Novel Coronavirus (2019-nCoV)

Background

On 31 December 2019 the World Health Organisation (WHO) was informed by the People’s Republic of China that cases of pneumonia with an unknown aetiology were being seen, initially originating from Wuhan city in Hubei Province. In January 2020 the WHO announced that a novel coronavirus had been detected in patient samples, known as 2019-nCoV or more commonly as Wuhan novel coronavirus.

Coronaviruses are a large family of zoonotic viruses, meaning that they are transmitted between animals and people. Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS) are Coronaviruses which were transmitted to humans by civet cats and camels respectively.

Throughout January 2020, 2019-nCoV has rapidly spread across China, despite the Chinese government enforcing strict travel bans and restrictions in Hubei Province, with many thousands of confirmed cases being identified. Furthermore, there is a growing number of reported cases around the world including cases of human-to-human transmission, of which one of the most concerning relates to a German man who is believed to have caught the virus from a visiting Chinese co-worker. It is understood that the Chinese co-worker only developed her symptoms several days after returning to China.

Epidemiological data regarding the incubation period is still to be fully realised by researchers, however it is believed to lie between 2-10 days, with some researchers indicating a time nearer to 5 days. The transmission and fatality rates of 2019-nCoV are yet to be fully appreciated, however with documented transmission from individuals without any respiratory symptoms to others, there is an increasing sense of concern. The current consensus is that the case fatality rate lies between 2-3%, versus 10% for SARS and 34% for MERS, with a transmissibility of between one to two and one to four, i.e. on average one infected person is likely to pass on the virus to 2-4 other people without containment measures.

As a result of the emerging crisis the WHO Director–General announced that the outbreak is a Public Health Emergency of International Concern.

Current concerns

As of writing, the current confirmed total number of cases of 2019-nCoV has exceeded 17,000 internationally, mostly in China but with smaller numbers of confirmed cases in a further 27 countries, with the first death outside of China being reported in Manila, Philippines.

The UK Foreign and Commonwealth Office (FCO), the US Centres for Disease Control and Prevention (CDC) and the European Centre for Disease Prevention and Control (ECDC) have advised against all travel lo Hubei Province and all but essential travel to mainland China. As this is an ever-evolving picture, regular updates should be sought prior to any travel in or from China.

Many countries across all continents are increasingly enforcing travel bans on Chinese citizens coming from mainland China, including the UK, USA, Australia and New Zealand, and Hong Kong has recently closed its border to mainland China.

Worldwide, international airlines have ceased all flights to major Chinese cities, including British Airways and Virgin Atlantic.

How is it spread?

There is currently no exact understanding of the mechanism in which 2019-nCoV is spread, however other similar viruses are spread by cough droplets and it is suspected to be the same in this case.

Preventative strategies

The general advice for preventing infection in areas with no specifically highlighted risk is similar to that for the common flu virus and revolves around good basic hygiene techniques, including

Regular and thorough hand washing with soap and water for at least 20 seconds
Routine use of alcohol-based hand sanitisers (minimum 60% alcohol), especially after coughing or sneezing
Thorough hand hygiene decontamination when handling or consuming food
Using disposable tissues when coughing and sneezing, disposing of the tissue immediately in a bin and then washing or sanitising hands
Coughing or sneezing into the inner elbow if no tissues available
Avoid touching eyes, mouth and nose where possible.

In areas where there is a heightened risk, such as mainland China or any subsequent countries where the risk or incidence level is elevated, additional precautions are essential, including

Avoid close contact with anyone exhibiting flu-like symptoms
Avoid public spaces, transport or hospitals (where possible)
Use of a disposable and certified N95 face mask and eye protection if continued self-isolation is not possible
Follow advice and updates from local health authorities
Avoid animals where possible
Ensure that food is prepared and cooked properly

What are the symptoms of 2019-nCoV?

In general, the virus can result in flu-like symptoms such as

Fever
Cough
Sore throat
Headache
Breathing difficulty
Muscle pain
Tiredness and
Generally feeling unwell

In more serious cases, reported symptoms include severe pneumonia, respiratory distress syndrome and sepsis, all of which can result in death. Certain ‘at risk’ groups seem to be more vulnerable to developing a severe illness.

Who is at risk?

It is believed that the following groups would be at a greater risk of developing serious complications from contracting 2019-nCoV:

Individuals with a chronic heart, respiratory, kidney, liver or neurological disease
Individuals with diabetes
Young children
Older people
Immunocompromised individuals, such as those receiving chemotherapy

Criteria for surveillance

The WHO interim guidance for identifying suspected cases of 2019-nCoV relates to the presenting symptoms and the risk of exposure. The definition of a ‘suspect case’ relates to individuals who present with an acute respiratory infection who, in the 14 days prior to onset, had close contact with an individual confirmed as having 2019-nCoV, visited a healthcare setting where 2019-nCoV cases were being treated, or travelled to or from areas with a presumed ongoing community transmission.

Close contact is defined as:

Healthcare related exposure, either through direct care of a patient with confirmed 2019-nCoV, working with infected colleagues, visiting patients or staying in a close environment with an infected patient
Close proximity working with a 2019-nCoV patient – eg a classroom
Travelling by any means with an infected patient
Living in the same accommodation as an infected patient

Diagnosis and Testing

For individuals who present with an acute respiratory infection and who demonstrate a likelihood of contracting 2019-nCoV, isolation in an appropriate hospital setting is required, such as a government ‘fever centre’ in China or an Emergency Department of a large hospital outside of China. Hospital settings will be required to provide isolation and access to testing and contact tracing. Supportive treatments should also be offered, and although there is no definitive treatment for 2019-nCoV, new medications are currently under review and being considered for human trials. All countries would be expected to comply with the international agreements to report any confirmed cases to the WHO.

The current method for confirming 2019-nCoV is by analysing upper and lower respiratory tract specimens by using an RT-PCR test.

Travel Advice

The UK Government along with many other nations are currently advising against ‘all but essential travel’ to mainland China and ‘all travel’ to Hubei Province. Individuals who have visited Hubei province in China within the last 14 days are requested to remain at home and isolated from contact with others as much as possible. This means 14 days from the time in which you left China and includes not going to work, into public areas or travelling. The UK Government also requires these individuals to notify the National Health Service by calling 111.

For any individuals who have travelled to other areas of mainland China recently who develop a fever, cough or shortness of breath, the advice remains as above, however emergency assistance should also be sought, either by calling 111 or 999.

Individuals travelling or working overseas should take the same steps as above to self-isolate if they have recently travelled to China as well as contacting their local medical authorities if symptoms develop.

Repatriation Restrictions

Commercial repatriations into and from China are suspended until further notice and as per the travel guidance provided by the FCO

Commercial repatriations into and from other countries with confirmed cases of 2019-nCoV will continue at the moment, however these will be subject to international medical and travel updates and will be reviewed on a case by case basis.

Air ambulance transfers from China are currently available on a case by case basis and are strictly determined by the medical condition of the patient, confirmation that they have had a negative RT-PCR test, and their location. In all cases, if an air ambulance is approved, the patient will need to be delivered to the airport and the air ambulance by a local ambulance.

Air Ambulance providers will likely have increased infection control measures for any flights in or out of mainland China.

Outlook

The current rise in reported cases and deaths in China as well as new cases arising in other countries is leading many experts to believe that this will soon be declared a pandemic.

The WHO will continue to provide support to the Chinese government in their efforts to try and contain this extraordinary outbreak as well as providing support to less affluent countries.

Although a full epidemiological understanding is not fully understood, it is likely that the effects of 2019-nCoV will be felt for many weeks, maybe months.

Authors

Dr Alex Gill Stuart Phillips RN

Sources & Useful links

World Health Update - Coronavirus (2019-nCoV)