key: cord-280970-gy0kfhy6 authors: Peng, Fujun; Tu, Lei; Yang, Yongshi; Hu, Peng; Wang, Runsheng; Hu, Qinyong; Cao, Feng; Jiang, Taijiao; Sun, Jinlyu; Xu, Guogang; Chang, Christopher title: Management and Treatment of COVID-19: The Chinese Experience date: 2020-04-17 journal: Can J Cardiol DOI: 10.1016/j.cjca.2020.04.010 sha: doc_id: 280970 cord_uid: gy0kfhy6 With over 1,800,000 cases and 110,000 deaths globally, COVID-19 is one of worst infectious disease outbreaks in history. The objective of this paper is to critically review the available evidence regarding the lessons learned from the Chinese experience regarding COVID-19 prevention and management. The steps that have led to a near disappearance of new cases in China included rapid sequencing of the virus to establish testing kits which allowed tracking of infected persons in and out of Wuhan. In addition, aggressive quarantine measures included the complete isolation of Wuhan and then later Hebei and the rest of the country, as well as closure of all schools and non-essential businesses. Other measures included the rapid construction of two new hospitals and the establishment of Fangcang shelter hospitals. In the absence of a vaccine, the management of COVID-19 included antivirals, high flow oxygen, mechanical ventilation, corticosteroids, hydroxychloroquine, tocilizumab, interferons, intravenous immunoglobulin and convalescent plasma infusions. These measures appeared to provide only moderate success. While some measures have been supported by weak descriptive data, their effectiveness is still unclear pending well-controlled clinical trials. In the end, it was the enforcement of drastic quarantine measures that stopped SARS-CoV-2 from spreading. The earlier the implementation, the less likely resources will be depleted. The most critical factors in stopping a pandemic are early recognition of infected individuals, carriers and contacts, and early implementation of quarantine measures with an organized, proactive and unified strategy at a national level. Delays result in significantly higher death tolls. Since mid-December 2019, there has been a worldwide outbreak of COronaVIrus Disease 90 (COVID)-19, caused by SARS-CoV-2 (formerly 2019-nCoV or and first detected in 91 Wuhan, China. The incubation period is 1 to 14 days (mean: 5-6 days) in most cases, but can be 92 as long as 24 days. 1 The most commonly seen characteristics of COVID-19 are fever, cough and 93 abnormal chest computed tomography (CT). 2, 3 At present, the Chinese chrysanthemum bat is 94 thought to be the origin of SARS-CoV-2 based on sequence homology of 96% between 95 SARS-CoV-2 and Bat-CoV-RaTG13. 4 , 5 The pangolin has been proposed as an intermediate host, 96 but this has not been confirmed. 6, 7 Human-to-human transmission of SARS-CoV-2 occurs 97 mainly via respiratory droplets, 1 direct contact, 1 asymptomatic transmission, 8, 9 and intrafamilial Managing the spread of the epidemic 128 The most important strategy to combat a pandemic is to prevent it from even happening. This shortage of personal protection equipment (PPE), which was mitigated by using reserve 210 supplies, acquiring donations, and production increases (Appendix 1 and Figure S1 ). Wuhan is shown in Figure 2 . Table S1 . 240 Emergency staffing was arranged as needed within a half hour. do not require supplemental oxygen, and hyperoxemia may induce further respiratory 306 injury and even higher mortality. 29 The indications for supplemental oxygen should be Pharmacologic agents 345 We summarize the treatment of 327 pooled cases of severe cases with COVID-19 ( (Table 3) . 10, 36 365 interferon-α2b inhalation, 17 (28%) patients received arbidol and lopinavir/ritonavir, and 8 (13%) 369 received interferon-α2b by inhalation. 37 Chen et al reported that 75 of 99 confirmed patients in 370 Wuhan received antiviral treatment, including oseltamivir, ganciclovir, and lopinavir and 371 ritonavir. 38 The duration of antiviral treatment was 3-14 days. 38 15 Zhou et al proposed that hydroxychloroquine could serve as a better therapeutic agent than 400 chloroquine due to reduced toxicity, fewer side effects, lower cost and relative safety in 401 pregnancy. 47 Yao et al used physiologically-based pharmacokinetic (PBPK) models and found 402 that hydroxychloroquine was more potent than chloroquine at inhibiting SARS-CoV-2 in vitro. 403 They recommended hydroxychloroquine sulfate 400 mg twice daily for 1 day, followed by 200 404 mg twice daily for 4 days to treat SARS-CoV-2 infection. 48 The efficacy and safety data of 405 chloroquine or hydroxychloroquine from high-quality clinical trials are urgently needed. A retrospective study found that low-to-moderate dose glucocorticoid therapy had no effect 419 on the time to viral clearance in patients with COVID-19. Glucocorticoids are not recommended 420 in mild cases because there was no improvement in the rate of radiographic recovery. 52 However, 421 a single-center in Wuhan shared that early, low-dose and short-term (1-2mg/kg/d for 5-7 days) 422 corticosteroids was associated with a faster improvement of clinical symptoms and absorption of 423 focal lung lesions in severe cases of COVID-19. 53 Another study analyzed 15 critical cases and 424 suggested that a low dose and short duration of corticosteroids (methylprednisolone <1 mg/kg, 425 less than 7 days) may be beneficial for critically ill patients with COVID-19. 54 Vaccine development 489 The development of a vaccine for SARS-CoV-2 has been accelerated as a priority project. improve sample collection and the accuracy of SARS-CoV-2 nucleic acid detection. 77 The 513 patients' position should be assessed and changed regularly to avoid decubitus skin injury. Due to the fact that cardiac insufficiency can lead to a coagulation disorder and that severe 533 COVID-19 patients were reported to have increased level of D-dimer, low molecular weight 534 heparin was recommended to treat COVID-19 patients in the early phase of disease. 81 As in 535 SARS-CoV, ACE2 has similarly been identified as the receptor for SARS-CoV-2 to enter cells. 82 The use of angiotensin converting enzyme inhibitors (ACEI) may not be of any benefit because 537 it does not bind to the ACE2 receptor. This also means that discontinuing ACEI in patients with 538 COVID-19 is not necessary. With regard to angiotensin receptor blockers (ARBs), there is 539 evidence that ARBs could lead to increased expression of ACE2, thus worsening disease, but this Effectiveness and importance of public health interventions 562 The WHO-China joint mission report reported that China's vigorous public health measures 563 to prevent the COVID-19 are the most "ambitious, agile and aggressive disease containment 564 effort in history". 86 The drastic measures taken are listed in Table 4 . If not for a national strategy Once it is recognized that there is a new, potentially lethal virus, the virus needs to be 587 isolated, the viral genome sequenced, and testing kits validated and released for rapid 588 distribution. Infected individuals and their contacts need to be tracked and isolated. The earlier 589 this is done, the less impact there will be on the personal and professional lives of people and the 590 economy, and the less resources will be needed. When more people are infected, the drastic 591 measures including shutting down cities and restricting travel will need to be more widespread, 592 healthcare resources will be exhausted and the economy will take a bigger hit. 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The impact of transmission control measures during the first 50 days of the COVID-19 epidemic in China. medRxiv Abbreviations: NA: not available; HRCT: high-resolution computed tomography; ARDS: acute respiratory distress syndrome; ICU: intensive care unit; MAP: mean arterial pressure; SBP: systolic blood pressure; SD: standard deviation; HR: heart rate; bpm: beats per minute; sec: second; *: The elderly and immunosuppressed may present with atypical symptoms. Symptoms due to physiologic adaptations of pregnancy or adverse pregnancy events, such as dyspnea, fever, gastrointestinal symptoms or fatigue, may overlap with COVID19.†: Fast breathing (in breaths/min): < 2 months: ≥ 60; 2-11 months: ≥ 50; Enforcement laws including <Law of the People's Republic of China on the prevention and treatment of infectious diseases>, <Surveillance protocol for pneumonia cases from novel coronavirus (second edition)>, <Preventive measures against infectious diseases in business and service business sites>, <Provisions on the emergency handling of entry-exit inspection and quarantine for public health emergencies at border ports>, etc. Temperature screening on the public occasions, such as hospitals, supermarket Purchasing daily necessities on a regular schedule Delivering food and disinfectants for every family Real time disinfection of public areas.