Covid-19: Summary of Current Clinical Evidence for GPs

Updated 12 Mar 2020

Version 7

This is a summary of the current evidence around Covid-19, caused by the SARS-Cov2 virus.

The purpose of this document is to provide supplemental information regarding Covid-19 that is not
readily accessible and available from DDHS Victoria Guidelines, or Department of Health (Federal)
Guidelines relating to Covid-19.

It is hoped that this information will help to shape and inform our response in our individual contexts.

Case fatality rate by age​ (based on 72,314 cases of Covid 19 confirmed, suspected and
asymptomatic)

Age Death Rate

> 80 years old 14.8%

70-79 years old 8.0%

60-69 years old 3.6%

50-59 years old 1.3%

40-49 years old 0.4%

10-39 years old 0.2%

0-9 years old No fatalities

Case fatality rate by gender

● Male 2.8%
● Female 1.7%

Risk Factors

1. Cardiovascular disease (case fatality rate 10.5%)

2. Diabetes (CFR 7.3%)
3. Chronic respiratory disease (CFR 6.3%)
4. Hypertension (CFR 6.0%)
5. Cancer (CFR 5.6%)

Pregnancy​: clinical outcomes in pregnant women have been similar to those of non-pregnant
adults, and have been associated with excellent recovery rates. This is based on a very small case

1
series of 9 pregnant women in China, hence more studies are required. In general, pregnant women
are more susceptible to pathogens when compared to the general population.

Overall CFR (case fatality rate):​ 2.3%

Summary of Case Fatality

The good news is that young children are not as susceptible to the virus as older people. Of note,
during the SARS 2003 outbreak, there were no fatalities amongst young children either.

Given the likelihood of under-reporting of cases in China, it is believed that the case fatality rate is
closer to 1%. In comparison, the seasonal flu is estimated to be 0.1%.

Stratification (based on DDHS Vic Guidelines)

Two key groups of patients:

1. Those systemically well with mild coryzal symptoms (estimated to be 80-85% of cases)
2. Those systemically unwell with evidence of lower respiratory tract infection, and symptoms
such as shortness of breath, fever and productive cough (estimated to be 15-20% of cases)

Clinical Progression

Patients may have mild symptoms in week one, before becoming systemically unwell in week two.

Those systemically unwell typically have clinical and radiological features of viral pneumonia.

Thereafter, patients may develop sepsis, acute respiratory distress syndrome (ARDS) or multi-organ
failure.

ARDS has a mortality rate of 40%

The median time from onset of illness to hospitalisation for novel coronavirus pneumonia patients
was seven days (range 4–8 days), with acute respiratory distress syndrome (ARDS) experienced on
day eight (range 6–12 days).

Key Symptoms

Given delays in diagnostic confirmation of influenza vs covid-19 in the GP setting, accurate

differentiation of influenza vs covid-19 based on symptoms will be crucial.

Based on two studies of 52 and 138 patients respectively with Covid-19, the key symptoms were:

1. Fever (98%)
2. Non-productive, dry cough (59-77%)
3. Dyspnoea (63.5%)
4. Fatigue (69.6%)

The following symptoms were present, but not as common:

2
 1. Myalgia (11.5%)
2. Diarrhoea & Nausea (10.1%)
3. Rhinorrhoea (6%)
4. Arthralgia (2%)

The 10.1% of patients who initially presented with diarrhoea and nausea subsequently developed
fever and dyspnoea 1-2 days later.

In comparison, in a study of >1,000 patients with influenza, key differentiating symptoms from
Covid-19 are:

1. Nasal congestion (84-92%)

2. Sore throat (64-81%)
3. Myalgia (49-86%)

Amongst other symptoms that overlap with Covid-19.

Therefore, it may be extrapolated that, patients with:

● Fever, dry cough, dyspnoea ​without​ rhinorrhoea and/or myalgias are more likely to have
Covid-19

While patients with

● Rhinorrhoea, myalgias and sore throat are more likely to have influenza

ICU Admission

Approximately 10% of symptomatic, confirmed cases require ICU admission.

Asymptomatic patients

Based on information from the Diamond Princes cruise ship, up to 47% of positive cases were
asymptomatic at the time of testing. Sample size of 542 positive cases.

There are case reports of asymptomatic transmission of the virus, up to 48 hours before the onset of
symptoms. The first known case report was published in NEJM on the German cluster on 30th
January 2020.

Investigations

If patient fits criteria, send off two nasopharyngeal +/- throat swabs (use FLOQ swabs) for:
- Respiratory Multiplex PCR
- Coronavirus Covid-19

FBE demonstrates leucopenia in 25% of cases, and lymphopenia in 63% of cases.

DDHS Victoria may recommend collection of serum tube for storage by VIDRL when a serological
test has been developed.

3
Co-infection

A preprint published on medRxiv found that 5.8% of cases infected with COVID-19 were co-infected
with other pathogens including, influenza, respiratory syncytial virus, rhinovirus, metapneumovirus,
parainfluenza, chlamydia, boca virus, mycoplasma pneumoniae, and other species of coronaviruses.

Imaging Findings

In patients recovering from COVID-19 pneumonia (without severe respiratory distress during the
disease course), lung abnormalities on chest CT showed greatest severity approximately ​10 days
after initial onset of symptoms.

In patients recovering from COVID-19 infection, four stages of evolution on chest CT were identified:
1. early stage (0-4 days);
2. progressive stage (5-8 days);
3. peak stage (10-13 days);
4. and absorption stage (≥14 days)

Management

Primarily supportive care.

Patients at risk of developing ARDS need to be in a facility where they can be mechanically
ventilated, to improve their survival chances.

Aerosol generating procedures (AGPs)

Aerosol generating procedures (AGPs) should be avoided where possible, as this may cause the
virus to become airborne.

Examples of AGPs include: endo-tracheal intubation, non-invasive ventilation (BiPAP, CPAP,

HFOV), manual ventilation before intubation, cardiopulmonary resuscitation, sputum induction,
suctioning.

Nebuliser use should be discouraged​ and alternative administration devices (for example, spacers)
should be used.

DDHS Victoria Guidance version 7, 15 Feb 2020

4
Patient placement

A dedicated toilet / commode should be used where possible, ​ensuring lid is closed when flushed to
reduce any risk of aerosolisation.

Persons under investigation and​ suspected cases of COVID-19 infection may be cohorted together
where single rooms are not available.

Maintain a record of all persons entering the patient’s room including all staff and visitors.

Environmental cleaning and disinfection

For all routine and discharge cleaning, after cleaning with a neutral detergent use a chlorine-based
disinfectant (for example, sodium hypochlorite) at a minimum strength of 1000ppm, or other product
with claims against coronaviruses.

Formula: White King Bleach, sodium hypochlorite 4% chlorine may be diluted to 0.5%
chlorine (1 part bleach, 7 parts water) to form 5000ppm.

​ minimum
Coles and Woolworths stock products based on benzalkonium chloride. A
concentration of 0.05% is required. Check product labels.

A one-step detergent/chlorine-based product may also be used.

The patient isolation room should be cleaned at least once daily and following any aerosol
generating procedure (AGP) or other potential contamination.

Droplet and contact precautions should be implemented during any cleaning and disinfection of a
room (that is, ensure appropriate PPE is used).

Discharge cleaning

If there is a possibility that the virus may have become airborne because:

1. an aerosol generating procedure was performed (ie. nebuliser used)

2. severe symptoms suggestive of pneumonia

It is recommended that the room be left for ​30 minutes ​before cleaning and disinfection is
commenced.

The exact duration in which SARS-Cov2 can persist in the environment is unclear at this time, but
the coronaviruses that caused SARS and MERS were able to persist in the environment for over 48
hours, at an average room temperature of 20 degrees celsius.

5
Mutations and Immunity

According to a Chinese study of 103 cases, published on 3 Mar 2020, the SARS-Cov2 virus has
mutated into two major subtypes: S and L.

Nevertheless, there is no clinical evidence that re-infection with the L subtype is possible in a person
already immune to the S subtype (and vice versa).

As such, the ​prevailing view​ amongst experts is that re-infection with SARS-CoV-2 does not occur
once immunity develops, unless evidence to the contrary emerges.

Transmissibility post-recovery

Although there are case reports of patients testing positive post-recovery, it is believed these are
‘false positives’ due to the detection of dead virions or viral fragments.

Nevertheless, the standard protocol is for 2 consecutive negative PCR tests, 24 hours apart, before
sometime is declared ‘non-infectious’.

Possible Therapeutics under trial

1. Remdesivir, a new anti-viral. Had demonstrated efficacy in mouse models for SARS and
MERS coronaviruses. Safety in humans was demonstrated in trials involving Ebola. RCT
currently underway in China, and is the most promising candidate to date. Not approved by
FDA or TGA as yet.
2. Lopinavir and Ritonavir - HIV medication. Had activity against SARS and MERS. Efficacy
unclear in SARS-Cov2.
3. Chloroquine phosphate may improve fever, improves ground-glass opacities on CT. No
adverse effects reported. Hydroxychloroquine may be a safer and less toxic alternative.
Korean Clinical Guidelines recommend the use of hydroxychloroquine.
4. Telmisartan and Losartan - ARBs. By blocking angiotensin receptors, it may inhibit the entry
of SARS-Cov2 into the alveoli epithelial cells. Some published studies suggest that people
on ARBs are less prone to getting ‘colds’. This has not been confirmed with RCTs as yet.
However, this is acknowledged by respiratory and infectious diseases specialists.

Disclaimer

Written by a rural GP, for other GP colleagues. This document is not meant to replace authorised
guidance from the department of health, or any formal health authority.

6
Sources

1. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in

Wuhan, China: a descriptive study. Lancet. (Published 29 January 2020)
2. Time Course of Lung Changes On Chest CT During Recovery From 2019 Novel Coronavirus
(COVID-19) Pneumonia (Published 13 Feb 2020)
3. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases
(Covid-19) - China, 2020, China CDC Weekly (Published 17 Feb 2020)
4. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan,
China: a single-centered, retrospective observational study. Lancet. (Published 24 February
2020)
5. DDHS Victoria Coronavirus disease 2019 (COVID-19) Guideline for health services and general
practitioners 15 February 2020 Version 7
6. COVID-19, Australia: Epidemiology Report 3: Reporting week ending 19:00 AEDT 15 February
2020. COVID-19 National Incident Room Surveillance Team
7. Interim guidance for environmental cleaning in non-healthcare facilities exposed to SARS-CoV-2 -
ECDC technical report (accessed 28 Feb 2020)
8. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected
Pneumonia in Wuhan, China. JAMA. (7 Feb 2020)
9. Clinical Characteristics and 30-Day Outcomes for Influenza A 2009 (H1N1), 2008-2009 (H1N1),
and 2007-2008 (H3N2) Infections. JAMA. (8 Sept 2010)
10. Positive RT-PCR Test Results in Patients Recovered From COVID-19. JAMA. (27 Feb 2020)
11. What are the risks of COVID-19 infection in pregnant women?. The Lancet. 12 Feb 2020
12. On the origin and continuing evolution of SARS-CoV-2. National Science Review. 3 Mar 2020.
13. Interim List of Household Products and Active Ingredients for Disinfection of the COVID-19 Virus. 
NEA Singapore. Accessed 12 Mar 2020

Dr James S Wei

General Practitioner

Standish Street Surgery

Myrtleford, Victoria, Australia

james.wei.standish@gmail.com

Published on: ​www.covid19forgps.com