Clinical Characteristics of Patients Hospitalized with Coronavirus Disease, Thailand

COVID-19 fatality rates in hospitalized patients: A new systematic review and meta-analysis

BACKGROUND

SARS-COV2 or COVID-19 disease is an infectious illness that emerged for the first time at the end of 2019, in Wuhan, China and rapidly turned out to be an international pandemic with deleterious effects all over the world. In March 2021, A. Macedo et al., has published the first meta-analysis of hospital mortality, so the authors decided to update those data at a time of emergence of new therapies and increasing vaccination rates.

METHODS

As the outcome of interest was the mortality in hospitalized general patients, the authors looked for articles evaluating the clinical characteristics of those patients, consulting PUBMED (The US National Library of Medicine) and EMBASE (Medical database) in an independent selection using predefined terms of search. A meta-analysis random-effect model was estimated using Mantel-Haenszel method. Heterogeneity among studies was tested using Tau2 statistics and Chi2 statistics.

RESULTS

In a first instance 25 articles were included for final analysis with a total of 103,840 patients, but as the goal was to update the anterior data, these studies were analysed together with the 21 studies of the previous meta-analysis, with a total of 114609 patients. The mortality rate of COVID-19 general patients admitted to the hospital was 16% (95% CI 12; 21, I2 =100%).

CONCLUSION

Global hospital mortality of COVID-19 of general patients was 16%, with quite different rates according to the different geographic areas analysed.

The COVID-19, tuberculosis and HIV/AIDS: Ménage à Trois

In December 2019, a novel pneumonic condition, Coronavirus disease 2019 (COVID- 19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), broke out in China and spread globally. The presentation of COVID-19 is more severe in persons with underlying medical conditions such as Tuberculosis (TB), Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) and other pneumonic conditions. All three diseases are of global concern and can significantly affect the lungs with characteristic cytokine storm, immunosuppression, and respiratory failure. Co-infections of SARS-CoV-2 with HIV and Mycobacterium tuberculosis (Mtb) have been reported, which may influence their pathogenesis and disease progression. Pulmonary TB and HIV/AIDS patients could be more susceptible to SARS-CoV-2 infection leading to lethal synergy and disease severity. Therefore, the biological and epidemiological interactions of COVID-19, HIV/AIDS, and TB need to be understood holistically. While data is needed to predict the impact of the COVID-19 pandemic on these existing diseases, it is necessary to review the implications of the evolving COVID-19 management on HIV/AIDS and TB control, including therapy and funding. Also, the impact of long COVID on patients, who may have this co-infection. Thus, this review highlights the implications of COVID-19, HIV/AIDS, and TB co-infection compares disease mechanisms, addresses growing concerns, and suggests a direction for improved diagnosis and general management.

Respiratory viral co-infections in patients with COVID-19 and associated outcomes: A systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to critically assess the published literature related to community-acquired viral co-infections and COVID-19 and to evaluate the prevalence, most identified co-pathogens, and relevant risk factors. Furthermore, we aimed to examine the clinical features and outcomes of co-infected compared to mono-infected COVID-19 patients. We systematically searched PubMed, Web of Science, Embase, Scopus, and The Cochrane Library for studies published from 1 November 2019 to 13 August 2021. We included patients of all ages and any COVID-19 severity who were screened for respiratory viral co-infection within 48 h of COVID-19 diagnosis. The main outcome was the proportion of patients with a respiratory viral co-infection. The systematic review was registered to PROSPERO (CRD42021272235). Out of 6053 initially retrieved studies, 59 studies with a total of 16,643 SARS-CoV-2 positive patients were included. The global pooled prevalence was 5.01% (95% CI 3.34%-7.27%; I2  = 95%) based on a random-effects model, with Influenza Viruses (1.54%) and Enteroviruses (1.32%) being the most prevalent pathogens. Subgroup analyses showed that co-infection was significantly higher in paediatric (9.39%) than adult (3.51%) patients (p-value = 0.02). Furthermore, co-infected patients were more likely to be dyspnoeic and the odds of fatality (OR = 1.66) were increased. Although a relatively low proportion of COVID-19 patients have a respiratory viral co-infection, our findings show that multiplex viral panel testing may be advisable in patients with compatible symptoms. Indeed, respiratory virus co-infections may be associated with adverse clinical outcomes and therefore have therapeutic and prognostic implications.

Bacterial co-infections and antimicrobial resistance associated with the Coronavirus Disease 2019 infection

Bacterial co-infections are typically associated with viral respiratory tract infections and pose a significant public health problem around the world. COVID-19 infection damages tissues lining the respiratory track and regulates immune cells/cytokines leading to microbiome dysbiosis and facilitating the area to be colonized by pathogenic bacterial agents. There have been reports of different types of bacterial co-infection in COVID-19 patients. Some of these reports showed despite geographical differences and differences in hospital settings, bacterial co-infections are a major cause of morbidity and mortality in COVID-19 patients. The inappropriate use of antibiotics for bacterial infections, particularly broad-spectrum antibiotics, can also further complicate the infection process, often leading to multi drug resistance, clinical deterioration, poor prognosis, and eventually death. To this end, researchers must establish a new therapeutic approach to control SARS-CoV-2 and the associated microbial coinfections. Hence, the aim of this review is to highlight the bacterial co-infection that has been recorded in COVID-19 patients and the status of antimicrobial resistance associated with the dual infections.

An overview of gastrointestinal diseases in patients with COVID-19: A narrative review

Coronavirus disease-2019 (COVID-19), caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), has emerged as a global health concern. This study aimed to review the epidemiology and pathophysiology of COVID-19 and provide evidence for the implementation of control measures. We utilized several online databases, including MEDLINE (National Library of Medicine, Bethesda, Maryland, USA), PubMed, EMBASE, Web of Science, and Google Scholar, to collect relevant published papers using a combination of the following keywords: "COVID-19," "SARS-CoV-2," "novel coronavirus," "epidemiology," and "pathophysiology." The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used in this study. Globally, approximately 3-46% of patients with SARS-CoV-2 infection experience gastrointestinal symptoms. The clinical spectrum of COVID-19 is wide, ranging from mild to severe, and even fatal. COVID-19 was initially reported as a respiratory tract disease; however, gastrointestinal symptoms have only recently been reported. COVID-19 Patients with gastrointestinal symptoms may have more severe clinical manifestations and poor prognosis. This study highlights the need to better understand the mechanisms involved in the development of gastrointestinal symptoms in patients with COVID-19 to prevent the further spread of this pathogen.

Asthma and risk of infection, hospitalization, ICU admission and mortality from COVID-19: Systematic review and meta-analysis

OBJECTIVE

As COVID-19 spreads across the world, there are concerns that people with asthma are at a higher risk of acquiring the disease, or of poorer outcomes. This systematic review aimed to summarize evidence on the risk of infection, severe illness and death from COVID-19 in people with asthma.

DATA SOURCES AND STUDY SELECTION

A comprehensive search of electronic databases including preprint repositories and WHO COVID-19 database was conducted (until 26 May 2020). Studies reporting COVID-19 in people with asthma were included. For binary outcomes, we performed Sidik-Jonkman random effects meta-analysis. We explored quantitative heterogeneity by subgroup analyses, meta regression and evaluating the I2 statistic.

RESULTS

Fifty-seven studies with an overall sample size of 587 280 were included. The prevalence of asthma among those infected with COVID-19 was 7.46% (95% CI = 6.25-8.67). Non-severe asthma was more common than severe asthma (9.61% vs. 4.13%). Pooled analysis showed a 14% risk ratio reduction in acquiring COVID-19 (95% CI = 0.80-0.94; p < 0.0001) and 13% reduction in hospitalization with COVID-19 (95% CI = 0.77-0.99, p = 0.03) for people with asthma compared with those without. There was no significant difference in the combined risk of requiring admission to ICU and/or receiving mechanical ventilation for people with asthma (RR = 0.87 95% CI = 0.94-1.37; p = 0.19) and risk of death from COVID-19 (RR = 0.87; 95% CI = 0.68-1.10; p = 0.25).

CONCLUSION

The findings from this study suggest that the prevalence of people with asthma among COVID-19 patients is similar to the global prevalence of asthma. The overall findings suggest that people with asthma have a lower risk than those without asthma for acquiring COVID-19 and have similar clinical outcomes.

Epidemiological and Clinical Characteristics of Pediatric COVID-19 in the Tertiary Care System in Thailand: Comparative Delta and pre-Delta Era

Background

Few studies had focused on the epidemiological and clinical characteristics of pediatric COVID-19 (SARS-CoV-2) during Delta and pre-Delta eras in Asia, despite it being a pandemic.

Objective

To study the epidemiological and clinical characteristics of three waves of pediatric COVID-19 infections in a tertiary-care setting in Thailand.

Methods

This retrospective study reviewed all PCR-confirmed pediatric (0-18 years of age) COVID-19 infections between January 13, 2020, and October 31, 2021, in a tertiary care system in Thailand.

Results

1,019 patients, aged 0.02 - 18 years, 552 (54.2%) male, and 467 (45.8%) female, with a median age of 9.2 years, were enrolled. Asymptomatic cases accounted for 35.7%, of which 106 (18.9%) had abnormal chest X-ray findings. Most cases were classified as having mild clinical symptoms, with only 8 (0.8%) and 4 (0.4%) developing a severe and critical illness, respectively. There were no deaths. The Delta variant appeared more transmissible than previous ones, but we did not see any difference in disease severity. Upper respiratory tract symptoms were predominant, while few cases had lower respiratory tract involvement. The sensitivity and specificity of dyspnea symptoms to predict radiologically confirmed pneumonia were 14% and 95%, respectively, with a likelihood ratio of 3.37. The overall prognosis was good, with only 13 (1.3 %) needing respiratory support. All cases showed clinical improvement with a decent recovery.

Conclusion

Pediatric COVID-19 during the Delta variant predominance era generally appeared more transmissible but benign. One-fifth of cases had pneumonia, but few cases needed respiratory support. Prevention remains important for disease control.

The Prevalence and Impact of Coinfection and Superinfection on the Severity and Outcome of COVID-19 Infection: An Updated Literature Review

Patients with viral illness are at higher risk of secondary infections—whether bacterial, viral, or parasitic—that usually lead to a worse prognosis. In the setting of Corona Virus Disease 2019 (COVID-19), the Severe Acute Respiratory Syndrome Coronavirus-type 2 (SARS-CoV-2) infection may be preceded by a prior microbial infection or has a concurrent or superinfection. Previous reports documented a significantly higher risk of microbial coinfection in SARS-CoV-2-positive patients. Initial results from the United States (U.S.) and Europe found a significantly higher risk of mortality and severe illness among hospitalized patients with SARS-CoV-2 and bacterial coinfection. However, later studies found contradictory results concerning the impact of coinfection on the outcomes of COVID-19. Thus, we conducted the present literature review to provide updated evidence regarding the prevalence of coinfection and superinfection amongst patients with SARS-CoV-2, possible mechanisms underlying the higher risk of coinfection and superinfection in SARS-CoV-2 patients, and the impact of coinfection and superinfection on the outcomes of patients with COVID-19.

COMMON VARIABLE IMMUNODEFICIENCY: PREDISPOSING OR PROTECTIVE FACTOR FOR SEVERE COMPLICATIONS OF COVID-19?

Coronavirus disease 2019 (COVID-19) is an emerging infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The usual presentation of the disease is a common cold-like illness but it can present with more severe and sometimes fatal manifestations. Immunocompromised patients such as those with common variable immunodeficiency (CVID) also are among the infected population. A limited number of reports have been published concerning CVID patients with COVID-19. The main reported symptoms were fever, cough, dyspnea and fatigue while the median duration of illness was 19 (interquartile range 14-26.5) days. Total recovery rate was 88.4%. It is still unknown whether primary immunodeficiency interacts as a predisposing or protective factor against the severe forms of COVID-19. Substitute immunoglobulin (IG) therapy is the only treatment option for CVID. Some reports suggest that early administration of intravenous IGs or convalescent plasma infusion may positively influence the outcome of COVID-19 in these patients.

Clinical Implications of Hematologic and Hemostatic Abnormalities in Children With COVID-19

Leukopenia, thrombocytopenia, elevated D-dimer, and prolonged prothrombin time are considered poor prognostic factors in adults with acute Coronavirus Disease 2019. The prognostic significance of these abnormalities among pediatric patients remains underreported in the literature. This retrospective cohort study evaluates the prognostic implications of hematologic and hemostatic derangements in patients younger than 22-years-of-age who were admitted to a tertiary-care referral institution for management of acute Coronavirus Disease 2019 infection. Leukopenia and thrombocytopenia were identified as independent prognostic factors of disease severity. Although the majority of children, with available results, had elevated D-dimer or prolonged prothrombin time upon initial presentation, these markers were not found to be associated with the development of severe clinical complications.

Knowledge, attitude, and practices toward COVID-19 among the international travelers in Thailand

BACKGROUND

International travel is among the leading impactful factors of COVID-19 transmission; thus, adequate knowledge, good attitude and good preventive practices toward COVID-19 for international travelers are particularly essential for successful pandemic control.

METHODS

A cross-sectional, questionnaire-based study was conducted to determine knowledge, attitude and practices (KAP) of international travelers (both Thai and non-Thai) and expatriates in Thailand. The data were collected at the Thai Travel Clinic, Bangkok, Thailand and via online platforms during May to October 2020. The independent T-test, Chi-square test and multiple regression analysis (MRA) were applied to determine factors influencing the KAP.

RESULTS

Of 399 travelers, 46.6% were male, 72.1% had a Bachelor's degree or higher, and the mean age was 35.6 ± 9.6 years. Due to unexpected travel restrictions and lock down, 77.9% of participants were Thai and the respective major purpose of travel was business/work. Travel cancellation/postponement was reported at 73.9%. While sufficient knowledge (≥ 60% correct answers) was reported in 77.9% of participants, a low percentage of correct answers was found in the questions regarding disease transmission. The travelers reported a neutral attitude and an overall moderate concern regarding the COVID-19 situation. Adequate preventive practices were determined by the average practice score 3.54 ± 0.38 (0 = never and 4 = always). The MRA revealed that the factors influencing good practices were travelers who: i) enrolled from outside the hospital (online platform); ii) received pretravel advice at hospital; iii) were female; iv) participated before the declaration of the end of the outbreak; v) were aged 40-49 years, and vi) visited friends and relatives.

CONCLUSIONS

The majority of travelers in this study had sufficient knowledge, a neutral attitude and adequate preventive practices toward COVID-19. The factors influencing good practices included pretravel advice, sex, age and the point in the timeline of the outbreak. In order to better control the COVID-19 pandemic situation, pretravel counselling and advice should be promoted as a means to improve knowledge, particularly in disease transmission, increase awareness and emphasize appropriate preventive measures toward COVID-19 among international travelers. Furthermore, preventive practices should be bolstered at all times regardless of the outbreak situation.

Impact of COVID-19 pandemic on liver, liver diseases, and liver transplantation programs in intensive care units

Emerging worldwide data have been suggesting that coronavirus disease 2019 (COVID-19) pandemic consequences are not limited to the respiratory and cardiovascular systems but encompass adverse gastrointestinal manifestations including acute liver injury as well. Severe cases of liver injury associated with higher fatality rates were observed in critically ill patients with COVID-19. Intensive care units (ICU) have been the center of disposition of severe cases of COVID-19. This review discusses the pathogenesis of acute liver injury in ICU patients with COVID-19, and analyzes its prevalence, consequences, possible drug-induced liver injury, and the impact of the pandemic on liver diseases and transplantation programs.

Frequency of respiratory pathogens other than SARS-CoV-2 detected during COVID-19 testing

The frequencies of 19 respiratory pathogens other than SARS-CoV-2 were assessed in 6,"?>235 Brazilian individuals tested for COVID-19. Overall, only 83 individuals who tested positive for SARS-CoV-2 had codetection of other pathogens. Individuals infected with Rhinovirus/Enterovirus, Human Coronavirus (HCoV)-HKU1, HCoV-NL63, HPIV-4, Influenza A (-H1N1 and other subtypes), Influenza B, Human Respiratory Syncytial Virus and Human Metapneumovirus were less likely to test positive for SARS-CoV-2. Infection with Streptococcys pyogenes, Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Bordetella pertussis were more frequent in individuals who tested negative for SARS-CoV-2, but without significancy. We found 150 individuals infected with ≥2 pathogens other than SARS-CoV-2, only 3 out of whom tested positive for COVID-19. The codetection frequency was low in individuals diagnosed with COVID-19. Other viral infections may provide a cross-reactive, protective immune response against SARS-CoV-2. Screening for bacterial respiratory infections upon COVID-19 testing is important to drive suitable therapeutic approaches and avoid unnecessary antibiotic prescription.

Co-infection of SARS-CoV-2 and influenza viruses: A systematic review and meta-analysis

We conducted this meta-analysis to determine the proportion of co-infection with influenza viruses in SARS-CoV-2 positive patients and to investigate the severity of COVID-19 in these patients. We included studies with SARS-CoV-2 infection confirmed by qRT-PCR and influenza virus infection (A and/or B) by nucleic acid tests. The proportion of co-infection was compared between children and adults, and between critically ill or deceased patients compared to overall patients. Fifty-four articles were included. The overall proportion of co-infection was 0.7%, 95%CI = [0.4 – 1.3]. Most influenza co-infections were due to the influenza A virus (74.4%). The proportion of co-infection with influenza viruses among children (3.2%, 95% CI = [0.9 – 10.9]) was significantly higher than that in adult patients (0.3%, 95% CI = [0.1 – 1.2]), p-value <0.01. The proportion of co-infection with influenza viruses among critically ill patients tended to be higher than that in overall patients (2.2%, 95% CI = [0.3 – 22.4] versus 0.6%, 95% CI = [0.3 – 1.2], respectively, p-value = 0.22). Screening for pathogens in co-infection, particularly influenza viruses in patients infected with SARS-CoV-2, is necessary. This warrants close surveillance and investigation of the co-incidences and interactions of SARS-CoV-2 and other respiratory viruses, which is facilitated by the expansion of syndromic diagnosis approaches through the use of multiplex PCR assays.

Asymptomatic SARS-CoV-2 infection: A systematic review and meta-analysis

Quantification of asymptomatic infections is fundamental for effective public health responses to the COVID-19 pandemic. Discrepancies regarding the extent of asymptomaticity have arisen from inconsistent terminology as well as conflation of index and secondary cases which biases toward lower asymptomaticity. We searched PubMed, Embase, Web of Science, and World Health Organization Global Research Database on COVID-19 between January 1, 2020 and April 2, 2021 to identify studies that reported silent infections at the time of testing, whether presymptomatic or asymptomatic. Index cases were removed to minimize representational bias that would result in overestimation of symptomaticity. By analyzing over 350 studies, we estimate that the percentage of infections that never developed clinical symptoms, and thus were truly asymptomatic, was 35.1% (95% CI: 30.7 to 39.9%). At the time of testing, 42.8% (95% prediction interval: 5.2 to 91.1%) of cases exhibited no symptoms, a group comprising both asymptomatic and presymptomatic infections. Asymptomaticity was significantly lower among the elderly, at 19.7% (95% CI: 12.7 to 29.4%) compared with children at 46.7% (95% CI: 32.0 to 62.0%). We also found that cases with comorbidities had significantly lower asymptomaticity compared to cases with no underlying medical conditions. Without proactive policies to detect asymptomatic infections, such as rapid contact tracing, prolonged efforts for pandemic control may be needed even in the presence of vaccination.

Sero-surveillance for SARS-CoV-2 infection among healthcare providers in four hospitals in Thailand one year after the first community outbreak

BACKGROUND

Thailand was the first country outside China to report SARS-CoV-2 infected cases. Since the detection of the first imported case on January 12th, 2020 to the time this report was written, Thailand experienced two waves of community outbreaks (March-April 2020 and December 2020-March 2021). We examined prevalence of SARS-CoV-2 seropositivity among healthcare providers (HCPs) in four hospitals approximately one year after SARS-CoV-2 first detected in Thailand. By March 2021, these hospitals have treated a total of 709 coronavirus disease 2019 (COVID-19) patients.

METHODS

Blood specimens, collected from COVID-19 unvaccinated HCPs during January-March 2021, were tested for the presence of SARS-CoV-2 immunoglobulin G (IgG) antibodies to nucleocapsid (IgG-nucleocapsid) and spike (IgG-spike) proteins using Euroimmune® enzyme-linked immunosorbent assays.

RESULTS

Of 600 HCPs enrolled, 1 (0.2%) tested positive for the SARS-CoV-2 IgG-spike antibodies, but not the IgG-nucleocapsid.

CONCLUSION

The presence of SARS-CoV-2 IgG antibodies was rare in this sample of HCPs, suggesting that this population remains susceptible to SARS-CoV-2 infection.

Coinfections with Bacteria, Fungi, and Respiratory Viruses in Patients with SARS-CoV-2: A Systematic Review and Meta-Analysis

Background: Coinfection with bacteria, fungi, and respiratory viruses in SARS-CoV-2 is of particular importance due to the possibility of increased morbidity and mortality. In this meta-analysis, we calculated the prevalence of such coinfections. Methods: Electronic databases were searched from 1 December 2019 to 31 March 2021. Effect sizes of prevalence were pooled with 95% confidence intervals (CIs). To minimize heterogeneity, we performed sub-group analyses. Results: Of the 6189 papers that were identified, 72 articles were included in the systematic review (40 case series and 32 cohort studies) and 68 articles (38 case series and 30 cohort studies) were included in the meta-analysis. Of the 31,953 SARS-CoV-2 patients included in the meta-analysis, the overall pooled proportion who had a laboratory-confirmed bacterial infection was 15.9% (95% CI 13.6–18.2, n = 1940, 49 studies, I² = 99%, p < 0.00001), while 3.7% (95% CI 2.6–4.8, n = 177, 16 studies, I² = 93%, p < 0.00001) had fungal infections and 6.6% (95% CI 5.5–7.6, n = 737, 44 studies, I² = 96%, p < 0.00001) had other respiratory viruses. SARS-CoV-2 patients in the ICU had higher co-infections compared to ICU and non-ICU patients as follows: bacterial (22.2%, 95% CI 16.1–28.4, I² = 88% versus 14.8%, 95% CI 12.4–17.3, I² = 99%), and fungal (9.6%, 95% CI 6.8–12.4, I² = 74% versus 2.7%, 95% CI 0.0–3.8, I² = 95%); however, there was an identical other respiratory viral co-infection proportion between all SARS-CoV-2 patients [(ICU and non-ICU) and the ICU only] (6.6%, 95% CI 0.0–11.3, I² = 58% versus 6.6%, 95% CI 5.5–7.7, I² = 96%). Funnel plots for possible publication bias for the pooled effect sizes of the prevalence of coinfections was asymmetrical on visual inspection, and Egger’s tests confirmed asymmetry (p values < 0.05). Conclusion: Bacterial co-infection is relatively high in hospitalized patients with SARS-CoV-2, with little evidence of S. aureus playing a major role. Knowledge of the prevalence and type of co-infections in SARS-CoV-2 patients may have diagnostic and management implications.

Epidemiological and clinical characteristics of non-severe and severe pediatric and adult COVID-19 patients across different geographical regions in the early phase of pandemic: a systematic review and meta-analysis of observational studies

This systematic and meta-review aimed to compare clinical presentation, outcomes, and care management among patients with COVID-19 during the early phase of the pandemic. A total of 77 peer-reviewed publications were identified between January 1, 2020 and April 9, 2020 from PubMed, Google Scholar, and Chinese Medical Journal databases. Subsequently, meta-analysis of 40 non-overlapping studies, comprising of 4844 patients from seven countries, was conducted to see differences in clinical characteristics and laboratory outcomes across patients from different geographical regions (Wuhan, other parts of China and outside China), severity (non-severe, severe and fatal) and age groups (adults and children). Patients from Wuhan had a higher mean age (54.3 years) and rates of dyspnea (39.5%) compared with patients from other parts of China and outside China. Myalgia, fatigue, acute respiratory distress syndrome (ARDS) and fatalities were also significantly more prevalent among Wuhan patients. A significant dose–response increase in prevalence of diabetes, D-dimer, white blood cells, neutrophil levels and ARDS was seen from non-severe to severe and fatal outcomes. A significant increase in mean duration of symptom onset to admission was seen between non-severe cases (4.2 days) and severe and fatal cases (6.3 days and 8.8 days, respectively). Proportion of asymptomatic cases was higher in children (20%) compared with adults (2.4%). In conclusion, patients with COVID-19 from Wuhan displayed more severe clinical disease during the early phase of the pandemic, while disease severity was significantly lesser among pediatric cases. This review suggests that biomarkers at admission may be useful for prognosis among patients with COVID-19.

Understanding viral shedding of severe acute respiratory coronavirus virus 2 (SARS-CoV-2): Review of current literature

OBJECTIVE

Transmission of SARS-CoV-2 has significant implications for hospital infection prevention and control, discharge management, and public health. We reviewed available literature to reach an evidenced-based consensus on the expected duration of viral shedding.

DESIGN

We queried 4 scholarly repositories and search engines for studies reporting SARS-CoV-2 viral shedding dynamics by PCR and/or culture available through September 8, 2020. We calculated the pooled median duration of viral RNA shedding from respiratory and fecal sources.

RESULTS

The review included 77 studies on SARS-CoV-2. All studies reported PCR-based testing and 12 also included viral culture data. Among 28 studies, the overall pooled median duration of RNA shedding from respiratory sources was 18.4 days (95% CI, 15.5-21.3; I2 = 98.87%; P < .01). When stratified by disease severity, the pooled median duration of viral RNA shedding from respiratory sources was 19.8 days (95% CI, 16.2-23.5; I2 = 96.42%; P < .01) among severely ill patients and 17.2 days (95% CI, 14.0-20.5; I2 = 95.64%; P < .01) in mild-to-moderate illness. Viral RNA was detected up to 92 days after symptom onset. Viable virus was isolated by culture from -6 to 20 days relative to symptom onset.

CONCLUSIONS

SARS-COV-2 RNA shedding can be prolonged, yet high heterogeneity exists. Detection of viral RNA may not correlate with infectivity since available viral culture data suggests shorter durations of shedding of viable virus. Additional data are needed to determine the duration of shedding of viable virus and the implications for risk of transmission.

Guidelines for Reopening a Nation in a SARS-CoV-2 Pandemic: A Path Forward

Background and Objectives: Action, not fear, is the path forward in the coronavirus infectious disease 2019 (COVID-19) pandemic. Since early 2020, the world's nations have faced conundrums over severe acute respiratory syndrome corona virus type 2 (SARS-CoV-2) infections resulting in COVID-19 resulting in national closures, and thus, a clear understandable plan that nations can implement is required to reopen. The healthcare benefits of reopening a nation more likely than not exceed the benefits of continued pandemic-related closure. Pandemic-related closures have resulted in countless delayed or avoided urgent care evaluations. Furthermore, routine care of acute and chronic illnesses, including evaluations, diagnoses, and treatments, has also been delayed. Isolation, loss of income, and fear have resulted in mental health conditions or exacerbated existing conditions. The magnitude of untoward ramifications is unknown and may ultimately represent an inestimable degree of danger and morbidity, and even death. The pandemic of SARS-CoV-2 has created an atmosphere of fear of COVID-19 that has directly and indirectly injured the world's population. Since this has resulted in increasing morbidity and mortality, creating economic chaos, and near systemic collapse of educational systems with no well described plan forward, it is the purpose of this study to provide guidelines that provide a path forward to safely open a nation. Physicians often equipped by their education, training, and experiences across disciplines are uniquely positioned to comprehend, coordinate, and teach other physicians, business owners, and municipal and government leaders from guidelines. As such, physicians may take the lead in a path forward to reopening a nation, including opening businesses, educational facilities, and religious establishments, while minimizing the risk of SARS-CoV-2 infection. Materials and Methods: Reviews of the literature among the disciplines of environmental air, sanitation, social interaction, medical testing, vaccination, protection, and disease prevention and safety allowed for the conceptualization and eventual genesis of identifiable interventions which either reduce the viral load in the environment or inactivate the virus from replication. Each of the guidelines was selected based on the principle that it involved the elimination or inactivation of the viral particle. With a reduction in viral load or inactivation of replication, the implementation of these guidelines is expected to allow for reopening a nation with an increased level of safety. Results: The guidelines identified, including air exchange (ventilation), air filtration, personal protective filtering devices (masks), hand hygiene, social distancing, screening and testing, vaccines, high-risk patient protection, medical management, and adjunctive therapies, are described and referenced. Conclusions: In that the pandemic is primarily a public health issue, the path forward is best coordinated by local, regional, and national physicians. Many physicians with a breadth of experiences are uniquely positioned to coordinate the implementation of these interdisciplinary guidelines. Using these guidelines as a planned, coordinated action, not fear, is a path forward. Nations have a decision to make: closuring versus opening.

Prevalence and outcomes of co-infection and superinfection with SARS-CoV-2 and other pathogens: A systematic review and meta-analysis

INTRODUCTION

The recovery of other pathogens in patients with SARS-CoV-2 infection has been reported, either at the time of a SARS-CoV-2 infection diagnosis (co-infection) or subsequently (superinfection). However, data on the prevalence, microbiology, and outcomes of co-infection and superinfection are limited. The purpose of this study was to examine the occurrence of co-infections and superinfections and their outcomes among patients with SARS-CoV-2 infection.

PATIENTS AND METHODS

We searched literature databases for studies published from October 1, 2019, through February 8, 2021. We included studies that reported clinical features and outcomes of co-infection or superinfection of SARS-CoV-2 and other pathogens in hospitalized and non-hospitalized patients. We followed PRISMA guidelines, and we registered the protocol with PROSPERO as: CRD42020189763.

RESULTS

Of 6639 articles screened, 118 were included in the random effects meta-analysis. The pooled prevalence of co-infection was 19% (95% confidence interval [CI]: 14%-25%, I2 = 98%) and that of superinfection was 24% (95% CI: 19%-30%). Pooled prevalence of pathogen type stratified by co- or superinfection were: viral co-infections, 10% (95% CI: 6%-14%); viral superinfections, 4% (95% CI: 0%-10%); bacterial co-infections, 8% (95% CI: 5%-11%); bacterial superinfections, 20% (95% CI: 13%-28%); fungal co-infections, 4% (95% CI: 2%-7%); and fungal superinfections, 8% (95% CI: 4%-13%). Patients with a co-infection or superinfection had higher odds of dying than those who only had SARS-CoV-2 infection (odds ratio = 3.31, 95% CI: 1.82-5.99). Compared to those with co-infections, patients with superinfections had a higher prevalence of mechanical ventilation (45% [95% CI: 33%-58%] vs. 10% [95% CI: 5%-16%]), but patients with co-infections had a greater average length of hospital stay than those with superinfections (mean = 29.0 days, standard deviation [SD] = 6.7 vs. mean = 16 days, SD = 6.2, respectively).

CONCLUSIONS

Our study showed that as many as 19% of patients with COVID-19 have co-infections and 24% have superinfections. The presence of either co-infection or superinfection was associated with poor outcomes, including increased mortality. Our findings support the need for diagnostic testing to identify and treat co-occurring respiratory infections among patients with SARS-CoV-2 infection.

Antimicrobial Resistance Threats in the emerging COVID-19 pandemic: Where do we stand?

Antimicrobial resistance (AMR) continues to exert a substantial toll on the global health and world economy and is now expected to be hidden by COVID-19 for a while. The wrong consumption of antibiotics during the COVID-19 pandemic will raise disastrous effects on AMR management and antibiotic stewardship programs. This is related to the concerns extrapolated due to an increase in mortality rates in patients with bacterial coinfections. Importantly, the immune system of COVID-19 patients in regions with high AMR may be fighting on two fronts altogether, the virus and MDR bacteria. Current control policies to manage AMR and prioritization of antibiotic stewardship plans are mandatory during this pandemic. This review aims to discuss the rising concerns of the excess use of antibiotics in COVID-19 patients highlighting the role of bacterial coinfections in these patients. Types of prescribed antibiotics and the development of antibiotic resistance is addressed as well.

Epidemiology, clinical characteristics, and treatment outcomes of patients with COVID-19 at Thailand's university-based referral hospital

Background

The epidemiology and outcomes of COVID-19 patients in Thailand are scarce.

Methods

This retrospective cohort study included adult hospitalized patients who were diagnosed with COVID-19 at Siriraj Hospital during February 2020 to April 2020.

Results

The prevalence of COVID-19 was 7.5% (107 COVID-19 patients) among 1409 patients who underwent RT-PCR for SARS-CoV-2 detection at our hospital during the outbreak period. Patients with COVID-19 presented with symptoms in 94.4%. Among the 104 patients who were treated with antiviral medications, 78 (75%) received 2-drug regimen (lopinavir/ritonavir or darunavir/ritonavir plus chloroquine or hydroxychloroquine), and 26 (25%) received a 3-drug regimen with favipiravir added to the 2-drug regimen. Disease progression was observed in 18 patients (16.8%). All patients with COVID-19 were discharged alive.

Conclusions

The prevalence of COVID-19 was 7.5% among patients who underwent RT-PCR testing, and 10% among those having risk factors for COVID-19 acquisition. Combination antiviral therapies for COVID-19 patients were well-tolerated and produced a favorable outcome.

Population-Based COVID-19 Screening in Mexico: Assessment of Symptoms and Their Weighting in Predicting SARS-CoV-2 Infection

Background and Objectives: Sentinel surveillance in the early stage of the COVID-19 pandemic in Mexico represented a significant cost reduction and was useful in estimating the population infected with SARS-CoV-2. However, it also implied that many patients were not screened and therefore had no accurate diagnosis. In this study, we carried out a population-based SARS-CoV-2 screening in Mexico to evaluate the COVID-19-related symptoms and their weighting in predicting SARS-CoV-2 infection. We also discuss this data in the context of the operational definition of suspected cases of COVID-19 established by the Mexican Health Authority’s consensus. Materials and Methods: One thousand two hundred seventy-nine subjects were included. They were screened for SARS-CoV-2 using RT-PCR. The weighting of COVID-19 symptoms in predicting SARS-CoV-2 infection was evaluated statistically. Results: Three hundred and twenty-five patients were positive for SARS-CoV-2 and 954 were negative. Fever, asthenia, dysgeusia, and oxygen saturation predicted SARS-CoV-2 infection (odds ratios ranged from 1.74 to 4.98; p < 0.05). The percentage of asymptomatic COVID-19 patients was 36% and only 38.15% met the Mexican operational definition. Cq-values for the gene N of SARS-CoV-2 were significantly higher in asymptomatic subjects than in the groups of COVID-19 patients with neurological, respiratory, and/or musculoskeletal manifestations (p < 0.05). Conclusions: Dysgeusia, fever, and asthenia increased the odds of a positive result for COVID-19 1.74–4.98-fold among the study population. Patients with neurological, respiratory, and/or musculoskeletal manifestations had higher viral loads at COVID-19 diagnosis than those observed in asymptomatic patients. A high percentage of the participants in the study (61.85%) did not meet the operational definition for a suspected case of COVID-19 established by the Mexican Health Authority’s consensus, representing a high percentage of the population that could have remained without a COVID-19 diagnosis, so becoming a potential source of virus spread.

Determining the communicable period of SARS-CoV-2: A rapid review of the literature, March to September 2020

IntroductionStandard testing for infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is based on RT-PCR tests, but detection of viral genetic material alone does not indicate ongoing infectious potential. The ability to isolate whole virus represents a better proxy for infectivity.AimThe objective of this study was to gain an understanding of the current literature and compare the reported periods of positive SARS-CoV-2 detection from studies that conducted RT-PCR testing in addition to experiments isolating whole virus.MethodsUsing a rapid review approach, studies reporting empirical data on the duration of positive RT-PCR results and/or successful viral isolation following SARS-CoV-2 infection in humans were identified through searches of peer-reviewed and pre-print health sciences literature. Articles were screened for relevance, then data were extracted, analysed, and synthesised.ResultsOf the 160 studies included for qualitative analysis, 84% (n = 135) investigated duration of positive RT-PCR tests only, 5% (n = 8) investigated duration of successful viral isolations, while 11% (n = 17) included measurements on both. There was significant heterogeneity in reported data. There was a prolonged time to viral clearance when deduced from RT-PCR tests compared with viral isolations (median: 26 vs 9 days).DiscussionFindings from this review support a minimum 10-day period of isolation but certain cases where virus was isolated after 10 days were identified. Given the extended time to viral clearance from RT-PCR tests, future research should ensure standard reporting of RT-PCR protocols and results to help inform testing policies aimed at clearance from isolation.

How fever is defined in COVID-19 publications: a disturbing lack of precision

OBJECTIVES

Fever is the single most frequently reported manifestation of COVID-19 and is a critical element of screening persons for COVID-19. The meaning of "fever" varies depending on the cutoff temperature used, the type of thermometer, the time of the day, the site of measurements, and the person's gender and race. The absence of a universally accepted definition for fever has been especially problematic during the current COVID-19 pandemic.

METHODS

This investigation determined the extent to which fever is defined in COVID-19 publications, with special attention to those associated with pregnancy.

RESULTS

Of 53 publications identified in which "fever" is reported as a manifestation of COVID-19 illness, none described the method used to measure patient's temperatures. Only 10 (19%) publications specified the minimum temperature used to define a fever with values that varied from a 37.3 °C (99.1 °F) to 38.1 °C (100.6 °F).

CONCLUSIONS

There is a disturbing lack of precision in defining fever in COVID-19 publications. Given the many factors influencing temperature measurements in humans, there can never be a single, universally accepted temperature cut-off defining a fever. This clinical reality should not prevent precision in reporting fever. To achieve the precision and improve scientific and clinical communication, when fever is reported in clinical investigations, at a minimum the cut-off temperature used in determining the presence of fever, the anatomical site at which temperatures are taken, and the instrument used to measure temperatures should each be described. In the absence of such information, what is meant by the term "fever" is uncertain.

COVID-19 fatality rates in hospitalized patients: systematic review and meta-analysis

Background

Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. Although general and local public health report deathly cases, case fatality rates are still largely unknown. Thus, we sought to evaluate the mortality of COVID-19.

Methods

We searched PubMed and EMBASE databases for articles evaluating the clinical characteristics of COVID-19 patients that included clinical outcomes, between December 2020 and 24 April 2020. Two authors performed an independent selection using predefined terms of search.

Results

We retrieved 33 studies with a total of 13,398 patients with COVID-19 diagnosis. The mortality rate of the COVID‐19 patients was 17.1% (95% CI 12.7; 22.7, I² = 96.9%). For general patients admitted to the hospital (excluding critical care-only studies) the mortality rate of the COVID‐19 was 11.5% (95% CI 7.7; 16.9, I² = 96.7%). Among critical illness studies (n = 7) we found a 40.5% mortality (95% CI 31.2; 50.6, I² = 91.8%).

Conclusion

High COVID-19 mortality among general admitted patients and critical care cases should guide resources allocations and economic burden calculations during the pandemics.

East-West differences in clinical manifestations of COVID-19 patients: A systematic literature review and meta-analysis

The coronavirus disease 2019 (COVID-19) pandemic is currently not under control. We aimed to assess whether there are differences in clinical manifestations between COVID-19 patients from the East (East and South-East Asian countries including China, South Korea, and Thailand) and the West (North American, European, and Middle East countries, including the United States, Italy, France, and Iran). For this meta-analysis, we searched for eligible studies about COVID-19 in three databases: PubMed, EMBASE, and the Cochrane Library. Studies were divided into two cohorts for analysis: the East and the West. Stata 13.1 software was used for the meta-analysis. Of the 1527 studies initially identified by the literature search, 169 full-text articles were retrieved and screened for eligibility. Fifty-seven of these, describing 19,353 patients, were deemed eligible for inclusion. Of these, 45 studies with 8416 patients were from the East while 12 studies with 10,937 patients were from the West. The results indicated that the incidences of cough, headache, dizziness, nasal congestion, and digestive symptoms in COVID-19 patients from the East were lower than those in the West. The laboratory data showed that there were no significant differences in the levels of lymphocytes, leukocytes, C-reactive protein, and platelet counts between the two groups. In addition, our results also showed that the incidence of cardiac and kidney injury, as well as increased levels of creatinine, alanine transaminase, and aspartate transaminase, were significantly higher in patients from the West than from the East. Our meta-analysis indicated that there are differences in the clinical manifestations of COVID-19 in patients from the East and the West. COVID-19 patients from the West appear to suffer more severe liver, kidney, and heart damage due to SARS-CoV-2.

Co-infection of SARS-COV-2 and Influenza A Virus: A Case Series and Fast Review

Coronavirus disease 2019 (COVID-19) occurs in the influenza season and has become a global pandemic. The present study aimed to examine severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) co-infection with influenza A virus (IAV) in an attempt to provide clues for the antiviral interventions of co-infected patients. We described two patients who were co-infected with SARS-CoV-2 and IAV treated at Wuhan Union Hospital, China. In addition, we performed a review in PubMed, Web of Science and CNKI (from January 1 up to November 1, 2020) with combinations of the following key words: “COVID-19, SARS-COV-2, influenza A and co-infection”. A total of 28 co-infected patients were enrolled in the analysis. Of the 28 patients, the median age was 54.5 years (IQR, 34.25–67.5) and 14 cases (50.0%) were classified as severe types. The most common symptoms were fever (85.71%), cough (82.14%) and dyspnea (60.71%). Sixteen patients had lymphocytopenia on admission and 23 patients exhibited abnormal radiological changes. The median time from symptom onset to hospital admission was 4 days (IQR, 3–6), and the median time of hospital stay was 14 days (IQR, 8.5–16.75). In conclusion, patients with SARS-COV-2 and IAV co-infection were similar to those infected with SARS-COV-2 alone in symptoms and radiological images. SARS-COV-2 co-infection with IAV could lead to more severe clinical condition but did not experience longer hospital stay compared with patients infected with SARS-COV-2 alone.

Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis

Background

The proportion of patients infected with SARS-CoV-2 that are prescribed antibiotics is uncertain, and may contribute to patient harm and global antibiotic resistance.

Objective

The aim was to estimate the prevalence and associated factors of antibiotic prescribing in patients with COVID-19.

Data Sources

We searched MEDLINE, OVID Epub and EMBASE for published literature on human subjects in English up to June 9 2020.

Study Eligibility Criteria

We included randomized controlled trials; cohort studies; case series with ≥10 patients; and experimental or observational design that evaluated antibiotic prescribing.

Participants

The study participants were patients with laboratory-confirmed SARS-CoV-2 infection, across all healthcare settings (hospital and community) and age groups (paediatric and adult).

Methods

The main outcome of interest was proportion of COVID-19 patients prescribed an antibiotic, stratified by geographical region, severity of illness and age. We pooled proportion data using random effects meta-analysis.

Results

We screened 7469 studies, from which 154 were included in the final analysis. Antibiotic data were available from 30 623 patients. The prevalence of antibiotic prescribing was 74.6% (95% CI 68.3–80.0%). On univariable meta-regression, antibiotic prescribing was lower in children (prescribing prevalence odds ratio (OR) 0.10, 95% CI 0.03–0.33) compared with adults. Antibiotic prescribing was higher with increasing patient age (OR 1.45 per 10 year increase, 95% CI 1.18–1.77) and higher with increasing proportion of patients requiring mechanical ventilation (OR 1.33 per 10% increase, 95% CI 1.15–1.54). Estimated bacterial co-infection was 8.6% (95% CI 4.7–15.2%) from 31 studies.

Conclusions

Three-quarters of patients with COVID-19 receive antibiotics, prescribing is significantly higher than the estimated prevalence of bacterial co-infection. Unnecessary antibiotic use is likely to be high in patients with COVID-19.

Neurological Manifestations in COVID-19 Infection: A Systematic Review and Meta-Analysis

BACKGROUND

Growing evidence showed that coronavirus disease 2019 (COVID-19) infection may present with neurological manifestations. This review aimed to determine the neurological manifestations and complications in COVID-19.

METHODS

We conducted a systematic review and meta-analysis that included cohort and case series/reports involving a population of patients confirmed with COVID-19 infection and their neurologic manifestations. We searched the following electronic databases until April 18, 2020: PubMed, Embase, Scopus, and World Health Organization database (PROSPERO registration number: CRD42020180658).

RESULTS

From 403 articles identified, 49 studies involving a total of 6,335 confirmed COVID-19 cases were included. The random-effects modeling analysis for each neurological symptom showed the following proportional point estimates with 95% confidence intervals: "headache" (0.12; 0.10-0.14; I2 = 77%), "dizziness" (0.08; 0.05-0.12; I2 = 82%), "headache and dizziness" (0.09; 0.06-0.13; I2 = 0%), "nausea" (0.07; 0.04-0.11; I2 = 79%), "vomiting" (0.05; 0.03-0.08; I2 = 74%), "nausea and vomiting" (0.06; 0.03-0.11; I2 = 83%), "confusion" (0.05; 0.02-0.14; I2 = 86%), and "myalgia" (0.21; 0.18-0.25; I2 = 85%). The most common neurological complication associated with COVID-19 infection was vascular disorders (n = 23); other associated conditions were encephalopathy (n = 3), encephalitis (n = 1), oculomotor nerve palsy (n = 1), isolated sudden-onset anosmia (n = 1), Guillain-Barré syndrome (n = 1), and Miller-Fisher syndrome (n = 2). Most patients with neurological complications survived (n = 14); a considerable number of patients died (n = 7); and the rest had unclear outcomes (n = 12).

CONCLUSION

This review revealed that neurologic involvement may manifest in COVID-19 infection. What has initially been thought of as a primarily respiratory illness has evolved into a wide-ranging multi-organ disease.

SARS-CoV-2, SARS-CoV, and MERS-CoV viral load dynamics, duration of viral shedding, and infectiousness: a systematic review and meta-analysis

BACKGROUND

Viral load kinetics and duration of viral shedding are important determinants for disease transmission. We aimed to characterise viral load dynamics, duration of viral RNA shedding, and viable virus shedding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in various body fluids, and to compare SARS-CoV-2, SARS-CoV, and Middle East respiratory syndrome coronavirus (MERS-CoV) viral dynamics.

METHODS

In this systematic review and meta-analysis, we searched databases, including MEDLINE, Embase, Europe PubMed Central, medRxiv, and bioRxiv, and the grey literature, for research articles published between Jan 1, 2003, and June 6, 2020. We included case series (with five or more participants), cohort studies, and randomised controlled trials that reported SARS-CoV-2, SARS-CoV, or MERS-CoV infection, and reported viral load kinetics, duration of viral shedding, or viable virus. Two authors independently extracted data from published studies, or contacted authors to request data, and assessed study quality and risk of bias using the Joanna Briggs Institute Critical Appraisal Checklist tools. We calculated the mean duration of viral shedding and 95% CIs for every study included and applied the random-effects model to estimate a pooled effect size. We used a weighted meta-regression with an unrestricted maximum likelihood model to assess the effect of potential moderators on the pooled effect size. This study is registered with PROSPERO, CRD42020181914.

FINDINGS

79 studies (5340 individuals) on SARS-CoV-2, eight studies (1858 individuals) on SARS-CoV, and 11 studies (799 individuals) on MERS-CoV were included. Mean duration of SARS-CoV-2 RNA shedding was 17·0 days (95% CI 15·5-18·6; 43 studies, 3229 individuals) in upper respiratory tract, 14·6 days (9·3-20·0; seven studies, 260 individuals) in lower respiratory tract, 17·2 days (14·4-20·1; 13 studies, 586 individuals) in stool, and 16·6 days (3·6-29·7; two studies, 108 individuals) in serum samples. Maximum shedding duration was 83 days in the upper respiratory tract, 59 days in the lower respiratory tract, 126 days in stools, and 60 days in serum. Pooled mean SARS-CoV-2 shedding duration was positively associated with age (slope 0·304 [95% CI 0·115-0·493]; p=0·0016). No study detected live virus beyond day 9 of illness, despite persistently high viral loads, which were inferred from cycle threshold values. SARS-CoV-2 viral load in the upper respiratory tract appeared to peak in the first week of illness, whereas that of SARS-CoV peaked at days 10-14 and that of MERS-CoV peaked at days 7-10.

INTERPRETATION

Although SARS-CoV-2 RNA shedding in respiratory and stool samples can be prolonged, duration of viable virus is relatively short-lived. SARS-CoV-2 titres in the upper respiratory tract peak in the first week of illness. Early case finding and isolation, and public education on the spectrum of illness and period of infectiousness are key to the effective containment of SARS-CoV-2.

FUNDING

None.

Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis

BACKGROUND

Bacterial co-pathogens are commonly identified in viral respiratory infections and are important causes of morbidity and mortality. The prevalence of bacterial infection in patients infected with SARS-CoV-2 is not well understood.

AIMS

To determine the prevalence of bacterial co-infection (at presentation) and secondary infection (after presentation) in patients with COVID-19.

SOURCES

We performed a systematic search of MEDLINE, OVID Epub and EMBASE databases for English language literature from 2019 to April 16, 2020. Studies were included if they (a) evaluated patients with confirmed COVID-19 and (b) reported the prevalence of acute bacterial infection.

CONTENT

Data were extracted by a single reviewer and cross-checked by a second reviewer. The main outcome was the proportion of COVID-19 patients with an acute bacterial infection. Any bacteria detected from non-respiratory-tract or non-bloodstream sources were excluded. Of 1308 studies screened, 24 were eligible and included in the rapid review representing 3338 patients with COVID-19 evaluated for acute bacterial infection. In the meta-analysis, bacterial co-infection (estimated on presentation) was identified in 3.5% of patients (95%CI 0.4-6.7%) and secondary bacterial infection in 14.3% of patients (95%CI 9.6-18.9%). The overall proportion of COVID-19 patients with bacterial infection was 6.9% (95%CI 4.3-9.5%). Bacterial infection was more common in critically ill patients (8.1%, 95%CI 2.3-13.8%). The majority of patients with COVID-19 received antibiotics (71.9%, 95%CI 56.1 to 87.7%).

IMPLICATIONS

Bacterial co-infection is relatively infrequent in hospitalized patients with COVID-19. The majority of these patients may not require empirical antibacterial treatment.

Clinical course and potential predictive factors for pneumonia of adult patients with Coronavirus Disease 2019 (COVID-19): A retrospective observational analysis of 193 confirmed cases in Thailand

Clinical spectrum of Coronavirus Disease 2019 (COVID-19) remains unclear, especially with regard to the presence of pneumonia. We aimed to describe the clinical course and final outcomes of adult patients with laboratory-confirmed COVID-19 in the full spectrum of disease severity. We also aimed to identify potential predictive factors for COVID-19 pneumonia. We conducted a retrospective study among adult patients with laboratory-confirmed COVID-19 who were hospitalized at Bamrasnaradura Infectious Diseases Institute, Thailand, between January 8 and April 16, 2020. One-hundred-and-ninety-three patients were included. The median (IQR) age was 37.0 (29.0-53.0) years, and 58.5% were male. The median (IQR) incubation period was 5.5 (3.0-8.0) days. More than half (56%) of the patients were mild disease severity, 22% were moderate, 14% were severe, and 3% were critical. Asymptomatic infection was found in 5%. The final clinical outcomes in 189 (97.9%) were recovered and 4 (2.1%) were deceased. The incidence of pneumonia was 39%. The median (IQR) time from onset of illness to pneumonia detection was 7.0 (5.0-9.0) days. Bilateral pneumonia was more prevalent than unilateral pneumonia. In multivariable logistic regression, increasing age (OR 2.55 per 10-year increase from 30 years old; 95% CI, 1.67-3.90; p<0.001), obesity (OR 8.74; 95%CI, 2.06-37.18; p = 0.003), and higher temperature at presentation (OR 4.59 per 1°C increase from 37.2°C; 95% CI, 2.30-9.17; p<0.001) were potential predictive factors for COVID-19 pneumonia. Across the spectrum of disease severities, most patients with COVID-19 in our cohort had good final clinical outcomes. COVID-19 pneumonia was found in one-third of them. Older age, obesity, and higher fever at presentation were independent predictors of COVID-19 pneumonia.

Clinical characteristics and risk factors for coronavirus disease 2019 (COVID-19) among patients under investigation in Thailand

To manage coronavirus disease 2019 (COVID-19), a national health authority has implemented a case definition of patients under investigation (PUIs) to guide clinicians' diagnoses. We aimed to determine characteristics among all PUIs and those with and without COVID-19. We retrospectively reviewed clinical characteristics and risk factors for laboratory-confirmed COVID-19 cases among PUIs at a tertiary care center in Bangkok, Thailand, between March 23 and April 7, 2020. Reverse transcription-polymerase chain reaction for SARS-CoV-2 RNA was performed. There were 405 evaluable PUIs; 157 (38.8%) were men, with a mean age ± SD of 36.2 ± 12.6 years. The majority (68.9%) reported no comorbidities. There were 53 (13.1%) confirmed COVID-19 cases. The most common symptoms among those were cough (73.6%), fever (58.5%), sore throat (39.6%), and muscle pain (37.4%). Among these patients, diagnoses were upper respiratory tract infection (69.8%), viral syndrome (15.1%), pneumonia (11.3%), and asymptomatic infection (3.8%). Multivariate analysis identified close contact with an index case (OR, 3.49; 95%CI, 1.49-8.15; P = 0.004), visiting high-risk places (OR, 1.92; 95%CI, 1.03-3.56; P = 0.039), productive cough (OR, 2.03; 95%CI, 1.05-3.92; P = 0.034), and no medical coverage (OR, 3.91; 95%CI, 1.35-11.32; P = 0.012) as independent risk factors for COVID-19 among the PUIs. The majority had favorable outcomes, though one (1.9%) died from severe pneumonia. COVID-19 was identified in 13% of PUIs defined per a national health authority's case definition. History of contact with a COVID-19 patient, visiting a high-risk place, having no medical coverage, and productive cough may identify individuals at risk of COVID-19 in Thailand.

Gastrointestinal manifestation as clinical predictor of severe COVID-19: A retrospective experience and literature review of COVID-19 in Association of Southeast Asian Nations (ASEAN)

Background and Aim

Coronavirus disease 19 (COVID-19) has caused over 200 000 deaths worldwide. Thailand announced the first confirmed case outside mainland China in January 2020. The disease also spread widely across Association of Southeast Asian Nations (ASEAN). Gastrointestinal manifestations could be presenting symptoms of COVID-19. This study aimed to determine the prevalence of gastrointestinal manifestations of COVID-19 patients in Thailand and review important aspects of this disease in ASEAN.

Methods

Thai patients diagnosed with COVID-19 at Thammasat University Hospital, Thailand, were evaluated between 1 January 2020 and 30 April 2020. Patients' data, clinical presentation, exposure risk, past medical history, laboratory results, and treatment outcomes were extensively reviewed.

Results

A total of 352 COVID-19 tests were performed, and 40 patients with positive tests were studied. The mean age was 30.5 years, and 55% were female. Most (82.5%) had no underlying diseases. Comorbidities were associated with severe COVID-19 (odds ratio [OR] 29.93; 95% confidence interval [CI] 2.31-388.40, P = 0.009). Gastrointestinal symptoms were present in 12 patients (30%). The most common presenting symptoms were anorexia (17.5%) and diarrhea (15%). Gastrointestinal symptoms developed before (9.1%), concurrent with (63.6%), and after (27.3%) respiratory symptoms. Diarrhea was significantly associated with severe COVID-19 (OR 38.52; 95% CI 3.11-476.70, P = 0.004). Twenty-four patients (60%) received antiviral drugs; 40% had only supportive care. Only one patient required intensive care. No patient died.

Conclusions

Gastrointestinal manifestations in COVID-19 patients are common symptoms and can occur anytime during the disease course. Patients presenting with only gastrointestinal symptoms should raise clinical suspicion for COVID-19 in areas with high disease incidence. Clinically severe COVID-19 was associated with comorbidities and diarrhea.

Adjunctive favipiravir for severe COVID-19: a retrospective observational study of the first 41 patients in Thailand

Background

Favipiravir is a promising drug for COVID-19, but evidence from a robust clinical trial is limited.

Objective

To describe the demographics, clinical characteristics, and various antiviral treatment regimens (with and without favipiravir) of patients with severe and nonsevere COVID-19.

Method

We conducted a retrospective observational study in all COVID-19 patients admitted at Bamrasnaradura Infectious Diseases Institute (BIDI) from January 8 to March 30, 2020. We compared the demographics, clinical characteristics, and various antiviral treatment regimens of 12 severe and 29 nonsevere COVID-19 patients in Thailand.

Results

Adjunctive favipiravir was given to only severe cases. The median length of hospitalization of patients either receiving favipiravir or not receiving favipiravir was not significantly different (P = 0.8549), but those who received adjunctive favipiravir became reverse transcriptase–polymerase chain reaction negative 2 days sooner than the other group (median: 6 days vs. 8 days; P = 0.1125).

Conclusion

The findings suggested that adjunctive favipiravir might not be effective for patients with severe COVID-19, but further studies with larger sample sizes are needed.

Occurrence and transmission potential of asymptomatic and presymptomatic SARS-CoV-2 infections: A living systematic review and meta-analysis

BACKGROUND

There is disagreement about the level of asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We conducted a living systematic review and meta-analysis to address three questions: (1) Amongst people who become infected with SARS-CoV-2, what proportion does not experience symptoms at all during their infection? (2) Amongst people with SARS-CoV-2 infection who are asymptomatic when diagnosed, what proportion will develop symptoms later? (3) What proportion of SARS-CoV-2 transmission is accounted for by people who are either asymptomatic throughout infection or presymptomatic?

METHODS AND FINDINGS

We searched PubMed, Embase, bioRxiv, and medRxiv using a database of SARS-CoV-2 literature that is updated daily, on 25 March 2020, 20 April 2020, and 10 June 2020. Studies of people with SARS-CoV-2 diagnosed by reverse transcriptase PCR (RT-PCR) that documented follow-up and symptom status at the beginning and end of follow-up or modelling studies were included. One reviewer extracted data and a second verified the extraction, with disagreement resolved by discussion or a third reviewer. Risk of bias in empirical studies was assessed with an adapted checklist for case series, and the relevance and credibility of modelling studies were assessed using a published checklist. We included a total of 94 studies. The overall estimate of the proportion of people who become infected with SARS-CoV-2 and remain asymptomatic throughout infection was 20% (95% confidence interval [CI] 17-25) with a prediction interval of 3%-67% in 79 studies that addressed this review question. There was some evidence that biases in the selection of participants influence the estimate. In seven studies of defined populations screened for SARS-CoV-2 and then followed, 31% (95% CI 26%-37%, prediction interval 24%-38%) remained asymptomatic. The proportion of people that is presymptomatic could not be summarised, owing to heterogeneity. The secondary attack rate was lower in contacts of people with asymptomatic infection than those with symptomatic infection (relative risk 0.35, 95% CI 0.10-1.27). Modelling studies fit to data found a higher proportion of all SARS-CoV-2 infections resulting from transmission from presymptomatic individuals than from asymptomatic individuals. Limitations of the review include that most included studies were not designed to estimate the proportion of asymptomatic SARS-CoV-2 infections and were at risk of selection biases; we did not consider the possible impact of false negative RT-PCR results, which would underestimate the proportion of asymptomatic infections; and the database does not include all sources.

CONCLUSIONS

The findings of this living systematic review suggest that most people who become infected with SARS-CoV-2 will not remain asymptomatic throughout the course of the infection. The contribution of presymptomatic and asymptomatic infections to overall SARS-CoV-2 transmission means that combination prevention measures, with enhanced hand hygiene, masks, testing tracing, and isolation strategies and social distancing, will continue to be needed.

Occurrence and transmission potential of asymptomatic and presymptomatic SARS-CoV-2 infections: A living systematic review and meta-analysis

BACKGROUND

There is disagreement about the level of asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We conducted a living systematic review and meta-analysis to address three questions: (1) Amongst people who become infected with SARS-CoV-2, what proportion does not experience symptoms at all during their infection? (2) Amongst people with SARS-CoV-2 infection who are asymptomatic when diagnosed, what proportion will develop symptoms later? (3) What proportion of SARS-CoV-2 transmission is accounted for by people who are either asymptomatic throughout infection or presymptomatic?

METHODS AND FINDINGS

We searched PubMed, Embase, bioRxiv, and medRxiv using a database of SARS-CoV-2 literature that is updated daily, on 25 March 2020, 20 April 2020, and 10 June 2020. Studies of people with SARS-CoV-2 diagnosed by reverse transcriptase PCR (RT-PCR) that documented follow-up and symptom status at the beginning and end of follow-up or modelling studies were included. One reviewer extracted data and a second verified the extraction, with disagreement resolved by discussion or a third reviewer. Risk of bias in empirical studies was assessed with an adapted checklist for case series, and the relevance and credibility of modelling studies were assessed using a published checklist. We included a total of 94 studies. The overall estimate of the proportion of people who become infected with SARS-CoV-2 and remain asymptomatic throughout infection was 20% (95% confidence interval [CI] 17-25) with a prediction interval of 3%-67% in 79 studies that addressed this review question. There was some evidence that biases in the selection of participants influence the estimate. In seven studies of defined populations screened for SARS-CoV-2 and then followed, 31% (95% CI 26%-37%, prediction interval 24%-38%) remained asymptomatic. The proportion of people that is presymptomatic could not be summarised, owing to heterogeneity. The secondary attack rate was lower in contacts of people with asymptomatic infection than those with symptomatic infection (relative risk 0.35, 95% CI 0.10-1.27). Modelling studies fit to data found a higher proportion of all SARS-CoV-2 infections resulting from transmission from presymptomatic individuals than from asymptomatic individuals. Limitations of the review include that most included studies were not designed to estimate the proportion of asymptomatic SARS-CoV-2 infections and were at risk of selection biases; we did not consider the possible impact of false negative RT-PCR results, which would underestimate the proportion of asymptomatic infections; and the database does not include all sources.

CONCLUSIONS

The findings of this living systematic review suggest that most people who become infected with SARS-CoV-2 will not remain asymptomatic throughout the course of the infection. The contribution of presymptomatic and asymptomatic infections to overall SARS-CoV-2 transmission means that combination prevention measures, with enhanced hand hygiene, masks, testing tracing, and isolation strategies and social distancing, will continue to be needed.

SARS-CoV-2 detection, viral load and infectivity over the course of an infection

OBJECTIVES

To summarise the evidence on the detection pattern and viral load of SARS-CoV-2 over the course of an infection (including any asymptomatic or pre-symptomatic phase), and the duration of infectivity.

METHODS

A systematic literature search was undertaken in PubMed, Europe PubMed Central and EMBASE from 30 December 2019 to 12 May 2020.

RESULTS

We identified 113 studies conducted in 17 countries. The evidence from upper respiratory tract samples suggests that the viral load of SARS-CoV-2 peaks around symptom onset or a few days thereafter, and becomes undetectable about two weeks after symptom onset; however, viral loads from sputum samples may be higher, peak later and persist for longer. There is evidence of prolonged virus detection in stool samples, with unclear clinical significance. No study was found that definitively measured the duration of infectivity; however, patients may not be infectious for the entire duration of virus detection, as the presence of viral ribonucleic acid may not represent transmissible live virus.

CONCLUSION

There is a relatively consistent trajectory of SARS-CoV-2 viral load over the course of COVID-19 from respiratory tract samples, however the duration of infectivity remains uncertain.

Proportion of asymptomatic coronavirus disease 2019: A systematic review and meta-analysis

We aim to systematically review the characteristics of asymptomatic infection in the coronavirus disease 2019 (COVID‐19). PubMed and EMBASE were electronically searched to identify original studies containing the rate of asymptomatic infection in COVID‐19 patients before 20 May 2020. Then mate‐analysis was conducted using R version 3.6.2. A total of 50 155 patients from 41 studies with confirmed COVID‐19 were included. The pooled percentage of asymptomatic infection is 15.6% (95% CI, 10.1%‐23.0%). Ten included studies contain the number of presymptomatic patients, who were asymptomatic at screening point and developed symptoms during follow‐up. The pooled percentage of presymptomatic infection among 180 initially asymptomatic patients is 48.9% (95% CI, 31.6%‐66.2%). The pooled proportion of asymptomatic infection among 1152 COVID‐19 children from 11 studies is 27.7% (95% CI, 16.4%‐42.7%), which is much higher than patients from all aged groups. Abnormal CT features are common in asymptomatic COVID‐19 infection. For 36 patients from 4 studies that CT results were available, 15 (41.7%) patients had bilateral involvement and 14 (38.9%) had unilateral involvement in CT results. Reduced white blood cell count, increased lactate dehydrogenase, and increased C‐reactive protein were also recorded. About 15.6% of confirmed COVID‐19 patients are asymptomatic. Nearly half of the patients with no symptoms at detection time will develop symptoms later. Children are likely to have a higher proportion of asymptomatic infection than adults. Asymptomatic COVID‐19 patients could have abnormal laboratory and radiational manifestations, which can be used as screening strategies to identify asymptomatic infection.

By systematically reviewing the proportion and clinical features of asymptomatic infection in COVID‐19, our study provides a useful quantity to understand the true burden of this disease.

Co-infections in people with COVID-19: a systematic review and meta-analysis

OBJECTIVES

In previous influenza pandemics, bacterial co-infections have been a major cause of mortality. We aimed to evaluate the burden of co-infections in patients with COVID-19.

METHODS

We systematically searched Embase, Medline, Cochrane Library, LILACS and CINAHL for eligible studies published from 1 January 2020 to 17 April 2020. We included patients of all ages, in all settings. The main outcome was the proportion of patients with a bacterial, fungal or viral co-infection. .

RESULTS

Thirty studies including 3834 patients were included. Overall, 7% of hospitalised COVID-19 patients had a bacterial co-infection (95% CI 3-12%, n=2183, I2=92·2%). A higher proportion of ICU patients had bacterial co-infections than patients in mixed ward/ICU settings (14%, 95% CI 5-26, I2=74·7% versus 4%, 95% CI 1-9, I2= 91·7%). The commonest bacteria were Mycoplasma pneumonia, Pseudomonas aeruginosa and Haemophilus influenzae. The pooled proportion with a viral co-infection was 3% (95% CI 1-6, n=1014, I2=62·3%), with Respiratory Syncytial Virus and influenza A the commonest. Three studies reported fungal co-infections.

CONCLUSIONS

A low proportion of COVID-19 patients have a bacterial co-infection; less than in previous influenza pandemics. These findings do not support the routine use of antibiotics in the management of confirmed COVID-19 infection.

Systematic review with meta-analysis: liver manifestations and outcomes in COVID-19

BACKGROUND

The incidence of elevated liver chemistries and the presence of pre-existing chronic liver disease (CLD) have been variably reported in COVID-19.

AIMS

To assess the prevalence of CLD, the incidence of elevated liver chemistries and the outcomes of patients with and without underlying CLD/elevated liver chemistries in COVID-19.

METHODS

A comprehensive search of electronic databases from 1 December 2019 to 24 April 2020 was done. We included studies reporting underlying CLD or elevated liver chemistries and patient outcomes in COVID-19.

RESULTS

107 articles (n = 20 874 patients) were included for the systematic review. The pooled prevalence of underlying CLD was 3.6% (95% CI, 2.5-5.1) among the 15 407 COVID-19 patients. The pooled incidence of elevated liver chemistries in COVID-19 was 23.1% (19.3-27.3) at initial presentation. Additionally, 24.4% (13.5-40) developed elevated liver chemistries during the illness. The pooled incidence of drug-induced liver injury was 25.4% (14.2-41.4). The pooled prevalence of CLD among 1587 severely infected patients was 3.9% (3%-5.2%). The odds of developing severe COVID-19 in CLD patients was 0.81 (0.31-2.09; P = 0.67) compared to non-CLD patients. COVID-19 patients with elevated liver chemistries had increased risk of mortality (OR-3.46 [2.42-4.95, P < 0.001]) and severe disease (OR-2.87 [95% CI, 2.29-3.6, P < 0.001]) compared to patients without elevated liver chemistries.

CONCLUSIONS

Elevated liver chemistries are common at presentation and during COVID-19. The severity of elevated liver chemistries correlates with the outcome of COVID-19. The presence of CLD does not alter the outcome of COVID-19. Further studies are needed to analyse the outcomes of compensated and decompensated liver disease.

Spatial and temporal dynamics of SARS-CoV-2 in COVID-19 patients: A systematic review and meta-analysis

BACKGROUND

The spatial and temporal dynamics of SARS-CoV-2 have been described in case series and retrospective studies. In this study, we provide a coherent overview of the duration of viral detection and viral RNA load in COVID-19 patients, stratified by specimen type, clinical severity, and age.

METHOD

We systematically searched PubMed/MEDLINE and Cochrane review database for studies published between 1.11.2019 and 23.04.2020. We pooled the data of selected studies (22/7226 (650 patients) for meta-analysis) to estimate duration of viral detection and visualized viral load over time.

FINDINGS

Our analysis showed consistent viral detection from specimen from the upper respiratory tract (URT), the lower respiratory tract (LRT), and faeces, irrespective of the clinical severity of COVID-19. Our analysis suggests that SARS-CoV-2 persists for a longer duration in the LRT compared to the URT in adult patients (5•7 days in mild; 5•9 days in moderate-severe patients). The differences in the duration of viral detection between mild and moderate-severe patients is limited in the LRT, but an indication of longer duration of viral detection for moderate-severe patients was observed in feces (15 days in mild vs. 21 days in moderate-severe patients) and the URT (12 days in mild vs. 16 days in moderate-severe patients). Further, viral load was demonstrated to peak in earlier stages of infection in the URT compared to LRT.

INTERPRETATION

This review may aid mathematical modelling and help in defining appropriate endpoints for clinical trails with antivirals in COVID-19.

FUNDING

The project has received funding support from Innovation Fund Denmark.

Diabetes as a risk factor for greater COVID-19 severity and in-hospital death: A meta-analysis of observational studies

AIMS

To estimate the prevalence of established diabetes and its association with the clinical severity and in-hospital mortality associated with COVID-19.

DATA SYNTHESIS

We systematically searched PubMed, Scopus and Web of Science, from 1st January 2020 to 15th May 2020, for observational studies of patients admitted to hospital with COVID-19. Meta-analysis was performed using random-effects modeling. A total of 83 eligible studies with 78,874 hospitalized patients with laboratory-confirmed COVID-19 were included. The pooled prevalence of established diabetes was 14.34% (95% CI 12.62-16.06%). However, the prevalence of diabetes was higher in non-Asian vs. Asian countries (23.34% [95% CI 16.40-30.28] vs. 11.06% [95% CI 9.73-12.39]), and in patients aged ≥60 years vs. those aged <60 years (23.30% [95% CI 19.65-26.94] vs. 8.79% [95% CI 7.56-10.02]). Pre-existing diabetes was associated with an approximate twofold higher risk of having severe/critical COVID-19 illness (n = 22 studies; random-effects odds ratio 2.10, 95% CI 1.71-2.57; I2 = 41.5%) and ~threefold increased risk of in-hospital mortality (n = 15 studies; random-effects odds ratio 2.68, 95% CI 2.09-3.44; I2 = 46.7%). Funnel plots and Egger's tests did not reveal any significant publication bias.

CONCLUSIONS

Pre-existing diabetes is significantly associated with greater risk of severe/critical illness and in-hospital mortality in patients admitted to hospital with COVID-19.

Coronavirus Disease of 2019: a Mimicker of Dengue Infection?

At the beginning of 2020, the national health system and medical communities are faced with unprecedented public health challenges. A novel strain of coronavirus, later identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread globally, marking another pandemic of coronaviruses. This viral disease is responsible for devastating pneumonia, named coronavirus disease of 2019 (COVID-19), and projected to persist until the end of the year. In tropical countries, however, concerns arise regarding the similarities of COVID-19 with other infectious diseases due to the same chief complaint, which is fever. One of the infectious disease of a primary concern is dengue infection, which its peak season is approaching. Others report that there are cases of serological cross-reaction of COVID-19 and dengue infection. In this comprehensive review, we underscore the importance of knowing similar clinical presentations of both diseases and emphasize why excluding COVID-19 in the differentials in the setting of a pandemic is imprudent.

4-month-old boy coinfected with COVID-19 and adenovirus

A 4-month-old boy with a history of muscular ventricular septal defect and atopic dermatitis presented with decreased oral intake, loose stools, stuffy nose, mild cough and diaphoresis. The patient had an in-home exposure to COVID-19. The initial respiratory pathogen panel was positive for adenovirus, consistent with his symptoms. The following day, the COVID-19 PCR was also positive. The patient was treated with supportive care, isolation precautions were implemented and the patient was discharged on day 4. This case demonstrates the importance of testing for COVID-19 even if a patient tests positive for another virus due to the possibility of coinfection, especially in children, in order to limit spread of COVID-19 to others.

Clinical features, isolation, and complete genome sequence of severe acute respiratory syndrome coronavirus 2 from the first two patients in Vietnam

In January 2020, we identified two severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)‐infected patients in a familial cluster with one person coming from Wuhan, China. The complete genome sequences of two SARS‐CoV‐2 strains isolated from these patients were identical and 99.98% similar to strains isolated in Wuhan. This is genetically suggestive of human‐to‐human transmission of SARS‐CoV‐2 and indicates Wuhan as the most plausible origin of the early outbreak in Vietnam. The younger patient had a mild upper respiratory illness and a brief viral shedding, whereas the elderly with multi‐morbidity had pneumonia, prolonged viral shedding, and residual lung damage. The evidence of nonsynonymous substitutions in the ORF1ab region of the viral sequence warrants further studies.

Transmission of SARS‐CoV‐2 is a global public health and clinical concern.

This report describes clinical features, virus isolation, and complete genome sequences from the first two SARS‐CoV‐2 infections in Vietnam.

Epidemiological and phylogenetic analysis suggested evidence of human‐to‐human transmission of SARS‐CoV‐2. Comparison of SARS‐CoV‐2 strains isolated from these two patients with those from Wuhan showed high similarities.

Nonsynonymous substitutions existed in the ORF1ab region of the viral sequence.

Compared with mild clinical and virological manifestations in the younger patient, the elderly suffered from pneumonia, prolonged viral shedding, and residual lung damage.