What is 2019-nCoV?
2019-nCoV (originally known as Wuhan Virus) is in the coronavirus family along with SARS Virus (Severe Acute Respiratory Syndrome) and MERSCoV (Middle-Eastern Respiratory Syndrome Coronavirus). Both of these viral infections caused a stir Worldwide due to a relatively high mortality in those affected, even though the incidence remained very uncommon. SARS was particularly nasty once it got established in crowded hospitals as many of those affected were actually the healthcare workers looking after the patients. The cynic in me also thinks they caused a stir because they had catchy acronyms which allowed the media to present popular horror stories to frighten the public into watching more news stories…!
There is emerging evidence from researchers analysing the genetic sequence that suggests 2019-nCoV is a “recombinant virus between the bat coronavirus and an origin‐unknown coronavirus … [with a] snake the most probable wildlife animal reservoir”. As is the case with most new coronaviruses there is an animal source; SARS was from horse-shoe bats, MERSCoV from camels (“Camel Flu”, as I like to call it), and countless other new infections in animals such as swine acute diarrhoea syndrome, mouse hepatitis virus and even ferret systemic coronavirus! I particularly like the idea of Ferret Fever…
What is the current situation?
As of the 5th February the World Health Organisation have reported 24,554 confirmed cases of 2019-nCoV; 24,363 in China (16,678 from Hubei Province where Wuhan City is located) and 191 from the rest of the World; almost all cases outside of China had a travel history to China. So far only 2 cases have been detected in the UK out of 414 tested.
There have been 492 deaths (all in China, except 1), and those that have died had severe co-morbidities that would predispose them to a high mortality from any viral respiratory infection. The mortality is therefore currently around 2% but remember, in the initial stages of an outbreak the epidemiology is skewed towards severe cases as widespread surveillance for mild or asymptomatic cases has not yet been done; the overall mortality will be lower than this.
Okay, so on the face of it, this does sound bad but let’s just take a breath and try and bring some context to this. Hubei Province has a population of about 60 million, almost as big as the UK (65 million); which means the incidence of 2019-nCoV infection in Hubei is about 1 in 3,500, and in China with a population of about 1.4 billion the incidence is 1 in 60,000.
Let’s compare this to something more familiar, “common” influenza. In the USA this influenza season (2019/2020) there have been 19 million cases of flu, 180,000 admissions to hospital and 10,000 deaths. If we extrapolate these figures to China then there have been about 760,000 cases of influenza with 40,000 deaths so far this year which significantly dwarfs the situation with 2019-nCov. Even in the UK there are 2-3,000 deaths a year from influenza. Influenza is still a much higher risk to public health in the UK than 2019-nCoV.
What has China done about 2019-nCoV ?
In my opinion the response from the Chinese authorities has been amazing. They have been quick to implement strict quarantine measures and quick to share information with the WHO and the global community. This has meant that diagnostic tests have been rapidly developed and vaccines are already being worked on. I doubt any other country in the World could have achieved this. They have even built a 1000 bed hospital in 10 days; in contrast in September 2019 the Health and Social Care Secretary Matt Hancock announced the UK will spend £2.8 billion on 6 new hospitals to be built in 5 years!
The Chinese authorities were also quick to close Huanan Seafood Wholesale Market in Wuhan City where poultry, snake, bats, and other farm animals were being sold. But as of the 1st January this year it was increasingly clear that the outbreak was no longer due to the exposure at the seafood market; there was evidence that 2019-nCoV could also spread from human-to-human.
How does 2019-nCoV infection present?
Like most coronaviruses, 2019-nCoV infection presents with a flu-like illness; fever, cough, sore throat, shortness of breath. The key aspect is the travel history i.e. has the patient potentially been exposed to 2019-nCoV … if not then it’s not the 2019-nCoV.
The current case definition for infection is:
Severe acute respiratory infection requiring admission to hospital, with clinical or radiological evidence of pneumonia, or acute respiratory distress syndrome
Acute respiratory infection of any degree of severity (including at least one of: shortness of breath or cough)
Fever with no other symptoms
In the 14 days before the onset of illness:
- Travel to China, Hong Kong, Japan, Macau, Malaysia, Republic of Korea, Singapore, Taiwan, or Thailand OR
- Contact with confirmed case of 2019-nCoV, defined as:
- Living in the same household, OR
- Direct contact with the case or their body fluids or their laboratory specimens, or in the same room of a healthcare setting when an aerosol generating procedure is undertaken on the case OR
- Direct face-to-face contact with a case for any length of time OR
- Within 2 metres of the case in any other setting not listed above, for more than 15 minutes OR
- Instruction from PHE that they are a contact of a confirmed case
How is 2019-nCoV diagnosed?
The current sample types required from patients in the UK with possible 2019-nCoV are:
- Viral nose and throat swab OR nasopharyngeal aspirate (NPA) for PCR
- Sputum OR bronchoalveolar lavage (BAL) for PCR
- 5ml Clotted blood (1ml for children <12 years old) for antibody testing (acute and convalescent 14 days later)
Testing should be discussed with the local Public Health England Health Protection Team before sending samples to the Reference Laboratory; this should be done by the Duty Microbiologist or Infectious Diseases Physician.
REMEMBER to take samples for all “normal” respiratory infections as well as those required for 2019-nCoV, your patient is far more likely to be ill from a “usual” condition. Note: local laboratory testing for Influenza Virus as well as other causes of pneumonia should be undertaken in a Category 3 facility, which is normal protocol.
Dealing with the media and public concerns
I returned from holiday to find a free newspaper on the train saying “deadly virus” and was travelling next to two young men wearing surgical masks! No one even mentioned the virus in Fuerteventura!
So what about the concern for bringing “our” citizens home from China? I’m not convinced this was entirely driven by health advice. Putting asymptomatic people on an aeroplane with others is OK as the virus (as with all respiratory viruses) is transmissible through droplets; no droplets on hands or in the air (sneezing and coughing) means no virus risk. However it does place all these people in close proximity with others who have a high risk factor for exposure, so if someone on board the aeroplane becomes symptomatic all on board are then at risk of further exposure. I suspect this evacuation was more political and media led. As for the “all must leave” message, well the WHO currently advise against the application of any travel or trade restrictions on China.
The other story that caught my eye regarded the transferring of asymptomatic people in a coach from the evacuation aeroplane to their quarantine facility. A member of the transporting team could clearly be seen in full PPE next to the “unprotected” coach driver. The PPE was unnecessary; remember it’s the symptomatic patients who spread the virus. It was poor practice to be in PPE as all PPE should be removed after assessment of a patient, be it within the patient’s room or anteroom. If the PPE is contaminated wearing it on a coach around the country or around the hospital clearly puts more people at risk and is against advice.
In contrast the PHE infection control advice that “all transfer staff should wear full PPE and maintain a 2 metre PPE protection zone around the patient and their equipment” (see PPE below) is recommended for confirmed symptomatic patients and enables the staff member to be able to respond to the patient’s needs if required, can you imagine trying to explain that “the patient was chocking but we delayed our treatment as we had to put on our PPE!”?
So will a surgical face mask help me on the underground? No, normal surgical face masks do not filter air and will not stop someone inhaling anything! Why wear them in surgery then?!? A surgical mask stops contamination from skin and sweat from the surgeon “dropping” onto the surgical site and should prevent the surgeon touching their nose and mouth during the procedure! Why are patients asked to wear these face masks during transport across a hospital (see PPE below)? The patient should wear a ‘surgical mask’ if this can be tolerated to prevent large respiratory droplets being expelled into the environment by the wearer, essentially it’s the same as the “coughing into a tissue” advice given to the public with Influenza Virus.
Of course people get concerned, it’s only natural, but playing into these fears (especially fuelled by the media) is not helpful.
How is 2019-nCoV treated?
There is no specific treatment for 2019-nCoV. Patients require good supportive care with fluids and ventilator support.
Infection Control Precautions
It is important to keep in mind that all of the current strategies for dealing with 2019-nCoV, including the current infection control precautions, are to try and prevent it becoming established in the population like influenza.
Human-to-human transmission of 2019-nCoV can occur, and has been demonstrated in this outbreak. By far the most important method of spread is respiratory droplets so hand hygiene is critical. This was the same for SARS and MERSCoV where the main factor related to the spread of infection in hospitals was how close did you get to the patient, i.e. were you in an area where respiratory droplets would land (within 2 metres) and therefore be contaminated by the patient?
All travellers from Hubei Province are expected to self-isolate themselves within their own homes for 14 days whether they have symptoms or not; travellers from other areas of mainland China should isolate themselves if symptomatic. If they develop any of the symptoms of 2019-nCoV infection they should ring NHS 111 for advice rather than attend their GP practice or local hospital. NHS 111 will arrange for the patient to be assessed in the appropriate setting. A symptomatic patient attending a healthcare setting unannounced will put other people at risk of infection.
Infection control within the home - all exposed and symptomatic patients should “catch it, bin it, kill it” using tissues when coughing or sneezing. The virus is likely to only survive about 15 minutes on a tissue, like other respiratory viruses. Then the person should wash their hands with soap and water.
A summary of the infection control requirements in hospital is in the table, for more details see the current guidance from the Department of Health.
With soap and water or alcohol hand gel
FFP3 face protection including eye protection, long-sleeved fluid repellent gown and gloves at all times
Remove ALL PPE in anteroom or before leaving room if anteroom not available
Use “buddy” system with extra staff observing correct use of PPE
Side room (negative pressured if available otherwise neutral pressure) with anteroom if available and own toilet facility
Door to be kept closed
Keep exposed staff to a minimum
Record all staff in contact with patient
Keep visitors to a minimum
Offer visitors PPE training and use if wanted
Deep cleaning of the clinical area (including anteroom) daily and after patient is discharged using 1,000 ppm chlorine
If aerosol generating procedures performed allow 20 minutes for particles to settle then decontaminate as above
If patients require investigations in other departments, inform those departments of patient’s condition in advance
Where possible carry out all investigations in the patients side room
During transport patient should wear a surgical face mask if they can tolerate it, all transfer staff should wear full PPE and maintain a 2 metre PPE protection zone around the patient and their equipment
Patient should be last on a list and deep cleaning commence after patient’s departure
So rather than go back to bed and hide under the duvet I think I’m just going to stop watching the news and only read the bulletins from WHO or Public Health England to get my outbreak information from now on… although perhaps I should have stayed on holiday for a few weeks longer until all of this settled down… now there’s an idea!
In other news today, a Briton has claimed the Guinness World Record for the largest onion bhaji ever made; the media headline is likely to be something like “Panic as National mango chutney shortage after over production of a gargantuan Indian side dish!”