N. Rinaldi JP. Available evidence on risk factors associated with COVID-19's poorer outcomes, worldwide and in Brazil

Objectives: Analyse availability and quality of existing evidence on COVID-19's risk factors and underlying health conditions that are associated with poorer outcomes, worldwide and in Brazil. Methods: EBMR (Ovid), Google Scholar, MEDLINE (OvidSP), PubMed, CINAHL (EBSCO) and Cochrane Library databases were screened, plus Brazilian government epidemiological reports. A body of 25 articles plus 1 report met the inclusion criteria. Results: Available data are still disconnected and several biases exist throughout literature, mainly due to COVID-19 novelty aspect. Hypertension was the most analysed risk factor, followed by diabetes and chronic obstructive pulmonary disease. Availability of Brazilian data is significantly scarce and only governmental reports are readily available. Conclusion: Further studies, with good methodological designs, are needed to provide good levels of evidence in order to provide solid background to help the pandemic’s mitigation strategies.

Development of an Inactivated Vaccine Candidate, BBIBP-CorV, with Potent Protection against SARS-CoV-2

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) threatens global public health. The development of a vaccine is urgently needed for the prevention and control of COVID-19. Here, we report the pilot-scale production of an inactivated SARS-CoV-2 vaccine candidate (BBIBP-CorV) that induces high levels of neutralizing antibodies titers in mice, rats, guinea pigs, rabbits, and nonhuman primates (cynomolgus monkeys and rhesus macaques) to provide protection against SARS-CoV-2. Two-dose immunizations using 2 μg/dose of BBIBP-CorV provided highly efficient protection against SARS-CoV-2 intratracheal challenge in rhesus macaques, without detectable antibody-dependent enhancement of infection. In addition, BBIBP-CorV exhibits efficient productivity and good genetic stability for vaccine manufacture. These results support the further evaluation of BBIBP-CorV in a clinical trial.

Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China

BACKGROUND

The ongoing coronavirus disease 2019 (COVID-2019) pandemic has swept all over the world, posing a great pressure on critical care resources due to large number of patients needing critical care. Statements from front-line experts in the field of intensive care are urgently needed.

METHODS

Sixteen front-line experts in China fighting against the COVID-19 epidemic in Wuhan were organized to develop an expert statement after 5 rounds of expert seminars and discussions to provide trustworthy recommendation on the management of critically ill COVID-19 patients. Each expert was assigned tasks within their field of expertise to provide draft statements and rationale. Parts of the expert statement are based on epidemiological and clinical evidence, without available scientific evidences.

RESULTS

A comprehensive document with 46 statements are presented, including protection of medical personnel, etiological treatment, diagnosis and treatment of tissue and organ functional impairment, psychological interventions, immunity therapy, nutritional support, and transportation of critically ill COVID-19 patients. Among them, 5 recommendations were strong (Grade 1), 21 were weak (Grade 2), and 20 were experts' opinions. A strong agreement from voting participants was obtained for all recommendations.

CONCLUSION

There are still no targeted therapies for COVID-19 patients. Dynamic monitoring and supportive treatment for the restoration of tissue vascularization and organ function are particularly important.

Does Early Childhood Vaccination Protect Against COVID-19?

The coronavirus disease 2019 (COVID-19) is an on-going pandemic caused by the SARS-coronavirus-2 (SARS-CoV-2) which targets the respiratory system of humans. The published data show that children, unlike adults, are less susceptible to contracting the disease. This article aims at understanding why children constitute a minor group among hospitalized COVID-19 patients. Here, we hypothesize that the measles, mumps, and rubella (MMR) vaccine could provide a broad neutralizing antibody against numbers of diseases, including COVID-19. Our hypothesis is based on the 30 amino acid sequence homology between the SARS-CoV-2 Spike (S) glycoprotein (PDB: 6VSB) of both the measles virus fusion (F1) glycoprotein (PDB: 5YXW_B) and the rubella virus envelope (E1) glycoprotein (PDB: 4ADG_A). Computational analysis of the homologous region detected the sequence as antigenic epitopes in both measles and rubella. Therefore, we believe that humoral immunity, created through the MMR vaccination, provides children with advantageous protection against COVID-19 as well, however, an experimental analysis is required.

Features of enteric disease from human coronaviruses: Implications for COVID-19

Coronaviruses have long been studied in both human and veterinary fields. Whereas the initial detection of endemic human respiratory coronaviruses was problematic, detection of these and newly discovered human coronaviruses has been greatly facilitated with major advances in the laboratory. Nevertheless, technological factors can affect the accuracy and timeliness of virus detection. Many human coronaviruses can be variably found in stool samples. All human coronaviruses have been variably associated with symptoms of gastroenteritis. Coronaviruses can occasionally be cultured from enteric specimens, but most detection is accomplished with genetic amplification technologies. Excretion of viral RNA in stool can extend for a prolonged period. Culture‐positive stool samples have been found to exceed a fourteen day period after onset of infection for some coronaviruses. Virus can also sometimes be cultured from patients' respiratory samples during the late incubation period. Relatively asymptomatic patients may excrete virus. Both viable and nonviable virus can be found in the immediate environment of the patient, the health care worker, and less often the public. These lessons from the past study of animal and human coronaviruses can be extended to presumptions for severe acute respiratory syndrome coronavirus 2. Already, the early reports from the coronavirus disease‐2019 pandemic are confirming some concerns. These data have the cumulative potential to cause us to rethink some current and common public health and infection control strategies.

coronaviruses are variably found in human enteric samples during the course of infection.

abdominal and intestinal illnesses are associated with coronavirus infections.

enteric excretion of live virus and viral RNA have been confirmed.

occasionally, live virus can be found in stool samples to exceed a fourteen day period after disease onset, and virus can also be cultured from these samples during the late incubation period or from asymptomatic individuals.

Identification of RT-PCR-Negative Asymptomatic COVID-19 Patients via Serological Testing

Asymptomatic individuals with coronavirus disease (COVID-19) have been identified via nucleic acid testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); however, the epidemiologic characteristics and viral shedding pattern of asymptomatic patients remain largely unknown. In this study, serological testing was applied when identifying nine asymptomatic cases of COVID-19 who showed persistent negative RT-PCR test results for SARS-CoV-2 nucleic acid and no symptoms of COVID-19. Two asymptomatic cases were presumed to be index patients who had cleared the virus when their close contacts developed symptoms of COVID-19. Three of the asymptomatic cases were local individuals who spontaneously recovered before their presumed index patients developed symptoms of COVID-19. This report presents the epidemiologic and clinical characteristics of asymptomatic individuals with SARS-CoV-2 infection that were undetected on RT-PCR tests in previous epidemiologic investigations probably due to the transient viral shedding duration.

COVID-19: Monitoring the propagation of the first waves of the pandemic

Introduction: A phenomenological approach is proposed to monitor the propagation of the first waves of the COVID-19 pandemic.

Method: A large set of data collected during the first months of 2020 is compiled into a series of semi-logarithmic plots, for a selection of 32 countries from the five continents.

Results: Three regimes are identified in the propagation of an epidemic wave: a pre-epidemic regime 1, an exponential-growth regime 2, and a resorption regime 3. A two-parameters scaling of the first-wave death variation reported in China is used to fit the first-wave data reported in other countries. Comparison is made between the propagation of the pandemic in different countries, which are classified into four groups, from Group A where the pandemic first waves were contained efficiently, to Group D where the pandemic first waves widely spread. All Asian countries considered here, where fast and efficient measures have been applied, are in Group A. Group D is composed of Western-European countries and the United States of America (USA), where late decisions and confused political communication (pandemic seriousness, protection masks, herd immunity, etc.) led to a large number of deaths.

Discussion:The threat of resurging epidemic waves following a lift of lockdown measures is discussed. The results obtained in Asian countries from group A, as Hong Kong and South Korea, are highlighted, and the measures taken there are presented as examples that other countries may follow.

Health systems preparedness for COVID-19 pandemic

Some nations in the world and some states in India have had more success in containing this pandemic. Recent efforts in strengthening the health sector have focused largely on reforms in modes of financing, but as the pandemic brings home to us, the main challenge in India remains the challenge of the organization of public services using a health systems understanding. A close to community comprehensive primary health care, quality assurance, and planned excess capacity in public health systems, a more robust disease surveillance systems that can integrate data on new outbreaks and the indigenous technological capacity to scale up innovation and manufacture of essential health commodities are some of our most important requirements for both epidemic preparedness and response.

COVID-19, Australia: Epidemiology Report 17 (Fortnightly reporting period ending 24 May 2020)

Confirmed cases in Australia notified up to 24 May 2020: notifications = 7,135; deaths = 102. The incidence of COVID-19 has markedly reduced since a peak in mid-March. There have been no cases reported in SA, the NT or the ACT in the last four weeks. The numbers of new cases reported from other jurisdictions continue to be very low. Testing rates have been higher across all jurisdictions, with Victoria reporting an 85% testing rate increase and NSW a 40% increase over this period. The positivity rate nationally continues to remain very low at less than 0.1% over the reporting period. Continued high rates of testing are necessary to detect and mitigate the spread of COVID-19 in the community. Over the past fortnight, 45% of cases acquired their infection overseas. Of cases considered to be locally acquired over this period, most were associated with contacts of confirmed cases or were associated with known outbreaks. The highest rate of COVID-19 continues to be among people aged 65-79 years. Three-quarters of all cases in this age group have been associated with overseas travel, including several outbreaks linked to cruise ships. The lowest rate of disease is in children under 18, a pattern reflected in international reports. A small proportion of cases overall have experienced severe disease, requiring hospitalisation or intensive care with some fatalities. The crude case fatality rate amongst Australian cases is 1.4%. People who are older and have one or more comorbidities are more likely to experience severe disease. A combination of early case identification, physical distancing, public health measures and a reduction in international travel have likely been effective in slowing the spread of the disease in Australia. In addition, the median number of days between symptom onset and diagnostic testing has improved considerably from 7 days in the early phase of the outbreak to 1 day in the latest phase of the epidemic. Internationally, as at 24 May 2020, there have been recent increases in the number of daily cases reported globally. The largest numbers of both cases and deaths have been reported in the United States. Of the confirmed cases reported globally, the case fatality rate is approximately 6.5%. Countries in South America are starting to see rapid acceleration, while the United States is seeing a very slow decline in its daily new case numbers. In the South East Asia region, India and Bangladesh are seeing accelerating epidemics, compounded by the recovery from Cyclone Amphan. Increasing numbers of cases are also being reported in Africa, although the numbers are much smaller. In the Pacific there are very few daily new cases reported.

Considerations for an Individual-Level Population Notification System for Pandemic Response: A Review and Prototype

The outbreak of the coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, spread worldwide after its emergence in China. Whether rich or poor, all nations are struggling to cope with this new global health crisis. The speed of the threat's emergence and the quick response required from public health authorities and the public itself makes evident the need for a major reform in pandemic surveillance and notification systems. The development and implementation of a graded, individual-level pandemic notification system could be an effective tool to combat future threats of epidemics. This paper describes a prototype model of such a notification system and its potential advantages and challenges for implementation. Similar to other emergency alerts, this system would include a number of threat levels (level 1-5) with a higher level indicating increasing severity and intensity of safety measures (eg, level 1: general hygiene, level 2: enhanced hygiene, level 3: physical distancing, level 4: shelter in place, and level 5: lockdown). The notifications would be transmitted to cellular devices via text message (for lower threat levels) or push notification (for higher threat levels). The notification system would allow the public to be informed about the threat level in real time and act accordingly in an organized manner. New Zealand and the United Kingdom have recently launched similar alert systems designed to coordinate the ongoing COVID-19 pandemic response more efficiently. Implementing such a system, however, faces multiple challenges. Extensive preparation and coordination among all levels of government and relevant sectors are required. Additionally, such systems may be effective primarily in countries where there exists at least moderate trust in government. Advance and ongoing public education about the nature of the system and its steps would be an essential part of the system, such that all members of the public understand the meaning of each step in advance, similar to what has been established in systems for other emergency responses. This educational component is of utmost importance to minimize adverse public reaction and unintended consequences. The use of mass media and local communities could be considered where mobile phone penetration is low. The implementation of such a notification system would be more challenging in developing countries for several reasons, including inadequate technology, limited use of data plans, high population density, poverty, mistrust in government, and tendency to ignore or failure to understand the warning messages. Despite the challenges, an individual-level pandemic notification system could provide added benefits by giving an additional route for notification that would be complementary to existing platforms.

Real-time monitoring the transmission potential of COVID-19 in Singapore, March 2020

BACKGROUND

As of March 31, 2020, the ongoing COVID-19 epidemic that started in China in December 2019 is now generating local transmission around the world. The geographic heterogeneity and associated intervention strategies highlight the need to monitor in real time the transmission potential of COVID-19. Singapore provides a unique case example for monitoring transmission, as there have been multiple disease clusters, yet transmission remains relatively continued.

METHODS

Here we estimate the effective reproduction number, Rt, of COVID-19 in Singapore from the publicly available daily case series of imported and autochthonous cases by date of symptoms onset, after adjusting the local cases for reporting delays as of March 17, 2020. We also derive the reproduction number from the distribution of cluster sizes using a branching process analysis that accounts for truncation of case counts.

RESULTS

The local incidence curve displays sub-exponential growth dynamics, with the reproduction number following a declining trend and reaching an estimate at 0.7 (95% CI 0.3, 1.0) during the first transmission wave by February 14, 2020, while the overall R based on the cluster size distribution as of March 17, 2020, was estimated at 0.6 (95% CI 0.4, 1.02). The overall mean reporting delay was estimated at 6.4 days (95% CI 5.8, 6.9), but it was shorter among imported cases compared to local cases (mean 4.3 vs. 7.6 days, Wilcoxon test, p < 0.001).

CONCLUSION

The trajectory of the reproduction number in Singapore underscores the significant effects of successful containment efforts in Singapore, but it also suggests the need to sustain social distancing and active case finding efforts to stomp out all active chains of transmission.

Vitamin D Levels and COVID-19 Susceptibility: Is there any Correlation?

Coronavirus disease (COVID-19) is a major pandemic and now a leading cause of death worldwide. Currently, no drugs/vaccine is available for the treatment of this disease. Future preventions and social distancing are the only ways to prevent this disease from community transmission. Vitamin D is an important micronutrient and has been reported to improve immunity and protect against respiratory illness. This short review highlights the important scientific link between Vitamin D levels and susceptibility to COVID-19 in patients. This review also discusses recommendations for Vitamin D dose required for healthy as well as COVID-19 susceptible patients for protection and prevention.

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COVID-19 is a pandemic outbreak affecting people globally.

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Vitamin D supplementation could increase the immunity and decrease the COVID-19 susceptibility

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The mechanisms linking Vitamin D levels and immune system have been described in this review

Potential fecal transmission of SARS-CoV-2: Current evidence and implications for public health

Coronavirus disease 2019 (COVID-19) emerged in Hubei Province, China in December 2019 and has since become a global pandemic, with hundreds of thousands of cases and over 165 countries affected. Primary routes of transmission of the causative virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), are through respiratory droplets and close person-to-person contact. While information about other potential modes of transmission are relatively sparse, evidence supporting the possibility of a fecally mediated mode of transmission has been accumulating. Here, current knowledge on the potential for fecal transmission is briefly reviewed and the possible implications are discussed from a public health perspective.

Consensus for prevention and management of coronavirus disease 2019 (COVID-19) for neurologists

Coronavirus disease 2019 (COVID-19) has become a pandemic disease globally. Although COVID-19 directly invades lungs, it also involves the nervous system. Therefore, patients with nervous system involvement as the presenting symptoms in the early stage of infection may easily be misdiagnosed and their treatment delayed. They become silent contagious sources or 'virus spreaders'. In order to help neurologists to better understand the occurrence, development and prognosis, we have developed this consensus of prevention and management of COVID-19. It can also assist other healthcare providers to be familiar with and recognise COVID-19 in their evaluation of patients in the clinic and hospital environment.

Fecal specimen diagnosis 2019 novel coronavirus-infected pneumonia

The emergence and spread of 2019 novel coronavirus-infected pneumonia (COVID-19) from Wuhan, China, it has spread globally. We extracted the data on 14 patients with laboratory-confirmed COVID-19 from Jinhua Municipal Central hospital through 27 January 2020. We found that compared to pharyngeal swab specimens, nucleic acid detection of COVID-19 in fecal specimens was equally accurate. And we found that patients with a positive stool test did not experience gastrointestinal symptoms and had nothing to do with the severity of the lung infection. These results may help to understand the clinical diagnosis and the changes in clinical parameters of COVID-19.

The impact of ethnicity on clinical outcomes in COVID-19: A systematic review

BACKGROUND

The relationship between ethnicity and COVID-19 is uncertain. We performed a systematic review to assess whether ethnicity has been reported in patients with COVID-19 and its relation to clinical outcomes.

METHODS

We searched EMBASE, MEDLINE, Cochrane Library and PROSPERO for English-language citations on ethnicity and COVID-19 (1st December 2019-15th May 2020). We also reviewed: COVID-19 articles in NEJM, Lancet, BMJ, JAMA, clinical trial protocols, grey literature, surveillance data and preprint articles on COVID-19 in MedRxiv to evaluate if the association between ethnicity and clinical outcomes were reported and what they showed. PROSPERO:180654.

FINDINGS

Of 207 articles in the database search, five reported ethnicity; two reported no association between ethnicity and mortality. Of 690 articles identified from medical journals, 12 reported ethnicity; three reported no association between ethnicity and mortality. Of 209 preprints, 34 reported ethnicity - 13 found Black, Asian and Minority Ethnic (BAME) individuals had an increased risk of infection with SARS-CoV-2 and 12 reported worse clinical outcomes, including ITU admission and mortality, in BAME patients compared to White patients. Of 12 grey literature reports, seven with original data reported poorer clinical outcomes in BAME groups compared to White groups.

INTERPRETATION

Data on ethnicity in patients with COVID-19 in the published medical literature remains limited. However, emerging data from the grey literature and preprint articles suggest BAME individuals are at an increased risk of acquiring SARS-CoV-2 infection compared to White individuals and also worse clinical outcomes from COVID-19. Further work on the role of ethnicity in the current pandemic is of urgent public health importance.

FUNDING

NIHR.

Longer incubation period of coronavirus disease 2019 (COVID-19) in older adults

OBJECTIVE

The aim of this study was to explore any age-related change in the incubation period of COVID-19, specifically any difference between older (aged ≥65 years) and younger adults.

METHODS

Based on online data released officially by 21 Chinese cities from January 22 to February 15, 2020, the incubation period of COVID-19 patients who had travelled to Hubei was studied according to age. Previous studies were reviewed and compared.

RESULTS

The study recruited 136 COVID-19 patients who had travelled to Hubei during January 5-31, 2020, stayed for 1-2 days, and returned with symptom onset during January 10-February 6, 2020. The median age was 50.5 years (range 1-86 years), and 22 patients (16.2%) were aged ≥65 years. The age-stratified incubation period was U-shaped with higher values at extremes of age. The median COVID-19 incubation period was 8.3 (90% confidence interval [CI], 7.4-9.2) days for all patients, 7.6 (90% CI, 6.7-8.6) days for younger adults, and 11.2 (90% CI, 9.0-13.5) days for older adults. The 5th/25th/75th/90th percentiles were 2.3/5.3/11.3/14.2 days for all, 2.0/5.0/10.5/13.2 days for younger adults, and 3.1/7.8/14.4/17.0 days for older adults. There were 11 published studies on COVID-19 incubation periods up to March 30, 2020, reporting means of 1.8-7.2 days, and medians of 4-7.5 days, but there was no specific study on the effect of age on incubation period. One study showed that severe COVID-19 cases, which included more elderly patients, had longer incubation periods.

CONCLUSION

Based on 136 patients with a travel history to Hubei, the epicenter of COVID-19, the COVID-19 incubation period was found to be longer in older adults. This finding has important implications for diagnosis, prevention, and control of COVID-19.

COVID-19: What Should Interventional Radiologists Know and What Can They Do?

The outbreak of coronavirus disease 2019 (COVID-19) in late December 2019 in Wuhan, China, has been characterized as a "pandemic" by the World Health Organization and has resulted in 81,603 confirmed cases in China, among the 334,981 cases confirmed in 189 countries as of 09:00 am, March 24, 2020 (China central standard time). During the past 3 months, hundreds of thousands of Chinese health care workers, including interventional radiologists (IRs), have been fighting this battle against the horrifying COVID-19 disease. As IRs, what should we know and what can we do when facing this challenge? This paper shares the experience we have gone through.

Patients of COVID-19 may benefit from sustained Lopinavir-combined regimen and the increase of Eosinophil may predict the outcome of COVID-19 progression

OBJECTIVES

To explore the epidemiological information, clinical characteristics, therapeutic outcomes and temporal progression of laboratory findings in 2019-coronavirus disease (COVID-19) patients exposed to lopinavir.

METHODS

We collected data from ten COVID-19 patients admitted between January 22, 2020 and February 11, 2020 at Xixi hospital in Hangzhou, China.

RESULTS

Of ten patients, secondary, tertiary and quartus patients emerged; the incubation period was 3-7 days. Mainly initial symptoms were cough and low fever (37.3-38.0°C). An asymptomatic case presented normal radiography, the others had ground glass opacities. All cases (three transferred, seven discharged) were exposed to lopinavir on initial hospitalization. Three patients stopped lopinavir because of adverse effects, two of them deteriorated, one was hospitalized longer than others who with sustained lopinavir use. Levels of potassium, albumin, and lymphocytes were low, but increased persistently after treatment. Eosinophil values were low on initial hospitalization, then all returned to normal before discharge. Viral load of SARS-CoV-2, radiography and eosinophil improved continuously in 3-14, 6-8 and 7-9 days, respectively.

CONCLUSIONS

Increasing eosinophils may be an indicator of COVID-19 improvement. The COVID-19 patients may benefit from sustained lopinavir use. More research on a larger scale is needed to verify these points.

COVID-19 complicated by pulmonary embolism treated with catheter directed thrombectomy

Summary: COVID-19 is a recently identified illness that is associated with thromboembolic events. We report a case of pulmonary embolism in a patient with COVID-19, treated by catheter directed thrombectomy. A 57 year old patient presented to the emergency center with severe COVID-19 symptoms and developed massive pulmonary embolism. The patient was treated with catheter directed thrombolysis (CDT) and recovered completely. Coagulopathy associated with COVID-19 is present in all severe cases and is a dynamic process. We describe a case of massive/high risk pulmonary embolism, in a patient with COVID-19 receiving full anticoagulation, who was treated by percutaneous intervention. CDT can be an additional therapeutic option in patients with COVID-19 and pulmonary embolism that present with rapid clinical collapse.

Coronavirus Disease 2019 and Diabetes: The Epidemic and the Korean Diabetes Association Perspective

Diabetes has been associated with more severe outcomes and higher mortality in coronavirus disease 2019 (COVID-19) patients compare to morbidity and mortality in patients without diabetes. Several mechanisms may play a role in this greater morbidity and mortality, especially uncontrolled hyperglycemia, an impaired immune system, pre-existing proinflammatory states, multiple comorbidities, and dysregulated angiotensin-converting enzyme 2 signaling. Thus, the diabetes medical community emergently needs to know about COVID-19 and its effects on patients with diabetes, as they must take precautions to carefully manage these patients during the COVID-19 pandemic. The Korean Diabetes Association provides some guidance and practical recommendations for the management of diabetes during the pandemic. This report provides insight into the association between diabetes and COVID-19, proper management of diabetes in patients with COVID-19 and an official suggestion by the Korean Diabetes Association for managing the COVID-19 outbreak.

Epidemiology of COVID-19 Among Children in China

OBJECTIVE

To identify the epidemiological characteristics and transmission patterns of pediatric patients with the 2019 novel coronavirus disease (COVID-19) in China.

METHODS

Nationwide case series of 2135 pediatric patients with COVID-19 reported to the Chinese Center for Disease Control and Prevention from January 16, 2020, to February 8, 2020, were included. The epidemic curves were constructed by key dates of disease onset and case diagnosis. Onset-to-diagnosis curves were constructed by fitting a log-normal distribution to data on both onset and diagnosis dates.

RESULTS

There were 728 (34.1%) laboratory-confirmed cases and 1407 (65.9%) suspected cases. The median age of all patients was 7 years (interquartile range: 2-13 years), and 1208 case patients (56.6%) were boys. More than 90% of all patients had asymptomatic, mild, or moderate cases. The median time from illness onset to diagnoses was 2 days (range: 0-42 days). There was a rapid increase of disease at the early stage of the epidemic, and then there was a gradual and steady decrease. The disease rapidly spread from Hubei province to surrounding provinces over time. More children were infected in Hubei province than any other province.

CONCLUSIONS

Children of all ages appeared susceptible to COVID-19, and there was no significant sex difference. Although clinical manifestations of children's COVID-19 cases were generally less severe than those of adult patients, young children, particularly infants, were vulnerable to infection. The distribution of children's COVID-19 cases varied with time and space, and most of the cases were concentrated in Hubei province and surrounding areas. Furthermore, this study provides strong evidence of human-to-human transmission.

Presence of mismatches between diagnostic PCR assays and coronavirus SARS-CoV-2 genome

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; initially named as 2019-nCoV) is responsible for the recent COVID-19 pandemic and polymerase chain reaction (PCR) is the current standard method for its diagnosis from patient samples. This study conducted a reassessment of published diagnostic PCR assays, including those recommended by the World Health Organization (WHO), through the evaluation of mismatches with publicly available viral sequences. An exhaustive evaluation of the sequence variability within the primer/probe target regions of the viral genome was performed using more than 17 000 viral sequences from around the world. The analysis showed the presence of mutations/mismatches in primer/probe binding regions of 7 assays out of 27 assays studied. A comprehensive bioinformatics approach for in silico inclusivity evaluation of PCR diagnostic assays of SARS-CoV-2 was validated using freely available software programs that can be applied to any diagnostic assay of choice. These findings provide potentially important information for clinicians, laboratory professionals and policy-makers.

Chest CT Findings in Coronavirus Disease-19 (COVID-19): Relationship to Duration of Infection

In this retrospective study, chest CTs of 121 symptomatic patients infected with coronavirus disease-19 (COVID-19) from four centers in China from January 18, 2020 to February 2, 2020 were reviewed for common CT findings in relationship to the time between symptom onset and the initial CT scan (i.e. early, 0-2 days (36 patients), intermediate 3-5 days (33 patients), late 6-12 days (25 patients)). The hallmarks of COVID-19 infection on imaging were bilateral and peripheral ground-glass and consolidative pulmonary opacities. Notably, 20/36 (56%) of early patients had a normal CT. With a longer time after the onset of symptoms, CT findings were more frequent, including consolidation, bilateral and peripheral disease, greater total lung involvement, linear opacities, "crazy-paving" pattern and the "reverse halo" sign. Bilateral lung involvement was observed in 10/36 early patients (28%), 25/33 intermediate patients (76%), and 22/25 late patients (88%).

Interim Guidelines on Antiviral Therapy for COVID-19

Since the first case was reported in Wuhan, Hubei Province, China on December 12, 2019, Coronavirus disease 2019 (COVID-19) has spread widely to other countries since January 2020. As of April 16, 2020, 10635 confirmed cases have been reported, with 230 deaths in Korea. COVID-19 patients may be asymptomatic or show various clinical manifestations, including acute symptoms such as fever, fatigue, sore throat; pneumonia presenting as acute respiratory distress syndrome; and multiple organ failure. As COVID-19 has such varied clinical manifestations and case fatality rates, no standard antiviral therapy regimen has been established other than supportive therapy. In the present guideline, we aim to introduce potentially helpful antiviral and other drug therapies based on in vivo and in vitro research and clinical experiences from many countries.

Epidemiology reveals mask wearing by the public is crucial for COVID-19 control

Objective

The pandemic 2019 Coronavirus disease (COVID-19) is the greatest concern globally. Here we analyzed the epidemiological features of China, South Korea, Italy and Spain to find out the relationship of major public health events and epidemiological curves.

Study design

In this study we described and analyzed the epidemiological characteristics of COVID-19 in and outside China. We used GAM to generate the epidemiological curves and simulated infection curves with reported incubation period.

Results

The epidemiological curves derived from the GAM suggested that the infection curve can reflect the public health measurements sensitively. Under the massive actions token in China, the infection curve flattened at 23rd of January. While surprisingly, even before Wuhan lockdown and first level response of public emergency in Guangdong and Shanghai, those infection curve came to the reflection point both at 21st of January, which indicated the mask wearing by the public before 21st Jan were the key measure to cut off the transmission. In the countries outside China, infection curves also changed in response to measures, but its rate of decline was much smaller than the curve of China's.

Conclusion

The present analysis comparing the epidemiological curves in China, South Korea, Italy and Spain supports the importance of mask wearing by the public. Analysis of the infection curve helped to clarify the impact of important public health events, evaluate the efficiencies of prevention measures, and showed wearing masks in public resulted in significantly reduced daily infected cases.

Age-Related Morbidity and Mortality among Patients with COVID-19

On March 11, 2020, the World Health Organization declared coronavirus disease (COVID-19), caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. During the COVID-19 pandemic, an age-associated vulnerability in the burden of disease has been uncovered. Understanding the spectrum of illness and the pathogenic mechanism of the disease in a vulnerable population is critical, especially during the pandemic. Herein, we reviewed published COVID-19 epidemiology data from several countries to identify any consistent trends in the relationship between age and COVID-19-associated morbidity or mortality. We also reviewed the literature for studies explaining the difference in the host response to SARS-CoV-2 infection according to age. The insights from these data will be useful in determining the treatment policies and preventive measures of COVID-19.

Elevated plasma levels of selective cytokines in COVID-19 patients reflect viral load and lung injury

A recent outbreak of pneumonia in Wuhan, China was found to be caused by a 2019 novel coronavirus (2019-nCoV or SARS-CoV-2 or HCoV-19). We previously reported the clinical features of 12 patients with 2019-nCoV infections in Shenzhen, China. To further understand the pathogenesis of COVID-19 and find better ways to monitor and treat the disease caused by 2019-nCoV, we measured the levels of 48 cytokines in the blood plasma of those 12 COVID-19 patients. Thirty-eight out of the 48 measured cytokines in the plasma of 2019-nCoV-infected patients were significantly elevated compared to healthy individuals. Seventeen cytokines were linked to 2019-nCoV loads. Fifteen cytokines, namely M-CSF, IL-10, IFN-α2, IL-17, IL-4, IP-10, IL-7, IL-1ra, G-CSF, IL-12, IFN-γ, IL-1α, IL-2, HGF and PDGF-BB, were strongly associated with the lung-injury Murray score and could be used to predict the disease severity of 2019-nCoV infections by calculating the area under the curve of the receiver-operating characteristics. Our results suggest that 2019-nCoV infections trigger extensive changes in a wide array of cytokines, some of which could be potential biomarkers of disease severity of 2019-nCoV infections. These findings will likely improve our understanding of the immunopathologic mechanisms of this emerging disease. Our results also suggest that modulators of cytokine responses may play a therapeutic role in combating the disease once the functions of these elevated cytokines have been characterized.

An evidence-based framework for priority clinical research questions for COVID-19

BACKGROUND

On 31 December, 2019, the World Health Organization China Country Office was informed of cases of pneumonia of unknown aetiology. Since then, there have been over 75 000 cases globally of the 2019 novel coronavirus (COVID-19), 2000 deaths, and over 14 000 cases recovered. Outbreaks of novel agents represent opportunities for clinical research to inform real-time public health action. In 2018, we conducted a systematic review to identify priority research questions for Severe Acute Respiratory Syndrome-related coronavirus (SARS-CoV) and Middle East Respiratory Syndrome-related coronavirus (MERS-CoV). Here, we review information available on COVID-19 and provide an evidenced-based framework for priority clinical research in the current outbreak.

METHODS

Three bibliographic databases were searched to identify clinical studies published on SARS-CoV and MERS-CoV in the outbreak setting. Studies were grouped thematically according to clinical research questions addressed. In February 2020, available information on COVID19 was reviewed and compared to the results of the SARS-CoV and MERS-CoV systematic review.

RESULTS

From the research objectives for SARS-CoV and MERS-CoV, ten themes in the literature were identified: Clinical characterisation, prognosis, diagnosis, clinical management, viral pathogenesis, epidemiological characterisation, infection prevention and control/transmission, susceptibility, psychosocial, and aetiology. For COVID19, some information on clinical presentation, diagnostic testing, and aetiology is available but many clinical research gaps have yet to be filled.

CONCLUSIONS

Based on a systematic review of other severe coronaviruses, we summarise the state of clinical research for COVID-19, highlight the research gaps, and provide recommendations for the implementation of standardised protocols. Data based on internationally standardised protocols will inform clinical practice real-time.

Coronavirus: Update Related to the Current Outbreak of COVID-19

In December 2019, some cases of viral pneumonia were epidemiologically related to a new coronavirus in the province of Hubei, China. Subsequently, there has been an increase in infections attributable to this virus throughout China and worldwide. The World Health Organization (WHO) has officially named the infection coronavirus disease 2019 (COVID-19), and the virus has been classified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This appears to be a virus from Rhinolophus bats, but the intermediate host has not yet been identified. The mechanism of infection of SARS-CoV-2 is not yet known; it appears to have affinity for cells located in the lower airways, where it replicates. The interhuman transmission of coronaviruses mainly occurs through saliva droplets and direct and indirect contact via surfaces. As of March 10, 2020, the number of cases worldwide was 113,702. Along with severe acute respiratory syndrome (SARS) and Middle Eastern respiratory syndrome (MERS), COVID-19 appears to cause a severe clinical picture in humans, ranging from mild malaise to death by sepsis/acute respiratory distress syndrome. The prognosis is worse in elderly patients with comorbidities. To date, there is no specific therapy for COVID-19. Prevention of SARS-CoV-2 infection implies strategies that limit the spread of the virus. WHO and other international and national bodies have developed continuously updated strategic objectives and provisions to contain the spread of the virus and infection.

Case-Fatality Risk Estimates for COVID-19 Calculated by Using a Lag Time for Fatality

We estimated the case-fatality risk for coronavirus disease cases in China (3.5%); China, excluding Hubei Province (0.8%); 82 countries, territories, and areas (4.2%); and on a cruise ship (0.6%). Lower estimates might be closest to the true value, but a broad range of 0.25%-3.0% probably should be considered.

Clinical and virologic characteristics of the first 12 patients with coronavirus disease 2019 (COVID-19) in the United States

Data on the detailed clinical progression of COVID-19 in conjunction with epidemiological and virological characteristics are limited. In this case series, we describe the first 12 US patients confirmed to have COVID-19 from 20 January to 5 February 2020, including 4 patients described previously^1-3. Respiratory, stool, serum and urine specimens were submitted for SARS-CoV-2 real-time reverse-transcription polymerase chain reaction (rRT-PCR) testing, viral culture and whole genome sequencing. Median age was 53 years (range: 21-68); 8 patients were male. Common symptoms at illness onset were cough (n = 8) and fever (n = 7). Patients had mild to moderately severe illness; seven were hospitalized and demonstrated clinical or laboratory signs of worsening during the second week of illness. No patients required mechanical ventilation and all recovered. All had SARS-CoV-2 RNA detected in respiratory specimens, typically for 2-3 weeks after illness onset. Lowest real-time PCR with reverse transcription cycle threshold values in the upper respiratory tract were often detected in the first week and SARS-CoV-2 was cultured from early respiratory specimens. These data provide insight into the natural history of SARS-CoV-2. Although infectiousness is unclear, highest viral RNA levels were identified in the first week of illness. Clinicians should anticipate that some patients may worsen in the second week of illness.

Ações federais para apoio e fortalecimento local no combate ao COVID-19: a Atenção Primária à Saúde (APS) no assento do condutor

Resumo O Ministério da Saúde, por intermédio da Secretaria de Atenção Primária à Saúde e em parceria com a Secretaria de Vigilância em Saúde construiu e implementou estratégias da Atenção Primária à Saúde (APS) no âmbito do apoio aos gestores locais e em articulação com o Conselho Nacional de Secretários Estaduais (CONASS) e Municipais de Saúde (CONASEMS) para o combate ao COVID-19. Essas ações têm a APS como a grande responsável por diversas áreas e recursos físicos, humanos e financeiros, assim como permite impulsionar o avanço nacional para o uso de tecnologias de informação e comunicação e novas parcerias para realização de pesquisas.

Perioperative Management of Patients Infected with the Novel Coronavirus: Recommendation from the Joint Task Force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists

The outbreak of the new Coronavirus disease, COVID-19, has been involved in 77,262 cases in China as well as in 27 other countries as of February 24, 2020. Because the virus is novel to human beings, and there is no vaccine yet available, every individual is susceptible and can become infected. Healthcare workers are at high risk, and unfortunately, more than 3,000 healthcare workers in China have been infected. Anesthesiologists are among healthcare workers who are at an even higher risk of becoming infected because of their close contact with infected patients and high potential of exposure to respiratory droplets or aerosol from their patients' airways. In order to provide healthcare workers with updated recommendations on the management of patients in the perioperative setting as well as for emergency airway management outside of the operating room, the two largest anesthesia societies, the Chinese Society of Anesthesiology (CSA) and the Chinese Association of Anesthesiologists (CAA) have formed a task force to produce the recommendations. The task force hopes to help healthcare workers, particularly anesthesiologists, optimize the care of their patients and protect patients, healthcare workers, and the public from becoming infected. The recommendations were created mainly based on the practice and experience of anesthesiologists who provide care to patients in China. Therefore, adoption of these recommendations outside of China must be done with caution, and the local environment, culture, uniqueness of the healthcare system, and patients' needs should be considered. The task force will continuously update the recommendations and incorporate new information in future versions.

Risk of nosocomial transmission of coronavirus disease 2019: an experience in a general ward setting in Hong Kong

BACKGROUND

Coronavirus disease 2019 (COVID-19) was first reported in Wuhan in December 2019 and has rapidly spread across different cities within and outside China. Hong Kong started to prepare for COVID-19 on 31st December 2019 and infection control measures in public hospitals were tightened to limit nosocomial transmission within healthcare facilities. However, the recommendations on the transmission-based precautions required for COVID-19 in hospital settings vary from droplet and contact precautions, to contact and airborne precautions with placement of patients in airborne infection isolation rooms.

AIM

To describe an outbreak investigation of a patient with COVID-19 who was nursed in an open cubicle of a general ward before the diagnosis was made.

METHOD

Contacts were identified and risk categorized as 'close' or 'casual' for decisions on quarantine and/or medical surveillance. Respiratory specimens were collected from contacts who developed fever, and/or respiratory symptoms during the surveillance period and were tested for SARS-CoV-2.

FINDINGS

A total of 71 staff and 49 patients were identified from contact tracing, seven staff and 10 patients fulfilled the criteria of 'close contact'. At the end of 28-day surveillance, 76 tests were performed on 52 contacts and all were negative, including all patient close contacts and six of the seven staff close contacts. The remaining contacts were asymptomatic throughout the surveillance period.

CONCLUSION

Our findings suggest that SARS-CoV-2 is not spread by an airborne route, and nosocomial transmissions can be prevented through vigilant basic infection control measures, including wearing of surgical masks, hand and environmental hygiene.