Updated April 30, 2020
Whether or not the virus has entered your Emergency Department yet, the COVID-19 pandemic is here.
In many ways, we are all affected by this global struggle, so it is imperative we are armed with the most up to date information to best prepare ourselves and our patients. Depending on your location and catchment area, your role may vary from being the physician caring for COVID-19 patients… to enforcing public health strategies like social distancing and proper hygiene.
With constant updates and new information emerging on a daily basis, much of which is conflicting or staggered in release, it can be challenging to keep the facts straight. Where possible, links are embedded throughout this article to the most updated statistics.[bg_faq_start]
The King of Coronaviruses
Updated March 16, 2020
COVID-19 (Coronavirus Disease 2019) is a betacoronavirus, similar in structure to both SARS and Middle Eastern Respiratory Syndrome (MERS). It is also known as SARS-2 or SARS-CoV-2.
SARS had 8096 confirmed cases and 774 deaths. (case fatality 9.6%)1
- First found in China in 2002, spreading to 26 countries through 2003.
MERS had 2494 confirmed cases and 858 deaths. (case fatality 34%)2
- Outbreaks have occurred in 2012, 2015, and 2018, mostly in the Arabian peninsula.
Though similar in symptoms, the seasonal flu is not a coronavirus and is caused by Influenza A and B, Orthomyxoviruses. In Canada during the 2018-2019 flu season, there were 48,818 confirmed cases and 224 deaths. (case fatality 0.46%)3
As of the start of March, this year the flu has caused 49,501 Canadian cases – 265 ICU admissions and 85 deaths.4 (case fatality ~0.17%)
The COVID-19 pandemic first started in Wuhan, China. This industrial city is one of the top 30 most populated in the world. Geographically it is also a transportation hub for travel through central China, making Wuhan the perfect storm for a viral outbreak, especially around the Lunar New Year (January 25) which is traditionally a time to travel to be with family.[bg_faq_end][bg_faq_start]
Pandemic – A Global Struggle
On March 11th, 2020, the WHO Director General Tedros Adhanom declared that COVID-19 is a pandemic. The WHO does not follow specific criteria anymore regarding spread or deaths for the definition of a pandemic but is loosely considered a worldwide spread of a new disease affecting large populations of people. Previously they had a six-phase classification system.
Prior pandemics include:
- H1N1 Swine Flu – 2009-2010 – During the 14 month pandemic, the Centre for Disease Control estimates there were 105 million cases worldwide, with 936,000 hospitalizations, and 75,000 deaths attributable to “(H1N1)pdm09”, with an estimated case fatality rate of 0.07%. Novel vaccination creation helped bring an end to this pandemic, though the strain continued to circulate seasonally in subsequent years.
- Spanish Flu – 1918-1919 – Despite its name, there is no universal consensus on the origin of this H1N1 influenza. Estimates suggest half of the world’s population became infected (500 million), and an estimated 25 to 50 million died, although data is quite limited. This would represent a case fatality rate of 5 – 10%.
Table 1: COVID-19 Timeline
Updated April 23, 2020
|Dec 1, 2019||First case known (retrospectively)|
|Dec 31, 2019||First reports of a pneumonia cluster in Wuhan|
|Jan 1, 2020||Huanan Seafood Wholesale is shut down|
|Jan 2, 2020||41 total cases identified|
|Jan 8, 2020||Identification of SARS-CoV-2|
|Jan 10, 2020||First death (patient with cirrhosis, cancer)|
|Jan 13, 2020||First international case (Thailand)|
|Jan 19, 2020||First case in the United States|
|Jan 23, 2020||Human-to-human transmission confirmed. Hubei cities on lockdown.|
|Jan 25, 2020||First Canadian case. ~2000 confirmed Chinese cases.|
|Jan 30, 2020||WHO declares state of emergency|
|Feb 2, 2020||First death outside of China (Philippines). ~12,000 cases in China.|
|Feb 11, 2020||Virus coined COVID-19 by WHO.|
|Feb 14, 2020||First case in Africa (Egypt). ~66,000 cases in China.|
|Feb 23, 2020||Multiple countries close borders with Iran (28 confirmed cases). Italy cancels Venice Carnival and sporting events, places certain towns on lockdown (>150 cases). ~80,000 cases globally|
|Feb 26, 2020||Brazil announces first confirmed case in Latin America. Iran’s deputy health minister announces he has COVID-19.|
|Feb 27, 2020||Pilgrimages to Mecca suspended. Switzerland bans events >1000 people.|
|March 1, 2020||Louvre closes, France bans events >5000 people. Italy incidence surpasses 1000 cases. South Korean cases double to over 3000 in two days.|
|March 3, 2020||WHO announces COVID-19 has higher mortality than flu (3.4% compared to <1%), but transmits less efficiently. Iran temporarily releases prisoners from crowded jails.|
|March 9, 2020||Canada’s first COVID-19 death. Italy locks down entire country.|
|March 11, 2020||WHO announces pandemic status. NBA suspended, followed shortly by NHL.|
|March 13, 2020||Italy’s death toll tops 1000 victims. Europe is epicenter of pandemic, as Chinese incidence continues to fall.|
|March 15, 2020||>150,000 global cases. Italian cases increase beyond 21,000. Cases in surrounding countries and Iran continue to surge.|
|March 18, 2020||Canadian-US borders close to non-essential travel in addition to previous barrier to Canada for international non-citizens.|
|March 19, 2020||Global cases soar beyond 200,000. Confirmed American cases double overnight to ~7000.|
|March 27, 2020||Global cases surpass 500,000. President Trump signs $2 trillion aid package for US economy.|
|April 6, 2020||Canadian federal government implements Canada Emergency Response Benefit as Canadian cases near 15,000|
|April 15, 2020||Global cases surpass 2 000 000. President Trump announces decision to withdraw US funding from World Health Organization.|
|April 17, 2020||Canada extends closure of border with US for additional 30 days.|
|April 20, 2020||Global case counts attain 2 314 000. Ontario announces possible peak in community transmission. Oil prices plunge amidst Saudi-Russian production increases and global lack of demand.|
|April 23, 2020||Saskatchewan is first province to release plan for reopening. Summer gatherings continue to be cancelled, including the Calgary Stampede (for the first time since 1923). North Korea states that no cases have yet been identified in that country.|
Global Prevalence & Mortality
Updated April 23, 2020
As of April 23, 2020, there have been 2,544,792 global cases (73,657 new in the last 24h). 175,694 people have died of COVID-19 (case fatality ~7%).
The top 3 affected countries by case number are the United States (800,926), Spain (208,389), and Italy (187,327).
This information is updated daily as WHO “Situation Reports” and can be found here.
As of April 23, 2020, there have been 38,923 confirmed cases in Canada with 1871 deaths. Updated counts can be found here.
The CDC has a map showing countries with COVID-19 cases. Case numbers are likely underreported due to milder cases that are not caught.5[bg_faq_end][bg_faq_start]
Updated March 19, 2020
Understanding of transmission is incomplete, but is thought to be via respiratory droplets, similar to influenza.
The virus most likely originated in bats, but the eventual transmission to humans is currently a subject of speculation. A seafood market that also sold live animals in Wuhan is thought to be ground-zero.
Early reports of asymptomatic transmission were contested6, but further cases have now been reported.7–9 Adding to this assumption is research showing SARS-CoV-2 RNA is found in the respiratory secretions of patients prior to symptom onset.10 One paper suggests that pooled patient cases show a median transmission interval of 4 days between infected to previously uninfected patients. This supports substantial transmission prior to symptomatology.20
The predominant mode of transmission is thought to be similar to other respiratory viruses. Viral particles in respiratory droplets can either directly come into contact with another person’s mucus membranes, or can be transmitted through a contaminated surface or fomite. Though surface stability does not guarantee virility in vivo, SARS-CoV-2 was recently found to remain stable on plastic and stainless steel for 2-3 days.11
Though still speculative, governing bodies are quite ubiquitously assuming transmission via airborne particles is also possible in the highest risk scenarios. Airborne viral particles have been shown to last around 3 hours before denaturing.11 The creation of airborne or “aerosolized” particles are thought to only be of clinical risk during iatrogenic procedures such as intubation, manual ventilation, high flow oxygen administration, nebulizer treatment, open suctioning, and non-invasive ventilation. 12,13
In epidemiology, the reproductive number, or R⌀, is the average number of people that an infected individual passes the infection on to:
- R⌀ < 1 means the epidemic will burn out
- R⌀ = 1 then the epidemic will proceed at a steady and linear rate
- R⌀ > 1 means the epidemic will increase at an exponential rate
Data from Wuhan from cases in December 2019 through January 2020 suggested an R⌀ of between 2.5 to 2.9.14 This is significantly higher than the estimated R⌀ of 1 in SARS-CoV in 2003 and MERS-CoV in 2012 – 2015.15
It should be noted that the R⌀ is a function of many factors including:
- Infectivity of the pathogen
- Case fatality rate – The greater the case fatality rate, the less those infected will be able to spread disease to the general population, as they are more likely hospitalized or dead
- Human behaviours – public health measures can reduce the R⌀ – On the Diamond Princess cruise ship (the antithesis of social distancing), the R⌀ was ~15.16
Two reports totalling 18 cases were reviewed regarding pregnant patients with COVID-19. There were no vertical transmissions of virus from mother to baby.17,18 Transmission through breast milk has not yet been shown, though respiratory transmission while in close contact with an infant is of course possible.[bg_faq_end][bg_faq_start]
Updated March 17, 2020
The incubation period for COVID-19 is still an evolving area of research, but in recent publications it seems to be around 5 days before patients experience an onset of fever and respiratory symptoms. 95 percent of patients have symptoms prior to 12 days after transmission.19–22 Practice guidelines may therefore assume an incubation period of up to 14 days. 23[bg_faq_end][bg_faq_start]
Clinical Picture and Findings
Updated April 30, 2020 17,19,24–27
In a report of 1,482 hospitalized patients with confirmed COVID-19 in the United States, the most common presenting symptoms were cough (86%), fever or chills (85%), and shortness of breath (80%), diarrhea (27%), and nausea (24%).28
Very Common Findings (>50%):
- Fever – 44-98% (6 studies) – It should be noted that some studies24 defined fever as a temperature greater than 37.3 degrees Celsius, and in the largest cohort25, only 44% of patients had a fever at time of admission – LACK OF FEVER DOES NOT EXCLUDE COVID-19
- Fatigue – 23-70% (3 studies)
- Cough – 59-82% (6 studies)
- Lymphopenia – 83% with lymphocyte count less than 1.5×10*9 g/L on admission (1 study of 1099 patients)
- Bilateral Infiltrates – 37-79% (6 studies, combination CXR & CT)
- Ground Glass Opacities – 12-88% (8 studies, including 2 meta-analyses showing 88% and 69%)
- Peripheral Localization of Opacities/Consolidation – 44-76% (2 studies)
Common Findings (15-50%):
- Shortness of Breath – 19-42% (4 studies) – One additional study showed 64% SOB prevalence, but all in critically ill patients)
- Sputum production – 19-34% (3 studies)
- Myalgia or arthralgia – 11-35% (5 studies)
- Leukopenia – 34% with WBC less than 4.0×10*9 g/L on admission (1 study of 1099 patients)
- Unilateral Infiltrates – 21-51% (2 studies, including 1 meta-analysis showing 25%)
- Mixed Ground Glass + Consolidation – 26-29% (2 studies)
Uncommon Findings (<15%):
- Headache – 8-14% (5 studies)
- Sore throat – 5-14% (2 studies)
- Nausea and vomiting – 1-14% (5 studies)
- Diarrhea – 2-10% (5 studies)
- Leukocytosis – 5.9% with WBC greater than 10×10*9 g/L on admission (1 study of 1099 patients)
A report from the Chinese Center for Disease Control and Prevention that included data from around 45,000 confirmed cases stated that 81% of cases were mild (no or mild pneumonia), 14% severe (hypoxia, lung infiltrates >50%), and 5% critical (respiratory failure, septic shock, organ failure). Case fatality was 2.3%.29
Though neither sensitive nor specific, 61% of COVID-19 patients had a CRP greater than 10mg/L, 41% had an LDH greater than 250U/L, and 46% had a D-dimer greater than 500 on admission25. Elevated CRP, LDH, and D-dimer levels throughout a patient’s course in hospital were more often in seen in non-survivors24,30.[bg_faq_end][bg_faq_start]
Precautions in the ED
Updated March 18, 2020
Protocols for screening, isolation, and personal protective equipment (PPE) will be specific to your local organizations.
The recommendations in Canadian tertiary care centres for triaging were originally focussed on travellers from Wuhan. This broadened to include many more “high risk” countries of travel, but with the global spread and chance of community transmission, even broadening triage questions to include any international travel or sick contacts will soon become too narrow. Please watch your own local guidelines for expected and continuous changes.
Personal Protective Equipment recommendations have also been a subject of contention. Until recently, the CDC had been recommending that airborne precautions be taken when interacting with confirmed or suspected COVID-19 patients. This would require a negative pressure room, fluid-resistant gown, gloves, face shield, and N95 masks (or better) at all times. This comes with massive health care costs considering the PPE and isolation requirements.25 The more recent CDC guidelines now align fairly closely with the WHO:
- Triage nurses should be screening patients for respiratory symptoms, travel history, and sick contacts. Patients with respiratory symptoms should immediately be given a surgical mask to wear. Enhanced PPE for triage nurses is not recommended other than spatial distancing (>1 meter) and advisement that non- face-to-face triaging options or the use the glass partitions would be ideal.
- COVID-19 suspects should be in isolation rooms, ideally with negative pressure or advanced HEPA filtration. Current minimum PPE recommendations are based on “Enhanced Droplet/Contact”, meaning gowns, gloves, masks, and face shields should be used at all times… and airborne precautions with the corresponding upgrade to N95 masks should be used during aerosol-generating procedures (intubation, suction, administration of high flow O2, non-invasive ventilation, nebulization, etc).
- Much more info about Droplet/Contact vs Airborne precautions and the theory behind aerosol-generating procedures can be found within our COVID Intubation page.
Updated April 29, 2020
Testing protocols are location specific, so please discuss this with your local department and health authority. In general, viral nasopharyngeal, oropharyngeal, and sputum swabs can be used for PCR testing and should be labelled as COVID-19 suspects, though you should ensure you use the correct swab and medium that are mandated locally. Notify your health authority when sending the samples if that is part of your local protocol.
At present, there remains a lack of systematic reviews concerning the effectiveness of nasopharyngeal testing as the primary means of diagnosis. Recent studies are showing a sensitivity of 70 to 90% for single-test pharyngeal PCR.31 32,33 Although it can increase sensitivity, the American College of Radiologists has recommended against the use of Chest CT as a diagnostic measure.34 Repeated RT-PCR of nasopharyngeal swabs remains the gold standard rule-out test.
Recent research has indicated a role for serologic (i.e. antibody-mediated) tests in the management of COVID-19 cases, particularly in the confirmation of diagnosis. However, the delay between symptom onset and development of a detectable antibody response (12 and 14 days for IgM and IgG respectively) limits the utility of this method in the acute setting.35 However, when feasible, testing with both modalities was shown to significantly increase sensitivity compared to either test alone.[bg_faq_end][bg_faq_start]
Updated April 23, 2020
For mild illness in patients without co-morbid conditions, both the WHO and CDC have released guidelines about appropriate care (and isolation) at home. Follow the hyperlinks to the full recommendations on healthcare contact, isolation, hygiene, and contacts. In general, they advise plenty of cleaning and washing, respiratory precautions, good ventilation, and avoiding exposure to others.
In the ED and hospital, care is supportive with appropriate infection precautions, and may include management of severe sepsis and ARDS. The WHO and CDC recommend steroids not be used in COVID-19 due to prior evidence in MERS and SARS that showed harm or no reliable benefit.36
A recent paper in the Lancet suggested that patients with hypertension or diabetes mellitus may be at increased risk for COVID-19 infection due to common pharmaceuticals in these populations (particularly ACE inhibitors and ARBs) up-regulating ACE2, which coronaviruses are thought to bind to.37,38 A recent study has shown that discontinuing ACE inhibitors and ARBs in covid-positive patients was associated with increased mortality.39 Presently, recommendations do not advise empiric discontinuation of ACEI/ARB therapy in the presence of a covid-19 diagnosis. Unless contraindications exist (e.g. hyperkalemia), healthy patients taking these medications are also advised to continue taking them.
It was also suggested that ibuprofen may cause this up-regulation of ACE2. Despite some initial confusion on their stance, the WHO has since clarified that based on the evidence currently available, they do not recommend against the use of ibuprofen beyond the usual known side effects that limit its use.
Chloroquine may emerge as a potential treatment for COVID-19. Spurred by studies showing effect on SARS, in vitro studies showed activity against SARS-CoV-2. Early results in multiple RCTs show decreased exacerbation of pneumonia, shortened disease course, and hastening of a virus-negative conversion. The drug has been forwarded for inclusion in upcoming treatment guidelines by China’s National Health Commission.40 Pharmacologic similarities suggest Hydroxychloroquine may also have an effect, with RCTs ongoing. Contrary to recent tweets by President Donald Trump, the combination of Hydroxychloroquine and Azithromycin have only been suggested as having possible effect against SARS-CoV-2 viral load. This 32-patient non-randomized trial is promising, but as yet there is little published to support patient-centred outcomes.41 Presently, some studies have shown promising results in vitro for both drugs; however, these drugs are also associated with significant toxicologic effects outside narrow treatment dosing.42 A recent review of 45 articles published prior to March 30, 2020 found insufficient evidence to recommend for or against the use of these drugs in vivo.43
Randomized Controlled Trials are being conducted on remdesivir and lopinavir-ritonavir, antivirals with documented activity against related coronaviruses like SARS and MERS. Initial results from a trial (n = 199) published in NEJM found no benefit from combined lopinavir-ritonavir beyond standard care.44 Recent results of a randomized trial published in The Lancet have shown no significant clinical benefit to use of remdesivir, although there was a trend towards reduced hospitalization time.45 A number of other existing antivirals and immunomodulators are also being studied, including oseltamivir (Tamiflu), which at this point is considered ineffective. News reports covering statements from medical authorities in China suggest that favipiravir may show promise in treatment in less severe cases while Indian officials reported success with the combination of lopinavir and ritonavir along with chloroquine and oseltamivir. Currently, available reviews do not conclusively support or recommend against the use of antiviral therapy in the management of COVID-19 infections. This may change as subsequent studies and trial data are eventually published.46
In general, off-label use is not recommended outside the context of a clinical trial. These are ongoing, including a recently-launched WHO trial to study the effects of four interventions: remdesivir, chloroquine, and hydroxychloroquine, as well as lopinavir-ritonavir both with and without interferon-beta.47
Globally, COVID-19 has now passed the stage where containment of the virus is possible, so important questions are being raised about the triaging of patients and resource allocation in scenarios where case numbers exceed system capacity. Recent literature has focused on the use of frailty status in lieu of chronological age when assessing which patients are most likely to benefit from ICU support.48,49[bg_faq_end]
Update contributors: Ben Forestell, Evan Formosa, Afsheen Mehar, Kevin Boreskie, Joseph Darcel. Original copyediting and upload: Andy Tolmie
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The COVID-19 epidemic is escalating and although confirmed cases in North America fall short of 25 as per the latest CDC and Canadian Public Health reports, the threat is real. As frontline healthcare specialists, it is imperative that we are up to date with the latest information so that we can contain the spread, appropriately manage our patients and protect our healthcare team. Knowledge is power. Be informed!
This article provides an up to date and condensed summary of the epidemiology, transmission, clinical manifestations and diagnostic testing for suspected COVID-19 patients. Additionally, we have summarized general isolation protocols and precautions, as well as tips to decrease your risk of infection as a healthcare provider. Remember that appropriate triage screening protocols and a thorough history can help diagnose and contain the infection. Mask all patients presenting with any infectious respiratory symptoms, take the proper precautions and ask the right questions!