Important COVID-19 resources for healthcare professionals

COVID-19 test kit price gouging (right click -> Translate to English): https://www.tagesspiegel.de/berlin/tib-molbiol-berliner-firma-produziert-corona-tests-fuer-die-ganze-welt/25602142.html

Apparently each test kit only cost €2.50, with lab work only costing additional €10, but governments are being charged €65-100 and more per test.

It appears that the SARS-CoV-2 virus has mutated into three different strains, as reported in Italy (right click -> Translate to English): https://www.laprovinciacr.it/news/cremona/242463/coronavirus-mappa-genetica-3-virus-isolati-in-italia.html

Two different strains have been reported from China, designated L and S. L is the newer strain that is more aggressive, but has thankfully not spread as effectively as the original S strain. CORRECTION: It is estimated that around 62% of infections are with the L type. Source: On the origin and continuing evolution of SARS-CoV-2

Italy is reaching critical stage only two weeks after the outbreak started and is now drafting in retired doctors, shutting down schools, and even considering setting an upper age for critical care eligibility based on most likely survival. Source (right click -> Translate to English): Coronavirus, the doctors of intensive care in Lombardy: "Timely actions or disastrous health calamity". The hypothesis of access priorities: "First who is most likely to survive"
This is a warning to all other countries to not underestimate this virus.

Some encouraging news emerging from research into chloroquine's effects on COVID-19. The hypothesis is that it acts as an ionophore (substance that transports particular ions across a lipid membrane in a cell) for Zn2+ ions, which in turn hinder the action of virus' RNA polimerase, impeding it's replication.

Recommended dose of chloroquine phosphate is 500mg twice per day for 10 days. Additional Zinc supplementation may improve the results somewhat, but Zinc on its own will not help as it cannot enter intracellular space without the help of chloroquine.

Sources:

• Zn²⁺ Inhibits Coronavirus and Arterivirus RNA Polymerase Activity In Vitro and Zinc Ionophores Block the Replication of These Viruses in Cell Culture
• Expert consensus on chloroquine phosphate for the treatment of novel coronavirus pneumonia.

Sex and comorbidities (WHO estimates): Mortality in males is 4.7% vs. 2.8% in females. If there are no comorbidities the death rate is 1.4%. In patients with coronary heart disease the death rate is 13.2%, with diabetes it's 9.2%, with high blood pressure it's 8.4%, with COPD it's 8% and with cancer it's 7.6%.

You've probably heard of flattening the curve by now, but here's a great illustration if you need one to drive home the point for some people.

The other thing worth knowing is the length of time that the SARS-CoV-2 virus survives on the surfaces. We now have an actual study done on this and here are the numbers:

• HCoV-19 remained viable in aerosols throughout the duration of our experiment (3 hours).
• HCoV-19 was most stable on plastic and stainless steel and viable virus could be detected up to 72 hours post application though the virus titer was greatly reduced from 10(3.7) to 10(0.6) after 72 hours for plastic and after 48 hours for stainless steel.
• The median half-life estimate for HCoV-19 was roughly 5.6 hours on steel and 6.8 hours on plastic.
• No viable virus could be measured after 4 hours on copper for HCoV-19 and 8 hours for SARS-CoV-1.
• No viable virus could be measured after 24 hours on cardboard for HCoV-19 and 8 hours for SARS-CoV-1.
• Individual replicate data were noticeably noisier for cardboard than other surfaces, so caution is advised in interpreting this result.
• Both viruses exhibited exponential decay in virus titer across all experimental conditions.

Our findings show that the stability of HCoV-19 and SARS-CoV-1 under the experimental circumstances tested is similar. This indicates that differences in the epidemiology of these viruses likely arise from other factors, including high viral loads in the upper respiratory tract and the potential for individuals infected with HCoV-19 to shed and transmit the virus while asymptomatic. Our results indicate that aerosol and fomite transmission of HCoV-19 are plausible, as the virus can remain viable and infectious in aerosols for multiple hours and on surfaces up to days. This echoes the experience with SARS-CoV-1, where these modes of transmission were associated with nosocomial spread and superspreading events, and provides guidance for pandemic mitigation measures. 

Source: Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1

So what's going on with the ACE2 receptor and ACE inhibitors/ARBs?

In short, from what we know, ACE inhibitors (-prils) and Angiotensin II Receptor Blockers (ARBs/-sartans) should in theory be protective based on animas studies and known human physiology, however the fact remains that patients with high blood pressure have seen worse outcomes, so the jury is still out on what exactly is going on.

ACE inhibitors/ARBs do increase the expression of the ACE2 receptor and ACE2 receptor does appear to be the entry point for the SARS-CoV-2 virus, so we must remain vigilant in this regard.

If you have the time watch this video for the full explanation: The ACE-2 Receptor - The Doorway to COVID-19 (ACE Inhibitors & ARBs) via YouTube - MedCram.com

The official recommendation from the European Society of Cardiology is to continue treatment with ACE inhibitors/ARBs unless instructed otherwise by the doctor.

Source: Position Statement of the ESC Council on Hypertension on ACE-Inhibitors and Angiotensin Receptor Blockers

Further reading:

• ACE-2: The Receptor for SARS-CoV-2 (rndsystems.com)
• Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? (thelancet.com)
• The Coronavirus Conundrum: ACE2 and Hypertension Edition (nephjc.com)
• ACE2: from vasopeptidase to SARS virus receptor (cell.com)

Last week saw a lot of discussion around ibuprofen use in COVID-19.

It's well known that any medicine lowering fever will reduce the body's immune response and with it the ability to fight off an infection, that's why it's not recommended to give children paracetamol/ibuprofen after vaccination if it can be avoided.

In the case of COVID-19 the general consensus has been that paracetamol should be used instead of ibuprofen if possible. NSAIDs have a fairly broad range of actions including reduced inflammation, which may hinder the immune system in other ways, therefore it makes sense to avoid them in potentially serious infections.

On the other hand some NSAIDs like indomethacin and naproxen have been shown to have some antiviral properties so the decision isn't that simple.

Given anecdotal reports of COVID-19 causing only low grade fever and the fact that it can be quite an insidious disease with initially resolving as an upper respiratory tract infection before coming back with a vengeance in the form of pneumonia, it would make sense to avoid taking any antipyretic medication if at all possible.

Recommended reading/watching:

• Use of NSAIDs in patients with COVID-19: what is the evidence? (CPA)
• Coronavirus Pandemic Update 40: Ibuprofen and COVID-19 (are NSAIDs safe?), Trials of HIV medications (YouTube)
• Dr. John Campbell - Reducing fever, Part 2 (YouTube)

Official statements:

• Advice about Anti-Inflammatory medication and COVID-19 (HSE)
• NSAIDs (NHS) 

Can reinfection occur with COVID-19?

In recent weeks we have seen conflicting reports in the mainstream media around the possibility of reinfection with the SARS-CoV-2 virus.

The first thing we must realise is that the SARS-CoV-2 ​RT-PCR test itself is only about 70% sensitive so it can and does miss around 30% of positive infections. That fact alone can easily explain a situation where someone might test negative but in fact still be infected and then later test positive again.

In terms of actual studies this study done on rhesus monkeys found that reinfection did NOT occur after 28 days of the initial infection. This means that at least in the short term there is a sufficiently strong immune response to this virus that it offers protection against reinfection and that any anecdotal reports of reinfection are most likely just false negative test results.

The world is now eagerly awaiting an antibody assay for COVID-19, which will enable us to test much more widely and find out exactly how far this virus has spread and get a better idea of the real mortality and hospitalization rate and how soon things can return back to normal.

Source:

• Reinfection could not occur in SARS-CoV-2 infected rhesus macaques
• Immunity to COVID-19 and is Reinfection Possible? (YouTube)

Let's connect:

• ICPHA COVID-19 Forum Thread (Register)
• ICPHA Private Facebook group
• ICPHA Facebook page
• ICPHA Twitter account
• ICPHA announcement channel and chat room

Why do healthcare workers appear to be especially susceptible to COVID-19?

Rishi Desai, MD, MPH, Chief Medical Officer at Osmosis, Infectious Disease Physician & Former Outbreak Investigator at the Center for Disease Control (CDC) explains that the most likely explanation is the large initial inoculum (viral dose) that doctors receive in handling the sickest patients at a very close distance, especially surgeons and intensivist/anesthesiologists.

Otolaryngologists and even ophthalmologists are also at increased risk due to close proximity to their patients when performing the exams.

Li Wenliang, the Chinese doctor who first alerted the world to the COVID-19 and eventually succumbed to the disease, was an ophthalmologist, so it's likely he received large and repeated doses of the virus. He was only 33 years old when he died from COVID-19 on 7 February 2020.

As of 30th March 2020, 61 doctors have died in Italy during the COVID-19 pandemic and we are seeing first deaths among pharmacists now as well.

Thankfully, pharmacy staff are not exposed in the same way as doctors and nurses are, however we still deal with a lot of sick people on a daily basis so we need to be extra vigilant whenever anyone presents with respiratory infection symptoms and is not wearing a mask or some other form of protection.

Since the outbreak first started in China a furious debate has raged around the appropriateness of using face masks, however at this point it's fairly obvious that any protection (even just surgical masks) is better than no protection. At the very least the initial dose is smaller, especially if everyone is wearing one. As front line health professionals dealing with a vulnerable and high risk cohorts of patients we should absolutely all be wearing face masks.

There are many improvised multi-use face masks becoming available at the moment, which can be disinfected in a washer/dryer, oven or even in a microwave, so until the proper N95/FFP2-3 masks become readily available we should at least be using these, somewhat improvised solutions.

Let's connect:

• ICPHA COVID-19 Forum Thread (Register)
• ICPHA Private Facebook group
• ICPHA Facebook page
• ICPHA Twitter account
• ICPHA announcement channel and chat room