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Viewpoint
January 23, 2020

Coronavirus Infections—More Than Just the Common Cold

Author Affiliations
  • 1Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
  • 2National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
JAMA. 2020;323(8):707-708. doi:10.1001/jama.2020.0757

Human coronaviruses (HCoVs) have long been considered inconsequential pathogens, causing the “common cold” in otherwise healthy people. However, in the 21st century, 2 highly pathogenic HCoVs—severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV)—emerged from animal reservoirs to cause global epidemics with alarming morbidity and mortality. In December 2019, yet another pathogenic HCoV, 2019 novel coronavirus (2019-nCoV), was recognized in Wuhan, China, and has caused serious illness and death. The ultimate scope and effect of this outbreak is unclear at present as the situation is rapidly evolving.

Coronaviruses are large, enveloped, positive-strand RNA viruses that can be divided into 4 genera: alpha, beta, delta, and gamma, of which alpha and beta CoVs are known to infect humans.1 Four HCoVs (HCoV 229E, NL63, OC43, and HKU1) are endemic globally and account for 10% to 30% of upper respiratory tract infections in adults. Coronaviruses are ecologically diverse with the greatest variety seen in bats, suggesting that they are the reservoirs for many of these viruses.2 Peridomestic mammals may serve as intermediate hosts, facilitating recombination and mutation events with expansion of genetic diversity. The surface spike (S) glycoprotein is critical for binding of host cell receptors and is believed to represent a key determinant of host range restriction.1

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    3 Comments for this article
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    Lets step back a bit and take a breath
    Maurice Stutzman, Ohio State University, MD | Family Medicine, Private Practice
    Is anyone wondering, like me, about Washington State's nursing home coronavirus cases? Thus far, there is no known connection to the “novel” COVID-19 virus originating from China. So, this coronavirus’ source seems to be local. Primary care physicians who do geriatric care and take care of patients in nursing homes often have had “clusters” of patients who died from respiratory disease despite testing negative for the usual culprits. Our final diagnosis would then be recorded as “Pneumonia - unspecified.”

    Due to the availability of new diagnostic tools and treatments, we have new diseases, or have seen an increase in
    diagnosis of certain diseases almost unheard of 40 or 50 years ago. Chronic diseases such as sleep apnea are now tested for and treated. Due to aggressive screening and the benefits of early autism treatment, by necessity, its diagnosis has increased. (No it is not due to immunizations.) We now have an over-diagnosis of Vitamin D deficiency due to the use of arbitrarily defined “normal” levels.

    The ability to test for a disease increases the likeliness of its diagnosis. Today, the diagnosis of coronavirus is directly proportional to the amount of testing being done. Hence, S. Korea (besides China - whose testing numbers are unknown) has the most diagnoses. As of March 2, South Korea performed 106,591 with Italy next at 23,345. It is no surprise that these two countries (outside of China) have the highest incidence of COVID-19 infections. As testing becomes prevalent in the US, we are going to see similar increases in its diagnosis due to the “novel” discovery that coronavirus rather than being pandemic is a virus that has natural endemic and seasonal characteristics.

    As with all endemic viruses, its spread is directly proportional to population density, crowded living conditions, and time of the year. Hence, its spread in China, cruise ships, and nursing homes this winter with the majority of deaths seen among our most vulnerable.

    Whether this coronavirus strain is more virulent (see swine flu), may act synergistically with other viruses (see Hepatitis A with Hepatitis C), or is just affecting highly vulnerable populations (elderly frail, immuno-compromised) is not yet fully known.

    What is known is that South Korea’s (one of the most thoroughly tested populations thus far) fatality rate for COVID-19 after testing nearly 140,000 people is 0.6%. For comparison, during the 2018/2019 US influenza endemic, the 65 and older population had a death rate of 0.83%.

    So what can we do? Promote prevention. Get immunizations up to date. Constantly use infection precautions. Be diligent, and we should be fine. A vaccine should help.
    CONFLICT OF INTEREST: None Reported
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    Comment for Maurice Stuzman:"Lets step back and take a breath"
    Mike Mage, Scientist Emeritus | NIH
    The genomic sequences of the SARS-CoV-2 isolates seem to fit the pattern of originating from the first cases in Wuhan in December 2019.

    https://doi.org/10.1101/2020.03.04.976662

    If the same data support these sequences being compatible with a "natural endemic", please point us to the analysis.
    CONFLICT OF INTEREST: None Reported
    Prescient Caution about COVID-19 and the Common Cold
    Michael McAleer, PhD (Econometrics), Queen's | Asia University, Taiwan
    Although published on 23 January 2020, and before the World Health Authority (WHO) named the disease COVID-19 on 11 February 2020 and declared it a pandemic on 11 Match 2020, much of the contents of this Viewpoint are strikingly prescient.

    A cautionary tale was: “The ultimate scope and effect of this outbreak is unclear at present as the situation is rapidly evolving” and “the ultimate scope and effects of the outbreak remain to be seen.”

    The world has changed rapidly since the initial critical analysis.

    Like SARS, where the transmission process does not yet seem to be
    fully understood, higher fatality rates from COVID-19 have occurred in older patients and those experiencing medical comorbidities, among other factors.

    Despite the WHO having placed SARS-CoV and MERS-CoV on its Priority Pathogen list in 2017, safe and effective vaccines have not yet been discovered.

    The paper ends with the warning:

    “Effective response requires prompt action from the standpoint of classic public health strategies to the timely development and implementation of effective countermeasures … and sustained preparedness.”

    Almost 8 weeks after publication, the prescient caution that was highlighted stands in stark contrast to what has transpired from a public health perspective.
    CONFLICT OF INTEREST: None Reported
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