Updated FAQ about Novel Coronavirus Infection
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Updated FAQ about Novel Coronavirus Infection
Updated February 17, 2020
1. What do we know so far?
2. Global Situation update
3. Hong Kong Situation update
4. What countries have imposed restrictions on travelers from Hong Kong?
5. How many cases ARE there?
6. What are the characteristics of the disease?
7. Who is at risk?
8. How is the disease spread?
9. Can it be spread through drainage pipes?
10. What about Cruise Ships?
11. What other events have led to transmission?
12. What is the chance of dying from COVID-19?
13. The WHO declared a PHEIC. What does this mean?
14. Is this now an epidemic? A pandemic? What is the difference?
15. What is the role of masks?
16. How does testing work?
17. Are there treatments? What about a vaccine?
18. How do you actually control an epidemic?
19. Why did they close the schools? What is social distancing?
20. How does quarantine work in Hong Kong?
21. The Seven habits of Highly Protected People
22. Where can I get reliable information? Managing the Infodemic
What do we know so far?
On 31 December 2019, the World Health Organisation was alerted to a cluster of 44 cases of
pneumonia in Wuhan City, Hubei Province of China. Shortly thereafter, Chinese authorities
confirmed that they had identified a new virus, from the coronavirus family, and temporarily
named it 2019-nCoV. The WHO has now named the virus SARS-CoV-2 and the disease it
causes as COVID-19.
Coronaviruses are a large family of viruses, some causing illness in people and others that
circulate among animals, including camels, cats and bats. Human coronaviruses cause
illnesses ranging from the common cold to more severe diseases including pneumonia.
Rarely, animal coronaviruses can evolve and infect people and then spread between people
such as has been seen with MERS (Middle East Respiratory Syndrome, thought to have
spread via camels) and SARS (Severe Acute Respiratory Syndrome, thought to have spread
via civet cats). Both viruses likely originated in bats. It is thought, but not yet confirmed, that
2019-nCoV may also have originated in bats, or possibly snakes, and then amplified in some
unknown intermediate animal. An intermediate host is needed because the bat-borne virus
lacks the necessary hardware to attach to human cells.There is recent, as yet unpublished data suggesting that the stepping stone was via
PANGOLINS. Pangolins are scaly long-snouted ant-eaters that are sold, controversially, for
their meat and scales. Their even greater use is in traditional Chinese medicine, in which
parts of the animal are used to treat ailments such as skin diseases, menstrual disorders and
arthritis.
On January 26, China banned wildlife markets until the coronavirus epidemic is over. There
is increasing pressure to enforce a permanent end to the trade of exotic animals.
In addition, some experts recommend compiling a watch list of all animals that could
potentially transmit viruses to humans.
Global Situation Update
The Chinese have now officially named the disease NCP, or Novel Coronavirus Pneumonia.
The WHO, however, calls it COVID-19 disease, to reflect the fact that not all cases result in
pneumonia.
The numbers have become increasingly hard to interpret, as cases are counted differently in
different places.
The WHO includes only laboratory-confirmed cases, and reports a total of 50,580
cases worldwide and 1524 deaths
China has now started reporting clinically-identified cases (without a positive
laboratory confirmation) and based on this, others report the total as more than
69,000 cases and 1669 deaths
The new counting method in China resulted in a large spike in cases during the week
of February 10th; however we don’t know if these are new cases, or retrospectively
determined cases
China counts only cases with pneumonia. It is impossible to know how many milder
or even asymptomatic cases there may be.
WHO includes Hong Kong, Taipei and Macao in their China numbers, resulting in
different numbers of exported cases (526 vs 610)
Regardless of how you count the cases, more than 99% of cases continue to be reported from
China, and more than 70% from Wuhan and Hubei province.
On February 7, the death of 34-year-old Wuhan doctor, Li Wenliang, who sounded the alarm
about the virus in December only to be punished, sparked an outpouring of grief and anger
over the government's handling of the crisis, and demands for greater freedom of press. The
Chinese law prohibiting giving out information on an epidemic was also an issue in the 2003
SARS outbreak. There is growing pressure on the Chinese central government to change this
law.
WHO numbers dashboard:
http://who.maps.arcgis.com/apps/opsdashboard/index.html#/c88e37cfc43b4ed3baf977d77e4a
0667
Hong Kong Centre for Health Protection numbers dashboard:
https://chp-dashboard.geodata.gov.hk/nia/en.htmlJohns Hopkins CSSE dashboard: https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd402994234 67b48e9ecf6 The Coronavirus App: https://coronavirus.app/ Hong Kong Situation Update As of February 16, 2020, Hong Kong has reported 57 confirmed cases of novel Coronavirus infection and one death. Of the cases in Hong Kong, 13 are imported, 26 are close contacts of known cases, but 18 are locally, or possibly locally acquired, with no known epidemiological links. This does suggest that some limited community transmission is occurring; however the numbers are increasing only slowly. Control mechanisms, so far, seem to be working. By way of comparison, Singapore has reported 72 confirmed cases, including several cases that may have been transmitted locally. Thailand has reported 33cases and Japan 43 cases plus 285 cases on a cruise ship docked in Yokahama. Hong Kong has now effectively closed its borders with China, by imposing a 14 day mandatory quarantine for anyone arriving from the Mainland. It is hoped that this will slow the spread enough to contain any community outbreak. Hong Kong has also enacted strict and very proactive social distancing measures, such as closing the schools and asking civil servants and many others to work from home. These measures, implemented even in the absence of a significant local outbreak, are designed to avert a possible epidemic. Singapore has also closed its borders to all foreign travelers from mainland China, as has Australia, New Zealand, the US, India, the Maldives and others. What countries have imposed restrictions on travelers from Hong Kong? Some countries have also imposed some sort of restriction on travelers from Hong Kong. Currently these include: Taiwan The Philippines Bangladesh Kiribati Kuwait Marshall Islands Mauritius Micronesia Mongolia North Korea (they’ve closed their borders to all tourists) Palau
Samoa
The Seychelles
Tonga
Vanuatu
The exact nature of these restrictions varies and the situation is constantly changing. It’s best
to check before planning travel.
How many cases ARE there?
The true number of cases affected by the virus remains a matter of speculation. Modelling by
scientists at Imperial College London suggests that there are many more cases than reported,
As of January 31, they estimated that there were 140,000 or more cases in Wuhan city alone.
The uncertainty over numbers is related to differences in what constitutes a case, and
difficulties in finding and counting milder cases. China counts only pneumonia cases; other
places have detected patients with milder disease. If there are many mild or minimally
symptomatic cases, then the count is likely far higher than reported, but the average severity
is likely lower. Some of the cases detected outside of China have had only minimal
symptoms and have recovered quickly, suggesting that the spectrum of disease can vary from
mild to severe.
What are the characteristics of the disease?
2019-nCoV appears to cause mild to severe respiratory illness with symptoms including:
Fever (83%)
Malaise
Dry cough (82%)
Difficulty breathing
Pneumonia in both lungs (75%) or one lung (25%) on chest X-ray
Diarrhea (3-6%)
A preliminary study out of China looking at 1099 patients admitted with Novel Coronavirus
Pneumonia found the following:
1. The median incubation period was 3 days, with a range of 0 to 24 days
2. Only 44% had fever at presentation, although 88% developed it later
3. Cough occurred in 70%
4. Diarrhea (3.7%) and vomiting (5%) were less common
5. The median time from symptom onset to pneumonia was 4 days
6. 5% needed ICU
7. 1.4% died
8. When they included data from Guangdong province (603 cases) where effective
prevention had been undertaken, the death rate dropped to 0.88%
These percentages are based on Chinese numbers, which only count cases of pneumonia. The
full clinical picture of 2019-nCoV is still not completely clear. It is thought that about 20% of
pneumonia cases are severe, but again, this is based on incomplete and possibly skewed data.
The incubation period is estimated to be between 1 and 14 days, with an average of 3 days.
The estimated range will likely be narrowed as more data become available.Who is at risk?
It appears that anyone can get the disease. Cases have been found in all age-groups, from
newborn to very elderly. However, it is increasingly apparent that the risk of developing
severe disease is higher in:
The elderly – those over 60, and especially those over 80
Those with underlying health problems, especially cardiovascular disease or diabetes
Men account for 2/3 of severe cases
Although case numbers are too small for certainty, it appears that pregnant women and
children are not at high risk for severe disease.
How is the disease spread?
Transmission is thought to be by respiratory droplets. That means it is spread by sick people
coughing or sneezing out the virus in droplets which can be breathed in by another person, or
can settle on objects (known as “fomites” in med-speak). It is thought that diseases spread by
droplet transmission may also be transmitted by people touching contaminated fomites and
then touching their eyes, nose or mouth. This is why hand-washing is so important.
It is not known for sure how long the virus can persist on surfaces; currently it’s thought to be
a few hours.
The disease is thought to be spread mainly be sick, symptomatic patients. Asymptomatic
transmission has, however, been reported. It is not clear how common this is; the WHO has
stated that it is likely to be rare.
A small case study showed no virus in breastmilk.
Currently the R0, or average number of people infected by a single sick person, is estimated
to be between 2 and 4, higher than for seasonal flu and SARS. The massive control measures
underway are designed to try to reduce the R0 to less than 1, so that the disease stops
spreading.
Can it be spread through drainage pipes?
There is some preliminary evidence that the virus may also be spread by the fecal-oral route.
During the SARS outbreak in 2003, there was a superspreading event at a housing estate in
Hong Kong called Amoy Gardens. Over 300 people were infected via defective bathroom
drainage pipes that allowed the aerosolization of virus from diarrhea (sorry to be graphic!).
So when 4 people from the same block of a housing estate in Tsing Yi were confirmed to
have been infected with SARS-CoV-2, there were fears that the same thing was happening in
2020. The affected block was rapidly evacuated , all the residents tested (fortunately
negatively), and the drainage system investigated. A blocked ventilation pipe was found in
the toilet of one of the cases; it is not at all clear if any transmission occurred as a result, as
the other 3 cases in the building might have been infected at a hotpot dinner they all attended.
Nonetheless, good maintenance of drainage pipes is recommended.What about Cruise Ships?
There is a large outbreak on a cruise ship called the Diamond Princess, currently docked off
Yokohama, Japan. 285 cases out of 3700 passengers have tested positive and the rest are
confined to their rooms on the ship in quarantine. The ship was en route from Singapore to
Yokahama, when an elderly passenger who disembarked in Hong Kong was diagnosed with
COVID—19. If this cruise ship were a country, it would have the largest outbreak outside of
China. Some countries, including Hong Kong, are making arrangements to repatriate their
citizens currently trapped on board.
Several other episodes have all turned out to be false alarms:
The MS Westerdam left Hong Kong on Feb 1, 2020 and was meant to disembark in
Shanghai. The ship attempted to change itinerary but was denied docking in Japan,
then Manila, Taiwan, Guam , Malaysia and Thailand before finally being allowed to
dock in Sianhoukville in Cambodia even though no cases were on board.
Subsequently, an 83 year old American woman who disembarked tested positive for
Coronavirus in Malaysia.
World Dream Cruise docked at Kai Tak was quarantined after 3 previous passengers
had tested positive on a previous cruise. The infected cases were on board Jan 19-
24; a a new cruise set sail on Feb 2, and on Feb 4th was denied docking in Kaohsiung,
Taiwan. The ship then came to Hong Kong on Feb 5 and all 3700 passengers were
tested. No cases were found and all the passengers were released
The Royal Caribbean (Anthem of the Seas) was quarantined in New Jersey for several
days because 4 passengers had flu-like symptoms and were feared to have
coronavirus infection. It was eventually released when all passengers tested
negative.
Hong Kong has closed both cruise terminals since Feb 6th, 2020.
Cruise ships may pose a special hazard because of the close mixing of people from many
countries, often including many elderly higher risk people. talked over the food.
What other events have led to transmission?
There have been several “cluster” events leading to the infection of many people. These
include
Business networking events and conferences– 20 cases in 6 countries were traced to
a business conference in Singapore. 15 cases in Germany and Spain were linked to a
conference in Bavaria
Family hotpot dinners – Two clusters in Hong Kong
Church services – Two clusters in Singapore have been linked to church services
Cruise ships – as aboveIt has also been speculated that eating at buffets is a risk factor. At al buffet, people may socialise and talk while taking food, allowing invisible and visible droplets of saliva to travel onto food and utensils. Buffet food can be also be left out for up to 4 hours so that many people may have lingered over the food before you. Some risk-management people have noted that there have NOT been spreading events on airplanes, and wondered if the meal arrangements may be the reason. What is the chance of dying of COVID-19? The case fatality rate of 2019 nCoV is the topic of some debate and uncertainty. Just looking at the official numbers, the death rate is approximately 2%. Many experts feel this is an overestimate, as it is likely that there are a great many more mild cases than have been reported. In addition, in cases outside of Hubei province, the death rate appears to be much lower. There have been only 4 deaths outside of China, out of nearly 600 cases. This would imply a case fatality rate well under 1%. Preliminary modelling data put the death rate at around 1%, as did a recent case series report from China. More data is needed before an accurate assessment can confidently be made. It is always the case, that the case fatality rate cannot be fully understood until the epidemic is over. Is this now an epidemic? A pandemic? What is the difference? An epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area. Outbreak carries the same definition as epidemic, but is often used for a more limited geographic area. A pandemic refers to an epidemic that has spread globally, usually affecting a large number of people. HIV/AIDS is an example of a pandemic, one of the most destructive ones in history. The Spanish influenza in 1918-1919 is another. The latter is estimated to have killed 50 million people worldwide. By contrast, the emergence of Ebola Fever Disease in West Africa in 2016 was an outbreak that became an epidemic, but never turned into a pandemic. 2019-nCoV started as an outbreak in Wuhan, but would now qualify as an epidemic. As global cases are still limited, it does not yet constitute a pandemic. The public health measures being taken are designed to try to prevent it from becoming one. The WHO declared a PHEIC. What does this mean? The WHO declares a PHEIC (pronounced “fake”), or Public Health Emergency of International Concern when there is an extraordinary event that is determined to constitute a public health risk globally through the international spread of disease and to potentially require a coordinated international response. A key consideration in declaring a PHEIC is whether the disease threat is dire enough to risk countries enacting travel and trade restrictions, with potentially very serious economic consequences. Since the tool was developed in 2007, the WHO has only declared a PHEIC 5 times, once for Swine Flu in 2009, once for polio resurgence in 2014, twice for Ebola and once for Zika virus. Although initially the WHO declined to declare 2019-nCoV a PHEIC, on January 30 they changed their mind due to increased international transmission and some cases of person-to- person spread outside of China. This is meant to help mobilize international response, and in
particular to help protect countries with weaker healthcare systems. The WHO may
recommend travel restrictions, but has not done so in this case. Many countries, including the
US, Singapore, Australia and Japan have made their own decision to close their borders with
China.
What is the role of masks?
Public health officials in Hong Kong have recommended that people wear a surgical mask
when taking public transport, when in crowded places or when sick themselves. This is
reasonable advice, but masks have become quite difficult to obtain. Should you be worried if
you don’t have access to face masks? How important are they?
The answer is, not very. Most people wear masks incorrectly, often contaminating themselves
when putting them on or taking them off, touching their face due to the discomfort they
cause, taking them off to eat, or by re-using them.
Masks are most important for sick people, to prevent them spreading their viral droplets
around when they cough or sneeze. They also can be important for healthcare professionals
who have close contact with sick people; in this case special virus-filtering masks (N95
masks) may be recommended. For healthy people, their role is less clear. They likely make
sense in highly infected areas such as Wuhan itself, where the chance of coming in contact
with a coronavirus patient is quite high. In Hong Kong, this likelihood is low at present, and
face masks have less of a role.
In all cases, other measures are far more important, in particular hand-washing. Try to avoid
touching your face and practice hand hygiene frequently. If you do wear a mask, make sure
to wash your hands before putting it on and after taking it off, and pay attention to how often
you touch your face.
The following information on correct use of medical masks derives from the practices in
health-care settings:
1. place mask carefully to cover mouth and nose and tie
securely to minimise any gaps between the face and the
mask;
2. while in use, avoid touching the mask;
3. remove the mask by using appropriate technique (i.e. do not touch the front but
remove the lace from behind);
4. after removal or whenever you inadvertently touch a used mask, clean hands by using
an alcohol-based handrub or soap and water if visibly soiled
5. replace masks with a new clean, dry mask as soon as they become damp/humid;
6. do not re-use single-use masks; discard single-use masks after each use and dispose of
them immediately upon removal.How does testing for Coronavirus work? Testing for 2019nCoV infection involves taking a swab from the nose or mouth and looking for the DNA of the virus (PCR testing). In Hong Kong, testing can only be done by the government virology lab, and, as of this week, by all the government hospital cluster laboratories. The test takes about 3 hours to run, but usually takes longer as it is run in batches. Private hospitals and doctors’ offices cannot do the test. Patients who may have been exposed, or who are suspected cases, must go through the public hospital system. Are there treatments? What about a vaccine? There are no definitive treatments for novel Coronavirus infection. Treatment is largely supportive, involving provision of intravenous fluids, antibiotics, inhalers, oxygen and close monitoring. Severe cases may require mechanical ventilation or ECMO (Extracorporeal Membrane Oxygenation). ECMO is a technique of providing prolonged heart and lung support to persons whose own are unable to provide an adequate amount of gas exchange or perfusion to sustain life. Chinese hospitals have been treating coronavirus patients with HIV drugs -- an oral two-pill combination of antiretroviral drugs called Kaletra. These drugs target an enzyme called protease which is found in coronaviruses as well as in the HIV virus. When protease is disrupted, the virus has difficulty reproducing itself. These treatments do look promising, although not curative. Studies are underway. Standard antiviral drugs such as Tamiflu do not work. Some other medications like Ribavirin and Interferon may have limited effect. Another antiviral drug, Remdesivir, is showing promise. This drug was developed initially as a treatment for Ebola virus and Marburg virus disease, but has shown some effect in other coronavirus infections such as MERS-CoV. Trials are underway. Several candidate vaccines are in development including one in Hong Kong. However, even if development is expedited, these vaccines are months to a year away at a minimum and are therefore unlikely to be the answer to controlling the epidemic. How do you actually control an epidemic? It’s all about getting the R0 – the number of people infected by a single sick person, down below 1. Once this happens, the disease will die out. To do this, human-to-human transmission must be curbed. The main strategies for doing this are isolation, quarantine, contact tracing and social distancing. Isolation is used to separate ill persons from those who are healthy. Patients who are sick with coronavirus infection will be isolated in hospital and separated from other patients. Hong Kong greatly expanded its isolation capacity after SARS, and currently all confirmed cases are isolated in special units.
Quarantine is used to separate and restrict the movement of well persons who may have
been exposed to a communicable disease to see if they become ill. These people may have
been exposed to the disease and do not know it, or they may have the disease but do not show
symptoms. Currently, close contacts of novel coronavirus cases are being quarantined in
several holiday centres around Hong Kong.
Contact tracing is defined as the identification and follow-up of persons who may have
come into contact with an infected person. The department of health is diligent in this regard;
contacts of Coronavirus cases are being followed up and quarantined.
Why did they close the schools? What is social distancing?
Social distancing is a public health safety intervention used to reduce the likelihood of
transmitting communicable disease. Social distancing involves minimizing exposure to
infected individuals by avoiding large public gathering venues, and by following proper
personal hygiene practices.
Closing the schools was done pre-emptively, as part of a social distancing strategy. During
the SARS epidemic in 2003, the government was criticized for not closing schools quickly
enough. That critique certainly can’t be levied this time, as the schools have been closed even
in the absence of a local outbreak.
Cancelling mass gatherings and closing workplaces are other examples of social distancing.
We have all been affected by event cancellations and many people are now working from
home. It is all not very much fun, but worth it in the end if it averts an epidemic.
What we can say for now is that so far the public health measures being taken seem to have
worked. We have not had a huge number of cases. Time will tell and hindsight will be 20/20.
How does quarantine work in Hong Kong?
Since February 8th, Hong Kong has required anyone entering Hong Kong from mainland
China, regardless of whether they are a Hong Kong resident or not, to be quarantined for 14
days.
Some people ARE exempted, for example:
cross-boundary goods vehicle drivers and necessary accompanying personnel;
cross-boundary coach and shuttle drivers and necessary crew members;
air crew disembarking from planes at Hong Kong International Airport and
entering Hong Kong;
crew members of aircrafts of air freight operators who need to commute to and
from the Mainland for performance of necessary duties related to freight
forwarding;
government officials carrying out governmental duties;
government agents and contractors supporting the operation of cross-boundary
functions;
crew members of goods vessels; and
crew members of fishing vessels and fish collectors (including mainland
fishermen deckhands).They are subject to medical surveillance
How quarantine works
Hong Kong residents are mainly confined to their own homes
Non-residents must stay at booked centres or in government-run centres,
which include Lady MacLehose Holiday Village (full), Lei Yue Mun Holiday
site, Po Leung Kuk Jockey Club, and soon Pak Tam Chung Holiday Camp, as
well as in Sai Kung Outdoor Recreation Centre.
300 mobile units are being built, and other sites are being looked for
There is a fine ($25000) and 6 month prison sentence for non-compliance
Quarantine is also required for asymptomatic close contacts of known cases
Electronic wristbands are being used to monitor some people
Quarantine is monitored by visits from Centre for Health Protection staff,
contact by phone, twice daily temperature checks and daily symptom records
There is also a 24 hour hotline for people under quarantine
Known or Suspected cases of COVID-19 are ISOLATED in hospital
Asymptomatic close contacts of known or suspected cases and asymptomatic visitors or
HK residents returning from mainland China are QUARANTINED – either at home or
in a quarantine centre.
The Seven Habits of Highly Protected People
1. Avoid crowded places and close contact with people who are unwell
2. Frequently wash hands with soap and water for at least 20 seconds (the time taken to
sing “happy birthday” twice). Use alcohol hand-rub when soap and water is not
available.
3. Wear a mask if you have respiratory symptoms or if you need to be in a crowded
place. Make sure to wash your hands before putting a mask on and after taking it off.
4. Cover your mouth and nose with tissue or your flexed elbow when coughing or
sneezing and dispose of the tissue immediately afterwards.
5. Avoid visiting live animal markets and the consumption of raw or undercooked meat.
6. Observe good personal hygiene and learn to avoid touching your face
7. Seek medical attention promptly if you are unwell. Make sure to share your travel
history with your healthcare provider
Simple things prevent infection, if we are consistent and vigilant about applying them.
Good Sources of Information
There is a great deal of information circulating online, not all of it good. The WHO has called
it an Infodemic, and has launched a concerted attempt to counter the false information and
rumours that are circulating, via a number of social media platforms including (including
Weibo, Twitter, Facebook, Instagram, LinkedIn, Pinterest) and their website.
https://www.who.inthttps://www.facebook.com/WHO/ https://twitter.com/WHO https://www.weibo.com/whoinchina?is_hot=1 https://www.instagram.com/WHO/ https://www.linkedin.com/company/world-health-organization/ https://www.pinterest.ch/worldhealthorganization/ Other good sources: Hong Kong Centre for Health Protection https://www.chp.gov.hk/en/features/102465.html Public Health England https://www.gov.uk/government/publications/wuhan-novel-coronavirus-background- information/wuhan-novel-coronavirus-epidemiology-virology-and-clinical-features Centers for Disease Control (CDC) US: https://www.cdc.gov/coronavirus/2019-nCoV/index.html The New York Times, The Washington Post and The Boston Globe have deep experience in health reporting
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