{"id":47642,"date":"2020-05-28T13:56:43","date_gmt":"2020-05-28T12:56:43","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=47642"},"modified":"2020-06-09T18:19:34","modified_gmt":"2020-06-09T17:19:34","slug":"aser-garcia-rada-on-the-front-lines-of-the-response-to-covid-19-in-spain","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2020\/05\/28\/aser-garcia-rada-on-the-front-lines-of-the-response-to-covid-19-in-spain\/","title":{"rendered":"Aser Garcia Rada: On the front lines of the response to covid-19 in Spain"},"content":{"rendered":"

The devil is in the details, as they say. As the SARS-CoV-2 pandemic declines in the Northern hemisphere and lockdowns ease in Europe, early identification of new cases and <\/span>contact tracing<\/span><\/a> become paramount to tackle new expected outbreaks. <\/span>Resources<\/span><\/a>, personnel, infrastructures, <\/span>technology<\/span><\/a> and <\/span>extensive social debate<\/span><\/a> are needed, but also awareness on the <\/span>wide variety of mild symptoms of covid-19<\/span><\/a>.<\/span><\/p>\n

So far media and scientific research have focused on the clinical characteristics <\/span>of those\u00a0<\/span>admitted to hospital<\/span><\/a> and<\/span> severely ill patients<\/span><\/a>, on <\/span>intensive care management<\/span><\/a>, and on <\/span>complications leading to death<\/span><\/a>. However, information remains scarce on the clinical features of people with <\/span>mild or moderate symptoms.<\/span><\/a>\u00a0Growing evidence shows that undocumented infections<\/span><\/a> and transmission from <\/span>asymptomatic<\/span><\/a>, <\/span>pre symptomatic,<\/span><\/a> or <\/span>mildly symptomatic patients<\/span><\/a> are responsible for the rapid spread of the disease.<\/span><\/p>\n

Still most people consider that this infection involves what have broadly been defined as the \u201ctypical symptoms\u201d of a respiratory disease: <\/span>fever, cough, and shortness of breath<\/span><\/a>. Moreover, many still think that if they don’t have fever or cough, that it could not be covid-19.\u00a0<\/span><\/p>\n

Recent research<\/span><\/a> found that only a third of 5,700 patients hospitalized for this disease in the New York metropolitan area had fever upon admission, which doesn’t seem particularly high for a symptom to be considered \u201ctypical.\u201d We also know now that although SARS-CoV-2 is transmitted through respiratory secretions and produces severe pneumonia, covid-19 is\u00a0<\/span>a systemic disease<\/span><\/a> that affects most body systems and can express itself in multiple ways.<\/span><\/p>\n

As I mentioned in <\/span>a previous opinion piece<\/span><\/a>, in Spain’s primary care sector, family physicians, paediatricians and nurses are mostly doing phone follow up of patients isolating at home with mild symptoms. In Madrid, our country\u2019s epicentre, we’ve noticed the strikingly broad spectrum of such manifestations.<\/span><\/p>\n

Gastrointestinal symptoms such as diarrhoea, anorexia, and nausea are frequent complaints, as has also been described for <\/span>patients admitted to hospital<\/span><\/a>. They are <\/span>particularly frequent in children<\/span><\/a>, who usually suffer <\/span>a less aggressive clinical course<\/span><\/a> and have less<\/span>\u00a0cough, fever, or shortness of breath<\/span><\/a> compared with adults<\/span>. But a wide range of symptoms is also possible, including an unusual <\/span>severe pediatric multisystem inflammatory syndrome<\/span><\/a>.<\/span><\/p>\n

For both adults and children, we have seen several other symptoms such as sore throat, rhinorrhoea, nasal congestion,<\/span>\u00a0<\/span>sputum production, thorax oppression, weakness, malaise, myalgia, back pain, confusion, dizziness, headache, abdominal pain, vomits, chills, or conjunctivitis. Such variety is unlikely to be explained by coinfection with other viruses,\u00a0\u00a0which <\/span>has been found to be very low (2.1%)<\/span><\/a>.<\/span><\/p>\n

Since mid-March <\/span>anosmia, hyposmia, and dysgeusia have begun to be consistently noticed as particularly related to covid-19<\/span><\/a>, sometimes <\/span>as the only present symptom<\/span><\/a>.\u00a0<\/span><\/p>\n

In Madrid we have also noticed a wide variety in the intensity of symptoms and combinations, something particularly noticeable while broad widespread transmission was taking place under <\/span>lockdown<\/span><\/a> and most people were only seeing\u00a0<\/span>household contacts.<\/span><\/a><\/p>\n

While <\/span>the NHS<\/span><\/a> has only added changes to smell or taste to the original list of suspicious symptoms, some more have been recently included by <\/span>the CDC<\/span><\/a> or <\/span>the Spanish Minister of Health<\/span><\/a>. However, unawareness of <\/span>this diversity<\/span><\/a> remains widespread.<\/span><\/p>\n

As <\/span>lockdowns are eased in Spain<\/span><\/a>, citizens are told to remain home if symptomatic. But while <\/span>Madrid, Catalonia, and other regions<\/span><\/a> still lack <\/span>proper contact tracing programs<\/span><\/a>, I am concerned that <\/span>such unawareness<\/span><\/a> might also contribute to the a second wave.<\/span><\/p>\n

Until we have a better understanding of these<\/span>\u00a0clinical presentations, c<\/span>ovid<\/span>-19 should be suspected if the previously mentioned symptoms appear, as well as characteristic conditions, such as sudden loss of smell or taste.<\/span>\u00a0If tests are not available and symptoms remain mild, <\/span>self-isolation<\/span><\/a> should be encouraged and facilitated by local authorities, particularly for <\/span>those most vulnerable to the disease<\/span><\/a>.<\/span><\/p>\n

As further knowledge becomes available, our growing concern about the\u00a0<\/span>severe manifestations affecting multiple organs<\/span><\/a> must also focus on mild symptoms. Because that’s where the devil seems to be hiding.<\/span><\/p>\n

Aser Garc\u00eda Rada\u00a0<\/i><\/b>is a paediatrician who works at a primary care center in Madrid. Twitter: @AserGRada<\/b><\/a>\u00a0<\/span><\/i><\/p>\n

Competing interests<\/strong>: None declared<\/em><\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

The devil is in the details, as they say. As the SARS-CoV-2 pandemic declines in the Northern hemisphere and lockdowns ease in Europe, early identification of new cases and contact […]<\/p>\n

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