novel strain of coronavirus — SARS-CoV-2 — was first detected in December 2019 in Wuhan, a city in China’s Hubei province with a population of 11 million, after an outbreak of pneumonia without an obvious cause. The virus has now spread to over 150 countries across the globe, and was characterised as a pandemic by the World Health Organization (WHO) on 11 March 2020,.
As of 23 March 2020, there were 332,930 laboratory-confirmed cases of coronavirus disease 2019 (COVID-19) infection, with 14,510 reported deaths. The number of cases and deaths outside of China overtook those within the country on 16 March 2020.
Pharmacists are likely to come across worried patients, and those with cold and flu symptoms which may appear similar to those of COVID-19. This article gives a brief overview of the new virus and what to look out for.
What are coronaviruses?
SARS-CoV-2 belongs to a family of single-stranded RNA viruses known as coronaviridae, a common type of virus which affects mammals, birds and reptiles.
In humans, it commonly causes mild infections, similar to the common cold, and accounts for 10–30% of upper respiratory tract infections in adults. More serious infections are rare, although coronaviruses can cause enteric and neurological disease. The incubation period of a coronavirus varies but is generally up to two weeks.
Previous coronavirus outbreaks include Middle East respiratory syndrome (MERS), first reported in Saudi Arabia in September 2012, and severe acute respiratory syndrome (SARS), identified in southern China in 2003,. MERS infected around 2,500 people and led to more than 850 deaths while SARS infected more than 8,000 people and resulted in nearly 800 deaths,. The case fatality rates for these conditions were 35% and 10%, respectively.
SARS-CoV-2 is a new strain of coronavirus that has not been previously identified in humans. Although the incubation period of this strain is currently unknown, the United States Centers for Disease Control and Prevention indicate that symptoms may appear in as few as 2 days or as long as 14 days after exposure. Chinese researchers have indicated that SARS-CoV-2 may be infectious during its incubation period.
The number of cases and deaths outside of China overtook those within it on 16 March 2020
Where has the new coronavirus come from?
It is currently unclear where the virus has come from. Originally, the virus was understood to have originated in a food market in Wuhan and subsequently spread from animal to human. Some research has claimed that the cross-species transmission may be between snake and human; however, this claim has been contested,.
Mammals such as camels and bats have been implicated in previous coronavirus outbreaks, but it is not yet clear the exact animal origin, if any, of SARS-CoV-2.
How contagious is COVID-19?
Increasing numbers of confirmed diagnoses, including in healthcare professionals, has indicated that person-to-person spread of SARS-CoV-2 is occurring. The preliminary reproduction number (i.e. the average number of cases a single case generates over the course of its infectious period) is currently estimated to be between 1.4 to 2.5, meaning that each infected individual could infect between 1.4 and 2.5 people.
Similarly to other common respiratory tract infections, MERS and SARS are spread by respiratory droplets produced by an infected person when they sneeze or cough. Measures to guard against the infection work under the current assumption that SARS-CoV-2 is spread in the same manner.
How is COVID-19 diagnosed?
As this coronavirus affects the respiratory tract, common presenting symptoms include fever and dry cough, with some patients presenting with respiratory symptoms (e.g. sore throat, nasal congestion, malaise, headache and myalgia) or even struggling for breath.
In severe cases, the coronavirus can cause pneumonia, severe acute respiratory syndrome, kidney failure and death.
The case definition for COVID-19 was amended on 13 March 2020 and is now based on symptoms regardless of travel history or contact with confirmed cases. Diagnosis is suspected in patients requiring admission to hospital with signs and symptoms of pneumonia, acute respiratory distress syndrome or influenza, and in those with a new, continuous cough or fever who are well enough to stay in the community (see Box 1). A diagnostic test has been developed, and countries are quarantining suspected cases.
Box 1: Who qualifies as a suspected COVID-19 case?
Patients who meet the following criteria (inpatient definition):
Those requiring admission to hospital AND
Those who have either clinical or radiological evidence of pneumonia OR
Acute respiratory distress syndrome OR
Influenza like illness (fever ≥37.8°C and at least one of the following respiratory symptoms, which must be of acute onset: persistent cough [with or without sputum], hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing).
Patients who meet the following criteria and are well enough to remain in the community:
New continuous cough AND/OR
Individuals with a cough or fever who live alone should now stay at home for 7 days from the onset of symptoms. Households should all self-isolate for 14 days if one member shows symptoms.
Clinicians should be alert to the possibility of atypical presentations in patients who are immunocompromised. Alternative clinical diagnoses and epidemiological risk factors should be considered.
The government launched its coronavirus action plan on 3 March 2020, which details four stages: contain, delay, mitigate, research. On 12 March 2020, the UK moved to the delay phase of the plan and raised the risk level to ‘high’.
On 16 March 2020, Johnson said that the UK is “now approaching the fast growth part of the upward curve” and, without drastic action, cases could double every 5 or 6 days. He announced social distancing measures, such as working from home and avoiding social gatherings, as well as household isolation for those with symptoms,.
On 17 March 2020, Britons were advised to avoid all non-essential internation travel for an initial period of 30 days.
Further social distancing measures were announced later in the week, including closing all schools in the UK except for vulnerable children and those of key workers, such as pharmacists and other health and social care staff, teachers and delivery drivers. Restaurants, cafes, pubs, leisure centres, nightclubs, cinemas, theatres, museums and other businesses were also told to close.
On 22 March 2020, Johnson announced that the most vulnerable people, including those who have received organ transplants, are living with severe respiratory conditions or specific cancers, and some people taking immunosuppressants, should stay in their homes for at least the next 12 weeks.
On 23 March 2020, Johnson warned that, without a huge national effort to halt the growth of coronavirus, “there will come a moment when no health service in the world could possibly cope; because there won’t be enough ventilators, enough intensive care beds, enough doctors and nurses”.
He announced a strict lockdown of the UK to be enforced by police, instructing people to stay at home except to buy essential food and medicines, one form of exercise a day, any medical need, and travelling to and from essential work. He said that all gatherings of more than two people in public must stop and, with immediate effect, all shops selling non-essential goods, libraries, playgrounds, outdoor gyms and places of worship must close. All social events, including weddings, baptisms and other ceremonies, but excluding funerals must be cancelled, he added.
What should I do if a patient thinks they have COVID-19?
Patients have been advised not to go to their community pharmacy if they are concerned that they have COVID-19. Those with a new, continuous cough or a high temperature who live alone should self-isolate for seven days from the onset of symptoms. Households should all self-isolate for 14 days if one member shows symptoms. There is no need for people with minor symptoms to telephone NHS 111 or to be tested for COVID-19.
However, given the outbreak has coincided with the cold and flu season, it is likely that patients may present in the pharmacy with queries about the virus, or with concerns about their cold or flu symptoms.
Community pharmacies were told by NHS England and NHS Improvement on 27 February 2020 that, in the unlikely event that a suspected case does present, they must prepare a “designated isolation space”.
If the pharmacy does not have a suitable room to isolate a suspected patient, an area that would keep a patient at least two metres away from staff and other patients in the pharmacy should be prepared so that it can be cordoned off.
Patients who present with a new, continuous cough or a high temperature should be told to return home immediately and self-isolate. If, in the clinical judgement of the pharmacist, the person is too unwell to return home, they and any accompanying family should be invited into the designated isolation space where emergency services should be contacted.
The Royal Pharmaceutical Society is publishing ongoing guidance on contingency planning for COVID-19, which includes measures to protect the pharmacy team, such as limiting the number of people within the pharmacy at the same time, keeping at least two metres apart from staff and people coming into the pharmacy, and sectioning the pharmacy to encourage social distancing with floor markings (using tape) or barriers. The RPS has also produced a table to help pharmacists distinguish between COVID-19, a cold, the flu and hayfever.
The General Pharmaceutical Council said on 3 March 2020 that it recognises pharmacists may need to depart from established procedures in order to care for patients during the coronavirus outbreak and that regulatory standards are designed to be flexible and to provide a framework for decision-making in a wide range of situations.
In a joint statement with ten other health regulators, the GPhC said: “Where a concern is raised about a registered professional, it will always be considered on the specific facts of the case, taking into account the factors relevant to the environment in which the professional is working”.
What can I do to protect my staff?
An updated standard operating procedure (SOP) for community pharmacies, published on 22 March 2020, sets out measures to protect pharmacy staff, including advising customers to keep a distance of at least two metres from other people. If it is too crowded to maintain this distance, entry and exit to the pharmacy can be managed and customers should be advised to wait outside at least two metres away from others. Pharmacies may wish to consider installing full screens to protect members of staff from airborne particles.
In general, it is not recommended that pharmacy staff need to wear facemasks to protect against the virus. These would only be required in high risk situations, such as supporting a person showing symptoms of COVID-19 in an emergency.
Staff who have a new continuous cough or a high fever should stay at home, self-isolate and work from home if well enough to do so. Those who fall into one of the vulnerable groups at particular risk of complications from COVID-19 should not see patients face-to-face, regardless of whether the patient has possible COVID-19 or not. Remote working should be prioritised for these staff.
What about ‘business as usual’ during the pandemic?
Pharmacies are on the frontline of the fight against coronavirus and demand for services is high. The updated standard operating procedure (SOP) for community pharmacies specifies that, if under significant pressure, at the discretion of the responsible pharmacist, pharmacies may close their doors to the public for up to 2.5 hours a day, including lunch. However, all pharmacies are expected to be open to the public between 10am and 12 noon and 2pm and 4pm as a minimum. 100 hours pharmacies should be open between 10am and 12 noon, and 2pm and 6pm as a minimum.
The SOP also says that pharmacies should consider ‘buddying’ arrangements with another local pharmacy to maintain access to pharmaceutical services in the event of a temporary closure.
In Scotland, the minor ailments service has been expanded earlier than planned so that it is open to everyone from 23 March 2020.
The General Pharmaceutical Council has stopped all routine inspections of pharmacies and submission of revalidation records has been postponed. The GPhC is contacting pharmacy professionalswho have left the register within the past three years to ask if they would be willing to temporarily rejoin during the COVID-19 pandemic.
What is happening with testing for COVID-19?
As of 23 March 2020, 83,945 people had been tested for COVID-19 in the UK. Testing has switched from testing all suspected cases to focussing on patients who are admitted to hospital with respiratory illnesses.
However, on 18 March 2020, the Department of Health and Social Care announced that officials are working to increase the number of tests that can be conducted by Public Health England (PHE) and the NHS to 25,000 a day over the next four weeks. In the prime minister’s daily press conference on 18 March 2020, deputy chief medical officer Jenny Harries said that clinical staff would be one of the groups that are prioritised.
The government is also working with companies to rapidly develop a test to establish whether people have developed immunity, which it said “will help get NHS and other critical public sector staff back to work as fast as they can”. At the 18 March 2020 press conference, Patrick Vallance, the government’s chief scientific adviser, referred to the antibody test as a “game changer” and said that work was progressing very fast, with PHE “looking at this today”.
The increased testing will also include developing a point-of-care swab test outside of hospitals, so people with suspected symptoms can quickly find out if they have coronavirus.
How can cross-infection be prevented?
The WHO has created a range of infographics to illustrate how patients can protect themselves and others from getting sick; however, most of the advice is similar to what would be provided for colds and flu (see Figure).
Figure: Infographic – How to reduce the risk of coronavirus infection
Source: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.
There is no specific treatment for COVID-19. Although vaccines can be developed to treat viruses, owing to the novel nature of this infection, no vaccine has currently been developed and the process to develop one may take 12 to 18 months. As an example, many antiviral agents have been identified to inhibit SARS in vitro, but there are currently no approved antiviral agents or vaccines available to tackle any potential SARS or SARS-like outbreaks, such as MERS or SARS-CoV-2.
There has been a lot of talk in the news and on social media about how certain medications can exacerbate the symptoms of COVID-19, what is the current advice around these medications?
The advice was issued following concerns circulated on social media that these medicines could predispose them to adverse outcomes should they become infected with COVID-19.
Both societies recommended that patients taking these medicines who present as unwell, or with a suspected or known COVID-19 infection, should be assessed on an individual basis and their medication managed according to established guidance. Inappropriate cessation of therapy could lead to a decline in control of blood pressure, heart failure or any other condition the individuals takes these medicines for.
Similar concerns have also arisen around the use of ibuprofen following unverified claims, backed by Oliver Veran, France’s health minister, that ibuprofen may exacerbate symptoms of the virus.
On 17 March 2020, the NHS issued updated guidance for patients to clarify that there is not sufficient evidence to support advice for patients to stop using NSAIDs without consulting their doctor but advised that individuals with COVID-19 take paracetamol to treat their symptoms.
The Committee of Human Medicines — an advisory body of Medicines and Healthcare products Regulatory Agency — and the National Institute for Health and Care Excellence have been instructed to review the evidence on the impact of NSAIDs on the severity of COVID-19 infection and the NHS’s position will be kept under constant review.
Box 2: In quotes
Matt Hancock, health and social care secretary: “The public can be assured that the whole of the UK is always well-prepared for these types of outbreaks and will remain vigilant and keep our response under constant review in the light of emerging scientific evidence.”
Boris Johnson, prime minister:“I believe that [the social distancing measures] are overwhelmingly worth it to slow the spread of the disease, to reduce the peak, to save life, minimise suffering and to give our NHS the chance to cope.”
Tedros Ghebreyesus, director-general at the World Health Organization: “This is a unique virus with unique features. This virus is not influenza. We are in unchartered territory.”