PART 8. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”

“Why this looks like the beginning of a pandemic

These outbreaks outside of China, along with the latest science on Covid-19, suggest we may soon see a rapid rise in infections — both in China and in more countries around the world. Here’s why.

1) The virus is very contagious and some people seem to be able to infect others before they know they’re sick: Researchers currently believe one infected person generally infects two to three others, which would make the new coronavirus more contagious than other coronaviruses, like SARS and MERS.

“TRYING TO STOP INFLUENZA-LIKE TRANSMISSION IS LIKE TRYING TO STOP THE WIND. IT’S VIRTUALLY IMPOSSIBLE.”…

2) Countries are still mostly looking for the disease in people who’ve traveled from China: The main method of screening in many countries is still testing passengers coming from China, or from Hubei province only. But as we’ve seen, spread is happening beyond those people. And other cases may be undetected…

3) With flu season ongoing, it can take time to identify cases and outbreaks: “The challenge with this illness is that the clinical symptoms resemble other viral illnesses, like flu,” said Inglesby. So people with the flu, and doctors examining them, may not even be thinking of Covid-19 yet, especially in people who haven’t traveled to China.

4) China may also see another surge in cases soon as travel restrictions are gradually lifted: The country has taken extraordinarily draconian measures to stop this virus, quarantining millions, and shutting down transit and travel. But the business community is growing increasingly frustrated with the restrictions, and is pressuring government officials to ease some of the restrictions…

5) Many countries are only now getting testing up and running: Even the US — with one of the most highly-resourced health systems in the world — doesn’t have adequate diagnostic capacity right now:

Reminder: As of today (Feb 23), the US remains extremely limited in #COVID19 testing. Only 3 of ~100 public health labs have @CDC test kits working and CDC is not sharing what went wrong with the kits. How to know if COVID19 is spreading here if we are not looking for it.

6) Some people may have abdominal pain before respiratory symptoms — and that’s not something health officials are screening for: This coronavirus is still very new, and we don’t know its entire spectrum of illness yet, but we’re learning the disease may sometimes surface in surprising ways. Though it’s a respiratory infection, a recent JAMA article found some have abdominal symptoms such as discomfort first. This means “we may not be detecting cases that do not present in the classic way with fever and respiratory symptoms,” said William Schaffner, an infectious disease expert at Vanderbilt University….

We need to prepare for a pandemic…

For now, countries need to move from trying to contain the virus to mitigating its harm — reducing the spread, and caring for the very sick, said Jennifer Nuzzo, an infectious disease expert and senior scholar at the Johns Hopkins Center for Health Security. “It is beyond time,” she added.” (A)

“On Tuesday, Feb. 18, no coronavirus cases had been reported in Iran. On Sunday, the government announced 43 cases and eight deaths. Some 152 cases (and at least three deaths) were confirmed in Italy on Sunday, up from three cases on Thursday. The number of infected people in South Korea jumped to 763 (and six deaths) in just days.

As of Monday, Covid-19 was detected in at least 29 countries. In nations with few or no reported cases so far, particularly in South America and Africa, the absence of evidence shouldn’t be interpreted as evidence of absence. More likely, it reflects lack of testing.

Is the Covid-19 outbreak now a pandemic, whether or not the World Health Organization calls it that yet? If so, what’s next?

In a world ill-prepared for a potentially life-threatening, easily transmitted disease like Covid-19, the most effective way to mitigate the pandemic’s impact is to focus on supporting health care systems that already are overburdened…

This is the main reason every country’s top priority should be to protect its health care workers.

The United States and other countries in the Northern Hemisphere already are in the throes of a moderately severe flu season. Their inventories of protective equipment used by doctors, nurses and emergency medical workers — N-95 respirator masks, gloves, eye protection, disposable suits — are running low. These limited supplies must go to health care workers first, rather than the public. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained: If infected health care workers die in large numbers, entire societies may be shaken to the point of panic.

Governments should also conduct Covid-19 preparedness drills in local hospitals and expand hospitals’ temporary capacity, for example, by setting up emergency tents in parking lots, as is already happening in some places in the United States. To minimize the strain on overstressed acute-care hospitals, supportive nursing care might have to be provided, in makeshift facilities and patients’ homes, as was done during severe pandemics in the past, such as the Great Influenza of 1918-19…

Ensuring all of this means facing the hard facts of this unfolding pandemic — and that requires thorough, transparent disclosures to the public. Past experiences, with the anthrax-laced letters in 2001 and the 2014 Ebola outbreak, suggest that people react more rationally and show greater resilience to a full-blown crisis if they are prepared intellectually and emotionally for it.” (B)

“The number of coronavirus cases in South Korea has soared to about 602, according to The New York Times. More than half of those cases involve members of, or those somehow linked to, the religious sect, the Shincheonji Church of Jesus, where a so-called superspreader infected at least 37 people last week.

A so-called superspreader infected at least 37 people at her church with the new coronavirus, and dozens of additional worshippers are also showing symptoms of the disease, called COVID-19, according to news reports.

The 61-year-old woman attends the Shincheonji Church of Jesus the Temple of the Tabernacle of the Testimony in Daegu, South Korea, according to the international news outlet AFP. The city, located in the southern part of the country, is home to about 2.5 million people. The woman, called “Patient 31” by Korea’s Centers for Disease Control and Prevention, developed a fever on Feb. 10 and attended four church services before being diagnosed with COVID-19. ..

Authorities described the outbreak as a “super-spreading event,” as the lone woman transmitted the infection to an unusually high number of people, according to Reuters. Current estimates suggest that a single person with the novel coronavirus spreads the infection to about 2.2 additional people, on average. The surge of infection at the church brings the total number of confirmed cases in South Korea to 104; one death associated with the virus has occurred in the country so far.” (C)

“Rain was falling on the night of Jan. 18, so the windows of the Tokyo party boat were shut. Inside were about 90 guests of a local taxi association who were celebrating the new year as the vessel floated down the Sumida River. Also on board, unbeknown to them, was a coronavirus capable of spreading ferociously.

It did just that. A driver in his 70s soon fell ill with fever; he later tested positive. The same day as his diagnosis, his mother-in-law died; she also was infected. Officials then discovered that 10 others from the boat were, too, including an employee who had served passengers from Wuhan, China. Still more who did not attend the party caught the virus after coming into contact with those who did.

As public health officials look for clues to one of the biggest uncertainties about the new coronavirus epidemic — whether it will eventually expand rapidly beyond its center in China — they are closely studying clusters of cases that have emerged recently in Japan.

The issue has taken on more urgency as passengers have begun walking off a contaminated cruise ship in Yokohama where 634 people have tested positive for the virus and two later died. Experts fear that some who were cleared to leave an onboard quarantine could later test positive, spreading infections on land in the same way that the party boat has done.

Alarmed officials are rushing to learn more about how the virus is transmitted, including how many of those infected experience mild symptoms or none at all, and whether it can be spread by people who are symptom-free.” (D)

“Most of the Americans who were being monitored at the University of Nebraska Medical Center for coronavirus after evacuating a cruise ship in Japan tested positive for the virus, the hospital says.

UNMC said in a statement Thursday that the US Centers for Disease Control and Prevention verified the Nebraska Public Health Lab results showing that 11 of the 13 patients have the novel coronavirus. The other two evacuees who were taken to the Omaha hospital tested negative, the statement said.

Bert Kelly, a CDC spokesman, told CNN that the agency has verified the results, bringing the total of confirmed cases in the United States to 26.

The hospital had said some of the patients had tested positive in Japan but some “came with a lack of clarity of what their test results were,” Shelly Schwedhelm told CNN. Schwedhelm is the UNMC/Nebraska Medical Executive Director of Emergency Management and Biopreparedness who has clinical oversight of the quarantine and biocontainment units.

Nine of the patients had tested positive for the virus in Japan and were positive again after being rested in the United States, another CDC spokesman, Joe Smith, told CNN on Friday.” (E)

“Preventing the spread of infectious disease is the essence of public health work, but the scale of efforts by state and local health departments across the country to contain the virus known as COVID-19, experts said, has rarely been seen. Since early February, thousands of people returning to the United States from mainland China, the center of the outbreak, have been asked to isolate themselves at home for 14 days…

Local health officials check in daily by email, phone or text. They arrange tests for people who come down with symptoms, and in some cases, groceries and isolated housing. There is no centralized tally in the United States of people being monitored or asked to remain in isolation, and they are scattered across the nation’s nearly 3,000 local health jurisdictions.

People arriving from mainland China are added each day, while those who have completed 14-day “self-quarantine” periods are released from oversight. In California alone, the department of public health has been monitoring more than 6,700 returning travelers from China, while health officials in Washington State have tracked about 800, and officials in Illinois more than 200.

At least 34 cases have been confirmed in the U.S. and more infections are expected…

 “All hands on deck are being pulled into this,’’ said Dr. Marcus Plescia, the chief medical officer for the Association of State and Territorial Health Officials, a nonprofit organization that represents public health agencies across the country. “If it really blows up, at some point, it could overwhelm state and local health departments.”…

In Washington, where the first coronavirus patient in the United States was confirmed on Jan. 21, health officials tracked down and monitored 69 individuals with whom the man had come in contact, including work colleagues, health workers and other patients present in a clinic he visited when he first felt sick. Still, there have been issues. One person the man had been in contact with and who had developed symptoms of illness flew on a plane to Wisconsin during the 14-day period when she was supposed to be isolated at home.

 “There is no way, with something this large, that you can make it seal-proof,’’ said Dr. Wiesman, who has started twice-weekly conference calls with the chief health officers in every state and territory to share tips and seek advice on how to manage the shifting challenges of the coronavirus response. While enforcing total compliance with isolation orders may not be possible, Dr. Wiesman said, “We have to try for 80 to 85 percent, and hopefully that will work.’’

Federal authorities are in charge of setting guidelines to manage the danger, such as deciding how much risk a returning traveler poses and who should be tested for the coronavirus. But the day-to-day work putting those policies in place and tracking thousands of people falls to the vast, decentralized network of local health departments across the country. Travelers’ data, culled from federal customs officials, is passed on to state health agencies, who farm out lists of people returning from China to local health departments.” (F)

Health experts sounded the alarm Friday over the worldwide threat of the coronavirus, with officials “warning of its “likely” community spread in the United States and the World Health Organization cautioning that “the window of opportunity is narrowing” for containing the outbreak worldwide.

The COVID-19 coronavirus, which erupted in China in December, has killed at least 2,360 people and sickened at least 77,900 worldwide, the majority of cases in mainland China.

Dr. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, told reporters Friday that U.S. health officials are preparing for the coronavirus to become a pandemic.

“We’re not seeing community spread here in the United States, yet, but it’s very possible, even likely, that it may eventually happen,” she said. “Our goal continues to be slowing the introduction of the virus into the U.S. This buys us more time to prepare communities for more cases and possibly sustained spread.”

She said the CDC is working with state and local health departments “to ready our public health workforce to respond to local cases.” These measures include collaboration with supply chain partners, hospitals, pharmacies and manufacturers to determine what medical supplies are needed.

She said the “day may come” here where we have to shut down schools and businesses like China has done.” (G)

“In the U.S., the number of confirmed cases rose to at least 34, as a number of evacuated individuals from the Diamond Princess cruise ship have tested positive.

Several other Americans who were on board the ship have been diagnosed and hospitalized in Japan, according to the CDC. As of Friday afternoon, there were no plans to evacuate those patients. The U.S. Department of State said it will not rescue other Americans who choose to go on cruises in Asia.

“Such repatriation flights do not reflect our standard practice, and should not be relied upon as an option for U.S. citizens,” Ian Brownlee, an executive within the Department of State, said during a media briefing Friday.

On its website, the department has warned Americans to reconsider any planned cruises to or within Asia, saying such trips “may be impacted by travel restrictions affecting their itineraries or ability to disembark, or may be subject to quarantine procedures implemented by the local authorities.

How countries are able to contain the virus and prevent it from sustained person-to-person transmission will be important in determining the “ultimate end game” of the virus, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told NBC News.

“If infection control gets out of control in many of these countries throughout the world, then it’s going to be very difficult to prevent cases from then going, by travel, to all parts of the world,” Fauci said. “That’s how a pandemic starts.”

As part of a team of international scientists led by the World Health Organization, the National Institutes of Health and the CDC have staff members in China, observing containment and infection control efforts. They’re scheduled to travel into the epicenter of the outbreak, Wuhan, on Saturday.

“We still believe we can contain the virus,” WHO Director-General Dr. Tedros Adhanom Ghebreyesus said Friday during a media briefing. “But the window of opportunity is narrowing.”” (H)

“About 150 prescription drugs — including antibiotics, generics and some branded drugs without alternatives — are at risk of shortage if the coronavirus outbreak in China worsens, according to two sources familiar with a list of at-risk drugs compiled by the Food and Drug Administration.

Why it matters: China is a huge supplier of the ingredients used to make drugs that are sold in the U.S. If the virus decreases China’s production capability, Americans who rely on the drugs made from these ingredients could be in trouble.

What they’re saying: The FDA declined to comment on the list, but said in a statement that it’s “keenly aware that the outbreak could impact the medical product supply chain,” and has devoted additional resources toward identifying potential vulnerabilities to U.S. medical products stemming specifically from the outbreak.

The agency has been in contact with hundreds of drug and medical device manufacturers, and it’s also coordinating with global regulators like the European Medicines Agency.

It pointed out that there aren’t any vaccines, gene therapies or blood derivatives licensed by the FDA that are manufactured in China, although raw materials for many products do come from China and other southeastern Asian countries. The agency is in contact with biologics manufacturers to monitor supply concerns.

“If a potential shortage or disruption of medical products is identified by the FDA, we will use all available tools to react swiftly and mitigate the impact to U.S. patients and health care professionals,” said an FDA spokesperson.” (I)

“A group of 46 Congress members sent a letter to the Trump administration Feb. 20 urging the government not to give exclusive licenses to any drugmaker that develops a coronavirus vaccine using U.S. taxpayer funds.

The lawmakers expressed concern that if drugmakers are given excluisve licenses on coronavirus treatments or vaccines, they would raise the prices and make treatments inaccessible for many people affected by the virus.” (J)

“As the novel coronavirus, called COVID-19, continues to spread across the globe, Cleveland’s major hospitals are preparing for potential cases.

From screening patients for the virus to protecting medical providers, local health care systems are taking precautions to ensure that if they do get a case of COVID-19, it doesn’t spread, as it has in China.

“Part of preparedness is thinking ahead,” said Dr. Amy Ray, medical director of infection prevention at the MetroHealth System…

Early identification of patients who are at risk for COVID-19 infection is important, Ray said.

MetroHealth staff who schedule urgent appointments in doctors’ offices are trained to look for patients who are having fever and cough, or fever and shortness of breath, and have traveled in China or been in close contact with someone who traveled there, Ray said…

At the Cleveland Clinic, the electronic medical records vendor turned on a function that automatically prompts those who are checking in patients or taking calls to ask if patients have traveled to China and are experiencing symptoms such as cough and fever, said Dr. Tom Fraser, vice chairman of infectious disease at the Clinic…

At MetroHealth’s main campus in south Tremont area, officials have set aside a two-bed unit, called the Special Diseases Care Unit, for possible COVID-19 patients.

The unit has its own blood lab and an anteroom where health care workers can put on and take off their protective gear. The Infection Prevention Team is looking for other areas of MetroHealth with negative-pressure ventilation systems that could be used to care for COVID-19 patients, Ray said.

Portable X-ray and other equipment can be brought to the isolation rooms to minimize the need to move patients through the hospital, limiting the danger of transmission to others…

At each hospital system, medical personnel wear protective gear that covers their nose, mouth and eyes to examine patients suspected of having COVID-19. That means wearing fitted respirators, a face shield or goggles, gloves and a gown.

Keeping health care workers protected and healthy is a priority because they come in contact with so many others, Saade said.

“A big problem in these big epidemics — thankfully, we’re not there yet — is that you don’t have enough health care workers to help with people care,” he said…

While it’s ideal to isolate all patients in the hospital, if there were a COVID-19 outbreak, those with lesser symptoms would need to self-quarantine at home, Saade said.

“If we have just a few people, we can isolate them,” he said. “That’s not something that can happen if it’s widespread.”

Fraser said that a lot of the precautions that health systems are taking for COVID-19 are built on day-to-day infection-prevention practices.

In the end, it all comes down to the basics, he said.

“Everybody’s seen the Hazmat suits and stuff like that on TV. But if we don’t wash our hands well between patients, then you can have all kinds of fancy suits” but not be protected, Frazer said.

“Clean hands going in, and clean hands going out” is the “fail safe,” he said. “Because not everybody is going to come with a sign that says ‘I’ve got coronavirus.’ ”

The Clinic emphasizes daily basic infection-prevention practices, such as hand hygiene and proper cough etiquette.

“Those kind of basics, without those, everything else would fall apart,” Fraser said.” (K)

Labs in the US will start looking for the new coronavirus this week (L)

Specialized respirators are key to stopping spread of coronavirus to medical staff (M)

Flowchart to Identify and Assess 2019 Novel Coronavirus for the evaluation of patients who may be ill with or who may have been exposed to 2019 Novel Coronavirus (2019-nCoV)

For the evaluation of patients who may be ill with or who may have been exposed to 2019 Novel Coronavirus (2019-nCoV) (N)

Coronavirus: What it does to the body (O)

How the coronavirus can kill people (P)

Coronavirus Disease 2019 Information for Travel

This page includes information about Coronavirus Disease 2019 (COVID-19) for travelers and travel related industries. (Q)

Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019 (COVID-19), February 2020 (R)

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