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SARS-CoV-2 Can Spread Rapidly in Homeless Shelters

HealthDay News — Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can spread rapidly in homeless shelters, according to two studies published in the April 22 early-release issue of the U.S. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report.

Farrell A. Tobolowsky, D.O., from the CDC in Atlanta, and colleagues offered testing for SARS-CoV-2 to residents and staff members at three homeless shelters during March 30 to April 1, 2020, after notification of a confirmed COVID-19 case at one of the shelters. The researchers found that 10.5 percent of the 181 persons tested were positive (15 residents and four staff members). Repeat testing was performed on April 7 to 8; additional cases were identified after residents and staff members sought health care. COVID-19 was diagnosed in 35 of 195 residents and eight of 38 staff members overall (18 and 21 percent, respectively).

Emily Mosites, Ph.D., from the CDC COVID-19 Emergency Response, and colleagues performed SARS-CoV-2 testing in five homeless shelters (one in Boston, one in San Francisco, three in Seattle) that had experienced clusters of COVID-19, in 12 shelters in Seattle where a single case in each had been identified, and in two shelters in Atlanta where no known cases had been reported. The researchers found that a high proportion of residents and staff members had positive test results after identification of a cluster (17 and 17 percent in Seattle; 36 and 30 percent in Boston; and 66 and 16 percent in San Francisco, respectively), while prevalence of infection was low in Seattle shelters (5 and 1 percent, respectively) and in Atlanta shelters (4 and 2 percent, respectively).

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“Testing all persons can facilitate isolation of those who are infected to minimize ongoing transmission in these settings,” Mosites and colleagues write.

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Abstract/Full Text – Tobolowsky

Abstract/Full Text – Mosites

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Healthcare Workers Struggle to Balance Commitment to Work With Safety of Family During COVID-19

A perspective article published in the New
England Journal of Medicine
described the current dilemma of many emergency
department employees: is my work care for patients with coronavirus disease
2019 (COVID-19) endangering my loved ones?

Dr Christian Rose, MD, a physician at an
emergency department in San Francisco, California, wrote about his
mother-in-law who was diagnosed with bronchiolitis obliterans, a chronic,
progressive and eventually fatal lung condition, in 2019. Though there is no
cure for the disease, and Dr Roses’ mother-in-law committed to the recommended physiotherapy
and breathing exercises in an effort to stymie disease progression. But Dr.
Rose’s work, should it bring COVID-19 home, may obviate her efforts and
endanger her life.  

The position of doctors during a pandemic is a challenging one. Because they comprise the core of outbreak response programs, healthcare workers are at a substantially elevated risk for developing COVID-19—and for spreading it. Work-related stress is believed to weaken immune response and increase the risk of developing infection in healthcare providers, who may then take the infection, with potentially higher viral loads, home to their close contacts. In the time of COVID-19, as has been the case with past outbreaks, many healthcare workers report stigma from the public and from family members.

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For his mother-in-law, despite her painstaking adherence to hand-hygiene recommendations, and respiratory droplet precautions, Dr Rose’s work may make her significantly more vulnerable. For this reason, after particularly high-risk exposures, healthcare practitioners may elect to stay with colleagues, or at hotels, simply to stay away from family members and decrease any potential risks. Dr Rose reports doing just this after treating a patient who required intubation for possible COVID-19.

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As the COVID-19 pandemic unfolds and the US
healthcare system struggles to adapt, so too do healthcare workers. Is it
irresponsible to remain in the house with high-risk family members, friends? “We
wonder whether our commitment to our community puts our families at risk,” Dr
Rose wrote. “[But if we] stop coming to work, the health care system will face
further stress, and patient outcomes will suffer.” As with other pandemic
response efforts, the answer may lie in one another: “[in] times like these…a
colleague’s spare bed may be the closest approximation of home that we can


Rose C. Am I part of the cure or am I part of the disease? Keeping coronavirus out when a doctor comes home [published online March 18, 2020]. N Engl J Med. doi:10.1056/NEJMp2004768

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Test Vaccine Elicits Strong Ab Response to SARS-CoV-2 in Mice

HealthDay News — Microneedle array (MNA) delivery of trimeric coronavirus spike (S) protein subunit vaccines seems promising for immunization against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, according to research published online April 2 in EBioMedicine.

Noting that coronavirus S protein is considered a key target for vaccines for prevention of coronavirus infection, Eun Kim, from the University of Pittsburgh School of Medicine, and colleagues report on the development of MNA-delivered Middle East Respiratory Syndrome (MERS) Coronavirus (MERS-CoV) vaccines and their preclinical immunogenicity. Codon-optimized MERS-S1 subunit vaccines fused with a foldon trimerization domain were generated to mimic the native viral structure. Immune stimulants were engineered into this trimeric design in variant constructs. By evaluating virus-specific immunoglobulin G antibodies in the serum of vaccinated mice and using virus neutralization assays, the preclinical immunogenicity of the MERS-CoV vaccine was comprehensively tested when delivered subcutaneously by traditional needle injection or intracutaneously by dissolving MNAs.

The researchers found that MERS-S1 subunit vaccines delivered by MNA elicited strong and long-lasting antigen-specific antibody responses. Clinically translatable MNA SARS-CoV-2 subunit vaccines were designed and produced within four weeks of identification of the SARS-CoV-2 S1 sequence. These MNA-delivered SARS-CoV-2 S1 subunit vaccines elicited potent antigen-specific antibody responses, which were seen starting two weeks after immunization.

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“Testing in patients would typically require at least a year and probably longer,” a coauthor said in a statement. “Recently announced revisions to the normal processes suggest we may be able to advance this faster.”

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Abstract/Full Text

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Cardiac Injury Linked to Increased Mortality in COVID-19

HealthDay News — Cardiac injury is associated with increased mortality in hospitalized patients with coronavirus disease 2019 (COVID-19), according to a study published online March 25 in JAMA Cardiology.

Shaobo Shi, M.D., from Renmin Hospital of Wuhan University in China, and colleagues explored the association between cardiac injury and mortality in a cohort study conducted from Jan. 20, 2020, to Feb. 10, 2020. The final analysis included 416 hospitalized patients with COVID-19.

The researchers found that common symptoms included fever, cough, and shortness of breath (80.3, 34.6, and 28.1 percent, respectively). Overall, 82 patients had cardiac injury; these patients were older, had more comorbidities, and had higher leukocyte counts than patients without cardiac injury. They also had a higher proportion of multiple mottling and ground-glass opacity in radiographic findings (64.6 versus 4.5 percent). Compared with those without cardiac injury, a greater proportion of those with cardiac injury required noninvasive mechanical ventilation (3.9 versus 46.3 percent) or invasive mechanical ventilation (4.2 versus 22 percent). Patients with cardiac injury more often had complications and had higher mortality compared with those without cardiac injury (51.2 versus 4.5 percent). The risk for death was increased among patients with versus without cardiac injury during the time from symptom onset and from admission to end point (hazard ratios, 4.26 and 3.41, respectively).

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“Although the exact mechanism of cardiac injury needs to be further explored, the findings presented here highlight the need to consider this complication in COVID-19 management,” the authors write.

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Abstract/Full Text

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Common Features on Chest CT May Aid Diagnosis of COVID-19

HealthDay News — Chest computed tomography (CT) has a low rate of misdiagnosis of novel coronavirus (COVID-19), according to a study published online March 4 in the American Journal of Roentgenology.

Yan Li, Ph.D., and Liming Xia, M.D., both from the Huazhong University of Science and Technology in Wuhan, China, reviewed clinical information, CT images, and corresponding image reports from the first 51 patients with a diagnosis of COVID-19 infection confirmed by nucleic acid testing (23 women and 28 men; age range, 26 to 83 years) and two patients with adenovirus (one woman and one man; ages 58 and 66 years).

The researchers report that COVID-19 was misdiagnosed as a common infection in the initial CT study in two inpatients with underlying disease and COVID-19. At the initial CT study, viral pneumonia was correctly diagnosed in the remaining 49 patients with COVID-19 and two patients with adenovirus. Common CT features of COVID-19 included ground-glass opacities and consolidation with or without vascular enlargement, interlobular septal thickening, and air bronchogram sign. Uncommon CT features included the “reversed halo” sign and pulmonary nodules with a halo sign. The investigators noted overlap between the CT findings of COVID-19 and the CT findings of adenovirus infection.

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“We found that chest CT had a low rate of missed diagnosis of COVID-19 (3.9 percent; two of 51) and may be useful as a standard method for the rapid diagnosis of COVID-19 to optimize the management of patients,” the authors write.

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Abstract/Full Text

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Combating COVID-19: Best Practices That Clinicians Need to Know

As the number of
global cases of coronavirus disease 2019 (COVID-19) rises, it is imperative
that healthcare providers stay informed and prepared with the best clinical
practices to combat the SARS-CoV-2 virus. Following appropriate guidelines and
practicing proper technique will benefit both patients and clinicians and
better prevent the further spread of the virus.

It has been established that the virus mostly spreads from person to person via close contact or respiratory droplets. The Centers for Disease Control and Prevention (CDC) defines close contact with a patient with COVID-19 as being within 6 feet for an extended period of time or having direct contact with the patient’s bodily fluids (ie, sputum, blood, respiratory droplets).1 When treating patients in such close proximity, it is especially important to use personal protective equipment (PPE), which can help to reduce the risk of acquiring the virus.

PPE and Isolation Precautions

In a podcast interview,
Betsey Todd, MPH, RN, a nurse epidemiologist and clinical editor of American Journal of Nursing, noted the
importance of proper PPE and how it varies depending on the 4 categories of
isolation precautions: standard, contact, droplet, and airborne precautions.2

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Unlike standard precaution, contact, droplet, and airborne precautions are all types of transmission precautions that Ms Todd notes may be used in combination. While contact precautions include the use of gloves and gowns to treat conditions such as methicillin-resistant Staphylococcus aureus, other conditions such as influenza infections or tuberculosis may require more PPE, such as a face mask or shield (droplet precautions) or an N95 respirator and negative pressure rooms (airborne precautions), respectively.2

When discussing the treatment of patients with suspected or
confirmed COVID-19, Ms Todd noted that there is relative certainty that the
virus spreads by droplets, which might suggest the need for a mask and face
cover. However, she notes that because the virus is still so new, “the CDC
recommends for patients that are suspected of having or have confirmed COVID-19,
that [health care providers] go ahead and use, not droplet, but airborne
precautions, and place the patient in a negative pressure room if available.”

Ms Todd went on to note that “regular surgical-type masks are made for containing droplets from [a clinician’s] own mouth…whereas N95 respirators or other kinds of particulate respirators are made to protect what [clinicians are] breathing in.” Therefore, she suggests the use of airborne precaution technique.

Proper PPE would not be as effective if not worn correctly. When
wearing a mask, make sure to fit-test by taking a moment to make sure that the
mask fits appropriately. Take a few deep breaths to ensure there is no leakage
around or near the mask.2

When asked who should be wearing the N95 masks, Ms Todd replied, “the CDC and World Health Organization are really trying to strongly push back against the idea that everybody should go around wearing any kind of mask… . People think that it will protect them out in public, but the fact is that N95s are not appropriate for wearing long periods of time.”

The World Health Organization noted earlier this month in a news release that the “shortages [in PPE] are leaving doctors, nurses, and other frontline workers dangerously ill-equipped to care for COVID-19 patients, due to limited access to supplies such as gloves, medical masks, respirators, goggles, face shields, gowns, and aprons.”3

Practices for Healthcare
Providers and Patients

Amy Fuller, DNP, director of the Master’s Nurse Program at Endicott College in Beverly, Massachusetts, described steps nurse practitioners (NPs) and physician assistants (PAs) can take to ensure the best prevention and treatment techniques.

Because the 2019 coronavirus outbreak has overlapped with the
current influenza season, Dr Fuller noted that “it’s hard to differentiate
because they both have the same kind of symptoms. But the incidence and
prevalence for the flu is so much greater than for the coronavirus.” For
nurses, NPs, and PAs, she noted that it should be “common sense” that if a
patient is “coughing or sneezing, put a mask on.”

She continued by noting that both healthcare providers and patients should be “realistic” and that the SARS-CoV-2 virus will “be here with more of a presence than it is currently.” Healthcare providers should inform their patients to “avoid crowded places” and “avoid close contact with people who are sick,” in addition to avoiding cruise travel and nonessential air travel and staying at home as much as possible to further reduce the risk of exposure.4

recommendation was for healthcare providers to be mindful of the patients who
present to their practices and make sure to triage them immediately. It is
important to be mindful of their symptomology, their contact with others, and
their travel history.

Both clinicians and patients should avoid touching their face, nose, and eyes; be sure to wash their hands often with soap and water (for at least 20 seconds) or with at least 60% alcohol-containing hand sanitizer if soap and water are not available; and to clean and disinfect common surface areas in the home.4

When asked
whether a patient should be self-quarantined or seen in a medical practice, Dr
Fuller noted that it depends on the case. “I would certainly recommend
self-quarantine if they have the risk factors…if [patient] symptoms are mild,
and most cases are mild, [the patients] don’t require any kind of

If a patient
presents with symptoms, “the caveat could be that the nurse, NP, or PA can
check on the patient in 12 hours and see how they are doing or instruct them to
call back if their symptoms get worse. But if they just have cold-like symptoms
with no fever, I’m not entirely invested in sending them to the hospital.”

There is
currently no vaccine or antiviral to treat this infection. Current treatments
may include fever-reducing medications but “the last thing we want to do is
have a big rush of people to the hospital who only have mild, cold-like

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Risks and Symptoms to Look
Out For

According to the CDC, it is important for healthcare providers to pay attention to symptoms such as fever, cough, and shortness of breath.4 While human coronaviruses can cause disease similar to a common cold, more severe cases can cause pneumonia, severe acute respiratory syndrome, and even death.5 Individuals with a higher risk for COVID-19 include older adults and those with chronic medical conditions such as heart disease, diabetes, and lung disease. Emergency warning signs that require immediate medical attention include difficulty breathing or shortness of breath, persistent pain or pressure in the chest, new confusion or inability to arouse, and/or bluish lips or face. Although these are not all inclusive, the CDC urges adults with these symptoms to contact their medical providers. 


Healthcare providers are at the forefront, caring for infected
patients and increasing their own risk of exposure to the virus. The
information surrounding COVID-19 is constantly being updated as we learn more
about the virus, the illnesses it causes, and who is at risk.

It is imperative that clinicians continue to read new information and stay updated, practice recommended hygiene, wear the appropriate PPE, and make sure that their patients are educated. Following the appropriate steps will help to reduce the spread of the virus and hopefully prevent further exposure in uninfected individuals.


  1. What healthcare personnel should know about caring for patients with confirmed or possible COVID-19 infection. Centers for Disease Control and Prevention.  Updated February 29, 2020.
  2. Bonsall L, Todd B. COVID-19: what nurses need to know about personal protective equipment (PPE). Lippincott Nurs Cent. March 6, 2020. Accessed March 10, 2020.
  3. Shortage of personal protective equipment endangering health workers worldwide. World Health Organization. March 3, 2020. Accessed March 11, 2020.
  4. People at risk for serious illness from COVID-19.Centers for Disease Control and Prevention. Updated March 9, 2020. Accessed March 11, 2020.
  5. Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health. World Health Organization. Accessed March 11, 2020.

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10 Myths About COVID-19

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As infections with severe acute
respiratory distress syndrome coronavirus 2 (SARS-CoV-2) continue to increase,
there has been a concurrent increase in news and data, both accurate and
inaccurate. Therefore, we have undertaken a review of a considerable amount of
this information, and attempted to clarify some of the most recurrent misconceptions. 

For example, “coronavirus” is not the appropriate identifier for the cause of the current infection causing epidemics in >40 countries. Coronavirus is the name of a family of viruses, which cause infections in humans and animals.1,2 The current outbreak is caused by a strain of coronavirus that has been named SARS-Cov-2; the constellation of respiratory symptoms caused by this virus is called Coronavirus Disease 2019 (COVID-19).3

1. COVID-19 is a pandemic.

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Although the World Health Organization (WHO) has avoided deeming the virus a pandemic, WHO director-general Tedros Adhanom Ghebreyesus said, “This virus has pandemic potential. This is not a time for fear. This is a time for taking action to prevent infection and save lives now.” A pandemic is described as an epidemic that has progressed to a global scale. The term epidemic is applied for the case of an infection that spreads more rapidly than expected, over a large geographic area.5

2. You can get COVID-19 from products shipped from China.

The United States Centers for Disease Control and Prevention has not found any evidence to suggest that animals or animal products imported from China pose a risk for spreading COVID-19 in the United States.6 While it may be possible that a person can get COVID-19 by touching a surface or object that has the viral particles on it and then touching their own mouth, nose, or eyes, there has been no evidence to support this as the main way the virus spreads. In fact, one study reported that while the virus may live on surfaces for up to 9 days, “Data on the transmissibility of coronaviruses from contaminated surfaces to hands were not found. However, it could be shown with influenza A virus that a contact of 5 [seconds] can transfer 31.6% of the viral load to the hands.”7

3. Any cough-based illness is COVID-19.

It is important to remember that in the
United States, it is still flu season, and although it may be wrapping up, it
can last through May.8 Further, there are several families of
viruses that cause respiratory symptoms; these viruses (eg, rhinoviruses,
adenoviruses, respiratory syncytial virus, human parainfluenza viruses)
are the cause of the common cold, and circulate year-round.9,10 

When is a cough concerning? If you feel sick with cough, fever and difficulty breathing, and have been in close contact with a person known to have COVID-19, or if you live in or have recently traveled from an area with ongoing spread of COVID-19.6

4. Community spread means anyone, anywhere can get the infection at any time.

The term community spread is used to describe a situation wherein the exact source of an infection cannot be identified.11 This commonly occurs in the setting of an epidemic: once the cases of an infection reach a certain point, a person may become infected without typical risk factors such as travel to an endemic area, or a person has close-contact with a sick person. In this situation, one may not know when or where they encountered an infected individual. This person may also not yet know they are ill, as they may still be in an incubation or asymptomatic stage of the illness. However, contact is still a requisite for transmission, knowingly or unknowingly. Community spread of infections can be ameliorated through the practice of hand hygiene, and staying home when you feel unwell.6,12 

5. Everyone who gets infected with SARS-CoV-2 will die or conversely, only elderly, sick people will die. 

Although the majority of cases that result in death are among the elderly, and individuals with chronic health conditions, COVID-19 has affected mostly all age groups, as well as people with no underlying diseases. There have been no deaths reported among children aged <9 years, who represent only 1% of all cases of infection.13 Individuals aged 10 to 19 years demonstrate a similar incidence, and those aged 20 to 29 years account for roughly 8% of cases.14 People aged 30 to 79 years, however, account for 87% of cases.13

The fatality rate for COVID-19 is also skewed toward the elderly: people aged 70 to 79 years have a fatality rate of 8%, compared with 14.8% among those aged >80 years.13 People with any underlying comorbidity have a higher fatality rate.14 In addition, reports indicate more people of the male sex have been infected; they have also more often presented with more severe infection, and have had higher death rates.14 

6. COVID-19 is more transmissible/deadlier than the flu.

This is tricky. Such statements can seem
true if one is only looking at certain pieces of data; but data needs context.
For example, the case fatality rate is frequently reported as being higher than
that of the flu; however, it has already been demonstrated that fatality rates
vary substantially across patient populations. Moreover, comparing a rate of
one infection to another when the factors that influence that rate (number of individuals
infected and number of fatalities) are so significantly different is
cumbersome. Seasonal influenza has a fatality rate of <1%,15
compared with the roughly 2% fatality rate currently reported for SARS-CoV-2.
However, any subgroup analyses (eg, individuals who have died) of the roughly 35
million annual cases of the flu will, more often than not, mathematically find
a smaller number compared with an analysis of the roughly 114,000 cases of

However, current data on the transmissibility of SARS-CoV-2 are more reliable in that calculations definitively take into account more variables.17 These data demonstrate that this infection is slightly more transmissible than the flu; preventive measures, however, are the same. For this reason, all major health organizations, government officials, and even mass transit systems stress the importance of washing your hands frequently, coughing/sneezing into the crook of your elbow, and staying home when ill.6,12

7. Facial masks will keep you from getting sick.

The use of facial masks as a preventive measure for COVID-19 is not presently recommended for the general public.18 Healthcare workers who have direct contact with known cases of SARS-CoV-2 are recommended to use an N95 respirator mask, in conjunction with appropriate gowning and gloving techniques, and only in the hospital/clinic setting.18,19 The N95 filtering facepiece respirator functions by removing particles from the air as the individual breathes through the mask.19 Unlike these, other facemasks are only effective at preventing one from inhaling large respiratory droplets. The use of a non-N95 facemask is effective in preventing a person who is feeling unwell, or has a cough/sneeze-based illness from spreading an ongoing infection.

8. You should not travel internationally, at all.

The CDC issues travel recommendations for several infectious diseases, including COVID-19.20 A Warning Level 3 indicates avoidance of all nonessential travel to a given location. An Alert Level 2 advises that people with chronic medical conditions and older adults should avoid travel to such locations. Watch Level 1 means that the CDC does not recommend cancelling travel to such places. Due to the circulation and air filtration system on airplanes, the risk for infection transmission is low; the CDC does, however, recommend conscientious hand hygiene in this case.

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Cruise ships put large numbers of people, potentially from a number of countries around the world, in frequent and close contact with each other; therefore the CDC strongly recommends frequent hand washing and avoidance of touching your face, and staying in your cabin and notifying the onboard medical center immediately if you feel unwell. 

9. Flu or pneumonia vaccines will also help prevent COVID.

There are insufficient data to support the advocacy of the influenza or pneumococcal vaccines to prevent COVID-19.21 While these 2 illnesses have similar symptomology to COVID-19, the vaccines are formulated to be active specifically against the influenza virus and streptococcal bacteria, neither of which contribute to COVID-19. However, it is highly recommended that everyone who is indicated to receive either vaccine does so because it may aid in simplifying the evaluation of potential SARS-CoV-2 infections.21,22 

10. Heat will kill the virus.

Although a few high-ranking government
officials have alluded to the possibility that high temperatures will kill the
virus, there is not presently enough evidence to state this with scientific
certainty. While the rate of most viral infections decreases during the summer
months as a result of higher temperatures and humidity, there are 2 important
caveats: people are less likely to be in close quarters with each other for
lengthy periods, and although countries in the northern hemisphere are entering
warmer months, the opposite is true for countries in the  southern hemisphere.23 Further,
previous experience with and research on the other Coronavirus epidemics (SARS and
MERS) demonstrated that this family of viruses may have little problem
surviving in warmer climates.23


  1. Peiris JSM. Coronaviruses. In: Greenwood D, Barer M, Slack R, Irving W, eds. Medical Microbiology: A Guide to Microbial Infections. 18th ed. Elsevier; 2012:587-593.
  2. Fehr AR, Perlman S. Coronaviruses: an overview of their replication and pathogenesis. Methods Mol Biol. 2015;1282:1-23.
  3. The World Health Organization. Naming the coronavirus disease (COVID-19) and the virus that causes it. Updated February 11, 2020. Acessed March 6, 2020.
  4. Nebehay S, Shields M. “Fatal mistake” for countries to assume they won’t get coronavirus -WHO chief. Reuters. Published February 27, 2020. Accessed March 6, 2020.
  5. Grennan D. What is a pandemic? [published online March 5, 2019]. JAMA. doi:10.1001/jama.2019.0700
  6. Centers for Disease Control and Prevention. How COVID-19 spreads. Updated March 4, 2020. Accessed March 6, 2020.
  7. Kampf G, Todt D, Pfaender S, Steinmann E. Persistance of coronaviruses on inanimate surfaces and their inactivation with biocidal agents [published online February 6, 2020]. J Hosp Infect. doi:10.1016/j.jhin.2020.01.022
  8. Centers for Disease Control and Prevention. The flu season. Updated July 12, 2018. Accessed March 6, 2020.
  9. National Institutes of Health. Understanding a common cold virus. Updated April 13, 2019. Accessed March 6, 2020.
  10.  Centers for Disease Control and Prevention. Common colds: protect yourself and others. Updated February 11, 2019. Accessed March 6, 2020.
  11. Centers for Disease Control and Prevention. CDC confirms possible instance of community spread of COVID-19 in U.S. Updated February 26, 2020. Accessed March 6, 2020.
  12. Canadian Centre for Occupational Health and Safety. Good hygiene practices-reducing the spread of infections and viruses. Updated March 6, 2020. Accessed March 6, 2020.
  13. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China [published online February 24, 2020]. JAMA. doi:10.1001/jama.2020.2648
  14. Guan W, Ni Z, Hu Y, et al. Clinical chartacteristics of coronavirus disease 2019 in China [published online February 28, 2020].  N Engl J Med. doi:10.1056/NEJMoa2002032
  15.  Centers for Disease Control and Prevention. Disease burden of influenza. Updated January 10, 2020. Accessed March 6, 2020.
  16. Johns Hopkins. Coronavirus COVID-19 global cases. Updated March 6, 2020. Accessed March 6, 2020.
  17. Swerdlow DL, Finelli L. Preparation for possible sustained transmission of 2019 Novel Coronavirus: lessons from previous epidemics [published online February 11, 2020]. JAMA. doi:10.1001/jama.2020.1960
  18. The World Health Organization. Coronavirus disease (COVID-19) advice for the public: when and how to use masks. Updated March 6, 2020. Accessed March 6, 2020.
  19. Centers for Disease Control and Prevention. Frequently asked questions about personal protective equiptment. Updated February 29, 2020. Accessed March 6, 2020.
  20. Centers for Disease Control and Prevention. Travel: frequently asked questions and answers. Updated March 3, 2020. Accessed March 6, 2020.
  21. Yale Medicine. COVID-19 (Coronavirus Disease 2019). Accessed March 6, 2020.
  22. University of Chicago Medicine. COVID-19: what we know so far about the 2019 novel coronavirus. Published on February 13, 2020. Accessed March 6, 2020.
  23. Le Page M. Will heat kill the coronavirus?. New Scientist. 2020;245(3270):6-7.

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