Coronavirus or COVID-19 Droplet Precautions
Coronavirus, or more specifically 2019 novel coronavirus (2019-nCoV), is a beta coronavirus that rapidly developed into an epidemic centered in China. The World Health Organization (WHO) officially named the virus COVID-19. Coronaviruses are zoonotic viruses commonly found in bats, rabbits, camels, and even pangolins. The coronavirus is an enveloped RNA virus, and the “corona” in its name is due to its appearance under electron microscopy. The ring or crown of protein spikes on the envelope of the virus gives it the distinctive features. Coronavirus infection is of an important health concern in humans and causes the common cold as well as other respiratory infections causing respiratory illnesses. Some important prior variants of the novel coronavirus include those causing severe acute respiratory syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS), which is less genetically similar to COVID-19 than SARS is. SARS-CoV has not been seen since 2014, while cases of MERS-CoV still occur and cause health problems.
2019-nCoV likely made its jump from animal to human infection in a seafood market in Wuhan, China. Similar to past outbreaks, COVID-19 was first an animal disease that then found its way to become a human respiratory infection. The exact animal that the virus originated from is an of yet unknown. One theory is that the virus may have come from the pangolin. These animals have large scales and look like an anteater, and an armadillo had a cute armored baby. Pangolins are illegally trafficked in China and throughout Asia, where the scales and meat are consumed. One study found that pangolins carry a coronavirus with genetic makeup dramatically similar to the 2019-nCoV. After initial transmission to a human host or hosts, 2019-nCoV rapidly began human to human transmission. This is similar to what was seen when SARS-CoV emerged in the early 2000s, and on the spectrum of likely of infection versus the chance of death, COVID-19 is a respiratory disease with rates similar to those seen with SARS.
Infection with novel coronavirus may result in no symptoms, nausea, and diarrhea, or respiratory illness may develop with severity ranging from cold-like symptoms to pneumonia, acute respiratory distress syndrome, sepsis, and death. The most common findings are fever, fatigue, myalgias, dyspnea, and dry cough. Mortality of over 4% has been documented. Death occurs with the progression from pneumonia to multiorgan dysfunction and acute respiratory distress syndrome.
Coronavirus Outbreak Climbs
The spread of COVID-19 occurs from person to person via droplet contact with an infected person sneezing or coughing near a noninfected individual. These respiratory droplets contain and spread the virus person to person. Infection control experts have not yet determined if the spread can also occur form simply touching contaminated objects and then contacting one’s face near the nose, mouth, and eyes, but this is very likely. Personal protective equipment in the forms of face masks can help reduce exposure to the droplets containing the virus as can eye shields. As the outbreak climbs, it will be increasingly important to protect oneself from droplets, avoid hand to hand contact with infected persons, and practice good hand hygiene. In addition, early testing and containment can prevent the spread. The Centers for Disease Control and Prevention (CDC) is the only organization in the United States with the ability to test for coronavirus. Recently the CDC has made its test available to state agencies to increase the speed of diagnosis. Preventing the continued climb of the outbreak requires diligent testing and containment as well as vigilant infection control efforts.
Reported cases of respiratory illness and infection caused by this virus have passed 45,000 worldwide, with 1,115 reported deaths. These numbers exceed the prior coronavirus outbreaks of SARS and MERS by significant numbers. It is very likely that the number of cases and deaths is much higher. One only needs to look at recent unrest in Hong Kong to see the suppression and censorship tactics at play in China to realize that China is likely manipulating the actual case numbers reported. The death toll from COVID-19 has already surpassed that of the 2003 SARS outbreak. While SARS had a death rate of around 10%, COVID-19 appears to be lower in the 2-4% range. If a 2-4% mortality rate seems minor and not that deadly to you, compare it to the 1918 Spanish flu that killed more people than the first world war and had a 2.5% mortality rate.
How contagious and how fast the virus might spread is unclear, but infectious disease experts from the WHO and other organizations have expressed that what we see now is just the beginning. A global pandemic is possible, and an outbreak on that scale would change the world. We have yet to reach a tipping point, and already the number of deaths and confirmed cases have surpassed both SARS and MERS. The WHO has not named COVID-19 a pandemic yet, but with 24 countries involved and “secondary spread” or the spread to people who have not traveled to the epidemic zone are all indicating it is only a matter of time before coronavirus becomes a pandemic. Recall that a pandemic is not about severity or cases or death rates, but rather, it is about how many regions the disease has appeared and expanded in.
Infection Prevention and Control Strategies
Protecting yourself and your patients from the spread of nCoV are important. In the hospital setting in China, the nosocomial spread has been as high as 41%. This rate suggests that health care facilities may well become the point at which we stop COVID-19 or the place we tip into a dangerous global pandemic. Three keys to preventing the spread of coronaviruses are good handwashing with soap and water, the use of alcohol gel, and droplet precautions.
Some of the most effective ways to prevent infection and control the spread in clinical practice are frequent, correct hand washing, gowns, gloves, facemasks, and use of patient isolation. When washing hands use soap and water for at least 20 seconds or alcohol hand gels with 60% alcohol, jewelry must be removed when washing to have a maximum decontamination effect, and using a hand brush while washing can improve effectiveness. Fomites in the form of pens, stethoscopes, white coats, cellphones, and other “traveling” objects are areas to focus on control and prevention efforts. Liberal use of alcohol sprays and gels are very important. One habit that should occur before and after removing gloves or contact with a patient or the patient environment is hand washing. Poor infection control habits can be one of the hardest behaviors to changs because they become engrained. Wash your hands, protect your eyes, nose, and mouth, and minimize the spread through objects and the environment.
Implement Droplet and Contact Precautions
There are three types of precautions used to prevent the spread of disease-causing microorganisms. These include contact, droplet, and airborne precautions, all of which are important in preventing the spread of respiratory illness. With the SARS outbreak, they proved effective in curbing the spread of the SARS-CoV.
Contact precautions as they sound are about preventing contact with objects, surfaces, or patients contaminated with an infectious agent and contact with the agent itself. Transmission, both directly and indirectly, can be prevented with contact precautions. The use of gowns and gloves are central in contact precautions. Droplet precautions are directed at preventing spread and infection when a patient sneezes or coughs. Droplets are large water droplets in the air that travel up to 3 feet and contain the infectious organism. For example, infectious agents that spread by droplet transmission include gram-negative bacteria that cause meningitis Neisseria meningitides, mumps virus, influenza, pertussis. Airborne precautions are directed and reducing or preventing the spread of small particles that remain suspended in the air or attached to dust particles. Some common agents spread via airborne routes include measles, chickenpox, and tuberculosis.
The media is constantly showing images of people wearing a variety of surgical and dust masks, but in reality, the use of masks by healthy people is not recommended. Surgical masks to prevent droplet transmission should be worn only by patients that are sick. Droplet and airborne precautions are not the same, nor are the masks used in infection control programs for these the same. It is unclear if COVID-19 can spread via the airborne route or only the droplet route. Simple surgical mask are adequate for droplets but airborne agents require special masks or respirators.
Why do we see doctors in Wuhan hospitals wearing gowns, gloves, face shields, and N95 masks? Because those together are the most cautious approach short of biohazard suits. Should a widespread US outbreak occur, I guarantee you will see something similar in our healthcare facilities, and in fact, this is the CDC recommendation for health care personnel. Everyone should wash their hands before they eat, touch their eyes, mouth or nose, and, of course, after the bathroom, but skip the surgical mask or the dental mask. If you do wear a paper mask in the community like the three people I saw last night in the supermarket you should consider using an airborne precautions mask or NIOSH N95 grade mask. It is likely a global shortage will develop for these and we can expect to see a fake N95 masks for sale.
Suspected Novel Coronavirus COVID-19 Infection
In the United States at present, the current CDC guideline is for anyone with a fever and symptoms of lower respiratory illness such as cough or dyspnea (shortness of breath) with close contact with a confirmed case or travel to China with the prior 14 days be tested. Fever is either subjective or measured. Close contact occurs if you have been within 6 feet of someone infected for a prolonged period without proper personal protective equipment, PPE, including N95 mask, or had unprotected direct contact with secretions from an infected person or were coughed on while not wearing full PPE.
To diagnose COVID-19, the collection of several specimens is recommended. The specimens that should be collected for patients suspected of COVID-19 or 2019-nCoV infection include both the upper respiratory tract and lower respiratory tract specimens. This means both nasal and oropharyngeal swabs, as well as sputum samples along with blood serum. These samples are shipped on ice to the CDC for testing and analysis to determine the presence of infection. The CDC performs real-time reverse transcription-polymerase chain reaction (rRT-PCR) assay on the samples to detect the presence of COVID-19 as the cause of a respiratory infection. This is the same testing using to detect SARS-CoV and MERS-CoV infected persons.
The coming weeks will indicate if we have reached a pandemic with this infection and what the global impact this coronavirus, known by an evolving list of names (COVID-19, novel coronavirus, 2019-nCoV), will truly have. For now, hand hygiene, vigilance, isolation, quarantine, and supportive care remain out best options. Novel retro-viral and vaccines hold promise but are many months away at the earliest and maybe too late to reverse the devastating global impact that might just have started with a trafficked pangolin.