Both the Journal of the American Medical Association (JAMA) and the Centers for Disease Control and Prevention’s (CDC’s) Morbidity and Mortality Weekly Report (MMWR) published initial clinical guidelines, which aim to help US healthcare providers identify and correctly handle suspected cases involving the novel coronavirus (2019-nCoV).

2019-nCoV was first identified in Wuhan, China, the country that continues to report more than 99% of cases. US officials today confirmed the 12th US case.

Intensive care often needed

The virus, which shares similarities with both MERS-CoV (Middle East respiratory syndrome coronavirus) and the SARS (severe acute respiratory syndrome) virus, causes acute respiratory distress syndrome in about one third of patients that requires intensive care, writes Carlos del Rio, MD, of the Emory University School of Medicine, and Preeti N. Malani, MD, MSJ, of the University of Michigan, in the JAMA article.

Most clinical presentations of the virus will be nonspecific and include fever and a dry cough, with about 30% of patients also experiencing shortness of breath.  

Based on case reports from China, the median age of patients is between 49 and 56 years, and cases in children have been rare.

“When a patient presents with fever and respiratory symptoms (in particular a dry cough), clinicians should obtain a detailed travel history. If the patient has a history of travel to Hubei Province in the last 14 days, they should be considered a person under investigation (PUI),” the authors write. As should patients who had any travel to China in the preceding 14 days, and any patients who had close contact with a confirmed 2019-nCoV patient.

Upon identifying a PUI, clinicians should immediately notify their health facilities’ infection prevention team and state health authorities. If the novel coronavirus is suspected, the patient should have a face mask placed immediately, and healthcare practitioners should wear N95 respirators.

“What interventions will ultimately control this outbreak is unclear because there is currently no vaccine, and the effectiveness of antivirals is unproven. However, basic public health measures such as staying home when ill, handwashing, and respiratory etiquette including covering the mouth and nose during sneezing and coughing were effective in controlling SARS,” which also originated in China, the authors conclude.

CDC suggests special isolation, if possible

In MMWR, CDC experts’ interim clinical guidelines are based on the management and prevention of respiratory illnesses, including influenza, MERS, and SARS.

The MMWR guidelines identify the same three types of PUIs—symptomatic patients with (1) a travel history to Wuhan, (2) a travel history to China, or (3) close contact with a confirmed 2019-nCoV case—but also suggest patients be immediately placed in some form of medical isolation.

“These patients should be asked to wear a surgical mask as soon as they are identified, and directed to a separate area, if possible, separated by at least 6 ft (2 m) from other persons. Patients should be evaluated in a private room with the door closed, ideally an airborne infection isolation room, if available. Health care personnel entering the room should use standard precautions, contact precautions, airborne precautions, and eye protection (e.g., goggles or a face shield),” the authors write.

The CDC experts recommend testing both the upper and lower respiratory tracts of PUIs, and encouraged the continued use of the influenza vaccine to protect all patients from seasonal influenza which is currently circulating in the United States.

“The critical role that the U.S. health care system plays in halting or significantly slowing U.S. transmission of 2019-nCoV is already evident: eight of the first 11 U.S. cases were detected by clinicians collaborating with public health to test persons at risk,” the authors concluded.

“The early recognition of cases in the United States reduces transmission risk and increases understanding of the virus, including its transmission and severity, to inform national and global response actions.”

See also:

Feb 5 JAMA viewpoint

Feb 5 MMWR interim clinical guidance