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COVID-19 Information for Texas Mutual Policyholders
A Population Health Perspective of Covid-19 and the Workplace
Edward J. Bernacki, MD, MPHProfessor of Population Health
Dell Medical School-UT at Austin
Webinar:Texas Mutual Insurance Company
May 29, 2020
Agenda• Covid-19 Description, Distribution,
Magnitude• Business Considerations• Testing Options• Workers’ Compensation
2019 Novel CoronavirusDecember 31, 2019◦ Cluster of pneumonia cases of unknown
etiology identified in Wuhan, China
January 7, 2020◦ Confirmed that the cluster was associated with a
novel coronavirus, 2019-nCoV
•COVID-19• COVID-19 – name of the disease• SARS-CoV-2 virus causing COVID-19
Sources: World Health Organization. Pneumonia of unknown cause-China. World Health Organization www.who.int/csr/don/12-january-2020-novel-coronavirus-china
Routes of Transmission
Animal
Human
• Animal-to-Human
Transmission
OtherHumans
• Human-to-HumanTransmission
Travel Related Exportation of Cases
Source: The Lancet Published online October 11, 2017 Lancet. doi: https://doi.org/10.1016/S0140-6736(17)32092-5
Symptoms and Signs • Fever (low or high grade) (80-88%)• Dry cough (63-69%)• Loss of appetite (39-84%• Fatigue (38-46%)• Sputum production (33-42%)• Chest pain or pressure (28-36%)• Dyspnea (shortness of breath) (19-35%)• Myalgia and/or arthralgia (muscle and joint pain) (15-33%)• Sore throat (12-14%)• Headache (11-15%)• Chills (6-11%)• Nausea or vomiting (5-10%)• Diarrhea (4-29%• Nasal congestion (4-5%)• Abdominal pain (4%)• Anosmia and dysgeusia (loss of smell and taste) (85% moderate/severe)
Infectious for 11 days from onsetSpread
• Droplets◦ Close contact (6ft)
• Asymptomatic (10-50%)• R0=1.5-5.7 (Measles=18,
Flu=1.6)
Proportion of + tests in Austin (15%)
COVID-19 Basics
Incubation Period?• 2-14 days (average 5 days)
Source: www.michigan.gov/documents/mdhhs/nCOV-2019_General_Fact_Sheet_v2-4-20_680266_7.pdf
https://coronavirus.jhu.edu/us-map
Case Fatality Rate (CFR)(as of May 12,2020)
GeographyCV-Wuhan: 5.8%CV-China: 0.7%CV-Texas 0.03%CV-New York: 0.12%CV-New Jersey: 0.08%CV-Sweden: 0.02%Flu-US:0.01%Age (U.S.) CV≥65 years: 2.7%-10.4%20-64 years: 0.1%-1.4%<20 years: almost 0%
Probability of getting and dying (current) from Covid-19 (120K deaths) increased from 0.87% to 0.90% in U.S.
*Based on 55,924 laboratory-confirmed cases described in the WHO-China Joint Mission on Coronavirus Disease (COVID-19), 16-24 Feb 2020. Source: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf**Based on 44,672 confirmed cases reported in JAMA, 24 Feb 2020. Source: https://jamanetwork.com/journals/jama/fullarticle/2762130
Source: https://medium.com/@eolszewski/the-data-on-your-chances-of-dying-from-covid-19-coronavirus-394276153b83
Mortality Rate
Mortality Rate
Source: https://medium.com/@eolszewski/the-data-on-your-chances-of-dying-from-covid-19-coronavirus-394276153b83
https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm
Business Considerations Actions an employer can take to mitigate the risk of COVID-19 infection related to potential respiratory and contact spread:
1. Employee issues (e.g., education and medical surveillance) 2. Travel issues 3. Social distancing methods 4. Disinfection practices and contact spread measures 5. Personal protective equipment (e.g., masks, gloves, and face shields) 6. Ventilation issues 7. Policies and procedures 8. Industry-specific recommendations
Source: http://www.mdguidelines.com
Screening to avoid having workers with potential COVID symptoms to enter the workplace:
• Daily/periodic questionnaires and/or temperature measurements. If positive, restrict employee from workplace and advise evaluation by a healthcare provider. RTW when cleared by provider.
• Screen subcontractors, suppliers, and visitors.
Employee Issues: COVID-19 Surveillance
Source: http://www.mdguidelines.com
• Sick employees should stay home- to eliminate all contact between the healthy workers and anyone with potentially infectious symptoms.
• Sick employees should be evaluated by a healthcare provider and encouraged to undergo testing if available.
Employee Issues: Sick Employees with Possible COVID Symptoms
Source: http://www.mdguidelines.com
Employees in contact with an infected person should self isolate for 14 days and undergo medical screening especially for high risk exposures. High risk exposure would include long duration of contact, whether employee was using any personal protective equipment, and the type of personal protective equipment used (cloth face covering vs. respirator).
Employees Issues: Contact with a Covid-19 Positive Person
Source: http://www.mdguidelines.com
• The sick employee who test positive should follow current CDC guidelines, quarantining at home. A symptom-based approach recommends recording temperatures twice daily until 72 hours (3 days) have passed without fever or treatment with any fever-reducing medications. A minimum of 10 days must have passed since the onset of symptoms.
• A testing-based approach requires two negative PCR viral tests obtained at least 24 hours apart and improvement in respiratory symptoms without fever. At least 10 days have passed since exposure. Usually pertains to employees with no symptoms.
Employee Issues: Employees Testing Positive for COVID-19-RTW
Source: http://www.mdguidelines.com
Employee Issues: Essential Critical Workers Exposed to Covid-19
Source: http://www.mdguidelines.com
Definition: Law enforcement, 911 Call Center, Fusion Center, Hazard Material, Janitorial Staff, Food Production, IT, Transportation, Energy and Government Workers.
May work but must wear masks, undergo daily screening, social distancing and go home immediately at any sign of illness. Confine for 14 days if exhibiting signs if illness.
Risks differ considerably by mode of transportation, geographic locations, and current state of the epidemic in any given locale. Any trips that can be canceled or postponed should be canceled.
For employees returning from travel to a high risk area may elect to self-quarantine and work from home for a minimum of 2 weeks to avoid direct contact with other workers.
Travel Issues
Source: http://www.mdguidelines.com
.
• Consider rotating workers between home and work settings to reduce workplace population densities.
• Increase distances between workers, installing temporary barriers, marking 6-foot distances on the floor between co-workers.
• Consider: social spacing in cafeterias, closing cafeterias or having workers eat their own food at their workstations.
• Consider one-way walkways through a workplace.
• Reorganize shifts to spatially and temporally, spread workers.
• Provide barriers for employees whose who interact with the general public.
• Consider discouraging carpooling and mass transit (encouraging the use of masks if using either of those options).
• Minimize reasons for external individuals and the public to enter a workplace.
Social Distancing Methods
Source: http://www.mdguidelines.com
• Clean commonly touched worksite surfaces frequently (e.g., hourly or between shifts), including machine controls, door handles, bathroom doors, bathroom fixtures, faucet handles, lunch tabletops, breakrooms, etc.
• Avoid shared equipment when possible (e.g., keyboards), and clean common surfaces between shifts or between worker usage.
• Clean surfaces with an EPA-approved viricidal agents. Use agents containing 62-71% ethanol, 0.5% hydrogen peroxide, 0.1% sodium hypochlorite for at least 1 minute.
The EPA has a list of products active against human coronavirus, with recommendations for the duration of contact time.
• Provide ample hand sanitizer and hand-sanitizer stations.
• Encourage frequent hand hygiene (hand washing or use of alcohol-based hand disinfectants).
Disinfection Practices and Contact Spread Measures
Source: http://www.mdguidelines.com
PPE measures (masks, gloves, and face shields) help to slow spread of the COVID 19 virus:
• Mainly indicated to prevent spread from infected to non-infected persons!!!
• Use face shields where there is potential for human-related splashes or droplet exposures.
• Appropriate PPE for cleaning a workspace contaminated by the virus is a face mask and gloves
If there are concerns about aerosols, an N95 mask is recommended for HCW.
Personal Protective Equipment
Source: http://www.mdguidelines.com
Increased ventilation (general and local) has been underutilized as a potential COVID-19 control:
• Use local ventilation to supply clean air to a worker’s workspace.
• Utilize increased air exchanges in the HVAC system to dilute the generalambient air including High Efficiency Particulate Air (HEPA) filters in the HVACsystem.
• Where possible, use portable HEPA filtration systems for small work areas.
Ventilation Issues
Source: http://www.mdguidelines.com
High Risk Workplaces and Occupations
Source: https://www.visualcapitalist.com/wp-content/uploads/2020/04/covid-19-occupational-risk-scores.html?mod=article_inline
Risk Ratios for the Association between Broad Occupational Groups and Testing Positive for SARS-CoV-2 in Hospital
Source: Occupation and risk of COVID-19: prospective cohort study of 120,621 UK Biobank participants (URL: medrxiv.org/content/10.1101/2020.05.22.20109892v1.full.pdf).
Risk Ratios for the Association between Detailed Occupational Groups and Testing Positive for SARS-CoV-2 in Hospital
Source: Occupation and risk of COVID-19: prospective cohort study of 120,621 UK Biobank participants (URL: medrxiv.org/content/10.1101/2020.05.22.20109892v1.full.pdf).
https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/bulletins/coronaviruscovid19relateddeathsbyoccupationenglandandwales/deathsregistereduptoandincluding20april2020
Men working in low-skilled or caring, leisure and other Service occupations had the highest rates of death involving COVID-19
• A total of 2,494 deaths involving the coronavirus (COVID-19) in the working age population (those aged 20 to 64 years) of England and Wales were registered up to and including 20 April 2020.
• Nearly two-thirds of these deaths were among men with 9.9 deaths per 100,000 compared with 5.2 deaths per 100,000 females.
• Men working in the lowest skilled occupations had the highest rate of death with 21.4 deaths per 100,000 males ; men working as security guards had 45.7 deaths per 100,000.
• Men working in social care had significantly raised death rates: 23.4 deaths per 100,000.
• Among men, occupations with raised death : taxi drivers and chauffeurs (36.4 deaths per 100,000); bus and coach drivers (26.4 deaths per 100,000); chefs (35.9 deaths per 100,000); and sales and retail assistants (19.8 deaths per 100,000).
Source: Office of National Statistics Coronavirus (COVID-19) related deaths by occupation, England and Wales: deaths registered up to and including 20 April 2020
Occupational Mortality Facts
Structural and socioeconomic challenges in meat and poultry processing facilities make these workplaces high risk: workers speaking many different primary languages, an incentive to work while ill (limited medical leave and disability policies), attendance bonuses that could encourage to work while sick. At home, many workers live in crowded, multigenerational settings and share transportation to and from work, increasing risk fortransmission of disease.
Recommended changes:
• Adjust start and stop times of breaks and shifts, add outdoor breakrooms
• Install physical barriers between workers.
• Screen all workers and visitors, isolate workers who become ill at work.
• Require universal face coverings and provide training on donning and doffing PPE.
• Assign additional staff to sanitize high-touch areas.
• Add hand-sanitizer dispensers and handwashing stations.
• Develop culturally informed messaging.
• Include messaging about behaviors to limit spread of virus at home.
• Add additional vehicles to shuttle routes.
.
Food Production Facilities
Tests for SARS-CoV-2 / COVID-19
• CDC Position: Serologic testing should not be used to determine immune status in individuals until the presence, durability, and duration of immunity is established.
• May be useful in future as more information is available.
Source: https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antibody-tests-guidelines.html
Antibody Testing
Work Related or Not?Occupational Disease or Ordinary Disease of Life. Burden of Proof on Insurance Carrier/Policyholder or Employee?
Burden of Proof on Employer/Insurance Carrier-Presumed Work-Related: Essential Workers, First Responders and Healthcare Workers in Washington (EO),California (EO), Hawaii (EO), Mass.(Comm.), So. Carolina (Comm.) No. Carolina (Comm.), Federal (TSA), MD Comm.)Occupational Disease: New York
Texas—not an occupational illness, burden of proof on employee.
Workers’ Compensation Issues
References• Hoehl, S.; Berger, A.; Kortenbusch, M.; Cinatl, J.; Bojkova, D.; Rabenau, H.; Behrens, P.; Böddinghaus, B.; Götsch, U.; Naujoks, F.; Neumann, P.;
Schork, J.; Tiarks-Jungk, P.; Walczok, A.; Eickmann, M.; Vehreschild, M. J. G. T.; Kann, G.; Wolf, T.; Gottschalk, R.; Ciesek, S., Evidence of SARS-CoV-2 Infection in Returning Travelers from Wuhan, China. New England Journal of Medicine 2020.https://www.nejm.org/doi/full/10.1056/NEJMc2001899
• Zhao, J.; Yuan, Q.; Wang, H.; Liu, W.; Liao, X.; Su, Y.; Wang, X.; Yuan, J.; Li, T.; Li, J.; Qian, S.; Hong, C.; Wang, F.; Liu, Y.; Wang, Z.; He, Q.; He, B.;Zhang, T.; Ge, S.; Liu, L.; Zhang, J.; Xia, N.; Zhang, Z., Antibody Responses to SARS-CoV-2 in Patients of Novel Coronavirus Disease 2019. SSRN2020. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3546052#
• FDA, Policy for Diagnostics Testing in Laboratories Certified to Perform High Complexity Testing under CLIA prior to Emergency Use Authorization forCoronavirus Disease-2019 during the Public Health Emergency; Immediately in Effect Guidance for Industry and Food and Drug Administration Staff.2020. https://www.regulations.gov/docket?D=FDA-2020-D-0987
• CDC, Situation summary. https://www.cdc.gov/coronavirus/2019-nCoV/summary.html.• Biotech, M., Mesa Biotech Receives Emergency Use Authorization from FDA for a 30 Minute Point of Care Molecular COVID-19 Test. Mesa Biotech:
2020. https://www.mesabiotech.com/news/euacoronavirus• Daily, H., Wuhan Institute of Virology, Chinese Academy of Sciences and others have found that 3 drugs have a good inhibitory effect on new
coronavirus. Chen, L., Ed. 2020. http://news.cnhubei.com/content/2020-01/28/content_12656365.html• FDA, ID NOW COVID-19; Food and Drug Administration: 2020. https://www.fda.gov/media/136525/download• Wetsman, N., FDA authorizes first antibody-based test for COVID-19. The Verge 2 April, 2020• Muoio, D., Scanwell Health, myLAB Box unveil more at-home COVID-19 testing services. MobiHealthNews 20 March, 2020.• Nadi, A., An at-home fingerprick blood test may help detect your exposure to coronavirus. NBC NEWS 04 April, 2020.• Shi, W.; Peng, X.; Liu, T.; Cheng, Z.; Lu, H.; Yang, S.; Zhang, J.; Li, F.; Wang, M.; Zhang, X.; Gao, Y.; Shi, Y.; Zhang, Z.; Shan, F., Deep Learning-
Based Quantitative Computed Tomography Model in Predicting the Severity of COVID-19: A Retrospective Study in 196 Patients. SSRN 2020. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3546089
• Herold, T.; Jurinovic, V.; Arnreich, C.; Hellmuth, J. C.; Bergwelt-Baildon, M.; Klein, M.; Weinberger, T., Level of IL-6 predicts respiratory failure inhospitalized symptomatic COVID-19 patients. medRxiv 2020, 2020.04.01.20047381.https://www.medrxiv.org/content/medrxiv/early/2020/04/04/2020.04.01.20047381.full.pdf
References Continued• CDC, 2019 Novel Coronavirus RT-PCR Identification Protocols. https://www.cdc.gov/coronavirus/2019-ncov/lab/rt-pcr-detectioninstructions.html.• Corman, V. M.; Landt, O.; Kaiser, M.; Molenkamp, R.; Meijer, A.; Chu, D. K.; Bleicker, T.; Brunink, S.; Schneider, J.; Schmidt, M. L.; Mulders, D. G.;
Haagmans, B. L.; van der Veer, B.; van den Brink, S.; Wijsman, L.; Goderski, G.; Romette, J. L.; Ellis, J.; Zambon, M.; Peiris, M.; Goossens, H.; Reusken, C.; Koopmans, M. P.; Drosten, C., Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill 2020, 25 (3). https://www.ncbi.nlm.nih.gov/pubmed/31992387
• Li, Q.; Guan, X.; Wu, P.; Wang, X.; Zhou, L.; Tong, Y.; Ren, R.; Leung, K. S. M.; Lau, E. H. Y.; Wong, J. Y.; Xing, X.; Xiang, N.; Wu, Y.; Li, C.; Chen, Q.; Li, D.; Liu, T.; Zhao, J.; Liu, M.; Tu, W.; Chen, C.; Jin, L.; Yang, R.; Wang, Q.; Zhou, S.; Wang, R.; Liu, H.; Luo, Y.; Liu, Y.; Shao, G.; Li, H.; Tao, Z.; Yang, Y.; Deng, Z.; Liu, B.; Ma, Z.; Zhang, Y.; Shi, G.; Lam, T. T. Y.; Wu, J. T.; Gao, G. F.; Cowling, B. J.; Yang, B.; Leung, G. M.; Feng, Z., Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia. New England Journal of Medicine 2020. https://www.nejm.org/doi/full/10.1056/NEJMoa2001316
• Sheridan, C., Coronavirus and the race to distribute reliable diagnostics. https://www.nature.com/articles/d41587-020-00002-2.• WHO, Diagnostic detection of Wuhan coronavirus 2019 by real-time RTPCR -Protocol and preliminary evaluation as of Jan 13, 2020.
https://www.who.int/docs/default-source/coronaviruse/wuhan-virus-assay-v1991527e5122341d99287a1b17c111902.pdf?sfvrsn=d381fc88_2 (accessed 01/26/2020).
• WHO, Novel Coronavirus (2019-nCoV) technical guidance: Laboratory testing for 2019-nCoV in humans. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/laboratory-guidance
• Assunção, M., Iceland’s coronavirus testing suggests 50% of cases have no symptoms. NY Daily News 01 April, 2020• Ministry for Foreign Affairs, Large scale testing of general population in Iceland underway In Government of Iceland, Government of Iceland: 2020.
https://www.government.is/news/article/2020/03/15/Large-scale-testing-of-general-population-in-Iceland-underway/• Ren, X.; Liu, Y.; Chen, H.; Liu, W.; Guo, Z.; Chen, C.; Zhou, J.; Xiao, Q.; Jiang, G.-M.; Shan, H., Application and Optimization of RT-PCR in Diagnosis of
SARS-CoV-2 Infection. medRxiv 2020.• Wang, W.; Xu, Y.; Gao, R.; Lu, R.; Han, K.; Wu, G.; Tan, W., Detection of SARS-CoV-2 in Different Types of Clinical Specimens. JAMA 2020.
https://doi.org/10.1001/jama.2020.3786• Wölfel, R.; Corman, V. M.; Guggemos, W.; Seilmaier, M.; Zange, S.; Müller, M. A.; Niemeyer, D.; Jones, T. C.; Vollmar, P.; Rothe, C.; Hoelscher, M.;
Bleicker, T.; Brünink, S.; Schneider, J.; Ehmann, R.; Zwirglmaier, K.; Drosten, C.; Wendtner, C., Virological assessment of hospitalized patients with COVID-2019. Nature 2020. https://doi.org/10.1038/s41586-020-2196-x
• US Department of Homeland Security. Master List of Questions. https://www.dhs.gov/publication/st-master-question-list-covid-19. April 7, 2020.
References Continued• Hoehl, S.; Berger, A.; Kortenbusch, M.; Cinatl, J.; Bojkova, D.; Rabenau, H.; Behrens, P.; Böddinghaus, B.; Götsch, U.; Naujoks, F.; Neumann, P.; Schork, J.;
Tiarks-Jungk, P.; Walczok, A.; Eickmann, M.; Vehreschild, M. J. G. T.; Kann, G.; Wolf, T.; Gottschalk, R.; Ciesek, S., Evidence of SARS-CoV-2 Infection in Returning Travelers from Wuhan, China. New England Journal of Medicine 2020. https://www.nejm.org/doi/full/10.1056/NEJMc2001899
• Zhao, J.; Yuan, Q.; Wang, H.; Liu, W.; Liao, X.; Su, Y.; Wang, X.; Yuan, J.; Li, T.; Li, J.; Qian, S.; Hong, C.; Wang, F.; Liu, Y.; Wang, Z.; He, Q.; He, B.; Zhang, T.; Ge, S.; Liu, L.; Zhang, J.; Xia, N.; Zhang, Z., Antibody Responses to SARS-CoV-2 in Patients of Novel Coronavirus Disease 2019. SSRN 2020. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3546052#
• FDA, Policy for Diagnostics Testing in Laboratories Certified to Perform High Complexity Testing under CLIA prior to Emergency Use Authorization for Coronavirus Disease-2019 during the Public Health Emergency; Immediately in Effect Guidance for Industry and Food and Drug Administration Staff. 2020. https://www.regulations.gov/docket?D=FDA-2020-D-0987
• CDC, 2019 Novel Coronavirus RT-PCR Identification Protocols. https://www.cdc.gov/coronavirus/2019-ncov/lab/rt-pcr-detectioninstructions.html.• CDC, Situation summary. https://www.cdc.gov/coronavirus/2019-nCoV/summary.html.• Biotech, M., Mesa Biotech Receives Emergency Use Authorization from FDA for a 30 Minute Point of Care Molecular COVID-19 Test. Mesa Biotech: 2020.
https://www.mesabiotech.com/news/euacoronavirus• BGI, BGI Responds to Novel Coronavirus with Real-Time Detection Kits, Deploys Emergency Team to Wuhan. 2020.
https://www.bgi.com/global/company/news/bgi-responds-to-novel-coronavirus-with-real-time-detection-kits-deploys-emergency-team-towuhan/• Daily, H., Wuhan Institute of Virology, Chinese Academy of Sciences and others have found that 3 drugs have a good inhibitory effect on new coronavirus.
Chen, L., Ed. 2020. http://news.cnhubei.com/content/2020-01/28/content_12656365.html• FDA, ID NOW COVID-19; Food and Drug Administration: 2020. https://www.fda.gov/media/136525/download• Verdict, Cepheid to develop automated molecular test for coronavirus. Verdict Medical Devices: 2020. https://www.medicaldevicenetwork.com/news/cepheid-
automated-test-coronavirus/• Wetsman, N., FDA authorizes first antibody-based test for COVID-19. The Verge 2 April, 2020• Muoio, D., Scanwell Health, myLAB Box unveil more at-home COVID-19 testing services. MobiHealthNews 20 March, 2020. • Nadi, A., An at-home fingerprick blood test may help detect your exposure to coronavirus. NBC NEWS 04 April, 2020.• Shi, W.; Peng, X.; Liu, T.; Cheng, Z.; Lu, H.; Yang, S.; Zhang, J.; Li, F.; Wang, M.; Zhang, X.; Gao, Y.; Shi, Y.; Zhang, Z.; Shan, F., Deep Learning-Based
Quantitative Computed Tomography Model in Predicting the Severity of COVID-19: A Retrospective Study in 196 Patients. SSRN 2020.https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3546089
• Herold, T.; Jurinovic, V.; Arnreich, C.; Hellmuth, J. C.; Bergwelt-Baildon, M.; Klein, M.; Weinberger, T., Level of IL-6 predicts respiratory failure in hospitalized symptomatic COVID-19 patients. medRxiv 2020, 2020.04.01.20047381. https://www.medrxiv.org/content/medrxiv/early/2020/04/04/2020.04.01.20047381.full.pdf
References Continued• CDC, 2019 Novel Coronavirus RT-PCR Identification Protocols. https://www.cdc.gov/coronavirus/2019-ncov/lab/rt-pcr-detectioninstructions.html.• Corman, V. M.; Landt, O.; Kaiser, M.; Molenkamp, R.; Meijer, A.; Chu, D. K.; Bleicker, T.; Brunink, S.; Schneider, J.; Schmidt, M. L.; Mulders, D. G.;
Haagmans, B. L.; van der Veer, B.; van den Brink, S.; Wijsman, L.; Goderski, G.; Romette, J. L.; Ellis, J.; Zambon, M.; Peiris, M.; Goossens, H.; Reusken, C.; Koopmans, M. P.; Drosten, C., Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill 2020, 25 (3). https://www.ncbi.nlm.nih.gov/pubmed/31992387
• Li, Q.; Guan, X.; Wu, P.; Wang, X.; Zhou, L.; Tong, Y.; Ren, R.; Leung, K. S. M.; Lau, E. H. Y.; Wong, J. Y.; Xing, X.; Xiang, N.; Wu, Y.; Li, C.; Chen, Q.; Li, D.; Liu, T.; Zhao, J.; Liu, M.; Tu, W.; Chen, C.; Jin, L.; Yang, R.; Wang, Q.; Zhou, S.; Wang, R.; Liu, H.; Luo, Y.; Liu, Y.; Shao, G.; Li, H.; Tao, Z.; Yang, Y.; Deng, Z.; Liu, B.; Ma, Z.; Zhang, Y.; Shi, G.; Lam, T. T. Y.; Wu, J. T.; Gao, G. F.; Cowling, B. J.; Yang, B.; Leung, G. M.; Feng, Z., Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia. New England Journal of Medicine 2020. https://www.nejm.org/doi/full/10.1056/NEJMoa2001316
• Sheridan, C., Coronavirus and the race to distribute reliable diagnostics. https://www.nature.com/articles/d41587-020-00002-2.• WHO, Diagnostic detection of Wuhan coronavirus 2019 by real-time RTPCR -Protocol and preliminary evaluation as of Jan 13, 2020.
https://www.who.int/docs/default-source/coronaviruse/wuhan-virus-assay-v1991527e5122341d99287a1b17c111902.pdf?sfvrsn=d381fc88_2 (accessed 01/26/2020).
• WHO, Novel Coronavirus (2019-nCoV) technical guidance: Laboratory testing for 2019-nCoV in humans. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/laboratory-guidance
• Assunção, M., Iceland’s coronavirus testing suggests 50% of cases have no symptoms. NY Daily News 01 April, 2020• Ministry for Foreign Affairs, Large scale testing of general population in Iceland underway In Government of Iceland, Government of Iceland: 2020.
https://www.government.is/news/article/2020/03/15/Large-scale-testing-of-general-population-in-Iceland-underway/• Ren, X.; Liu, Y.; Chen, H.; Liu, W.; Guo, Z.; Chen, C.; Zhou, J.; Xiao, Q.; Jiang, G.-M.; Shan, H., Application and Optimization of RT-PCR in Diagnosis of
SARS-CoV-2 Infection. medRxiv 2020.• Wang, W.; Xu, Y.; Gao, R.; Lu, R.; Han, K.; Wu, G.; Tan, W., Detection of SARS-CoV-2 in Different Types of Clinical Specimens. JAMA 2020.
https://doi.org/10.1001/jama.2020.3786• Wölfel, R.; Corman, V. M.; Guggemos, W.; Seilmaier, M.; Zange, S.; Müller, M. A.; Niemeyer, D.; Jones, T. C.; Vollmar, P.; Rothe, C.; Hoelscher, M.;
Bleicker, T.; Brünink, S.; Schneider, J.; Ehmann, R.; Zwirglmaier, K.; Drosten, C.; Wendtner, C., Virological assessment of hospitalized patients with COVID-2019. Nature 2020. https://doi.org/10.1038/s41586-020-2196-x
• US Department of Homeland Security. Master List of Questions. https://www.dhs.gov/publication/st-master-question-list-covid-19. April 7, 2020.• Salzberger, B., Gluck, T., Ehrensein, B., “Successful containment of COVID-19: the WHO-Report on the COVID-19 outbreak of China”,
April, 28. 2020, https://www.ncbi.nlm.nih.gov/pubmed/32185635
