The COVID -19 infection, which is sweeping across the globe has also inflicted us in Kuwait. We are in the community spread stage, which is the main wave of this pandemic cycle. The government of Kuwait has initiated and is implementing very careful health-related practices to overcome this burden associated with medical professionals and police.
- Overview of the COVID 19 (SARS-COV-2)
Coronaviruses were first identified in the 1960s. They get their name from their crown-like shape. Sometimes, but not often, a coronavirus can infect both animals and humans.
The 7th new strain of Coronavirus was identified in Wuhan, China on Dec 31st 2019 and 11th February 2020 the new strain was named as COVID 19 by WHO and followed by the March 31st 2020 the infection was announced as a pandemic.
The COVID 19 virulence (infectivity), transmission and death rate differ from region to region and this variation depends on the government policy, the efficiency of the health care system and the public corporation.
Previously identified the different strains of known Coronavirus
- MERS (Middle East respiratory syndrome), SARS (severe acute respiratory syndrome) are the two strains of known Coronavirus which were identified with an endemic outbreak in 2012 and 2003 respectively. Mortality rates were recorded as 858 by MERS in 2012 and 774 by SARS in 2003.
- How to Predict the Epidemic spread of the infection?
It’s dependent on two main factors and some associated factors,
- R= Reproductive ratio
- n = Infection doubling time
The previous Coronavirus’ strains SARS and MERS were spread triple than the influenza virus.
Whereas in every two to three days numbers of infected individuals doubles contracted with COVID-19. (Please note that roughly doubling time is 3 to 4 days but the associated factors are contributing to shortening the doubling time)
Transmission Graph (comparing SARS with n COVID-19)
- How to differentiate the COVID 19 symptoms from seasonal viral flu?
Initially, 80 per cent of patients contracted with COVID-19 showed symptoms of fever and dry cough then progressively they develop shortness of breath whereas runny nose and sneezing are rare symptoms compared to the seasonal flu.
Please do not underestimate the symptoms, if you develop any symptom immediately contact your doctor to make sure to rule out the COVID-19 infection. The recovery in the initial (mild) phase is very high that’s is mostly fever with dry cough or along with other symptoms as mentioned below in the table.
In severe cases, the patient shows breathlessness, a respiratory rate increase of more than 30/minute in adult, Oxygen saturation falls below 93 percentage, significant radiological changes develop in the lung fields.
In the critical case, death is mostly inevitable and cardiovascular problems (10.5 per cent), Diabetes Mellitus (7.3 per cent), chronic respiratory diseases (6.3 percent), Cancers (5.6 per cent), organ transplant, immune compromise status are additionally attributing to this mortality rate.
The incubation period of the virus is considered to be 1 to 14 days but the average incubation period is 5.2 days but maximum incubation period was identified up to 24 days. This maximum incubation period is very similar to the recovery period of mild Coronavirus. It’s also observed that the recovery period strangely coinciding with the duration of critically affected patient’s disease span to death.
So, the patient quarantined for 14 days, better to adhere with another 10 days of self-isolation from the family and community as we see a few proportions of the patients are showing longer incubation period.
The government lockdown policies are also made with the above-mentioned incubation period concept. To achieve good control of the disease transmission, the government may impose the lockdown to a maximum of 48 days, that’s just short of 02 months. Another advantage of this lockdown policy is that the asymptomatic individual variedly with long incubation period can be identified within the society or spontaneous recovery occurs within the time in such asymptomatic patient.
- Does Seasonal Change have any influence on this virus spread?
‘New virus behaves very differently in the environment than the existing viruses’
Absolute humidity strongly modulates the airborne survival and transmission of the Influenza virus (existing virus).
The reproductive number is pretty stable in COVID 19. “Changes in the weather alone (example increase the environmental temperature or humidity) will not necessarily lead to a decline in case counts without the implementation of extensive public health interventions”
_Harvard University epidemiology unit.
Even seasonal infections can happen out of season when they are new because new viruses have a temporarily but important advantage which is few or no individuals in the population are immune to them.
Old viruses which have been in the population for longer, operate in a thinner margin that is most individuals are immune and they have to work hard to infect the few who aren’t.
If there are ongoing contradictory findings in multiple studies as with influenza virus, it may be more likely that the various transmission routes (direct/ indirect contact short-range droplet, long as even short-range airborne droplet nuclei) may predominate in different settings, making the airborne route for that particular pathogen more of an opportunistic pathway rather than the norm.
- Flattening the curve
The capacity of the health care system to handle the current situation of the outbreak – Social distance, hand hygiene, respiratory hygiene such precautionary measures as our responsible participation will be able to prolong the doubling time of virus spread. So our health care system will be able to corps-up the current situation efficiently. Thus will decrease the mortality.
The pattern of n COVID 19 severity of the illness is identified in three groups
- Mild stage: 81 percentage of the patients fall in this category and spontaneously they recover with supportive treatment.
- Moderate to the severe stage: 14 percentage of the patient falls in this category and need definite hospital admissions.
- Severe to the critical stage: 5 percentage of contracted person falls in the category more than 50 per cent does not recover. This stage is one of the biggest burdens to the existing healthcare system in the country.
So early identification of the contracted cases and medical support will help to flatten the curve and reduce the mortality rates.
Initially, the mortality rate was estimated at approximately three per cent from the contracted cases but recent data on April 15, 2020, shows this is increased to 5 percentage. Thus approximately 2 million people are infected across the globe and little more than one hundred thousand are lost their lives in this battle.
- Role of ‘HydroxyChloroquine’ in COVID 19 treatment
One study shows Zinc ion inhibits coronavirus’ RNA polymerase activity in vitro and zinc ionophores block the replication of the virus in cell culture. (PLOS pathogens study)
Here Hydroxychloroquine acts as an ionophore to zinc ions at the level of the host’s cell membrane.
It means zinc blocks RNA dependent RNA polymerase (RdRP) activity, if I make it simple, the ribosomes of the cell can’t translate the mother viral RNA to make baby viral RNA with the presence zinc ion.
The study is not having strong evidence like double-blinded randomized study etc.
The chemical is not recommended to take as a prophylaxis treatment for COVID 19. The adverse effect of the drug should be carefully weighed with the beneficial effect by a professional before starts as a treatment.
- What are the specific lab tests are available to identify this virus?
- a) Nasopharyngeal swab test: (PCR-Test) it can identify the viral load (the test based on antigen) in the body and its sensitivity declines with time. The duration taken for this test is 1 to 3 days, the government is working to get the test results within 45 minutes in future.
- b) Total antibody test: This test is based on antibodies produced in the body against the novel coronavirus, it’s a rapid test, can get the result within 15 minutes, when the patient keep a drop of blood on the kit (just like pregnancy kit). The kit highlights positivity with two lines.
In the case of COVID -19, developing antibody does not effectively prove the immunity for the second infection so far.
The below-mentioned graph clarifies us, the test PCR is more sensitive in the initial phase of the infection then the Antibody test becomes more sensitive in the later phase. One more variation can be observed with the PCR test. In the initial phase of the disease, it may become negative even with COVID 19 contracted patient. So WHO recommends the susceptible individual should undergo testing thrice during illness in a regular interval.
- Aerosol and droplets
An aerosol is a small droplet lesser than 10 microns can travel far than the droplets (median droplets size produce by respiration, sneezing and coughing are around about 20 microns). The droplet effectively can travel up to 2 meters.
Only an aerosol can sustain a maximum of 03 hours in the air in specific circumstances. Once the infected aerosols which are lesser than 5 microns which can reach until the alveoli and can interfere with the oxygen and carbon dioxide exchange mechanism at the site that makes shortness of breath. The diameter of aerosols are between the 5 to 10 microns can impact the tracheal branches of the lungs.
Most of the aerosol infections can prevent by N-95 mask, WHO advises this kind of mask to wear the health care professionals who work in the intensive care unit and involve in aerosol related activities.
The Wuhan study shows- The viral loads are more in the floor of the ICU and toilets shared by patients where the aerosolization occurs during the defecation process and urination.
One famous study shows the aerosol which is more dangerous than the droplets are produced more in normal talk than the cough and sneeze.
- How long does the virus sustain in different objects?
The virus sustains in plastic materials for up to 72 hours, then 24 hours in stainless steel, and in other objects lesser than 24 hours.
- Can I reuse the mask?
Particularly the N-95 masks can be reused without effecting the efficiency of the mask by treating it with hydrogen peroxide solution for 4 hours. Another study shows that heating in an oven in 75-degree temperature and treating in ultraviolet rays as well.
- Contact time and transmission of the virus to the susceptible individual:
Contact with lab-confirmed COVID 19 patient for more than 15 minutes has a 5 percentage chance of being infected. The health workers who deal with the patient with 2meters distance also are at high-risk of contracting the virus.
- Gender and age distribution and mortality rates:
Initially, thought to be the extreme ages are a vulnerable population to this pandemic infections, but children under 10 years are showing very resistant to this infection but they can be asymptomatic vectors. But the elderly people more than 80 years are significantly suffering from the disease and comorbidity is the additional factor is attributing to this age group.
The age group 30 to 70 years are mostly infected by COVID 19, it could be they are the population mostly interacting with the society and could be a breadwinner of the family.
Male gender is slightly more affected than female.
- Different phases of COVID 19 transmission
According to the MoH Sri Lanka on 15th April 2020, we are in the late phase of the epidemic (5th phase) the infection rate will decrease in a couple of weeks, so we should be very careful and adhere to the precautionary measures stringently, not only to decrease the infectivity rate but also to overcome the battle against the coronavirus.
The virus cycle actively evolves in an epidemic area just shorter than 2 months, this mechanism is explained under the 3rd FAQ of this article.
So once again I am reminding the readers to adhere to the healthy practice with COVID 19 precautionary measures, some are highlighted below from the WHO link:
- Recognize that COVID-19 is a new and concerning disease, but that outbreaks can be managed with the right response and that the vast majority of infected people will recover.
- Begin now to adopt the rigorous practice the most important preventive measures for COVID-19 by frequently washing your hands and always covering your mouth and nose when sneezing or coughing.
- Continually update yourself on COVID-19 and its signs and symptoms (i.e. fever and dry cough), because the strategies and response activities will constantly improve as new information on this disease is being updated every day.
- Be prepared to actively support a response to COVID-19 in a variety of ways, including the adoption of more stringent ‘social distancing’ practices and helping the high-risk elderly population.
What’s New in Treatment?
The German experience shows extracted antibodies from the COVID 19 recovered patient was given via transfusion to five critically ill COVID 19 patients who were admitted in the ICU in German. Among these patients 3 of them recovered and discharged, and 2 of them are out of critical stage.
- The chance to get Re-Infected: The German experience gives an idea after 14 days of the illness, the patient started to develop enough quantity of antibodies (IgM and IgG), then the chance of reinfection is unlikely (at the moment)
NB: Anti-viral agents are in a developing phase to treat the patients some of them are really promising and effective in some patients. Vaccine also under trial.
For additional reading about n COVID- 19 click the links mentioned below:
- Public awareness article about COVID-19 ‘Do not Panic be Proactive’ this article was published in Times- Kuwait magazine on 14th March 2020.
- Public awareness article ‘What do we need to know about the Corona virus’ this article was published in a famous newspapers ‘Daily news’ Sri Lanka in English and The ‘Thinakaran’ in Tamil language.
Sources: WHO, CDC, Lancet (Wuhan Publication), PLOS biology, Harvard Epidemiology unit, Medmastery. Recent Webinars (China and German)