This is a preprint version of an article submitted for publication in the Medical Journal of Australia. Changes may be made before final publication. A link to the final version will be supplied when it is published.
AN outbreak of a new coronavirus, not yet formally named, but currently termed the 2019 novel coronavirus (nCoV-2019), has emerged in the city of Wuhan in Hubei province in central China.
The first cases were noted as a cluster of patients with pneumonia that were all linked to a live animal market, and testing has found the presence of a new coronavirus. Coronaviruses are a group of viruses that affect both animals and humans, and several (OC43, 229E, HKU1, and NL63) are a cause of the common cold (here, and here). However, two previous coronaviruses have caused significant outbreaks associated with more severe disease – the 2002/3 Severe Acute Respiratory Syndrome (SARS) coronavirus and the Middle East Respiratory Syndrome (MERS) coronavirus that emerged in 2012. Chinese authorities and researchers should be commended for their rapid sharing of viral sequences which has enabled laboratories worldwide to develop diagnostic tests within weeks of discovery of the pathogen.
Information on this new virus and its impact is being updated daily. We know that this virus can cause severe disease, although active surveillance of contacts is required to define the milder end of the disease spectrum and to estimate the true hospitalisation and case fatality ratio. Exported cases have been helpful in defining the probable incubation period of 4-10 days (average 7 days, and maximum 14 days), which supports current official reports of the limited extent of infection within China.
At the time of writing (23 January, 2020), all cases have either had a history of residence or travel to Wuhan city, except for two cases that have had contact with confirmed cases. Recent unconfirmed reports of multiple healthcare workers infected by a single patient raises the possibility of highly infective “super-spreaders”, a feature of previous coronavirus outbreaks. We do not yet know if there are host or epidemiological risk factors associated with infection or severe disease, the transmission dynamics or the duration of infectivity. The timing of infectiousness relative to symptom onset is a particularly important parameter with implications for public health control.
During the next few weeks for the Chinese New Year holidays, it is estimated that around 400 million people will travel within China, and 7 million people will travel from China to other countries, including around 10 000-20 000 from Wuhan to Australia. The northern hemisphere influenza season is also in full swing.
For clinicians, two current clinical scenarios are: (i) pre-travel advice for those who are planning travel to China, and (ii) the care of patients who return from China. At the time of writing, WHO have only made non-specific recommendations for those travelling to Wuhan (Box 1).
Box 1: Pre-travel advice for travellers (WHO)
It would also seem prudent to recommend influenza vaccination to reduce the possibility of diagnostic confusion; to reinforce the need for good respiratory hygiene, and to give advice on actions in the event of illness, including the importance of volunteering a travel history to health professionals.
The experience with SARS and MERS also reinforces the need for health services (both internationally and within Australia) to promptly identify patients with suspected infection and implement effective infection control measures. It is likely to be difficult to distinguish patients with nCoV-2019 from those with other respiratory viral infections, including influenza. The cases reported to date have almost universally reported fever, with varying proportions reporting cough, dyspnoea, chest discomfort and fatigue. Currently, specific testing for nCoV-2019 can be limited to those presenting with 14 days of exposure and a history of travel to Wuhan or contact with a known case. However, these criteria may well change if there is further spread within China or to other countries, and clinicians should refer to current information to guide testing and management (Box 2).
Box 2: Useful sources of official information
International situation reports and resources
Nucleic acid assays for nCoV-2019 are already available at several Australian reference laboratories and testing should be performed in conjunction with jurisdictional public health units. At present, current World Health Organization (WHO) advice is to test patients that meet the case definition for nCoV-2019 infection, regardless of whether another respiratory virus is detected, as co-infections may occur. However, balancing the need to maintain a low threshold of suspicion with the capacity of reference laboratories to perform timely tests is likely to become a challenge in the current absence of rapid, accredited tests that can be used in diagnostic laboratories.
The lessons of the past are instructive, particularly the experience in Canada with its similar federated government and comparable healthcare system to Australia. In 2003, an outbreak of SARS coronavirus in Toronto infected 438 people and caused 44 deaths, including many healthcare workers. Following this public health disaster, two important reviews were conducted – the National Advisory Committee on SARS and Public Health, and Ontario’s Campbell SARS Commission. The former reinforced the need for a strong and adequately funded nationally co-ordinated public health and laboratory system and led to the establishment of the Public Health Agency of Canada.
The Campbell SARS Commission made detailed recommendations, including endorsing the “importance of the precautionary principle that reasonable efforts to reduce risk need not await scientific proof, [which] was demonstrated over and over during SARS“.
It made recommendations to ensure clear governance, preparing for the need for unexpected interventions (including the closure of three hospitals to control the outbreak), the effective distribution of outbreak alerts and directives, the need for effective crisis communication, and the value of robust and timely surveillance. With the involvement of healthcare workers as cases, the Commission highlighted the need to listen to front line workers and unions and ensure a robust safety culture and effective infection control.
We have many more information (and misinformation)-sharing tools than were available in 2003, including rapid genomic sequencing and online databases to generate and disseminate primary data, pre-print servers to disseminate research findings, research centres and platforms to rapidly collect data and evaluate interventions, and social media platforms to disseminate public health messages. However, the fundamental structure of our public healthcare system remains largely unchanged, with the same channels of formal communication and direction through a national network-based system of public health.
It is too early to tell how this outbreak will unfold, but we need to be prepared at all levels of the healthcare system, with a key tenet of this response being rapid and reliable communication. This should include advice to clinicians and patients on who, how and when testing should be performed, and how to manage patients with suspected and confirmed infection. Australia is yet to be significantly challenged directly by any of the three coronavirus outbreaks to date – should this outbreak spread to Australia, public health authorities, governments at all levels, researchers and clinicians, laboratories and the community will need to work together in a timely manner to ensure an effective response.
Professor Allen Cheng is Director of the Infection Prevention and Healthcare Epidemiology Unit, Alfred Health; School of Public Health and Preventive Medicine, Monash University.
Professor Deborah Williamson is from the Department of Microbiology, Melbourne Health Pathology; Microbiological Diagnostic Unit, University of Melbourne.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.