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The devastating damage that the novel coronavirus inflicts on the human body can set off inflammatory havoc. As we learn more, doctors are gaining clues to hopefully prevent deaths and improve treatment.
Last December, COVID-19 entered the world stage as a flu-like illness causing fever, dry cough and a sore throat.
Since then, the list of how the illness can present has expanded, and expanded again, to include gastrointestinal symptoms like diarrhea, general aches, loss of taste and smell and serious blood-clotting problems, among others.
Of the more than five million infections globally so far, 2.4 million have recovered.
Most infected people have so few symptoms they are better off at home. The minority of serious infections in patients — mainly those over 65, though no age group is left unscathed — can confound health professionals caring for them.
The illness can worsen to a severe stage called Acute Respiratory Distress Syndrome, which includes severe lung inflammation and damage. These are often the patients who are admitted to intensive care units and need life support such as ventilation.
Dr. Lynora Saxinger, an infectious disease physician at the University of Alberta, co-chairs a provincial scientific advisory board reviewing how COVID-19 manifests and what it means for reducing transmission and extending treatment beyond current care measures.
“The landscape shifts really quickly,” Saxinger said. “We just want to make sure that we’re not missing [what] could be spreading, because that’s where we’re going to run into trouble.”
Not typical clots
As initial anecdotes about inflammatory-like effects such as blood-clotting complications mounted into a clearer signal for caution, clinicians adapted their care while scientists worked to understand why it happens.
Now, Saxinger said there’s more evidence of clotting damage in both large and small blood vessels. “This virus is doing different things in the body.”
A better understanding of how COVID-19 manifests could inform efforts to reduce its transmission. (Lee Jin-man/Associated Press)
Experts say some of these inflammatory effects look to be unique to this particular coronavirus, which is known as SARS CoV-2.
Dr. Zain Chagla, an associate professor of infectious disease at McMaster University in Hamilton, Ont., said the wide extent of clotting with this virus differs from other infections, including from the deadly SARS and MERS coronaviruses. With COVID-19, the clots occur in veins in the legs and lungs, as well as in arterial ones that cause strokes and can lead surgeons to resort to amputating a patient’s limbs.
Medical researchers have also found tiny clots that damaged tissue throughout the body in hospitalized patients and in autopsies.
Chagla said this means that “from a therapeutic standpoint,” it might be better to give patients a low dose of heparin, an anticoagulant or blood thinner. It’s often used before surgery and in a variety of medical conditions to prevent and treat clots.
Clinical trial researchers are also exploring the use of high-dose anti-coagulants in carefully selected patients, Chagla said.
This week, Health Minister Patty Hajdu announced an accelerated path for clinical trials to help find answers to urgent COVID-19 diagnosis, treatment, mitigation or prevention questions while keeping patients safe.
On Friday, Montserrat Puig of the U.S. Food and Drug Administration and her team published what they called a road map for effective treatment of COVID-19, based on both repurposing existing approved drugs as well as those still under development.
The review, published in Frontiers in Immunology, unravels factors leading to the “cytokine storm” that can rampage in people with severe COVID-19. Cytokines are small molecules released by the body’s immune system to co-ordinate response against an infection or injury, ranging from a mild fever to suspected deaths in the 1918 flu pandemic.
Heparin, an anticoagulant or blood thinner, is used for a variety of conditions, including, at low doses, COVID-19. ( Jeffrey Sauger/Bloomberg/Getty)
Scientists are still working to understand the key events in cells, tissues and the body’s immune system that tips the balance from a normal, protective, “hey, come help” call for reinforcements to an unnecessary, four-alarm call that leads to a life-threatening overreaction.
Puig wrote that potential drugs include those that could block the virus from entering our cells in the first place, antivirals to stop the virus from making copies of itself and therapies called monoclonal antibodies that dampen the haywire response from cytokines.
Inflammatory storm unleashed
People who develop symptoms of COVID-19 do so within 14 days, and it mostly occurs about five days after exposure.
The anticipated subsequent waves of the pandemic mean COVID-19 won’t be one-and-done, said Dr. Lynora Saxinger. (Martin Weaver/CBC)
Saxinger said when patients struggle with congested lungs and poor blood pressure control, it’s often a manifestation of lung inflammation in response to the infection.
She said there’s also an arc to the story of how the disease marches through the body from initial infection to damage to recovery or death.
“The initial infection triggers this body-wide response that is devastating,” Saxinger said. “Then, when the infection itself might be coming under control, it’s almost like you unleash this storm of immune reactivity and inflammation.”
Once the storm is set off, doctors say treating the infection itself is unlikely to help much.
So, what could help? As physicians report more symptoms, scientists working in parallel are exploring why and how the virus replicates in some tissues and organs so well.
Matthew Miller, an associate professor of infectious disease and immunology at McMaster, is following the scientific advances.
The virus seems to use a receptor called ACE2 to enter human cells. Miller said many groups of researchers are working to understand what cells in our body have active proteins where the virus might be able to replicate and cause disease.
“Knowing what cells a virus is capable of infecting is really important, because it can help us anticipate what types of diseases or what types of symptoms it might cause,” Miller said.
It’s thought that the infectious dose a person is exposed to, as well as minute, genetic differences in the individual and whether they have underlying health conditions (like heart disease or diabetes) all play a role in how COVID-19 manifests.
Understand virus to guide reopening
For now, medical researchers are exploring how ramping up a beneficial aspect of the immune response that cells normally use to kill off a virus could be complemented with “immune modulators” to tamp down overreactions. It’s a delicate balance and timing is key.
Miller said as we learn more about the unique features of SARS-CoV-2, governments and public health officials have been forced to “learn on the fly” and adapt pandemic plans built for a different respiratory infection: influenza, commonly called flu.
“One of the areas that this pandemic has really brought to light is that there’s not enough focus on prevention control measures,” he said.
Countries imposed and eased lockdowns without a firm grasp on what measures work best for this particular virus, leading to differences across the globe and shifting recommendations on wearing masks or physical distancing.
“I think we’re all learning that we don’t understand nearly as well as we should,” Miller said.
WATCH | Why we should expect waves of COVID-19:
What mathematical simulations tell us about how the COVID-19 pandemic will play in the real world. 5:04
Public health basics like staying home when sick, handwashing and cough etiquette apply to all respiratory pathogens. It’s the specifics that are still a work in progress.
For Saxinger, these knowledge gaps mean that understanding COVID-19 will be a long-term effort.
“It’s not just going to be a one, we’re done,” Saxinger said. “We are all going to have to figure out the best way to manage people and try to give them the best outcomes possible.”
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The Canadian government says it will donate up to 200,000 vaccine doses to fight the mpox outbreak in Congo and other African countries.
It says the donated doses of Imvamune will come from Canada’s existing supply and will not affect the country’s preparedness for mpox cases in this country.
Minister of Health Mark Holland says the donation “will help to protect those in the most affected regions of Africa and will help prevent further spread of the virus.”
Dr. Madhukar Pai, Canada research chair in epidemiology and global health, says although the donation is welcome, it is a very small portion of the estimated 10 million vaccine doses needed to control the outbreak.
Vaccine donations from wealthier countries have only recently started arriving in Africa, almost a month after the World Health Organization declared the mpox outbreak a public health emergency of international concern.
A few days after the declaration in August, Global Affairs Canada announced a contribution of $1 million for mpox surveillance, diagnostic tools, research and community awareness in Africa.
On Thursday, the Africa Centres for Disease Control and Prevention said mpox is still on the rise and that testing rates are “insufficient” across the continent.
Jason Kindrachuk, Canada research chair in emerging viruses at the University of Manitoba, said donating vaccines, in addition to supporting surveillance and diagnostic tests, is “massively important.”
But Kindrachuk, who has worked on the ground in Congo during the epidemic, also said that the international response to the mpox outbreak is “better late than never (but) better never late.”
“It would have been fantastic for us globally to not be in this position by having provided doses a much, much longer time prior than when we are,” he said, noting that the outbreak of clade I mpox in Congo started in early 2023.
Clade II mpox, endemic in regions of West Africa, came to the world’s attention even earlier — in 2022 — as that strain of virus spread to other countries, including Canada.
Two doses are recommended for mpox vaccination, so the donation may only benefit 100,000 people, Pai said.
Pai questioned whether Canada is contributing enough, as the federal government hasn’t said what percentage of its mpox vaccine stockpile it is donating.
“Small donations are simply not going to help end this crisis. We need to show greater solidarity and support,” he said in an email.
“That is the biggest lesson from the COVID-19 pandemic — our collective safety is tied with that of other nations.”
This report by The Canadian Press was first published Sept. 13, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
HALIFAX – The Nova Scotia government says it could be months before it reveals how many people are on the wait-list for a family doctor.
The head of the province’s health authority told reporters Wednesday that the government won’t release updated data until the 160,000 people who were on the wait-list in June are contacted to verify whether they still need primary care.
Karen Oldfield said Nova Scotia Health is working on validating the primary care wait-list data before posting new numbers, and that work may take a matter of months. The most recent public wait-list figures are from June 1, when 160,234 people, or about 16 per cent of the population, were on it.
“It’s going to take time to make 160,000 calls,” Oldfield said. “We are not talking weeks, we are talking months.”
The interim CEO and president of Nova Scotia Health said people on the list are being asked where they live, whether they still need a family doctor, and to give an update on their health.
A spokesperson with the province’s Health Department says the government and its health authority are “working hard” to turn the wait-list registry into a useful tool, adding that the data will be shared once it is validated.
Nova Scotia’s NDP are calling on Premier Tim Houston to immediately release statistics on how many people are looking for a family doctor. On Tuesday, the NDP introduced a bill that would require the health minister to make the number public every month.
“It is unacceptable for the list to be more than three months out of date,” NDP Leader Claudia Chender said Tuesday.
Chender said releasing this data regularly is vital so Nova Scotians can track the government’s progress on its main 2021 campaign promise: fixing health care.
The number of people in need of a family doctor has more than doubled between the 2021 summer election campaign and June 2024. Since September 2021 about 300 doctors have been added to the provincial health system, the Health Department said.
“We’ll know if Tim Houston is keeping his 2021 election promise to fix health care when Nova Scotians are attached to primary care,” Chender said.
This report by The Canadian Press was first published Sept. 11, 2024.
ST. JOHN’S, N.L. – Newfoundland and Labrador‘s chief medical officer is monitoring the rise of whooping cough infections across the province as cases of the highly contagious disease continue to grow across Canada.
Dr. Janice Fitzgerald says that so far this year, the province has recorded 230 confirmed cases of the vaccine-preventable respiratory tract infection, also known as pertussis.
Late last month, Quebec reported more than 11,000 cases during the same time period, while Ontario counted 470 cases, well above the five-year average of 98. In Quebec, the majority of patients are between the ages of 10 and 14.
Meanwhile, New Brunswick has declared a whooping cough outbreak across the province. A total of 141 cases were reported by last month, exceeding the five-year average of 34.
The disease can lead to severe complications among vulnerable populations including infants, who are at the highest risk of suffering from complications like pneumonia and seizures. Symptoms may start with a runny nose, mild fever and cough, then progress to severe coughing accompanied by a distinctive “whooping” sound during inhalation.
“The public, especially pregnant people and those in close contact with infants, are encouraged to be aware of symptoms related to pertussis and to ensure vaccinations are up to date,” Newfoundland and Labrador’s Health Department said in a statement.
Whooping cough can be treated with antibiotics, but vaccination is the most effective way to control the spread of the disease. As a result, the province has expanded immunization efforts this school year. While booster doses are already offered in Grade 9, the vaccine is now being offered to Grade 8 students as well.
Public health officials say whooping cough is a cyclical disease that increases every two to five or six years.
Meanwhile, New Brunswick’s acting chief medical officer of health expects the current case count to get worse before tapering off.
A rise in whooping cough cases has also been reported in the United States and elsewhere. The Pan American Health Organization issued an alert in July encouraging countries to ramp up their surveillance and vaccination coverage.
This report by The Canadian Press was first published Sept. 10, 2024.
