Thursday afternoon, I brazenly told my director that the coronavirus needn’t warrant immediate concern. I didn’t want to add to the typical hysteria that leads to people purchasing too many medical supplies that then results in a supply chain shortage. After all, it seemed well contained in China and the case in Washington State was so far away. I went on to ensure him that I would keep an eye on things. Exactly six minutes later, news broke of a suspected case in College Station, Texas, which was just 100 miles away (face in palm). Since then, three more US cases have been confirmed in the Chicago area and Southern California with more around the world. This is clearly not entirely confined to China and therefore it was time to do some further investigation.
An outbreak of a 2019 novel coronavirus (2019-nCoV) in Wuhan City, Hubei Province, China began in the final days of 2019. Patients afflicted with the virus have been linked to a seafood and animal market in Wuhan. Recent reports indicate the virus has made its way out of China and into multiple countries.
What is the Coronavirus?
Coronavirus is the name for a family of common viruses. It is likely that within a lifetime, most people have had a coronavirus that felt much like the common cold. These viral illnesses affect the upper respiratory system with symptoms that include runny nose, sore throat, and headache. In immunocompromised patients, infants, the elderly, and those with significant comorbidity, a coronavirus can have a more profound effect, progressing to a lower respiratory tract illness. Most reports suggest that the elderly, infirm and those with significant comorbidities are the most likely to require intensive care or to die. This is similar to the pattern we see in patients infected with influenza. The case fatality rate is as yet uncertain but appears to be significantly higher than that with seasonal influenza.
What makes this strand different?
This virus, now called 2019 Novel Coronavirus (2019-nCoV), is unique in that it is able to mutate and cross species from animal to human. There are striking similarities with both the Severe Acute Respiratory Syndrome coronavirus (SARs-CoV) of 2002, and the Middle East Respiratory Syndrome coronavirus (MERS-CoV) 1of 2012/2015, both causing increasingly severe and sometimes fatal symptoms in patients.
Discussion surrounding the notion that animals are likely the culprit has researchers in opposition. The Journal of Medical Virology published that “snake is the most probable animal reservoir”2 but other researchers remain skeptical. Virologists quoted in Science News believe it to be unlikely, stating that “animal reservoirs for human viruses tend to be mammals” and further state that the genetics for this specific virus suggest bats.3 At the time of writing we just don’t know yet, with more information and speculation appearing daily.
Patients testing positive for the 2019-nCoV present with a variety of common symptoms including fever, cough, and fatigue. A Lancet article posted January 24th, provides detailed clinical data and outcomes of 41 positive 2019-nCoV patients from a hospital in Wuhan.4 Whilst the patients presented with a variety of common complaints, notably these were primarily lower respiratory tract symptoms (dry cough, shortness of breath), as opposed to upper respiratory tract symptoms (such as rhinorrhea, sneezing, or sore throat). All 41 had pneumonia with abnormal findings on chest CT, specifically bilateral subsegmental ground-glass opacities. Of these patients, one-third were admitted to the ICU and six resulted in death. The authors note that the fatal cases resemble the presentation of SARS-CoV. The median onset of symptoms to dyspnea was 8 days, to ARDS was 9 days, and to mechanical ventilation was 10.5 days.4
According to the World Health Organization, “Not enough is known about the epidemiology of 2019-nCoV to draw definitive conclusions about the full clinical features of disease, the intensity of the human-to-human transmission, and the original source of the outbreak”.5 What we can assert from the evidence is that the virus can be transmitted from person to person via droplets if not using any PPE such as a kn95 mask, as the patient population with no link to the animal market continues to grow.
Current thinking is that the disease has a transmission rate of >1 (each person infects more than one other person) and that it is transmissible before symptoms appear. This combination of high asymptomatic transmissibility is not good news and essentially means that under normal circumstances the disease would be self sustaining in a population.
In China, travel bans and restrictions have been initiated in an effort to quarantine the virus, and emergency hospitals have been constructed to meet the needs of quickly rising patient population. In other parts of the world, screening stations have been established in international airports. In the UK, recent travellers from Wuhan have been advised by the government to remain indoors and avoid contact with others, even if asymptomatic.6 Many hospitals are implementing High Consequence Infectious Disease Screening tools to assist clinicians in their care of potentially infected patients. Various governmental health organizations are updating information and statistical data daily. The data sharing and consortiums in place to protect the public through scientific knowledge sharing are quite impressive. Of note, the initial reports from clinicians in Wuhan published in the Lancet and the New England Journal of Medicine have been made open-access and freely available.
The news is scary. As clinicians, we have to be mindful that laypersons see headlines and articles filled with alarming statistics, and the first hint of a cough then becomes terrifying. It is also frightening when little is known about this virus and if you, their trusted clinician, don’t have the answers (even if it’s because there are none), this can increase anxiety. Have patience with your patients and remind them of the common practices that eliminate transmission of droplet spread viruses: hand hygiene, avoiding people who are sick, staying home if ill, covering coughs and sneezes, disinfecting frequently touched surfaces, and other similar common sense measures.
In addition to the usual excellent care you provide your patients, specifically ask about travel history from affected areas in your history-taking. Check out our previous blogs on how to take a good travel history here.7 Be sure to check in with your local/state or national health department for regular updates and take a moment to verify your facilities policy and screening tools for High Consequence Infectious Disease. Report confirmed cases to the appropriate authorities. Utilize appropriate PPE and as always, look after yourself and your team. Look at our post from Janos on the MERS outbreak in 20151 too for some more information on preparing your own department.
Some difficult questions
When SARS and MERS1 came out there was a significant risk to health care workers. We don’t know what the risks are yet with this new coronavirus, but we have heard that healthcare workers have been infected and at least one has died. Healthcare workers typically see patients at a point when they are producing the most amount of virus, and we engage in activities that are in close proximity (e.g. examining a patient), or which cause increased levels of droplets (e.g. nebulisers). The bottom line is that we as healthcare workers are in the front line for this disease and that’s something that we need to think about. The St Emlyn’s team are currently pondering through a number of very difficult questions about how we handle the potential difficulties with this scenario. I’ll give you the questions below as we are keen to hear your views (Ed – I suspect this might be a podcast/new blog soon).
- Where are you going to put suspected patients?
- Is the room where you put them designed for infective patients?
- Is it a negative pressure room?
- Do you have sufficient PPE to manage a patient for what inevitably may be many hours and possibly days in the ED?
- Should you cohort all suspected patients together, or do they need to be isolated from each other?
- When was the last time your team trained with PPE?
- How would you move patients within, or between hospitals, or from the scene?
- How do you choose who treats the patient?
- The most experienced?
- The most senior?
- The most recently trained?
- The ones who are very healthy? (most likely to survive infection)
- Should we exclude certain groups e.g. Pregnancy? (Ed – yes you should).
- Should we ask people to volunteer to be on the corona-team and similarly allow others to opt out of dealing with these patients
- How would you deal with people refusing to come to work?
- What advice would you give people about leaving work? For example – should you handle laundry in dept?
- What advice are you going to give partners and families of those dealing with suspected patients?
- How would you deal with one of your colleagues getting infected/getting admitted/put on ICU/dying of a coronavirus infection?
Maybe you feel that these questions are challenging. They are designed to be, but none are out-with reality. We know from past outbreaks that staff health and wellbeing is a really important part of the response and that these events put an incredibly high psychological burden on colleagues8–12. We have an opportunity to be pro-active and realistic about what might come to pass.
One of my favourite quotes when talking on major incidents is below. It’s very ,very wise advice and applies equally to patients and staff.
Keeping up to date
Lastly don’t forget to keep up to date on the latest developments. It’s likely that by the time you read this the situation may have changed such is the fast moving pace of the incident.
We recommend a daily dip into the following resources.
- BMJ Coronavirus https://www.bmj.com/coronavirus
- NEJM Coronavirus https://www.nejm.org/coronavirus
- Public Health England https://www.gov.uk/government/publications/wuhan-novel-coronavirus-background-information/wuhan-novel-coronavirus-epidemiology-virology-and-clinical-features
- CDC https://www.cdc.gov/coronavirus/index.html
- BMJ Coronavirus https://www.bmj.com/coronavirus
The Numbers as of today (we know these will increase):
SARsCoV -2003- 8,089 infected, 774 associated deaths
MERsCoV- 2012- 2,494 confirmed cases, 585 associated deaths
2019nCoV-2019- 2,030 confirmed cases*, 56 associated deaths*
*as of 1/26/20 at 1300
- 1.Baombe J. How to prepare your department for a Mers outbreak. St Emlyn’s. https://www.stemlynsblog.org/how-to-prepare-your-ed-for-a-mers-cov-outbreak/. Published 2015. Accessed 2020.
- 2.Ji W, Wang W, Zhao X, Zai J, Li X. Homologous recombination within the spike glycoprotein of the newly identified coronavirus may boost cross‐species transmission from snake to human. J Med Virol. January 2020. doi:10.1002/jmv.25682
- 3.Garcia de Jesus E. No, snakes probably aren’t the source of that new coronavirus in China. ScienceNews. https://www.sciencenews.org/article/snakes-probably-not-source-spread-new-coronavirus-outbreak-china. Published January 24, 2020. Accessed January 26, 2020.
- 4.Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet. January 2020. doi:10.1016/s0140-6736(20)30183-5
- 5.World Health Organization. Outbreak of pneumonia caused by the new coronavirus. World Health Organization. https://www.who.int/ith/2020-24-01-outbreak-of-Pneumonia-caused-by-new-coronavirus/en/. Accessed January 26, 2020.
- 6.Public Health England. Wuhan Novel Coronavirus – Information for the Public. gov.uk. https://www.gov.uk/guidance/wuhan-novel-coronavirus-information-for-the-public. Published January 24, 2020. Accessed January 27, 2020.
- 7.Baombe J. Taking a Travel History. St Emlyn’s. https://www.stemlynsblog.org/taking-travel-history-ed-stemlyns/. Published 2017. Accessed 2020.
- 8.Styra R, Hawryluck L, Robinson S, Kasapinovic S, Fones C, Gold WL. Impact on health care workers employed in high-risk areas during the Toronto SARS outbreak. Journal of Psychosomatic Research. February 2008:177-183. doi:10.1016/j.jpsychores.2007.07.015
- 9.Chong M-Y, Wang W-C, Hsieh W-C, et al. Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital. Br J Psychiatry. August 2004:127-133. doi:10.1192/bjp.185.2.127
- 10.Wu P, Fang Y, Guan Z, et al. The Psychological Impact of the SARS Epidemic on Hospital Employees in China: Exposure, Risk Perception, and Altruistic Acceptance of Risk. Can J Psychiatry. May 2009:302-311. doi:10.1177/070674370905400504
- 11.Maunder R, Hunter J, Vincent L, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003;168(10):1245-1251. https://www.ncbi.nlm.nih.gov/pubmed/12743065.
- 12.Lin C-Y, Peng Y-C, Wu Y-H, Chang J, Chan C-H, Yang D-Y. The psychological effect of severe acute respiratory syndrome on emergency department staff. Emergency Medicine Journal. January 2007:12-17. doi:10.1136/emj.2006.035089