Everything you should know about the 2019 coronavirus and covid-19

Evolving Knowledge on Treatment for COVID-19

Currently, remdesivir, an antiviral agent, is the only Food and Drug Administration-approved drug for COVID-19. There is an array of drugs approved for other indications, as well as multiple investigational agents, that are being studied for the treatment of COVID-19 in clinical trials around the globe. These trials can be accessed at ClinicalTrials.gov. In addition, providers can access and prescribe investigational drugs or agents that are approved or licensed for other indications through various mechanisms, including Emergency Use Authorizations (EUAs), Emergency Investigational New Drug (EIND) applications, compassionate use or expanded access programs with drug manufacturers, and/or off-label use.

Whenever possible, the Panel recommends that promising, unapproved, or unlicensed treatments for COVID-19 be studied in well-designed, controlled clinical trials. This includes drugs that have been approved or licensed for other indications. The Panel recognizes the critical importance of clinical research in generating evidence to address unanswered questions regarding the safety and efficacy of potential treatments for COVID-19. However, the Panel also realizes that many patients and providers who cannot access such trials are still seeking guidance about whether to use these agents.

A large volume of data and publications from randomized controlled trials, observational cohorts, and case series are emerging at a very rapid pace, some in peer-reviewed journals, others as manuscripts that have not yet been peer reviewed, and, in some cases, press releases. The Panel continuously reviews the available data and assesses their scientific rigor and validity. These sources of data and the experiences of the Panel members are used to determine whether new recommendations or changes to the current recommendations are warranted.

Finally, it is important to stress that the rated treatment recommendations in these Guidelines should not be considered mandates. The choice of what to do or not to do for an individual patient is ultimately decided by the patient and their provider.

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Febrile Neutropenia

Cancer patients with febrile neutropenia should undergo molecular diagnostic testing for SARS-CoV-2 and evaluation for other infectious agents; they should also be given empiric antibiotics, as outlined in the NCCN Guidelines.26 Low-risk febrile neutropenia patients should be treated at home with oral antibiotics or intravenous infusions of antibiotics to limit nosocomial exposure to SARS-CoV-2. Patients with high-risk febrile neutropenia should be hospitalized per standard of care.26 Empiric antibiotics should be continued per standard of care in patients who test positive for SARS-CoV-2. Clinicians should also continuously evaluate neutropenic patients for emergent infections.

Clinical Presentation

The estimated incubation period for COVID-19 is up to 14 days from the time of exposure, with a median incubation period of 4 to 5 days.6,18,19 The spectrum of illness can range from asymptomatic infection to severe pneumonia with acute respiratory distress syndrome (ARDS) and death. Among 72,314 persons with COVID-19 in China, 81% of cases were reported to be mild (defined in this study as no pneumonia or mild pneumonia), 14% were severe (defined as dyspnea, respiratory frequency ≥30 breaths/min, saturation of oxygen [SpO₂] ≤93%, a ratio of arterial partial pressure of oxygen to fraction of inspired oxygen [PaO₂/FiO₂] <300 mm Hg, and/or lung infiltrates >50% within 24 to 48 hours), and 5% were critical (defined as respiratory failure, septic shock, and/or multiorgan dysfunction or failure).20 In a report on more than 370,000 confirmed COVID-19 cases with reported symptoms in the United States, 70% of patients experienced fever, cough, or shortness of breath, 36% had muscle aches, and 34% reported headaches.3 Other reported symptoms have included, but are not limited to, diarrhea, dizziness, rhinorrhea, anosmia, dysgeusia, sore throat, abdominal pain, anorexia, and vomiting.

The abnormalities seen in chest X-rays vary, but bilateral multifocal opacities are the most common. The abnormalities seen in computed tomography of the chest also vary, but the most common are bilateral peripheral ground-glass opacities, with areas of consolidation developing later in the clinical course.21 Imaging may be normal early in infection and can be abnormal in the absence of symptoms.21

Common laboratory findings in patients with COVID-19 include leukopenia and lymphopenia. Other laboratory abnormalities have included elevated levels of aminotransferase, C-reactive protein, D-dimer, ferritin, and lactate dehydrogenase.

While COVID-19 is primarily a pulmonary disease, emerging data suggest that it also leads to cardiac,22,23 dermatologic,24 hematological,25 hepatic,26 neurological,27,28 renal,29,30 and other complications. Thromboembolic events also occur in patients with COVID-19, with the highest risk occurring in critically ill patients.31

The long-term sequelae of COVID-19 survivors are currently unknown. Persistent symptoms after recovery from acute COVID-19 have been described (see Clinical Spectrum of SARS-CoV-2 Infection). Lastly, SARS-CoV-2 infection has been associated with a potentially severe inflammatory syndrome in children (multisystem inflammatory syndrome in children, or MIS-C).32,33 Please see Special Considerations in Children for more information.

Critical Illness

Critically ill patients may have acute respiratory distress syndrome, septic shock that may represent virus-induced distributive shock, cardiac dysfunction, elevation in levels of multiple inflammatory cytokines that provoke a cytokine storm, and/or exacerbation of underlying comorbidities. In addition to pulmonary disease, patients with critical illness may also experience cardiac, hepatic, renal, central nervous system, or thrombotic disease.

As with any patient in the intensive care unit (ICU), successful clinical management of a patient with COVID-19 includes treating both the medical condition that initially resulted in ICU admission and other comorbidities and nosocomial complications.

For more information, see Care of Critically Ill Patients With COVID-19.

Cited by 504 articles

• Pandemic Perspective: Commonalities Between COVID-19 and Cardio-Oncology.

  Brown SA, Zaharova S, Mason P, Thompson J, Thapa B, Ishizawar D, Wilkes E, Ahmed G, Rubenstein J, Sanchez J, Joyce D, Kalyanaraman B, Widlansky M.
  Brown SA, et al.
  Front Cardiovasc Med. 2020 Dec 4;7:568720. doi: 10.3389/fcvm.2020.568720. eCollection 2020.
  Front Cardiovasc Med. 2020.

  PMID: 33344513
  Free PMC article.

• Recent Progress in the Drug Development Targeting SARS-CoV-2 Main Protease as Treatment for COVID-19.

  Cui W, Yang K, Yang H.
  Cui W, et al.
  Front Mol Biosci. 2020 Dec 4;7:616341. doi: 10.3389/fmolb.2020.616341. eCollection 2020.
  Front Mol Biosci. 2020.

  PMID: 33344509
  Free PMC article.

  Review.

• Impact of repurposed drugs on the symptomatic COVID-19 patients.

  Hussain I, Hussain A, Alajmi MF, Rehman MT, Amir S.
  Hussain I, et al.
  J Infect Public Health. 2020 Dec 7;14(1):24-38. doi: 10.1016/j.jiph.2020.11.009. Online ahead of print.
  J Infect Public Health. 2020.

  PMID: 33341481
  Free PMC article.

  Review.

• Coronavirus vaccine development: from SARS and MERS to COVID-19.

  Li YD, Chi WY, Su JH, Ferrall L, Hung CF, Wu TC.
  Li YD, et al.
  J Biomed Sci. 2020 Dec 20;27(1):104. doi: 10.1186/s12929-020-00695-2.
  J Biomed Sci. 2020.

  PMID: 33341119
  Free PMC article.

  Review.

• Acute Kidney Injury in COVID-19: The Chinese Experience.

  Zheng X, Zhao Y, Yang L.
  Zheng X, et al.
  Semin Nephrol. 2020 Sep;40(5):430-442. doi: 10.1016/j.semnephrol.2020.09.001. Epub 2020 Sep 4.
  Semin Nephrol. 2020.

  PMID: 33334457
  Free PMC article.

  Review.

General Prevention Measures

Transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is thought to mainly occur through respiratory droplets transmitted from an infectious person to those within 6 feet of the person. Less commonly, airborne transmission of small droplets and particles of SARS-CoV-2 that are suspended in the air can result in transmission to those who are more than 6 feet from an infectious individual. Although rare, infection through this route of transmission can also occur in persons who pass through a room that was previously inhabited by an infectious person. SARS-CoV-2 infection via airborne transmission of small particles tends to occur after prolonged exposure (>30 minutes) to an infectious person who is in an enclosed space with poor ventilation.1 The risk of SARS-CoV-2 transmission can be reduced by covering coughs and sneezes and maintaining a distance of at least 6 feet from others. When consistent distancing is not possible, face coverings may further reduce the spread of infectious droplets from individuals with SARS-CoV-2 infection to others. Frequent handwashing is also effective in reducing the risk of infection.2 Health care providers should follow the Centers for Disease Control and Prevention (CDC) recommendations for infection control and appropriate use of personal protective equipment.3

Development of the Guidelines

Each section of the Guidelines is developed by a working group of Panel members with expertise in the area addressed in the section. Each working group is responsible for identifying relevant information and published scientific literature and for conducting a systematic, comprehensive review of that information and literature. The working groups propose updates to the Guidelines based on the latest published research findings and evolving clinical information.

New Guidelines sections and recommendations are reviewed and voted on by the voting members of the Panel. To be included in the Guidelines, a recommendation must be endorsed by a majority of Panel members. Updates to existing sections that do not affect the rated recommendations are approved by Panel co-chairs without a Panel vote. Panel members are required to keep all Panel deliberations and unpublished data considered during the development of the Guidelines confidential.

Method of Synthesizing Data and Formulating Recommendations

The working groups critically review and synthesize the available data to develop recommendations. Aspects of the data that are considered include, but are not limited to, the source of the data, the type of study (e.g., case series, prospective or retrospective cohorts, randomized controlled trial), the quality and suitability of the methods, the number of participants, and the effect sizes observed. Each recommendation is assigned two ratings according to the scheme presented in Table 1.

Table 1. Recommendation Rating Scheme

To develop the recommendations in these Guidelines, the Panel uses data from the rapidly growing body of published research on COVID-19. The Panel also relies heavily on experience with other diseases, supplemented with evolving personal clinical experience with COVID-19.

In general, the recommendations in these Guidelines fall into the following categories:

• The Panel recommends using for the treatment of COVID-19 (rating). Recommendations in this category are based on evidence from clinical trials or large cohort studies that demonstrate clinical or virologic efficacy in patients with COVID-19, with the potential benefits outweighing the potential risks.
• There are insufficient data for the Panel to recommend either for or against the use of for the treatment of COVID-19 (no rating). This statement is not a recommendation; it is used in cases when there are insufficient data to make a recommendation.
• The Panel recommends against the use of for the treatment of COVID-19, except in a clinical trial (rating). This recommendation is for an intervention that has not clearly demonstrated efficacy in the treatment of COVID-19 and/or has potential safety concerns. More clinical trials are needed to further define the role of the intervention.
• The Panel recommends against the use of for the treatment of COVID-19 (rating). This recommendation is used in cases when the available data clearly show a safety concern and/or the data show no benefit for the treatment of COVID-19.

Clinical Data for COVID-19

• A case-control study compared outcomes in 52 consecutive patients with COVID-19 treated with anakinra and 44 historical controls. The patients in both groups were all admitted to the same hospital in Paris, France. Case patients were consecutive admissions from March 24 to April 6, 2020, with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or lung infiltrates on chest imaging typical of COVID-19, and either significant hypoxia (SpO₂ ≤93% with ≥6L/min O₂) or worsening hypoxia (SpO₂ ≤93% with >3L/min O₂ and a loss of ≥3% of O₂ saturation on room air in the previous 24 hours). The historic controls were patients who fulfilled the same eligibility criteria and admitted to the hospital during the same period. As standard of care for both groups, some patients received hydroxychloroquine, azithromycin, or parenteral beta-lactam antibiotics. Anakinra was dosed as 100 mg subcutaneous (SQ) twice daily for 72 hours, followed by anakinra 100 mg SQ daily for 7 days. Clinical characteristics were similar between the groups, except that the cases had a lower mean body mass index than the controls (25.5 kg/m2 vs. 29.0 kg/m2, respectively), longer duration of symptoms (mean of 8.4 days for cases vs. 6.2 days for controls), and a higher frequency of hydroxychloroquine use (90% for cases vs. 61% for controls) and azithromycin use (49% for cases vs. 34% for controls). The primary outcome of admission to the intensive care unit for mechanical ventilation or death occurred among 13 case patients (25%) and 32 control patients (73%) (hazard ratio 0.22; 95% confidence interval, 0.11 to 0.41). However, within the first 2 days of follow up, in the control group, six patients (14%) had died and 19 patients (43%) had reached the composite primary outcome, which further limited intragroup comparisons and specifically analyses of time to event. C-reactive protein (CRP) levels decreased by Day 4 among those receiving anakinra. Thromboembolic events occurred in 10 patients (19%) who received anakinra and in five control patients (11%). The clinical implications of these findings are uncertain due to limitations in the study design related to unmeasured confounding combined with the very high early event rate among the retrospective controls.4
• A single-center, retrospective cohort study compared outcomes in 29 patients following open-label use of anakinra to outcomes in 16 historical controls enrolled at the same medical center in Italy. All patients had COVID-19 with moderate to severe acute respiratory distress syndrome (ARDS) that required non-invasive ventilation and evidence of hyperinflammation (CRP ≥100 mg/L and/or ferritin ≥900 ng/mL). High-dose intravenous anakinra 5 mg/kg twice daily was administered for a median of 9 days, followed by SQ administration of anakinra 100 mg twice daily for 3 days to avoid inflammatory relapses. Patients in both the anakinra and control groups received hydroxychloroquine and lopinavir/ritonavir. In the anakinra group, reductions in CRP levels were noted over several days following anakinra initiation, and the 21-day survival rate was higher than in the control group (90% vs. 56%, respectively; P = 0.009). However, the patients in the anakinra group were younger than those in the control group (median age 62 years vs. 70 years, respectively), and fewer patients in the anakinra group had chronic kidney disease. High-dose anakinra was discontinued in seven patients (24%) because of adverse events (four patients developed bacteremia and three patients had elevated liver enzymes); however, retrospective assessment showed that these events occurred with similar frequency in the control group. An additional group of seven patients received low-dose SQ anakinra 100 mg twice daily; however, treatment in this group was stopped after 7 days because of lack of clinical or anti-inflammatory effects.5
• Other small case series have reported anakinra use for the treatment of COVID-19 and anecdotal evidence of improvement in outcomes.6

Considerations in Pregnancy

• BTK inhibitors: There is a paucity of data on human pregnancy and BTK inhibitor use. In animal studies, in doses exceeding the therapeutic human dose, acalabrutinib and ibrutinib were associated with interference with embryofetal development.8,9 Based on these data, BTK inhibitors may be associated with fetal malformations when use occurs during organogenesis. The impact of use later in pregnancy is unknown. Risks of use should be balanced against potential benefits.
• JAK inhibitors: There is a paucity of data on the use of JAK inhibitors in pregnancy. Fetal risk cannot be ruled out. Pregnancy registries provide some outcome data on tofacitinib used during pregnancy for other conditions (e.g., ulcerative colitis, rheumatoid arthritis, psoriasis). Among the 33 cases reported, pregnancy outcomes were similar to those among the general pregnant population.10-12 Risks of use should be balanced against potential benefits.

How are coronaviruses diagnosed?

COVID-19 can be diagnosed similarly to other conditions caused by viral infections: using a blood, saliva, or tissue sample. However, most tests use a cotton swab to retrieve a sample from the inside of your nostrils.

The CDC, some state health departments, and some commercial companies conduct tests. See your state’s health department website to find out where testing is offered near you.

On April 21, 2020, the Food and Drug Administration (FDA) approved the use of the first COVID-19 home testing kit.

Using the cotton swab provided, people will be able to collect a nasal sample and mail it to a designated laboratory for testing.

The emergency-use authorization specifies that the test kit is authorized for use by people whom healthcare professionals have identified as having suspected COVID-19.

Talk to your doctor right away if you think you have COVID-19 or you notice symptoms.

Your doctor will advise you on whether you should:

• stay home and monitor your symptoms
• come into the doctor’s office to be evaluated
• go to the hospital for more urgent care

Rationale

Increased intracellular zinc concentrations efficiently impair replication in a number of RNA viruses.1 Zinc has been shown to enhance cytotoxicity and induce apoptosis when used in vitro with a zinc ionophore (e.g., chloroquine). Chloroquine has also been shown to enhance intracellular zinc uptake in vitro.2 The relationship between zinc and COVID-19, including how zinc deficiency affects the severity of COVID-19 and whether zinc supplements can improve clinical outcomes, is currently under investigation.3 Zinc levels are difficult to measure accurately, as zinc is distributed as a component of various proteins and nucleic acids.4

Zinc supplementation alone or in combination with hydroxychloroquine for prevention and treatment of COVID-19 is currently being evaluated in clinical trials. The optimal dose of zinc for the treatment of COVID-19 is not established. The recommended dietary allowance for elemental zinc is 11 mg daily for men and 8 mg for nonpregnant women.5 The doses used in registered clinical trials for COVID-19 vary between studies, with a maximum dose of zinc sulfate 220 mg (50 mg of elemental zinc) twice daily.

Long-term zinc supplementation can cause copper deficiency with subsequent reversible hematologic defects (i.e., anemia, leukopenia) and potentially irreversible neurologic manifestations (i.e., myelopathy, paresthesia, ataxia, spasticity).6,7 Zinc supplementation for a duration as short as 10 months has been associated with copper deficiency.8 In addition, oral zinc can decrease the absorption of medications that bind with polyvalent cations.5 Because zinc has not been shown to have clinical benefit and may be harmful, the Panel recommends against using zinc supplementation above the recommended dietary allowance for the prevention of COVID-19, except in a clinical trial (BIII).

Rationale for Use in Patients With COVID-19

The kinase inhibitors are proposed as treatments for COVID-19 because they can prevent phosphorylation of key proteins involved in the signal transduction that leads to immune activation and inflammation (e.g., the cellular response to proinflammatory cytokines such as interleukin -6).6 This immunosuppression could potentially reduce the inflammation and associated immunopathologies that have been observed in patients with COVID-19. Additionally, JAK inhibitors, particularly baricitinib, have theoretical direct antiviral activity through interference with viral endocytosis, potentially preventing entry into and infection of susceptible cells.7

Asymptomatic or Presymptomatic Infection

Asymptomatic SARS-CoV-2 infection can occur, although the percentage of patients who remain truly asymptomatic throughout the course of infection is variable and incompletely defined. It is unclear what percentage of individuals who present with asymptomatic infection progress to clinical disease. Some asymptomatic individuals have been reported to have objective radiographic findings that are consistent with COVID-19 pneumonia.10,11 The availability of widespread virologic testing for SARS-CoV-2 and the development of reliable serologic assays for antibodies to the virus will help determine the true prevalence of asymptomatic and presymptomatic infection. See Therapeutic Management of Patients With COVID-19 for recommendations regarding SARS-CoV-2–specific therapy.

What treatments are available?

There’s currently no treatment specifically approved for COVID-19, and no cure for an infection, although treatments and vaccines are currently under study.

Instead, treatment focuses on managing symptoms as the virus runs its course.

Seek medical help if you think you have COVID-19. Your doctor will recommend treatment for any symptoms or complications that develop and let you know if you need to seek emergency treatment.

Other coronaviruses like SARS and MERS are also treated by managing symptoms. In some cases, experimental treatments have been tested to see how effective they are.

Examples of therapies used for these illnesses include:

• antiviral or retroviral medications
• breathing support, such as mechanical ventilation
• steroids to reduce lung swelling
• blood plasma transfusions

How can you prevent coronaviruses?

The best way to prevent the transmission of infection is to avoid or limit contact with people who are showing symptoms of COVID-19 or any respiratory infection.

The next best thing you can do is practice good hygiene and physical distancing to prevent bacteria and viruses from being transmitted.

Prevention tips

• Wash your hands frequently for at least 20 seconds at a time with warm water and soap. How long is 20 seconds? About as long as it takes to sing your “ABCs.”
• Don’t touch your face, eyes, nose, or mouth when your hands are dirty.
• Don’t go out if you’re feeling sick or have any cold or flu symptoms.
• Stay at least 6 feet (2 meters) away from people.
• Cover your mouth with a tissue or the inside of your elbow whenever you sneeze or cough. Throw away any tissues you use right away.
• Clean any objects you touch a lot. Use disinfectants on objects like phones, computers, and doorknobs. Use soap and water for objects that you cook or eat with, like utensils and dishware.

Symptoms

The most common symptoms of COVID-19 include dry cough, fever, and shortness of breath. It is thought that symptoms can appear between 2-14 days after exposure although there have been isolated cases which suggest this may be longer. If you develop symptoms, you should stay at home to prevent the spread of the disease into the community. Wearing a face mask will help prevent the spread of the disease to others.

According to the Centers for Disease Control and Prevention (CDC), symptoms of COVID-19 include:

• Fever or chills
• Cough
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea

Rescue Therapies for Mechanically Ventilated Adults With Acute Respiratory Distress Syndrome

Recommendations

For mechanically ventilated adults with COVID-19, severe ARDS, and hypoxemia despite optimized ventilation and other rescue strategies:

• The Panel recommends using recruitment maneuvers rather than not using recruitment maneuvers (CII).
• If recruitment maneuvers are used, the Panel recommends against using staircase (incremental PEEP) recruitment maneuvers (AII).
• The Panel recommends using an inhaled pulmonary vasodilator as a rescue therapy; if no rapid improvement in oxygenation is observed, the treatment should be tapered off (CIII).

Rationale

There are no studies to date assessing the effect of recruitment maneuvers on oxygenation in severe ARDS due to COVID-19. However, a systematic review and meta-analysis of six trials of recruitment maneuvers in non-COVID-19 patients with ARDS found that recruitment maneuvers reduced mortality, improved oxygenation 24 hours after the maneuver, and decreased the need for rescue therapy.24 Because recruitment maneuvers can cause barotrauma or hypotension, patients should be closely monitored during recruitment maneuvers. If a patient decompensates during recruitment maneuvers, the maneuver should be stopped immediately. The importance of properly performing recruitment maneuvers was illustrated by an analysis of eight randomized controlled trials in non-COVID-19 patients (n = 2,544) which found that recruitment maneuvers did not reduce hospital mortality (RR 0.90; 95% CI, 0.78–1.04). Subgroup analysis found that traditional recruitment maneuvers significantly reduced hospital mortality (RR 0.85; 95% CI, 0.75–0.97), whereas incremental PEEP titration recruitment maneuvers increased mortality (RR 1.06; 95% CI, 0.97–1.17).25

Although there are no published studies of inhaled nitric oxide in patients with COVID-19, a Cochrane review of 13 trials of inhaled nitric oxide use in patients with ARDS found no mortality benefit.26 Because the review showed a transient benefit in oxygenation, it is reasonable to attempt inhaled nitric oxide as a rescue therapy in COVID patients with severe ARDS after other options have failed. However, if there is no benefit in oxygenation with inhaled nitric oxide, it should be tapered quickly to avoid rebound pulmonary vasoconstriction that may occur with discontinuation after prolonged use.

Treatment in the hospital

Your healthcare provider will decide on what approach to take for your treatment. There are drugs that have shown some benefit in reducing the severity of illness or risk of death for patients in the hospital by:

• Slowing the virus.

  Remdesivir (Veklury) is an antiviral medication approved by FDA to treat COVID-19. The current NIH COVID-19 Treatment Guidelines recommend remdesivir for certain patients who are hospitalized with COVID-19. Remdesivir is given to patients by infusion through their veins.

  Antiviral medications reduce the ability of the virus to multiply and spread through the body.

• Reducing an overactive immune response.

  Dexamethasone is a steroid medication, similar to a natural hormone produced by the body. The NIH COVID-19 Treatment Guidelines recommend dexamethasone, or a similar medication, to prevent or reduce injury to the body for some hospitalized patients with severe COVID-19. Dexamethasone is recommended for patients who need supplemental oxygen.

  In patients with severe COVID-19, the body’s immune system may overreact to the threat of the virus, worsening the disease. This can cause damage to the body’s organs and tissues. Some treatments can help reduce this overactive immune response.

• Treating complications. COVID-19 can damage the heart, blood vessels, kidneys, brain, skin, eyes, and gastrointestinal organs. It also can cause other complications. Depending on the complications, additional treatments might be used for severely ill hospitalized patients, such as blood thinners to prevent or treat blood clots.
• Supporting the body’s immune function. Plasma from patients who have recovered from COVID-19 (called convalescent plasma) can contain antibodies to the virus. This could help the immune system recognize and respond more effectively to the virus, but currently the NIH COVID-19 Treatment Guidelines find there is not enough evidence to recommend these treatments.

References

1. Yam LY, Chen RC, Zhong NS. SARS: ventilatory and intensive care. Respirology. 2003;8 Suppl:S31-35. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15018131.
2. Twu SJ, Chen TJ, Chen CJ, et al. Control measures for severe acute respiratory syndrome (SARS) in Taiwan. Emerg Infect Dis. 2003;9(6):718-720. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12781013.
3. Centers for Disease Control and Prevention. The National Personal Protective Technology Laboratory (NPPTL): respirator trusted-source information. 2020. Available at: https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource1quest2.html. Accessed September 23, 2020.
4. Milton DK, Fabian MP, Cowling BJ, Grantham ML, McDevitt JJ. Influenza virus aerosols in human exhaled breath: particle size, culturability, and effect of surgical masks. PLoS Pathog. 2013;9(3):e1003205. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23505369.
5. Qian H, Li Y, Sun H, Nielsen PV, Huang X, Zheng X. Particle removal efficiency of the portable HEPA air cleaner in a simulated hospital ward. Building Simulation. 2010;3:215-224. Available at: https://link.springer.com/article/10.1007/s12273-010-0005-4.
6. Offeddu V, Yung CF, Low MSF, Tam CC. Effectiveness of masks and respirators against respiratory infections in halthcare workers: a systematic review and meta-analysis. Clin Infect Dis. 2017;65(11):1934-1942. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29140516.
7. World Health Organization. Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. 2020. Available at: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. Accessed April 8, 2020.
8. Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html. Accessed September 28, 2020.
9. Bartoszko JJ, Farooqi MAM, Alhazzani W, Loeb M. Medical masks vs N95 respirators for preventing COVID-19 in healthcare workers: a systematic review and meta-analysis of randomized trials. Influenza Other Respir Viruses. 2020;14(4):365-373. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32246890.
10. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22563403.
11. Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. Br J Anaesth. 2017;119(3):369-383. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28969318.

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What is COVID-19?

COVID-19 is the disease caused by an infection of the SARS-CoV-2 virus, first identified in the city of Wuhan, in China’s Hubei province in December 2019. COVID-19 was previously known as 2019 Novel Coronavirus (2019-nCoV) respiratory disease before the World Health Organization (WHO) declared the official name as COVID-19 in February 2020.

The SARS-CoV-2 virus belongs to the family of viruses called coronaviruses, which also includes the viruses that cause the common cold, and the viruses that cause more serious infections such as severe acute respiratory syndrome (SARS), which was caused by SARS-CoV in 2002, and Middle East respiratory syndrome (MERS), which was caused by MERS-CoV in 2012. Like the other coronaviruses, the SARS-CoV-2 virus primarily causes respiratory tract infections, and the severity of the COVID-19 disease can range from mild to fatal.

Serious illness from the infection is caused by the onset of pneumonia and acute respiratory distress syndrome (ARDS).

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