
  • Washing hands regularly and properly after touching animals
  • Cleaning and disinfection of animal farms on a regular basis
  • Quarantining specific areas of outbreak, monitoring animal movement, establishing animal health surveillance system
  • Culling infected animals and ensuring proper disposal of carcasses
  • Avoiding consumption of raw meat or undercooked meat and other animal products, including sample tasting while cooking
  • Washing hands before eating, or immediately after handling raw meat and other animal products; avoid cross-contamination of foods
  • Always clean up after walking or working in fields and on farmlands. Also, clean up after performing any activity that involves touching the soil, such as gardening, watering plants, outdoor camping, etc.
  • Workers on a farm should employ regular and thorough hand washing practices, before and after touching animals
  • Farm workers should avoid exposing family members to soiled clothes, footwear, tools, etc. from the farm
  • According to current reports, pets, such as cats and dogs, are not known to transmit the virus
• To avoid human to human transmission:
  • If infected, covering one’s mouth and nose using a tissue, while sneezing or coughing; always wearing a surgical face mask
  • Caretakers of infected individuals are also asked to follow stringent safety protocols
  • Self-isolation: Staying home to avoid infection spread
  • Social distancing, where a minimum distance (ideally six feet) is maintained from each other in public and closed spaces, where possible, to avoid any potential infection spread
  • Maintaining good personal hygiene
  • Avoiding contact with infected individuals, where possible
  • Taking precautions while coming into direct (physical) contact with body fluids of infected individuals
  • Washing hands properly with soap and water, after visiting or touching infected individuals
  • Washing hands frequently, and definitely before eating or touching one’s face (eyes, nose, or mouth)
  • Cleaning and disinfecting commonly touched surfaces, such as doorknobs and computer keyboards, as necessary; the use of a chlorine-based disinfectant is recommended
  • Maintaining good practices and ensuring overall public health and sanitation
  • Providing suitable treatment and medical care for conditions causing poor immunity
  • Avoiding travel to regions where the viral outbreak is reported
  • Individuals, who have traveled to the endemic regions, are asked to observe for any changes to their health status for a minimum period of 14 days
• Supplying clean drinking water and facilitating proper disposal of sewage/sanitary waste in communities
• Raising awareness about the infection through public education and awareness campaigns
• Educating immunocompromised patients and older adults by creating an awareness of possible infections, to better prepare them in seeking timely medical help

Recommendations for providers, personnel, and staff within healthcare settings:

• Initiating and instituting suitable measures for early and effective infection-control within the healthcare facility
• Practicing proper hand washing techniques - applicable for all healthcare professionals
• Informing and educating patients, caretakers, and hospital visitors on maintenance of proper hygiene practices and cleanliness
• Taking care to wear personal protective items, such as masks and gloves, while attending to infected individuals (for all healthcare workers and family members/caretakers of the infected)
• Using suitable (single-use) disposables such as gloves with long and tight-fitting cuffs, full-sleeve gowns, goggles, etc.
• Having well-trained staff handle samples from animals and humans 
• Disinfection and regular cleaning of hospital spaces and surfaces, such as patient rooms, consultation rooms, medical equipment, intensive care units, and surgical procedure areas, using antifungal disinfectants
• Cleaning and disinfecting hospital environment; adherence to standard bio- and other medical- wastes disposal techniques
• Use of proper disposal techniques while handling tissues, diapers, other contaminated items; washing hands thoroughly, after disposing them
• Advanced cleaning techniques in the hospital environment, including UV light, hydrogen peroxide, use of proper air cleaning, filtration, and ventilation techniques

Duly notifying local health departments to help prevent infection outbreaks in healthcare settings.

What is the Prognosis of Coronavirus Disease 2019? (Outcomes/Resolutions)

• Individuals with mild illnesses are known to fully recover with timely and appropriate treatment
• The prognosis of individuals, who are old or immunocompromised and having severe infections, depend on early recognition of the condition and prompt treatment
• Without adequate supportive care and therapy, Coronavirus Disease 2019 can result in complications, such as respiratory distress and organ failure, which may result in fatalities. Deaths are also observed due to comorbidities such as high blood pressure, cardiovascular diseases, and uncontrolled diabetes
• From what is observed, the death rate is between 2.5% to 3.5% among the general population. However, 15% of the affected individuals over the age of 80 years are known to succumb to COVID-19; in individuals with pre-existing cardiovascular diseases, the death rate is nearly 11%

At this time (March 2020), there are no vaccines available against Coronavirus Disease 2019. Research is underway to develop an effective vaccine against this strain of coronavirus, and several first round of tests have been conducted.

Based on current reports, even though COVID-19 is comparatively milder than Middle East respiratory syndrome and severe acute respiratory syndrome that has been responsible for thousands of deaths worldwide, it is more contagious than MERS and SARS.

Additional and Relevant Useful Information for Coronavirus Disease 2019:

According to authoritative scientific bodies, mammals, such as bats, and other warm-blooded animals are the primary hosts for coronaviruses. It is highly unlikely and improbable that snakes, which are cold-blooded reptiles, can be the host for the Wuhan coronaviruses.

We sincerely acknowledge and thank Dr. Ravi Kamepalli for reviewing the article. His valuable input and feedback have helped enrich the contents of this article.

Ravi Kamepalli, MD, FIDSA, CWSP.
Board Certified Infectious Disease, Wound Care, and Obesity Medicine.
Regional Infectious Diseases and Infusion Center, Inc.,
830 West High Street, Suite 255, Lima, OH 45801 USA