Published in Italian by Roberto Gava, M.D., Pharmacologist and Toxicologist (Padua, Italy)
Original article here: www.robertogava.it/come-distinguere-coronavirus-sindrome-virale
Translated for Knowlative by Ludovico Feletto, M.D. and used with the permission of the author.
The continuous evolution of the Coronavirus epidemic called “SARS-CoV-2”, that is the virus that causes CoVID [CoronaVirus Disease] and is affecting our country, is creating a justified alarm in many people, …basically in everyone!
Our rulers do well to try to use every system to stem the spread of the infection for the simple reason that the most seriously ill people (especially the elderly, but not only) could be in critical conditions that need assisted breathing. Our Intensive Care Hospital Centres, however, have limited assistance capacities and, therefore, if the number of infected people rises sharply in a few days or weeks, the available places will saturate quickly and there will be no room for others (in these days, in Italy, we have already reached the saturation point, but, precisely for this reason, Intensive Care Units are being equipped in new structures or other departments … some entire sections of the hospitals are being transformed into Emergency Departments).
The “Stay at home” order serves just for this reason: to mitigate the peak of new patients in order to spread their numbers over a longer period of time, allowing people who recovered from the emergency to be transferred from the Intensive Care Unit to the general medicine wards leaving the place for new patients.
The extension of the epidemic practically to all the Regions of our country, and also to the rest of Europe together with a growing increase in fatal cases and the involvement of relatively young and healthy subjects also suggests that the virus is worsening, but for now these are only hypotheses.
Obviously, people are afraid and, as I wrote in my previous article on this same topic (1), “the fear of disease can itself create disease, because it creates tension, stress and prolonged stress unmasks the weak points of a person: it can raise the blood pressure, it can cause cardiac arrhythmias, it disturbs sleep and digestion … and eventually weakens the immune system. Just what shouldn’t happen in this period!”.
Fear is controlled by reasoning, but this needs motivation, knowledge …
It is the reason why I thought of providing the information here below.
The infection is mainly transmitted within the family
We all know that human Coronaviruses are transmitted from one infected person to another mainly through direct contact with saliva, coughing and sneezing (within a range of about 1-1.5 meters), but from an official document of the World Health Organization (WHO) (2) it emerged that, in China, the main cause of contagion (78-85%) occurred within the family.
Transmission in the air over long distances (over 2 meters), especially if in large environments or outdoors, is not an important cause of diffusion (2), therefore you should not prevent from going out for a walk, it would rather be advisable, especially on beautiful sunny days (the open air and the sun greatly hinder the spread and shorten the survival of all viruses).
Is Coronavirus infection very contagious?
According to the data released by the WHO (2), it emerges that if you have direct personal contact with an infected person, the probability of becoming infected is not absolutely high, because it is only 1-5%.
We also know that you can be infected if you touch the hand of a patient or objects that the patient has just touched, but only if:
- the patient has recently touched objects, given that the virus seems to survive for a short time outside the person (perhaps not more than 3-4, even if some authors speculate that, inside houses, it can survive even 4-5 days);
- after touching the contaminated object, the virus does not infect us by entering through our skin, but only if we put our hands in our mouths or touch our nose: the oral and nasal mucous membranes (3).
For this reason, it is advisable to wash your hands often, especially when you return home or have been in public places.
Finally, remember that a patient can spread Coronavirus during the symptoms of the disease but, as for all viroses, it can also do so in the 5-6 days preceding the clinical manifestation of the symptoms (according to some even in the previous 15 days) and therefore before that it turns out that s/he was really infected: this is the serious problem of viral diseases that facilitates their spread.
Due to all these reasons, this new Coronavirus infection is likely to spread to all countries of the world, because those who are healthy today could become sick in the next few days and, if this is true, in the meantime they would contribute to spread the virus. And this because no one is taking action to teach the population how to protect themselves.
The symptoms of Coronavirus infection
According to the WHO (2), the symptoms of SARS-CoV-2 infection are not specific and the presentation of the disease can vary from no symptoms (asymptomatic subject) to severe pneumonia and death.
Usually, at the beginning, this infection is almost always deceitful and starts as if it were a common flu syndrome with symptoms such as those of the common cold or of a simple pharyngitis. The duration of these symptoms varies, because it depends on the strength of individual’s immune system.
If the subject is immunologically weak, the infection intensifies and then the local symptoms become systemic (because the viruses extend to the whole organism) and a fever appears. Given that this virus seems to have a particular affinity for lung tissue, in weaker, elderly and/or immunosuppressed subjects, it induces basal or disseminated pneumonia that occurs with respiratory difficulty, persistent dry cough and high fever. In some subjects this symptomatology becomes particularly serious and can lead to death.
More specifically, starting from February 20, 2020 and based on the study of 55,924 Chinese subjects who obtained confirmation of the infection with the pharyngeal swab, the most represented signs and symptoms were the following:
- fever (87.9%),
- dry cough (67.7%),
- exhaustion (38.1%),
- mucous expectoration by coughing (33.4%),
- breathing difficulty (18.6%),
- sore throat (13.9%),
- headache (13.6%),
- muscle pain (14.8%),
- chills (11.4%),
- nausea or vomiting (5.0%),
- nasal congestion (4.8%),
- diarrhea (3.7%),
- bloody sputum (0.9%),
- conjunctival congestion (0.8%).
Two other studies (4, 5) have shown similar symptoms.
In addition, there is almost always a marked reduction in lymphocytes (typically 500-600/mcl) and in most patients the concentrations of c-reactive protein (CRP), lactic dehydrogenase enzyme (LDH), ferritin, liver transaminases and serum amyloid A protein (acute phase protein) are elevated (6).
Evolution and duration of the infection
We all know that about 80% of infected people develop only a mild disease.
Only in the most severe cases the infection can cause basal pneumonia, usually bilateral, with severe acute respiratory difficulty and, rarely, death (7).
In fact, 14-15% of patients are so severe that they need to breathe highly concentrated oxygen (and not just for a few days, more often for 2-3 weeks), while the really more serious ones (about 5% of people) need ICU admission in order to have assisted breathing.
According to the aforementioned WHO document (2), the duration of the disease from its symptomatic onset to recovery is on average 2 weeks in previously healthy patients who had mild symptoms during the disease.
The disease lasts about 3-6 weeks in serious and critically ill patients who have become so because they were already previously ill or immunosuppressed for various reasons (refer to my previous article) (1).
At the first symptoms one wonders: am I infected with Coronavirus?
Since Coronavirus infection initially expresses itself sneakily and with trivial symptoms such as those of the common cold or simple pharyngitis, at the beginning the person can underestimate his ailments and do nothing. This can happen to everyone: anyone of us could, at any time, take a cold with mild fever and general malaise and therefore be concerned: is it a normal seasonal virosis or is it the beginning of a mild-moderate Coronavirus infection?
These subsequent questions are, then, obvious:
- What should I do?
- Do I need the pharyngeal swab?
- Do I have to go to the emergency room?
- Do I need to quarantine?
- What about contacts with family members?
- And the job?
It should be immediately specified that it is recommended not to go to the emergency room if there are no important symptoms (high fever with evident respiratory difficulty) which would suggest a lung involvement (the virus causes interstitial pneumonia with important respiratory difficulty). It is easy that in this situation the sick feel abandoned at home, above all because the Doctors can also get the infection, some have actually become ill and therefore are scarce and they, too, are afraid of getting sick.
The result is that many patients, especially those who live alone, risk staying at home without treatment … and then the fear increases!
Main differences with seasonal viral syndromes
It is therefore important to understand what are the main differences between Coronavirus infection and a common and non-dangerous seasonal viral infection … at least to reassure many people and to explain what they must do to those particularly at risk and with doubtful initial symptoms!
It should be immediately said that differentiating these two pathologies is sometimes difficult, it is of exclusive medical competence and the analysis must be personalized on the individual case.
However, given the emergency of the moment, I think it is important to provide some parameters to people who experience this period with particular anxiety.
We specify that the exact diagnosis of the type of infection is possible only with the microbiological examination of a sample taken with the pharyngeal swab that uses the PCR (Polymerase Chain Reaction) technique, an examination that provides the result in a few hours.
Unfortunately, even this test can make mistakes in some cases (both false positives and false negatives are always possible) and therefore it should be repeated a second time for greater security.
As for how to distinguish Coronavirus infection from a common and non-dangerous seasonal viral infection, the studies published in this last month and some WHO documents (8) certainly allow us to give some important information.
For example, it seems to be sure that SARS-CoV-2 rarely ills young people under the age of 18 and, if they become ill, it induces only a mild flu-like disease in them (4): depending on the weak points of the affected subject , it can present the symptoms of a catarrhal cold with nasal secretion or the symptoms of a rhino-pharyngitis or a rhino-sinusitis (usually frontal) which in some cases evolves into laryngotracheitis with hoarseness and altered tone of the voice.
Furthermore, preliminary data from studies conducted in China indicate that children affected by the virus have been infected by adults, rather than vice versa, while in the case of the flu virus the opposite occurs: children are an important vehicle of community transmission of the flu virus and it is they that infect adults.
Another element that allows to distinguish the SARS-CoV-2 virosis from the viruses of the flu syndrome that affects the upper respiratory tract is that the first one has a longer incubation than the flu syndrome and therefore it spreads a little less quickly. But, at the end, it involves a greater number of people because many think they are well and therefore do not use precautions and spread the virus coming in contact with healthy people.
This is the reason why our rulers decided to close all of Italy, to declare it “Red Zone” and to ask everyone to “Stay at home” for about 15 days in order to limit the peak of the epidemic and reduce the number of contacts and, therefore, also of contagions.
SARS-CoV-2 is practically never expressed only with common cold symptoms (sneezing and nasal discharge) (2, 6). These symptoms may exist, but only at an early stage and then three evolutions can occur:
- The symptoms intensify, rapidly change and worsen in the respiratory symptoms typical of the Coronavirus SARS-CoV-2 and therefore you can say that the person has actually this pathology (usually this happens in immunologically weak subjects or in the elderly);
- The symptoms remain those of a common cold that the person recognizes as his usual symptomatology that he has already presented other times and that resolves in a few days as it usually happens to him (this means that the person has not been infected by the virus SARS-CoV-2);
- The symptoms of a cold or pharyngitis or pharyngo-laryngotracheitis tend to last many days (generally 7-10 days) without improving or worsening. This means that the organism is likely to have come into contact with the SARS-CoV-2 virus, but the organism is strong enough to contain the infection by preventing it from spreading and causing the organic damage it could cause (usually this happens in young adults or elderly adults who still have a fairly good immune system).
So, if you have a simple symptomatology of rhinitis, rhinosinusitis or nasopharyngitis (i.e. little more than a common cold), if it is accompanied by a fever, and these symptoms do not rapidly deteriorate accompanied by persistent dry cough and difficulty in breathing, but remain for 7-10 days and then they gradually decrease probably you had a mild form of SARS-CoV-2 infection. In this case you could also be happy you have passed the infection and you have acquired a state of immunity!
The important recommendation in all these cases, until you are sure of the diagnosis and therefore until you heal, is to stay indoors avoiding close contact with others.
In general, however, SARS-CoV-2 infection has its own clinical characteristics which, especially when the infection is of a serious entity and according to the data provided by the aforementioned WHO document (2), allow to differentiate it easily enough from common seasonal viroses (colds, rhinosinusitis, nasopharyngitis, laryngotracheitis, flu syndrome, etc.) (See Picture 2).
Let’s now face the problem of Coronavirus mortality, so as not to run the risk of falling ill and dying more from the consequences of fear than from the action of this new virus.
Seasonal flu syndrome mortality
In Italy mortality from seasonal flu syndrome (therefore NOT ONLY from real flu virus) seems to be around 7,000 people per year.
According to InfluNet (the Italian national epidemiological and virological surveillance system for influenza virus, coordinated by our Ministry of Health with the collaboration of the Istituto Superiore di Sanità)(Translator’s note: the equivalent of US Centers for Disease Control), influenza syndrome affects approximately 6-7 million people every year, i.e. 9% of the population.
In Italy, influenza viruses directly cause approximately 300-400 deaths each year, with about 200 deaths from primary viral pneumonia, however, according to the estimates of the various studies, these deaths must be added 4-8,000 “indirect” deaths caused by pulmonary (bacterial pneumonia) or cardiovascular (heart failure) complications of influenza.
The numerous viruses that cause seasonal flu syndromes can in fact create complications especially in the elderly or in any case in all people who before suffering from the flu were already suffering from serious chronic diseases or immunodeficiencies.
It is therefore estimated that our seasonal flu mortality rate (i.e. the ratio of dead to infected) is less than one per thousand, that is 0.1%.
Is it easier to die of seasonal flu syndrome or Coronavirus SARS-CoV-2?
If we compare with the new Coronavirus, one might then ask: our seasonal flu syndrome is more dangerous than the SARS-CoV-2 infection, considering that only in Italy the deaths for flu every year are more than those caused so far in China by the new virus?
In general, the answer, which for now is based only on provisional data, should be “YES”, because it is true that CoVID mortality seems to be around 2.3% (according to the China CDC of 11 February, there 1,023 deaths out of 44,672 confirmed infected Chinese cases) (9). Chinese mortality from Coronavirus rises to 3-4% if it is calculated instead as the ratio between the deceased and the sick, but, in any case, it is still higher than that of the flu syndrome. However, since the latter affects millions of people, it ultimately causes more deaths.
This count, however, should be made when this epidemic is over. It is now far too early to draw conclusions: they are highly provisional data considering that we do not know the exact number of people infected with CoDIV, which is likely to be higher (many people are poorly symptomatic and therefore have not been recorded. Besides, apart from the first 2 weeks of checks with pharyngeal swabs that were done at all, now the swabs are made only for diagnostic confirmation in serious subjects with respiratory difficulty and therefore many symptomatic people with milder forms are invited not to go to the emergency room and remain at home without a certain diagnosis).
According to the latest numbers released by the Italian government updated to 16 March 2020, however, it appears that the Italian mortality caused directly by the SARS-CoV-2 virus is exceptional, it seems 3-4% higher. The deaths from complications of this infection in subjects immunologically weak, elderly and/or carriers of various chronic pathologies, it is around 7.7% in Italy (10) and 3.9% worldwide (11).
In light of these data and in view of the fact that this pandemic shows no sign of slowing down (with the exception of China), at present it can be suspected that it will probably cause a number of deaths similar or perhaps greater than that of the flu syndrome.
The substantial difference between flu viruses and Coronaviruses is that: while the normal viruses that cause seasonal flu syndrome are known to our body and cannot infect the whole population because many people are already immunized (because vaccinated or because already protected by natural antibodies formed from previous contacts), this new Coronavirus, however, is unknown to our immune system, therefore it finds people immunologically unprepared and therefore spreads much faster (as it seems it has been doing in recent times in Italy and in other countries of the world) and can also cause serious harm, which appears to be occurring in a larger percentage, although for now within fewer infected people.
In any case, I believe that we will have to wait another 1-2 months for more precise data, but it is likely that in the meantime, for the reasons just expressed, the CoVID will extend all over the world and last at least another 2-3 months.
Is SARS-CoV-2 Coronavirus infection really dangerous?
If we look at the mortality rates of other epidemics, we can see that CoVID is not very dangerous, even if it seems to have a great capacity and rapid spread.
During this period, in fact, Nipah and Hendra viruses raged in Southeast Asia, with mortality rates of 30-60%, yet they do not generate all this social alarm (See Picture 3).
It is true, however, that “we are obviously touched by what affects us directly” and, not considering seasonal flu, all other viruses (apart from the latter) have alarmed us but not really scared us … since they have not touched “our home” but other countries in the world.
Finally, it should be remembered that SARS-CoV-2 has now become pandemic, while the other viral epidemics in Table 2 have been more localized (with the exception of Dengue) and therefore CoVID affects a greater number of people.
Factors influencing SARS-CoV-2 Coronavirus mortality
For the data we have, we can also say that Coronavirus mortality is strongly influenced by the age of the affected person, by pre-existing health conditions and, above all, by the help that the patient obtains from the National Health System (Traslator’s note: Italian health system).
The health conditions of the affected country are very important, because 20% of infected people in China have needed hospital treatment for weeks (2), however most of the beds were already occupied by people who were hospitalized for other diseases. So, as we have already said, CoVID sufferers die in a higher percentage if there are no beds available in the Intensive Care wards.
Therefore, the most important thing is first to contain the spread of the virus to keep the number of seriously ill patients low and, then, to increase the number of hospital beds (including medical supplies and medical and nursing staff) until there will be enough to assist all the seriously ill (this is exactly what our government has tried to do since the early days).
Who dies from the new Coronavirus?
They are essentially elderly (about 84%) and immunosuppressed … and among these the mortality is obviously much higher than the 2.3% reported by Chinese studies, but the same also happens for the common flu.
In any case, I repeat, the Chinese mortality of 2.3% is very approximate.
According to the data released by our Department of Civil Protection (4) Italian mortality fluctuates around 5-6%, however it is likely that they are overestimated precisely because less swabs/tests are made and because Intensive Care is saturated and hospitals in the more affected Regions do not have the opportunity to keep many people intubated to allow them to pass the pneumonia phase … so all the elderly are really at high risk.
Furthermore, according to a WHO document (2), the mortality rate for people infected and who had pathologies before the CoVID varies according to the type of pathology (Picture 4).
What is interesting to note from the analysis of these data is that the mortality among people who were healthy before falling ill with Coronavirus is only 1.4%.
It should also be stressed instead that, according to the China CDC document of 11.2.2020 (9), mortality rises up to 49% in patients defined as seeriously critical (it is the elderly who previously had serious pre-existing pathologies before CoVID).
The age of infected people is also important
In the light of the available data, the age of the infected people is also important and, in this regard, the data provided by the study of the Chinese epidemic concerning mortality according to the age of the sick are also interesting (2).
It has been understood that the younger you are, the less likely you are to become infected and the less likely you are to become seriously ill or die if you become infected (Picture 5).
To read this table (Picture 5) correctly, care must be taken not to misunderstand the data shown. In fact, if we consider for example the age group between 20 and 29 years, we see that this represents 13.5% of all Chinese people. Well, the table does not tell us that 8.1% of people between 20 and 29 years of age became infected, but only that 8.1% of infected people were in this age group and that 0,2% of those who contracted the infection in this age group died. This means that the probability that young people of this age have to get the infection is much lower than the average.
Is mortality different between men and women?
As for the division of this infection between the two sexes, it should be remembered that Chinese data show that women fall ill slightly less frequently than men, develop a less serious pathology and recover sooner. Furthermore, mortality among women is 2.8%, while among men it is 4.7%.
We do not know why this virus is more aggressive against men and I do not think it depends on the immunoprotective effect of estrogens, because this virosis especially affects the elderly and at a certain age estrogen production is practically the same in the two sexes.
If the infection occurs during pregnancy, what is the risk of the mother and her baby?
The disease does not seem to be more serious if taken during pregnancy, because the study of 9 childbirth of infected women in the last trimester of pregnancy (they are small numbers, but we only have these) revealed that the children were born with cesarean section and healthy without being infected.
However, it is not known what can happen to fetuses if the infection affects their mother in the first or second trimester of pregnancy, since these children are not yet born.
People most at risk
As I wrote in my previous article (1), viruses can enter and multiply in all the people who come in contact with them, however the effects can be very different, because they depend on many interfering factors (the characteristics of the virus, the charge viral, the physio-pathological conditions of the person, his age, the lifestyle of the person, etc.).
As for this new Coronavirus, the data available so far (9, 10, 11) allow us to say that this infection may be more dangerous for the elderly over 80 and for those suffering from serious chronic diseases (in fact the dead belong to mainly to this group of people).
For all other information on this infection, I refer to what I wrote in the previous article.
In any case, I would say that the most important thing to avoid infection, in addition to the rules recommended by our Rulers, is to keep our immune system functioning properly with a correct lifestyle and to follow the non-pharmacological advice that I have indicated in the other article.
If you are looking for a solution and you are serious about it
you will always find it to any problem …
but are you willing to seriously commit yourself?
As always, it depends on each of us
and also on how soon we begin to correct our mistakes
See bibliography in Document 1