Ontario's top doctor warns of reports COVID-19 causes prolonged issues for young people

TORONTO -- Ontario’s top doctor is warning young people who may be getting casual about protecting themselves from COVID-19 that he’s getting reports of patients returning with prolonged health issues.

Dr. David Williams said Thursday that Ontario is seeing a spike in cases among the 20 to 39 age group, who he believes may be less stringent about public health measures.

The 20 to 39 age category accounts for 9,758 cases of COVID-19 in the province, which is the second highest behind the 40 to 59 age group.
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Williams said he has received anecdotal reports from physicians and medical groups in Ontario that patients in the 20-39 age group, who only had mild COVID-19 symptoms, are returning to the doctor after recovering with prolonged "effects and issues."

"I wouldn’t be too casual about not caring about getting infected because it's a new disease and we still have a lot to learn," Williams said. "We're starting to see some cases where people who had a relatively insignificant case of COVID-19 later on are having some effects and issues.”

Williams said it's not known how many young patients are complaining of prolonged symptoms.

"Just because you may be young and think the kind of condition is just going to be like a flu like illness for a few days, a bit of shortness of breath … You don’t know what the longer term aspects are,” he added. "I'm not saying I know something will definitely happen, (but) I've heard some anecdotal reports."

In Ontario, there have been 11 people between the ages of 20 and 39 who have died with COVID-19. Earlier this week, the province reported its first fatality in a person under the age of 19 with COVID-19, but said the coroner was investigating whether the disease was the cause of death.

"Prevention is still important," Williams said. "Being casual and frivolous on this is not a good thing to do."

"Wait until we have all the science."

In the face of increasingly widespread fears of a COVID-19 pandemic, what concrete steps can a person take right now to prevent the infection? Read our practical guide based on official sources.
In this Special Feature, we explain how to maximize the chances of staying healthy during the COVID-19 outbreak.

All data and statistics are based on publicly available data at the time of publication. Some information may be out of date. Visit our coronavirus hub and follow our live updates page for the most recent information on the COVID-19 pandemic.

To date, public health officials have reported tens of thousands of cases of COVID-19, the respiratory disease caused by the new coronavirus, SARS-CoV-2.

This situation has caused many people around the world to feel anxious about becoming infected, and social media outlets and public forums abound with questions about how to keep COVID-19 at bay.

This Special Feature is a practical guide that describes the best ways to avoid a respiratory infection at home, at work, at school, and while traveling.

The recommendations that we outline are based on those of official sources, including the World Health Organization (WHO), the Centers for Disease Control and Protection (CDC), and the American Red Cross, as well as our correspondence with a WHO spokesperson.
How to stay safe where you live

“Based on the information received so far, and on our experience with other coronaviruses, COVID-19 appears to spread mostly through respiratory droplets (when a sick person coughs, for example) and close contact,” a WHO spokesperson told Medical News Today.

In light of that information, the spokesperson said, the WHO recommend preventive actions to minimize exposure to droplets.

During day-to-day activities, people can take the following measures to prevent infection, in accordance with WHO guidelines:

Clean the hands regularly with an alcohol-based sanitizer, or wash them with soap and water. The CDC also make this recommendation, advising that sanitizer should contain “at least 60% alcohol” and that people should wash their hands for at least 20 seconds.
Clean surfaces — such as kitchen seats and work desks — regularly with disinfectant.
Avoid crowded areas when going out, for people over 60 years old and people with any underlying health problems.
Try to avoid close contact with people who display flu-like symptoms, including coughing and sneezing.
Get accurate information about COVID-19. Some good sources include the Pan American Health Organization and WHO websites.

The American Red Cross also advise against touching the mouth, nose, or eyes when out and about, before having a chance to wash the hands.

The number of new COVID-19 cases is on the rise in many regions across the globe. But not everyone who comes into contact with SARS-CoV-2, the new coronavirus, develops COVID-19.

Stay informed with live updates on the current COVID-19 outbreak and visit our coronavirus hub for more advice on prevention and treatment.

A group of scientists from the Francis Crick Institute, in London, along with colleagues at University College London, both in the United Kingdom, may have found a clue as to why some people can fight off a SARS-CoV-2 infection better than others.

Their work recently appeared in the journal Science.
Surprise discovery

The research team originally set out to develop a high-sensitivity test to detect antibodies to the SARS-CoV-2 virus.

Scientists can use this type of test to establish whether a person has antibodies after they had COVID-19, which is a key piece of information for those trying to establish how long immunity may last after SARS-CoV-2 infection.

As part of their work, the scientists used serum samples provided by people who did not have COVID-19. To their surprise, they found antibodies that reacted to SARS-CoV-2 in some of the samples.

In their paper, the researchers describe a scientific theory that exposure to any of the common human coronaviruses, which can cause the common cold, may lead to immunity against the other common human coronaviruses. They refer to this as immune cross-reactivity.

here are four seasonal common human coronaviruses, all of which mostly cause mild disease. The vast majority of people have an infection with at least one of these viruses at some point.

Scientists already know that our bodies do not build up long-lasting immunity to these viruses, which is why a person can contract an infection with a common human coronavirus more than once in their lifetime.

But can a previous exposure to a common human coronavirus provide at least temporary protection against SARS-CoV-2?

Signaling a potential breakthrough for immunization programs in resource-poor countries, researchers have announced at the American Society of Tropical Medicine and Hygiene (ASTMH) conference that regulatory authorities -- after conducting a rigorous review of stability data -- will for the first time allow a vaccine in Africa to be transported and stored for as long as four days without refrigeration or even an icepack.

The meningitis A vaccine known as MenAfriVac®, created to meet the needs of Africa's meningitis belt, can now be kept in a controlled temperature chain (CTC) at temperatures of up to 40°C for up to four days, a decision that could help increase campaign efficiency and coverage and save funds normally spent maintaining the challenging cold chain during the "last mile" of vaccine delivery.

The outcome of the review and decisions of the Drugs Controller General of India (DCGI), supported by a Health Canada analysis and confirmed by the World Health Organization (WHO) Vaccines Pre-qualification Programme, was revealed during a presentation this afternoon at the ASTMH conference in Atlanta by Godwin Enwere, MD, medical director for the Meningitis Vaccine Project. The regulatory approval has the effect of permitting the re-labeling of MenAfriVac®, while ensuring that the vaccine remains effective and safe throughout its life cycle.

Costing less than US$0.50 per dose, the innovative vaccine that is manufactured by Serum Institute of India Ltd. (SIIL) has dramatically reduced disease burden in the first countries to introduce it, according to recently-published findings. MenAfriVac® is the first vaccine designed specifically to help health workers eliminate meningococcal A epidemics from Africa's "meningitis belt," which includes 26 countries from Senegal to Ethiopia.

"The potential for some vaccines to remain safely outside the cold chain for short periods of time has been widely known for over 20 years," said Dr. Michel Zaffran, director of Optimize, the PATH-WHO collaboration aimed at improving immunization systems and technologies. "But this is the first time that a vaccine intended for use in Africa has been tested and submitted to regulatory review and approved for this type of use. And we expect this announcement to build momentum for applying the CTC concept to other vaccines and initiatives, allowing us to save more lives in low-income countries."

Evidence of the heat stability of MenAfriVac® was validated by a team of experts from WHO, PATH, SIIL, and Health Canada. In collaboration with the government of Benin, the Meningitis Vaccine Project (MVP), Optimize, and the WHO regional office for Africa, a pilot use of the MenAfrivac® vaccine in a CTC will be conducted during the upcoming MenAfriVac® campaign in the northern part of the country, from November 15 through 25. Benin is the 10th country to introduce the vaccine, as well as the first country to work with the new CTC implementation guidelines, developed through WHO's Immunization Practices Advisory Committee.

"Vaccines save and improve lives wherever they are used, but reaching the millions of children in last mile communities like those in rural Africa continues to challenge us," said Dr. Orin Levine, director of Vaccine Delivery at the Bill & Melinda Gates Foundation. "Today's announcement marks a new milestone because it allows us to extend the delivery of the MenAfriVac vaccine from the traditional cold chain and reach more people across Africa, safely and efficiently."

New evidence of vaccine's efficacy in combating meningitis A in Africa

Other research discussed at the conference in Atlanta suggests that MenAfriVac® has already begun to do its job, eliminating meningitis A in the first countries where it was introduced. The authors of a recent paper in Clinical Infectious Diseases say they expect to see the impact repeated in all the countries that roll out the new vaccine.

The new article reports that swabs taken from the throats of thousands of Burkina Faso residents prior to and in the year that followed the introduction of MenAfriVac® suggested that infection with the bacteria causing meningitis A had been eliminated in vaccinated and unvaccinated populations in Burkina Faso. According to one of the authors, Dr. Marie-Pierre Préziosi, director of the Meningitis Vaccine Project, "our findings show that the bacteria causing meningitis A have disappeared from the noses and throats of those too old or too young to have received the vaccine, resulting from a phenomenon known as 'herd immunity.'"

"From early evidence in the first introducing countries, based on public health surveillance combined with these hard data, we can say the signs are very promising," Préziosi said. "We have herd immunity, which we were expecting. And we can also show that after introduction in Burkina Faso, we saw the lowest level of epidemic meningitis in 15 years."

She noted that the experience of Chad is particularly dramatic because the country's limited cold chain capacity had led authorities to immunize target populations in four phases. The first was carried out in 2011, and the other regions were set to receive the vaccine this year. The effect of the vaccine seemed evident almost immediately. In 2012, not a single group A meningitis case was identified in the three vaccinated areas, while the regions that had not yet received the vaccine suffered severe outbreaks caused by meningitis A.

A five-week old infant most likely contracted a vaccine strain of yellow fever virus through breastfeeding, according to a case report published in CMAJ (Canadian Medical Association Journal).

"Until recently, avoidance of vaccination of breastfeeding women with yellow fever vaccine had been based on theoretical grounds only," writes Dr. Susan Kuhn, with coauthors. "We report the probable transmission of vaccine strain of yellow fever virus from a mother to her infant through breastfeeding," which supports current recommendations for breastfeeding mothers to avoid the vaccine.

The yellow fever vaccine is a live-virus vaccine that has been used since the 1940s.

When the infant was 10 days old the mother received pre-travel advice and travel vaccinations, including one for yellow fever. Subsequently, they traveled to Venezuela for one week and breastfeeding was continued. The infant did not receive vaccinations.

"The previously healthy five-week old infant male presented to the hospital with a two-day history of fever and irritability," write the authors. "The day before his admission, he had been noted to have focal seizures on alternating sides." Testing of the spinal fluid revealed evidence of recent infection with the yellow fever virus. Given that the travellers elected to stay in urban Venezuela where yellow fever is not known to be a risk, the authors concluded that the likely explanation was transmission of the yellow fever vaccine strain through breastfeeding.

The baby showed no sign of insect bites, had not been in contact with sick people, was not exposed to animals in Canada or elsewhere, had no history of herpes infections in family members and had not had any vaccinations prior to his symptoms.

"This probable case of yellow fever virus further supports the current recommendations for avoidance of yellow fever vaccination in lactating mothers of infants under nine months of age," write the authors. "While there may be situations in which the mother will have unavoidable and significant risk of yellow fever exposure, the risk to the infant due to maternal vaccination must be weighed against the risk of wild-type virus infection."

The authors conclude that travelling women should adjust their plans to reduce or limit their risk of exposure or postpone their trip entirely until their infant is no longer breastfeeding or is old enough to be vaccinated.

Vaccines: Don't leave home without them
Many Americans traveling overseas at risk for measles, hepatitis A, studies suggest

While Americans should be fully vaccinated before travelling internationally to avoid infection with highly contagious diseases such as measles and hepatitis A, many are not, suggest two studies being presented at IDWeek 2015™. The findings suggest the lack of pretravel vaccination was a factor in illness outbreaks.

More than half of eligible Americans visiting a travel clinic prior to international travel did not receive the measles, mumps and rubella (MMR) vaccine as recommended, despite being at risk for measles, according to one study. Another study reports on a 2015 hepatitis A outbreak at a popular resort destination in Mexico which could have been avoided with proper vaccinations. Researchers in this study noted that exposure to contaminated food and water while travelling internationally is the most common way Americans become ill with this virus.

"Americans planning international travel should see their health care providers or visit a travel clinic four to six weeks before the trip to learn what vaccines are recommended before heading to their destinations," said Emily Hyle, MD, lead author of the measles vaccination study and Instructor at Harvard Medical School and Massachusetts General Hospital, Boston. "Many travelers don't realize their risk of exposure to infections and that many can be avoided with vaccination."

Measles Vaccination Study

A study of more than 40,000 U.S. travelers found that 16 percent were eligible for the MMR vaccine -- meaning they were not immunized or under-immunized and were medically eligible -- but fewer than half of them received the vaccine during pre-travel consultation, despite Centers for Disease Control and Prevention (CDC) guidelines. While continuous measles transmission was eliminated in the United States 15 years ago, it is a significant problem globally, with more than 20 million cases occurring annually. Americans who are not vaccinated risk getting sick with the measles if exposed, as well as bringing it back home and infecting others. Most of the measles outbreaks in this country have been caused by unvaccinated people being infected with measles overseas and traveling to the United States.

The research focused on 40,810 adults born after 1956 who received pre-travel consultations between 2009 and 2014 at 24 sites associated with Global TravEpiNet (GTEN), a -CDC-supported consortium of clinical sites that provide pre-travel health care. Of those adults, 6,612 (16 percent) were eligible for vaccination, but only 3,135 (47 percent) received the MMR vaccination before travel.

"Measles is one of the most contagious diseases in the world and even brief exposure can lead to infection," said Dr. Hyle. "Many travelers heading to developed countries, including those in Europe, might not realize that there are outbreaks of measles occurring in those areas, and they are at risk for becoming ill."

Measles can lead to pneumonia, brain swelling, hospitalization and occasionally, death.

Hepatitis A Vaccination Study

Uncommon in the United States, hepatitis A outbreaks are more likely to occur in areas with inadequate sanitation and limited access to clean water. U.S. travelers to these regions should take precautions by ensuring they are up to date on vaccination. Hepatitis A can lead to fever, nausea, exhaustion, jaundice and stomach pain.

Researchers reported on an outbreak of hepatitis A infection in Tulum, Mexico, a popular resort destination along the Caribbean Sea. They reported on 29 cases of acute heptitis A that occurred in Americans who traveled to Tulum between Jan. 5 and March 20, 2015. Of the patients, 17 (63 percent) stayed at one of nine resorts within a few miles of each other, 23 (79 percent) reported eating seafood and 16 (62 percent) said they ate ceviche, raw seafood cured in lime juice. None had received the hepatitis A vaccination prior to travel.

"Hepatitis A vaccination prior to travel is the most effective way to avoid infection, regardless of length of stay or quality of lodging," said Monique Foster, MD, MPH, lead author of the hepatitis A study, and Epidemic Intelligence Service Officer in the Division of Viral Hepatitis at CDC in Atlanta. "Travelers to areas where hepatitis A may be a problem should avoid consuming non-bottled water, uncooked fruit and vegetables, and undercooked meats, including raw fish and shellfish such as found in ceviche.

As governments from countries including the U.S.,Canada , Germany, Italy and the U.K., explore the possibility of issuing so-called "immunity passports," a leading global health and legal scholar warns that such action poses significant practical, equitable, and legal issues. In contrast, if and when a vaccine is developed, vaccination certificates will likely play an important role in ending the pandemic and protecting global health.

Writing in The Lancet, Alexandra L. Phelan, SJD, LLM, LLB, an assistant professor at Georgetown University Medical Center and a faculty member of its Center for Global Health Science and Security, writes that immunity passports "create an artificial restriction on who can and cannot participate in social and economic activities," warning that this creates "a perverse incentive for individuals to seek out infection."

"Immunity passports would be ripe for both corruption and implicit bias" and would "exacerbate the harm inflicted by COVID-19 on already vulnerable populations," Phelan argues. And she adds that the people "most incentivised to seek out infection might also be those unable or understandably hesitant to seek medical care due to cost and discriminatory access."

Immunity passports would also face legal challenges, argues Phelan, who is also an adjunct professor at Georgetown Law and a member of its O'Neill Institute for National and Global Health Law. While the International Health Regulations prohibit health measures that are discriminatory and impede international travel, at present, she explains, countries may not have laws to expressly address discrimination experienced by those without "immunoprivilege."

"Immunity passports would risk enshrining such discrimination in law and undermine the right to health of individuals and the population through the perverse incentives they create," she writes.

In contrast, if and when a vaccine is developed, "vaccination certificates" may be an important tool to incentivize vaccination, evidence protection, and resume international trade and travel. Unlike immunity passports, vaccination certificates are expressly permissible under the International Health Regulations, which govern when countries can use them. Phelan sets out the legal steps required to be able to use vaccination certificates in the COVID-19 response.

"Until a COVID-19 vaccine is available, and accessible, which is not guaranteed, the way out of this crisis will be built on established public health practices of testing, contact tracing, quarantine of contacts, and isolation of cases," Phelan concludes. "The success of these practices is largely dependent on public trust, solidarity and addressing -- not entrenching -- the inequities and injustices that contributed to this outbreak becoming a pandemic.

Loss of smell and taste has been anecdotally linked to COVID-19 infections. In a study published April 12, 2020 in the journal International Forum of Allergy & Rhinology, researchers at UC San Diego Health report the first empirical findings that strongly associate sensory loss with COVID-19, the respiratory disease caused by the novel coronavirus.

"Based on our study, if you have smell and taste loss, you are more than 10 times more likely to have COVID-19 infection than other causes of infection. The most common first sign of a COVID-19 infection remains fever, but fatigue and loss of smell and taste follow as other very common initial symptoms," said Carol Yan, MD, an otolaryngologist and head and neck surgeon at UC San Diego Health. "We know COVID-19 is an extremely contagious virus. This study supports the need to be aware of smell and taste loss as early signs of COVID-19."

Yan and colleagues surveyed 1,480 patients with flu-like symptoms and concerns regarding potential COVID-19 infection who underwent testing at UC San Diego Health from March 3 through March 29, 2020. Within that total, 102 patients tested positive for the virus and 1,378 tested negative. The study included responses from 59 COVID-19-positive patients and 203 COVID-19-negative patients.

Yan said the study demonstrated the high prevalence and unique presentation of certain sensory impairments in patients positive with COVID-19. Of those who reported loss of smell and taste, the loss was typically profound, not mild. But encouragingly, the rate of recovery of smell and taste was high and occurred usually within two to four weeks of infection.

"Our study not only showed that the high incidence of smell and taste is specific to COVID-19 infection, but we fortunately also found that for the majority of people sensory recovery was generally rapid," said Yan. "Among the Covid-19 patients with smell loss, more than 70 percent had reported improvement of smell at the time of survey and of those who hadn't reported improvement, many had only been diagnosed recently."

Sensory return typically matched the timing of disease recovery. Interestingly, the researchers found that persons who reported experiencing a sore throat more often tested negative for COVID-19.

In an effort to decrease risk of virus transmission, UC San Diego Health now includes loss of smell and taste as a screening requirement for visitors and staff, as well as a marker for testing patients who may be positive for the virus.

Other known symptoms of COVID-19 include fever, fatigue, cough and difficulty breathing. Respondents in Yan's study were most often persons with milder forms of COVID-19 infection who did not require hospitalization or intubation. The findings, she said, underline the importance of identifying early or subtle symptoms of COVID-19 infection in people who may be at risk of transmitting the disease as they recuperate within the community.

"It is our hope that with these findings other institutions will follow suit and not only list smell and taste loss as a symptom of COVID-19, but use it as a screening measure for the virus across the world," Yan said.

Co-authors include: Farhoud Faraji, Divya P. Prajapti, Christine E. Boone and Adam S. DeConde, all at UC San Diego.

The novel SARS-CoV-2 coronavirus that emerged in the city of Wuhan, China, last year and has since caused a large scale COVID-19 epidemic and spread to more than 70 other countries is the product of natural evolution, according to findings published today in the journal Nature Medicine.

The analysis of public genome sequence data from SARS-CoV-2 and related viruses found no evidence that the virus was made in a laboratory or otherwise engineered.

"By comparing the available genome sequence data for known coronavirus strains, we can firmly determine that SARS-CoV-2 originated through natural processes," said Kristian Andersen, PhD, an associate professor of immunology and microbiology at Scripps Research and corresponding author on the paper.

In addition to Andersen, authors on the paper, "The proximal origin of SARS-CoV-2," include Robert F. Garry, of Tulane University; Edward Holmes, of the University of Sydney; Andrew Rambaut, of University of Edinburgh; W. Ian Lipkin, of Columbia University.

Coronaviruses are a large family of viruses that can cause illnesses ranging widely in severity. The first known severe illness caused by a coronavirus emerged with the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic in China. A second outbreak of severe illness began in 2012 in Saudi Arabia with the Middle East Respiratory Syndrome (MERS).

On December 31 of last year, Chinese authorities alerted the World Health Organization of an outbreak of a novel strain of coronavirus causing severe illness, which was subsequently named SARS-CoV-2. As of February 20, 2020, nearly 167,500 COVID-19 cases have been documented, although many more mild cases have likely gone undiagnosed. The virus has killed over 6,600 people.

Shortly after the epidemic began, Chinese scientists sequenced the genome of SARS-CoV-2 and made the data available to researchers worldwide. The resulting genomic sequence data has shown that Chinese authorities rapidly detected the epidemic and that the number of COVID-19 cases have been increasing because of human to human transmission after a single introduction into the human population. Andersen and collaborators at several other research institutions used this sequencing data to explore the origins and evolution of SARS-CoV-2 by focusing in on several tell-tale features of the virus.

The scientists analyzed the genetic template for spike proteins, armatures on the outside of the virus that it uses to grab and penetrate the outer walls of human and animal cells. More specifically, they focused on two important features of the spike protein: the receptor-binding domain (RBD), a kind of grappling hook that grips onto host cells, and the cleavage site, a molecular can opener that allows the virus to crack open and enter host cells.

Evidence for natural evolution

The scientists found that the RBD portion of the SARS-CoV-2 spike proteins had evolved to effectively target a molecular feature on the outside of human cells called ACE2, a receptor involved in regulating blood pressure. The SARS-CoV-2 spike protein was so effective at binding the human cells, in fact, that the scientists concluded it was the result of natural selection and not the product of genetic engineering.

This evidence for natural evolution was supported by data on SARS-CoV-2's backbone -- its overall molecular structure. If someone were seeking to engineer a new coronavirus as a pathogen, they would have constructed it from the backbone of a virus known to cause illness. But the scientists found that the SARS-CoV-2 backbone differed substantially from those of already known coronaviruses and mostly resembled related viruses found in bats and pangolins.

"These two features of the virus, the mutations in the RBD portion of the spike protein and its distinct backbone, rules out laboratory manipulation as a potential origin for SARS-CoV-2" said Andersen.

Josie Golding, PhD, epidemics lead at UK-based Wellcome Trust, said the findings by Andersen and his colleagues are "crucially important to bring an evidence-based view to the rumors that have been circulating about the origins of the virus (SARS-CoV-2) causing COVID-19."

"They conclude that the virus is the product of natural evolution," Goulding adds, "ending any speculation about deliberate genetic engineering."