Background Information
On 31st December 2019, the World Health Organisation (WHO) China Country Office was informed of cases of pneumonia with unknown etiology detected in Wuhan City, Hubei Province, of China. From 31st December 2019 to 3rd January 2020, a total of 44 case-patients with pneumonia of unknown etiology were reported. Chinese authorities identified the causative agent as a new type of coronavirus, which was isolated on 7 January 2020.
What is the Virus Called?
2019-novel coronavirus (2019-nCoV).
Some sources are using the term Wuhan novel coronavirus (WN-CoV).
How severe is the disease?
The emergence of 2019-nCoV is an ongoing situation, and the severity of the disease is yet to be fully assessed. Centres for Disease Control and Prevention (CDC) reports that ‘While severe illness, including illness resulting in a number of deaths has been reported in China, other patients have had milder illness and been discharged.’
Patients with confirmed 2019-nCoV infection have reportedly had mild to severe respiratory illness with symptoms of:
- Fever
- Cough
- Shortness of breath
In addition the WHO reports that ‘(2019-)nCoV may present with mild, moderate, or severe illness; the latter includes severe pneumonia, ARDS, sepsis and septic shock’.
As of 23rd Jan 2019, a total of 581 confirmed cases have been reported to the WHO for 2019-nCoV globally:
- Of the 581 cases reported, 571 cases were reported from China.
- Of the 571 cases, 95 cases are severely ill.
- Seventeen deaths have been reported (all from Hubei Province).
25% of confirmed cases reported by China have been classified by Chinese health authorities as seriously ill (from Wubei Province: 16% severely ill, 5% critically ill, and 4% having died).
Daily updates on the number of confirmed 2019-nCoV cases can be found in the WHO situational reports.
The below articles include further information on the symptoms and severity of two other human coronaviruses, MERS-CoV and SARS.
Coronaviruses: An Overview of Their Replication and Pathogenesis
SARS and MERS: recent insights into emerging coronaviruses
Host Factors in Coronavirus Replication
Laboratory Use
The WHO has produced a number of ‘Disease Commodity Packages‘ (DCP) which detail the critical medical supplies and consumables (along with their related technical specifications) needed by healthcare professionals to respond quickly to infectious disease outbreaks. A DCP has been published for 2019-nCov, based largely on existing DCP’s for MERS-CoV and SARS-CoV.
The 2019-nCoV DCP classifies 2019-nCoV at biosafety level (BSL) 2, with the virus culture classified as BSL3. This classification is to be confirmed. Both SARS-CoV and MERS-CoV have similar biosafety levels. The epidemic potential of the virus is listed as ‘under investigation’. The epidemic potential of both MERS and SARS is described as ‘High’
How quickly is the disease spreading?
The WHO began publishing daily situation reports on 2019-nCoV on 21st January 2019:
- In the first report, dated 20th January, the WHO reported that up until that point it had received 282 reports of confirmed 2019-nCoV infection globally.
- On 21st Jan, the number of reports of confirmed 2019-nCoV infection had risen by 32 cases from the previous day, a rise of 11%.
- On 22nd Jan the number of reports of confirmed 2019-nCoV infection had risen by 267 cases from the previous day, a rise of 46%.
The vast majority of cases have been reported in China (571), however confirmed 2019-nCov cases infected in China have been exported to the US, Thailand, Japan and Republic of Korea.
Transmission
Although the initial outbreak in Wuhan City was associated with exposure at the Huanan Seafood market (and hence a zoonotic, animal-to-human transmission), there is increasing evidence that the virus spreads from human to human. Nevertheless the exact mode of transmission of 2019-nCoV is currently unknown and further investigation is urgently needed in this area.
The CDC reports the following:
‘When person-to-person spread has occurred with MERS and SARS, it is thought to have happened via respiratory droplets produced when an infected person coughs or sneezes, similar to how influenza and other respiratory pathogens spread. Spread of MERS and SARS between people has generally occurred between close contacts.’
Public Health England also offer a similar assessment:
‘We do not know the routes of transmission of WN-CoV; however, other coronaviruses are mainly transmitted by large respiratory droplets and direct or indirect contact with infected secretions. In addition to respiratory secretions, other coronaviruses have been detected in blood, faeces and urine.
Under certain circumstances, airborne transmission of other coronaviruses is thought to have occurred via unprotected exposure to aerosols of respiratory secretions and sometimes faecal material.’
The below paper discusses the high rate of SARS-CoV and MERS-CoV transmission between patients and healthcare workers:
SARS and MERS: recent insights into emerging coronaviruses
However, so far there have been very few reports of hospital outbreaks or 2019-nCoV infections of health care workers, which is a prominent feature of MERS-CoV and SARS-CoV.
The below articles discuss the transmission of known coronaviruses in depth:
SARS and MERS: recent insights into emerging coronaviruses
Coronaviruses: An Overview of Their Replication and Pathogenesis
Host Determinants of MERS-CoV Transmission and Pathogenesis.
Jumping species—a mechanism for coronavirus persistence and survival
Transmission of MERS-Coronavirus in Household Contacts
MERS coronavirus: diagnostics, epidemiology and transmission
How can transmission be prevented?
Advice on transmission prevention of 2019-nCov has been provided by the WHO. These are standard recommendations for the general public to reduce exposure to and transmission of a range of illnesses are as follows, which include hand and respiratory hygiene, and safe food practices.
The CDC offers similar advice for the general prevention of the spread of respiratory viruses.
The below articles discuss investigations into preventing coronavirus transmission:
SARS and MERS: recent insights into emerging coronaviruses
What are the current treatment options?
There is currently no vaccine available for 2019-nCoV, and no recommended antiviral treatment. Treatment is therefore symptomatic and supportive.
The WHO advises the following supportive care if necessary (as for MERS-Cov) but patients should be assessed on a case-by-case basis.
- Oxygen Therapy
- Mechanical Ventilation of severe cases (40%)
- Use of Oximeter highly recommended
- Intubation, ICU, ECMO required for severe patients
- Antibiotics
- Analgesia/Antipyretics
Several studies into the treatment of MERS-CoV and SARS-CoV, have investigated the use of antibodies, IFNs, inhibitors of viral and host proteases, and host-directed therapies however the efficacy of such treatments remains unclear. Investigations into the use of antivirals such as Ribavirin, Lopinavir and Ritonavir have been inconclusive and are ongoing.
The below articles discuss investigations into the treatment of coronaviruses:
Coronaviruses: An Overview of Their Replication and Pathogenesis
SARS and MERS: recent insights into emerging coronaviruses
What diagnostic tests are available to confirm 2019-nCoV infection?
There is currently no commercially available diagnostic test to aid in the confirmation of 2019-nCoV infection, however the CDC has stated that they have confirmed the diagnosis of a US case of 2019-nCov using a newly developed real-time reverse transcription polymerase chain reaction (rRT-PCR) test.
Their website states that they are:
‘Developing a diagnostic test to detect this virus in clinical specimens, accelerating the time it takes to detect infection. Currently, testing for this virus must take place at CDC, but in the coming days and weeks, CDC will share these tests with domestic and international partners’.
The WHO has produced laboratory guidance for the testing for other coronaviruses (MERS-CoV). Routine confirmation of MERS-CoV infection is based on detection of unique sequences of virus RNA by nucleic acid amplification tests (NAAT) such as rRT-PCR with confirmation by nucleic acid sequencing when necessary. Similar information is available from the CDC.
The below articles discuss diagnosis of coronavirus infection in detail:
SARS and MERS: recent insights into emerging coronaviruses
MERS coronavirus: diagnostics, epidemiology and transmission
Coronaviruses: An Overview of Their Replication and Pathogenesis
________________________________________________________________________________________
It is essential to learn as much as possible during a disease outbreak into order to gain evidence on how best to diagnosis, treat and prevent new diseases and learn how to mitigate against future outbreaks. Here we provide access to resources that can be taken and adapted for use in settings where the cases occur.
What is research and what is public health surveillance?
There is an important difference in collecting data, samples or clinical information for public health use or for research.
If identifiable data, samples or information are being collected for the purpose of analysis and publication, then this is research and there for fully informed consent is required. Stepping over this key line therefore requires a protocol and ethics approval.
Existing article materials on Corona virus, MERS Ncov and Sars Ncov on The Global Health Network
ISARIC
- This is an international resource for facilitating the collection of standardised clinical data on patients hospitalised with suspected or confirmed infection with novel coronavirus (nCoV). The Case Record Form (CRF) has undergone extensive review and validation by international clinical experts.
- 8 Dec 2012. A sample plan for sample collection with regards to a potential novel coronavirus outbreak, developed by Kenneth Baillie and ISARIC's Working Group 3.
- 20 Feb 2013. ISARIC Novel Coronavirus CRF Version 1.3, archived
- 20 Feb 2013. Bibliography: Articles of Interest for potential nCoV treatment
- 23 Jan 2013. A CRF aiming to provide feedback on the process to inform future work with ethical committees and regulatory agencies.
- 10 Dec 2012. Clinical research needs for patients infected with the Novel Coronavirus - Proposals from ISARIC
CONSISE:
- 8 May 2013. Novel Coronavirus (MERS-CoV)
- 25 Sep 2013. Available CONSISE Influenza Protocols
Global Health Training Centre: