Note: This is the third of a series of clinical briefs on the coronavirus outbreak. The information on this subject is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available.
Last updated March 19, 2020

Clinical Context

Concern continues to grow regarding the rapid spread and clinical effects of the 2019 novel coronavirus first described in Wuhan, China. According to report from the World Health Organization (WHO), there were 7818 confirmed cases of infection towards the end of January 2020. This quickly exceeded 120,000 cases as of March 12, 2020.^[1] The COVID-19 outbreak quickly changed from a global emergency of international concern to a global pandemic as declared by WHO on March 11, 2020.

The outbreak of the COVID-19 coincided with China's Lunar New Year, its busiest travel period of the year. Travelers were faced with the daunting decision of whether to forgo national celebrations given the risk for infection and the CDC’s level 3 warning to avoid nonessential travel to China.  At the time, the Chinese government had 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 COVID-19 as incubation period of the virus is currently estimated to range from 1-14 days. However, more detailed information from those already infected is needed to determine the infectious period of the virus. One key 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.html

Huge 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 quick facts 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 COVID-19 2019 was described in patients who were admitted to designated hospitals in Wuhan, China, with laboratory-confirmed diagnosis of COVID-19. ^[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 to outcomes of those who were not.

The researchers' findings indicated that of the 41 patients admitted with confirmed infection with COVID-19, 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 COVID-19, it provides researchers a small window to characterize the virus. We can conclude that the COVID-19 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 against the coronavirus; however, Chinese scientists are vigorously working to create one. Treatment is supportive at this time. 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:

Source: http://www.CDC.gov/coronavirus/2019-nCoV/hcp/clinical-criteria

Immediate 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 COVID-19 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.

Clinical Implications

• In a recent study published, the most common symptoms of infection with COVID-19 were fever (98%), cough (76%), myalgia or fatigue (44%), and sputum production (28%).
• Patients with suspected infection with COVID-19 should be masked and placed in isolation immediately. Healthcare providers seeing patients under investigation for the same should practice contact precautions (including goggles or face shield) and respiratory precautions. Healthcare providers should immediately report cases suspicious for COVID-19 to local public health officials.
• Implications for the Healthcare Team: The healthcare team needs to monitor updates regarding the outbreak and update protocols regarding the evaluation and management 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 COVID-19 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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