CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson
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March 11, Pandemics 2020 ▪ Pandemics happen when a disease emerges to infect people WHO declared easily and spreads from person to person in an efficient and COVID-19 sustained way globally pandemic ▪ This is the first pandemic known to be caused by the emergence of a new coronavirus ▪ Different countries can be in different phases of the pandemic at any point in time and different parts of the same country can also be in different phases of a pandemic ▪ The duration and severity of a pandemic can vary depending on the characteristics of the virus and the public health response
COVID-19 Etiology: SARS-CoV-2, a Human Coronavirus (HCoV) ▪ Common HCoVs (lower pathogenicity): – HCoV-229E (alpha) – HCoV-NL63 (alpha) – HCoV-OC43 (beta) – HCoV-HKU1 (beta) ▪ Other HCoVs (higher pathogenicity): – SARS-CoV (beta) – MERS-CoV (beta) – SARS-CoV-2* (beta) The illness COVID-19 is caused by SARS-CoV-2, which is more like SARS-CoV than MERS-CoV https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it
COVID-19 Emergence: Linkage of Early COVID-19 Cases* to Huanan Seafood Wholesale Market – Wuhan, China (N = 47) (N = 196) (N = 81) https://www.healthpolicy-watch.org/ Adapted from Li 2020, N Engl J Med; DOI: 10.1056/NEJMoa2001316. * Total N=324 persons with complete exposure histories among 425 total cases
COVID-19 Dissemination: Rapid and Widespread affecting all Global Regions https://www.healthmap.org/covid-19/
COVID-19: Signs/Symptoms ▪ No particular set of signs or symptoms can reliably discriminate COVID-19 from other respiratory viral illnesses such as influenza – Subacute to acute onset – Non-productive cough – Fever or “feverish” (often low-grade or not initially measurable) – Some reports of isolated diarrhea alone preceding cough and fever ▪ Median incubation period estimated to be 4-6 days (range 2-14 days) ▪ Most people will recover spontaneously with supportive care ▪ Complications include pneumonia, respiratory failure, multiorgan system failure Liu 2020, Chinese Med J; DOI: 10.1097/CM9.0000000000000744. Wang 2020, JAMA; doi:10.1001/jama.2020.1585. Guan 2020, N Engl J Med; DOI: 10.1056/NEJMoa2002032. Chen 2020, Lancet; https://doi.org/10.1016/S0140-6736(20)30211-7
Age Distribution and Case Fatality Rate COVID-19 China through 11-Feb-2020 (N = 44,672 confirmed cases) 30.0% 25.0% Percent of total cases 20.0% 15.0% 10.0% 5.0% 0.0% 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 ≥ 80 Age, years adapted from Zhang 2020, China CDC Weekly Rep; 2(8):113-122.
Age Distribution and Case Fatality Rate COVID-19 China through 11-Feb-2020 (N = 44,672 confirmed cases) 30.0% 20.0% Fraction of total cases Case fatality rate 25.0% 16.0% Percent of total cases Case fatality rate 20.0% 12.0% 15.0% 8.0% 10.0% 4.0% 5.0% 0.0% 0.0% 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 ≥ 80 Age, years adapted from Zhang 2020, China CDC Weekly Rep; 2(8):113-122.
Illness Severity COVID-19 - China through 11-Feb-2020 Mild Severe 80.9% 13.8% 44,672 Critical* patients 4.7% Missing 0.6% adapted from Zhang 2020, China CDC Weekly Report; 2(8):113-122. * 1,023 (49%) deaths among 2,087 critically ill patients
SARS-CoV-2 in Human Samples and Transmission ▪ Respiratory secretions – main mode of transmission – Infection is spread through respiratory droplets in the air and that land on surfaces – Transmission from persons who are pre-symptomatic or who may have asymptomatic infection is possible but the contribution of these infections to overall numbers of illness appears to be small at this time ▪ Stool – unlikely at this time – Readily detectable by RT-PCR but only one report of replication-competent virus cultured ▪ Perinatal – no transmission yet observed – Not detected by RT-PCR in amniotic fluid, cord blood, neonatal throat swab, breast milk Zou 2020, N Engl J Med; DOI: 10.1056/NEJMc2001737. Pan 2020 , Lancet Infect Dis; https://doi.org/10.1016/S1473-3099(20)30113-4. Zhang 2020; China CDC Weekly: http://weekly.chinacdc.cn/en/article/id/ffa97a96-db2a-4715-9dfb-ef662660e89d. Chen 2020; Lancet: https://doi.org/10.1016/ S0140- 6736(20)30360-3 Zhu 2020l Transl Pedtr: http://dx.doi.org/10.21037/tp.2020.02.06
COVID-19: High-Risk Groups ▪ Comorbidity and advanced age increase risk for severe illness and death – Cardiovascular disease, diabetes, chronic respiratory disease (CFR >5%) ▪ Immunocompromised (medical, acquired) – no data at present – For persons with HIV, risk likely greatest at low CD4 cell counts or if not virally suppressed – Nonetheless all should take precautions given this is a new virus – CDC estimates that > 50% of people with HIV are more than 50 years old ▪ Pregnancy – Current observational data only exist for women infected in third trimester – Maternal morbidity similar to that of uninfected women without COVID-19 – No definitive evidence infection transmitted perinatally Zhang 2020, China CDC Weekly Report; 2(8):113-122 Rasmussen 2020; Am J Obstet Gynecol: https://doi.org/10.1016/j.ajog.2020.02.017
COVID-19 Prevention Messages
Preparedness and Response Framework for Pandemics Containment Mitigation • Intensify case finding and contact tracing Transmission • Deploy medical interventions • Isolate cases and quarantine contacts outpaces o Antivirals, vaccines • Characterize illness containment • Early institution of multilayered NPIs • Prepare for mitigation with nonpharmaceutical efforts interventions (NPI) Adapted from: Holloway 2014, MMWR Recomm Rep;63(No. RR-6). Qualls 2017, MMWR Recomm Rep; 66(No. RR-1). Jernigan 2020, MMWR Early Release: February 25, 2020.
Overview ▪ Preparing to work with SARS CoV-2* in the Laboratory • Risk Assessment • Biosafety • Transport • Manipulation • Waste management ▪ Coronavirus Features ▪ Diagnostic Tests *SARS CoV-2 is the virus that causes COVID-19. • CDC Real-Time RT-PCR
Laboratory Biosafety Before work begins: Perform a biological risk assessment1 1. Identify Hazards ▪ Facility ▪ Biological agent ▪ Personnel 2. Weigh the likelihood of an accident against Life cycle of specimen consequences of exposure 3. Mitigate risk using controls Transport from clinic to lab ▪ Shipping – Category B packaging • Regulated UN3373 – triple packaging1 Likelihood Manipulation of specimen ▪ Accessioning – receipt of specimen ▪ RNA extraction Waste is Category B – autoclave or incinerate Consequence 1. https://www.who.int/docs/default-source/coronaviruse/laboratory-biosafety-novel-coronavirus-version-1-1.pdf?sfvrsn=912a9847_2 2. https://www.who.int/ihr/publications/WHO-WHE-CPI-2019.20/en/
Coronavirus features Envelope protein Membrane protein Nucleocapsid and Genomic RNA Enveloped +ssRNA virus ▪ Proteins • Nucleocapsid (N) Spike protein • Envelope protein (E) • Membrane protein (M) • Spike protein (S) Genetic Sequence High identity to ▪ SARS 2003 (80-85%) ▪ Bat SL CoV (85-90%)
Laboratory Tests World Health Organization Coronavirus disease (COVID-19) technical guidance: Laboratory testing for 2019-nCoV in humans1 ▪ Five diagnostic test protocols for polymerase chain reaction (PCR) of COVID-19 • China (genetic primers and probes only) • Thailand • Hong Kong All tests detect virus – no detection of humoral • Japan response for convalescent phase • Germany • USA (CDC) Many more tests commercially available and in development ▪ Antibody detection (igM/IgG) ▪ Automated ▪ Point of Care (POC) lateral flow or “dipstick” Under evaluation by Foundation for Innovation New Diagnostics (FIND) in coordination with WHO2 1. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/laboratory-guidance 2. https://www.finddx.org/covid-19/
CDC Laboratory Test: Real-Time RT-PCR Panel for Detection of COVID-191 Human Specimens ▪ Respiratory • Pharyngeal washes or swabs Extract RNA • Bronchiolar lavage + Taq polymerase master mix • Tracheal aspirates • Sputum 1. https://www.cdc.gov/coronavirus/2019-ncov/downloads/rt-pcr-panel-for-detection-instructions.pdf
Infection Prevention and Control (IPC) for COVID-19
Note: The information presented in these slides is intended for non-US healthcare settings. WHO guidance is incorporated.
What is IPC? ▪ The science of preventing or stopping the spread of infections during healthcare delivery – hospitals, outpatient clinics, dialysis centers, long-term care facilities, traditional practitioners ▪ Goal: support maintenance of essential healthcare services by containing and preventing COVID-19 transmission within healthcare facilities
IPC Priorities for COVID-19 ▪ IDENTIFY – Early identification of suspected cases presenting for healthcare is critical ▪ ISOLATE – Prompt isolation of suspected cases to reduce opportunities for transmission in healthcare setting ▪ INFORM – Communication with public health response (initiate laboratory testing, coordinate contact tracing, etc.)
Standard and Transmission-based Precautions ▪ Standard Precautions – Set of practices that apply to care of all patients in all healthcare settings ▪ Transmission-based Precautions – Set of practices specific for patients with known or suspected infectious agents that require additional control measures to prevent transmission – Used in addition to Standard Precautions
Standard Precautions ▪ Hand hygiene Elements that apply to ▪ Personal protective equipment patients with respiratory ▪ Respiratory hygiene and cough etiquette infections ▪ Cleaning and disinfection of devices and environmental surfaces ▪ Safe injection practices ▪ Medication storage and handling
Transmission-based precautions for COVID-19 ▪ Use adequately ventilated single rooms or ward rooms ▪ Wear PPE for contact and droplet precautions* ▪ Use disposable or dedicated patient care equipment (e.g., stethoscopes, blood pressure cuffs) ▪ Avoid transporting COVID-19 patients out of room unless medically necessary ▪ Cohort HCWs to care for patients with COVID-19 ▪ Restrict number of visitors allowed *WHO recommendations https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125
PPE for COVID-19* ▪ Gloves (non-sterile, examination) ▪ Medical mask ▪ Eye protection (goggles or face shield) ▪ Gown (long-sleeved, non-sterile) *Note: information on this slide is PPE as recommended by WHO. PPE guidance for U.S. healthcare settings can be found on CDC COVID-19 website: https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control- recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html
Aerosol-generating procedures (AGPs) ▪ AGPs associated with increased risk of transmission of other coronaviruses (SARS-CoV and MERS-CoV) ▪ Perform AGPs in adequately ventilated rooms – Negative pressure room (at least 12 air exchanges/hour) or natural ventilation (air flow at least 160 L/s per patient) ▪ Wear appropriate PPE – Gloves (non-sterile, examination) – Particulate respirator – Eye protection (goggles or face shield) – Gown (long-sleeved, non-sterile) https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125
Differences in WHO and CDC Recommendations for PPE Caring for suspected or Aerosol-generating procedures for confirmed COVID-19 patients COVID-19 patients WHO gloves, gown, eye protection, gloves, gown, eye protection, respirator medical mask CDC gloves, gown, eye protection, gloves, gown, eye protection, respirator respirator* or facemask (if respirator not available) *CDC has been recommending respirators for U.S. healthcare facilities – Consistency with previously published SARS, MERS, and novel/severe influenza A guidance – Cautious and aggressive approach in the U.S. – Facemasks are acceptable alternative when supply chain of respirators cannot meet the demand (CDC guidance updated March 10, 2020)
Key Points for PPE Use ▪ PPE relies on consistent and correct use by healthcare personnel – trainings and practice for healthcare personnel in advance ▪ Risk of self-contamination is higher when removing PPE – Remove PPE slowly and carefully – Do not touch front of masks, respirators, or facial protection (likely most contaminated) ▪ Instructions for putting on and removing PPE – https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence.pdf
Environmental cleaning and disinfection ▪ Routine cleaning and disinfection procedures ▪ Focus cleaning on frequently touched and frequently contaminated surfaces – Light switches, bed rails, door handles, sinks, bathrooms ▪ Hospital-grade disinfectants effective – Products active against enveloped viruses https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-508.pdf
Keeping patients safe ▪ Hand hygiene ▪ Respiratory hygiene – Ensure patients cover their nose and mouth with tissue or elbow when coughing or sneezing – Offer medical mask to patients with suspected COVID-19 while in waiting rooms – Perform hand hygiene after contact with respiratory secretions
IPC Resources ▪ WHO IPC technical guidance for COVID-19 – https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infection- prevention-and-control ▪ WHO Q&A for health care workers – https://www.who.int/news-room/q-a-detail/q-a-on-infection-prevention-and-control-for-health-care- workers-caring-for-patients-with-suspected-or-confirmed-2019-ncov ▪ Best practices for environmental cleaning in HCFs in Resource-Limited Settings – https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-508.pdf ▪ CDC Interim IPC Recommendations for COVID-19 in Healthcare Settings – https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html ▪ IPC trainings (not specific for COVID-19) – https://ipc.ghelearning.org/courses
CDC COVID-19 Resources ▪ CDC COVID-19 Web Site https://www.cdc.gov/covid19 ▪ CDC COVID-19 Information for Healthcare Professionals https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html • CDC Risk Categorization for U.S. Healthcare Personnel https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html • Interim Healthcare Infection Prevention and Control Recommendations for Persons Under Investigation for Coronavirus Disease 2019 https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html • Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management- patients.html • Interim Guidance for Preventing Coronavirus Disease 2019 from Spreading to Others in Homes and Communities https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-prevent-spread.html • Interim Guidance for Healthcare Professionals https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html
CDC COVID-19 Resources ▪ Coronavirus Disease 2019 Update—What Clinicians Need to Know to Prepare for COVID-19 in the United States https://emergency.cdc.gov/coca/calls/2020/callinfo _030520.asp ▪ CDC COVID-19 Information for Laboratories https://www.cdc.gov/coronavirus/2019- nCoV/lab/index.html ▪ Public Health Image Library (PHIL) https://phil.cdc.gov/ ▪ Crisis & Emergency Risk Communication (CERC) Templates https://emergency.cdc.gov/cerc/resources/templat es-tools.asp
WHO COVID-19 Resources ▪ WHO COVID-19 Homepage https://www.who.int/emergencies/diseases/novel- coronavirus-2019 ▪ WHO Situation Reports https://www.who.int/emergencies/diseases/novel-coronavirus- 2019/situation-reports ▪ Technical Guidance (by topic) https://www.who.int/emergencies/diseases/novel- coronavirus-2019/technical-guidance/ ▪ Checklist for Risk Communication and Community Engagement https://www.who.int/publications-detail/risk-communication-and-community- engagement-readiness-and-initial-response-for-novel-coronaviruses-(-ncov)
Other Useful Resources ▪ Johns Hopkins University COVID-19 Global Case Map https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html?fbclid= IwAR0BVBHgwKy6kLekBHRdykqqVlFE6flM659Hev4Ktr_dbL76pY-LO36- Am8#/bda7594740fd40299423467b48e9ecf6
Thank you! For more information, contact CDC COVID-19 International Taskforce (ITF) Email Box 1-800-CDC-INFO (232-4636) email@example.com TTY: 1-888-232-6348 www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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