Where are we now with COVID‐19?

Dear Sir,

As a practicing front‐line clinician in the acute adult general medical field, I read Dr Stein's recent insightful article on novel coronavirus (COVID 19) ¹ with great interest.

News reports in the United Kingdom and around the world carry daily updates and increasing speculation about the potential global impact as the virus spreads much as Dr Stein predicted.

However, a number of questions appear to be emerging that were not covered when Dr Stein published his editorial in IJCP.

The risk of death from COVID 19 seems to be in those aged greater than 40 years and probably linked to other health factors, in particular pre‐existing health issues including cardiac disease. ² Moreover, these authors reporting early observations from China, appear to suggest that a possible cytokine storm or fulminant myocarditis may be predeterminants of risk of death from this disease; with raised cardiac troponin, myoglobin, C‐reactive protein and Interleukin‐6 being predictors of risk of death. As the evidence progresses, are these markers which we should be routinely be assessing in confirmed cases of COVID 19?

In addition it seems to be that data are emerging that children are likely to present with milder symptoms that older adults, with a recent paper suggesting that 13% of children who screen positive are asymptomatic, 42% have mild upper respiratory tract symptoms, 45% display classic (adult) symptoms and no child has severe or critical features. ³ It has also been reported from China that infection in children seems to be rare. ⁴ Do these observations, albeit on limited data suggest that children and the young may be unknowing harbours of the virus which if transmitted to older and more vulnerable adults could result in more severe infection?

Another question which seems to be emerging is that of the unknown transmission of the disease. In a recent and very small sample from Singapore, ⁵ it might appear that the virus has a relatively mild course in many affected patients, and that the faeco‐oral route as well as the more classic respiratory route of transmission may be a factor. These early observations appear to be supported by more robust data which imply that at the height of the China outbreak, some 36% of cases observed occurred in patients without previous clear exposure to the virus. ⁶ Based on these early data, it appears to be the case that it is increasingly likely that person to person spread of the virus responsible for COVID 19 becomes more common between apparently relatively unaffected people or those with only mild coryzal symptoms as the virus becomes endemic within communities. Does this raise questions for screening strategies, public health policy and front‐line clinical teams as the illness spreads within communities? In addition is it possible that published overall mortality rates may be overestimates as the true denominator (the total numbers with COVID‐19) is unknown because of mild cases, perhaps especially among children and younger adults, not presenting for screening?

I would be most interested in Dr Stein's thoughts on these questions, and any other insights that he may have on new and emerging concerns or topics since his editorial was published.