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 INSPILIP Digital Scientific Journal Código ISSN 2588-0551

Open Access Review article

A Perspective about Coronavirus Disease 2019 (COVID-19)

Citation

Farfan-Cano, G. A Perspective Galo Guillermo Farfán Cano a,

about Coronavirus Disease 2019
(COVID-19). Digital Scientific
Journal INSPILIP. V. (4) Num 2,
Guayaquil, Ecuador
Correspondence
a. Society of Infectious diseases of Guayas, King Juan Carlos University, University of
Guayaquil, Northern of Guayaquil General Hospital "Los Ceibos" (IESS). Guayaquil,
Ecuador. galofarcan@gmail.com
Identification of the responsibility and contribution of the authors:
The author declare to have contributed similarly to the original idea, study design, data
collection, data analysis, writing the draft and writing the article (GFC).

Galo Farfán Cano. Guayaquil,

Abstract
Ecuador. Email:
galofarcan@gmail.com COVID-19 is the acronym for coronavirus disease 2019, which is caused by
SARS-CoV-2, that was isolated and genotyped from respiratory samples

Received: 03/26/2020 collected from patients in the city of Wuhan (China), after an outbreak of
Accepted: 04/30/2020 pneumonia of non-identified etiology on december 2019. Its arrival to
Published: 05/04/2020
Ecuador has highlighted the relevance of this microorganism, and its
characteristics. Below, we propose a brief review of the literature in relation
The authors declares to be free from any
personal or commercial association that of this new pathogen and its disease, as well as key points for its control at
may pose a conflict of interest in
connection with the article, as well as health facilities.
having respected the ethical principles of
research, such as having requested Keywords: Communicable Diseases; Coronavirus; SARS Virus; COVID-19;
authorizations from the institution where
the study was carried out. , permission to
use the data, informed consents and in the
case of observational studies and clinical
trials, authorization from a CEISH, ARCSA,
DIS, Environment, among others. In
addition, the license to publish images of
the person or persons that appear in the
manuscript. Therefore, the magazine is
not responsible for any damage to third
parties.

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Abstrato among the population; Initially named

COVID-19 é o acrónimo para doença Wuhan virus, it was later renamed 2019-

coronavírus 2019, que é causada pela SRA- nCoV (2019 novel coronavirus) and was

CoV-2, que foi isolada e genotipada a partir determined to be an agent of the

de amostras respiratórias recolhidas de coronavirus family, closely related to

doentes na cidade de Wuhan (China), após SARS-CoV, the causative agent of the 2003

um surto de pneumonia de etiologia não severe acute respiratory syndrome (SARS).

1, 2
identificada em dezembro de 2019. A sua

chegada ao Equador destacou a relevância The government of the People's Republic of

deste microorganismo, e as suas China, through the Chinese Center for

características. A seguir, propomos uma Disease Control, reported the outbreak to

breve revisão da literatura em relação a the WHO on January 3, 2020; As of January

este novo patógeno e sua doença, bem como 30, 2020, the WHO Director-General

pontos-chave para seu controle nas declared the outbreak of a new strain of

unidades de saúde. coronavirus as a public health emergency of

Palavras-chave: Doenças Transmissíveis; international importance (the fifth time

Coronavirus; Vírus SARS; COVID-19; since 2005), for the various health systems

Introduction to prepare to take preventive and

It is estimated that between late November contingency measures, because of the

and early December 2019 in the People's possible global spread of the disease; on

Republic of China, in the city of Wuhan in March 11, 2020, the WHO, through the

Hubei Province, an epidemiological event Director-General, declared COVID-19

of interest occurred, when a series of reports (coronavirus disease 2019) a pandemic. 3, 4,

5
of pneumonia of unknown origin appeared

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Figure 1. COVID-19 case distribution map.

Source: World Health Organization; Available from
https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd

The pandemic as of 19 March 2020 reported M [matrix transmembrane protein located

242,191 confirmed cases, 84,962 recovered inside the envelope]). 8

and 9843 deaths worldwide 6. Ecuador Coronaviruses, including OC43, NL63,

remains in widespread quarantine; April 22 hCoV-229E, and HKU1 which very

reports 10,850 confirmed cases, 1262 commonly affect humans, generally cause

recovered and 537 deaths confirmed by mild respiratory infections; viral agents

COVID-19. 7 such as Severe Acute Respiratory

Development Syndrome Coronavirus (SARS-CoV) and

Virological aspects the Middle East Respiratory Syndrome

Concerning microbiology, the family Coronavirus (MERS-CoV) usually appear

Coronaviridae are single-stranded as zoonotic infectious agents in humans,

enveloped RNA viruses (with two viral through a series of mutations until they

glycoproteins, S [richly glycosylated] and reach humans, which is what was presumed

to have caused the 2019-nCoV infection. 9

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11
Zhu et al. , were able to isolate from

alveolar bronchial wash samples from 7

patients in Beijing, from which nucleic

acids were subsequently extracted, using

cell culture media, performing impartial

Figure 2. Novel Coronavirus SARS-CoV-2
(Electronic particle transmission micrograph of
high-performance sequencing (for viruses
SARS-CoV-2 virus isolated from a patient).
Captured and color-enhanced image at NIAID's and bacteria, as etiology was unknown),
Integrated Research Center (IRF) in Fort Detrick,
Maryland. Credit: NIAID. Available from: and Real-Time Reverse Transcription PCR
https://www.flickr.com/photos/niaid/49645402917/.

In 2002, cases of severe acute respiratory (RT-PCR) assay for viral RNA detection,

syndrome were reported in China's with the "goal of obtaining a consensus

Guangdong province. The virus was spread RdRp region of bread-CoV"; the extracted

by a doctor who treated these patients while RNA was used as a template for cloning and

staying at a hotel in Hong Kong on February genome sequencing, obtaining 20.000 viral

21, 2003, who became ill and died the next readings from individual samples, showing

day. During his stay at the hotel, he was able over 85% identity with a bat-SARS-like

to transmit the virus to 10 other residents in CoV (bat-SL-CoVZC45, MG772933.1). 11

Singapore, Vietnam, Canada, and the To further characterize the virus, they

United States. This small group, in turn, proceeded to obtain de novo sequences of

allowed the spread of the infection to 8000 the 2019-nCoV genome, from clinical

other people in 29 countries. Ten years later samples and isolation of respiratory

in the Arabian Peninsula, cases of severe epithelial cell viruses, obtaining two near-

pneumonia were reported, with 50% death complete coronavirus sequences

among the infected 10. (BetaCoV/Wuhan/IVDC-HB-04/2020,

BetaCoV/Wuhan/IVDC-HB-05/2020

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EPI_ISL_402121) and a full sequence conclusion the isolated viruses were distinct

(BetaCoV/Wuhan/IVDC-HB-01/2020 from MERS-CoV and SARS-CoV, the

11
EPI_ISL_402119) , which had 89% three coronaviruses [2019-nCoV Wuhan,

nucleotide sequence identity with CoV (bat- together with 2 SARS-like strains derived

SL-CoVZC45, MG772933.1), for which from bats (ZC45 and ZXC21)] form a

they were grouped within the sarbecovirus distinct clade, and were therefore

subgenre, which has the typical determined to constitute a new viral agent

organization of a betronaacovirus; in (2019-nCoV).11

Figura 3. Organización del genoma del SARS-CoV-2 (aislamiento Wuhan-Hu-1, GenBank Acc
MN908947). Furfur. Wikimedia Commons, the free media repository. Crédito: Furfur. Disponible en:
https://commons.wikimedia.org/wiki/File:SARS-CoV-2_genome.svg. Licencia CC-ASA-4.0
internacional.
Yang et al. 12 proposed that the Vero E6 and Huh7 cells; in serum

angiotensin-converting enzyme receptor neutralization trials in Vero E6 cells, using

could be key in 2019-nCoV infection for the the five patient serums that were positive for

virus to access systemic circulation, and IgG. The researchers report that all samples

infect other organs with such receptors, like were able to neutralize 100 DICT50

SARS-CoV 2002-2003. 12 (infectious dose of tissue culture at 50%), as

Zhou et al. 13, successfully isolated the well as cross-neutralization with anti-

virus (called 2019-nCoV SARS-CoV horse serum at dilutions of

BetaCoV/Wuhan/WIV04/2019) from the 1:40. 13

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14
Kim et al. in Korea, they isolated from coronavirus 2 of severe acute respiratory

nasopharyngeal and oropharyngeal samples syndrome (SARS-CoV-2).16

by amplifying the RNA of the replicated Based on microbiological research, it was

virus cell culture medium, and analysis of determined that fluid or tissue samples from

the NGS sequence with a gene compared to the airways are the main source for

57 human coronaviruses (including determining the infectious agent employing

Wuhan), a Beta coronavirus called polymerase chain reaction (PCR)

BetaCoV/Korea/KCDC03/2020, which has detection.10-15

been shown to have a homology greater Clinical manifestations

than 99.5% with SARS-CoV-213. Various The criteria for identifying suspicious cases

authors12-14 determined that SARS-CoV and have changed throughout the evolution and

SARS-CoV-2 have an interaction with the epidemiological dynamics in Ecuador can

angiotensin 2-converting enzyme receptor; range from 4 days to 14 days (interquartile

15
Zhang et al. , Pangolin-CoV as the range of 2-7 days)17-19. Among the main

common ancestor of 2019-nCoV (similarity criteria are the return of countries with

to the 91.02% genome) instead of the Bat- active outbreak 14 days prior to the onset of

CoV RaTG13 (similarity to the 90.55) symptoms, being a health worker in the

genome, plus pangolin-CoV's S1 protein is units and environments that care for patients

more close to 2019-nCoV than RaTG13. 15 with acute respiratory failure of unknown

Thus, with the evidence collected based on etiology, or having a history of contact with

the taxonomy, the coronavirus study group positive cases of COVID-19.17-19

(CSG) formally recognized it as the sister For early-stage symptoms, the most

strain of SARS-CoV, and designated it as common is fever (99%; 88% in hospitalized

patients), followed by fatigue (70%), dry

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cough (59%), anorexia (40%), myalgias The average age affected between 30-50

(35%), dyspnoea (31%) expectoration years; 81% will have mild pictures,

(27%), diarrhoea (4%)9, 19-23. rhinorrhea is unusual19, 22-23.

Pneumonia (this being the most common 14 to 15% will have pneumonia or have

complication) and bronchitis have been severe cadres in need of hospital

reported in advanced stages or as hospitalization, and 5% will have severe

complications of evolution. Irregular cases in need of hospitalization in intensive

shadows, and radiopacity in frosted glass care unit19, 22-23.

have also been reported in chest Lethality ranges from 2 to 3%, it can be

tomography images, in patients with increased to 14% in over 80s, and mortality

COVID-19 9, 19-23. is close to 50% in severe cases22-23. Risk

The onset of dyspnoea has been reported factors include advanced age, baseline

after 8 days; as well as acute respiratory respiratory pathology, comorbidities, and

distress syndrome (ARSD) being common immunosuppression. 19, 22-23

in patients with severe illness, arrhythmias, Diagnosis

acute heart failure, and shock. 9, 19-23 Lymphopenia has been observed in 83% of

The transmission mechanism is by droplets cases, thrombocytopenia in 36%, and may

(greater than 5 microns) at 1 to 2.5 meters be accompanied by elevated C-reactive

19-
away, after prolonged contact with people protein (CRP), transaminases, D-dimer
22
with symptoms, or contaminated surfaces, ; however, for the diagnosis of the

hence it is more contagious in symptomatic infectious agent, the gold standard is real-

phase 19, 22-23. time polymerase chain reaction (RT-PCR),

10-16
from respiratory samples .

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If this methodology is not available, a chest associated adrenal insufficiency is

CT scan can be used, since alterations have considered, the use of hydrocortisone 24

been reported in 86% of cases 19-22, with the should be considered. Echocardiography is

frosted glass sign being the most also recommended in the initial phase and

predominant; it may present in a single lobe the follow-up of resuscitation. Dobutamine

or be multilobar, mono-lobar or bilateral in is recommended in the event of persistent

chest radiography and should call for shock or if myocardial dysfunction.24

bilateral infiltration or patchy lobar. 19-22 Antibiotics are not recommended at the

Therapeutic Recommendations beginning but can be introduced according

There is no specific antiviral treatment, and to clinical, analytical, or microbiological

treatments are therefore conditioned in results, especially when other etiology or

many countries that have implemented bacterial superinfection cannot be ruled out.
24
therapeutic indications based on clinical

trials currently underway. One of the proposed drugs is Lopinavir

Within the clinical management of adults, (protease inhibitor, used in the treatment of

the use of systemic steroids is not generally HIV) potentiated with Ritonavir, as it has

recommended, based on previous studies in been mentioned that it has activity against

patients with MERS, SARS, and even the protease 3CL, with modest activity

influenza, from which it was demonstrated against SARS-CoV-2 20 based on its

that they were not beneficial and even antiviral activity against MERS-CoV in

produced a delay in viral clearance. In cases vitro. 25

of septic shock, vasopressors should be Cao et al, (26) conducted an open,

administered (MAP =/< to 65 mm/Hg), only randomized, controlled trial, which

if prolonged beyond 24 hours and if included hospitalized adult patients with

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confirmed SARS-CoV-2 infection, one room with negative pressure, for the

group was assigned to receive Lopinavir management of severe COVID-19 29. There

400 mg/ritonavir 100 mg (LPV/r) (n 99) are studies with Remdesivir in the United

versus standard care group (EC); the States, South Korea, and China, which have

research did not show a difference in the demonstrated efficacy in animal models for

time of clinical improvement between the SARS-CoV and MERS-CoV. 16, 27, 28

LPV/r group and EC (average of 16 days in Chloroquine (CQ) and hydroxychloroquine

both groups). They showed a shorter stay in (HCQ) have been mentioned as efficient, in

the intensive care unit in the LPV/r group SARS-CoV-2 infection. 29

compared to EC (mean 6 days vs. 11 days The use of hydroxychloroquine in SARS-

respectively), and from randomization to VOC-2 infection has been reported to have

discharge (mean 12 vs. 14 days). Mortality a maximum dose in adults of up to 1200

was numerically lower in the LPV/r group mg/day [CQ maximum dose of 500 mg] 29.

(19.2%) than in EC (25.0%). Clinical It has been stated that it "exerts an antiviral

improvement was higher in the LPV/r group effect during pre- and post-infection

than in EC (45.5% vs. 30.0%). They conditions by interfering with the

concluded that LPV/r did not accelerate glycosylation of angiotensin-converting

clinical improvement significantly, but it enzyme 2 (ACE2) (the SARS-CoV cell

did reduce mortality, and decreased receptor) and blocking the fusion of the

detection of viral RNA in patients with virus with the host cell". 29

severe COVID-19. 26 Gautret et al., conducted a trial in patients

In Spain, therapeutic studies are being from Marseille, who received

carried out with Lopinavir/r + IFN-β1b s.c, hydroxychloroquine sulfate 200 mg 3 times

and Lopinavir/r + IFN -α2b nebulized in a a day for 10 days, while those who did not

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receive the hydroxychloroquine served as a macrophage inflammatory protein 1 alpha

control group. The percentage of patients (MIP1A), and TNF- α have been found;

with negative PCR-RT results in based on this information, Xu et al.,

nasopharyngeal samples differed from 3-4- conducted a study of 21 patients who were

5 and 6 days after inclusion; on the 6th day eligible for treatment with Tocilizumab,

after inclusion, 70% of patients with patients received standard of care regimen

hydroxychloroquine were virologically with Lopinavir, methylprednisolone, other

cured, compared to 12.5% of the control symptomatic relief medications, and

group. 30 oxygen therapy, and Tocilizumab 400mg

Tocilizumab has been mentioned as a was added intravenously. They were able to

therapeutic alternative in the management show that the body temperature returned to

of COVID-19, based on experimental data; normal limits in all patients on day 1 of

based on the proinflammatory cytokines Tocilizumab, and remained stable

released in the pathogenesis of SARS, thereafter, accompanied by symptomatic

which include Interleukin (IL)-6, Tumor symptomatic relief in subsequent days.

Necrosis Factor α (TNF- α) and IL-12, as Patients significantly increased peripheral

well as on the MERS in which elevated oxygen saturation, 75% of patients required

values of IL-6, IL- 1β and IL-8 were less supplemental oxygen. One patient was
19
detected . Similarly, in intensive care taken off mechanical ventilation on day 1.

patients with COVID-19, elevated values of Another critical patient was taken off

IL-6, IL-2, IL-7, IL-10, granulocyte colony- ventilation and regained consciousness on

stimulating factor (G-CSF), interferon- day 5. 90.5% of the patients were

inducing protein-γ (IP10), monocyte discharged (including two critical patients),

chemoattractant protein (MCP1), and the rest remained in hospital, but

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without heat spikes, and with notable of QT prolongation; its use is recommended

improvement in symptoms; concluding that in combination with hydroxychloroquine,

symptom relief, as well as a decrease in the as it enhances the effect of the latter. 30

deterioration of patients with severe Fluid therapy should be used only in

COVID-19, was evident in the group that patients with shock, and the use of systemic

received tocilizumab. 19, 31-34 steroids should be avoided (except for

24
Within hospital management, there is no asthma as background comorbidity) .

proven evidence against the use of non- Pronation has been mentioned as a possible

steroidal anti-inflammatory drugs factor in improving prognosis by not

(NSAIDs) in these patients, but paracetamol worsening from a respiratory point of view.

I always preferred 22. 24

The use of antibiotics is not generally Favipiravir (FPV) is an antiviral medication

recommended in these cases, but if that was subjected to an open control study

necessary ceftriaxone or doxycycline are as an experimental treatment for COVID-

recommended instead of quinolones or 19, versus Lopinavir/Ritonavir (LPV/r)

macrolides since the latter and some days 1-14, 400/100 mg twice a day) plus

pharmacological agents used in antiviral IFN-α by aerosol inhalation (5 million U

treatment can prolong the QT wave. 22 twice a day), while FPV was administered

Azithromycin has been mentioned for on day 1 at doses of 1600 mg twice a day

showing in vitro activity against Zika and and from day 2-14 at doses of 600 mg twice
30
Ebola , viruses, as well as in the a day, plus interferon (IFN) -α by aerosol

prevention of severe respiratory tract inhalation (5 million U twice a day); the

infections, however, its use should be FPV arm showed significant improvement

considered with caution because of the risk in chest imaging (91.43%) compared to the

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control group. Multivariate Cox regression as well as the use of surgical masks (based

showed faster viral clearance with FPV. 34 on the method of transmission), while FPP2

A multicenter, open-label, randomized trial and FPP3 respirators are recommended in

35
was also conducted comparing EC + FPV the case of procedures that generate

vs Arbidol from February 20 to March 12 in aerosols. 19

patients with uncomplicated disease; a Among the key points recommended for

clinical recovery rate of 71.43% with FPV prevention in the hospital environment, are

and 55.86% with Arbidol was observed; a limiting how the virus can enter the facility

reduction in cough relief and fever and infect others (especially by canceling

reduction time was also evident among elective procedures, enabling the use of

patients without comorbidities, as well as in telemedicine, limiting entry and exit points

patients with hypertension or diabetes who to health facilities) 36.

35
received FPV . Among the adverse Isolation precautions should be instituted

effects, reactions of psychiatric symptoms, for symptomatic patients as soon as possible

gastrointestinal symptoms, and uric acid in a ventilated area and separate triage

elevation were observed in 2.5% of cases. should be performed (preferably by placing

Therefore, Chen and collaborators (2020) patients with suspected VID-19 in rooms

propose it as a therapeutic alternative, based with closed doors and private bathrooms) 36.

on the improvement observed after 7 days Healthcare personnel should be protected

of treatment in uncomplicated patients. 36 by emphasizing hand hygiene, installing

Infection prevention and control barriers to limit contact with triage patients,

Hand hygiene is the main method to avoid prioritizing the use of particle filtering

the transmission of the virus both in the respirators, and isolation rooms for airborne

community and in the hospital environment, pathogens 36.

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For those patients who require procedures removed between patients or is

that generate aerosols (since the most contraindicated by the manufacturer. 39

common route of dissemination is airborne, In case of a shortage of hospital

without ruling out hand contact with disinfectants, decontamination can be

colonized surfaces or by the generation of performed with 0.1% sodium hypochlorite

aerosols) 36. (1:50 dilution if household bleach is used at

Healthcare personnel in contact with a an initial concentration of 5%) after

38
confirmed or suspected case of VOC-19 cleaning with a neutral detergent ,

should wear personal protective equipment although no data are available for the

(PPE) for contact, droplets and airborne effectiveness of this approach against

pathogens: fit-tested FFP2 or FFP3 SARS-CoV-2; surfaces that may be

respirator (N95), eye protection (i.e., damaged by sodium hypochlorite can be

goggles or face shield), long-sleeved gown cleaned with a neutral detergent, followed

and waterproof gloves 38. by 70% ethanol. 39-40.

41
To optimize the use of PPE, especially in Van Doremalen et al. , analyzed the

the event of a shortage, it is acceptable for stability of SARS-CoV-2 in aerosols and on

staff to use the same respirator while caring surfaces, describing that in aerosols the

for several patients with the same diagnosis virus remained viable for 3 hours (mean 1.1

(without removing the respirator, if the to 1.2 hours), in copper the viability was

respirator is not damaged, dirty or similar; the longest viability was in plastic
39
contaminated) , as this will moderate the (6.8 hours) and stainless steel (5.6 hours);

consumption of PPE. The maximum time a thus they propose that the transmission of

respirator can be used is 4 hours if it is not SARS-CoV-2 by aerosols and fomites is

plausible since it can remain viable for

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37, 38
hours in aerosols and even days on surfaces. secretions, or other bodily fluids . It is
41
currently not possible to specify a longer

The use of facemasks and respirators is safe life of the N-95 disposable respirator,

based on previous experience of the H1N1 but based on experience in industrial

pandemic, hence the recommendation that environments 8 hours of continuous or

NIOSH-certified surgical masks and N95 intermittent use have been indicated as a

respirators (which have a 95% particle safe duration37-40. Its prolonged use or reuse

filtering capacity) and FFP2 (which have a by the same user is recommended in

92% filtering capacity) or FFP3 (which scenarios such as the H1N1 influenza

have a 99% filtering capacity). 41-42 pandemic, as long as it retains its unaltered

The widespread use of N95 ventilators has shape, and its fixation on the face is

been strongly commented on in patients adequate, always consulting experts in

with pulmonary tuberculosis, especially infection prevention and control. 32

because of the mechanism of transmission Respirators for use in the sanitary

by aerosols, and has recommended them as environment must always comply with

an option for the optimization of PPE, in NIOSH certification

cases of epidemic outbreaks 42, 43. (http://www.cdc.gov/niosh/npptl/respirator

They should not be stored in pockets, plastic s/disp_part/particlist.html) 45, can be used in

bags, or confined areas. Continuous use of addition to the N series, the R (oil particle

up to 8 hours or no more than 5 uses is resistance) and P (strongly resistant oil

recommended 42. However, they should be particle resistant) 95, 99 and 100 46. The

discarded after use during aerosol use of valve respirators by the sanitary is

generation procedures, or if they are recommended in the same patients that a

contaminated with blood, respiratory surgical mask would be used (except for

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surgical procedures, and only to prevent No scientific evidence has been found to

particles or infectious agents pass from the recommend the use of the NBC suit used in

patient to healthcare personnel). 45, 46 Ebola case care, to perform the care of
46-49
A standardized process involving rapid patients with COVID-19 , what

triage, isolation, and displacement of PAHO/WHO recommends is the use of a

patients with suspected COVID-19 should disposable long-sleeve gown to protect the

be created to minimize the risk of clothing of health personnel. In any case,

transmission and exposure of healthcare the use of PPE by health workers requires
44, 46
personnel and other patients . Current an assessment of the risk of transmission, as

recommendations include a single room, previously stated.

negative pressure room with at least 6 air Conclusions

changes per hour. 18, 44-46 SARS-CoV-2 is a betacoronavirus

The best strategy is prevention, avoiding (zoonotic viral agent) whose origin is not

touching your face with your hands, elucidated, and has been associated with a

especially the T-zone (eyes, nose, and mutation from preventing coronaviruses of

mouth), frequent hand washing, more if you bats or pangolins, which were transmitted to

are health workers, avoiding trips to areas humans; its route of dissemination between

with outbreaks or community distribution, humans is by droplets or aerosols (in

and in health workers the correct use of PPE sanitary facilities), as well as by contact of
46
. mucous membranes with particles on

Strategies should be implemented to surfaces through the hands.

optimize the supply of N95 respirators, such Symptoms are varied, with fever and fatigue

as extended use or reuse up to 5 times. 46, 47 being the most common, it can be

NBC suit (chemsuit)? associated with myalgia and dyspnoea

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(which can help us rule out diseases such as References

Dengue, Zika, or Chikungunya), diarrhoeal 1. Yoo J. The Fight against the 2019-nCoV
Outbreak: an Arduous March Has Just
bowel movements and other gastrointestinal
Begun. Journal of Korean Medical Science
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