Why are scientists baffled by the global COVID-19 outbreak?

Ernesto "Che" Guevara mural in Havana, Cuba. He was a physician revolutionary. (Dr. Noorali Bharwani)
Ernesto "Che" Guevara mural in Havana, Cuba. He was a physician revolutionary. (Dr. Noorali Bharwani)

Globally, there have been more than 10 million confirmed cases of COVID-19, including 500,000 deaths (WHO statistics).

It is estimated, more than one billion people face increased risk of severe COVID-19. Can we control this terrible pandemic? Hopefully, yes. But there are few challenges.

First challenge:

People with illnesses like diabetes, heart and lung problems and other medical conditions form 20 per cent of world’s population. This population is at increased risk of severe disease.

Analysing data from 188 countries (A. Clark et al. Lancet Glob. Health) the authors of this article estimate 1.7 billion people worldwide have an elevated risk of severe illness. The researchers also estimate nearly 350 million people – some of whom do not have underlying conditions – would require hospitalization if infected.

With these facts in mind, experts around the world are trying to assess how many high-risk people will need a vaccine once it is developed. The number will be in billions.

How many hospital beds will be needed? How many doctors, nurses and all other health care workers who are stressed and overworked will need care? Who will look after them?

Second challenge:

There are currently no drugs licensed for the treatment or prevention of COVID-19. According to some reports, there are at least 254 treatments and 172 vaccines currently in development to fight COVID -19. U.S. taxpayers are funding six COVID vaccines currently being fast tracked and tested. If the results are promising it may take at least a year before people can take advantage of it.

Third challenge:

Recognising the illness is not easy. Although majority of the patients with COVID-19 have classical symptoms that can be mild to severe, some patients may not exhibit any symptoms. You may not know you have symptoms of COVID-19 because they are similar to a cold or flu.

COVID-19 can make some people very ill. More rarely, the disease can be fatal. Older people, and those with pre-existing medical conditions (such as high blood pressure, heart problems or diabetes) appear to be more vulnerable. Many experts believe this kind of illness has not been seen before in our lifetime.

Fourth challenge:

Getting the facts from reliable sources versus the stories getting ahead of the science. This causes sheer confusion.

It is estimated between 1,500 and 2,000 articles per week are published on the subject. Majority of the articles are considered of poor quality by many experts. But there is some outstanding work going on at a speed not seen before in scientific research. That is extremely positive.

Fifth challenge:

Long term effects of COVID-19. COVID-19 affects individuals in many different ways. Scientists are only starting to understand the vast array of health problems caused by the virus, some of which may have long-term effects on patients and health systems.

Coronavirus is not only a respiratory virus, the virus can affect your brain, heart, liver, kidneys and other organs. Some patients experience blood clotting disorders that can lead to strokes, and extreme inflammation that attacks multiple organ systems. The virus can also cause neurological complications that range from headache, dizziness and loss of taste or smell to seizures and confusion.

Sixth challenge:

Getting people to follow preventive measures. For example, getting them to wear a mask. But mask alone will not prevent the spread of COVID-19. You must consistently and strictly adhere to good hygiene and public health measures, including frequent hand washing and physical distancing. Stay at home. Go out only for essential things and keep yourself mentally and physically active at home.

Take care. Be safe. Be patient. It’s not over yet!

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How reliable are COVID tests?

Columbia Icefield (Dr. Noorali Bharwani)
Columbia Icefield (Dr. Noorali Bharwani)

COVID-19 pandemic took us by surprise and hit us hard, spreading from country to country and continent to continent. It has been with us for the last six months or so and shows no sign of stopping. In fact, we are warned to be ready for the second wave.

In the meantime, scientists all over the world are working round the clock to find an appropriated vaccine and antibiotic that would help. Most urgent focus has been to increase access to tests to diagnose people with current infections.

The possibility of COVID-19 should be considered primarily in patients with new-onset of fever and/or respiratory tract symptoms like cough and difficulty breathing. In some ways, COVID-19 is similar to influenza.

However, there are some key differences between COVID-19 and the flu. COVID-19 causes severe disease in a higher percentage of cases than seasonal influenza.

We need to do a laboratory (microbiology) test to establish COVID-19 diagnosis. Sensitivity of testing depends on the type and quality of the specimen obtained and the duration of illness at the time of testing.

In case of COVID-19, the virus that causes the disease – SARS-CoV-2 – is detected through a test known as a reverse-transcription polymerase chain reaction test, or RT-PCR. This is the most common type of test used in Canada.

A study of the accuracy of RT-PCR testing for COVID-19 found the test did not detect the virus on day one of infection and produced false-negative results 38 per cent of the time on day five and at least 20 per cent of the time after day eight. If patient has symptoms but the test is negative then test result should be ignored and patient should be kept in quarantine and tested again.

Types of testing

I have been curious to know how accurate are the tests done to diagnose COVID-19. Here is what I learnt.

Nucleic acid-based testing – for detecting nuclear acid specific to the virus. This is the preferred initial diagnostic test for COVID-19.

Scientifically speaking, this is a nucleic acid amplification testing (NAAT), most commonly with a reverse-transcription polymerase chain reaction (RT-PCR) assay to detect SARS-CoV-2 RNA from the upper respiratory tract.

This test is the gold standard used in Canada and abroad to diagnose active COVID-19 infection in patients with symptoms. There are very few false positive results. False negative results depend on timing of the sample in relation to the stage of the illness.

False negatives can occur up to 30 per cent of the time if we swab people who are asymptomatic and swab them too soon after they’ve been exposed to COVID-19.

False positives depend a lot on the machine itself, but also how much COVID-19 is in a town or community that is being assessed. It is hard to nail down a rate that applies to every machine that is used.

Test sensitivity depends on timing of sample collection. According to Centre for Disease Control and Prevention (CDC) proper collection of specimens is the most important step in the laboratory diagnosis of infectious diseases. A specimen that is not collected correctly may lead to false negative test results.

Serology-based testing – for detecting antibodies to the virus.

Serologic tests are blood tests that look for antibodies in the blood. They can involve a number of laboratory techniques. This test is not intended for use in clinical diagnosis. Serological tests do not detect the virus itself. Instead, they detect the antibodies produced in response to an infection.

Health Canada confirms that authorized COVID-19 tests are well supported by evidence indicating they will provide accurate and reliable results. That means very few false positive results. In Alberta, any person who wants to be tested can now be tested, even if they don’t have symptoms.

I hope this information helps. Take care. Be safe.

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What have we learned about COVID-19?

Red Rock Coulee in Alberta, Canada. (Dr. Noorali Bharwani)
Red Rock Coulee in Alberta, Canada. (Dr. Noorali Bharwani)

Here is the good news. The spread of the COVID-19 pandemic in Canada is slowing down. But the bad news is, health officials warned it could come back with a vengeance this fall if contact tracing and testing aren’t stepped up.

What we are trying to do is to contain the virus because there is no vaccine or medications to kill the virus. Once the lockdown is lifted, it will leave many people vulnerable to infection as they begin to venture out again.

Unless there is a miracle, SARS-CoV-2 Vaccine will take time to be ready to be used.

The COVID-19 pandemic is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In March 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic.

Alberta has the third-most number of cases of COVID-19 in Canada. By June 3, there were 7,076 confirmed cases and 145 deaths. The majority of cases have been in the Calgary zone, which has 4,909 cases.

What do we know about coronaviruses?

Coronaviruses are a family of viruses that can cause illnesses such as the common cold, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). In 2019, a new coronavirus was identified as the cause of a disease outbreak that originated in China.

There are people who are infected but have no symptoms. Others have mild to moderate to severe symptoms.

Classical COVID-19 symptoms may appear two to 14 days after exposure to the virus. That is the incubation period. The common presentation is fever, cough, and tiredness.

Other symptoms can include: shortness of breath or difficulty breathing, muscle aches, chills, sore throat, loss of taste or smell, headache, and chest pain.

Other less common symptoms have been reported, such as rash, nausea, vomiting and diarrhea.

People who are older or who have existing chronic medical conditions, such as heart disease, lung disease, diabetes, severe obesity, chronic kidney or liver disease, or have compromised immune systems may be at higher risk of serious illness.

It is important you contact your health care provider if you have any of these symptoms. You should call 911 if you have trouble breathing, persistent chest pain or pressure, inability to stay awake, new confusion, blue lips or face.

The virus appears to spread easily among people. Data has shown that it spreads from person to person among those in close contact (within about six feet, or two meters). The virus spreads by respiratory droplets released when someone with the virus coughs, sneezes or talks. These droplets can be inhaled or land in the mouth or nose of a person nearby.

It can also spread if a person touches a surface with the virus on it and then touches his or her mouth, nose or eyes.

Prevention is better than cure. Since there is no vaccine to prevent COVID-19 the next best thing is to reduce your risk of infection by doing the following:

  1. Avoid large gatherings
  2. Avoid close contact
  3. Stay home as much as possible
  4. Wash hands often
  5. Wear a mask in public places
  6. Avoid touching your eyes, nose and mouth.

Yes, face masks combined with other preventive measures, such as frequent hand-washing and social distancing, help slow the spread of the disease.

If you have COVID-19 related symptoms you are legally required to isolate yourself.

If you have symptoms, take the online assessment to arrange testing.

Take care. Stay healthy.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

COVID-19: Cancer Care During the Pandemic

Are we ready for summer? (Dr. Noorali Bharwani)
Are we ready for summer? (Dr. Noorali Bharwani)

An article published in JAMA Oncology (online March 25, 2020) the authors report incidence and outcomes of COVID-19 in cancer patients who were treated at a tertiary cancer institution in Wuhan, China.

They found patients with cancer harbored a higher risk of COVID-19 compared with the community.

This increased risk of infection and death among cancer patients creates high psychological pressure of uncertainty. These patients and their families need guidance and support. Moreover, cancer treatments such as surgery, chemotherapy and radiotherapy suppress the immune system. This makes cancer patients more vulnerable to complications like infection.

Physicians and cancer patients have to decide: Does cancer treatment priority outweigh the risk of contracting infection with coronavirus?

An article in Lancet Oncology (Summary of international recommendations in 23 languages for patients with cancer during the COVID-19 pandemic – May 13, 2020), provides professional guidance to promote patients’ safety, treatment, and compliance, and ameliorating patients’ stress.

The authors identified six main areas of recommendations.

The first area concerns general considerations for patients with cancer during the COVID-19 pandemic.

Generally speaking, cancer patients’ immune system is not very strong. Especially the ones who are awaiting or undergoing treatment. The degree of immunosuppression depends on the type of cancer, the patient’s age, fitness, comorbidities, the type of therapy, and the time since last therapy.

Patients should familiarise themselves with COVID-19 symptoms. Early symptoms can be managed at home by way of self-isolation. Immediate medical attention should be sought for more severe symptoms, such as high fever, difficulty breathing, chest pain, confusion, and blue lips or face.

The second area of recommendation regards specific special measures that people with cancer should take to avoid COVID-19 infection. The best way to prevent infection is to avoid exposure to the virus by implementing strict hygienic and behavioural measures.

Hygienic measures include frequent hand washing, disinfecting objects, avoiding handling objects in public places, and washing fruits and vegetables.

Behavioural modifications include staying at home, not gathering in public places, and not touching other people. The use of a face mask is recommended.

The third area – patients with cancer should avoid people with a known exposure, infected asymptomatic people, and infected symptomatic people for at least 14 days and until their symptoms have resolved.

The fourth area of recommendation is related to mental health: guidance on managing anxiety and stress.

Some recommendations include breathing fresh air, engaging in physical exercise and creative activities, and having quality time with their families. Rest, sleep, and healthy eating are important. Talk to your friends and family frequently, engaging in pleasant activities, meditation, yoga and physical exercise. Patients who feel that they cannot cope with their stress should talk to their doctor.

The fifth area of concern is to maintain trust between physicians and patients to enhance patients’ confidence in medical staff decisions and improve their compliance with medical advice.

This may not be very easy. There has been a significant delay in continuity of care. Most patients understand the reasons for delay. But it is not easy.

As things improve with COVID-19 pandemic, cancer centers will be going through painful and difficult process of prioritising patients for treatment. Patients will be evaluated on a case-by-case basis, according to the overall clinical picture, the aggressiveness of the cancer, and the potential health risks from COVID-19.

Finally, the sixth area is the importance of containing spread of COVID-19 to vulnerable people. This can be done by keeping patients and visitors who have symptoms or have been exposed to an infected person not visit their cancer centre, but should first call their doctor’s office for further instruction.

We hope all patients and especially cancer patients get the treatment they need soon.

Take care. Be safe.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!