Update on COVID-19 pandemic
Over 60.8 million cases have been reported globally, with over 39 million cases recovered so far, and approximately 1.4 million deaths according to data compiled by the Center for Systems Science and Engineering at Johns Hopkins University. The US has the highest number of reported infections and deaths in the world. India has the second largest number of reported cases, followed by Brazil, France, Russia, Spain, the UK, Italy, and Argentina.
Johns Hopkins University: coronavirus COVID-19 global cases external link opens in a new window
[Figure caption and citation for the preceding image starts]: Number of COVID-19 cases reported weekly by WHO Region, and global deaths, as of 22 November 2020World Health Organization [Citation ends].
Key updates – what’s new
Epidemiology: updated data on children; updated risk factors (presence of comorbidities, cerebrovascular disease, blood group A)
Aetiology: new study from Wuhan indicates asymptomatic transmission is unlikely; updated data on incubation period in children.
Treatment algorithm: new NICE guidance on VTE prophylaxis recommends prophylactic low molecular weight heparin first-line.
Emerging: FDA issues emergency-use authorisation for casirivimab/imdevimab; WHO recommends against the use of remdesivir for the management of hospitalized patients; IDSA continues to recommend remdesivir, recommends against the routine use of bamlanivimab (except in patients at increased risk), and recommends against the routine use of tocilizumab and lopinavir/ritonavir; new data on ivermectin.
Prevention: new data on lifestyle modifications.
Complications: new NICE/SIGN/RCGP case definition of post-COVID syndrome; updated venous thromboembolism, cardiovascular complications, and paediatric inflammatory multisystem syndrome sections.
Prognosis: updated data on seroprevalence estimates.
Listen to our COVID-19 podcasts. The podcasts feature Best Practice editors talking about the latest developments in COVID-19 guidance.
BMJ talk medicine podcast: Covid-19 update external link opens in a new window
See our separate topic on the management of co-existing conditions in the context of COVID-19.
This topic is based on the best evidence currently available, but as this is a rapidly evolving situation, evidence is limited and some recommendations may be based on case reports, observational studies, and retrospective analyses, as well as randomised controlled trials and guidelines.
Original source of updateexternal link opens in a new window
Summary
Definition
History and exam
Other diagnostic factors
- fatigue
- myalgia or arthralgia
- sputum production/expectoration
- chest tightness
- gastrointestinal symptoms
- sore throat
- headache
- dizziness
- neurological symptoms
- ocular symptoms
- rhinorrhoea/nasal congestion
- chest pain
- cutaneous symptoms
- haemoptysis
- bronchial breath sounds
- tachypnoea
- tachycardia
- cyanosis
- crackles/rales on auscultation
Risk factors
- residence/work/travel in location with high risk of transmission
- contact with probable or confirmed case
- older age
- residence in a long-term care facility
- male sex
- ethnicity
- presence of comorbidities
- cardiovascular disease
- hypertension
- obesity
- diabetes
- chronic respiratory disease
- chronic kidney disease
- malignancy
- sickle cell disease
- solid organ transplant
- smoking
- cerebrovascular disease
- dementia
- chronic liver disease
- metabolic dysfunction-associated fatty liver disease
- surgery
- pregnancy
- immunosuppression
- autoimmune disease
- vitamin D deficiency
- air pollution
- climate and latitude
- residence in urban or deprived areas
- ACE inhibitor/angiotensin-II receptor antagonist use
- dyslipidaemia
- statin use
- proton-pump inhibitor use
- HIV infection
- thalassaemia
- Down's syndrome
- children with certain underlying conditions
- blood group A
- gut dysbiosis
Diagnostic investigations
1st investigations to order
- real-time reverse transcription polymerase chain reaction (RT-PCR)
- pulse oximetry
- ABG
- FBC
- comprehensive metabolic panel
- blood glucose level
- coagulation screen
- cardiac biomarkers
- serum C-reactive protein
- serum erythrocyte sedimentation rate
- serum lactate dehydrogenase
- serum interleukin-6 level
- serum procalcitonin
- serum ferritin level
- serum amyloid A level
- serum creatine kinase and myoglobin
- blood and sputum cultures
- chest x-ray
Emerging tests
- reverse transcription loop-mediated isothermal amplification (RT-LAMP)
- lung ultrasound
Treatment algorithm
Contributors
Expert advisers
Consultant and Honorary Senior Lecturer in Infectious Diseases
Royal Liverpool University Hospital and Liverpool School of Tropical Medicine
Liverpool
UK
Disclosures
NJB is partially supported by the National Institute of Health Research Health Protection Unit (NIHR HPRU) in Emerging and Zoonotic Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine. He is affiliated with Liverpool School of Tropical Medicine. The views expressed are those of the author and not necessarily those of the NHS, the NIHR, the Department of Health, or PHE.
Senior Clinical Lecturer and Defence Consultant in Infectious Diseases
Royal Liverpool University Hospital and Liverpool School of Tropical Medicine
Liverpool
UK
Disclosures
TEF is a consultant/expert panel member to the World Health Organization, and is funded by the UK Surgeon General, the NHS, and Liverpool School of Tropical Medicine. TEF is partially supported by the National Institute of Health Research Health Protection Unit (NIHR HPRU) in Emerging and Zoonotic Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine. He is affiliated with Liverpool School of Tropical Medicine. He has received research grants from the Wellcome Trust, Medical Research Council, and the UK Public Health Rapid Support Team (UK-PHRST). The views expressed are those of the author and not necessarily those of the NHS, the NIHR, the Department of Health, or PHE.
H. Barrie Fairley Professor of Critical Care
University Health Network and Interdepartmental Division of Critical Care Medicine
Director
Clinical Epidemiology and Health Care Research
Institute of Health Policy, Management and Evaluation
Dalla Lana School of Public Health
University of Toronto
Chief
Tory Trauma Program
Sunnybrook Hospital
Toronto
Canada
Disclosures
RF declares that he has no competing interests.
Peer reviewers
Professor
Division of Infectious Diseases and International Health
University of Virginia
Charlottesville
VA
Disclosures
WAP declares that he has no competing interests.
Attending Physician
The Fifth Medical Center of PLA General Hospital
Clinical Division and Research Center of Infectious Disease
Beijing
China
Disclosures
XZ declares that he has no competing interests.
Associate Professor in Medicine
Department of Clinical Microbiology and Infectious Diseases
Hadassah Hebrew University Medical Center
Jerusalem
Israel
Disclosures
RNP has received research grants from US-Israel Binational Science Foundation, Hebrew University, Rosetrees Trust, and SpeeDx. He is chair of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Mycoplasma and Chlamydia Infections (ESGMAC). RNP is a consultant for and has stocks in eDAS Healthcare. He is also chairperson of the Israeli Society for Infectious Diseases guidelines committee.
Editors
Section Editor (Infectious Diseases)/Drug Editor, BMJ Best Practice
Disclosures
AM declares that he has no competing interests.
Lead Section Editor, BMJ Best Practice
Disclosures
IC declares that she has no competing interests.
Comorbidities Editor, BMJ Best Practice
Disclosures
JC declares that she has no competing interests.
Expert advisers: comorbidities
Consultant, Older People's Medicine
Norfolk and Norwich University Hospitals
NHS Foundation Trust
Norwich
UK
Disclosures
MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018). MP has accepted sponsorship for travel expenses and accommodation costs from Astellas Pharma Ltd to attend the European Geriatric Society Meeting (Lisbon 2016).
Consultant Renal Physician
Honorary Associate Professor
Nephrology Department
Leeds Teaching Hospitals NHS Trust
Leeds
UK
Disclosures
AL is Associate Clinical Director of NIHR Leeds In-Vitro Diagnostics Co-operative, Co-Chair of UK Kidney Research Consortium Renal Clinical Study Group, Member of Kidney Research UK Research Grant Committee, Committee Member of NICE Kidney Injury Clinical Guideline Update 2018-20, Committee Member of NICE Diagnostic Assessment for Point of Care Creatinine Testing 2018-19. AL attended the Acute Dialysis Quality Initiative Meeting in San Diego 2018 (accommodation expenses); AL was a speaker at the AKI & CRRT Conference in San Diego 2019 (travel and accommodation expenses), the AKI Conference in Coventry 2019 (travel expenses), and the NIHR AKI and Sepsis Meeting in Leeds 2019 (no expenses).
Professor of Cardiology
Imperial College London (Royal Brompton Hospital)
London
UK
Disclosures
MC is a Non-Executive Director of NICE and Chair the Digital Health Committee of the European Society of Cardiology. MC’s university receives support for his research from Abbott, ResMed, Boston Scientific, and Medtronic. MC speaks at educational events and provides consultancy advice to a number of device, diagnostic, and pharmaceutical companies including Novartis, Servier, Bayer, Pfizer, AstraZeneca, Boehringer Ingelheim, Roche Diagnostics, Medtronic, Abbott, ResMed, and Boston Scientific. MC declares that none of these interests is directly related to topics advised on for this project.
Associate Professor (Clinical)
University of Leicester
Honorary Consultant Respiratory Physician
Glenfield Hospital
Leicester
UK
Disclosures
RAE has been reimbursed for a GSK Advisory Board meeting on Physical Activity and Asthma in November 2016, and three Chiesi Education meetings for GPs on COPD care in 2019. RAE received a travel award for ERS 2017 from Chiesi and participated in the GSK clinical experience programme - respiratory in August 2018. RAE participated in the BTS/SIGN guidelines for asthma update 2016 (no fee).
Consultant Physician and Head of Service
Diabetes and Endocrine Centre and the Diabetes Research Unit
Ipswich Hospitals NHS Trust
Ipswich
UK
Disclosures
GR has been paid for advisory board meetings with the following companies: Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Bayer. GR has received lecture fees from Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Novonordisk, Napp Pharmaceuticals Ltd.
Consultant Liaison Neuropsychiatrist
King’s College Hospital
South London and Maudsley NHS Foundation Trust
Honorary Senior Clinical Lecturer
Institute of Psychiatry, Psychology & Neuroscience
King’s College London
London
UK
Disclosures
SP declares that he has no competing interests.
BMJ Best Practice would like to gratefully acknowledge Dr Matthew Jones for his advice on a section of the stroke comorbidity content.
Matthew Jones, MD, FRCP
Consultant Neurologist
Greater Manchester Neurosciences Centre
Salford Royal Foundation Trust
Honorary Senior Lecturer
University of Manchester
Manchester
UK
Disclosures
AA and MJ declare that they have no competing interests.
Peer reviewers: comorbidities
Consultant, Older People's Medicine
Norfolk and Norwich University Hospitals
NHS Foundation Trust
Norwich
UK
Disclosures
MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018). MP has accepted sponsorship for travel expenses and accommodation costs from Astellas Pharma Ltd to attend the European Geriatric Society Meeting (Lisbon 2016).
Consultant Geriatrician
Liverpool University Hospitals NHS Foundation Trust
Visiting Professor
University of Cumbria
Carlisle
Honorary Clinical Associate Professor
University of Liverpool
Liverpool
UK
Disclosures
AA declares that he has no competing interests.
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