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)

  • avoiding close contact with people suffering from acute respiratory infections;
  • frequent hand-washing, especially after direct contact with ill people or their environment;
  • avoiding close contact with live or dead farm or wild animals;
  • travellers with symptoms of acute respiratory infection should practice cough etiquette (maintain distance, cover coughs and sneezes with disposable tissues or clothing, and wash hands).
  • Awareness of up-to-date travel information through Smart Traveller

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

Australian 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.

10 thoughts on “The 2019 novel coronavirus – what do we know so far?

  1. Professor Andrew Taylor-Robinson, Central Queensland University says:

    The unforeseen emergence of nCoV-2019 in China serves as a strict reminder of the continuing threat to global public health of zoonotic diseases. In order to expedite a concerted and collaborative multinational effort for disease control, in the short- to medium-term further significant investments and well-targeted management strategies are required. In evoking a one health philosophy this should be interdisciplinary in nature and encompass experiences from all geographical regions.

    While it appears likely that the Wuhan coronavirus was initially transmitted to humans from animals, the species from which it crossed over, and other possible reservoirs, needs to be identified. This is one of several current unknowns – others include the transmission route, incubation period, epidemic curve, pathogenesis, characteristics of susceptible groups, their survival rates and treatment responses.

    This outbreak brings to mind those of two related coronaviruses, causing severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS), earlier this century. The SARS-CoV arose in China in 2003, spread rapidly in the region but then disappeared as quickly as it came. In contrast, first identified in Saudi Arabia in 2012, the MERS-CoV still re-emerges intermittently through nosocomial outbreaks, community clusters and sporadic cases. It will be interesting to see which, if either, of these two distinct epidemiological pathways nCoV-2019 takes and how much global health security measures can play in disease control and prevention.

  2. Dr. Christoph Ahrens says:

    all very useful. Thanks

  3. Randal says:

    It should be kept in mind that if the higher-end estimates of numbers infected (90,000) is true, then the mortality rate is comparable to what we find from influnenza during each and every flu season (~1 in 1000).

    So yes, due diligence and monitoring are important, but perspective still needs to be kept. Remember the lessons of the swine flu ‘pandemic’.

  4. Anonymous says:

    We have received information on recommendations for school children and students returning from China, has there been any consideration of HCWs returning from China and how to manage them based on risk of exposure in China and the workplace specialty they are returning to. Should we be asking them to observe an incubation period as well?

  5. Allen Cheng says:

    Secondary bacterial infections were described in 4 of the 41 patients in the nCoV series in the Lancet. It’s not clear if these were pneumonia, or other ICU-related infections eg central line infections, UTIs.

  6. Peter Lake says:

    Do we have any idea yet whether secondary bacterial infection is involved especially in those patients who have died or are seriously ill?

  7. Anonymous says:

    please remind me what specific treatment there is for Coronavirus ?
    there is none !
    therefore otherwise healthy young people with nothing more than a fever or a runny nose
    should be dissuaded from flooding our Emergency departments and medical clinics for no real benefit
    to them but at risk to staff and other patients.

  8. Dr. Rey Tiquia says:

    Here is report from a frontline practitioner of traditional Chinese medicine in Jinan city, Shandong provice in China
    who looked after several patients when the Wuhan corona virus epidemic broke out. I have translated the report from Chinese into English.

    FromThe Perspective of Traditional Chinese Medicine We Look at the Wuhan Pneumonia of Unknown Cause and Origins
    SinaCom Internet Blog 新浪博客. January 8, 2020 :Yi San Sheng 一三生
    Translated from Chinese by Rey Tiquia

    Wen yi 瘟疫 ‘Warm factor epidemics’ occur once after an interval of a number of years. As for the magnitude of the epidemic, it can be as widespread as the SARS (Severe Acute Respiratory Syndrome or that Atypical Pneumonia fei dian非典) epidemic or small scale as just affecting our hand,foot and mouth
    像手足口or that of the ‘swine flu’ 猪流感 epidemic. Hence, there is nothing remarkable about it. It a normal phenomena 常态occurring in nature.The occurrence of warm factor epidemics wen yi n is related to abnormal weather/climactic conditions. After damage without a trace. This year (2019: Year of the Earth Pig 己亥年) the weather in winter was very unusual. The temperature was unusually high. And here, (Jinan, provincial capital of Shandong Province) the temperature was above zero degrees. Snow did not fall and it only rained a little bit. All of a sudden, it only became cold after the Winter Solstice 冬至过后. The coldest was only a dozen degrees below zero. Affected by this weather condition, the common colds 感冒and fevers children suffered were very different from previous years. They are not like the ‘meteorological cold qi damage’ shang han伤寒 from previous years. They are more similar to wen bing ‘warm factor diseases’ accompanied by symptoms resulting from ‘severe influence’ from ‘humidity’ and ‘heat’ 湿热重. Under this conditions, it is more appropriate to use herbal formula like Xiang zi san 香薷散or yin qiao san 银翘散…which are prescribed to people suffering from ‘common cold’ which come about during the summer season (please refer to previous article “Common colds and fevers children suffer this winter) are very different from previous years). More than a month ago, I treated an adult patient suffering from pneumonia with symptoms resulting from being affected by ‘severe humidity and heat’ shi re Zhong 湿热重. I used a materia medica formula with the ingredients of the ancient formula san ren tang 三仁汤 as the core (please refer to previous article ‘ Materia medica formulae for the treatment of pneumonia’). Seasonal diseases shi ling bing 时令病 manifest clinically as symptoms of ‘common cold’ gan mao and ‘cough’ 咳嗽. Compared to previous years, there were much more people suffering from ‘cough’ kesou during the winter season of this year exhibiting symptoms of fever (‘heat’ re) with ‘dampish-phlegm’(‘humidity’ shi) ( please refer to previous article ‘Characteristic Features of ‘winter cough’ in 2019’).

    Based on the abovementioned observations and reflection, I consider the ‘unexplained cases of pneumonia’ currently occurring in Wuhan as ‘humidity/heat type of warm factor epidemic’ shi re wenbing 湿热温病 . And the materia medica formula to be deployed in dealing with this epidemic are the following:
    1. 新加香薷散
    2. 甘露消毒丹
    3. 三仁汤
    4. 达原饮
    5. 千金苇茎汤
    6. 调胃承气汤
    7. 小承气 汤

    Addendum

    This year, 2019, is the Earth-Pig Year 己亥年. Calculations using the system of the Circulating Five Elements and Six Meteorological Qi wuyin liu qi 五运六气, currently, the ‘governing season’ zhuling主令 is the 6th sub-seasonal Qi ‘The六之气 ( xiao xue 小雪 November 22, 2019-Da Han 大寒 Greater Cold January20, 2020). The characterisitic feature of the 6th Subseasonal Qi are:
    1. The ‘Host’ Qi 主气 is “The Great Yang Coldness Water’ 太阳寒水.
    2. The ‘Guest Qi 客氣 is ‘the small yang bright elemental ministerial fire’ 少阳相火.
    3. In the ‘final sub-seasonal qi 终之气, ‘dread of the elemental fire takes command’ 畏火司令.
    4. ‘Dormant insects’ are starting to ‘stir .’ 蛰虫出见.
    5. Running water (in lakes and rivers) are not turning to ice 流水不冰.
    6. The earth qi (coming from the core of the planet) is surging upwards 地气大发.
    7. ‘The grass is raw’ 草乃生.
    8. ‘People still feel comfortable’ 人乃舒.
    9. ‘and the disease the above conditions bring aboutis the pestilential Warm factor epidemic 其病瘟厉.
    These shows that the athmospheric temperature this winter (in China) is rising. And this facilitates the emergence of warm factor epidemics.

  9. Anonymous says:

    What an excellent overview of the issue, risks and importance of clear messages and planning required at all levels of healthcare provision
    Very pertinent is the need to listen to frontline health care workers as per the Canadian reflections and ensure their protection

  10. Dr. Rey Tiquia says:

    What we do not know so far about the current 2019 novel corona virus, severe acute respiratory syndrome (SARS), swine flu etc is the fact that the outbreak of these epidemics are all seasonally mediated. The current epidemic happening in Wuhan China as well as the SARS epidemic that occurred in Southern China 17 years ago occured in winter and spring season, while the swine flu epidemic we experienced in Australia last June 2009 also occurred in winter <>.

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