Given the status quo projections, this translates to approximately 249,000 fewer premature deaths, 45,000 fewer deaths from lung cancer, and 4.2 million fewer YLL…
LIMA — Smokers have a harder time fighting off respiratory infections and are at higher risk for developing chronic lung disease — two factors associated with severe cases of COVID-19, the disease caused by the novel coronavirus — which is why some doctors are encouraging smokers to quit now to improve lung function before they get sick.
Researchers are still trying to determine the extent to which smoking itself can be attributed to worse outcomes from COVID-19, after preliminary studies in the U.S. and China found a possible link between the two.
“We know they have chronic inflammation of the lower lung,” said Dr. Rob Crane, a clinical physician with The Ohio State University Department of Family Medicine. “The air sacs tend to be more irritated. The basement membrane, that bottom lining of the lung, tends to get more broken up. You have cilia cells that don’t function in their reactions as well. And most acutely, the moment you inhale nicotine, it paralyzes the little hair cells, the cilia, that are the sweepers of the lung cleanup system.”
Oxygen diminishes when the lungs are congested with junk and fluid.
“That’s what kills people,” Crane said. “That’s why you find doctors trying to reposition people; put them on their stomach or sitting up or turned on their side so they can get that fluid drained different places and allow some parts of the lung to continue to ventilate.”
Crane, who is involved in tobacco cessation efforts and is the founder of the Preventing Tobacco Addiction Foundation, is one of the doctors using the coronavirus pandemic to encourage smokers to quit.
“There could hardly be a better motivator now than the risk of a horrendous death,” he said. “There are deaths and then there are deaths. But this death, where you asphyxiate, where you drown in your own secretions and then you go onto a ventilator and you probably don’t get off — you can’t say goodbye to your loved ones; you die alone — that’s right up there with really bad deaths.”
There were about 34.2 million active smokers in the U.S. in 2018, which accounts for about 14% of the adult population, according to the Centers for Disease Control and Prevention. But smoking is more common in Ohio, with about 21% of adults considered active smokers in 2017.
Crane said lung inflammation decreases just days after a person quits smoking. While the lung is not healed entirely, Crane explained those improvements help decrease the chances for chronic illness like heart disease.
Whether those changes are enough to improve a person’s chances of survival from COVID-19 are less clear.
Dr. Nora Volkow, director of the National Institute on Drug Abuse, wrote earlier this month that COVID-19 “could be an especially serious threat to those who smoke tobacco or marijuana or who vape” because the disease attacks the lungs. Likewise, she warned people with opioid and methamphetamine use disorders may also be at higher risk.
But even if active smoking is not directly related to COVID-19 complications, Crane said there are other benefits to quitting, like decreased risk of chronic disease. He said the most effective methods include smoking cessation medications and nicotine substitutes.
Mackenzi Klemann is a reporter with The Lima News.
Before COVID-19 was dominating headlines, many Americans were concerned about another deadly epidemic: vaping.
It’s been linked to more than 2,800 hospitalizations and deaths, though health officials haven’t linked any specific substance or products to the illnesses, and no single product has been associated with all of the cases.
E-cigarette sales in the United States steadily rose from 2016 to 2018, with youth-friendly, candy- and fruit-flavored products that critics say targeted teens fueling most of that growth. Facing mounting criticism as reports of vaping-associated lung disease rose, the popular vaping brand JUUL ended in-store sales of fruit- and candy-flavored products in November 2018.
But, according to a new study, those actions have had little effect. Sales of e-cigarettes remain strong even after the measures taken to curb purchases of youth-friendly products, raising questions about federal regulations and how to best protect American youth from harming themselves by vaping.
After companies stepped in to self-regulate, e-cigarette sales dropped for about two months but quickly rebounded, soon exceeding previous highs, according to the study by the American Cancer Society published in the American Journal of Public Health.
The study’s authors said the data show a glaring shortcoming in allowing e-cigarette companies largely to self-regulate in lieu of coordinated federal regulations. In December, more than a year after JUUL stopped selling fruit- and candy-flavored products, Congress did ban the sale of all tobacco and e-cigarettes to anyone younger than 21.
A spokesperson for JUUL told ABC News that the company is working closely with regulators, attorneys, public health officials and other stakeholders to combat underage use of its products and “will continue to reset the vapor category in the U.S. and seek to earn the trust of society.” Juul has also long maintained its products are intended for adults looking to switch from combustible cigarettes.
The Food and Drug Administration, which regulates tobacco products, said it was reviewing the findings of the recent study, which will be evaluated as part of a larger body of evidence.
The study, based on sales figures from the market research firm Nielsen, only collected data from brick-and-mortar retailers and may not show the whole picture. Online sales of vaping products could be much higher, especially among younger buyers, according to experts.
“The trends being reported in this paper are likely to be an underestimate of the total volume of sales across the country,” said Dr. Andy Tan, a public health researcher at Dana-Farber Cancer Institute.
The study didn’t track purchases by individual customers and wasn’t broken down into age groups. Nevertheless, the data offers a “snapshot” of e-cigarette sales over time in certain stores and suggests vaping continues to be popular despite the voluntary removal of fruit- and candy-flavored products by e-cigarette companies, Tan noted.
Outside surveys have corroborated the idea that many middle school and high school students simply switched to mint, menthol and tobacco flavors. Believing that the removal of a few flavors of a highly successful product would make a significant dent in usage is “highly naive,” Tan added, “because these products are highly addictive.”
Alex Liber, one of the study’s lead scientists, added: “JUUL was able to transition sales of other flavors easily by simply swapping which flavors were being displayed in stores.”
JUUL’s sales also likely got a boost, Liber added, thanks to new part-owner Altria, a massive distributor of tobacco products that also owns Philip Morris USA, the producer of Marlboro cigarettes.
From 2016 to 2019, according to a National Youth Tobacco survey, flavor preferences among high school students shifted, with those vaping menthol or mint flavors increasing to 57% from 16%.
Ultimately, the researchers concluded that JUUL’s self-regulation was insufficient to curb the use of these products, although it’s too soon to determine how big of an impact changing the legal purchasing age to 21 may have.
“Business acts to serve its own interests,” Liber said, “while well-constructed government regulation can serve the public interest.”
Heather J. Kagan, M.D., an internal medicine resident physician at The Johns Hopkins Hospital, is a contributor to the ABC News Medical Unit. Sony Salzman is the unit’s coordinating producer.
Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan city and rapidly spread throughout China, data have been needed on the clinical characteristics of the affected patients.
We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death.
The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission.
During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.)
In early December 2019, the first pneumonia cases of unknown origin were identified in Wuhan, the capital city of Hubei province.1 The pathogen has been identified as a novel enveloped RNA betacoronavirus2 that has currently been named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has a phylogenetic similarity to SARS-CoV.3 Patients with the infection have been documented both in hospitals and in family settings.4-8
The World Health Organization (WHO) has recently declared coronavirus disease 2019 (Covid-19) a public health emergency of international concern.9 As of February 25, 2020, a total of 81,109 laboratory-confirmed cases had been documented globally.5,6,9-11 In recent studies, the severity of some cases of Covid-19 mimicked that of SARS-CoV.1,12,13 Given the rapid spread of Covid-19, we determined that an updated analysis of cases throughout mainland China might help identify the defining clinical characteristics and severity of the disease. Here, we describe the results of our analysis of the clinical characteristics of Covid-19 in a selected cohort of patients throughout China.
The study was supported by National Health Commission of China and designed by the investigators. The study was approved by the institutional review board of the National Health Commission. Written informed consent was waived in light of the urgent need to collect data. Data were analyzed and interpreted by the authors. All the authors reviewed the manuscript and vouch for the accuracy and completeness of the data and for the adherence of the study to the protocol, available with the full text of this article at NEJM.org.
We obtained the medical records and compiled data for hospitalized patients and outpatients with laboratory-confirmed Covid-19, as reported to the National Health Commission between December 11, 2019, and January 29, 2020; the data cutoff for the study was January 31, 2020. Covid-19 was diagnosed on the basis of the WHO interim guidance.14 A confirmed case of Covid-19 was defined as a positive result on high-throughput sequencing or real-time reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay of nasal and pharyngeal swab specimens.1 Only laboratory-confirmed cases were included in the analysis.
We obtained data regarding cases outside Hubei province from the National Health Commission. Because of the high workload of clinicians, three outside experts from Guangzhou performed raw data extraction at Wuhan Jinyintan Hospital, where many of the patients with Covid-19 in Wuhan were being treated.
We extracted the recent exposure history, clinical symptoms or signs, and laboratory findings on admission from electronic medical records. Radiologic assessments included chest radiography or computed tomography (CT), and all laboratory testing was performed according to the clinical care needs of the patient. We determined the presence of a radiologic abnormality on the basis of the documentation or description in medical charts; if imaging scans were available, they were reviewed by attending physicians in respiratory medicine who extracted the data. Major disagreement between two reviewers was resolved by consultation with a third reviewer. Laboratory assessments consisted of a complete blood count, blood chemical analysis, coagulation testing, assessment of liver and renal function, and measures of electrolytes, C-reactive protein, procalcitonin, lactate dehydrogenase, and creatine kinase. We defined the degree of severity of Covid-19 (severe vs. nonsevere) at the time of admission using the American Thoracic Society guidelines for community-acquired pneumonia.15
All medical records were copied and sent to the data-processing center in Guangzhou, under the coordination of the National Health Commission. A team of experienced respiratory clinicians reviewed and abstracted the data. Data were entered into a computerized database and cross-checked. If the core data were missing, requests for clarification were sent to the coordinators, who subsequently contacted the attending clinicians.
The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death. These outcomes were used in a previous study to assess the severity of other serious infectious diseases, such as H7N9 infection.16 Secondary end points were the rate of death and the time from symptom onset until the composite end point and until each component of the composite end point.
The incubation period was defined as the interval between the potential earliest date of contact of the transmission source (wildlife or person with suspected or confirmed case) and the potential earliest date of symptom onset (i.e., cough, fever, fatigue, or myalgia). We excluded incubation periods of less than 1 day because some patients had continuous exposure to contamination sources; in these cases, the latest date of exposure was recorded. The summary statistics of incubation periods were calculated on the basis of 291 patients who had clear information regarding the specific date of exposure.
Fever was defined as an axillary temperature of 37.5°C or higher. Lymphocytopenia was defined as a lymphocyte count of less than 1500 cells per cubic millimeter. Thrombocytopenia was defined as a platelet count of less than 150,000 per cubic millimeter. Additional definitions — including exposure to wildlife, acute respiratory distress syndrome (ARDS), pneumonia, acute kidney failure, acute heart failure, and rhabdomyolysis — are provided in the Supplementary Appendix, available at NEJM.org.
Laboratory confirmation of SARS-CoV-2 was performed at the Chinese Center for Disease Prevention and Control before January 23, 2020, and subsequently in certified tertiary care hospitals. RT-PCR assays were performed in accordance with the protocol established by the WHO.17 Details regarding laboratory confirmation processes are provided in the Supplementary Appendix.
Continuous variables were expressed as medians and interquartile ranges or simple ranges, as appropriate. Categorical variables were summarized as counts and percentages. No imputation was made for missing data. Because the cohort of patients in our study was not derived from random selection, all statistics are deemed to be descriptive only. We used ArcGIS, version 10.2.2, to plot the numbers of patients with reportedly confirmed cases on a map. All the analyses were performed with the use of R software, version 3.6.2 (R Foundation for Statistical Computing).
DEMOGRAPHIC AND CLINICAL CHARACTERISTICS
Of the 7736 patients with Covid-19 who had been hospitalized at 552 sites as of January 29, 2020, we obtained data regarding clinical symptoms and outcomes for 1099 patients (14.2%). The largest number of patients (132) had been admitted to Wuhan Jinyintan Hospital. The hospitals that were included in this study accounted for 29.7% of the 1856 designated hospitals where patients with Covid-19 could be admitted in 30 provinces, autonomous regions, or municipalities across China (Figure 1).
Shown are the official statistics of all documented, laboratory-confirmed cases of coronavirus disease 2019 (Covid-19) throughout China, according to the National Health Commission as of February 4, 2020. The numerator denotes the number of patients who were included in the study cohort and the denominator denotes the number of laboratory-confirmed cases for each province, autonomous region, or provincial municipality, as reported by the National Health Commission.
The demographic and clinical characteristics of the patients are shown in Table 1. A total of 3.5% were health care workers, and a history of contact with wildlife was documented in 1.9%; 483 patients (43.9%) were residents of Wuhan. Among the patients who lived outside Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city; 25.9% of nonresidents had neither visited the city nor had contact with Wuhan residents.
The median incubation period was 4 days (interquartile range, 2 to 7). The median age of the patients was 47 years (interquartile range, 35 to 58); 0.9% of the patients were younger than 15 years of age. A total of 41.9% were female. Fever was present in 43.8% of the patients on admission but developed in 88.7% during hospitalization. The second most common symptom was cough (67.8%); nausea or vomiting (5.0%) and diarrhea (3.8%) were uncommon. Among the overall population, 23.7% had at least one coexisting illness (e.g., hypertension and chronic obstructive pulmonary disease).
On admission, the degree of severity of Covid-19 was categorized as nonsevere in 926 patients and severe in 173 patients. Patients with severe disease were older than those with nonsevere disease by a median of 7 years. Moreover, the presence of any coexisting illness was more common among patients with severe disease than among those with nonsevere disease (38.7% vs. 21.0%). However, the exposure history between the two groups of disease severity was similar.
RADIOLOGIC AND LABORATORY FINDINGS
Table 2 shows the radiologic and laboratory findings on admission. Of 975 CT scans that were performed at the time of admission, 86.2% revealed abnormal results. The most common patterns on chest CT were ground-glass opacity (56.4%) and bilateral patchy shadowing (51.8%). Representative radiologic findings in two patients with nonsevere Covid-19 and in another two patients with severe Covid-19 are provided in Figure S1 in the Supplementary Appendix. No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease.
On admission, lymphocytopenia was present in 83.2% of the patients, thrombocytopenia in 36.2%, and leukopenia in 33.7%. Most of the patients had elevated levels of C-reactive protein; less common were elevated levels of alanine aminotransferase, aspartate aminotransferase, creatine kinase, and d-dimer. Patients with severe disease had more prominent laboratory abnormalities (including lymphocytopenia and leukopenia) than those with nonsevere disease.
None of the 1099 patients were lost to follow-up during the study. A primary composite end-point event occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died (Table 3). Among the 173 patients with severe disease, a primary composite end-point event occurred in 43 patients (24.9%). Among all the patients, the cumulative risk of the composite end point was 3.6%; among those with severe disease, the cumulative risk was 20.6%.
TREATMENT AND COMPLICATIONS
A majority of the patients (58.0%) received intravenous antibiotic therapy, and 35.8% received oseltamivir therapy; oxygen therapy was administered in 41.3% and mechanical ventilation in 6.1%; higher percentages of patients with severe disease received these therapies (Table 3). Mechanical ventilation was initiated in more patients with severe disease than in those with nonsevere disease (noninvasive ventilation, 32.4% vs. 0%; invasive ventilation, 14.5% vs. 0%). Systemic glucocorticoids were given to 204 patients (18.6%), with a higher percentage among those with severe disease than nonsevere disease (44.5% vs. 13.7%). Of these 204 patients, 33 (16.2%) were admitted to the ICU, 17 (8.3%) underwent invasive ventilation, and 5 (2.5%) died. Extracorporeal membrane oxygenation was performed in 5 patients (0.5%) with severe disease.
The median duration of hospitalization was 12.0 days (mean, 12.8). During hospital admission, most of the patients received a diagnosis of pneumonia from a physician (91.1%), followed by ARDS (3.4%) and shock (1.1%). Patients with severe disease had a higher incidence of physician-diagnosed pneumonia than those with nonsevere disease (99.4% vs. 89.5%).
During the initial phase of the Covid-19 outbreak, the diagnosis of the disease was complicated by the diversity in symptoms and imaging findings and in the severity of disease at the time of presentation. Fever was identified in 43.8% of the patients on presentation but developed in 88.7% after hospitalization. Severe illness occurred in 15.7% of the patients after admission to a hospital. No radiologic abnormalities were noted on initial presentation in 2.9% of the patients with severe disease and in 17.9% of those with nonsevere disease. Despite the number of deaths associated with Covid-19, SARS-CoV-2 appears to have a lower case fatality rate than either SARS-CoV or Middle East respiratory syndrome–related coronavirus (MERS-CoV). Compromised respiratory status on admission (the primary driver of disease severity) was associated with worse outcomes.
Approximately 2% of the patients had a history of direct contact with wildlife, whereas more than three quarters were either residents of Wuhan, had visited the city, or had contact with city residents. These findings echo the latest reports, including the outbreak of a family cluster,4 transmission from an asymptomatic patient,6 and the three-phase outbreak patterns.8 Our study cannot preclude the presence of patients who have been termed “super-spreaders.”
Conventional routes of transmission of SARS-CoV, MERS-CoV, and highly pathogenic influenza consist of respiratory droplets and direct contact,18-20 mechanisms that probably occur with SARS-CoV-2 as well. Because SARS-CoV-2 can be detected in the gastrointestinal tract, saliva, and urine, these routes of potential transmission need to be investigated21 (Tables S1 and S2).
The term Covid-19 has been applied to patients who have laboratory-confirmed symptomatic cases without apparent radiologic manifestations. A better understanding of the spectrum of the disease is needed, since in 8.9% of the patients, SARS-CoV-2 infection was detected before the development of viral pneumonia or viral pneumonia did not develop.
In concert with recent studies,1,8,12 we found that the clinical characteristics of Covid-19 mimic those of SARS-CoV. Fever and cough were the dominant symptoms and gastrointestinal symptoms were uncommon, which suggests a difference in viral tropism as compared with SARS-CoV, MERS-CoV, and seasonal influenza.22,23 The absence of fever in Covid-19 is more frequent than in SARS-CoV (1%) and MERS-CoV infection (2%),20 so afebrile patients may be missed if the surveillance case definition focuses on fever detection.14 Lymphocytopenia was common and, in some cases, severe, a finding that was consistent with the results of two recent reports.1,12 We found a lower case fatality rate (1.4%) than the rate that was recently reportedly,1,12 probably because of the difference in sample sizes and case inclusion criteria. Our findings were more similar to the national official statistics, which showed a rate of death of 3.2% among 51,857 cases of Covid-19 as of February 16, 2020.11,24 Since patients who were mildly ill and who did not seek medical attention were not included in our study, the case fatality rate in a real-world scenario might be even lower. Early isolation, early diagnosis, and early management might have collectively contributed to the reduction in mortality in Guangdong.
Despite the phylogenetic homogeneity between SARS-CoV-2 and SARS-CoV, there are some clinical characteristics that differentiate Covid-19 from SARS-CoV, MERS-CoV, and seasonal influenza infections. (For example, seasonal influenza has been more common in respiratory outpatient clinics and wards.) Some additional characteristics that are unique to Covid-19 are detailed in Table S3.
Our study has some notable limitations. First, some cases had incomplete documentation of the exposure history and laboratory testing, given the variation in the structure of electronic databases among different participating sites and the urgent timeline for data extraction. Some cases were diagnosed in outpatient settings where medical information was briefly documented and incomplete laboratory testing was performed, along with a shortage of infrastructure and training of medical staff in nonspecialty hospitals. Second, we could estimate the incubation period in only 291 of the study patients who had documented information. The uncertainty of the exact dates (recall bias) might have inevitably affected our assessment. Third, because many patients remained in the hospital and the outcomes were unknown at the time of data cutoff, we censored the data regarding their clinical outcomes as of the time of our analysis. Fourth, we no doubt missed patients who were asymptomatic or had mild cases and who were treated at home, so our study cohort may represent the more severe end of Covid-19. Fifth, many patients did not undergo sputum bacteriologic or fungal assessment on admission because, in some hospitals, medical resources were overwhelmed. Sixth, data generation was clinically driven and not systematic.
Covid-19 has spread rapidly since it was first identified in Wuhan and has been shown to have a wide spectrum of severity. Some patients with Covid-19 do not have fever or radiologic abnormalities on initial presentation, which has complicated the diagnosis.
Supported by the National Health Commission of China, the National Natural Science Foundation, and the Department of Science and Technology of Guangdong Province.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
Drs. Guan, Ni, Yu Hu, W. Liang, Ou, He, L. Liu, Shan, Lei, Hui, Du, L. Li, Zeng, and Yuen contributed equally to this article.
This article was published on February 28, 2020, and last updated on March 6, 2020, at NEJM.org.
We thank all the hospital staff members (see Supplementary Appendix for a full list of the staff) for their efforts in collecting the information that was used in this study; Zong-jiu Zhang, Ya-hui Jiao, Xin-qiang Gao, and Tao Wei (National Health Commission), Yu-fei Duan and Zhi-ling Zhao (Health Commission of Guangdong Province), and Yi-min Li, Nuo-fu Zhang, Qing-hui Huang, Wen-xi Huang, and Ming Li (Guangzhou Institute of Respiratory Health) for facilitating the collection of patients’ data; the statistical team members Zheng Chen, Dong Han, Li Li, Zhi-ying Zhan, Jin-jian Chen, Li-jun Xu, and Xiao-han Xu (State Key Laboratory of Organ Failure Research, Department of Biostatistics, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, and Southern Medical University, respectively); Li-qiang Wang, Wei-peng Cai, Zi-sheng Chen (the Sixth Affiliated Hospital of Guangzhou Medical University) and Chang-xing Ou, Xiao-min Peng, Si-ni Cui, Yuan Wang, Mou Zeng, Xin Hao, Qi-hua He, Jing-pei Li, Xu-kai Li, Wei Wang, Li-min Ou, Ya-lei Zhang, Jing-wei Liu, Xin-guo Xiong, Wei-juna Shi, San-mei Yu, Run-dong Qin, Si-yang Yao, Bo-meng Zhang, Xiao-hong Xie, Zhan-hong Xie, Wan-di Wang, Xiao-xian Zhang, Hui-yin Xu, Zi-qing Zhou, Ying Jiang, Ni Liu, Jing-jing Yuan, Zheng Zhu, Jie-xia Zhang, Hong-hao Li, Wei-hua Huang, Lu-lin Wang, Jie-ying Li, Li-fen Gao, Cai-chen Li, Xue-wei Chen, Jia-bo Gao, Ming-shan Xue, Shou-xie Huang, Jia-man Tang, and Wei-li Gu (Guangzhou Institute of Respiratory Health) for their dedication to data entry and verification; Tencent (Internet-services company) for providing the number of hospitals certified to admit patients with Covid-19 throughout China; and all the patients who consented to donate their data for analysis and the medical staff members who are on the front line of caring for patients.
From the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University (W.G., W.L., J.H., R.C., C.T., T.W., S.L., Jin-lin Wang, N.Z., J.H., W.L.), the Departments of Thoracic Oncology (W.L.), Thoracic Surgery and Oncology (J.H.), and Emergency Medicine (Z.L.), First Affiliated Hospital of Guangzhou Medical University, and Guangzhou Eighth People’s Hospital, Guangzhou Medical University (C.L.), and the State Key Laboratory of Organ Failure Research, Department of Biostatistics, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University (C.O., P.C.), Guangzhou, Wuhan Jinyintan Hospital (Z.N., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology (Yu Hu), the Central Hospital of Wuhan (Y.P.), Wuhan No. 1 Hospital, Wuhan Hospital of Traditional Chinese and Western Medicine (L.W.), Wuhan Pulmonary Hospital (P.P.), Tianyou Hospital Affiliated to Wuhan University of Science and Technology (Jian-ming Wang), and the People’s Hospital of Huangpi District (S.Z.), Wuhan, Shenzhen Third People’s Hospital and the Second Affiliated Hospital of Southern University of Science and Technology, National Clinical Research Center for Infectious Diseases (L. Liu), and the Department of Clinical Microbiology and Infection Control, University of Hong Kong–Shenzhen Hospital (K.-Y.Y.), Shenzhen, the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai (H.S.), the Department of Medicine and Therapeutics, Chinese University of Hong Kong, Shatin (D.S.C.H.), and the Department of Microbiology and the Carol Yu Center for Infection, Li Ka Shing Faculty of Medicine, University of Hong Kong, Pok Fu Lam (K.-Y.Y.), Hong Kong, Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences (B.D.), and the Chinese Center for Disease Control and Prevention (G.Z.), Beijing, the State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou (L. Li), Chengdu Public Health Clinical Medical Center, Chengdu (Y.L.), Huangshi Central Hospital of Edong Healthcare Group, Affiliated Hospital of Hubei Polytechnic University, Huangshi (Ya-hua Hu), the First Hospital of Changsha, Changsha (J. Liu), the Third People’s Hospital of Hainan Province, Sanya (Z.C.), Huanggang Central Hospital, Huanggang (G.L.), Wenling First People’s Hospital, Wenling (Z.Z.), the Third People’s Hospital of Yichang, Yichang (S.Q.), Affiliated Taihe Hospital of Hubei University of Medicine, Shiyan (J. Luo), and Xiantao First People’s Hospital, Xiantao (C.Y.) — all in China.
Address reprint requests to Dr. Zhong at the State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Rd., Guangzhou, Guangdong, China, or at email@example.com.
A list of investigators in the China Medical Treatment Expert Group for Covid-19 study is provided in the Supplementary Appendix, available at NEJM.org.
Samuel James Brake (1), Kathryn Barnsley (2), Wenying Lu (1) , Kielan Darcy McAlinden (1), Mathew Suji Eapen (1) and Sukhwinder Singh Sohal (1),*
(1) Respiratory Translational Research Group, Department of Laboratory Medicine, School of Health Sciences, University of Tasmania, Launceston, Tasmania 7248, Australia; firstname.lastname@example.org (S.J.B.); Wenying.Lu@utas.edu.au (W.L.); email@example.com (K.D.M.); firstname.lastname@example.org (M.S.E.)
(2) School of Medicine, University of Tasmania, Hobart, Tasmania 7001, Australia;
* Correspondence: email@example.com; Tel.: +61-424-753-373
J. Clin. Med. 2020, 9(3), 841; https://doi.org/10.3390/jcm9030841
Received: 17 March 2020; Accepted: 18 March 2020; Published: 20 March 2020
|Age group||Fatality rates|
|40 – 49 years||0.4%|
|80 years and above||14.8%|
|Underlying health conditions|
|Chronic respiratory disease||6.3%|
|No underlying health conditions||0.9%|
(2) Are smokers more likely to contract and transmit SARS-CoV-2 than non-smokers?
(3) Are demographics with high smoking rates more vulnerable to Covid-19 outbreaks?
Conflicts of Interest
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