Elsevier Coronavirus Toolkit - Evidence-based content and resources for healthcare professionals

Common questions and misconceptions about COVID-19 discussed

1. Virus name:

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).

2. Disease:

Coronavirus disease (COVID-19). While most people with COVID-19 experienced mild or uncomplicated illness, approximately 14% developed a serious illness that required hospitalization and oxygen, and 5% required admission to an intensive care unit. In severe cases, COVID-19 can be complicated by acute respiratory disease syndrome (ARDS), sepsis and septic shock, multi-organ failure, acute kidney damage, and heart damage. Advanced age and comorbid diseases have been reported as risk factors for death, and a recent multivariate analysis confirmed older age with increased mortality. This study also changed the median duration of viral RNA detection to 20.0 days in survivors, but the SARS-CoV-2 virus was detectable until death in non-survivors. The longest viral duration observed in survivors was 37 days.

3. Origin of the virus:

There may be an animal source present. Given the similarity of SARS-CoV-2 to bat SARS-CoV-type coronaviruses, bats are likely to serve as reservoirs. Although RaTG13, sampled from a Rhinolophus affinis (bat), is ~ 96% overall identical to SARS-CoV-2, its “spike” diverges in its Receptor Binding Domain (RBD), suggesting that it may not efficiently bind to human ACE2. Malaysian pangolins (Manis javanica) illegally imported into the Guangdong province contain coronaviruses similar to SARS-CoV-2. Although the RaTG13 bat virus remains the closest genome-wide SARS-CoV-2, some pangolin coronaviruses show strong similarity to SARS-CoV-2 in the RBD, including six key residues of the RBD. This clearly shows that the SARS-CoV-2 “spike” protein optimized to bind human-type ACE2 is a result of natural selection. Neither bat beta-coronaviruses nor pangolin beta-coronaviruses, so far sampled, have polybasic cleavage sites. Although no animal coronaviruses have been identified that are similar enough to have served as the direct progenitor of SARS-CoV-2, the diversity of coronaviruses in bats and other species is massively underestimated. Mutations, insertions, and deletions can occur near

the S1-S2 junction of coronavirus, demonstrating that the polybasic cleavage site can arise from a natural evolutionary process. In summary, it could occur due to: a. Natural selection in a host animal before zoonotic transfer b. Natural selection in humans after zoonotic transfer c. Selection during passage

4. Transmission Mode:

Person-to-person through respiratory droplets in the air or deposited on surfaces, and possibly by the fecal-oral route.

5. Is it a man-made virus?

No. There is scientific evidence to support that these were natural mutations. SARS-CoV-2 is unlikely to arise through laboratory manipulation of a related SARS-CoV-like coronavirus. A study published in Nature Medicine tilted “The proximal origin of SARS-CoV-2” made a comparison of alpha and beta coronaviruses and identified two notable genomic features of SARS-CoV-2: a. Based on structural studies and biochemical experiments, SARS-CoV-2 appears to be optimized to bind to the human ACE2 receptor. b. the spike protein of SARS-CoV-2 has a functional polybasic (furin) cleavage site at the S1–S2 boundary through the insertion of 12 nucleotides, which additionally led to the predicted acquisition of three O-linked glycans around the site. c. They found a mutation in the SARS-CoV-2 receptor binding domain d. Cleavage site of polybasic furin and O-linked glycans: this has a role in determining viral infectivity and host rank. e. No poly-basic cleavage sites have been observed in the “lineage B” beta coronaviruses, even though other human beta coronaviruses, including HKU1 (lineage A), have those sites and the predicted O-linked glycans. Given the level of genetic variation in the spike, it is likely that viruses similar to SARS-CoV-2 will be discovered with partial or total poly-basic cleavage sites in other species. f. Finally, they propose two scenarios that can plausibly explain the origin of SARS-CoV-2: natural selection in an animal host before zoonotic transfer; and natural selection in humans after zoonotic transfer. They also discussed whether selection during passage could have resulted in SARS-CoV-2.

6. Virus symptoms

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may be asymptomatic or may cause acute respiratory illness. Acute respiratory disease may be mild but can lead to severe viral pneumonia. Full spectrum characterization of the new coronavirus disease (COVID-19) is ongoing, but the primary presentation is an influenza-like illness with symptoms of lower respiratory tract involvement: fever, cough, and shortness of breath. Acute respiratory disease caused by SARS-CoV-2 can progress to bilateral pneumonia, acute respiratory distress syndrome (ARDS), or death. Diffuse alveolar damage has been identified in the postmortem histopathology of the lungs of a COVID-19 patient who had respiratory failure and bilateral ground glass radiographic opacities. Early reports describe the potential for clinical deterioration during the second week of illness, with approximately 25-30% of hospitalized patients requiring intensive support and the mean time between initial symptoms and onset of ARDS in one study was 8 days. Frequent signs and symptoms include fever (83-98%), cough (46% -82%), myalgia or fatigue (11-44%), and difficulty breathing (31%) at the onset of illness. Sore throat has also been reported in some patients at the start of the clinical course. Less common symptoms include sputum production, headache, hemoptysis, and diarrhea. Some patients have experienced gastrointestinal symptoms such as diarrhea and nausea before developing fever and signs and symptoms of the lower respiratory tract. The course of fever among patients with SARS-CoV-2 infection is not yet fully understood; it can be long and intermittent.

7. Asymptomatic transmission:

SARS-CoV-2 is likely to be transmitted by asymptomatic individuals during the incubation period. High virus titers have been found in the oropharynx early in the disease during the period of minimal symptoms. Clinical cases and population monitoring of the incubation period demonstrate asymptomatic spread.

8. How long is the incubation period and how long can I stay infectious?

A pooled analysis of 181 confirmed COVID-19 cases reported between 4 January 2020 and 24 February 2020 estimated the median incubation period to be 5.1 days (95% CI, 4.5 to 5.8 days), and estimated that 97.5% of those who develop symptoms will do so within 11.5 days (CI, 8.2 to 15.6 days) of infection. Clinical descriptions of asymptomatic phases after possible exposure range from 2 to 14 days. A 14 day period for monitoring after potential exposure is generally recommended, and modeling predicts that 101 out of every 10,000 cases (99th percentile, 482) will develop symptoms after 14 days of active monitoring or quarantine.

9. What should you do if you have any of these symptoms?

  • Stay home except to get medical care.
  • Stay away from other people and animals in your home.
  • People should, as much as possible, stay in a specific room and away from other people in your home. If possible, you should use a separate - bathroom.
  • What should you do with your animals/pets: while sick, do not handle or touch pets or other animals.
  • Call before going to the doctor. Wear a mask.
  • Cover your nose and mouth when you cough and sneeze. Avoid sharing household items for personal use.
  • Clean your hands frequently.
  • Clean all frequent contact surfaces daily.

10. When to seek medical attention:

Seek medical attention promptly if your illness worsens (eg, if you have difficulty breathing). Before doing so, call your healthcare provider and tell them that you have COVID-19, or that you are being evaluated to see if you have it. Put on a mask before entering the hospital/office. These measures will help prevent infection or exposure from others in the office or waiting room at the healthcare provider’s office/hospital. Ask your healthcare provider to call your state or local health department. Individuals who are under active monitoring or facilitated self-monitoring should follow the directions provided by occupational health professionals or your local health department.

11. If you have a medical emergency or need to call 911:

Notify the call center staff that you have COVID-19 or that you are being evaluated to determine if you have COVID-19. If possible, put on a mask before the emergency medical service arrives.

12. Those at risk for CoVID-19:

We are all at risk of contracting the virus. But those who: have had close contact with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset, or have a history of travel from affected geographic areas within 14 days of symptom onset have a risk level considered to be at higher risk of possessing the active virus. is uncertain when no direct source of SARS-CoV-2/COVID exposure has been identified.

13. Why are older people at greater risk?

Physiological changes with age lead to decreased intrinsic capacity, such as malnutrition, cognitive decline, depressive symptoms, and these conditions must be managed comprehensively.

14. Based upon available information to date, those at high-risk for severe illness from COVID-19 include:

People aged 65 years and older. People who live in a nursing home or long-term care facility. People with chronic lung disease or moderate to severe asthma. People who have serious heart conditions. People who are immunocompromised including cancer treatment. People of any age with severe obesity (body mass index [BMI] >40) or certain underlying medical conditions, particularly if not well controlled, such as those with diabetes, renal failure, or liver disease might also be at risk. People who are pregnant should be monitored since they are known to be at risk with severe viral illness, however, to date data on COVID-19 has not shown increased risk.

15. Radiological tests and their function (CT, X-Ray, Ultrasound) and findings

Chest Imaging Considerations: Chest imaging is of no limited value in directing care to patients with Covid-19, because routine chest radiography does not affect clinical outcomes in people who come to a hospital with lower respiratory tract infection. The American College of Radiology (ACR) acknowledges that under the current shortage and delays in testing: “Some medical practices are requesting a CT scan of the chest to inform decisions about whether to screen a patient for COVID-19, admit a patient or provide other treatment. ACR strongly recommends taking caution in taking this approach. A normal chest CT scan does not mean that a person does not have COVID-19 infection, and an abnormal CT scan is not specific for the diagnosis of COVID-19. Normal CT should not dissuade or rule out a patient from being quarantined or providing other clinically indicated treatment when medically appropriate. Imaging findings on chest radiography are sufficient for evaluation of lung disease, and CT is not routinely recommended for diagnosis. However, additional clinical imaging may be helpful in some situations.

16. Diagnostic methods:

SARS-CoV-2 is not detected in standard respiratory viral panels, including those that test for previously identified beta-coronaviruses. Routine laboratory tests (blood counts, electrolytes) are not specific, but leukopenia/lymphopenia is common, and liver function abnormalities are seen more frequently in severe cases. To analyze SARS-CoV-2, samples are tested (nasopharyngeal/oropharyngeal aspirates or washes, nasopharyngeal/oropharyngeal swabs, bronchoalveolar lavage, tracheal aspirates, sputum, and serum) using a real-time reverse transcription (rRT) PCR assay for SARS-CoV-2.

17. How do doctors handle CoVID-19 cases?

COVID-19 should be considered in anyone with a fever with acute lower respiratory disease (eg. pneumonia) requiring hospitalization and without an alternative explanatory diagnosis such as influenza. Furthermore, given the increased evidence of community spread within the US, a doctor’s suspicion of COVID-19 is a sufficient indication to evaluate milder presentations that do not require hospitalization. The availability of tests also continues to expand as new test sites, procedures, and kits become available. The clinical criteria of the Centers for Disease Control (CDC) for a COVID-19 (PUI) investigational patient previously included clinical symptoms of acute respiratory disease and risk of exposure: traveling from an affected geographic area such as China, Iran, Italy, South Korea, or Japan; close contact with recently exposed travelers; and close contact with people who have a confirmed infection. PUI criteria and response protocols are subject to change as additional information becomes available.

18. Who prioritizes PCR testing for virus detection?

Priority 1: Guarantee optimal care options for all hospitalized patients, decrease the risk of nosocomial infections and maintain the integrity of the health system.

  • Hospitalized patients
  • Symptomatic healthcare workers

Priority 2: Make sure that people at increased risk of infection complication are quickly identified and properly evaluated

  • Patients in long-term care facilities with symptoms.
  • Patients older than 65 years with symptoms.
  • Patients with underlying conditions with symptoms.
  • First responders with symptoms

Priority 3: As resources allow, assess individuals in the surrounding community for rapidly increasing hospital cases to decrease community spread and ensure the health of essential workers

  • Critical infrastructure workers with symptoms.
  • Individuals who do not meet any of the above categories with symptoms
  • Health workers and first responders
  • Individuals with mild symptoms in communities experiencing high hospitalizations for COVID-19

No priority

  • Individuals without symptoms

19. How to prevent the virus?

There is currently no vaccine that protects against SARS-CoV, so infection control requires reduced person-to-person transmission by performing the following:

  • Wash your hands often with soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60% alcohol.
  • Avoid touching your eyes, nose, or mouth with your unwashed hands.
  • Avoid close contact with people who are sick.
  • Stay home when you are sick.
  • Cover your cough or sneeze with a disposable tissue, then throw it away.
  • Clean and disinfect frequently touched objects and surfaces. Use an alcohol-based hand sanitizer that contains at least 60% alcohol if soap and water are not available.

20. How long does the virus last on different surfaces?

The virus can remain viable and infectious in aerosols for hours, and on surfaces up to days; the median half-life of SARS-CoV-2 was approximately 1.1 hours in aerosols, 5.6 hours on stainless steel and 6.8 hours on plastic with virus still detectable (depending on the inoculum shed) on plastic and stainless steel after 72 hours

21. They say the virus is in the air and that's why I can't go out.

This statement is incorrect. The virus is not everywhere in the air. A route of transmission is aerosols only if there are infected people nearby.

22. I heard that masks are always effective.

Masks are not routinely recommended. Wearing a routine mask while in public is unlikely to be helpful to a healthy person. Also, the masks need to be changed every 20 minutes or so, or they become moist and ineffective when worn during the day. Instead, symptomatic individuals should utilize masks to reduce virus transmission by coughing, sneezing, or other aerosolized viral spread.

23. Can I make my own masks so I don't get sick?

It is not ineffective, but a minimum specific thickness size is required. The only recommended masks are N95 and their use is effective if you are caring for a sick person. Surgical masks are provided to sick patients to prevent spreading the virus.

24. Should I use gloves to prevent getting sick?

No. The use of gloves is recommended if you are healthcare personnel or if you are caring for a person in your home infected with the virus. Wash your hands often with soap and water for at least 20 seconds.

25. I read that taking supplements like vitamin C and foods like ginger and garlic can cure/prevent the virus.

This statement is completely false. There is nothing you can ingest to prevent or cure the virus. Vitamin C administration has been found not to decrease the average incidence of colds in the general population, but to halve the number of colds in physically active people. Regularly administered vitamin C has shortened the duration of colds, indicating a biological effect. However, the role of vitamin C in treating the common cold is unclear. The effects of vitamin C against infection should be further investigated.

26. Available/alternative treatments:

There is no current evidence to recommend a specific anti-COVID-19 treatment for patients with confirmed COVID-19. There are many ongoing clinical trials testing various potential antivirals; These are registered at Clinical Trials or in the Chinese Clinical Trials Registry.

Chloroquine and Hydroxychloroquine Chloroquine is an immunomodulatory drug. Previous studies on SARS-CoV have shown that it can block SARS virus infection by reducing virus / cell fusion. It is mainly used to treat malaria which has also been shown to be effective in reducing the viral replication of SARS-CoV and MERS-CoV. For SARS-CoV-2, preliminary data suggests effectiveness in reducing viral infection in vitro. The safety and efficacy of the use of COVID-19 caused by SARS-CoV-2 is unknown, although nonrandomized observation reports suggest a benefit. Clinical trials are ongoing and can be accessed at clinictrials.gov Efficacy of chloroquine or hydroxychloroquine for the treatment or prevention of COVID-19 is not established. Additional data is necessary to determine whether in vitro activity against SARS-CoV-2 corresponds to clinical efficacy for the treatment or prevention of COVID-19. Additional data is needed to corroborate initial efficacy reports and to identify the optimal dose and duration.

Chloroquine + Azithromycin A small, open, non-randomized, practical study enrolled 26 patients [6 asymptomatic, 22 with URI symptoms and 8 with LRTI symptoms] and 16 controls to observe the results on viral load on day 6 of treatment. Of the 26 patients in the treatment group, 6 also received azithromycin with daily electrocardiographic monitoring) and these 6 demonstrated faster resolution of viremia. Data with more severe presentations, safety data and high-quality clinical trial data are urgently needed. Clinical trials are ongoing and can be accessed at clinictrials.gov

27. Ibuprofen worsens the health status of a person with COVID-19:

This statement is not true. The speculative link between ibuprofen and increased ACE2 expression that leads to worse outcomes in COVID-19 patients indicating that it should not be used in COVID-19 patients is non-existent; there is no scientific evidence. Everything has been anecdotal.

28. Bend and stay home (based on Steven's Washington post) what can happen if we don't?

Patients sometimes wonder why they should bother practicing social distancing and personal hygiene, particularly if they feel at low risk of mortality from an acquired infection. Patients should be informed that infection control is important in mitigating an outbreak (slowing down the spread) even when containment is unlikely (stopping the spread). When infections can spread over time in a population, each person who becomes ill is more likely to have health care resources available when needed. Without mitigation measures such as social distancing, handwashing, and respiratory hygiene, infections are likely to increase rapidly and patient needs may exceed the capacity of the health system, increasing the risk of morbidity and mortality due to lack of access to medical care.

29. Pregnant or lactating women:

To date, there are limited data on clinical presentation and perinatal outcomes after COVID-19 infection during pregnancy or the puerperium. There is no evidence that pregnant women present with different signs and / or symptoms or have an increased risk of serious illness. So far, there is no evidence of mother-to-child transmission when infection manifests in the third trimester; this is based on negative samples of amniotic fluid, umbilical cord blood, vaginal discharge, neonatal throat swabs, and breast milk. Similarly, the evidence for an increase in severe maternal or neonatal outcomes is uncertain and limited to infection in the third trimester, with some reported cases of premature rupture of the membranes, fetal distress, and premature delivery. Relatively few cases of babies confirmed with COVID-19 experiencing mild illness have been reported. No vertical transmission has been documented. Mothers’ breast milk samples after first lactation were also negative for SARS-CoV-2

30. The virus does not affect children or young people:

In children with COVID-19, symptoms are generally less severe than adults and present primarily with cough and fever, and coinfection has been observed.

Relatively few cases of babies confirmed with COVID-19 experiencing mild illness have been reported. The virus infects us all.

31. Baking soda helps my throat and helps to mitigate the virus:

No scientific evidence has been found to reveal its detection against the coronavirus (and other viruses similar to the “common cold”), nor has the decrease in symptoms caused by viruses and infections affecting the respiratory tract been verified. Higher.

32. Saline water helps me to eliminate the virus:

In a study (Ramalingam, S. et. Al., 2019) using hypertonic saline nasal irrigation and gargling for the common cold, when individuals infected with similar viruses (rhinoviruses, coronaviruses, enteroviruses, and influenza viruses) were compared, 30% of individuals had a reduction in viral spread. These findings suggest that hypertonic saline nasal irrigation and gargling for the common cold may help reduce viral replication. The researchers suggested that alternatives such as nasal sprays are options, although they would not have the physical rinse component of nasal irrigation. Therefore, they suggest that a study to compare the two methodologies would be useful. They add in their study, “Our study has limitations, the study is not powered for efficacy endpoints. Therefore, we need a larger trial to confirm our findings. Lack of a placebo group is another limitation.” Finally, although these findings sound somewhat positive, the study does not have power for the efficacy endpoints. In fact, the new COVID-19 is not discussed in this study, therefore it would not have much application, and as mentioned, no potential efficacy was demonstrated.