COVID-19 in New York: What Pediatricians need to know!

Asif Noor, MD, FAAP

Dr. Asif Noor, MD, FAAP is a Pediatric Infectious Disease Specialist at NYU Winthrop Hospital and he co-chairs the Infectious Disease Committee of the NYS AAP Chapter 2)

Folks rumble on Corona
All along from Wuhan to Barcelona
A virus damned for misery and fear
A virus you need to brace as it comes near

The emergence of the new coronavirus aka COVID-19 in New York was inevitable.  As of March 5th, New York State has reported eleven confirmed cases. Nine of them can be linked directly to one particular person residing in Westchester.  This suggests local transmission of COVOID-19 in New York.

I would like to share:

1. Important facts about COVID-19,
2. Comparison of COVID -19 versus influenza
3. Approach to COVID -19 in office setting
4. Preparedness tips

If you are crunched for time there are a few tables at the end for quick reference.

Background: A novel animal coronavirus launched its spread from the industrial city of Wuhan in China few months ago, in late December 2019.  A cluster of atypical pneumonia cases linked to the Huanan wholesale seafood market in Wuhan prompted the initial investigation. By early January 2020, outbreak was declared as a public health emergency in China. Rapid spread and link to Wuhan during the prime stages of the outbreak in China was dealt with strict quarantine laws. As weeks passed by, cases without link to Wuhan emerged within China. On January 13^th the first case outside China was reported.  The following month of February was marked with an alarming situation. The number of new cases of COVID-19 surpassed in countries other than China.  These included imported cases but the worry was local transmission. South Korea, Iran, Italy and Japan currently have the highest COVID-19 counts outside mainland China with evidence of local transmission. Worldwide over 70 countries have confirmed cases and the list keeps on growing daily.

WHO and CDC predict an alarming situation. Travel restrictions, quarantines, hospital preparedness plans are in full swing since late February. Resources are being diverted to manage a catastrophe posed by COVID-19.  Experts are encouraging the need to prepare for a Pandemic!  Every new case is a Breaking News.

So what is this presumed apocalyptic virus? COVID -19’s uncertain potential creates many what’s, when’s and How’s. We need answers and we need them quick! Answers are indeed trickling in. An outpouring of initial evidence from large case series, epidemiological studies and histopathological analysis is now available. PubMed have over 500 articles and numerous expert opinions. At the same time many are trying to extrapolate COVID-19s potential by comparing it to seasonal influenza as well the other 21st century’s novel coronaviruses such as SARS 1 and MERS.

COVID -19: Name and the Virus

Coronavirus disease in 2019 aka COVID 19 is a novel human infecting betacoronavirus (of animal origin). It is similar to the two other bat derived coronaviruses, the 2002 SARS and 2012 MERS virus. SARS 1 hopped over from bats to civet (a small nocturnal mammal) and then to human. MERS virus jumped from bats to camels and then human, this current COVID-19 started with bats with intermediate host Pangolin (a scaly anteater) and then to humans.

The coronavirus is a single stranded RNA virus with crown like spikes over the surface, hence the name coronavirus. These spikes allow attachment to upper respiratory tract epithelium. A spectrum of respiratory illness follows invasion, a pattern seen similar to other high impact viruses. Severity mainly depends upon the host. Symptoms range from asymptomatic state, mild symptoms of upper respiratory tract infection to severe manifestations of pneumonia and respiratory failure (ARDS, septic shock).

Large case series clearly show that COVID-19 has affected disproportionately the elderly and people with underlying medical problems. Children less than 18 years account for only 2 % of the affected group. Majority of these children had mild upper respiratory symptoms. This is in contrast to seasonal influenza where 20 -30 % of infections are in children and the diseases is associated with complication. So far in the 2019-20 influenza season 125 pediatric deaths have been reported!

COVID-19: How does it spread and the incubation period.

It is spread from person to person. Humans are immune naive to this virus. It can be transmitted from person to person in close contact (< 6 feet) through respiratory droplet produced by coughing and sneezing. Transmission is almost always from symptomatic people. There are a few case reports citing presumed asymptomatic carrier transmission however it’s exceptionally infrequent.

The incubation period (interval between exposure and onset of symptoms) is cited to be a median of 5 days (range 1-14 days). Getting this incubation period right is important for purposeful quarantine of asymptomatic individuals. A few anecdotal case reports from China mention incubation period of 27 days but that’s not the standard and asymptomatic individuals will not be responsible for the vast majority of transmission.

COVID-19:  Infection potential and Mortality

In order to estimate impact of this virus, we need to understand two features of COVID 19, its contagiousness and mortality (case fatality rate). Remember these are just approximations and not true predictions.

Potential to spread:  How an infection spreads in a population is measured statistically by a “basic reproduction number”, also called R0. This number will predict how many new people each infected person will end up infecting if the infection is left unchecked.  If R0 is < 1 the infection will typically vanish over time. R0 more than one implies that a sick person can infect one person at least, who will infect others leading to spread. To provide a context, seasonal influenza has an R0 of 1.2, which means every five infected people will transmit it to a new sixth person. In 2019, we were faced with the highly contagious measles outbreak in NY. Measles has an R0 of 12-18 which implies each measles case will spread infection to 12-18 new unvaccinated people.

COVID-19 has an estimated R0 between 1.4 and 4 which is within range for other coronaviruses. Spread is inevitable given lack of vaccine and no herd immunity.

Potential to cause death: Another important aspect is the case fatality rate. The mortality rate of COVID-19 was initially reported as 2.3 %. However, earlier rates was calculated based on cases of pneumonia. As the number of laboratory confirmed cases includes the asymptomatic and minimally symptomatic, the case fatality rate continues to fall. It was revealed to be 1.4 % in 1099 laboratory confirmed cases by Guan et al. This rate is considerably lower than other animal coronaviruses: SARS (9.6 %) and MERS (34 %).

COVID 19: Testing

Common human coronaviruses (HKU1, NL63, 229E, OC43) detected by the widely available respiratory multiplex PCR panel or Film array are responsible for one quarter of common colds during winter months. It does not detect COVID -19.

New York State has the capability to perform real-time polymerase chain reaction assay to identify COVID-19. Large academic centers and commercial laboratories soon will have the ability to run the test.  If you suspect a child potentially can have COVID-19 on basis of exposure, travel to outbreak regions, and a work up is negative for common respiratory pathogens, you should send the test and also call local department of health: NYC (866)-692-3641, Nassau (516) 227-9639 and Suffolk (631) 854-0333 to discuss the potential case.

There is no vaccine, no approved treatment no prophylaxis. There are anecdotal reports on chloroquine, lopinavir/ritonavir use and some success with investigational use of remdesivir for compassionate use.

Undoubtedly, COVID-19 poses a public health threat. It requires a balanced response using appropriate resources to tackle it. An exaggerated response may overwhelm our healthcare and divert resources from where they are needed the most. Being prepared is what we should do. We should refrain at all cost from spreading fear and anxiety.

WHO and CDC predict an alarming situation.  Travel restrictions, quarantines, hospital preparedness plans are in full swing since late February. Resources are being diverted to manage a catastrophe posed by COVID-19.  Experts are encouraging the need to prepare for a Pandemic!  Every new case is Breaking News.

A few tables for your quick references: –

Table 1

Table 2

Table 3