The 2019-2020 Novel Coronavirus (Severe Acute Respiratory Syndrome Coronavirus 2) Pandemic: A Joint American College of Academic International Medicine-World Academic Council of Emergency Medicine Multidisciplinary COVID-19 Working Group Consensus Paper

Abstract

What started as a cluster of patients with a mysterious respiratory illness in Wuhan, China, in December 2019, was later determined to be coronavirus disease 2019 (COVID-19). The pathogen severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel Betacoronavirus, was subsequently isolated as the causative agent. SARS-CoV-2 is transmitted by respiratory droplets and fomites and presents clinically with fever, fatigue, myalgias, conjunctivitis, anosmia, dysgeusia, sore throat, nasal congestion, cough, dyspnea, nausea, vomiting, and/or diarrhea. In most critical cases, symptoms can escalate into acute respiratory distress syndrome accompanied by a runaway inflammatory cytokine response and multiorgan failure. As of this article's publication date, COVID-19 has spread to approximately 200 countries and territories, with over 4.3 million infections and more than 290,000 deaths as it has escalated into a global pandemic. Public health concerns mount as the situation evolves with an increasing number of infection hotspots around the globe. New information about the virus is emerging just as rapidly. This has led to the prompt development of clinical patient risk stratification tools to aid in determining the need for testing, isolation, monitoring, ventilator support, and disposition. COVID-19 spread is rapid, including imported cases in travelers, cases among close contacts of known infected individuals, and community-acquired cases without a readily identifiable source of infection. Critical shortages of personal protective equipment and ventilators are compounding the stress on overburdened healthcare systems. The continued challenges of social distancing, containment, isolation, and surge capacity in already stressed hospitals, clinics, and emergency departments have led to a swell in technologically-assisted care delivery strategies, such as telemedicine and web-based triage. As the race to develop an effective vaccine intensifies, several clinical trials of antivirals and immune modulators are underway, though no reliable COVID-19-specific therapeutics (inclusive of some potentially effective single and multi-drug regimens) have been identified as of yet. With many nations and regions declaring a state of emergency, unprecedented quarantine, social distancing, and border closing efforts are underway. Implementation of social and physical isolation measures has caused sudden and profound economic hardship, with marked decreases in global trade and local small business activity alike, and full ramifications likely yet to be felt. Current state-of-science, mitigation strategies, possible therapies, ethical considerations for healthcare workers and policymakers, as well as lessons learned for this evolving global threat and the eventual return to a "new normal" are discussed in this article.

Keywords: 2019-nCoV; COVID-19; International Health Security; coronavirus; global impact; pandemic; severe acute respiratory syndrome coronavirus 2.

Figure 1

Schematic representation of “flattening the curve” during an outbreak. (A) Typical course of a pandemic without targeted intervention (e.g. physical distancing). This scenario places undue burden on healthcare institutions and is likely to exceed preoutbreak capacity (indicated by dashed horizontal line) and resources available to treat affected patients; (B) modified curve resulting from the prompt implementation of mitigation measures (e.g. physical distancing). In this scenario, both the rate of increase of new cases and the peak number of cases are significantly lower, permitting the existing infrastructure to reasonably handle the increased demands associated with an outbreak

Figure 2

Age distribution of COVID-19 cases based on composite data from around the globe[79899099100101102103104]

Figure 3

Mortality associated with COVID-19 infections by age. Composite global data compiled from multiple sources[2879102130131132]

Figure 4

Mortality rates associated with different comorbid conditions. Additional factors that may predispose to increased mortality include morbid obesity, neurodegenerative diseases, and immunocompromised status. Data from Italy demonstrate that 25.1% of mortalities had 1 comorbid condition, 25.6% had two, and 48.5% had three or more illnesses. A report from China demonstrated 15.4% mortality for those with ≥2 comorbidities, compared to mortality of 5.6% for those with one or no comorbid condition[116133134135136137]

Figure 5

Comparison of composite global mortality rates by patient gender[138139140141]

Figure 6

Pooled testing algorithm (top) and optimization curves showing the relationship between the median testing pool size and the median number of testing kits required (bottom). Algorithm and graph courtesy of Dr. S Venkataramanaiah, Indian Institute of Management, Lucknow[177]

Figure 7

A schematic depicting the steps of the proning procedure to improve lung recruitment in COVID-19 patients; it is recommended that proning is initiated early in the hospital course, well before considering noninvasive or invasive ventilator support

Figure 8

Diagram showing the gradual, step-wise escalation of supplemental oxygen therapy, from nasal cannula to intubation and mechanical ventilation

Figure 9

Comparison of total reported infections versus the number of infected healthcare workers in three countries affected by high volumes of COVID-19 infections. Reported healthcare workers infection rates ranged from 5.2% in China to 13.5% in Spain as of mid-March 2020[316375376377378]