2019 Novel Coronavirus: Update for Orange County
January 23, 2020
An outbreak of respiratory disease caused by 2019 Novel Coronavirus (2019-nCoV) has been identified in Wuhan, Hubei Province, China. Over 500 cases and 17 deaths have been identified since the outbreak was identified in December. Traveler cases from Wuhan have been identified in other areas of China, including Beijing and Shenzhen, as well as Taiwan, Thailand, Japan, and South Korea. The first United States case was confirmed earlier this week in a Washington state traveler from Wuhan.
 
The initial illnesses are believed to be related to animal exposure at the Wuhan South China Seafood City (also called the South China Seafood Wholesale Market and the Hua Nan Seafood Market), which was closed on January 1. More recent cases have demonstrated that person-to-person transmission occurs, and several cases have been seen in healthcare workers who cared for cases, though it’s unclear how easily or sustainably the virus is spreading between people.  
 
Because the largest number of cases have been identified in Wuhan, public health surveillance is currently focused on travelers from this area. Earlier this week, China announced that they would be restricting travel out of Wuhan, though it is unclear at this point how comprehensive these restrictions will be. CDC has implemented symptom screening of travelers arriving from Wuhan, at Los Angeles International Airport, San Francisco International Airport, and John F. Kennedy International Airport in New York. Screening will be implemented soon at Atlanta Hartsfield-Jackson International Airport and Chicago O’Hare International Airport. Most travelers from Wuhan to the United States will pass through one of these airports and receive a health assessment upon arrival. If this assessment reveals no evidence of acute illness, they will be educated about the current outbreak and instructed to seek medical care if they develop illness. Orange County providers may care for patients who develop illness following travel from Wuhan.

Recommendations for  Providers:
  • Providers should immediately report all cases of suspected 2019-nCoV infection to the Orange County Health Care Agency at 714-834-8180 (after hours contact the OCHCA physician on call at 714-628-7008).

  • Providers should take a detailed travel history for patients with fever and acute respiratory illness to identify potential exposures. If a patient reports recent travel to China, the provider should clarify which cities and provinces were visited.


Clinical Presentation:
Based on experience with other coronaviruses, 2019-nCoV’s incubation period is presumed to extend up to 14 days. The virus’s transmission dynamics have yet to be determined.

The primary clinical symptoms have been respiratory, including fever, cough, and shortness of breath. A significant proportion of cases have had pneumonia. Cases of more mild illness are being identified as well; at this point it is not clear how likely severe illness is for persons infected. 

When to Test:
Patients who meet the following criteria should be tested for 2019-nCoV:

----- 1)   Fever and symptoms of lower respiratory illness (e.g., cough, shortness of breath)

--------- AND in the 14 days before symptom onset:

-------- History of travel from Wuhan City, China
--------- -or-
--------- Close contact with a person who is under investigation for 2019-nCoV while that ------------- person was ill.

----- 2)   Fever or symptoms of lower respiratory illness (e.g., cough, shortness of breath)

--------- AND in the last 14 days before symptom onset, close contact with an ill ------------------------- laboratory-confirmed 2019-nCoV patient

Note that these recommendations should serve as guidelines for providers. But fever may not always be present, and clinical judgment should always be used to guide testing. All laboratory testing for 2019-nCoV is currently performed by the CDC. 

Laboratory Testing:
All laboratory testing is currently being performed by the CDC. CDC will accept specimens for testing following a clinical case review by local public health.

Diagnosis is confirmed by PCR testing of appropriate clinical specimens. CDC recommends the collection of three specimen types:
  • Upper respiratory (nasopharyngeal AND oropharyngeal swabs)
  • Serum 
  • Lower respiratory (tracheal aspirate, bronchoalveolar lavage specimens, or sputum)

If a lower respiratory tract specimen is not obtainable, upper respiratory and serum specimens may be submitted alone for testing.

Specimens should be stored at 2-8°C and sent by courier to Orange County Public Health Laboratory prior to shipment to t he CDC.

More detailed guidance on specimen collection and laboratory biosafety can be found at:



Clinical Care:
Care is supportive. No vaccine or specific treatment for 2019-nCoV infection is available.

Infection Control Precautions:
Patients who qualify for assessment for 2019-nCoV should be asked to wear a surgical mask as soon as they are identified and be evaluated in a private room with the door closed, ideally an airborne infection isolation room if available. Healthcare personnel entering the room should use standard precautions, contact precautions, airborne precautions, and use eye protection (e.g., goggles or a face shield). 

If a patient that has suspected or confirmed 2019-nCoV is being cared for in a facility that can provide airborne precautions, OCHCA will not routinely recommend transfer to an alternate facility for care. 
 
An All Facilities Letter was distributed by the California Department of Public Health today which reviewed infection control issues and recommendations for healthcare facilities. It can be found at https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/AFL-20-09.pdf

Care of Contacts:
  • Contacts who have symptoms consistent with coronavirus infection should receive immediate evaluation and care.

  • Asymptomatic contacts will be assessed for risk by OCHCA.

Recommendations for Travelers:
CDC recommends avoiding non-essential travel to Wuhan, China.

Updated traveler recommendations can be found at https://wwwnc.cdc.gov/travel/notices/alert/novel-coronavirus-china .

Contact Information:
For questions or concerns, please contact the Communicable Disease Control Division at 714-834-8180.
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