2019 Novel coronavirus (2019-nCoV)Guideline for health services and general practitioners

23 January 2020

Version 1

Contents

Background............................................................................................................................................... 3

Summary of key actions required...........................................................................................................3Checklist of key actions for general practitioners........................................................................................3

Checklist of key actions for an emergency department or urgent care centre............................................4

Public health response objectives..........................................................................................................4

Case definitions........................................................................................................................................ 5Locations with evidence of human-to-human transmission of 2019-nCoV.................................................5

Definition of close contact........................................................................................................................... 5

Definition of casual contact.........................................................................................................................6

Case management.................................................................................................................................... 7Assessment and notification to the department..........................................................................................7

Patient transfer and destination health service...........................................................................................7

Treatment of cases..................................................................................................................................... 7

Contact management............................................................................................................................... 7Quarantine and exclusion........................................................................................................................... 7

Self-monitoring............................................................................................................................................ 8

Restrictions on travel.................................................................................................................................. 8

Summary of recommended actions for close contacts...............................................................................8

Summary of recommended actions for casual contacts.............................................................................8

Infection prevention and control.............................................................................................................9

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Background................................................................................................................................................. 9

Transmission-based precautions................................................................................................................9

Environmental management..................................................................................................................... 10

Laboratory testing for 2019-nCoV.........................................................................................................11Approval for testing................................................................................................................................... 11

Specimens for testing............................................................................................................................... 11

Specimen collection and transport............................................................................................................11

Handling of specimens within diagnostic laboratories...............................................................................11

Summary of testing requirements.............................................................................................................12

Information on testing for coronavirus at VIDRL.......................................................................................12

Exclusion of 2019-nCoV infection through testing....................................................................................13

Governance............................................................................................................................................. 14International response.............................................................................................................................. 14

Department Incident Management Team.................................................................................................14

Communications and media..................................................................................................................... 14

Role of Ambulance Victoria....................................................................................................................... 14

Prevention............................................................................................................................................... 14

Risk management at ports of entry.......................................................................................................15

The disease............................................................................................................................................. 15Infectious agent........................................................................................................................................ 15

Reservoir.................................................................................................................................................. 15

Mode of transmission................................................................................................................................ 15

Incubation period...................................................................................................................................... 16

Infectious period....................................................................................................................................... 16

Clinical presentation................................................................................................................................. 16

Information resources............................................................................................................................ 16

Background

2019 novel coronavirus (2019-nCoV) was first diagnosed in Wuhan City, Hubei Province, China in December 2019. Updated epidemiological information is available from the World Health Organization (WHO) and other sources. Current information on novel coronavirus is summarised in a section at the end of this guideline entitled ‘The disease’.

2019 Novel coronavirus (2019-nCoV): Guideline for health services and GPs – 23 January 2020 – V1 Page 3

Summary of key actions required

Checklist of key actions for general practitionersThe following actions should be undertaken when a patient presents to a general practice or community health service who may be a suspected case of 2019-nCoV:

1. Place a single-use surgical mask on the patient (single-use surgical face mask);2. Isolate the patient in a single room with door closed;3. Any person entering the room should don appropriate Droplet and Contact Precautions personal

protective equipment (single-use surgical face mask, eye protection, gown and gloves);4. If available, Airborne Precautions can be applied as well, which is a P2 respirator (N95 mask)

instead of a single-use surgical face mask;5. Conduct a medical assessment, and focus on:

a. Presenting symptoms, especially any evidence on history or examination of fever or lower respiratory tract symptoms and the date of onset of the illness;

b. Precise travel history, especially dates of travel in China or other countries of concern and the timing in relation to the date of onset of illness;

c. History of contact with sick travellers or people, overseas health care facilities and outdoor markets;

6. Consider the case definitions and whether your patient may fit the suspected case definition;7. Call the department to notify the case urgently by telephoning 1300 651 160, 24 hours a day;8. In discussion with the department, determine whether the patient:

a. Should be tested for 2019-nCoV;b. Whether the patient requires further assessment in an emergency department;c. How the patient will be transferred if requiring further assessment;

9. It is preferred that transfers to hospital via ambulance are organised by the department for suspected cases of novel coronavirus infection. However, if the patient is extremely unwell and requires immediate critical care, call 000 in the normal manner but advise that the patient may have suspected 2019-nCoV infection.

10. Remember to provide a face mask for the patient if being transferred to an emergency department.

Checklist of key actions for an emergency department or urgent care centreThe following actions should be undertaken when a patient presents to an emergency department or urgent care centre who may be a suspected case of 2019-nCoV:

1. Take the actions listed above;2. If available, Airborne Precautions could be applied as well, which is a P2 respirator (N95 mask)

instead of a single-use surgical face mask and a negative pressure ventilation room;3. Contact your infectious diseases unit and/or infection prevention and control lead to discuss the

case;4. Call the department to notify the case urgently by telephoning 1300 651 160, 24 hours a day.

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Public health response objectives

This situation is evolving rapidly with new clinical and epidemiological information and intelligence. At the present time, the public health response can be characterised as a ‘containment’ approach, whereby there will be an inclusive approach to identifying cases and a precautionary approach to the management of cases and contacts.

The overall objectives of the public health response are to:

1. Reduce the morbidity and mortality associated with 2019-nCoV infection through an organised response that focuses on containment of infection;

2. Rapidly identify, isolate and treat cases, to reduce transmission to contacts, including health care, household and community contacts;

3. Characterise the clinical and epidemiological features of cases in order to adjust required control measures in a proportionate manner;

4. Minimise risk of transmission in healthcare environments.

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Case definitions

The following case definitions are now in place in Victoria and in active use by the department and health sector:

1. Confirmed caseA person tested for 2019-nCoV at the Victorian Infectious Diseases Reference Laboratory and found to have 2019-nCoV infection.

2. Suspected caseBoth clinical and epidemiological criteria need to be met for a person to be classified as a suspected case.

Clinical criteria:fever or history of fever AND acute respiratory infection (shortness of breath or cough or sore throat)OR severe acute respiratory infection without fever requiring hospitalisation

AND

Epidemiological criteria:A history of being in a location designated by the department as a place where there is evidence of human to human transmission (see below) in the 14 days prior to symptom onsetORClose contact within 14 days of symptom onset with any of the following:o a confirmed or suspected case of 2019-nCoV;o a healthcare facility in a country where hospital-associated infections have been reported.

Locations with evidence of human-to-human transmission of 2019-nCoVThe department will declare locations where there is considered evidence of human-to-human transmission of 2019-nCoV for the purposes of the suspected case definition above.

As of 23 January 2020 the declared locations are:

Wuhan City, Hubei Province, China. No other locations at the present time.

The department will expand this list based on intelligence from public health surveillance and international authorities, as more information becomes available. Updates to this case definition will be shown on the department’s webpage for novel coronavirus and in updates to this Guide. See https://www.dhhs.vic.gov.au/novelcoronavirus

Definition of close contactFor the purposes of the suspected case definition, there is no currently agreed definition of close contact as there is a lack of definitive evidence. As interim advice, the department advises a precautionary understanding of close contact given a lack of definitive evidence of the mode of transmission.

In keeping with definitions of close contact developed in other jurisdictions, close contact means greater than 15 minutes face-to-face contact with a symptomatic suspected or confirmed case in any setting, or the sharing of a closed space with a symptomatic suspected or confirmed case for a prolonged period (e.g. more than 2 hours), without recommended PPE (Droplet and Contact Precautions).

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A close contact could include any person meeting any of the following criteria: living in the same household or household-like setting (e.g. in a boarding school or hostel); direct contact with the body fluids or laboratory specimens of a confirmed case without

recommended PPE; a person who spent two hours or longer in the same room (such as a GP or ED waiting room); a person in the same hospital room when an aerosol generating procedure is undertaken on the

case, without recommended PPE (Droplet and Contact Precautions); Aircraft passengers who were seated in the same row as the case, or in the two rows in front or two

rows behind a suspected or confirmed case of 2019-nCoV; face-to-face contact for more than 15 minutes with the case in any other setting not listed above.

Contact needs to have occurred within the period extending from the day of onset of symptoms in the case until the case is classified as no longer infectious by the treating team (usually 24 hours after the resolution of symptoms).

Healthcare workers and other contacts who have taken recommended infection control precautions, including the use of recommended PPE (Droplet and Contact Precautions), while caring for a suspected or confirmed case of 2019-nCoV are not considered to be close contacts.

Definition of casual contactCasual contact is defined as any person having less than 15 minutes face-to-face contact with a symptomatic probable or confirmed case in any setting or sharing a closed space with a symptomatic probable or confirmed case for less than two hours.

Healthcare workers caring for a confirmed case who have taken recommended infection control precautions including use of recommended PPE (Droplet and Contact Precautions) including Airborne Precautions will have face to face contact and are thus casual contacts.

For the purposes of public health contact tracing, other casual contacts may include:

• Extended family groups, e.g. in an Aboriginal community.• Contact tracing of people who may have had close contact on long bus or train trips should also be

attempted where possible, using similar seating/proximity criteria.• All crew-members on an aircraft who worked in the same cabin area as a suspected or confirmed

case of 2019-nCoV. If a crew member is the 2019-nCoV case, contact tracing efforts should concentrate on passengers seated in the area where the crew member was working during the flight and all of the other members of the crew.

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Case management

Assessment and notification to the departmentVictorian health services and general practitioners must call the department urgently on 1300 651 160, 24 hours a day, and notify the department of any individual who meets the criteria for suspected case of 2019-nCoV. Notification to the department will enable awareness, approval of testing at VIDRL, public health management and risk communication with the Victorian community.

The medical assessment prior to notification should focus on the following:

Presenting symptoms and signs, especially any evidence on history or examination of fever or lower respiratory tract symptoms and the date of onset of the illness;

Precise travel history, especially dates of travel and places visited in China or other countries of concern and the timing in relation to the date of onset of illness;

History of contact with sick travellers or people, overseas health care facilities and live animal markets.

Patient transfer and destination health serviceThe following is advice on where patients should be managed:

Patients should be assessed and managed by the health service they present to.

Transport of patients to other facilities should be avoided unless medically necessary.

Travellers identified as suspected cases at Melbourne Airport will likely be transferred to Royal Melbourne Hospital or Royal Children’s Hospital, for assessment.

Treatment of casesThis is at the discretion of the treating team and at the present time is supportive care only.

Admission to hospital should be considered when medically necessary, although in consultation with the department, there may be circumstances where admission is warranted in order to reduce the risk of transmission if the case resides in a communal environment, such as a hostel.

In consultation with the department, there may be agreement for a person not requiring hospitalisation who has confirmed novel coronavirus to be managed at home. The United States Centers for Disease Control and Prevention (USCDC) has developed principles for such home care management at https://www.cdc.gov/coronavirus/2019-ncov/guidance-home-care.html

Contact management

The department will conduct contact tracing for confirmed cases in the community and will seek assistance from a health service in relation to any contact tracing required for health service staff.

Quarantine and exclusionOn current evidence, there is no requirement for quarantine (where a person is isolated who is well) or testing of asymptomatic contacts of suspected or confirmed cases. No chemoprophylaxis is available for contacts.

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Close contacts should be excluded from schools and sensitive occupations or settings such as health care, aged care or child care during the 14 days after last unprotected contact with a case.

Self-monitoringHealthcare workers and other contacts who have taken recommended infection control precautions, including the use of recommended PPE, while caring for a suspected or confirmed case of 2019-nCoV are not considered to be close contacts.

Healthcare workers should be advised to self-monitor however, and if they develop symptoms consistent with 2019-nCoV infection they should isolate themselves and notify the department so they can be tested and managed as a suspected case of 2019-nCoV.

Restrictions on travelClose contacts should not travel within Australia or internationally within the 14 days after last contact with the infectious case, unless there has been a discussion with the department to assess risk.

Casual contacts do not need to restrict their movement. However they should isolate themselves and contact the department if they develop symptoms in the 14 days after last contact with the infectious case.

In summary, the approach to casual contacts is to recommend self-monitoring for 14 days following the last contact.

Summary of recommended actions for close contactsThe department will recommend the following actions for close contacts. In most cases the department will provide advice to close contacts directly. The department may ask a health service infection control team to provide advice to close contacts who are employed in a health service, in some circumstances. The actions that will be recommended for close contacts are:

• Counselling about risk and symptoms to check for and provision of a factsheet;• Self-monitoring and isolation if symptoms develop and the person to notify the department on 1300

651 160;• Exclusion from schools and sensitive occupations or settings such as health care, aged care or child

care during the 14 days after last unprotected contact with a case;• Restriction on travel as above.

Summary of recommended actions for casual contactsThe department will advise casual contacts to self-monitor and if they develop symptoms consistent with 2019-nCoV infection they should isolate themselves and notify the department so they can be tested and managed as a suspected case of 2019-nCoV.

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Infection prevention and control

BackgroundInfection prevention and control recommendations are based on the World Health Organization (WHO) guideline Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: Interim guidance January 2020 (https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected)

Transmission-based precautions

Advice for suspected and confirmed casesIn line with advice from the World Health Organization and the United States Centers for Disease Control and Prevention advice, the department recommends Droplet and Contact Precautions for suspected cases and confirmed cases of 2019-nCoV infection. If available, Airborne Precautions can also be used.

This means that in addition to Standard Precautions, all individuals, including family members, visitors and healthcare workers (HCWs) should apply Droplet and Contact Precautions. Where available, Airborne Precautions can also be used. This includes the following PPE:

• Single-use surgical face mask (or P2 respirator (N95 mask) where available);• Eye protection (e.g. goggles or face shield);• Long-sleeved gown;• Gloves (non-sterile).

All PPE should be single-use and disposed of into clinical waste when removed.

For hand hygiene, use an alcohol-based hand rub if hands are visibly clean, soap and water when hands are visibly soiled.

Advice for undertaking aerosol generating proceduresAerosol generating procedures (AGPs) should be avoided where possible. When required, AGPs must be carried out in a negative pressure ventilation room using Airborne and Contact Precautions which include the following personal protective equipment (PPE):

• P2 respirator (N95 mask);• Eye protection (e.g. goggles or face shield);• Long-sleeved gown;• Gloves (non-sterile).An example list of AGPs is provided by WHO at https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected

Patient placementA standard single room (Class S) with doors closed is sufficient, although cases may be placed into a negative-pressure ventilation room (Class N), where available.

A dedicated toilet / commode should be considered if possible, ensuring lid is closed when flushed to reduce any risk of aerosolization.

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Suspected cases of 2019-nCoV infection may be cohorted together where single rooms are not available.

Maintain a record of all persons entering the patient’s room including all staff and visitors.

Case movement and transfersWhere possible, all procedures and investigations should be carried out in the case’s room, with exception of AGPs which should be performed in a negative pressure room whenever possible.

Transfers to other healthcare facilities should be avoided unless it is necessary for medical care.

When to cease isolationPatients should remain isolated until no longer infectious. This should be discussed with the department, but as an interim measure, this is likely to be until 24 hours after the resolution of symptoms.

Environmental management

SignageClear signage should be visible to alert healthcare workers of required precautions before entering the room, see https://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/infection-control-signage

Management of equipmentPreferably, all equipment should be either single-use or single-patient-use disposable. Reusable equipment should be dedicated for the use of the case until the end of their admission. If this is not possible, equipment must be cleaned and disinfected (see Environmental cleaning and disinfection below) prior to use on another patient.

Disposable crockery and cutlery may be useful in the patient’s room as far as possible to minimise the number of items that need to be decontaminated.

Environmental cleaning and disinfectionFor all routine and discharge cleaning, after cleaning with a neutral detergent use a chlorine-based disinfectant (e.g. sodium hypochlorite) at a minimum strength of 1000ppm, or another product with claims against coronaviruses. A one-step detergent/chlorine-based product may also be used. Ensure manufacturer’s instructions are followed for dilution and use.

Waste managementDispose of all waste as clinical waste. Clinical waste may be disposed of in the usual manner.

LinenBag linen inside the patient room. Ensure wet linen is double bagged and will not leak.

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Laboratory testing for 2019-nCoV

Approval for testingThe Victorian Infectious Diseases Reference Laboratory (VIDRL) will undertake testing for 2019-nCoV in Victorian patients. The department has determined that no testing should be requested of VIDRL for 2019-nCoV without prior notification to the department and unless there is approval for testing by the department. It is likely that cases meeting the suspected case definition will be approved for testing, however the department must be notified in order that an assessment can be made.

Specimens for testingThe following specimens are recommended to be sent to VIDRL when testing for 2019-nCoV:

1. Respiratory specimens for coronavirus PCR / 2019-nCoV PCR - nasopharyngeal and throat swab in ambulatory patients and sputum (if produced) and/or endotracheal aspirate or bronchoalveolar lavage AND

2. Blood (serum) for storage for serology at a later date.

Lower respiratory tract specimens are likely to contain the highest virus loads based on experience with SARS and MERS coronaviruses.

At the current time there is no serological test for 2019-nCoV and blood when received at VIDRL will be stored for future testing, when testing is available and if the case is confirmed as 2019-nCoV infection.

The department is continuously reviewing whether there is a requirement for other specimens such as stool or urine to be sent to VIDRL. At the current time this is not recommended in cases of respiratory illness.

Specimen collection and transportWhen collecting a nasopharyngeal or throat specimen and/or deep respiratory specimen(s):

Use Contact and Airborne Precautions, which means a P2 respirator (N95 mask), eye protection, gown and gloves.

Collect in a room with negative pressure if available.

There are no special requirements for transport of samples to VIDRL. They can be transported as routine diagnostic samples for testing (i.e. Biological substance, Category B).

Handling of specimens within diagnostic laboratoriesAll diagnostic laboratories should follow appropriate biosafety practices, and testing on clinical specimens, including for other respiratory viruses, should only be performed by adequately trained scientific staff.

Current advice from the World Health Organization is that respiratory samples for molecular testing should be handled at Biosafety Level 2 (BSL2), with the United States Centers for Disease Control recommending that the following procedures involving manipulation of potentially infected specimens are performed at BSL2 within a class II biosafety cabinet:

• Aliquoting and/or diluting specimens;• Inoculating bacterial or mycological culture media;• Performing diagnostic tests that do not involve propagation of viral agents in vitro or in vivo;

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• Nucleic acid extraction procedures involving potentially infected specimens;• Preparation and chemical- or heat-fixing of smears for microscopic analysis.

Summary of testing requirementsFor reference, Table 1 provides further information on the collection, storage and transport of specimens that are currently recommended and may be recommended in the future.

Table 1. Information about testing of specimens for 2019-nCoV

For transporting samples, recommended options include viral transport medium (VTM) containing antifungal and antibiotic supplements, or Liquid Amies medium which is commonly available. Avoid repeated freezing and thawing of specimens.

If testing for other respiratory viruses such as influenza is being performed, ensure that dedicated swabs for viral testing (e.g. Copan ESwabTM) are collected to be sent to VIDRL for 2019-nCoV testing.

Information on testing for coronavirus at VIDRLThere are currently two types of molecular (PCR) test available for 2019-nCoV at VIDRL:

1. Real-time Wuhan Coronavirus PCR assay The test takes approximately 1-2 hours to perform. Results reported as positive or negative for 2019-nCoV. E.g. 2019-nCoV not detected. This test will be performed twice a day at the current time.

2. Pan-coronavirus PCR assay Initial screening takes approximately 3-4 hours to perform, followed by sequencing which will

take a further 2-3 hours. Results are reported as positive or negative for Coronavirus. If positive, the coronavirus strain is

reported, e.g. Coronavirus detected; 2019n-CoV strain identified.

2019 Novel coronavirus (2019-nCoV): Guideline for health services and GPs – 23 January 2020 – V1 Page 13

This test will be performed once a day at the current time.

The current VIDRL testing algorithm is as follows:

All suspected cases will be tested by both a pan-coronavirus assay and a real-time assay as above.

Real time results will be available quickly and will represent the provisional laboratory report.o At the current time, VIDRL will run the real-time assay twice a day with a morning and

afternoon run with results released through routine pathways. Results of the pan-coronavirus assay will follow some hours later, representing a back-up to the

real time assay.o At the current time, VIDRL will run the pan-coronavirus assay daily with the results

available within 4-18 hours of specimen receipt. Urgent specimens can be tested outside of these periods in consultation with the department. Viral culture will be attempted from any positive sample under high containment, but such testing

is not a diagnostic modality. Serum samples will be stored.

As experience with testing develops this algorithm may change.

Exclusion of 2019-nCoV infection through testingA single negative test result, particularly if this is from an upper respiratory tract specimen, may not exclude infection. Repeat sampling and testing of lower respiratory specimens is strongly recommended in severe or progressive disease. A positive alternate pathogen does not necessarily rule out 2019-nCoV infection, and evidence may emerge relating to the possibility of co-infection with other respiratory pathogens.

Current recommendations for exclusion of 2019-nCoV infection:

A person who meets the definition of a suspected case can have 2019-nCoV excluded on the basis of a single negative respiratory specimen tested at VIDRL if, in consultation with the department and the treating clinician, it is agreed an alternative diagnosis is more likely or if the infection is mild and does not require hospitalisation;

Two negative respiratory specimens, preferably lower respiratory specimens, and where possible taken 24 hours apart, are preferable before a patient is excluded as having 2019-nCoV. This may be particularly important when a person is severely unwell requiring hospitalisation.

Commercial assays available in most primary laboratories are unlikely to detect 2019-nCoV, therefore negative coronavirus PCR results from primary laboratories cannot be used to exclude 2019-nCoV. Any suspected case must have samples sent urgently to VIDRL.

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Governance

International responseThe World Health Organization has considered whether novel coronavirus should be declared a Public Health Emergency of International Concern (PHEIC) under the International Health Regulations 2005. At 23 January 2020, WHO has not made such a declaration.

Department Incident Management TeamThe Department of Health and Human Services (the department, DHHS) has formed an Incident Management Team to coordinate the public health and sector response. The Infection Clinical Network of Safer Care Victoria will be a network that is requested to provide comment and advice to the department, alongside national committees including the Communicable Diseases Network Australia (CDNA).

Communications and mediaThe department will coordinate communications and media in relation to suspected and confirmed cases of 2019-nCoV. In some instances, the department may – in collaboration with a Victorian health service – request a service to provide media responses in relation to one of more cases associated with that service. A health service should contact the department’s Media Unit with any queries.

Role of Ambulance VictoriaAmbulance Victoria may be activated by the department to transport suspected cases of 2019-nCoV from a port of entry, general practice or other setting to an emergency department, as required. When transfer of a patient is required, the department’s Communicable Diseases Section (1300 651 160) will coordinate the transfer with Ambulance Victoria. Ambulance Victoria’s State Health Commander or delegate will liaise with the general practice or setting directly to coordinate the transport of the patient to the emergency department.

If the patient is extremely unwell and requires immediate critical care, a general practitioner should call 000 in the normal manner but advise that the patient may have suspected 2019-nCoV infection.

Prevention

Clinicians are recommended to provide prevention messages to patients planning travel to countries affected by 2019-nCoV, including:

• Follow advice on influenza vaccination before travelling;• Hand hygiene and cough etiquette and respiratory hygiene;• Adhere to good food safety practices;• Consider avoiding live animal markets;• Check for travel advice or restrictions on https://www.smarttraveller.gov.au

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Risk management at ports of entry

At the current time, the WHO has not recommended any travel or trade restrictions.

Infection with 2019-nCoV was designated a Listed Human Disease (LHD) under the Biosecurity Act 2015 on 21 January 2020. The current arrangements to detect and respond to a potential case at ports of entry in Victoria, primarily Melbourne Airport, are:

1. If anyone shows symptoms of an infectious disease while travelling to Australia the airline must report this to a Biosecurity Officer from the Department of Agriculture, before arrival in Australia.

2. Biosecurity Officers will meet ill travellers on the incoming flight/vessel and administer a Traveller with Illness Checklist (TIC) to determine if they are carrying a serious infectious disease.

3. The Traveller with Illness Checklist has been amended to identify travel to Wuhan City within 14 days, if a traveller has a fever, and for this to cause a referral to Victorian DHHS.

4. The Biosecurity Officer then contacts a Human Biosecurity Officer (HBO) at the department to determine if this is a suspected case of 2019-nCoV and agree whether transfer to a hospital for testing is required.

5. If a traveller meets the criteria for a suspected case, the HBO may then organise transfer to Royal Melbourne Hospital or Royal Children’s Hospital via ambulance.

There is currently no thermal screening at Australian ports of entry. Direct flights from Wuhan City, China, come in to Sydney in NSW. There are no direct flights to Victoria from Wuhan City, China.

The disease

Infectious agentThe 2019 novel coronavirus (2019-nCoV) has been confirmed as the causative agent. Coronaviruses are a large and diverse family of viruses that include viruses that are known to cause illness of variable severity in humans, including the common cold, severe acute respiratory syndrome (SARS-CoV), and Middle East Respiratory Syndrome (MERS-CoV). They are also found in animals such as camels and bats.

ReservoirThe reservoir is essentially unknown, but probably zoonotic, meaning they are likely transmitted between animals and people; however an animal reservoir has not yet been identified for 2019-nCoV.

Initial cases were business operators at the Hua Nan Seafood Wholesale Market, which sold live animals such as poultry, bats, marmots, and wildlife parts. The source of the outbreak is still under investigation in Wuhan. Preliminary investigations have identified environmental samples positive for 2019-nCoV in Hua Nan Seafood Wholesale Market in Wuhan City, however some laboratory-confirmed patients did not report visiting this market.

Mode of transmissionThe mode or modes of transmission of 2019-nCoV are not yet fully known, although based on the nature of other coronavirus infections, transmission is likely respiratory. There have been cases with a strong history of exposure to the Hua Nan Seafood Wholesale Market in Wuhan City, China where live animals are sold. The World Health Organization has confirmed that available evidence now indicates human to human transmission has occurred. Limited human to human transmission has been observed in

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healthcare facilities and among family members. China has reported at least 14 cases in healthcare workers. At this time there is no clear evidence of sustained transmission.

However, the mechanism by which transmission occurred in these cases, whether through respiratory secretions after coughing or sneezing, or direct physical contact with the patient or via fomites after contamination of the environment by the patient, is unknown.

As a result, Droplet and Contact Precautions are recommended. Where available, Airborne Precautions can be applied, depending on the local healthcare facility.

Incubation periodThe incubation period is not yet known. However, the interim view on the incubation period is that it is up to 14 days, based on the nature of previous coronavirus infections.

Infectious periodThe infectious period is not yet known. It is likely that a patient is infectious once symptomatic, until up to 24 hours after symptoms resolve. However this is not confirmed and the treating team may identify a more prolonged period of infectiousness in some cases. Infectiousness might be influenced by patient age, immune status or medications, however more information is required.

Clinical presentationCommon signs of infection include respiratory symptoms, fever, cough, shortness of breath and breathing difficulties. Sore throat and headache have been reported.

In more severe cases, it appears that infection can cause pneumonia, severe acute respiratory syndrome and kidney failure. In summary there appears to be evidence of mild cases, through to severe acute respiratory infection (SARI) cases.

Initial information suggests illness is more likely in the middle-aged and elderly.

As of 22 January 2020 there have been nine confirmed deaths, all reported from Wuhan. Of the five fatalities for which information is available, ages ranged from 48 to 89 years and four had underlying medical conditions. The case fatality rate is unknown, but appears to be lower than for SARS but higher than the common cold. The case fatality rate may be higher in elderly, people with immune compromise or who have co-morbidities.

Confirmed cases in Wuhan have occurred in people aged 15 years to 89 years of age, but overall there are limited reports of cases in children.

Information resources

The department will place resources for health professionals on a website located at https://www.dhhs.vic.gov.au/novelcoronavirus

It is important that health professionals consult this website regularly, as case definitions and content of this guideline are likely to change regularly in the early days of the international response to this outbreak.

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