CDC COVID-19 ONE HEALTH UPDATE

Minesh Shah, Christina Scheel, Katie Wilson

Global Epidemiology

Pandemics

▪ Pandemics happen when a disease emerges to infect people easily and spreads from person to person in an efficient and sustained way globally

▪ This is the first pandemic known to be caused by the emergence of a new coronavirus

▪ Different countries can be in different phases of the pandemic at any point in time and different parts of the same country can also be in different phases of a pandemic

▪ The duration and severity of a pandemic can vary depending on the characteristics of the virus and the public health response

March 11, 2020

WHO declared COVID-19 pandemic

COVID-19 Etiology: SARS-CoV-2, a Human Coronavirus (HCoV)

▪ Common HCoVs (lower pathogenicity):– HCoV-229E (alpha) – HCoV-NL63 (alpha) – HCoV-OC43 (beta)– HCoV-HKU1 (beta)

▪ Other HCoVs (higher pathogenicity): – SARS-CoV (beta) – MERS-CoV (beta) – SARS-CoV-2* (beta) The illness COVID-19 is caused by SARS-CoV-2,

which is more like SARS-CoV than MERS-CoV

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it

COVID-19 Emergence: Linkage of Early COVID-19 Cases* to Huanan Seafood Wholesale Market – Wuhan, China

Adapted from Li 2020, N Engl J Med; DOI: 10.1056/NEJMoa2001316. * Total N=324 persons with complete exposure histories among 425 total cases

https://www.healthpolicy-watch.org/(N = 47) (N = 196) (N = 81)

COVID-19 Dissemination: Rapid and Widespread affecting all Global Regions https://www.healthmap.org/covid-19/

COVID-19: Signs/Symptoms

▪ No particular set of signs or symptoms can reliably discriminate COVID-19 from other respiratory viral illnesses such as influenza– Subacute to acute onset– Non-productive cough– Fever or “feverish” (often low-grade or not initially measurable)– Some reports of isolated diarrhea alone preceding cough and fever

▪ Median incubation period estimated to be 4-6 days (range 2-14 days)

▪ Most people will recover spontaneously with supportive care

▪ Complications include pneumonia, respiratory failure, multiorgan system failure

Liu 2020, Chinese Med J; DOI: 10.1097/CM9.0000000000000744. Wang 2020, JAMA; doi:10.1001/jama.2020.1585. Guan 2020, N Engl J Med; DOI: 10.1056/NEJMoa2002032. Chen 2020, Lancet; https://doi.org/10.1016/S0140-6736(20)30211-7

Age Distribution and Case Fatality Rate COVID-19China through 11-Feb-2020 (N = 44,672 confirmed cases)

adapted from Zhang 2020, China CDC Weekly Rep; 2(8):113-122.

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 ≥ 80

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Age, years

Age Distribution and Case Fatality Rate COVID-19China through 11-Feb-2020 (N = 44,672 confirmed cases)

adapted from Zhang 2020, China CDC Weekly Rep; 2(8):113-122.

0.0%

4.0%

8.0%

12.0%

16.0%

20.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 ≥ 80

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Fraction of total cases Case fatality rate

Illness Severity COVID-19 - China through 11-Feb-2020

adapted from Zhang 2020, China CDC Weekly Report; 2(8):113-122. * 1,023 (49%) deaths among 2,087 critically ill patients

44,672 patients

Critical* 4.7%

Severe 13.8%

Mild 80.9%

Missing 0.6%

SARS-CoV-2 in Human Samples and Transmission

▪ Respiratory secretions – main mode of transmission– Infection is spread through respiratory droplets in the air and that land on surfaces– Transmission from persons who are pre-symptomatic or who may have asymptomatic

infection is possible but the contribution of these infections to overall numbers of illness appears to be small at this time

▪ Stool – unlikely at this time– Readily detectable by RT-PCR but only one report of replication-competent virus cultured

▪ Perinatal – no transmission yet observed– Not detected by RT-PCR in amniotic fluid, cord blood, neonatal throat swab, breast milk

Zou 2020, N Engl J Med; DOI: 10.1056/NEJMc2001737. Pan 2020 , Lancet Infect Dis; https://doi.org/10.1016/S1473-3099(20)30113-4. Zhang 2020; China CDC Weekly: http://weekly.chinacdc.cn/en/article/id/ffa97a96-db2a-4715-9dfb-ef662660e89d. Chen 2020; Lancet: https://doi.org/10.1016/ S0140-6736(20)30360-3 Zhu 2020l Transl Pedtr: http://dx.doi.org/10.21037/tp.2020.02.06

COVID-19: High-Risk Groups

▪ Comorbidity and advanced age increase risk for severe illness and death– Cardiovascular disease, diabetes, chronic respiratory disease (CFR >5%)

▪ Immunocompromised (medical, acquired) – no data at present– For persons with HIV, risk likely greatest at low CD4 cell counts or if not virally suppressed– Nonetheless all should take precautions given this is a new virus – CDC estimates that > 50% of people with HIV are more than 50 years old

▪ Pregnancy– Current observational data only exist for women infected in third trimester– Maternal morbidity similar to that of uninfected women without COVID-19– No definitive evidence infection transmitted perinatally

Zhang 2020, China CDC Weekly Report; 2(8):113-122 Rasmussen 2020; Am J Obstet Gynecol: https://doi.org/10.1016/j.ajog.2020.02.017

COVID-19

Prevention Messages

Adapted from: Holloway 2014, MMWR Recomm Rep;63(No. RR-6). Qualls 2017, MMWR Recomm Rep; 66(No. RR-1). Jernigan 2020, MMWR Early Release: February 25, 2020.

• Intensify case finding and contact tracing• Isolate cases and quarantine contacts• Characterize illness• Prepare for mitigation with nonpharmaceutical

interventions (NPI)

• Deploy medical interventions o Antivirals, vaccines

• Early institution of multilayered NPIs

Transmissionoutpaces

containment efforts

MitigationContainment

Preparedness and Response Framework for Pandemics

Laboratory Diagnosis

Overview

▪ Coronavirus Features▪ Diagnostic Tests

• CDC Real-Time RT-PCR

▪ Preparing to work with SARS CoV-2* in the Laboratory • Risk Assessment• Biosafety• Transport• Manipulation• Waste management

*SARS CoV-2 is the virus that causes COVID-19.

Laboratory BiosafetyBefore work begins:Perform a biological risk assessment1

1. https://www.who.int/docs/default-source/coronaviruse/laboratory-biosafety-novel-coronavirus-version-1-1.pdf?sfvrsn=912a9847_22. https://www.who.int/ihr/publications/WHO-WHE-CPI-2019.20/en/

1. Identify Hazards▪ Facility▪ Biological agent▪ Personnel

2. Weigh the likelihood of an accident against consequences of exposure

Consequence

Lik

elih

ood

3. Mitigate risk using controls

Life cycle of specimen

Transport from clinic to lab▪ Shipping – Category B packaging

• Regulated UN3373 – triple packaging1

Manipulation of specimen▪ Accessioning – receipt of specimen▪ RNA extraction

Waste is Category B – autoclave or incinerate

Coronavirus features

Enveloped +ssRNA virus▪ Proteins

• Nucleocapsid (N)• Envelope protein (E)• Membrane protein (M)• Spike protein (S)

Envelope protein

Spike protein

Nucleocapsid and Genomic RNA

Membrane protein

Genetic SequenceHigh identity to

▪ SARS 2003 (80-85%)▪ Bat SL CoV (85-90%)

Laboratory TestsWorld Health Organization

Coronavirus disease (COVID-19) technical guidance: Laboratory testing for 2019-nCoV in humans1

▪ Five diagnostic test protocols for polymerase chain reaction (PCR) of COVID-19• China (genetic primers and probes only)• Thailand• Hong Kong• Japan• Germany • USA (CDC)

1. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/laboratory-guidance2. https://www.finddx.org/covid-19/

All tests detect virus – no detection of humoral response for convalescent phase

Many more tests commercially available and in development ▪ Antibody detection (igM/IgG) ▪ Automated▪ Point of Care (POC) lateral flow or “dipstick”

Under evaluation by Foundation for Innovation New Diagnostics (FIND) in coordination with WHO2

CDC Laboratory Test:Real-Time RT-PCR Panel for Detection of COVID-191

1. https://www.cdc.gov/coronavirus/2019-ncov/downloads/rt-pcr-panel-for-detection-instructions.pdf

Human Specimens▪ Respiratory

• Pharyngeal washes or swabs• Bronchiolar lavage• Tracheal aspirates• Sputum

Extract RNA+ Taq polymerase master mix

Infection Prevention and Control (IPC) for COVID-19

Note: The information presented in these slides is intended for non-US healthcare settings.

WHO guidance is incorporated.

What is IPC?

▪ The science of preventing or stopping the spread of infections during healthcare delivery

– hospitals, outpatient clinics, dialysis centers, long-term care facilities, traditional practitioners

▪ Goal: support maintenance of essential healthcare services by containing and preventing COVID-19 transmission within healthcare facilities

IPC Priorities for COVID-19▪ IDENTIFY

– Early identification of suspected cases presenting for healthcare is critical

▪ ISOLATE

– Prompt isolation of suspected cases to reduce opportunities for transmission in healthcare setting

▪ INFORM

– Communication with public health response (initiate laboratory testing, coordinate contact tracing, etc.)

Standard and Transmission-based Precautions

▪ Standard Precautions

– Set of practices that apply to care of all patients in all healthcare settings

▪ Transmission-based Precautions

– Set of practices specific for patients with known or suspected infectious agents that require additional control measures to prevent transmission

– Used in addition to Standard Precautions

Standard Precautions

▪ Hand hygiene

▪ Personal protective equipment

▪ Respiratory hygiene and cough etiquette

▪ Cleaning and disinfection of devices and environmental surfaces

▪ Safe injection practices

▪ Medication storage and handling

Elements that apply to patients with respiratory infections

Transmission-based precautions for COVID-19

▪ Use adequately ventilated single rooms or ward rooms

▪ Wear PPE for contact and droplet precautions*

▪ Use disposable or dedicated patient care equipment (e.g., stethoscopes, blood pressure cuffs)

▪ Avoid transporting COVID-19 patients out of room unless medically necessary

▪ Cohort HCWs to care for patients with COVID-19

▪ Restrict number of visitors allowed

*WHO recommendationshttps://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125

PPE for COVID-19*▪ Gloves (non-sterile, examination)

▪ Medical mask

▪ Eye protection (goggles or face shield)

▪ Gown (long-sleeved, non-sterile)

*Note: information on this slide is PPE as recommended by WHO. PPE guidance for U.S. healthcare settings can be found on CDC COVID-19 website: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-

recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html

Aerosol-generating procedures (AGPs)▪ AGPs associated with increased risk of transmission of

other coronaviruses (SARS-CoV and MERS-CoV)

▪ Perform AGPs in adequately ventilated rooms

– Negative pressure room (at least 12 air exchanges/hour) or natural ventilation (air flow at least 160 L/s per patient)

▪ Wear appropriate PPE

– Gloves (non-sterile, examination)

– Particulate respirator

– Eye protection (goggles or face shield)

– Gown (long-sleeved, non-sterile)

https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125

Differences in WHO and CDC Recommendations for PPE

*CDC has been recommending respirators for U.S. healthcare facilities

– Consistency with previously published SARS, MERS, and novel/severe influenza A guidance

– Cautious and aggressive approach in the U.S.

– Facemasks are acceptable alternative when supply chain of respirators cannot meet the demand (CDC guidance updated March 10, 2020)

Caring for suspected or confirmed COVID-19 patients

Aerosol-generating procedures for COVID-19 patients

WHO gloves, gown, eye protection, medical mask

gloves, gown, eye protection, respirator

CDC gloves, gown, eye protection, respirator* or facemask (if respirator not available)

gloves, gown, eye protection, respirator

Key Points for PPE Use

▪ PPE relies on consistent and correct use by healthcare personnel

– trainings and practice for healthcare personnel in advance

▪ Risk of self-contamination is higher when removing PPE

– Remove PPE slowly and carefully

– Do not touch front of masks, respirators, or facial protection (likely most contaminated)

▪ Instructions for putting on and removing PPE

– https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf

Environmental cleaning and disinfection

https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-508.pdf

▪ Routine cleaning and disinfection procedures

▪ Focus cleaning on frequently touched and frequently contaminated surfaces

– Light switches, bed rails, door handles, sinks, bathrooms

▪ Hospital-grade disinfectants effective

– Products active against enveloped viruses

Keeping patients safe

▪ Hand hygiene

▪ Respiratory hygiene

– Ensure patients cover their nose and mouth with tissue or elbow when coughing or sneezing

– Offer medical mask to patients with suspected COVID-19 while in waiting rooms

– Perform hand hygiene after contact with respiratory secretions

IPC Resources

▪ WHO IPC technical guidance for COVID-19

– https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infection-prevention-and-control

▪ WHO Q&A for health care workers

– https://www.who.int/news-room/q-a-detail/q-a-on-infection-prevention-and-control-for-health-care-workers-caring-for-patients-with-suspected-or-confirmed-2019-ncov

▪ Best practices for environmental cleaning in HCFs in Resource-Limited Settings

– https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-508.pdf

▪ CDC Interim IPC Recommendations for COVID-19 in Healthcare Settings

– https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

▪ IPC trainings (not specific for COVID-19)

– https://ipc.ghelearning.org/courses

COVID-19 Resources

CDC COVID-19 Resources ▪ CDC COVID-19 Web Site

https://www.cdc.gov/covid19

▪ CDC COVID-19 Information for Healthcare Professionals https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html• CDC Risk Categorization for U.S. Healthcare Personnel

https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html• Interim Healthcare Infection Prevention and Control Recommendations for Persons Under

Investigation for Coronavirus Disease 2019 https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html

• Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

• Interim Guidance for Preventing Coronavirus Disease 2019 from Spreading to Others in Homes and Communities https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-prevent-spread.html

• Interim Guidance for Healthcare Professionals https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html

CDC COVID-19 Resources

▪ Coronavirus Disease 2019 Update—What Clinicians Need to Know to Prepare for COVID-19 in the United Stateshttps://emergency.cdc.gov/coca/calls/2020/callinfo_030520.asp

▪ CDC COVID-19 Information for Laboratories https://www.cdc.gov/coronavirus/2019-nCoV/lab/index.html

▪ Public Health Image Library (PHIL) https://phil.cdc.gov/

▪ Crisis & Emergency Risk Communication (CERC) Templates https://emergency.cdc.gov/cerc/resources/templates-tools.asp

WHO COVID-19 Resources

▪ WHO COVID-19 Homepage https://www.who.int/emergencies/diseases/novel-coronavirus-2019

▪ WHO Situation Reports https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports

▪ Technical Guidance (by topic) https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/

▪ Checklist for Risk Communication and Community Engagement https://www.who.int/publications-detail/risk-communication-and-community-engagement-readiness-and-initial-response-for-novel-coronaviruses-(-ncov)

Other Useful Resources

▪ Johns Hopkins University COVID-19 Global Case Map https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html?fbclid=IwAR0BVBHgwKy6kLekBHRdykqqVlFE6flM659Hev4Ktr_dbL76pY-LO36-Am8#/bda7594740fd40299423467b48e9ecf6

For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank you!

COVID-19 International Taskforce (ITF) Email Box eocevent223@cdc.gov