CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson

 
CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson
CDC COVID-19
ONE HEALTH UPDATE

Minesh Shah, Christina Scheel, Katie Wilson
CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson
Global Epidemiology
CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson
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
CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson
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
CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson
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
CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson
COVID-19 Dissemination: Rapid and Widespread
affecting all Global Regions   https://www.healthmap.org/covid-19/
CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson
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
CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson
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.
CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson
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.
CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson
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.
Laboratory Diagnosis
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
COVID-19 Resources
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)                                        eocevent223@cdc.gov
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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