2019-Coronavirus: What Clinicians Need to Know

1. Clinical Context Concern continues to grow regarding the spread and clinical effect of the 2019 novel coronavirus first described in Wuhan, China. According to report from the World Health Organization (WHO) released on January 30, 2020, there were 7818 confirmed cases of infection globally so far. [1] Nonetheless, 18 countries have confirmed cases of the 2019 novel coronavirus. As of January 31st, WHO declared the 2019 Novel Coronavirus outbreak a global emergency of international concern.The outbreak of the 2019 novel coronavirus coincides with China's Lunar New Year, its busiest travel period of the year. Should foreign travelers avoid this celebration, given the risk for infection? The Centers for Disease Control and Prevention (CDC) says yes: It has issued a level 3 warning regarding all travel to China, which means that all nonessential travel should be avoided. Although the CDC's warning pertains to avoiding travel to any part of China, the Chinese government has already shut down all transportation in the city of Wuhan and other cities in Hubei province.Many more individuals might still develop an infection with the 2019 novel coronavirus. The incubation period of the virus is currently estimated to range from 2 to 10 days. However, more detailed information from those already infected is needed to determine the infectious period of the virus. One key unanswered question is whether the virus can be transmitted during the incubation period or from an asymptomatic person. The WHO and CDC continue to monitor this rapidly advancing situation and have provided interim guidelines to aid healthcare professionals in the diagnosis and management of this infection. The WHO has published updated advice for international travel on their website.[2] https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.htmlHuge knowledge gaps remain on the epidemiological, clinical, laboratory and radiological characteristics of this virus. The goal of this clinical brief is to provide information to healthcare professionals on what they need to know to manage this outbreak.Study Synopsis and Perspective In a recently published study by Chaolin Huang, MD, from Jin Yin-tan Hospital, Wuhan, China, and colleagues, published online January 24 in the Lancet, the epidemiological, clinical, laboratory, and radiological characteristics of the 2019 novel coronavirus was described in patients who were admitted to designated hospitals in Wuhan, China, with laboratory-confirmed diagnosis of 2019-nCoV.[3] Data were obtained from electronic medical records of patients (from December 16, 2019, to January 2, 2020), as well as from direct communication with patients and their families, using data collection forms. Data forms were independently reviewed by 2 researchers. They compared outcomes of patients admitted to the intensive care unit vs outcomes of those who were not.The researchers' findings indicated that of the 41 patients admitted with confirmed infection with 2019-nCoV, 27 (66%) had been exposed to the seafood market in Huanan. One family cluster was identified. Of the 41 patients, 30 (73%) were men and less than half (32%) had some form of comorbid condition (diabetes, 20%; hypertension, 15%; cardiovascular disease, 15%). Common presenting symptoms of the illness were as follows:• Fever, n=40 (98%)• Cough, n=31 (76%)• Lymphopenia, n=26 (63%)• Dyspnea, n=22 (55%; median time to onset, ~8 days; interquartile range, 5.0-13.0 days)• Myalgia or fatigue, n=18 (44%)Other less common symptoms were sputum production (28%), headache (8%), hemoptysis (5%), and diarrhea (3%).Abnormal findings on chest CT were 100% for all 41 patients. Ensuing complications included respiratory distress syndrome, 29%; anemia, 15%; acute cardiac injury, 12%; and secondary infection, 10%. Thirteen patients were admitted to the intensive care unit, and of these, 6 died. Laboratory findings of patients in the intensive care unit to non-intensive care unit patients showed higher plasma levels of interleukin 2 (IL-2), IL-7, IL-10, GSCF, IP10, MCP1, MIPQA, and TNF-α.Patients were empirically managed with oral and intravenous antibiotics, oseltamivir (75 mg orally twice daily) and corticosteroid therapy (methylprednisolone 40-120 mg daily), given as a combined regimen with codiagnosis of community-acquired pneumonia.This study had some limitations, including small sample size, lack of serological detection, and risk factors. Interpretation of study findings is limited as well, but given the lack of other published studies on the 2019 novel coronavirus, it provides researchers a small window to characterize the virus. We can conclude that the 2019-nCoV infection is similar to severe acute respiratory syndrome (SARS) and the Middle East Respiratory Syndrome Coronavirus (MERS), and is equally associated with intensive care unit admission and significant mortality. Further studies are needed to further define this virus.The CDC confirms that there are currently no vaccines or treatments against the coronavirus; however, Chinese scientists are vigorously working to create one. Risk may be reduced by infection control measures such as frequent hand washing in public areas and avoiding close contact with those with respiratory illnesses.Based on what is known about other coronaviruses (eg, MERS-CoV and SARS-CoV), the CDC has provided interim guidance for healthcare professionals on the identification of potential infected patients and reporting and testing of specimens: Clinical FeaturesEpidemiologic RiskFever and symptoms of lower respiratory illness (eg, cough, difficulty breathing)andIn the last 14 days before symptom onset, a history of travel from Wuhan City, China or In the last 14 days before symptom onset, close contact with a person who is under investigation for 2019-nCoV while that person was illFever or symptoms of lower respiratory illness (eg, cough, difficulty breathing)andIn the last 14 days, close contact with an ill patient with laboratory-confirmed 2019-nCoVSource: http://www.CDC.gov/coronavirus/2019-nCoV/hcp/clinical-criteriaImmediate notification by healthcare providers to their local state health department, as well as infection control of their healthcare facility, is imperative.The CDC recommends immediate testing of possible infected patients regardless of time of symptom onset, but discourages performing virus isolation in cell culture or initial characterization of viral agents identified in cultures of specimens from patients with suspected 2019-nCoV for biosafety reasons. Laboratory testing recommendations include collecting and testing from different sites and obtaining multiple clinical specimens. Additional guidance on collection, handling, and testing of specimen is available at CDC.gov.The funder of the study had no role in study design, data collection, analysis, or interpretation.Lancet. Published online January 24, 2020.Fever (98%)Cough (76%)Myalgia or fatigue (44%)Sputum production (28%)Less than 10% of patients had headache, diarrhea, and hemoptysis.More than half of patients developed dyspnea, at a mean of 8.0 days after the onset of symptoms.63% of patients were found to have lymphopenia. Abnormal chest computed tomography was noted in all patients.29% of patients developed acute respiratory distress syndrome, and 32% were admitted to the intensive care unit; 15% of patients in this series died.Routine respiratory precautions are recommended to community members to prevent infection with the novel coronavirus. There is no vaccine available.Treatment of the novel coronavirus is purely supportive.According to the CDC, patients with fever and cough or shortness of breath should be considered for investigation for the novel coronavirus if they had traveled from Wuhan City, China, in the past 14 days or had close contact with someone with suspected or confirmed infection with the novel coronavirus in the past 14 days.Patients with suspected infection with the novel coronavirus should be masked and placed in isolation immediately. Healthcare providers seeing patients under investigation for novel coronavirus should practice contact precautions (including goggles or face shield) and respiratory precautions.Healthcare providers should immediately report cases suspicious for the novel coronavirus to local public health officials.Specimens from patients under investigation for the novel coronavirus should be drawn from the lower respiratory tract, the upper respiratory tract, and the serum. Stool and urine samples may be collected and held.Given the risk for infection, it is not recommended to perform virus isolation in cell cultures in suspected cases of 2019 novel coronavirus infection.The CDC will facilitate testing of these specimens for the novel coronavirus. Currently, only the CDC can perform this testing. Study Highlights A study by Huang and colleagues, published in the January 24, 2020, issue of the Lancet, characterized the clinical presentation of 41 patients admitted to hospital with confirmed infection of the 2019 novel coronavirus.73% of patients were men, and only 32% had underlying illness. The median age of patients was 49 years.The most common symptoms of infection with the 2019 novel coronavirus were:Clinical Implications In a recent study published, the most common symptoms of infection with the 2019 novel coronavirus were fever (98%), cough (76%), myalgia or fatigue (44%), and sputum production (28%).Patients with suspected infection with the novel coronavirus should be masked and placed in isolation immediately. Healthcare providers seeing patients under investigation for novel coronavirus should practice contact precautions (including goggles or face shield) and respiratory precautions. Healthcare providers should immediately report cases suspicious for the novel coronavirus to local public health officials.Implications for the Healthcare Team: The healthcare team needs to monitor updates regarding the outbreak of the 2019 novel coronavirus and update protocols regarding the evaluation of patients with suspected infection. Clinicians are encouraged to use available interim guidelines from the CDC and WHO. Clinicians in contact with patients suspected of the novel corona virus should maintain contact and respiratory precautions. Team members should communicate frequently to remain current on updates from the CDC and WHO.
   

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