Scientific and Medical Advisory Board Position Statement:  Coronavirus, Influenza and other Viral Respiratory Diseases in Adults and Children with Mitochondrial Diseases

Last updated: March 2, 2020

GENERAL BACKGROUND

As the world prepares for a possible pandemic from the novel coronavirus disease (COVID-19 or COVD-19), we are reminded of the 2009 H1N1 Influenza pandemic that prompted the Scientific and Medical Advisory Board (SMAB) of the UMDF to issue a statement to our patients. As background, coronaviruses represent a large family of viruses that cause illnesses that range from the common cold to more severe diseases. Although many of us have probably had a coronavirus infection, having a coronavirus in the past will not be protective against COVID-19.  However, at this time, we have little specific data other than COVID-19 is a highly contagious viral respiratory disease that may have a higher fatality rate than the typical influenza (flu) virus. There are no data about how a patient with a mitochondrial disease will react to COVID-19, but we need to assume that patients with mitochondrial disease will be at a higher risk of adverse outcomes than otherwise healthy individuals. Unlike H1N1, which had the ability to attack the brain, there is no evidence to date suggesting that the coronavirus (SARS-CoV-2) that causes COVID-19 disease does so.  Nevertheless, there are concerns that we really do not know the full extent of the illness as information is limited. We know so little about this strain of Coronavirus because it has never been reported before, having arisen from viruses previously only observed in other species of animals.

In addition to causing respiratory symptoms, all respiratory viruses can also sometimes lead to bacterial infections including ear, eye and sinus infections or even a secondary bacterial pneumonia. In some cases, respiratory viruses can be dangerous, and result in respiratory distress and the need for immediate medical attention.  The risk of dehydration and subsequent organ failure has been noted in early reports, and as with other viral illnesses in mitochondrial patients, early administration of oral and intravenous fluids to prevent dehydration may be a very important part of effective treatment.

Respiratory viruses are especially dangerous for young babies, the elderly and people that have a chronic condition that puts them at risk (diabetes, asthma, heart disease, emphysema, cancer, and probably mitochondrial diseases). Most respiratory viruses do not have an effective antiviral medication although Tamiflu® (oseltamivir) may be helpful if given early in some cases. The internet is becoming crowded with case reports with theoretical treatments for COVID-19, and it is impossible to form a consensus opinion based on the details in these reports that have not undergone the scrutiny of scientific peer review. The best prevention for viruses is getting a vaccine — available for influenza, chickenpox, polio and some other infections. Although never 100% effective against preventing the common influenza illness, the flu vaccine does lower the risk and it is often a less severe illness if it occurs.  The “common” influenza virus can be devastating for persons with mitochondrial disease and the UMDF SMAB does recommend annual flu shots. There is no vaccine for this strain of coronavirus (SARS-CoV-2), and although there are now massive efforts, development, testing and distribution of a safe and effective vaccine will occur over the course of many months and possibly a year.

To keep some perspective, in the U.S., currently the most dangerous virus (influenza) kills as many as 61,000 people per year, with many more getting very sick and needing to be hospitalized.

SPECIFIC RECOMMENDATIONS

Because there are asymptomatic carriers – meaning that you can actually carry the coronavirus (SARS-CoV-2) in your body, but never show signs of the infection, it makes sense to follow some simple recommendations to prevent spread of, or acquiring the disease. Most importantly, let your primary care physician know first if you are experiencing symptoms rather than going to the emergency room. In addition, the U.S. Centers for Disease Control recommends the following:

  1. Avoid crowded public places during the flu season.

  2. Wash your hands with soap and water for at least 20 seconds often during the day. This is especially important after handling or touching surfaces or things where other people may have also touched them as well as after sneezing.

  3. Avoid rubbing your eyes, nose or putting your fingers in your mouth. Viruses can survive for many hours on surfaces you may touch, the virus can transfer to your fingers, then into your body when you touch your eyes, nose or mouth.

  4. Teach your children and others around you to sneeze or cough into a tissue. If they don’t have a tissue, then turn and sneeze into their elbow.  Viruses ride on small invisible drops of mucus from sneezes and coughs and then travel around the room to infect others.  Wash your hands with soap and water after sneezing.

  5. You and your child are most contagious during the first few days of a respiratory illness. Avoid going out where you may infect others and be especially careful of other people in your home. Don’t drink out of the same glasses, wash your hands often, and keep away from those with infection.

  6. Using a lot of cough and cold medications may not be helpful. A healthy diet, a multivitamin that includes zinc, and getting enough rest and exercise are important to prevent and treat viral respiratory infections.  

Additional considerations for patients with mitochondrial disease: Drinking extra fluids every day, before you or your child gets sick, may keep you a few steps ahead of the worst symptoms if you should get ill.

Finally, a few thoughts to parents about keeping their children with mitochondrial disease home from school. Be aware that relatively few children have been identified with COVID-19 disease, and so the impact on children with mitochondrial disease is unclear. If there are other family members attending school or attending a workplace in close proximity to other workers, keeping your child with a mitochondrial disease home from school may be giving you a false sense of security unless you practice effective handwashing and keep your other children away from the child with a mitochondrial disease.  Although strict quarantine may be protective, this seldom occurs in homes. 

If there are signs of illness (fever, cough, runny nose, achiness) then:

  1. A young infant with a mitochondrial disease and a fever should always be seen by a doctor, even if it seems like they just have a cold, as it may be COVID-19 disease, or influenza, which needs to be treated with the same degree of concern as would COVID-19.

  2. Until we know more, it makes sense to see a medical provider if the illness causes a high fever, or a fever that goes away and then comes back. These can be signs of a bacterial infection including pneumonia, ear infections, and sinus infections.

  3. Any sign of difficult breathing, unusual noises with breathing, not being able to drink liquids, severe coughing, extreme tiredness or constant fussiness in an infant or child is serious and requires urgent medical evaluation. Again, this is true for the mitochondrial patient regardless of a coronavirus pandemic.

  4. A parent or caregiver who is uncomfortable with the condition should be taken seriously and be encouraged to seek medical care.

  5. Protective face masks do not protect you from getting a respiratory infection as air comes in around the mask. They do however help prevent the person who is sick from spreading the virus to people around them. If you are sick, sneezing or coughing, you should stay home. Wearing a mask when you go out in public would limit contamination of other people but your mask will need to be replaced frequently, depending on the type of mask, at least daily.

Pneumonia and other problems from a respiratory illness can be very dangerous.  Antibiotics are effective for bacterial infections that can occur as a result of viral infections.  Getting medical attention can be life-saving.

Knowing when the flu and other dangerous viruses that are circulating in the community can help you in making sure that your family is not exposed. In public health emergencies (such as COVID-19 disease), take ALL possible precautions. Getting information from your local health department, the U.S. Centers for Disease Control (CDC) is important as not all information resources are safe and reliable. There is a smartphone app for the CDC or you can always access the most up-to-date information at www.cdc.gov.