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COVID-19

2019-nCoV Acute Respiratory Disease

Coronaviruses form a large family of viruses that may cause respiratory infections ranging from a mild cold to severe pneumonia. According to the World Health Organization (WHO), a new type of coronavirus, which had never been detected in humans before, was identified in the Chinese city of Wuhan on January 7, 2020. It has provisionally been named 2019-nCoV and rapidly spread to at least two dozen countries on different continents. By now, it accounts for >78,800 cases of illness and >2,400 fatalities (as of February 23, 2020).


Presentation

2019-nCoV has been described as the causative agent of respiratory infections of varying severity. To cover the entire spectrum of disease courses, the term coronavirus disease 19 (COVID-19) has been coined. More severe infections of the lungs are referred to as Severe Specific Contagious Pneumonia (SSCP) [1].

Fever above 39 °C, fatigue, and dry cough have been named as the most common symptoms in COVID-19 patients and are displayed by 60-100% of affected individuals [2] [3] [4]. Minor shares of patients present with dyspnea, productive cough, hemoptysis, myalgia, headache, sore throat, and rhinorrhea. Chest pain, abdominal pain, nausea, vomiting, and diarrhea have occasionally been observed. Interestingly, confusion can be noted in about 1 in 10 patients [2]. Whereas mild infections may be self-limiting with a few days [5], the illness may evolve over a week or longer and give rise to severe disease with acute respiratory distress syndrome and septic shock. These patients are worsening rapidly and at high risk of death from multiorgan failure.

Diagnostic imaging is likely to show inflammatory changes in the lower respiratory tract that allow for the diagnosis of pneumonia, with bilateral findings being very common [3] [4]. Ground-glass and consolidative opacities are frequently observed, while lung cavitation, discrete pulmonary nodules, pleural effusions, and lymphadenopathy are not characteristic of COVID-19 [6]. Of note, the absence of pathological findings on chest images does not rule out an infection with 2019-nCoV.

Neutrophilia and lymphopenia have been found in about a third of COVID-19 patients [2] [4].

Fever
  • Early symptoms of fever and cough are clinically indistinguishable from the usual winter suspects, such as influenza, while fever is an undifferentiated sign, common to hundreds of noninfective diseases from allergies to arthritis.[foreignpolicy.com]
  • Respiratory symptoms with fever can have a range of causes, and depending on your personal travel history and circumstances, 2019-nCoV could be one of them.[who.int]
  • After a 14-day incubation period, Duque said a person infected with coronavirus will experience cough, fever, headaches and body malaise.[onenews.ph]
  • Wuhan Coronavirus Symptom Fever The definition of fever is an elevation in body temperature or a high body temperature.[medicinenet.com]
  • Clinical criteria Fever or history of fever ( 38oC) and acute respiratory infection (sudden onset of respiratory infection with at least one of: shortness of breath, cough or sore throat).[sahealth.sa.gov.au]
Fatigue
  • The deceased Li Moumou, male, 66 years old, was admitted to the hospital for "intermittent cough, headache, fatigue and fever for 6 days" on January 16, 2020; dyspnea occurred on January 17, and multiple organs appeared at 10:35 on January 20 Functional[flutrackers.com]
  • Common symptoms at the onset of illness included fever (98% of cases), cough (76%), myalgia or fatigue (44%). Less common symptoms that were recorded included sputum production (28%), headache (8%), hemoptysis (5%) and diarrhea (3%).[contagionlive.com]
  • Fever above 39 C, fatigue, and dry cough have been named as the most common symptoms in COVID-19 patients and are displayed by 60-100% of affected individuals.[symptoma.com]
  • The most common symptoms reported as of January 2020 include: Fever Breathing difficulties such as breathlessness Cough Sore throat Fatigue or tiredness While there have been some deaths reported and some cases have been severe, the early indications[betterhealth.vic.gov.au]
Malaise
  • Symptoms are non-specific: fever myalgia malaise non-productive cough pleuritic pain dyspnea Laboratory tests The most common findings in a study of 138 hospitalized patients were 13: lymphopenia increased prothrombin time (PT) increased lactate dehydrogenase[radiopaedia.org]
  • After a 14-day incubation period, Duque said a person infected with coronavirus will experience cough, fever, headaches and body malaise.[onenews.ph]
Collapse
  • A man accused of imitating a coronavirus victim by collapsing on a subway train in central Moscow this month was arrested and will face up to five years in prison if found guilty, law enforcement officials have said.[nytimes.com]
  • The measures have been taken in the wake of a tourism collapse in both locations.[moodiedavittreport.com]
Vietnamese
  • Vietnamese authorities have locked down a commune of 10,000 people after six cases of the COVID-19 coronavirus were discovered there. It's the first mass quarantine outside of China since the virus first emerged from Wuhan.[youtube.com]
Cough
  • Infection control measures such as hand-washing and cough etiquette (cover coughs with disposable tissues or clothing) are therefore very important to help prevent new cases. April 2003.[msf.org]
  • […] parts of China, including Macau and Hong Kong, in the last 14 days and have a cough, high temperature or shortness of breath (even if it's mild) to Thailand, Japan, Taiwan, Singapore, Republic of Korea or Malaysia in the last 14 days and have a cough[nhs.uk]
  • Teach kids to use good “cough etiquette,” which can be tricky with little kids. But the perennial “cover your cough” and “sneeze into your elbow” are important. Try to avoid play dates when kids are sick or have kids stay home when they are sick.[med.ubc.ca]
  • Covering your mouth and nose when coughing and sneezing prevent the spread of germs and viruses. If you sneeze or cough into your hands, you may contaminate objects or people that you touch.[who.int]
  • […] or sneezing); Wear a mask if you have respiratory symptoms such as a cough or runny nose; Cover your mouth with a tissue paper when coughing or sneezing, and dispose the soiled tissue paper in the rubbish bin immediately; and Seek medical attention promptly[moh.gov.sg]
Dyspnea
  • The deceased Yin Moumou, female, 48 years old, became ill on December 10, 2019, developed dyspnea on December 27, and was transferred to Wuhan Jinyintan Hospital for treatment on December 31.[flutrackers.com]
  • Symptoms are non-specific: fever myalgia malaise non-productive cough pleuritic pain dyspnea Laboratory tests The most common findings in a study of 138 hospitalized patients were 13: lymphopenia increased prothrombin time (PT) increased lactate dehydrogenase[radiopaedia.org]
  • February 7 study published on JAMA found that the median time from first symptom to dyspnea was 5.0 days, to hospital admission was 7.0 days, and to ARDS was 8.0 days.[9] Previously. the China National Health Commission reported the details of the first[worldometers.info]
  • Minor shares of patients present with dyspnea, productive cough, hemoptysis, myalgia, headache, sore throat, and rhinorrhea. Chest pain, abdominal pain, nausea, vomiting, and diarrhea have occasionally been observed.[symptoma.com]
  • Common symptoms of SARS included fever, cough, dyspnea, and occasionally watery diarrhea.2 Of infected patients, 20% to 30% required mechanical ventilation and 10% died, with higher fatality rates in older patients and those with medical comorbidities[jamanetwork.com]
Productive Cough
  • The following day, a fever of 39.1 C (102.4 F) developed, along with a productive cough. By the evening of the next day, he started feeling better and went back to work on January 27. Figure 1. Figure 1.[nejm.org]
  • Symptoms are non-specific: fever myalgia malaise non-productive cough pleuritic pain dyspnea Laboratory tests The most common findings in a study of 138 hospitalized patients were 13: lymphopenia increased prothrombin time (PT) increased lactate dehydrogenase[radiopaedia.org]
  • Productive cough (a cough that produces phlegm) and headache are infrequent, hemoptysis (coughing up blood) and diarrhea occasional. It can take about a week before an infected person feels sick enough to seek medical care.[foreignpolicy.com]
  • Minor shares of patients present with dyspnea, productive cough, hemoptysis, myalgia, headache, sore throat, and rhinorrhea. Chest pain, abdominal pain, nausea, vomiting, and diarrhea have occasionally been observed.[symptoma.com]
Hemoptysis
  • Less common symptoms that were recorded included sputum production (28%), headache (8%), hemoptysis (5%) and diarrhea (3%). Dyspnoea developed in 55% of patients (median time for illness onset to dysponea 8.0 days [IQR: 5-13]).[contagionlive.com]
  • Productive cough (a cough that produces phlegm) and headache are infrequent, hemoptysis (coughing up blood) and diarrhea occasional. It can take about a week before an infected person feels sick enough to seek medical care.[foreignpolicy.com]
  • Minor shares of patients present with dyspnea, productive cough, hemoptysis, myalgia, headache, sore throat, and rhinorrhea. Chest pain, abdominal pain, nausea, vomiting, and diarrhea have occasionally been observed.[symptoma.com]
  • […] hypertension (15%), and/or cardiovascular disease (15%) median duration from first symptoms to hospital admission 7 days clinical features included fever in 98% cough in 76% dyspnea in 55% myalgia or fatigue in 44% sputum production in 28% headache in 8% hemoptysis[dynamed.com]
Sputum Production
  • Less common symptoms that were recorded included sputum production (28%), headache (8%), hemoptysis (5%) and diarrhea (3%). Dyspnoea developed in 55% of patients (median time for illness onset to dysponea 8.0 days [IQR: 5-13]).[contagionlive.com]
  • production in 28% headache in 8% hemoptysis in 5% diarrhea in 3% bilateral multiple lobular and subsegmental areas of consolidation were common findings on chest computed tomography laboratory testing revealed lymphopenia (lymphocyte count 1 109 cells[dynamed.com]
Diarrhea
  • Lingad Memorial General Hospital due to diarrhea and abdominal discomfort. Both tested negative for the 2019-nCoV and will be sent back to New Clark City to complete the 14-day quarantine period.[doh.gov.ph]
  • Less common symptoms that were recorded included sputum production (28%), headache (8%), hemoptysis (5%) and diarrhea (3%). Dyspnoea developed in 55% of patients (median time for illness onset to dysponea 8.0 days [IQR: 5-13]).[contagionlive.com]
  • Some patients have had vomiting, diarrhea, and similar stomach symptoms. The most severe cases have caused pneumonia, severe acute respiratory syndrome, kidney failure, and death.[onhealth.com]
  • Transmitted by human-to-human contact, it is characterized by the following flu-like symptoms: fever, headache, diarrhea, shivering, dry cough, and shortness of breath. The virus is believed to have come from bats and spread to other animals.[rappler.com]
  • Productive cough (a cough that produces phlegm) and headache are infrequent, hemoptysis (coughing up blood) and diarrhea occasional. It can take about a week before an infected person feels sick enough to seek medical care.[foreignpolicy.com]
Hiccup
  • And the ability of technology companies in Silicon Valley and elsewhere to deliver popular consumer goods such as TVs, cellphones and computers to their customers is likely to suffer hiccups.[marketwatch.com]
Intestinal Disease
  • These viruses are responsible for pulmonary, hepatic, CNS and intestinal disease. The natural animal host of SARS-CoV-2 remains undetermined 11.[radiopaedia.org]
Myalgia
  • Common symptoms at the onset of illness included fever (98% of cases), cough (76%), myalgia or fatigue (44%). Less common symptoms that were recorded included sputum production (28%), headache (8%), hemoptysis (5%) and diarrhea (3%).[contagionlive.com]
  • A 33-year-old otherwise healthy German businessman (Patient 1) became ill with a sore throat, chills, and myalgias on January 24, 2020. The following day, a fever of 39.1 C (102.4 F) developed, along with a productive cough.[nejm.org]
  • Symptoms are non-specific: fever myalgia malaise non-productive cough pleuritic pain dyspnea Laboratory tests The most common findings in a study of 138 hospitalized patients were 13: lymphopenia increased prothrombin time (PT) increased lactate dehydrogenase[radiopaedia.org]
  • Initial symptoms are fever, dry cough, myalgia (muscle pain), and fatigue. Productive cough (a cough that produces phlegm) and headache are infrequent, hemoptysis (coughing up blood) and diarrhea occasional.[foreignpolicy.com]
  • Minor shares of patients present with dyspnea, productive cough, hemoptysis, myalgia, headache, sore throat, and rhinorrhea. Chest pain, abdominal pain, nausea, vomiting, and diarrhea have occasionally been observed.[symptoma.com]
Headache
  • The deceased Li Moumou, male, 66 years old, was admitted to the hospital for "intermittent cough, headache, fatigue and fever for 6 days" on January 16, 2020; dyspnea occurred on January 17, and multiple organs appeared at 10:35 on January 20 Functional[flutrackers.com]
  • Affected people may experience: fever flu like symptoms such as coughing, sore throat and headaches difficulty breathing How you can help prevent novel coronavirus Everyone should practise hygiene and other measures to protect against infections.[health.gov.au]
  • Less common symptoms that were recorded included sputum production (28%), headache (8%), hemoptysis (5%) and diarrhea (3%). Dyspnoea developed in 55% of patients (median time for illness onset to dysponea 8.0 days [IQR: 5-13]).[contagionlive.com]
Forgetful
  • Medical expenses may be high in the event that you become sick or injured and require a visit to the hospital whilst in Japan so please do not forget to take out the necessary travel insurance.[japan.travel]
  • The Effect on Behavior and Real-World Decision Making When people say that the official figure is an underestimate, they forget this: the official figure isn’t an estimate for the true number of cases.[towardsdatascience.com]
  • [Source: Global Times] Let us never, never forget the human cost of this crisis. He Hui, a 54-year-old volunteer in Wuhan, died yesterday because of the novel coronavirus infection.[moodiedavittreport.com]
Neglect
  • Hindi namin kayo papabayaan (We will not neglect you) ," he said.[news.abs-cbn.com]
  • Xi and his government have banned the free flow of information and that officials neglected their responsibilities as the outbreak worsened. Mr.[nytimes.com]
  • Immunoinformatics addresses vaccine design for neglected tropical and emerging infectious diseases. Expert Rev.[frontiersin.org]

Workup

Precise criteria on whom to test for COVID-19 have been published by the WHO and the US American Centers for Disease Control and Prevention (CDC). They differ slightly and are prone to change as new data on the presence of 2019-nCoV outside the Hubei province, China, and possible routes of transmission become available [7] [8]. Beyond that, the WHO has prepared interim guidance for the laboratory diagnosis of 2019-nCoV infections and provides a list of institutions that may be contacted to this end [9]. They developed a series of genetic amplification assays, specifically real-time RT-PCR protocols, to confirm the presence of 2019-nCoV in respiratory samples [10] [11]. Nasopharyngeal and oropharyngeal swabs may be used as well as sputum, endotracheal aspirate or bronchoalveolar lavage. No recommendations have yet been given as to the preference of upper or lower respiratory specimens for virus detection in mild cases, although the use of lower respiratory material is strongly encouraged in severe and progressive disease.

Additionally, paired serum samples may be obtained from patients suspicious for 2019-nCoV infection [9]. They should be collected during the first week of illness as well as 2-3 weeks later and may allow for a more reliable diagnosis of mild infections once serological assays become available.

Of note, testing for 2019-nCoV should be carried out regardless of whether a conventional respiratory pathogen is found. Little is known about the prevalence of coinfections among COVID-19 patients and the presence of other pathogens does not rule out an infection with 2019-nCoV [9].

Any suspected and confirmed cases must immediately be reported to the relevant public health authorities. The same applies if unexpected results are obtained. In this context, it shall be emphasized that validation is still in progress for all test protocols published so far.

Treatment

No specific treatment directed against the causative agent is currently available. COVID-19 patients have been administered antivirals like oseltamivir, ganciclovir, lopinavir, and ritonavir, both intravenously and orally [2], but data regarding the efficacy of such measures are not yet available. Experiences from prior outbreaks of coronavirus-induced respiratory diseases are rather discouraging: No antiviral agents have been found to provide benefit for treating the Severe Acute Respiratory Syndrome (SARS) and the Middle East Respiratory Syndrome (MERS) [4].

Notwithstanding, patients benefit from meticulous supportive care and the treatment of comorbidities [2] [4]:

Oxygen therapy is most commonly applied to improve lung function; mechanical ventilation and extracorporeal membrane oxygenation may become necessary.
Broad-spectrum antibiotics and possibly antimycotics are administered to prevent and manage coinfections.
Corticosteroids have been applied. They may reduce pulmonary inflammation and prevent respiratory failure, but also affect many other physiological and pathological processes.
Furthermore, any deterioration in organ function, such as acute kidney injury, requires urgent attention and targeted measures.

Prognosis

Clinical and epidemiological data gathered to date suggest a higher risk of severe disease in the elderly, particularly in those with comorbidities [4]. The mortality rate of SSCP is currently estimated at 2-5% [1], but the overall share of SSCP in COVID-19 remains to be determined.

With regard to any patient's individual prognosis, Chen et al. stated that the characteristics of those who experienced poor outcomes were in line with the MuLBSTA score, an early warning model for predicting mortality in viral pneumonia [2]. This model considers the presence of multilobular infiltrates, low lymphocyte counts, bacterial coinfections, a personal history of smoking, hypertension, and advanced age as unfavorable prognostic factors [12].

Etiology

Lu and colleagues realized an in-depth characterization of 2019-nCoV and provided the full-length genome sequence of the pathogen [13]. According to their phylogenetic analyses, 2019-nCoV belongs to the genus of betacoronaviruses and the subgenus of sarbecoviruses. Another well-known sarbecovirus is SARS-CoV, which caused the pandemic of SARS between 2002 and 2004. Owing to their relatively close relationship, SARS-CoV-2 has been proposed by the Coronavirus Study Group of the International Committee on Taxonomy of Viruses as a more appropriate designation for the pathogen causing COVID-19 [14].

Interestingly, 2019-nCoV has been found to be even more closely related to two bat-derived SARS-like coronaviruses than to the causative agent of SARS [13]. Are we thus talking about a zoonotic disease? COVID-19 has, in fact, been described as a potential zoonosis [1], but an Italian-Brazilian study on the virus' evolution suggests the existence of an intermediate carrier: Benvenuto et al. have proposed that the virus has initially been harbored by bats but been transmitted to another, as-of-yet unknown animal species before infecting men [15]. Presumably, an animal sold at the seafood market in Wuhan, China, served as an intermediate host facilitating the emergence of the virus in humans [13]. Parallels can be drawn to prior coronavirus outbreaks, namely the aforementioned pandemic of SARS and the outbreak of MERS that started in 2012. Bats have been identified as the natural reservoir for both SARS-CoV and MERS-CoV, while other animals, namely the masked palm civet and dromedary camels, acted as intermediate hosts [16] [17].

Epidemiology

While nCoV-2019 emerged in the Chinese metropole Wuhan, travelers rapidly carried the virus across the country and beyond its borders, triggering secondary chains of transmission in a wider geographical area. On January 13, 2020, Thai authorities confirmed the first case outside China. To date, cases of COVID-19 had been reported from 28 countries in the Western Pacific Region including Australia, in South East Asia, the Eastern Mediterranean, Europe, and North America [18]. On February 14, 2020, 2019-nCoV has been confirmed in Africa. More than 78,811 people have fallen ill by now, and >2,400 patients succumbed to the disease, according to the Situation Report published by the WHO on February 23, 2020.

Even though cases registered outside China account less than 3% of the total number reported to date, public health services all over the world are preparing intensively for possible local outbreaks of the disease. Affected patients must promptly be identified to prevent any further spread of the disease. In this context, experts are most concerned with the low level or even lack of reports from moderate and high-risk countries with weaker health-care systems, such as those in South East Asia and Africa. This is in contrast to many epidemiologist's expectations, which are based on distinct prediction models for the spread of infectious diseases [19]. It is too soon to say whether the countries in question remain truly free of 2019-nCoV, if infected people have recovered before they were detected, or if the pathogen is indeed spreading under the radar. A coordinated international response is required to address this situation and to diminish the public health risk posed by 2019-nCoV, which is why the WHO declared the outbreak a public health emergency of international concern on January 30, 2020 [20].

Sex distribution
Age distribution

Pathophysiology

Transmission occurs from person to person, through droplets or by physical contact between two individuals [1]. Fomites may play a role in COVID-19 spread, too [18]. The incubation period may be as short as two days or extend over two weeks, and the possibility that the virus may be transmitted to others before symptoms develop should seriously be considered. While the infection from an asymptomatic contact has been reported in Germany, the respective case study was updated when new information became available that invalidated the original conclusions [5]. Thus, to date, there is no evidence that patients are contagious before presenting any symptoms. It is also not known for how long the virus may be spread by someone who has recovered from their illness.

Prevention

In order to prevent COVID-19, the basic principles to reduce the risk of contracting and transmitting acute respiratory infections apply. These principles include regular handwashing with soap, especially after direct contact with ill people or their environment, and the avoidance of close contact with those showing symptoms of respiratory disease. On the other side, people suffering from respiratory symptoms are encouraged to maintain their distance, to cover coughs and sneezes, and to take their personal hygiene seriously. Medical assistance should be sought early in the case of fever, cough, and possible exposure to 2019-nCoV. Unprotected contact with farm and wild animals should generally be minimized. In healthcare settings, infection prevention and control practices should be applied strictly and be enhanced where necessary.

On a larger scale, distinct measures can be taken to reduce the likelihood of pathogen emergence. Live animal markets, such as the seafood market in Wuhan, provide a perfect breeding ground for new infectious diseases: There's close contact between animals and humans and an extensive interchange of genetic material between viruses harbored by either species. These conditions largely increase the probability of human infection and eventual human-to-human transmission, which are two of the prerequisites for pandemics. That is why such animal markets have been subjected to harsh but well-founded criticism for years. It does not at all help the issue that the illicit trade with wild, possibly endangered animals is flourishing in those markets.

Summary

COVID-19 is an emergent infectious disease caused by coronavirus 2019-nCoV. This pathogen was first identified in the Chinese Hubei province and has subsequently been shown to originate from a live-animal market in the city of Wuhan. While the majority of infections is still registered in the province of Hubei, the disease rapidly spread throughout China and subsequently reached other countries on most continents. The WHO has assessed the current outbreak as a worldwide public health risk and declared it a Public Health Emergency of International Concern.

As of today, vaccines against COVID-19 are not available. Intense efforts are made by scientists in distinct countries to change that situation, but vaccines are not expected to be available in at least one more year. This increases the importance of strong measures to detect COVID-19 early, isolate and treat cases, trace contacts, and promote social distancing measures commensurate with the risk. According to the current appraisal of the WHO, it is still possible to interrupt virus spread if a global coordinated effort is made to this end and solidarity is demonstrated with other regions of the world that may need additional support [20].

Patient Information

Much commotion has arisen over the emergence of 2019-nCoV, a new coronavirus causing mild to severe respiratory infections in China and many other countries all over the world. While public health services are preparing for possible local outbreaks, calls for calm are reaching the general population. Indeed, the best people can do is to take simple preventive measures, such as avoiding close contact with anyone showing symptoms of respiratory illness, to seek medical advice in case of flu-like symptoms, and to provide information to health care workers to the best of their knowledge.

The disease caused by 2019-nCoV is commonly named COVID-19, as in "coronavirus disease 19". Symptoms typically develop within 2-14 days after exposure and include fever, fatigue, and cough. Some patients may also experience muscle aches, headaches, a sore throat or runny nose. While mild infections usually improve within a few days, COVID-19 may follow a severe course and lead to pneumonia, shock, and eventually death.

Because COVID-19 cannot be distinguished clinically from other causes of pneumonia, it is of utmost importance that patients provide precise information on recent travels, hospital stays, and close contact with anyone who may have been exposed. The patient's cooperation is key to counter the COVID-19 outbreak, to shorten the time until diagnosis and measures that prevent the exposure of others. If someone is identified as suspicious for COVID-19, they can be isolated, tested accordingly, and receive supportive care as needed.

References

Article

  1. Wu YC, Chen CS, Chan YJ. Overview of The 2019 Novel Coronavirus (2019-nCoV): The Pathogen of Severe Specific Contagious Pneumonia (SSCP). J Chin Med Assoc. 2020.
  2. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020.
  3. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020.
  4. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. Jama. 2020.
  5. Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. N Engl J Med. 2020.
  6. Chung M, Bernheim A, Mei X, et al. CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV). Radiology. 2020:200230.
  7. Centers for Disease Control and Prevention. Evaluating and Reporting Persons Under Investigation (PUI). https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html. Accessed February 14, 2020.
  8. World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed February 14, 2020.
  9. World Health Organization. Coronavirus disease (COVID-19) technical guidance: Laboratory testing for 2019-nCoV in humans. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/laboratory-guidance. Accessed February 14, 2020.
  10. Corman VM, Landt O, Kaiser M, et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill. 2020; 25(3).
  11. Centers for Disease Control and Prevention. CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel: Instructions for Use. 2020.
  12. Guo L, Wei D, Zhang X, et al. Clinical Features Predicting Mortality Risk in Patients With Viral Pneumonia: The MuLBSTA Score. Front Microbiol. 2019; 10:2752.
  13. Lu R, Zhao X, Li J, et al. Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet. 2020.
  14. Gorbalenya AE, Baker SC, Baric RS, et al. Severe acute respiratory syndrome-related coronavirus: The species and its viruses – a statement of the Coronavirus Study Group. bioRxiv. 2020:2020.2002.2007.937862.
  15. Benvenuto D, Giovannetti M, Ciccozzi A, Spoto S, Angeletti S, Ciccozzi M. The 2019-new coronavirus epidemic: evidence for virus evolution. bioRxiv. 2020:2020.2001.2024.915157.
  16. Mohd HA, Al-Tawfiq JA, Memish ZA. Middle East Respiratory Syndrome Coronavirus (MERS-CoV) origin and animal reservoir. Virol J. 2016; 13:87.
  17. Shi Z, Hu Z. A review of studies on animal reservoirs of the SARS coronavirus. Virus Res. 2008; 133(1):74-87.
  18. World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report – 34
  19. Mallapaty S. Scientists fear coronavirus spread in countries least able to contain it Nature. 2020.
  20. World Health Organization. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV). https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov). Accessed February 14, 2020.

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Last updated: 2020-02-24 08:06