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Trajectory of the COVID-19 Pandemic: Chasing a Moving Target

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Trajectory of the COVID-19 Pandemic: Chasing a Moving Target 1 Review Article Page 1 of 13 Trajectory of the COVID-19 pandemic: chasing a moving target Kamal Kant Sahu1, Ajay Kumar Mishra1, Amos Lal2^ 1Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, 01608, USA; 2Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota 55902, USA Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Amos Lal, MBBS, MD. Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota 55902, USA. Email: [email protected]; [email protected]. Abstract: The spread of COVID-19 has already taken a pandemic form, affecting over 180 countries in a matter of three months. The full continuum of disease ranges from mild, self-limiting illness to severe progressive COVID-19 pneumonia, multiorgan failure, cytokine storm and death. Younger and healthy population is now getting affected than before. Possibilities of airborne and fecal oral routes of transmission has increased the concern. In the absence of any specific therapeutic agent for coronavirus infections, the most effective manner to contain this pandemic is probably the non-pharmacological interventions (NPIs). The damage due to the pandemic disease is multifaceted and crippling to economy, trade, and health of the citizens of the countries. The extent of damage in such scenarios is something that is beyond calculation by Gross Domestic Product rate or currency value of the country. Unfortunately, unlike many other diseases, we are still away from the target antiviral drug and vaccine for severe acute respiratory syndrome (SARS- CoV-2) infection. The prime importance of NPIs like social distancing, staying in home, work from home, self-monitoring, public awareness, self-quarantine, etc. are constantly being emphasized by CDC, WHO, health ministries of all countries and social media houses. This is time of introspection and learning from our mistakes. Countries like China and South Korea who were initially the most hit countries could contain the disease spread by liberal testing of their population, stringent quarantine of people under investigation and isolation of the positive cases. Rest of the countries need to act urgently as well to bring an immediate halt in the community transmission. Keywords: COVID-19; coronavirus; pandemic; infection; vaccine Submitted Mar 23, 2020. Accepted for publication May 18, 2020. doi: 10.21037/atm-20-2793 View this article at: http://dx.doi.org/10.21037/atm-20-2793 th 1 Introduction world. As of 19 March 2020, there are 244,979 confirmed 7 2 cases in 180 countries with 10,035 deaths (3). Worst hit 8 Wuhan, a city in Hubei province of Eastern China has 3 countries are China, Italy, South Korea, Iran, France, Spain, 9 4 an approximate population of 11 million people. As per Germany and many other European countries (Figure 1). 10 th 5 epidemiologists, this city is considered as an epicenter Italy surpassed China on 19 March 2020 in terms of 11 6 for current COVID-19 pandemic (1,2). Subsequently, it having the highest number of active COVID-19 cases and 12 DEMO involved other parts of China and then to the rest of the more deaths (3). 13 ^ORCID ID: 0000-0002-0021-2033. © Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020 | http://dx.doi.org/10.21037/atm-20-2793 Page 2 of 13 Sahu et al. Trajectory of the COVID-19 Pandemic CHINA 61 Total Cases: 80,967 CANADA 62 Total Cases: 943 Recovered:71,150 Recovered:11 EUROPE Deaths: 3,248 63 Deaths: 12 Total Cases: 91,978 Recovered: 54,58 RUSSIA 64 Deaths: 4,148 Total Cases:253 65 Recovered:12 Deaths: 1 66 UNITED STATES 67 Total Cases: 18,121 Recovered:125 68 Deaths: 233 DEMO 69 SOUTH KOREA 70 Total Cases: 8,652 Recovered:2,233 71 Deaths: 3 IRAN 72 Total Cases:19,644 73 SOUTH AMERICA Recovered: 6,745 74 Total Cases: 2140 Deaths: -1,433 Recovered: 15 75 Deaths: 30 AUSTR ALIA 76 SOUTH AFRICA Total Cases: 876 Total Cases:202 Recovered:46 77 Recovered: -2 Deaths: 7 Deaths: -0 78 79 80 Figure 1 COVID-19 pandemic burden worldwide. 81 82 DEMO Disease background most of the COVID-19 cases are as a result of “community 38 83 14 spread” which means SARS-CoV-2 virus seems to be easily 39 84 Coronavirus family 15 sustaining and spreading in the community with most of 40 85 16 Severe acute respiratory syndrome (SARS-CoV-2) belongs the affected population unaware of how or from where they 41 86 17 18 to the family of Beta coronavirus which also has coronaviruses became infected. 42 87 19 responsible for previous outbreaks—SARS and the Middle 43 88 20 East respiratory syndrome (MERS) outbreaks. 44 89 Demographic details of the patients 21 45 90 22 SARS-CoV-2 viral infection can affect any individual 46 91 Possible routes of transmission 23 in a naïve susceptible population. Most retrospective 47 92 24 In the initial phase, most COVID-19 cases in China studies had cohort with age range between 50–80s (8,9). 48 93 25 were found to have a direct or indirect link to Huanan In addition to this, there are also studies reporting no 49 94 26 Seafood Market in Wuhan, possibly due to the zoonotic deaths in those under age 30 from Korea or under age 50 50 95 27 spill over from wild animals to the humans (4). Gradually, from Japan (5). These results were falsely perceived or at 51 96 st nd 28 as the transmission passed beyond 1 and 2 generations, least fail to alert the younger population especially the so 52 97 29 more cases were reported to have no direct link with the called “millennial generation” individuals, most of them 53 98 30 animal exposure and were instead related to community started thinking that they are immune to this virus. The 54 99 31 transmission from person to person (5). Currently, there is sense of false security and illusion did not persist long 55 100 32 enough evidence to suggest that respiratory droplets and enough as now we have concrete data from United States 56 101 33 direct contact with contaminated surfaces are the two most (US) that harbours close to 20,000 COVID-19 cases. As DEMO 102 34 common routes of SARS-CoV-2 transmission. Just like in per The Centres for Disease Control and Prevention 57 103 35 many endemic diseases, other possible routes like airborne (CDC), more younger patients in US are catching SARS- 58 104 th 36 or faecal oral transmission is being explored for SARS- CoV-2 infection. In their report dated 20 March 2020, 59 105 37 CoV-2 transmission (6,7). Now with each passing day, CDC mentions that 20% of the hospitalized patients and 60 106 107 © Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020 | http://dx.doi.org/10.21037/atm-20-2793 Annals of Translational Medicine, 2020 Page 3 of 13 61 12% of the intensive care patients from US belong to age Blood work and their significance 108 62 range of 20 to 44 years (10). Amongst the comorbidities, DEMO Laboratory studies including complete blood count, renal 63 hypertension, cardiovascular disorders, cerebrovascular 109 function test, liver function test, coagulation profile, D 110 64 disorders and diabetes are the top medical conditions dimer, serum calcitonin are the common lab tests for 111 65 who had more severe disease and required intensive care hospitalised COVID-19 patients. Various inflammatory 112 66 as compared to individuals without these comorbidities markers like C-reactive protein (CRP), procalcitonin, 113 67 (7-16). Specific subset of population like patients suffering ferritin, D-dimer, interleukin 2 (IL-2) are shown to be 114 68 from cancer, transplant recipients or other benign blood elevated in patients with COVID-19 and have been found 115 DEMO disorders need special attention for their underlying to be associated with vital organs dysfunction (38,39). 116 69 disease (17-20). Wang et al. in their case series of 138 hospitalised patients 117 70 reported following laboratory abnormalities: lymphopenia 118 71 Symptomatology and laboratory investigations (70.3%), deranged coagulogram (58%), elevated lactic acid 119 72 dehydrogenase (39.9%) and abnormal imaging findings 120 73 Symptomatology and Mortality rate of COVID-19 cases 74 (100%). Presence of lymphopenia, elevated D dimer values, 121 75 In general, most SARS-CoV-2 affected patients have only deranged renal functions have been reported as poor 122 76 mild symptoms, with approximately 20% developing prognostic factors with high chance of need of intensive care 123 77 moderated to severe illness (21). This means that most with high mortality (7,8). Other hematological parameters 124 78 patients can be managed with home quarantine only like thrombocytopenia has been found to be predicting the 125 79 and hospital isolation is required only for moderate to severity and worst prognosis (40,41). 126 80 sick population. The likelihood of having more severe 127 128 81 disease is multifactorial. Vulnerable population as per the Diagnostic modalities: how to investigate a 82 available literature are older individuals more than 60 years, suspected case? 129 130 38 83 pregnant women, patients with multiple comorbidities COVID-19 RT-PCR testing 131 39 84 and immunosuppressed individuals like cancer patients 132 40 85 (1,20,22-28). With regards to the gender predisposition, Amongst the available investigations, the COVID-19 real- 133 41 86 there are mixed reports with some mentioning that time reverse transcription polymerase chain (RT-PCR) 134 42 87 males have higher chance of acquiring the infection with test is used for the qualitative detection of nucleic acid 135 43 88 higher mortality rates when compared to females.
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