CDC COVID-19 ONE HEALTH UPDATE - Minesh Shah, Christina Scheel, Katie Wilson
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
CDC COVID-19 ONE HEALTH UPDATE Minesh Shah, Christina Scheel, Katie Wilson
Global Epidemiology
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 patientsSARS-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.2020.02.06COVID-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.2020.02.017COVID-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-PCRLaboratory 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.pdfInfection 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 facilitiesIPC 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 PrecautionsStandard 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 handlingTransmission-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-20200125PPE 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.htmlAerosol-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-20200125Differences 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.pdfEnvironmental 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.pdfKeeping 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 secretionsIPC 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/coursesCOVID-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.htmlCDC 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.
You can also read
