March 2020- Coronavirus

A note from the author— Happy March NCP friends! This month, rather than featuring a National Health

Awareness Month as the topic, I decided to feature an article based on the most recent health scare ripping across the globe: Coronavirus. As a nurse, I have been approached by many family and friends recently with questions about this disease, including what it is, how to protect yourself, and clarification regarding the actual severity of this disease. For an overview of Coronavirus, please read the article below and to keep up with the most current information as researchers learn more, visit the CDC’s or WHO’s websites at www.cdc.gov or www.who.int . What is a Coronavirus? Coronaviruses are a group of common viruses. They are named for the crown-like spikes on the surface of the virus. Coronaviruses are a large family of viruses that are common in people and many different species of animals, including camels, cattle, cats, and bats. Some coronaviruses only affect animals, but others can also affect humans. Most people get infected with human coronaviruses at some time in their life.

Rarely, animal coronaviruses can infect people and then spread between people such as with MERS-CoV, SARS-CoV, and now with this new virus (named SARS-CoV-2). Human coronaviruses cause respiratory illnesses. There are several different types of coronaviruses, including those that cause severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and coronavirus disease 2019 (COVID-19). The SARS-CoV-2 virus is a betacoronavirus, like MERS-CoV and SARS-CoV. All three of these viruses have their origins in bats. The sequences from U.S. patients are similar to the one that China initially posted, suggesting a likely single, recent emergence of this virus from an animal reservoir.

Early on, many of the patients at the epicenter of the outbreak in Wuhan, Hubei Province, China had some link to a large seafood and live animal market, suggesting animal-to-person spread. Later, a growing number of patients reportedly did not have exposure to animal markets, indicating person-to-person spread. Person-to-person spread was subsequently reported outside Hubei and in countries outside China, including in the United States. Some international destinations now have apparent community spread with the virus that causes COVID-19, including in some parts of the United States. Community spread means some people have been infected and it is not known how or where they became exposed. The Prevalence of Coronavirus Almost everyone gets a coronavirus infection at least once in their life, most likely as a young child. In the United States, coronaviruses are more common in the fall and winter, but anyone can come down with a coronavirus infection at any time. Past severe coronavirus outbreaks include:

• Middle East Respiratory Syndrome (MERS): About 858 people have died from MERS, which first appeared in Saudi Arabia and then in other countries in the Middle East, Africa, Asia, and Europe. In April 2014, the first American was hospitalized for MERS in Indiana and another case was reported in Florida. Both had just returned from Saudi Arabia. In May 2015, there was an outbreak of MERS in Korea, which was the largest outbreak outside of the Arabian Peninsula.

• Severe Acute Respiratory Syndrome ( SARS ): In 2003, 774 people died from an outbreak. As of 2015, there were no further reports of cases of SARS.

Coronavirus 2019 aka COVID-19 CDC is still responding to an outbreak of respiratory disease caused by a novel (new) coronavirus that was first detected in China and which has now been detected in almost 70 locations internationally, including in the United States. The virus has been named “SARS-CoV-2” and the disease it causes has been named “coronavirus disease 2019” (abbreviated “COVID-19”). On January 30, 2020, the International Health Regulations Emergency Committee of the World Health Organization declared the outbreak a “public health emergency of international concern” (PHEIC). On January 31, 2020, Health and Human Services Secretary Alex M. Azar II declared a public health emergency (PHE) for the United States to aid the nation’s healthcare community in responding to COVID-19. Early information out of China, where COVID-19 first started, shows that some people are at higher risk of getting very sick from this illness. This includes:

• Older adults • People who have serious chronic medical conditions like:

o Heart disease o Diabetes o Lung disease

If a COVID-19 outbreak happens in your community, it could last for a long time. (An outbreak is when a large number of people suddenly get sick.) Depending on how severe the outbreak is, public health officials may recommend community actions to reduce people’s risk of being exposed to COVID-19. These actions can slow the spread and reduce the impact of disease. If you are at higher risk for serious illness from COVID-19 because of your age or because you have a serious long-term health problem, it is extra important for you to take actions to reduce your risk of getting sick with the disease.

Situation in the United States There have been cases of COVID-19 in the U.S. related to travel and person-to-person spread. U.S. case counts are updated regularly on Mondays, Wednesdays, and Fridays. See the current U.S. case count of COVID-19. The COVID-19 outbreak in the United States is still developing. Here are some of the main points:

• Imported cases of COVID-19 in travelers have been detected in the U.S. • Person-to-person spread of COVID-19 was first reported among close contacts

of returned travelers from Wuhan. • During the week of February 23, CDC reported community spread of the virus

that causes COVID-19 in California (in two places), Oregon and Washington. Community spread in Washington resulted in the first death in the United States from COVID-19, as well as the first reported case of COVID-19 in a health care worker, and the first potential outbreak in a long-term care facility.

• In addition to CDC, many public health laboratories are now testing for the virus that causes COVID-19. View CDC’s Public Health Laboratory Testing map.

• With this increase in testing, now 19 states have reported cases of COVID-19 to CDC. View latest case counts, deaths, and a map of states with reported cases.

• U.S. COVID-19 cases include: o Imported cases in travelers o Cases among close contacts of a known case o Community-acquired cases where the source of the infection is unknown.

Symptoms of Coronavirus Reported illnesses have ranged from mild symptoms to severe illness and death for confirmed coronavirus disease 2019 (COVID-19) cases. The following symptoms may appear 2-14 days after exposure.

• Fever • Cough • Shortness of breath

Pay attention for potential COVID-19 symptoms including, fever, cough, and shortness of breath. If you feel like you are developing symptoms, call your doctor. If you develop emergency warning signs for COVID-19 get medical attention immediately. In adults, emergency warning signs*:

• Difficulty breathing or shortness of breath

• Persistent pain or pressure in the chest

• New confusion or inability to arouse

• Bluish lips or face

How does Coronavirus spread? Person-to-person spread The virus is thought to spread mainly from person-to-person.

• Between people who are in close contact with one another (within about 6 feet). • Through respiratory droplets produced when an infected person coughs or

sneezes. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. Can someone spread the virus without being sick?

• People are thought to be most contagious when they are most symptomatic (the sickest).

• Some spread might be possible before people show symptoms; there have been reports of this occurring with this new coronavirus, but this is not thought to be the main way the virus spreads.

Spread from contact with contaminated surfaces or objects It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads. How easily the virus spreads How easily a virus spreads from person-to-person can vary. Some viruses are highly contagious (spread easily), like measles, while other viruses do not spread as easily. Another factor is whether the spread is sustained, spreading continually without stopping. The virus that causes COVID-19 seems to be spreading easily and sustainably in the community (“community spread”) in some affected geographic areas. “Community spread” means people have been infected with the virus in an area, including some who are not sure how or where they became infected.

What is the Severity of COVID-19? Both MERS-CoV and SARS-CoV have been known to cause severe illness in people. Reported illnesses have ranged from mild to severe, including illness resulting in death. While information so far suggests that most COVID-19 illness is mild, a report Rn out of China suggests serious illness occurs in 16% of cases. Older people and people with certain underlying health conditions like heart disease, lung disease and diabetes, for example, seem to be at greater risk of serious illness. What to Do if You Get Sick Learn more about the symptoms associated with COVID-19. There are ongoing investigations to learn more. This is a rapidly evolving situation and information will be updated as it becomes available.

• Stay home and call your doctor • Call your healthcare provider and let them know about your symptoms. Tell them

that you have or may have COVID-19. This will help them take care of you and keep other people from getting infected or exposed.

• If you are not sick enough to be hospitalized, you can recover at home. • Know when to get emergency help • Get medical attention immediately if you have any of the emergency warning

signs listed above.

DON’T FREAK OUT: The Current Risk Assessment of COVID-19 Outbreaks of novel virus infections among people are always of public health concern. The risk from these outbreaks depends on characteristics of the virus, including how well it spreads between people, the severity of resulting illness, and the medical or other measures available to control the impact of the virus (for example, vaccine or treatment medications). The fact that this disease has caused illness, including illness resulting in death, and sustained person-to-person spread is concerning. These factors meet two of the criteria of a pandemic. As community spread is detected in more and more

countries, the world moves closer toward meeting the third criteria, worldwide spread of the new virus. Reported community spread of COVID-19 in parts of the United States raises the level of concern about the immediate threat for COVID-19 for those communities. The potential public health threat posed by COVID-19 is very high, to the United States and globally. At this time, however, most people in the United States will have little immediate risk of exposure to this virus. This virus is NOT currently spreading widely in the United States. However, it is important to note that current global circumstances suggest it is likely that this virus will cause a pandemic. This is a rapidly evolving situation and the risk assessment will be updated as needed. Current risk assessment:

• For most of the American public, who are unlikely to be exposed to this virus at this time, the immediate health risk from COVID-19 is considered low.

• People in communities where ongoing community spread with the virus that causes COVID-19 has been reported are at elevated, though still relatively low risk of exposure.

• Healthcare workers caring for patients with COVID-19 are at elevated risk of exposure.

• Close contacts of persons with COVID-19 also are at elevated risk of exposure. • Travelers returning from affected international locations where community spread

is occurring also are at elevated risk of exposure.

CDC has developed guidance to help in the risk assessment and management of people with potential exposures to COVID-19.

What to Expect Next More cases of COVID-19 are likely to be identified in the coming days, including more cases in the United States. It’s also likely that person-to-person spread will continue to occur, including in communities in the United States. It’s likely that at some point, widespread transmission of COVID-19 in the United States will occur. Widespread transmission of COVID-19 would translate into large numbers of people needing medical care at the same time. Schools, childcare centers, workplaces, and other places for mass gatherings may experience more absenteeism. Public health and healthcare systems may become overloaded, with elevated rates of hospitalizations and deaths. Other critical infrastructure, such as law enforcement, emergency medical services, and transportation industry may also be affected. Health care providers and hospitals may be overwhelmed. At this time, there is no vaccine to protect against COVID-19 and no medications approved to treat it. Nonpharmaceutical interventions would be the most important response strategy.

Prevention is Key: Protect Yourself Today

• Have supplies on hand o Contact your healthcare provider to ask about obtaining extra necessary

medications to have on hand in case there is an outbreak of COVID-19 in your community and you need to stay home for a prolonged period of time.

o If you cannot get extra medications, consider using mail-order for medications.

o Be sure you have over-the-counter medicines and medical supplies (tissues, etc.) to treat fever and other symptoms. Most people will be able to recover from COVID-19 at home.

o Have enough household items and groceries on hand so that you will be prepared to stay at home for a period of time.

• Take everyday precautions o Avoid close contact with people who are sick o Take everyday preventive actions

▪ Clean your hands often ▪ Wash your hands often with soap and water for at least 20

seconds, especially after blowing your nose, coughing, or sneezing, or having been in a public place.

▪ If soap and water are not available, use a hand sanitizer that contains at least 60% alcohol.

▪ To the extent possible, avoid touching high-touch surfaces in public places – elevator buttons, door handles, handrails, handshaking with people, etc. Use a tissue or your sleeve to cover your hand or finger if you must touch something.

▪ Wash your hands after touching surfaces in public places. ▪ Avoid touching your face, nose, eyes, etc. ▪ Clean and disinfect your home to remove germs: practice routine

cleaning of frequently touched surfaces (for example: tables, doorknobs, light switches, handles, desks, toilets, faucets, sinks & cell phones)

▪ Avoid crowds, especially in poorly ventilated spaces. Your risk of exposure to respiratory viruses like COVID-19 may increase in crowded, closed-in settings with little air circulation if there are people in the crowd who are sick.

▪ Avoid all non-essential travel including plane trips, and especially avoid embarking on cruise ships.

• If COVID-19 is spreading in your community, take extra measures to put distance between yourself and other people to further reduce your risk of being exposed to this new virus.

o Stay home as much as possible. ▪ Consider ways of getting food brought to your house through

family, social, or commercial networks • Have a plan for if you get sick:

o Consult with your health care provider for more information about monitoring your health for symptoms suggestive of COVID-19.

o Stay in touch with others by phone or email. You may need to ask for help from friends, family, neighbors, community health workers, etc. if you become sick.

o Determine who can provide you with care if your caregiver gets sick

The Truth about Facemasks and COVID-19 CDC does not recommend that people who are well wear a facemask to protect themselves from respiratory illnesses, including COVID-19. You should only wear a mask if a healthcare professional recommends it. A facemask should be used by people who have COVID-19 and are showing symptoms. This is to protect others from the risk of getting infected. The use of facemasks also is crucial for health workers and other people who are talking care of someone infected with COVID-19 in close settings (at home or in a healthcare facility).

The CDC’S Response to COVID-19 Global efforts at this time are focused concurrently on containing the spread and mitigating the impact of this virus. The federal government is working closely with state, local, tribal, and territorial partners, as well as public health partners, to respond to this public health threat. The public health response is multi-layered, with the goal of detecting and minimizing introductions of this virus in the United States. CDC is operationalizing all of its pandemic preparedness and response plans, working on multiple fronts to meet these goals, including specific measures to prepare communities to respond to local transmission of the virus that causes COVID-19. There is an abundance of pandemic guidance developed in anticipation of an influenza pandemic that is being repurposed and adapted for a COVID-19 pandemic. Highlights of the CDC’s response

• CDC established a COVID-19 Incident Management System on January 7, 2020. On January 21, CDC activated its Emergency Operations Center to better provide ongoing support to the COVID-19 response.

• The U.S. government has taken unprecedented steps with respect to travel in response to the growing public health threat posed by this new coronavirus:

o Effective February 2, at 5pm, the U.S. government suspended entry of foreign nationals who have been in China within the past 14 days.

▪ U.S. citizens, residents, and their immediate family members who have been in Hubei province and other parts of mainland China are allowed to enter the United States, but they are subject to health monitoring and possible quarantine for up to 14 days.

o On February 29, the U.S. government announced it was suspending entry

of foreign nationals who have been in Iran within the past 14 days.

o CDC has issued the following travel guidance related to COVID-19: ▪ China — Level 3, Avoid Nonessential Travel — updated February

22; ▪ Hong Kong — Level 1, Practice Usual Precautions — issued

February 19; ▪ Iran — Level 3, Avoid Nonessential Travel — updated February 28; ▪ Italy — Level 3, Avoid Nonessential Travel — updated February 28; ▪ Japan — Level 2, Practice Enhanced Precautions — updated

February 22; ▪ South Korea — Level 3, Avoid Nonessential Travel — updated

February 24. o CDC also recommends that all travelers reconsider cruise ship voyages

into or within Asia at this time. • CDC is issuing clinical guidance, including:

o On January 30, CDC published guidance for healthcare professionals on the clinical care of COVID-19 patients.

o On February 3, CDC posted guidance for assessing the potential risk for various exposures to COVID-19 and managing those people appropriately.

o On February 27, CDC updated its criteria to guide evaluation of persons under investigation for COVID-19.

o On February 28, CDC issued a Health Alert Network (HAN): Update and Interim Guidance on Outbreak of COVID-19.

• CDC has deployed multidisciplinary teams to support state health departments case identification, contact tracing, clinical management, and communications.

• CDC has worked with the Department of State, supporting the safe return of Americans who have been stranded as a result of the ongoing outbreaks of COVID-19 and related travel restrictions. CDC has worked to assess the health of passengers as they return to the United States and provided continued daily monitoring of people who are quarantined.

An important part of CDC’s role during a public health emergency is to develop a test for the pathogen and equip state and local public health labs with testing capacity.

• After distribution of a CDC rRT-PCR test to diagnose COVID-19 to state and local public health labs started, performance issues were identified related to a

problem in the manufacturing of one of the reagents. Laboratories were not able to verify the test performance.

• CDC worked on two potential resolutions to this problem. o CDC developed a new protocol that uses two of the three components of

the original CDC test kit to detect the virus that causes COVID-19 after establishing that the third component, which was the problem with the original test, can be excluded from testing without affecting accuracy. CDC is working with FDA to amend the existing Emergency Use Authorization (EUA) for the test, but in the meantime, FDA granted discretionary authority for the use of the original test kits.

▪ Public health laboratories can use the original CDC test kit to test for the virus that causes COVID-19 using the new protocol.

o Further, newly manufactured kits have been provided to the International Reagent Resource for distribution.

• Combined with other reagents that CDC has procured, there are enough testing kits to test more than 75,000 people.

• In addition, CDC has two laboratories conducting testing for the virus that causes COVID-19. CDC can test approximately 350 specimens per day.

• Commercial labs are working to develop their own tests that hopefully will be available soon. This will allow a greater number of tests to happen close to where potential cases are.

• CDC has grown the COVID-19 virus in cell culture, which is necessary for further studies, including for additional genetic characterization. The cell-grown virus was sent to NIH’s BEI Resources Repository for use by the broad scientific community.

The CDC’s Prevention Tatics There is currently no vaccine to prevent coronavirus disease 2019 (COVID-19). The best way to prevent illness is to avoid being exposed to this virus. The Centers for Disease Control and Prevention recommend these actions to help prevent the spread of respiratory diseases:

• Avoid close contact with people who are sick. • Avoid touching your eyes, nose, and mouth. • Stay home when you are sick. • Cover your cough or sneeze with a tissue, then throw the tissue in the trash. • Clean and disinfect frequently touched objects and surfaces using a regular

household cleaning spray or wipe. • Wash your hands often with soap and water for at least 20 seconds, especially

after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing. If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. Always wash hands with soap and water if hands are visibly dirty.

CDC’S Recommendations • Everyone can do their part to help us respond to this emerging public health

threat:

o It’s currently flu and respiratory disease season and CDC recommends getting a flu vaccine, taking everyday preventive actions to help stop the spread of germs, and taking flu antivirals if prescribed.

o If you are a healthcare provider, be on the look-out for: ▪ People who recently traveled from China or another affected area

and who have symptoms associated with COVID-19, and ▪ People who have been in close contact with someone with COVID-

19 or pneumonia of unknown cause. (Consult the most recent definition for patients under investigation [PUIs].)

o If you are a healthcare provider or a public health responder caring for a COVID-19 patient, please take care of yourself and follow recommended infection control procedures.

o If you are a close contact of someone with COVID-19 and develop symptoms of COVID-19, call your healthcare provider and tell them about your symptoms and your exposure.

• If you are a resident in a community where person-to-person spread of COVID-19 has been detected and you develop COVID-19 symptoms, call your healthcare provider and tell them about your symptoms.

• For people who are ill with COVID-19, but are not sick enough to be hospitalized, please follow CDC guidance on how to reduce the risk of spreading your illness to others. People who are mildly ill with COVID-19 are able to isolate at home during their illness.

• If you have been in China or another affected area or have been exposed to someone sick with COVID-19 in the last 14 days, you will face some limitations on your movement and activity for up to 14 days. Please follow instructions during this time. Your cooperation is integral to the ongoing public health response to try to slow spread of this virus.

References https://www.cdc.gov/coronavirus/2019-ncov/index.html https://www.webmd.com/lung/coronavirus#1 https://www.cdc.gov/coronavirus/index.html https://www.who.int/health-topics/coronavirus https://medlineplus.gov/coronavirusinfections.html https://news.christianacare.org/2020/02/update-on-coronavirus/ https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html