In medicine, we talk about quality a lot. But most of the time that we are talking about it, we're really not talking about quality at all. You see, quality...
In December 2019, an outbreak of a new coronavirus began in Wuhan City, China. Within weeks, it had spread throughout China and to a number of other countries. This post will outline the history of the outbreak, what we have learned from other, previous coronavirus outbreaks, and what physicians and hospitals need to know about managing suspected patients in order to control the outbreak.
Coronaviruses are common upper respiratory viruses that generally cause fairly mild infections. They account for about 5-10% of common colds and cause typical cold-like symptoms such as fever, cough, and sore throat. Like other upper respiratory viruses, they are spread by aerosolized droplets and primarily occur in the winter months. The regular coronaviruses are detected with the standard respiratory viral PCR panels that most hospitals use. These panels detect other common viruses such as influenza, rhinovirus, parainfluenza virus, and others. Treatment is supportive and there are no effective vaccines or anti-viral antibiotics. As with all respiratory viral infections, patients admitted to the hospital should be placed on droplet isolation.
Sometimes, Coronaviruses Go Rogue
From 2002 – 2004, an outbreak of a coronavirus resulted in SARS (Severe Acute Respiratory Syndrome). Overall, 8,098 people were known to become infected with 774 deaths, a 10% mortality rate. The natural host of the virus was the horseshoe bat and the outbreak was traced to a remote cave in Yunnan Province in China. From the bats in this cave, the SARS virus was spread to a masked palm civet, a cat-like wild animal in China that is often hunted for food. The civet was killed by a hunter and landed in a meat market in Guangdong, China in November 2002 where the virus then jumped to humans. Chinese health authorities were not forthcoming about the spreading Guangdong outbreak and did not report it to the World Health Organization (WHO) for several months, resulting in rapid spread of the infection due to a lack of public and healthcare worker awareness that it even existed. In February 2003, a businessman traveling from China became ill and was admitted to a hospital in Hanoi, Vietnam. An astute Italian physician working at the hospital, Dr. Carlo Urbani, recognized that the man’s infection was something different than regular influenza and notified the WHO. However, several healthcare workers at the hospital became infected; both the businessman and Dr. Urbani ultimately died of SARS. Meanwhile, a doctor from Guangdong unknowingly infected with SARS had traveled to Hong Kong where he stayed at the Metropole Hotel. He transmitted the virus to 16 international guests at the hotel who then traveled to Canada, Singapore, Viet Nam, and Taiwan, carrying the virus with them. On February 23, 2003, an elderly woman returning to Toronto from Hong Kong became ill with SARS and went to her local hospital. Canadien health authorities and healthcare workers did not have adequate infection control protocols in place and were unprepared for SARS and consequently within weeks, 257 people in Toronto were infected. In the United States, there were 27 cases and no deaths.
The incubation period for SARS ranged from 1-14 days but was usually 4-6 days. Like other coronaviruses, it was spread by droplets. With international efforts to stop the spread of the virus, the outbreak was contained and the last known case was in in January 2004. There are several lessons to be learned from SARS:
- Air travel permits rapid world-wide spread
- Don’t cover it up. By not being forthcoming about the emerging outbreak, Chinese authorities permitted the virus to quickly spread
- Rapid epidemiologic investigation is essential
- Countries must work together for epidemiological control
- Have a high clinical suspicion.
- Infection control works. Toronto did not have proper infection control practices in place, resulting in the Toronto outbreak
- Health personnel are at greatest risk
From 2012 – 2015, another coronavirus caused the Middle East Respiratory Syndrome. Overall, 1,227 people became infected with an average mortality rate of 37%. The natural host was the dromedary camel and the virus made the jump to humans in Saudi Arabia. There were two main outbreaks of MERS, the first in Saudi Arabia in 2014 when 402 people became infected. The second outbreak occurred in 2015 when a businessman traveled from the Arabian Peninsula to South Korea, unknowingly infected with the MERS virus. Ultimately, 150 Koreans became infected and the main locations that these people acquired their infections were hospitals and clinics that were not prepared to institute proper isolation precautions and infection control practices. Ultimately, the South Korean outbreak alone cost $8.5 billion. The main symptoms of MERS were cough, shortness of breath, and fever. Chest x-rays showed patchy pneumonia or ARDS patterns. There are several sessions to be learned from MERS:
- A single missed infected person can cause a nationwide outbreak
- Hospitals and ERs can accelerate spread
- Doctors in community hospitals and clinics are the first line of defense
- New coronavirus strains can have a very high mortality rate
- Outbreaks are expensive
Wuhan City is the 7th largest city in China with a population of 11 million. To put that in context, New York City has a population of 8.6 million, Los Angeles 4 million, and Chicago 2.7 million. Wuhan is a traditional manufacturing hub and the political, economic, and commercial center of Central China. Its location on the Yangtze River as well as its location at the intersection of several rail lines and highways makes it one of China’s main transportation hubs. The main rail station sees up to 80,000 people per day and the airport serves 20 million passengers per year with direct flights to Tokyo, Paris, London, San Francisco, and Chicago among other international destinations. In December, 2019, a new coronavirus called the “novel coronavirus” or 2019-nCoV appeared in Wuhan City and is believed to have originated at a Wuhan market where wild and domesticated animal meats are sold.
As with the SARS outbreak, Chinese health authorities were slow to recognize and report the emerging infection. The result was that the virus rapidly spread through Wuhan City and from there, to other towns and cities in China. Within weeks, the virus had spread to many other countries throughout the world, including the United States. Like other coronaviruses, the presenting symptoms are fever, cough, and shortness of breath. The incubation period is 1-14 days. In some people, the infection is rather mild but in others, it can result in severe illness. The mortality rate is about 3%.
When should 2019-nCoV be suspected?
- Fever AND symptoms of lower respiratory infection AND either:
- Travel from Wuhan City, China in the past 14 days
- Close contact in the past 14 days with a person under investigation for 2019-nCoV
Fever OR symptoms of lower respiratory infection AND:
Close contact in the past 14 days with a person with laboratory-confirmed 2019-nC0V
ALL of the following isolation procedures should be used in suspected cases in the emergency department and the hospital:
- Contact Isolation:
- Hand hygiene with soap and water (alcohol based hand sanitizer if soap & water not available)
- Droplet Isolation:
- Face shield or goggles
- Airborne Isolation
- Negative airflow room
- N-95 mask or PAPR
What should you do if you have a suspected case?
- Place patient in isolation immediately
- In the ER or hospital: contact + droplet + airborne islation
- In an office setting: put patients with a possible history in a private room with a closed door; give the patient, family members, and healthcare workers a regular mask until additional history is obtained to determine if the patient requires transfer to a hospital for full isolation and additional testing
- Obtain a full travel history
- Communicate with the hospital infection control personnel and the local health department to determine if the patient needs testing
- Currently, testing is only done at the CDC and requires prior permission from the CDC
When performing testing, ALL of the following should be submitted:
Sputum or bronchoalveolar lavage or tracheal aspirate
Nasopharyngeal AND oropharyngeal swab/wash/aspirate
Importantly, the standard respiratory viral panel test used by most hospitals does NOT detect 2019-nCoV. Therefore, a positive coronavirus test on a respiratory viral PCR panel does NOT indicate 2019-nCoV and instead indicates one of the regular coronaviruses that typically cause a common cold.
All testing should be performed with the patient in proper isolation, including airborne precautions; testing should not be performed in regular emergency department rooms or clinic rooms that are not capable of negative airflow. There is no effective anti-viral for 2019-nCoV so treatment is primarily supportive. For those patients who develop respiratory failure and require mechanical ventilation, intubation should be performed in a negative airflow room with all isolation precautions and should be performed by the most experienced physician available (this is not a procedure for trainees). If a person believes that he/she might have 2019-nCoV, then they should call ahead to the emergency department so that their throughput can be expedited and avoid exposing other patients in the waiting area.
The mainstays of response to any epidemiologic threat are preparedness, surveillance, containment, and education. Even though 2019-nCoV is frightening, influenza remains a greater threat to Americans. The CDC estimates that last year, 35 million Americans became infected with influenza and 34,000 died. So, even if 2019-nCoV is not present in your community, always use standard infection precautions:
- Maintain proper hand hygiene practices
- Cover your cough
- Stay home if you are sick
- Get your Influenza vaccination
- Use droplet isolation with any admitted patient with a suspected viral respiratory infection