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MARCH 24, 2020 -- Health officials and medical experts are racing to contain the rapidly spreading 2019 novel coronavirus (2019-nCoV), which has infected more than 43,107 individuals and killed more than 1018 in 25 countries as of February 11, according to the World Health Organization (WHO).
With the rapidly changing information, researchers are reporting two new case-series studies from China and a review of case-finding information in the United States. The largest case series published to date highlights the risk for hospital staff in the early part of the outbreak, with nearly one third of cases occurring in healthcare professionals.
Also today, the WHO announced that there is now an official name for the disease caused by this virus: COVID-19. "COVI" stands for coronavirus and "D" stands for disease.
Persons Evaluated for 2019 Novel Coronavirus in the United States
As of February 11, the total number of cases in the United States was 13, with the most recent case confirmed in California.
In January 2020, experts at the Centers for Disease Control and Prevention (CDC) answered clinical inquiries regarding approximately 650 individuals in the United States and tested 210 symptomatic persons for 2019-nCoV infection, according to a report published online February 7 in Morbidity and Mortality Weekly Report. Overall, 11 of the 210 screened tested positive for 2019-nCoV (and are included in the 13 patients currently reported in the United States).
Of those screened, 148 (70%) had travel-related risk only, 42 (20%) had been in close contact with an ill laboratory-confirmed case or with a person under investigation (PUI), and 18 (9%) reported both travel- and contact-related risks, Kristina L. Bajema, MD, from the Epidemic Intelligence Service and the National Center for Immunization and Respiratory Diseases, both at the CDC, and colleagues report.
Most (178 patients; 85%) of the individuals who required testing were identified in a healthcare setting, 26 (12%) through contact tracing, and six (3%) through airport screening.
In January, all testing had to be done in CDC laboratories. However, on February 4, the US Food and Drug Administration issued an emergency-use authorization for the CDC's 2019-nCoV Real-Time RT-PCR Diagnostic Panel, which allows it to be used at any CDC-qualified laboratory in the United States, which may speed testing and case finding.
Case Series of 138 Hospitalized Patients in China
Meanwhile, in the largest case series published thus far, Dawei Wang, MD, Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China, and colleagues found that patients infected with 2019-nCoV may appear to be doing well for the first several days of illness before becoming critically ill.
Among the 138 hospitalized patients included in the report, which was published online February 7 in JAMA, the median time from first symptom to the development of dyspnea was 5.0 days, to hospital admission was 7.0 days, and to acute respiratory distress syndrome (ARDS) was 8.0 days.
"What that's telling you is that this virus is really acting different [from other viral outbreaks]; this virus, when it gets in you, adapts itself so that you can wind up days later getting really serious disease…I think that's a heads up: If somebody comes in and has moderate to minimal symptoms, stay heads up for some deterioration over the next few days," Anthony Fauci, MD, Director, National Institute of Allergy and Infectious Diseases told JAMA editor Howard Bauchner, MD, in a February 6 interview.
The single-center case series, which included consecutive patients hospitalized with 2019-nCoV–infected pneumonia (NCIP) in Wuhan, China, between January 1 and January 28, 2020, revealed another noteworthy statistic: almost one third of patients (n = 40; 29%) were healthcare professionals presumed to be infected while in the hospital.
Most patients were treated with antiviral therapy (oseltamivir, 124 patients; 89.9%), and almost two thirds received antibacterial therapy (moxifloxacin, 89 [64.4%]; ceftriaxone, 34 [24.6%]; azithromycin, 25 [18.1%]; and glucocorticoid therapy, 62 [44.9%]).
"Bilateral distribution of patchy shadows and ground glass opacity was a typical hallmark of CT scan for NCIP," Wang and colleagues write.
Thirty-six patients (26.1%) required intensive care unit (ICU) admission for treatment of organ dysfunction, including acute respiratory distress syndrome (22 [61.1%]), arrhythmia (16 [44.4%]), and shock (11 [30.6%]).
When the investigators compared those who required intensive care with those who did not, they found that the ICU patients were more likely to be older (median age 66 years vs 51 years), and to have underlying comorbidities, such as hypertension (21 [58.3%] vs 22 [21.6%]), diabetes (8 [22.2%] vs 6 [5.9%]), cardiovascular disease (9 [25.0%] vs 11 [10.8%]), and cerebrovascular disease (6 [16.7%] vs 1 [1.0%]).
The proportions of men and women who needed ICU care compared with less seriously ill patients did not differ; this finding was inconsistent with a previous study that found that men were more likely to require ICU admission than women.
In addition, patients admitted to the ICU were more likely to experience sore throat, dyspnea, dizziness, abdominal pain, and anorexia.
Respiratory care for the ICU patients included high-flow oxygen therapy for four patients (11.1%), noninvasive ventilation for 15 patients (41.7%), and invasive ventilation for 17 patients (47.2%), four of whom were switched to extracorporeal membrane oxygenation.
"The onset of symptoms may help physicians identify the patients with poor prognosis. In this cohort, the overall rates of severe hypoxia and invasive ventilation were higher than those in the previous study, likely because the cases in the previous study were from the early epidemic stage of the NCIP, and the current cases are from the stage of outbreak," Wang and colleagues write.
Hospital-related Transmission Common
Based on clustering, timing of infection, and a possible source, Wang and colleagues suspect hospital-related infections occurred in 57 (41.3%) patients, of whom 17 (12.3%) were already in the hospital for other reasons and 40 (29%) were healthcare professionals.
Seven of the hospitalized patients were from the surgical department, five were from internal medicine, and five came from the oncology department. Of the healthcare workers who were infected, 31 (77.5%) worked on general hospital units, seven (17.5%) in the emergency department, and two (5%) in the ICU.
One patient came in with abdominal symptoms and was admitted to the surgical department. This patient was presumed to have infected 10 healthcare workers as well as four or more hospitalized patients in the same ward, all of whom presented with atypical abdominal symptoms.
Wang and colleagues believe rapid person-to-person transmission of the coronavirus may have occurred, in part because of the atypical symptoms that some patients experience early in the disease, Wang and colleagues write.
Case Series of 13 Patients in China
A case series of 13 patients in China adds data on younger patients (median age, 34 years) who were generally healthy at baseline, write De Chang, MD, PhD, College of Respiratory and Critical Care Medicine, Chinese PLA General Hospital, Beijing, and colleagues in a research letter published online February 7 in JAMA.
One patient was 2 years old and one was 15 years old; 10 were male. All but one patient were febrile before hospitalization; patients reported cough (46.3%), upper airway congestion (61.5%), myalgia (23.1%), and headache (23.1%).
Chest imaging revealed scattered opacities in the lower left lung of one patient and ground glass opacity in the right or both lungs of six patients. All patients recovered but 12 remained under quarantine in the hospital at the time of writing.
The authors speculate that the reason for the relatively few cases in very young and older individuals could be related to less frequent travel by younger and older individuals as opposed to decreased susceptibility.
"These data contribute information to understanding the early clinical manifestations of 2019-nCoV," Chang and colleagues write.
Recommendations for Clinicians
Clinicians should be aware of the general symptoms of COVID-19, many of which overlap with influenza, and ask about travel history for patients who present with fever and respiratory symptoms, "in particular a dry cough," write Carlos del Rio, MD, Division of Infectious Diseases at Emory University School of Medicine, Atlanta, Georgia, and Preeti N. Malani, MD, MSJ, Division of Infectious Diseases at the University of Michigan, Ann Arbor, and Associate Editor, JAMA, write in viewpoint published online February 5 in JAMA.
A patient who has traveled to Hubei Province during the last 14 days is considered a PUI. Clinicians who encounter a PUI should notify their facility's infection prevention team and their local or state health department. "State health departments then notify the CDC's Emergency Operations Center."
In addition to having the patient tested for 2019-nCoV, del Rio and Malani recommend that clinicians test patients for other respiratory pathogens, and, as this is influenza season, consider giving oseltamivir while awaiting results of influenza testing.
They note that wearing a regular face mask is probably not helpful unless there is a high likelihood of coronavirus exposure; however, if clinicians strongly suspect a patient might have 2019-nCoV, a face mask should be placed on the patient immediately and healthcare personnel should wear N95 respirators.
At this time, management of 2019-nCoV is mostly supportive. Researchers are studying the use of lopinavir/ritonavir, as previous studies found a possible clinical benefit in patients with SARS and MERS. The first US patient identified was treated with remdesivir, which is available through compassionate use.