Coronavirus
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The 2019 novel coronavirus originated in China and human-to-human spread is still largely contained there although there are now some secondary chains of infection internationally. The World Health Organization recently declared the outbreak a public health emergency of international concern.
On February 3rd 2020, Dr. Kirsten Patrick, deputy editor for CMAJ, interviewed three infectious disease specialists who work within the University Health Network in Toronto – Dr. Alon Vaisman, Dr. Susy Hota and Dr. Isaac Bogoch. They discuss:
- what's currently known about the coronavirus
- the state of the outbreak both in China and globally
- what health care practitioners can do to protect patients and themselves from infection
- how to approach the evaluation of a patient with possible coronavirus infection
- where to find reliable up-to-date information
- whether travel restrictions will be effective in slowing the spread of the virus globally
- the state of play on vaccine development
- and more
Podcast transcript
The 2019 novel coronavirus outbreak that began in China has spread in humans both within the region and internationally, with the World Health Organization recently declaring the situation a public health emergency of international concern. What should Canada's health care practitioners and the public be doing to protect themselves from infection and how is this outbreak likely to play out internationally? I'm Dr. Kirsten Patrick, deputy editor for CMAJ, and these are some of the questions I've asked of three infectious disease specialists working within the University Health Network in Toronto, Dr. Alon Vaisman, Dr. Susy Hota and Dr. Isaac Bogoch.
Dr. Alon Vaisman is an adult infectious diseases specialist at the Unviersity Health Network in Toronto and an infection control physician hospital epidemiologist…help manage our hospital's response to the virus including screening and testing of patients.
Dr Isaac Bogoch is an infectious disease physician based at the university of Toronto and TGH. I model the potential spread of the infection from China to elsewhere to see where the virus is likely to spread to via commercial air travel.
Dr Susy Hota is an infectious diseases specialist who co-leads the University of Toronto Microbiota Therapeutics Outcomes Program, has led various quality and patient safety initiatives within UHN and is currently co-leading the health network's response to the 2019-novel coronavirus.
Kirsten Patrick: What's known about the 2019 novel coronavirus – its origin and the state of the outbreak globally and as it relates to Canada?
Alon Vaisman: The current theory is that the virus originated through contact between humans and animals, specifically an animal in a market frequented by people in Wuhan in Hubei province, China. We believe that the organism is transmitted via large droplet transmission, similar to other respiratory viruses. There are now more than 17,000 cases that have been documented, the majority of which are in the area of the outbreak in Wuhan. But the virus has spread to numerous countries and as of today, February 3rd, 2020, there are four confirmed cases in Canada – 3 documented in Ontario and one case documented in British Columbia. All documented cases in Canada originated from contact in Wuhan, China, and all were relatively mild cases. All were identified quickly and had proper, prompt isolation as confirmed by the health agencies for the respective provinces.
KP: How are cases confirmed?
AV: The virus is confirmed by sending secretions from the respiratory tract (that is, a nasopharyngeal and throat swab) to, at this time, provincial and national public health agency labs – the national microbiology lab in Winnipeg confirms the findings of the provincial lab. The provincial health labs are reporting how many tests have been done on their websites, so they are being transparent about how many tests are being ordered.
KP: There's been some panic, in Canada and globally, about this outbreak. If I am a family doc in Ottawa and today a patient calls me saying that they recently returned home from a vacation in China, via Pearson airport in Toronto and now they feel unwell and should they come in to the practice, what should I tell them?
Susy Hota: Probably my first question to the individual would be 'How sick are they?' to establish whether it is appropriate for them to come in to the family practice or whether they need to be assessed in the hospital environment. Once that's clarified, the other main issue is what is the concern about being exposed in the areas where the outbreak is occurring and where there is the highest concentration of cases. So, what is the risk of coronavirus infection as opposed to this being one of the other run-of-the-mill type of respiratory virus we would see at this time of year? The questions that would help clarify this would be 'What were the exact dates of travel to the specific areas in China?' and 'Where exactly in China did you visit?' There are some excellent resources online to help you keep up to date with what's happening in different cities and areas in China to help decisions about potential exposure. And then, what did they do while they were there? Were they attending large gatherings, visiting any wet markets? Were they going into hospital or in health care at all? Did they have sick contacts? That's an important question to ask to clarify risk. The next part is understanding what the symptoms are. Are they compatible with the symptoms of this infection? Typically, patients who've had this novel coronavirus have presented with fever and cough, and sometimes shortness of breath. Other symptoms of a respiratory tract infection can be present. Myalgia and headache is also reported. Taking that all together, if they are able to be assessed in the family doctor's office then there are some instructions that should always be conveyed to the patient before they attend. They should do good hand hygiene and put on a mask when they enter the office area. And, of course, the family doctor's office has to be prepared with the right kind of personal protective equipment (PPE) with staff trained to ensure additional precautions. And if they are seen their public health officials can actually help with coordinating testing if it is warranted. But if there is any doubt that those precautions can be adhered to then the patient should be sent to the emergency department of the local hospital with clear information to the receiving hospital to let them know what's coming to their doorstep.
KP: If my practice is not fully trained to be able to see the patient and I send the patient to the local emergency department and they are seen there, what happens if they screen positive?
SH: In the emergency department these same questions are asked to clarify the locations and dates of the patient's travel, as well as the symptoms. And what happens immediately someone screens possible for likely infection they are taken as quickly as possible into a negative pressure room designed for patients who require airborne precautions. Any healthcare worker who will then be coming in to gather more information or to assess the patient will then have to put on a fit-tested N95 respirator, eye protection, gloves and gown after careful handwashing. More information is obtained, the infection prevention and control teams are alerted and help to guide further decision-making as to testing and clinical management of the patient. So they need to be triaged right away so that the appropriate management happens right from the start.
KP: There are presently just four confirmed cases in Canada, but sometimes news reports make it seem like coronavirus is everywhere. Health professionals like everyone else sometimes get their information form the media. Where can health care workers and the public in Canada find the most reliable resources to guide their behavior and practice?
SH: There have been false reports and misinformation and that can be quite damaging in terms of getting people fearful about things that are not actually happening. The lay media in Canada has actually made great efforts to get qualified experts to comment on the situation. That said, sometimes things don't quite come across and there can be time delays in getting accurate information. I direct people to the WHO website as well as the public health agency of Canada. They have great landing pages that will help to navigate you to information you are looking for. All the ministries of health as well have got their sources of information. In Ontario we have a webpage on the Ontario.ca website that has more local information. What's been great about this situation is that peer reviewed publications on the clinical characteristics and the epidemiology of the virus have been coming our quite rapidly. Certain organizations, for example the Infectious Diseases Society of America (IDSA) have an excellent resource centre and a landing page with links to some of these primary articles and also other appropriate websites, for clinicians to look at.
KP: What advice should we be giving to patients who are concerned, for example, if patients ask if they should be wearing a mask in public places?
SH: Many people are just looking for something they can do to help prevent the spread of the virus or to prevent getting sick. At this point in time there really is no reason for everybody in Canada to be wearing masks when they go out in public. Masks can be helpful but only in certain scenarios. We know that this kind of virus is usually spread through large droplets that are released when you're infected, and you cough or sneeze. Those large droplets containing virus particles can travel up to about 2 meters. If you're within that range, you might inhale those droplets, or they will get on surfaces that you then touch and contaminate yourself. So, knowing that mode of transmission, you can see that masks can actually be a useful barrier to protect your mucous membranes from contact with these droplets. As a result, we use these masks in health care stings when providers are seeing patients who have respiratory viruses, because of the kind of close face-to-face contact they are going to have with the patient who is infected. It's also helpful when symptomatic patients come in to health care settings because there are a whole bunch of vulnerable patients nearby and that barrier is going to protect others around them from being exposed to the droplets. But outside of that, when out in public, there's really no evidence that wearing a mask can help and, in fact, it can lead to some negative consequences. People can get afraid when they see someone wearing a mask. The people wearing the mask might have a false sense of security and could actually contaminate themselves by touching their faces more, by adjusting masks for example. What I would say is that everyone should be washing their hands very frequently and trying not to touch their face and that simple measure right there will reduce your risk.
KP: There have been estimates of case fatality rates circulating on social media, comparing with SARS CFRs for example, and patients do get anxious about the potential severity of the illness if they were exposed. Is it useful to communicate case fatality rates, infection rates etc. at this stage?
SH: It's useful from a clinical and an epidemiological standpoint because there are various scenarios that can play out. Knowing just how badly this virus affects the individual who's infected is important for obvious reasons – we want to be able to provide the right healthcare for people facing this infection. It also does tell us how much we need to concentrate on planning in our intensive care units, and higher-level care that can be provided for very sick people. The challenge is, early in an outbreak we usually have fairly inaccurate measures of case fatality, because our focus is often on getting to the people who end up at the point that they need hospital assessment. There's often a large pool of people with much milder symptoms that we don't even really learn about and so we tend to overestimate the case fatality early on. Later on, as serological studies are implemented in certain areas, we get a better sense of what it actually is. What we don't want is for the public to misinterpret what those numbers are, and they may feel, too, that they are being deceived if the numbers change over time.
KP: How can we reassure patients and the public about the measures that are being taken to prevent an outbreak in Canada like the SARS outbreak 17 years ago?
AV: The major difference is that the public health infrastructures are much better now. For example, infrastructures supporting the surveillance of patients and individual hospital infection control practice are much improved. Testing for the virus is more rapidly done than it was previously, which has improved the ability to identify and isolate cases quickly, and it also means that cases can undergo contact tracing very quickly so that we can identify who might have been exposed to the index patient. Communications have also been far better. So, Canada is in touch, not only with public health agencies across the world but also the WHO, to figure out what Canada needs to do in order to protect itself. As a result of the prompt response and good communication we haven't seen any person-to-person transmission events within Canada whatsoever, despite having four confirmed cases.
KP: What's your role in communicating with your counterparts across the country should the outbreak develop and involve more cities in Canada?
AV: Our role in hospital infection control also involves communicating with municipal and provincial health agencies, to update them on suspected and confirmed cases – at the municipal level we'd let agencies know about a potential case so that contact tracing can be done and at a provincial level we would communicate whether a confirmed case had been found so that everyone would be aware. We also coordinate responses in hospitals so that all are consistent in their measures to protect health care workers and staff against the virus, and my role also involves communicating with other physicians both locally and across the province/country should that be necessary.
KP: Who coordinates the international response that ensures the timely sharing of information?
Isaac Bogoch: The international response, now that this has been declared a public health emergency of international concern (PHEIC), will be mostly through the WHO. This means there is a centralized place for data collection and distribution, and for coordinating global efforts to help combat this infection. The WHO is working very closely with China but in addition they are also working very closely with other countries, particularly low-resource settings to help them prepare for potential imported infections.
KP: What are the possible trajectories for this outbreak, both within Canada and globally?
IB: I must preface my answer to a challenging question like that by time-stamping it. As of today, February 3rd, 2020, it is not entirely clear if the massive control efforts in China are going to be successful. The whole goal now is to contain the infection in China, get the spread of the infection under control in China and to limit spread internationally. At the same time, we are seeing exported cases to over a dozen countries. We are seeing small but real secondary chains of transmission in international destinations – in Japan, in the United States, and in Thailand. And, while the bulk of the efforts are focused on containing spread in China, we have to accept that there is a possibility that those efforts may not be successful and that there will be further international spread. But, as of today, it is not entirely clear which direction this is going to go. Having said that, the public health infrastructures in the countries with reported secondary chains of transmission are very good; cases have been confirmed, treated and the appropriate contact tracing has been done to limit further spread. Can secondary spread occur in countries that don't have this sort of sophisticated public health infrastructure? The answer is yes, but the whole goal of massive control efforts in china is to reduce spread of infection there and reduce the risk of spread of the infection to more international destinations so that we don't have to combat secondary chains of infection in other countries.
KP: Are the measures regarding travel restrictions, quarantining and so on that countries are taking likely to help contain the spread of the infection or are they likely to do more overall harm than good?
IB: People have very strong opinions of travel restrictions one way or another. The WHO and the International Health Regulations (IHR) are pretty clear that travel restrictions should be avoided; particularly they're clear that travel restrictions do more harm than good in terms of delivering resources to affected areas, economic ramifications and sociopolitical ramifications. Having said that, countries are sovereign states and will choose to do what they feel is in their best interests and in this situation, we've seen many countries enact travel restrictions to China. In the past travel restrictions have been used to attempt to curtail the spread of different infections internationally, for example, the H1N1 influenza pandemic recently. With H1N1 travel restrictions were put in place in many settings and studies were done subsequently to see if they were effective. And, at best, they were able to delay the introduction of the virus by a couple of weeks or so. Many might jump on some of these data and say that travel restrictions don't work. That's not clear. We do have to be very careful about the secondary damage of travel restrictions, though. In this case travel restrictions could prevent the affected country, China, from obtaining necessary supplies; restrictions have tremendous economic and potentially socio-political ramifications, not just in the country of origin but elsewhere in the world. So there are a number of negative impacts of travel restrictions, but, quite frankly, this is an unprecedented situation and the degree of travel restrictions already imposed in China by Chinese authorities in the affected areas has never been seen before. There are about 50-60 million people who are essentially cut off by rail, road and air, and now several other countries are also restricting travel to and from China. Yet it is not entirely clear if this degree of travel restriction will have any effect on the spread of the virus. The optics remain favourable for some countries to look like they are doing something. But it's not actually clear that these actions will slow the spread of the virus. It's really challenging for us to extrapolate from prior data and prior examples and apply it to this setting, and I think it's okay to say to the public and to the international scientific community that we are not entirely sure and certainly we cannot confidently say that a travel restriction will or will not help in this situation. It's quite unclear what the effectiveness of existing travel restrictions will be, and I think we'll know in about a week or two whether the effect of the massive efforts to control the infection within China have been effective or not.
KP: There have been some news stories about development of a 'novel coronavirus vaccine'. What does that mean for the current outbreak?
IB: There are efforts to develop a coronavirus vaccine and these started a while ago in response to SARS and MERS epidemics. Vaccine development is complex; it takes a long time and a lot of money to develop a new vaccine through appropriate laboratory investigations that move into phase 1, phase 2 and phase 3 clinical trials. This is extremely important because this is not the last time we'll see a novel coronavirus emerge. In the last 20 years we've seen 3 big ones emerge, so we can certainly appreciate that this will happen again. But will a vaccine be ready to be useful in the current epidemic? I think it's pretty clear that it won't because we're in the middle of an epidemic and the vaccines are pretty far away from public health and clinical utility - but we should keep working on it. For the Ebola virus epidemic of 2014 in West Africa, vaccines were rapidly deployed but I think we have to remember that there was well over a decade's worth of work put into that vaccine. And during that epidemi, the vaccine was already in advanced phases of testing. The vaccine was hugely helpful in getting that epidemic under control. We are not in that situation here with this novel coronavirus. We've had vaccine development for other recent emerging infectious diseases as well – for example, Zika virus of a couple of years ago and Chikungunya, which was imported to Latin America from endemic zones in 2013. There's been a huge push to develop a Zika virus vaccine, which would be extraordinarily helpful for people living in virus endemic zones and also for travelers. But the vaccine is not yet commercially available and it's been years. Likewise, there's been a push to develop a Chikungunya virus vaccine, which would also be helpful for protecting people in endemic regions and travelers – but this is also not commercially available. It takes a lot of work, time and money to establish a vaccine is safe and effective. I don't think we'll see a novel coronavirus vaccine deployed in the next year.
KP: If a vaccine is not our saving grace, what is the most important thing for the public, physicians and infection control specialists to be doing at this time?
AV: For physicians and the public in Canada, what we need to do to control this is to continue being vigilant, in other words, being updated on information that's coming out of China; understanding the epidemiology, the symptoms and what a compatible exposure history sounds like; and being vigilant to appropriately identify, screen and test potential patients. It's going to be tricky if we start to see any asymptomatic transmission and asymptomatic virus shedding, but we have to do the best we can. And the best approach is to use common sense things that we have at our disposal, such as encouraging hand hygiene, encouraging people not to go to work if and when they are sick, and then from the health care side is to use proper PPE – which is the same as that which is required for other infections. So as long as physicians and other healthcare providers understand the necessity of doing the things we should be doing anyway then we will properly be able to protect the public, patients and health care workers from spread of this virus.
SH: I think that one of the most important things we could do is work on our hand hygiene. It's not something we excel in in health care. We keep focusing on the respiratory precautions and aren't really thinking about that aspect. We could definitely improve on that and it's definitely an important measure to protect our patients and ourselves from new infections, or even the old infections. It's simple and it's something that the public should also be working on improving, especially when you've been in public areas you should definitely be washing your hands. The other part that's important is acknowledging how rapidly changing the landscape is and how, from one week to the next, things have really shifted. It's not unusual for this to be the case and we should not think of that as being disconcerting as much as 'this is my cue to keep on top of things'.
IB: There is an evolving situation in China and physicians and the public should keep up to date using reputable resources. The provincial public health agencies and the Public Health Agency of Canada have excellent high-quality updates on their websites and that's a good place to check for new information. More broadly, we must remember that, while we are in the middle of an epidemic right now, this will pass and there will be a period of time where we'll see a relative lull in infectious diseases of global health significance. And that is the time that we should be preparing for the next one. Know that this is going to happen again, and if it's not going to be a coronavirus it's going to be something else, and we really need to invest, not only as a country but also globally, in early detection systems, in global communication and coordination, and in epidemic management systems. We have to do this globally because we know that whatever happens on the other side of the world can quickly land on our doorstep. So we have to be prepared. And the right time to do this was yesterday.