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2019 Novel Coronavirus

Last updated: February 24, 2020
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On January 7, 2020, a novel or new coronavirus (COVID-19) was identified in Wuhan City, Hubei Province, China (WHO, 2020b) which is causing illness and death globally. The WHO has declared this new virus outbreak a "public health emergency of international concern" (WHO, 2020b). Situation reports - updated daily - can be viewed here. Thirty-five cases have been reported in the United States (WHO, 2020). You can also stay up-to-date with this situation map, showing confirmed cases and deaths by nation. 

You may recall the public health crises that occurred with the outbreaks of Severe Acute Respiratory Syndrome (SARS-CoV) in 2002 and Middle East Respiratory Syndrome (MERS-CoV) in 2012. As a point of comparison, over an eight month period (November 2002 to July 2003), there were over 8,000 cases of SARS-CoV, with over 770 fatalities (WHO, 2003). To date, MERS-CoV has affected over 2,400 people in 27 countries, including over 850 deaths (WHO, 2020a). Both of these illnesses were caused by a type of coronavirus (CoV), a large family of viruses named for their spiked surfaces that resemble crowns.

nCoV-definition-(1).pngCOVID-19 can cause a severe acute respiratory infection (SARI) with symptoms such as fever, cough, shortness of breath, and breathing difficulties (WHO, 2020b). Symptoms may appear in as few as two days or as long as 14 days after exposure (CDC, 2020). Coronaviruses are typically transmitted between animals (i.e. cats, camels, and bats) and humans, however it appears that the COVID-19 may pass from human to human. While most of the cases have been reported in China, this novel coronavirus has now spread to 24 countries. Travelers from Wuhan are being screened at major international airports and the city of Wuhan is now on lock down. A travel ban has been issued for 16 cities in the Hubei province and the CDC has warned against any non-essential travel to China (CDC, 2020).

The WHO released interim clinical management guidelines for severe acute respiratory infection (SARI) when novel coronavirus (COVID-19) infection is suspected (WHO, 2020c). The published guidelines are in draft format, based on strategies for treating MERS-CoV, and are being updated as new information is discovered. The following summarizes the major preliminary recommendations for health care providers. 
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Triage (WHO, 2020c)
  • Recognize symptoms and immediately place the patient on isolation.
  • Clinicians should be educated to have a high level of suspicion.
  • Start emergency treatments based on patient severity. COVID-19 may present with mild, moderate, or severe illness (severe pneumonia, ARDS, sepsis and septic shock).
Screening (WHO, 2020c)
Clinicians should screen for patients with:
  • SARI and a history of fever and cough requiring hospitalization, with no other etiology that explains the illness AND any of the following: history of travel to Wuhan, Hubei Province China in the 14 days prior to onset of symptoms; illness in a health care worker who has been working with patients with SARI, without regard to residence or history of travel; or patient develops an unusual or unexpected clinical course, particularly an unexpected deterioration despite appropriate treatment.
  • Acute respiratory illness of any severity who, within 14 days prior to the onset of illness had any of the following exposures: close physical contact with a confirmed case of COVID-19 infection while the patient was symptomatic; or health care facility in a country where hospital-associated COVID-19 infections have been reported.
Provide early supportive therapy and monitoring (WHO, 2020c)
  • Provide supplemental oxygen therapy to patients with SARI and respiratory distress, hypoxemia, or shock to reach target SpO2 > 90%.
  • Administer fluids conservatively in patients with SARI when there are no signs of shock.
  • Give empiric antibiotics to treat likely pathogens causing SARI; give antimicrobials within one hour of initial patient assessment for patients with sepsis.
Collect specimens for laboratory testing (WHO, 2020c)
  • Collect blood cultures before antimicrobial therapy, but do not delay antibiotic administration.
  • Collect specimens from both the upper respiratory tract (nasopharyngeal and oropharyngeal) and lower respiratory tract (sputum, endotracheal aspirate, bronchoalveolar lavage).
  • Laboratory specimens should be considered potentially infectious. 
Manage hypoxemic respiratory failure, acute respiratory distress syndrome (ARDS) and septic shock (WHO, 2020c)
  • Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is failing standard oxygen therapy.
  • Endotracheal intubation should be performed by a trained and experienced provider using airborne precautions.
  • Implement mechanical ventilation using lower tidal volumes (4-8 ml/kg predicted body weight) and lower inspiratory pressures (plateau pressure < 3 cm H2O).
  • In patients with severe ARDS, prone positioning for > 12 hours is recommended.
  • Use conservative fluid management for ARDS patients without tissue hypoperfusion.
  • In patients with moderate or severe ARDS, use higher PEEP instead of lower PEEP.
  • Manage septic shock following the latest guidelines.
Vigilant infection control practices coupled with early identification and treatment may help prevent the spread of this virus and potentially decrease the morbidity and mortality that has resulted from its predecessors.
References
Centers for Disease Control and Prevention. (2020). 2019 Novel Coronavirus, Wuhan, China. Retrieved from https://www.cdc.gov/coronavirus/2019-nCoV/clinical-criteria.html

World Health Organization (2003). Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 2003. Retrieved from https://www.who.int/csr/sars/country/table2004_04_21/en/

World Health Organization (2020a). Middle East respiratory syndrome coronavirus (MERS-CoV). Retrieved from https://www.who.int/emergencies/mers-cov/en/

World Health Organization (2020b). Coronavirus. Retrieved from https://www.who.int/health-topics/coronavirus

World Health Organization (2020c). Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected. Retrieved from https://www.who.int/internal-publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected
World Health Organization (2020d). Novel coronavirus (2019-nCoV) situation report. Retrieved from
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/

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