Novel Coronavirus Outbreak(2019-nCoV)

Updated - 2/10/2020

Alpert Medical School, Brown University

Emerging Infectious Disease Scholars (EIDS) program

NIH/NIAID: R25AI140490

Background & timeline• December 2019 – first identified as a cluster of pneumonia cases in

Wuhan, China• January 10, 2020 – first genome released by Fudan University in China• January 21, 2020 – first confirmed case in US from person who had

recently traveled to Wuhan, China• January 27, 2020 – CDC issued travel guidance recommending that

travelers avoid all nonessential travel to China • January 30, 2020 – WHO declared the outbreak a “public health

emergency of international concern” • January 31, 2020 – US President signed travel restrictions for those who

pose risk of transmitting 2019-nCoV due to travel history

“CDC Situation Summary.” https://www.cdc.gov/coronavirus/2019-nCoV/summary.html. Updated 2/5/2020.

Status of the Outbreak Updated – 2/10/2020

Coronavirus 2019-nCoV Global Cases by Johns Hopkins CSSE. https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6. Last updated 2/10/20, 11:03AM.

Map of mainland China.

World map of 2019-nCoV cases.

WHO Situation Report.

Coronaviruses

• Large family of single-stranded RNA viruses that are common in many different animal species, including camels, cattle, cats, bats

• Four main sub-groups – alpha, beta, gamma, delta• 7 types of coronaviruses have been identified that infect humans

• 4 generally cause common cold – 229E, NL63, OC43, HKU1• SARS-CoV – Severe Acute Respiratory Syndrome (Nov 2002-Jul 2003)• MERS-CoV – Middle East Respiratory Syndrome (first reported in 2012)• 2019-nCoV – today’s concern

“Human Coronavirus Types” https://www.cdc.gov/coronavirus/types.html

Insights from the 2019-nCoV genome• 2019-nCoV is a betacoronavirus (like SARS and MERS)

• Zoonotic origin – bats

• Comparison of the “spike proteins” (the critical glycoprotein responsible for viral binding and entry) showed 75% amino acid homology with SARS-CoV

• SARS-CoV uses the ACE2 receptor to infect human cells in the respiratory tract

• Based on initial modeling and in vitro studies, 2019-nCoV seems capable of binding ACE2 receptors, too

• Protease inhibitors (a class of HIV medications) may be helpful for treatment of cases of 2019-nCoV

• A mixture of anti-HIV (lopinavir and ritonavir) + anti-flu (oseltamivir) in large doses have been used for patients in Thailand to some success

• More research is needed• Remdesivir (antiviral) is being tested (active against MERS)

Gralinski LE, Menachery VD. Return of the Coronavirus: 2019-nCoV. Viruses. 2020 Feb;12(2):135. “Cocktail of flu, HIV drugs appears to help fight coronavirus: Thai doctors” https://www.physiciansweekly.com/cocktail-of-flu-hiv/“Gilead Sciences Statement on the Company’s Ongoing Response to the 2019 Novel Coronavirus (2019-nCoV)”https://www.gilead.com/news-and-press/company-statements/gilead-sciences-statement-on-the-company-ongoing-response-to-the-2019-new-coronavirus

Transmission of 2019-nCoV• Majority of person-to-person transmission happens among close contacts (about 6

feet) through transfer of respiratory droplets (cough, sneeze, contact with mucus membranes)

• Unclear if a person can get 2019-nCoV by touching a fomite with virus on it and then touching mouth/nose/eyes

• Similar to flu and other respiratory pathogens

• Period of infectivity/exact mode of transmission not yet known –• Some cases have been reported of spread from contact with infected patients with only very subtle

symptoms (pre-symptomatic)• These cases will inform the risk assessment and further preventive actions taken by public health

officials

• Symptoms – fever, cough, shortness of breath

• PCR testing confirms diagnosis of persons suspected of having 2019-nCoV• PCR testing available through the CDC and state DOH

• Risk of severe diseases is lower for children who may serve as reservoir

“How 2019-nCoV Spreads.” CDC. https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html. Updated 1/31/2020.2019 Novel Coronavirus—Important Information for Clinicians, JAMA, https://jamanetwork.com/journals/jama/fullarticle/2760782

Clinical course• Varies significantly from asymptomatic/mild illness to severe/fatal illness

• Patients with mild clinical presentation may not initially require hospitalization• Clinical signs and symptoms may worsen with progression to lower respiratory tract disease during

second week of illness, these patients should be monitored closely

• Limited number of reports of clinical presentation of 2019-nCoV infection – most are of hospitalized patients with pneumonia

• Fever (83-98%), cough (76-82%), myalgia or fatigue (11-44%), dyspnea

• Severe illness• Older patients or those with chronic medical conditions may be at higher risk for severe illness• Among hospitalized patients…

• 17-29% developed ARDS and 23-32% required intensive care for respiratory support• Other complications – acute cardiac injury (12%) and acute kidney injury (4-7%)• Case-fatality proportion among hospitalized patients as high as 11-15%

• Laboratory findings • Leukopenia (9-25%), leukocytosis (24-30%), lymphopenia (63%), elevated ALT and AST (37%)• Chest CT images have shown bilateral involvement in most patients• 2019-nCoV RNA detected from both upper and lower respiratory tract specimens

“Interim Clinical Guidance for Management of Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV)" https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Epidemiology of Disease Transmission

• Ro: inherent transmissibility of an infectious agent• Measured by the number of secondary cases generated by a single infected patient

• Ro is dynamic, depending on a variety of factors

• What determines Ro?• % of population susceptible• Mode of transmission – respiratory droplet/air-borne/etc.• Serial interval – mean amount of time between successive cases in chain of transmission

• interval between symptom onset from one person to symptom onset in another person after a transmission event

• Period of infectivity prior to symptom onset• Unique biological characteristics of pathogen • Public health responses – quarantines, travel restrictions, use of PPE

Comparison of epidemiological characteristics of other significant recent outbreaks

SARS MERS Flu 2019-nCoVRo

Control of pandemic requires Ro to be < 1

1.7-1.8 1.4-1.8 Unknown at this point, estimated to be between 1.4-4.1

Serial Interval 8-10 days 6.8 days 2-4 days ~7.5 days

Incubation period 4-6 days 5-6 days 2 days 4-7 days

Peak infectivity ~Day 10 ~Day 1-2 of illness TBD

Case-fatality Rate 11% 34.4% Highly dependent on year

2.2% - (4.3%?)

https://www.who.int/csr/sars/en/WHOconsensus.pdf - https://www.who.int/emergencies/mers-cov/en/ - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4987807/“Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China” -JAMA

CDC Recommendations - Screening• Requires clinical features & epidemiologic

risk based on travel history and/or contact with potential 2019-nCoV cases

• Specimens for Persons Under Investigation (PUI) should be collected as soon as possible once identified, regardless of time of symptom onset

• Goals of screening and containment are aimed at infection control without overwhelming healthcare systems or causing panic

CDC Recommendations – Guidance for Healthcare Professionals

• Healthcare providers should immediately notify infection control personnel and local health department in suspected 2019-nCoV cases

• PCR testing for 2019-nCoV is currently only available through the CDC• Local DOH will assist with collection, storage and shipment of specimens

• Adhere to appropriate isolation precautions and use of PPE for all Persons Under Investigation in hospital settings

https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html

CDC Recommendations – for everyone• Stay informed • Seek medical care if:

• you feel sick with fever, cough, shortness of breath• AND have traveled to China or were in close contact with someone with 2019-nCoV in the 14 days before onset

of symptoms• CDC “Do’s”: Take everyday preventive actions to stop the spread of germs

• Flu vaccine • Regular hand washing with soap and water for at least 20 seconds • Use alcohol-based hand sanitizer that contains at least 60% alcohol • Avoid touching eyes, nose, mouth with unwashed hands• Stay home when sick, especially when have a fever • Cover your cough or sneeze with a tissue or in elbow• Clean and disinfect frequently touched objects and surfaces

• CDC “Don’ts”• Don’t use facemasks in general public• Don’t spread myths or misinformation that may contribute to discrimination or bias against those of Asian

descent• These measures will serve to prevent further transmission of flu and other respiratory illness in

addition to the novel Coronavirus https://www.cdc.gov/coronavirus/2019-ncov/about/what-you-should-do.html

How to educate the public + prevent the spread of misinformation • Misinformation can fuel panic and exacerbate strain on health systems• A few examples of myths and misinformation on social media & the

internet…• Coronavirus genetically engineered by the US/China to include material from HIV virus (Epoch Times, Mother Jones)• Coronavirus related to Corona beer? • “Can I get coronavirus from eating Chinese food? What about ordering packages from China?”• Confusion between common coronaviruses in the common cold and the novel coronavirus• Can…protect me from the coronavirus? (WHO)

• Rinsing nose with saline solution• Inhaling essential oils to boost immunity• Gargling with mouthwash/eating garlic

WHO Myth Busters: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters

Keep calm and carry on…• In the community, measures to decrease the spread of other respiratory viruses will

modulate the spread of novel coronavirus• Stay home if ill• Good use of handwashing and alcohol swabs, decrease in contact

• Wider availability of diagnostic tests now becoming available at state level DOH• Vaccine development is ongoing at a rapid pace and will be key to limit subsequent waves

• Antiviral treatments are being evaluated

• We will continue to see an increase in new cases in China, here, and throughout the world in the near future

• Keep yourself informed and up to date on the latest news – reference resources provided in these slides

• CDC, Departments of Health and our healthcare systems are all responding proactively and appropriately, but this will cause significant disruption

Additional Resources

• CDC – Guidance and Updates• https://www.cdc.gov/coronavirus/2019-nCoV/summary.html)

• WHO – Situation Reports• https://www.who.int/emergencies/diseases/novel-coronavirus-

2019/situation-reports)

• Johns Hopkins University – Interactive Maps• https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda759

4740fd40299423467b48e9ecf6

• RI Department of Health – updated local info• https://health.ri.gov/diseases/respiratory/?parm=163