Infectious diseases Internal Medicine Pulmonology

Novel Coronavirus Outbreak (2019-nCoV, COVID-19)

Novel Coronavirus Outbreak

2019-nCoV is a new coronavirus detected in Wuhan, located in central China and has now been given the official name COVID-19. The virus is part of the same virus group that caused the outbreak of SARS (Severe Acute Respiratory Syndrome) in 2003 and MERS (Middle East Respiratory Syndrome) in 2012. The coronavirus infects birds and mammals and is found worldwide. SARS is likely to be spread from bats via carnivores and MERS from camels/dromedaries. The animal that caused the 2019-nCoV is still unknown, but the infection is suspected to have occurred in markets with live animals.

Every day new figures on the number of infected (currently [02/14/2020], >60’000) and deaths (currently [02/14/2020], >1’300) are released. Infections in patients who traveled from the Wuhan area have also been detected in many other parts of the world. The information regarding which areas in China are heavily affected by the virus is changing rapidly.

WHO has announced an international health emergency as of 01/30/2020.

The Public Health Authority has provisionally classified the infection as a public health emergency, which means that measures can be taken such as quarantining of the infected.

The Foreign Ministries have advised against travel to the Hubei province in China. Travelers to China should review their arrangements daily as the situation can change rapidly.

Etiology – Novel Coronavirus Outbreak

  • Contact with infected animals.
  • Infection can occur between people on close contact, for example through infected aerosols (large droplets).
  • Since inhalation of contaminated aerosols is considered to be the greatest risk of spreading the virus, infection should not occur before the patient begins to cough. Information stating that infectious risk exists during the incubation period is therefore unlikely to be true.

Symptoms / Clinical Findings

The coronavirus incubation period is 2-14 days and averages at about 5 days.

  • Fever
  • Respiratory symptoms from the lower respiratory tract with cough and shortness of breath.
  • Myalgia and arthralgia
  • Elevated mucus production in the respiratory tracts
  • Diarrhea less common
  • Signs of ARDS and organ failure in severe cases

Laboratory testing Indications

  1. Visit to Hubei or other province of mainland China where the infection is prominent *, within 14 days before symptom onset
    * According to official report or patient history. Currently covers all of China’s mainland (excluding Hong Kong and Macau) as there is no verified epidemiological knowledge regarding ongoing spread of infection.

    OR

  2. 2. Contacts ** with COVID-19 patients, within 14 days prior to symptom onset
    ** Contacts are defined as:
    – stay in a closed room or after face-to-face contact (<2 meters distance) with 2019-nCoV-infected person

    – living and/or staying in the same household or equivalent close contact with 2019-nCoV-infected person

    – airplane trip where fellow passengers are confirmed to be infected with 2019-nCoV (assessed in a case-by-case basis in accordance with international guidelines)

    AND

  3. Acute illness with fever, cough or dyspnoea without other known cause

    OR

    Acute infectious disease without known cause
    requiring hospital care *** Note that diagnosis of COVID-19 must not delay the management of other acute conditions that require rapid management such as pulmonary embolism and sepsis!

Suspected cases

All of the following criteria:

  1. Clinical picture compatible with infection caused by COVID-19
  2. Epidemiological link

Confirmed Cases

At least one of the following criteria:

  • Nucleic acid detection of COVID-19 gene fragments comprising at least two different regions of the viral genome, one of which is COVID-19 specific
  • Isolation of COVID-19

Suspected cases should not be referred to emergency rooms but should be handled via telephone contact and, if inpatient care is needed, should be cared for in single rooms, preferably at the infectious diseases clinic. Healthcare personnel at an infectious diseases clinic must be contacted immediately for a decision on continued treatment and a decision on how a suspected case should be transported to an appropriate clinic.

The outbreak emphasizes the importance of always asking for travel history early in patients presenting with infectious diseases symptoms.

Differential diagnoses

Diagnostics

Medical history

  • Travel history
    Stay in affected area?

Physical Examination

  • Fever?
  • Cough?
  • Dyspnea?

Lab

  • PCR sputum / induced sputum / BAL in the first place. Nasopharynx secretion, urine, feces or EDTA blood can also give diagnosis. Note that sampling from the airways should be done with personal protective equipment against airborne contamination, ie respiratory protection, such as when collecting samples for SARS and MERS diagnostics.
  • Serology, for any subsequent serologic testing, serum from the acute disease phase should be secured.
  • Virus isolation
  • CRP. Procalcitonin not particularly elevated
  • WBC usually in the normal range, lymphopenia in severe cases
  • Elevated liver transaminases in about 1/3 of cases

The complete genetic sequence for 2019 nCoV has been published and the WHO-recommended diagnostics demonstrating the presence of 2019 nCoV is available at the Public Health Authority.

Diagnostic Imaging

  • Lung X-ray / CT
    – Bilateral multiple “ground glass” changes on CT.
    – Widespread pneumonitis in more severe cases

Treatment – Novel Coronavirus Outbreak

No specific treatment is available but various existing antiviral agents are tested in individual cases, e.g. lopinavir/ritonavir in combination with oseltamivir. Supportive therapy (fluid, oxygen, etc.) should be administered as needed. Good hygiene practices, isolation rooms prevents further spread of disease. Systemic corticosteroid therapy is not advised.

Prognosis

Similarly to the common flu, the elderly and people with significant underlying comorbidities suffer the worst. The mortality from the infection is not fully known yet but has been estimated to be less than 3%.

Prophylaxis Novel Coronavirus Outbreak

Common face masks do not protect against infection. Special respiratory protection is used in hospitals. A general preventative measure is to avoid touching the face or eyes and to avoid contact with infected people.

Further Reading

  • https://www.cdc.gov/coronavirus/2019-ncov/index.html
  • https://www.who.int/emergencies/diseases/novel-coronavirus-2019
  • https://www.ecdc.europa.eu/en/current-risk-assessment-novel-coronavirus-situation