Last reviewed: 27 Sep 2020
Last updated: 23 Oct 2020
23 Oct 2020

Update on COVID-19 pandemic

Over 41.6 million cases have been reported globally, with over 28.3 million cases recovered so far, and approximately 1.1 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, Russia, Argentina, France, Spain, Colombia, and Peru.

Johns Hopkins University: coronavirus COVID-19 global cases external link opens in a new window

Key updates – what’s new

  • Epidemiology: updated data on infection in healthcare workers.

  • Etiology: new study on transmission during an indoor recreational hockey game.

  • History and exam: updated risk factors (ethnicity, cardiovascular disease, hypertension, malignancy, autoimmune disease, cerebrovascular disease, proton-pump inhibitor use, Down syndrome); updated diagnostic factor (neurologic symptoms).

  • Treatment algorithm: FDA officially approves remdesivir in hospitalized children ≥12 years of age and adults; interim results from WHO Solidarity trial find remdesivir appears to have little or no effect on 28-day mortality or in-hospital course among hospitalized patients.

  • Emerging: bamlanivimab trial put on hold for safety reasons; updated evidence for hydroxychloroquine, tocilizumab, and vitamin C.

  • Prevention: new Cochrane reviews on travel-related control measures including screening and quarantine; JNJ-78436735 vaccine trial paused due to adverse event.

  • Monitoring: new QCOVID clinical risk score.

  • Complications: updated neurologic complications and cytokine release syndrome. 

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 coexisting conditions in the context of COVID-19.  

BMJ Best Practice: Management of coexisting conditions in the context of COVID-19 external link opens in a new window

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 randomized controlled trials and guidelines.

See Epidemiology

Original source of updateexternal link opens in a new window

Summary

Definition

History and exam

Key diagnostic factors

  • fever
  • cough
  • dyspnea
  • altered sense of smell/taste

Other diagnostic factors

  • fatigue
  • myalgia or arthralgia
  • sputum production/expectoration
  • chest tightness
  • gastrointestinal symptoms
  • sore throat
  • headache
  • dizziness
  • neurologic symptoms
  • ocular symptoms
  • rhinorrhea/nasal congestion
  • chest pain
  • cutaneous symptoms
  • hemoptysis
  • bronchial breath sounds
  • tachypnea
  • 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
  • dyslipidemia
  • statin use
  • proton-pump inhibitor use
  • HIV infection
  • thalassemia
  • Down 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
  • CBC
  • 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
More 1st investigations to order

Investigations to consider

  • computed tomography (CT) chest
  • serology
  • antigen test
More investigations to consider

Emerging tests

  • reverse transcription loop-mediated isothermal amplification (RT-LAMP)
  • lung ultrasound
More emerging tests

Treatment algorithm

Contributors

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 reviewersVIEW ALL

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.

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