Recently an outbreak of a novel coronavirus, or nCoV, has been reported in the People’s Republic of China, in the city of Wuhan and surrounding region. It has spread quickly in that country, where it’s infected more than 4,000 so far, and to at least 15 other countries, including cases in the U.S.
nCoV is believed to have started in wild animal food markets in the district, similar to what we saw with SARS. This virus made the leap from animal to human, and transmission is now possible through human-to-human contact. Initially it was believed the virus was only contagious after a patient showed symptoms, but Chinese authorities recently reported patients may be able to transmit the disease in the 2–3-day period before showing symptoms.
Coronaviruses include a variety of presentations from the common cold up to more severe respiratory afflictions like Middle East Respiratory Syndrome (MERS) and SARS (severe acute respiratory syndrome). The nCoV outbreak has come with severe symptoms that have often included fever, chills, and body aches and often progressed to pneumonia, mimicking what we saw with SARS and MERS.
A public health alert and screening processes have been instituted for the United States, in particular at the airports in New York City, Los Angeles, and San Francisco. Recently China instituted a travel ban for Wuhan and the surrounding region, but with travel by residents ahead of the Chinese New Year, the length of time for incubation (10–14 days), and the sheer volume of people who live in the region, the reality of achieving containment is difficult. Screening efforts at ports of entry are utilizing the SARS model that was fairly effective back in 2003, but the first case of nCoV reported in the U.S. was described in Washington, where currently there is no screening at any ports of entry.
A patient infected with nCoV may present to EMS with mild, moderate, or severe illness. The latter may include severe pneumonia, ARDS, sepsis, and septic shock. Initial symptoms may include fever, cough, sore throat, nasal congestion, headache, muscle pain or malaise, shortness of breath, pneumonia, and potentially signs of sepsis or septic shock. The absence of fever does not exclude viral infection.
The World Health Organization’s clinical management recommendations for nCoV suggest a high index of suspicion when we see patients with acute respiratory infection and a history of fever or measured temperature of 100.4ºF (or 38ºC) or more and cough; onset around the last 10–14 days; and who appear to require hospitalization.
If we see a patient with severe ARI with a history of fever and cough and they appear as if they require admission to hospital and they have any of the following, their signs and symptoms may suggest exposure to nCoV:
A history of travel to Wuhan or China’s Hubei province in the 14 days prior to symptom onset;
They’re a healthcare worker who has been working in an environment where patients with severe acute respiratory infections are being cared for, regardless of place of residence or history of travel;
They develop an unusual or unexpected clinical course, especially sudden deterioration regardless of place of residence or history of travel;
Close physical contact with a confirmed case of nCoV infection while that patient was symptomatic; or
They’ve been in a healthcare facility in a country where hospital-associated nCoV infections have been reported.
There are a variety of methods to assess temperature in the prehospital environment. Use what works best for your organization (disposable chemical thermometers, oral electronic, tympanic, etc.), but whatever your device of choice, record temperatures in the PCR for all patients in whom a reading is obtained.
Standard precautions and respiratory hygiene rule the day. Coronaviruses are spread by familiar means: coughing and sneezing; close personal contact, such as touching or shaking hands; and touching a surface with the virus on it, then touching your mouth, nose, or eyes before washing your hands.
With that in mind, the precautions to utilize aren’t complicated. If you have a patient with signs and symptoms of cold or flu or if they are suffering from general malaise (weakness, body aches, etc.), it is important to emphasize the basics:
Wear gloves (and wash hands immediately after removal of gloves with alcohol-based cleaner or soap and water for at least 20 seconds);
Wear respiratory protection (N95 or P100);
Wear eye protection;
Place a mask on the patient (this does not have to be an N95 or a P100 mask and may be a surgical mask);
Remember to take their temperature.
Notify the receiving hospital if the patient reports a history of travel to Wuhan or Hubei in the 14 days prior to symptom onset. Check with ED staff before offloading to see where they want the patient placed.
EMS providers: Before removing respiratory protection, remove your gloves; clean your hands with an alcohol-based cleaner or soap and water for at least 20 seconds; then remove respiratory protection. Remember to wash your hands again after removing the gloves. Follow the same process for the removal of your eye protection.
Clean all surfaces and patient care equipment (monitors, cables, BP cuffs, stethoscopes, etc.) with a disinfectant designed to kill the coronavirus. A 1:10 solution of bleach will work if you are unsure.
The HHS Assistant Secretary for Preparedness and Response has developed an EMS playbook to help manage these types of incidents. It recommends that during the caller interrogation, if information about communicable diseases is offered, make sure the information is documented and relayed to the EMS units assigned to the incident in a manner consistent with your dispatch guidelines. Develop caller interrogation scripts in conjunction with public health agencies and incorporate them into dispatchers’ screening to ensure uniformity and consistency.
There is no vaccine or specific treatment for this outbreak of nCoV. Hospital treatment focuses on treating the presenting symptoms. Prehospital care includes fever management (cooling, acetaminophen, etc.), IV therapy, maintaining the airway, and adequate oxygenation.
Coronavirus presents EMS agencies with a variety of unique challenges. Outreach and education are critically important to maintain public confidence. Personnel should maintain standard precautions. The most important lesson is that we need to improve our preparedness for these types of incidents in the future.
Daniel R. Gerard, MS, RN, NRP, is EMS coordinator for the city of Oakland, Calif. He is a recognized expert in EMS system delivery and design, EMS/health-service integration, and service delivery models for out-of-hospital care.