COVID-19: How the ‘flu has generated a panicked community and what it really means

The recent Coronavirus outbreak has seen a varied response both in Australia and internationally, ranging from denial to outright hysteria. It makes sense – a lack of reliable information available about any emerging disease can lead to confusion or worse.

The purpose of this discourse is to provide the basics of what is known about the virus, and what steps you can take to help mitigate its impact on those most likely to be severely impacted.

The virus

Let’s get the big words out of the way early, COVID-19 is a disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Coronaviruses are one of several common ‘RNA’ viruses responsible for diseases with cold or flu-like symptoms in humans, other mammals and birds. Other examples include Rhinoviruses (the common cold virus) which is the single most common in humans, and Influenza viruses.

Coronaviruses can cause up to a third of community-acquired upper respiratory tract infections in any single year and have been detected everywhere they have been looked for worldwide. They are widespread in birds and mammals, being notably common in bats.

The name comes from their crown-like appearance in the electron microscope. Their molecular structure differs significantly from Rhinoviruses and Influenza viruses.

SARS-CoV-2 is in the same Coronavirus subgenus as the 2003 SARS coronavirus and the two viruses use the same surface receptor to enter cells. It appears likely that the disease originated in bats, although whether the transfer was direct or via an intermediate host is not known.

The disease

As COVID-19 is an emerging disease our understanding is incomplete and likely to change as we gain more knowledge. Symptoms range from mild or asymptomatic, to life threatening. It currently appears that around 80 per cent of cases are mild (fever, dry cough, sore throat), around 15 per cent severe (more than 50 per cent lung involvement within 24 – 48 hours) and around 5 per cent critical (respiratory failure, shock, or multiorgan dysfunction).

Overall case fatality rate appears to be around 2.3 per cent, with no deaths yet reported among non-critical cases. Note however that fatality rates have varied widely between locations (e.g. Chinese authorities reported mid-March that case fatality was 5.8% in Wuhan but 0.7% in the rest of China); although average age of patients appears to be a factor there is no clear reason for these differences.

Generally, the disease appears to be more severe in people aged > 40 or those with other medical conditions (notably heart disease, diabetes, chronic lung disease or other conditions leading to a general immunosuppressed state). Symptomatic infection appears uncommon in children.

The incubation period is thought to be within 14 days following exposure with most cases developing symptoms 4 – 5 days after exposure (and 97.5% within 11 ½ days). Rhinoviruses symptoms typically develop within 2 days of exposure, with a range of 20 hrs – 5 days. Influenza virus infections also typically develop around 2 days after exposure (with a range of 1 – 4 days) but can be difficult to distinguish from the common cold in early stages, with up to a third of infections being asymptomatic.

People with SARS-CoV-2 are potentially contagious 1 – 2 days before they develop symptoms. It is however not yet clear how significant this is for the spread of the disease. Some infections are asymptomatic but their frequency is also unknown.

Important to remember is that when it comes to a case of the ‘flu, according to the World Health Organisation there are an estimated 1 billion cases, 3 – 5 million severe cases and 290,000 – 650,000 deaths per year worldwide (considering seasonal variability).

Testing and diagnosis

Of all the reported cases, some have been clinically diagnosed and others confirmed by laboratory testing.

Virus RNA detection requires a two-step process and the ability to perform the second step requires knowledge of the RNA sequence of the virus. Australian scientists were the first outside of China to successfully isolate and sequence SARS-CoV-2, a significant technological feat given that Coronaviruses have generally proved difficult to grow in laboratory settings.

The first step however, is generalised and used as a basis for not only COVID-19 tests but myriad other tests as well. Consequently, test kits have run into short supply with the WA Department of Health advising on 13 March that in order to preserve supplies, tests are only to be conducted if:

• Patient has clinical illness compatible with COVID-19; AND
• Patient has documentary evidence they have returned from overseas in the last 14 days; OR
• Patient has been in close contact with a named person who has confirmed COVID-19 illness.

The lack of widespread testing is an international problem as it makes early detection of the disease difficult, and thus particularly hard to combat the disease, especially in its early phases. Authorities are re-visiting these criteria as new avenues for testing are explored, so please be aware that the conditions listed above may change.

Treatment, medication and vaccines

Currently there is no effective treatment for any Coronavirus infection. The only available medical interventions are supportive care and the thorough practice of good hygiene. Personal Protection Equipment for medical staff appears to be effective (the WHO recommends gown, gloves and mask with eye or face protection) and contrary to initial fears the virus does not appear to spread by aerosol.

Contrary to statements by certain politicians internationally, small molecule drugs or vaccines developed for influenza virus or Rhinovirus treatment can not be readily adapted to treat Coronaviruses: the viruses are generally too different in their form for such adaption to be effective.

There are no vaccines available for any Coronavirus at this stage (developmental work was shelved when the previous SARS and MERS outbreaks were contained) and even if a vaccine candidate were confirmed it would take many months to do the essential safety and efficacy treatment that is required before authorities would allow its widespread use.

Similarly, experimental drug treatments would require many months (if not years) of rigorous testing before their widespread use in patients would be allowed. Amongst other experimental treatments, some international studies have suggested that anti-malarials Chloroquine and Hydroxychloroquine might inhibit SARS-CoV-2. Clinical studies evaluating the safety and effectiveness of these and other potential treatments are underway, but again will require many months to reach a conclusion. Note that these substances can be extremely toxic and someone has already died in the United States after ingesting chloroquine intended for cleaning aquariums!

If you do exhibit symptoms, please follow the advice of your consulting medical practitioner regarding the usefulness of any anti-inflammatory or other medication. Do not rely on hearsay, so-called treatments you saw on social media, or the utterings of ‘leaders’!

Dos and do nots

At least one aspect of advice has remained consistent from the beginning. KEEP CALM!

The disease is not spread by aerosol to any great degree, so the practice of good hygiene and keeping a distance from others should help minimise its spread. The following are good things to do:

• Stay at home, unless you provide essential services or you really need to make that trip (e.g. purchasing food or medicines);
• Cover your coughs or sneezes with your elbow;
• Wash your hands regularly and thoroughly (the 20 second rule), especially prior to handling food;
• Avoid touching surfaces – SARS-CoV-2 appears to last a lot longer than Rhinoviruses do on solid surfaces – and if you do please wash your hands afterwards;
• Try to minimise touching your face, especially eyes, nose, mouth – this one may prove difficult as studies suggest we touch our faces anywhere up to 2,000 – 3,000 times per day;
• Do NOT shake hands or kiss in greeting: try a wave, namaste, even jazz hands!
• Practice social distancing – 2m is the recommended minimum distance; and
• Do NOT panic shop! Australia exports far more food than we consume and most toilet paper and other supplies are made right here in Oz. Nobody is going hungry and panic buying only adds stress to already compromised supply chains.

We all want a happy ending, especially for the vulnerable. Think of the elderly, the sick, and healthcare professionals. Think of the messages to which our impressionable children are being subjected. They all need our support; show some leadership, share the loo paper and most of all – keep calm!