The Speed of COVID-19 Spread, As Well As That of Its Changing Guidelines
From Wuhan, China, where the first epicenter of the COVID-19 pandemic originated, came the first evidence-based clinical practice guidelines1 applicable to COVID-19 disease and for prevention of the spread of the SARS-CoV-2 virus (which causes COVID-19 disease). This was released by the Zhongnan Hospital of Wuhan University and the China International Exchange and Promotive Association for Medical and Health Care (CPAM).
Relevant or irrelevant?
The world is now months further along since these guidelines were originally posted in February of 2020. Globally, nations and their communities have focused on “flattening the curve” of the spread of COVID-19 disease, but another curve was involved—the learning curve of this novel SARS-CoV-2 virus which causes the disease. What was “evidence-based” in February may no longer be recommended, as more evidence accrues to tweak the ever-changing guidelines.
Thus, this first advisory was relevant in February but may not be now. Many of the recommendations were common sense, such as barriers (face masks), no sharing of personal items, disinfecting, frequent handwashing (especially after exposure), and still apply today. However, it also has recommendations that have been augmented. The original numbered items, below, have matured into more stringent recommendations:
1. Wear an N95 mask if you can; otherwise a disposable surgical mask.
2. Avoid public transportation to go to the hospital. Ambulance or private vehicle is preferable.
3. In public, wear a mask and stay at least 1 meter away from others.
4. Family members who accompany people to the hospital should adhere to monitoring recommendations.
5. Visiting with relatives and friends should be limited.
6. Currently, there is no evidence of the efficacy of drug treatment.
What’s been the additional information that’s emerged?
Compare the above, with their corresponding numbers, below:
1. Any barrier is better than nothing. The use of facemasks has been incorporated in COVID-19 “cluster” areas, such as in nursing homes and other facilities.
2. Don’t use public transportation at all, except out of necessity. Arrange for transport to the hospital by ambulance or private vehicle.
3. In public, wear a mask and stay at least 6 feet (1.83 meters or more) from others—not just 1 meter.
4. Limit those who accompany a person to the hospital to just a driver, or better, go via ambulance with no family members accompanying.
5. Visiting relatives and friends should not occur.
6. Randomized controlled trials of hydroxychloroquine are in progress, but most significantly is the initial promise of remdesivir.
The rest of the story…
The rest of the guidelines have held up well:
· Isolation of those with—or suspected to have—COVID-19 disease, in a single-occupancy room that is well ventilated.
· Household articles should not be shared and should be disinfected with a chlorine solution frequently (500 mg/L concentration).
· Caregivers should not have underlying medical conditions.
· Handwashing/disinfecting should be done after contact, before leaving the patient’s room or house, before and after eating, after using the toilet, and after entering the house from outside.
· Contact with secretions, urine, or feces requires double-gloving and handwashing before AND after donning them.
· Vital signs should be taken frequently.
· Oxygen therapy should be provided if indicated.
· If bacterial infection complicates COVID-19 disease, use an antibiotic proven effective against community-acquired pneumonia, such as azithromycin.
· Reduce the risk of stress ulcers with H2 receptor antagonists or proton pump inhibitors.
· Use anticholinergics to reduce patients’ secretions and open their airways.
· Reduce the likelihood of embolism by giving recommended regimens of heparin if not contraindicated.
The recommendations by the CDC are living, breathing, growing documents.2 As the pandemic curve flattens, so does the learning curve, and the CDC is regularly updating information according to current evidence-based data, not that of several months ago, which is sure to be dated. Thus, for COVID-19 disease, the caveat is that February 2020’s medicine is not today’s medicine. Live in the present.
1. Jin YH, Cai L, Cheng ZS,et al. A rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia (standard version). Mil Med Res. 2020 Feb 6;7(1):4. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7003341/.