Coronavirus update

The CDC is significantly concerned about the spread of the virus. It issued “Interim Guidance for EMS Systems and 911 Public Safety Answering Points for 2019-nCoV in the United States”. The number of people infected with the virus doubles every six days. The initial mortality of 2019-nCoV is thought to be lower than its cousins SARS-CoV (10%) and MERS-CoV (35%). However, in one patient series in-hospital mortality was 14.4%. The number of males infected who become ill is twice that of females. It is thought that the X chromosome and sex hormones strengthen innate and adaptive immunity. People who are most likely to die are described by the acronym MuLBSTA; multi-lobular infiltration, lymphopenia, bacterial co-infection, smoking history, hypertension and age. Sadly, the Chinese physician who initially raised the alarm and was jailed, died of the infection at the age of 37. It is suggested that the virus acts mainly on lymphocytes, particularly T lymphocytes. The virus particles spread through the respiratory mucosa, infect other cells then cause a cytokine storm and a variety of other immune responses. Patients can develop Acute Respiratory Distress Syndrome (ARDS), septic shock (bacterial coinfection with highly resistant species like Acitenobacter baumannii makes this more likely), and multiple organ failure. Clearly, early identification and treatment are crucial.

Dispatch considerations

Modified caller queries should be based on input from municipalities, state and local public health departments, the EMS Medical Director, and information from the CDC. The purpose of the queries is to determine the likelihood the patient has signs, symptoms, and risk factors for 2019-nCoV. People who have the clinical features of fever or signs of lower respiratory illness (cough or shortness of breath) and have had a history of travel to the Hubei Province in China within 14 days of symptom onset are defined as a Person Under Investigation (PUI). Any person with these signs and symptoms (including healthcare workers) who has had close contact with a laboratory confirmed 2019-nCoV infected patient within 14 days of symptom onset are also deemed a PUI. EMS clinicians should be informed prior to arrival at the scene to allow ample time for the use of appropriate PPE. More details are available at https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html. When responding to US international airports or other points of entry, a knowledge of the CDC Quarantine Station Contact is essential. The CDC’s Emergency Operations Center is available at 770-488-7100 to help identify the appropriate Quarantine Station.

Patient handling considerations

When EMS providers are informed a patient meets PUI criteria, appropriate PPE should be used. PPE includes: disposable examination gloves (which should be changed if contaminated), disposable isolation gown, respiratory protection (N-95 or higher level respirator) and eye protection (goggles or disposable face shield fully covering the front and sides of the face).  Drivers who help move patients onto stretchers should also wear PPE. If the driver’s compartment is isolated, the driver should remove PPE, dispose it, and perform hand hygiene. If the driver’s compartment is not isolated the driver should remove and properly dispose the PPE with the exception of the respirator, which should continue to be used.  Personnel must avoid touching their faces while working. Procedures should be in place for advance notification of the receiving facility and for keeping the patient away from other people. Procedures that involve aerosolization are especially risky. Check with medical control for specific guidance. Ventilation equipment should be equipped with HEPA filtration to filter expired air. Check with the maker of your ventilators to confirm appropriate filtration capability and the effect of filtration on positive pressure ventilation.

General consideration

There are general guidelines for transporting these patients, documenting their care and cleaning vehicles. They are extensive and can be found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html. The dynamics of this virus change so rapidly that updates are necessary and found at https://wwwcdc.gov/coronavirus/2019-ncov/index.html. Additional information for healthcare workers can be found https://www.cdc.gov/coronavirus/2019-nCoV/guidance-hcp.html.

Healthcare worker potential exposure

Personnel with high or medium exposure should be monitored for 2019-nCov until 14 days after the last exposure. Asymptomatic healthcare workers should also be excluded from work for 14 days after the last exposure. A healthcare provider (HCP) with unprotected eyes, nose or mouth who performs or was present in the room during a procedure that increases the concentration of respiratory secretions or aerosols experienced a high level exposure. Examples of such procedures include: cardiopulmonary resuscitation, intubation, extubation, and nebulizer therapy. Medium exposures occur if gowns and gloves are not used during these procedures. An HCP with unprotected eyes, nose or mouth who is in close contact with a patient not wearing a face mask sustains a medium exposure. Not wearing gloves and coming into direct contact with the secretions or excretions of a patient also provides a medium risk. How many personnel can be excluded from work for 14 days before our ability to serve our patients is jeopardized? More details are found at https://www.cdc.gov/coronavirus/2019-nCoV/guidance-hcp.html

Summary

The World Health Organization is currently meeting to find a name other than 2019-nCoV. The new name will not be associated with a particular country, geographic area or population. This is important because this virus creates a global risk. As responsible healthcare providers, we must protect ourselves, patients, families, and the general public. We won't be truly prepared unless we use all the information available, including updates.

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References:

• https://www.cdc.gov/coronavirus/2019-nCoV/guidance-hcp.html Accessed February 7, 2020
• Hui DS, Azhar E, et al The continuing 2019-nCov epidemic threat of novel coronaviruses to global health-the latest 2019 novel coronavirus outbreak in Wuhan, China. International Journal of Infectious Diseases 2020; 91: 264-266.
• Cohen J, New coronavirus threat galvanizes scientists. Science 2020; 367: 492-3.