Belize has set a global example with its handling of COVID-19. This has allowed us to live relatively normal lives compared with the rest of the hemisphere. Our parks are filled with children, local tourism has seen an increase and families can enjoy a meal together at a restaurant with minimal restrictions. That being said, the Philip Goldson International Airport is set to open on August 15th and many Belizeans are rightfully concerned about a potential second wave of infections. Remaining vigilant and educated is important as this date approaches. In this article we will review the latest information on the transmission, prevention and treatment for COVID-19.
This information is accurate to the date of publication. It is key to remember that information is constantly updating, and the experts may change their perspectives based on new evidence. This is a good thing. A shift in opinion due to new information is not meant to deceive but rather to educate based on evidence. Science appear to lag, especially in pressing matters pertaining to COVID-19 (after all, all we want are answers), but gathering solid data requires time. I myself have had to bite my tongue on a few issues because, at the time, the information was not complete. It is through the scientific method that we elucidate truth.
Symptoms: What’s old?
The classic symptoms of COVID-19 are:
- Cough (50%)
- Fever (43%)
- Muscle pain (36%)
- Headache (34%)
- Shortness of breath (29%).
Uncommon symptoms include diarrhea, nausea, vomiting, abdominal pain, and loss of sense of smell and taste.1 Most cases are mild (81%) and about 14% of patients require hospitalization. Fatality rate varies by region. Take the following two examples. In China, the fatality rate was 2.3%, in Italy it was 7.2% in mid-March (Italy’s peak incidence).2,3
Asymptomatic infections have been well documented. The proportion of infections that are asymptomatic has not been systematically and prospectively studied. One review paper estimated that it is as high as 30 to 40 percent, depending on the study. Children seem to be more asymptomatic than adults.4
Symptoms: What’s new?
COVID-19 symptoms may linger for months.
A recent study has shown that COVID-19 symptoms may persist for months in some patients. The study, conducted in Italy, reassessed patients at a mean of 60 days after the onset of acute symptoms. The study reported persistent fatigue in about half of the patients. Shortness of breath persisted in 43.3% after 60 days meanwhile joint pain and chest pain persisted in 27.3% and 21.7% respectively. In total, 87.4% of patients report persistence of at least one symptom.5
COVID-19 can produce neurologic symptoms.
Loss of taste and smell are considered neurologic signs of COVID-19 however more serious neurologic complications have been reported. Brain injury (encephalopathy) has been reported in critically ill patients, but the cause has not been properly established. It is unclear whether the virus directly damages the brain or if brain injury is secondary to hypoxia (low oxygen saturation in the blood).6 Encephalopathy is common in critically patients regardless of the cause so this seems to be a reasonable explanation.
One rare complication of COVID-19 is Guillain-Barre Syndrome (GBS). This happens when the virus confuses the immune system, causing it to attack the insulation surrounding nerves. This leads to slowed conduction and increased electrical resistance in nerve tissue which manifests as paralysis.7 GBS is usually seen after diarrheal illnesses but it has been reported after some viral infections like Zika (and now COVID-19).
A large preliminary trial in the United Kingdom has generated attention after demonstrating that dexamethasone, a cheap steroid, reduces mortality among patients with COVID-19. 8 According to this study, a 17% reduction in mortality was seen among patients requiring at least oxygen therapy. In patients that require a ventilator, a 35% reduction in mortality was observed. It is very important to note that DEXAMETHASONE DOES NOT IMPROVE OUTCOMES FOR PATIENTS THAT DO NOT REQUIRE OXYGEN THERAPY. In other words, this drug should only be used as a treatment option in the hospital setting and should not be bought off pharmacy shelves. Dexamethasone has side effects and should not be taken unless indicated by a physician and must be reserved for patients that can potentially benefit from the drug.
Remdesvir is a novel antiviral medication developed by Gilead Sciences. Unlike dexamethsone, remdesvir is not so cheap. In an open letter from Daniel O’Day, Chairman & CEO of Gilead Sciences, he said:
“We have decided to price remdesivir well below this value. To ensure broad and equitable access at a time of urgent global need, we have set a price for governments of developed countries of $390 per vial. Based on current treatment patterns, the vast majority of patients are expected to receive a 5-day treatment course using 6 vials of remdesivir, which equates to $2,340 per patient”.9
Data from comparative, randomized trials are emerging. Overall, available data suggest there is likely some clinical benefit to remdesivir. Preliminary results from one large trial indicate that remdesivir reduced time to recovery from severe COVID-19; in a smaller second trial that was stopped early for poor enrollment, there was also a trend towards reduced time to recovery with remdesivir, but it was not statistically significant. Whether remdesivir reduces mortality remains uncertain.10,11
As discussed in a previous article. Vitamin D may be beneficial for patients infected with COVID-19 and is now recommended as a supplement in the healthy population since low vitamin D levels are associated with poorer outcomes. (See “Transmission and Prevention”, section on ‘Vitamin D’ below.)
Transmission and Prevention:
This is still a topic of controversy. The European CDC (ECDC) has warned the WHO that COVID-19 may be transmissible through the air particularly in enclosed spaces with poor ventilation. There have been several studies attempting to determine if this could be the case, but the results have been conflicting. Some scientists have managed to generate aerosols with COVID-19 in controlled conditions with viable virus but the extent to which this mechanism truly spreads the virus in real world conditions is unclear.12 COVID-19 RNA has been recovered in the vents of rooms of COVID-19 patients but the virus was not able to grow in culture. In other words, the material did not contain infectious virus.13
Until this information is properly reported, we should WEAR OUR MASKS IN PUBLIC.
A group of European medical societies have recommended that the public should make a conscious effort to receive the daily recommended dose of vitamin D. Some studies have noticed that there is a correlation between low vitamin D levels at the time of admission and worse outcomes. There may be some confounding factors for these data since vitamin D deficiency is also seen in patients with kidney disease and in the elderly. When vitamin D was given to patients hospitalized for severe COVID-19, it had no effect on outcome. References can be found in our last article. Perhaps having a healthy level upon admission is what is important, but speculation is the best we can do until further research is done. Nonetheless here are the recommendations given by these societies on vitamin D in the era of COVID-19:
“One of the best sources of vitamin D is through 15-30 minutes of direct sunlight exposure on your skin daily (taking care to avoid sunburn). As a result of the current global pandemic and particularly stay-at-home orders, individuals may be spending less time outdoors, resulting in fewer opportunities to obtain this important nutrient.
For those unable to spend at least 15-30 minutes with direct sun exposure each day, the easiest way to acquire vitamin D is through food supplemented with vitamin D and/or vitamin D nutritional supplements. Although some foods in the U.S. and elsewhere are fortified with vitamin D, the levels are often fairly low.”
Many approaches have been taken to develop a vaccine for the virus. Of these, 5 vaccines have made it to Phase III clinical trials. This is the last stage before the vaccine can be made public. If the results of the Phase III trials are positive, testing will begin in the general population.
Handwashing and Mask-wearing
Handwashing and mask-wearing are still the best ways to prevent the spread of COVID-19. Measures are recommended to reduce transmission of infection are summarized below:
- Diligent hand washing, particularly after touching surfaces in public.
- Use of hand sanitizer that contains at least 60 percent alcohol is a reasonable alternative if the hands are not visibly dirty.
- Respiratory hygiene (eg, covering the cough or sneeze), wearing a mask.
- Avoiding touching the face (in particular eyes, nose, and mouth). The American Academy of Ophthalmology suggests that people not wear contact lenses, because they make people touch their eyes more frequently.
- Cleaning and disinfecting objects and surfaces that are frequently touched.
- Ensure adequate ventilation of indoor spaces.
1. Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus Disease 2019 Case Surveillance – United States, January 22-May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(24):759-765. doi:10.15585/mmwr.mm6924e2
2. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. Published online February 24, 2020. doi:10.1001/jama.2020.2648
3. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy – PubMed. Accessed July 18, 2020. https://pubmed.ncbi.nlm.nih.gov/32203977/
4. Oran DP, Topol EJ. Prevalence of Asymptomatic SARS-CoV-2 Infection: A Narrative Review. Ann Intern Med. Published online June 3, 2020. doi:10.7326/M20-3012
5. Carfì A, Bernabei R, Landi F. Persistent Symptoms in Patients After Acute COVID-19. JAMA. Published online July 9, 2020. doi:10.1001/jama.2020.12603
6. Helms J, Kremer S, Merdji H, et al. Neurologic Features in Severe SARS-CoV-2 Infection. N Engl J Med. 2020;382(23):2268-2270. doi:10.1056/NEJMc2008597
7. Toscano G, Palmerini F, Ravaglia S, et al. Guillain-Barré Syndrome Associated with SARS-CoV-2. N Engl J Med. 2020;382(26):2574-2576. doi:10.1056/NEJMc2009191
8. Horby P, Lim WS, Emberson J, et al. Effect of Dexamethasone in Hospitalized Patients with COVID-19: Preliminary Report. Infectious Diseases (except HIV/AIDS); 2020. doi:10.1101/2020.06.22.20137273
9. An Open Letter from Daniel O’Day, Chairman & CEO, Gilead Sciences. Accessed July 21, 2020. https://stories.gilead.com/articles/an-open-letter-from-daniel-oday-june-29
10. Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the Treatment of Covid-19 – Preliminary Report. N Engl J Med. Published online May 22, 2020. doi:10.1056/NEJMoa2007764
11. Wang Y, Zhang D, Du G, et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet Lond Engl. 2020;395(10236):1569-1578. doi:10.1016/S0140-6736(20)31022-9
12. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020;382(16):1564-1567. doi:10.1056/NEJMc2004973
13. Guo Z-D, Wang Z-Y, Zhang S-F, et al. Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital Wards, Wuhan, China, 2020. Emerg Infect Dis. 2020;26(7):1583-1591. doi:10.3201/eid2607.200885