“You’ve got this great surveillance system out there — make sure the surveillance system is primed. Make sure you’re ready to act on the signals that come in from that surveillance system. You’ve got to be set up to rapidly assess whether or not they really have those symptoms, test those people, and, if necessary, isolate and trace their contacts.”
Bruce Aylward
“So it is not only information to make sure people are informed; it is also making sure people are informed to act appropriately.”
Sylvie Brand
Dry cough and fever
Short of breath, not sudden death
Call your doctor now
Unless you’re living under a rock—where by the way you wouldn’t need to know anything about catching SARS-CoV-2, the virus that causes COVID-19—you’re likely overwhelmed by the avalanche of information about this rapidly evolving epidemic. By the end of the first week of March the number of cases topped 100,000 globally with a death toll greater than 3,000. While the epidemic was still mainly focused in Asia, more than 7,000 cases were reported in Europe (the entire country of Italy is currently locked down). And as of March 9, the case count of COVID-19 stood at 564 in the U.S., where the epidemic continues to spread in a number of states.
Obviously, the one country in the world that has the most knowledge of and experience with COVID-19 is China. China, and specifically Hubei province, is where the disease emerged; it’s where over 80 percent of the cases have been recorded; and it’s where doctors and health authorities have been battling the epidemic for the past three months. A visit on March 10 by Chinese president Xi Jinping to Wuhan, the capital city and epicenter of the coronavirus outbreak, however, signaled that the battle had turned the corner.
Supporting the claim that spread of the virus has peaked and that transmission is slowing down in China, the number of new infections and deaths reported there have been declining. In a March 4 New York Times article, “Inside China’s All-Out War on Coronavirus,” Bruce Aylward, the leader of a World Health Organization team that visited China for two weeks in February, describes the surveillance system they’ve developed that appears to be one of the key reasons why the epidemic is slowing. His opinion, reinforced by other public health experts, is that rapid case finding is crucial.
Thus everyone needs to know what the symptoms of COVID-19 are—the topic of this Germ Gem—not only for their own good, but also to contribute to the surveillance system in their state as well as the entire country.
When should you consider if you have COVID-19? The disease COVID-2019 is a respiratory tract infection. Thus the main symptoms are a dry cough, shortness of breath, and fever. We’re still learning a lot about the exact percentages of patients with each of these symptoms as well as other symptoms and those with no symptoms at all, that is, those who are fortunate enough to be asymptomatic. (We also don’t know for sure how many asymptomatic patients can still transmit the virus to others, but we do know this happens.)
As you’re aware, the COVID-19 epidemic is unfolding during the flu season, which is also the time of year when there is an uptick of cases of the common cold (usually caused by rhinoviruses or by a more benign strain of coronavirus). Some reports suggest that only a minority of patients with COVID-19 have additional upper respiratory symptoms like runny nose or sore throat, which are very common with colds, in particular.
To make things more complicated, additional viruses, such as adenoviruses and respiratory syncytial virus, cause respiratory tract infections. Unless you’re reading this post in Wuhan, China or another hotspot of the COVID-19 epidemic, however, when you develop a cough, it is overwhelmingly most likely that you’re immune system is battling a common cold virus or influenza virus.
At this stage of the epidemic in the U.S., all you really need to know is when to contact your doctor or another health care professional for advice about next steps. If you develop a dry cough and also have a fever or shortness of breath, the time is now because you may have COVID-19. But much more likely, you have influenza for which there is a treatment (Tamiflu or Relenza). That treatment, however, needs to be started within 48 hours of getting sick. Your doctor will sort out whether you’re infected with a virus, or if you’re very ill, possibly a bacterial pneumonia which unlike all the viral respiratory tract infections mentioned above, is treated with an antibiotic. (The cough associated with bacterial pneumonia is typically productive or phlegmy, and most bacteria usually make people very sick fast.)
Diagnostic tests to establish COVID-19 infection were initially in short supply in the U.S., and the Center for Disease Control and Prevention (CDC) as well as the Federal Drug Agency were intensely criticized for the delay in getting testing off the ground. At this time, it appears that this situation is quickly being remedied, as this is a very high priority in the campaign against the virus.
Currently, it appears that there are very few tip-offs from the patient history regarding when to strongly consider COVID-19, other than travel history and exposure to patients with the disease. For example, the first case of COVID-19 in my home state of Minnesota was diagnosed on March 6—the patient had been on a cruise ship carrying others with SARS-CoV-2. And the second case, diagnosed two days later, was in a returning tourist from Europe. Current estimates suggest that symptoms may appear in as few as two days or as many as 14 days after exposure to the virus.
So if you feel sick with dry cough, fever, or difficulty breathing, especially if you’ve been in close contact with a person known to have COVID-19, call your healthcare professional. They will work with your state’s public health department and CDC to establish a diagnosis.
What is the spectrum of COVID-19? Like many infections, the clinical spectrum of illness is broad with many people only very mildly affected and some with more severe disease necessitating hospitalization. According to a recent article in Lancet (“COVID-19: what is next for public health?”), there appear to be three major patterns of the clinical course of infection: mild illness with presenting symptoms related to inflammation of the upper respiratory tract; non-life threatening pneumonia; and severe pneumonia with acute respiratory distress syndrome (ARDS) that begins with mild symptoms for seven days and then progresses to rapid deterioration requiring advanced life support.
In another recent Lancet article: “Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China,” details of the symptoms, signs, laboratory abnormalities, and epidemiological characteristics of 41 patients who were admitted to hospital are described. Most of the patients were men (73%), less than half had underlying diseases (32%), and the median age was 49 years. So far, it appears that older adults are at greater risk of severe COVID-19, and children are relatively spared. (Incidentally, there is a superb web-based presentation by National Public Radio available for children: Just for Kids: A Comic Exploring the New Coronavirus.)
Timing is everything. Bruce Aylward thinks the key learning principal from China’s handling of COVID-19 epidemic is speed. “The faster you can find the cases, isolate the cases, and track their close contacts, the more successful you’re going to be.” This same lesson (strong epidemiological surveillance and contact tracing) appears to explain why Singapore has had virtually no community spread and is recognized as the “gold standard” example of how to deal with the epidemic. Much the same can be said for Hong Kong.
So for those of us in America, where COVID-19 recently has found an unwelcoming home, “if you see (or hear) something—a dry cough with fever or shortness of breath—say something (to your doctor).”
