It seems like only yesterday that we had the last scare about a virus coming from the East, but it was actually back in 2003 that SARS hit the headlines.
An abbreviation for severe acute respiratory syndrome it came from the Guangdong province in China and there were 774 deaths worldwide out of 8,098 cases.1,2 MERS (Middle East respiratory syndrome) got less publicity but caused 858 deaths between 2012 and 2019.3 Both of these clinical syndromes were due to a coronavirus and we’ve now been hit with another one – Public Health England (PHE) has given it the slightly less catchy title of 2019-nCoV (novel coronavirus).
Originating from Wuhan City, in the Hubei province of China, it was first suspected on December 31st 2019 when a cluster of pneumonia diagnoses was noted, after which it took two weeks for the virus to be sequenced. By the beginning of February there had been 11,801 cases and 259 deaths officially reported in China, a mortality rate of around 2%4. At the time of writing there have been two cases in the UK. (UPDATE: a third case was confirmed as of 6th February)
2019-nCoV presents with typical symptoms of a respiratory tract infection such as a runny nose, general malaise, sore throat cough and temperature.4,6 Most patients will have upper respiratory tract symptoms but those with pre-existing cardiorespiratory conditions are more likely to have symptoms in the lower respiratory tract6 and those who are immunocompromised might present in an atypical way.
This coronavirus is classified as an airborne high consequence infectious disease (HCID)7 because it is very infectious and has a high fatality rate. HCIDs can spread easily within the community and healthcare settings, are difficult to recognise, and may not have effective prophylaxis or treatment.8 It is therefore important that we recognise a patient who may be at risk of 2019-nCoV so that they can be isolated (if encountered in the surgery) or signposted to the correct place (if they are calling from home), reducing the risk of spread to members of the public. The key reference for those wanting to update themselves on any changes to guidance is PHE’s interim guidance for primary care9, which is regularly updated; the principles of the guidance are outlined in the box below.
Principles of primary care management of a suspected case of 2019-nCoV9
- Identify possible cases as soon as possible
- Prevent transmission to other patients and staff
- Avoid direct physical contact
- Isolate the patient
- Obtain specialist advice
- Inform the local health protection team
Practices should be thinking about how to implement this so that there isn’t panic when the first possible case comes through the door. The first thing is to know which patients should make you concerned about 2019-nCoV. We know that an estimated 42% of UK adults are ‘unable to understand or make use of everyday health information’10 and so we can probably expect calls from people concerned about coronavirus who can simply be reassured. GP social media groups have already reported calls from patients who are concerned because they spent time with a friend from Japan or recently had a Chinese take away!
The PHE criteria are straightforward – the patient has to meet both epidemiological and clinical criteria as given in the box below.
PHE criteria for a possible case of 2019-nCoV11
1. Epidemiological criteria
- In the 14 days before the onset of illness the patient must have either:
- Travelled to China, Hong Kong, Japan, Macau, Malaysia, Republic of Korea, Singapore, Taiwan, or Thailand
- Had contact with a confirmed case of 2019-nCoV. A contact is defined as someone who is living in the same household or has been within two metres of the case. Within the healthcare setting, a contact is further defined as someone who has direct contact with the case or their bodily fluids or laboratory specimens or has been in the same room when an aerosol generating procedure has been carried out.
2. Clinical criteria
- Severe acute respiratory infection needing admission to hospital with clinical or radiological evidence of pneumonia or
- Acute respiratory infection of any degree of severity which includes at least one of fever, shortness of breath or cough or
- Fever with no other symptoms
This information was last updated on the PHE website on 6th February
It is much easier to manage a suspected case if the patient is on the phone, rather than in your surgery. This is one time when I am pleased that our practice moved to full phone triage a few years ago! The key thing to remember is that 2019-nCoV is not something that we should be attempting to diagnose or manage in primary care and that we should be staying as far away from the patient as possible. The government, other medical organisations and various media outlets often think that GPs are ‘best placed’ to do lots of things including help our patients to get a new boiler12 and sort out climate change13 so it makes a refreshing change to see that coronavirus is something that is firmly not primary care’s problem to deal with. These patients need to be in the big building up the road with the fancy machines, not in your surgery.
Members of the public who manage to find PHE’s online advice will be told to ring 111 if in England, Wales or Scotland or to ring their GP in Northern Ireland, but GPs in any part of the UK may get calls or visits from patients who haven’t seen that advice. If they phone and, after carrying out a phone risk assessment, the patient meets the criteria above, do not advise them to come down to the surgery9 or out of hours centre for a face to face assessment. They should stay indoors and avoid contact with other people and you should ‘seek further specialist advice from a local microbiologist, virologist or infectious diseases physician’. You should also tell your local health protection team.15
If the patient is at the surgery then hopefully they will tell reception about their concerns, at which point you need to isolate them. It would be worth working out in advance which room you are going to use for this purpose if needed. The patient should be told not to touch anything and no one should enter the room. If you need to talk to them, do so by phone. They should not be allowed to use a communal toilet and if they absolutely have to then they shouldn’t touch anything or anyone on the way to and from the toilet and should wash their hands thoroughly afterwards (although quite how they are going to do this without touching the sink or getting help from anyone else I’m not sure). As above, you need to talk to secondary care to find out where to send them and inform public health, who should be involved in any decision on transferring the patient and the mode of transport.
If it is only during a consultation that the risk of 2019-nCoV is disclosed then the same principles apply, but you should isolate the patient in the room that you were already using. The clinician should leave the room and wash their hands thoroughly with soap and water. Under no circumstances should a patient with suspected 2019-nCoV be examined in primary care. PHE don’t specify what we should be doing if a patient suspected to have 2019-nCoV is critically ill and in need of urgent face to face treatment/resuscitation in primary care, other than saying that transfer should be discussed with ambulance control, making them aware of the risks.
Once all the phone calls have been made, the patient has left the premises, and you have all recovered your composure with the help of some caffeine, the premises needs to be made safe so that you can continue to see patients that day. PHE tell us that ‘once a possible case has been transferred from the primary care premises, the room where the patient was placed should not be used, the room door should remain shut, with windows opened and the air conditioning switched off, until it has been cleaned with detergent and disinfectant. Once this process has been completed, the room can be put back in use immediately’ and their interim guidance for primary care has more detailed information about the cleaning process, including the strengths of disinfectant that should be used. All waste from the room should be quarantined until the results of definitive diagnostic tests are known and any communal areas where the patient spent time (e.g. the waiting room or a public toilet) should be cleaned in the same way before being used again.
Dr Toni Hazell is a GP in North London
- World Health Organisation. SARS. https://www.who.int/ith/diseases/sars/en/
- Nhs.uk. SARS. 2019. https://www.nhs.uk/conditions/sars/
- World Health Organisation. MERS. https://www.who.int/emergencies/mers-cov/en/
- Public Health England. Novel coronavirus (2019-nCoV): epidemiology, virology and clinical features. 2020. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-background-information/wuhan-novel-coronavirus-epidemiology-virology-and-clinical-features
- Chief Medical Officer. CMO confirms cases of coronavirus in England. 2020. https://www.gov.uk/government/news/cmo-confirms-cases-of-coronavirus-in-england
- Coronavirus symptoms and diagnosis. CDC. https://www.cdc.gov/coronavirus/about/symptoms.html
- Public Health England. Wuhan novel coronavirus (WN-CoV). https://www.gov.uk/government/collections/wuhan-novel-coronavirus
- Public Health England. High consequence infectious diseases (HCID). https://www.gov.uk/guidance/high-consequence-infectious-diseases-hcid#classification-of-hcids
- Public Health England. WN-CoV: interim guidance for primary care. https://www.gov.uk/government/publications/wn-cov-guidance-for-primary-care/wn-cov-interim-guidance-for-primary-care
- Public Health England. Local action on health inequalities Improving health literacy to reduce health inequalities. 2015. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/460709/4a_Health_Literacy-Full.pdf
- Public Health England. Investigation and initial clinical management of possible cases of novel coronavirus (2019-nCoV) infection. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases/investigation-and-initial-clinical-management-of-possible-cases-of-wuhan-novel-coronavirus-wn-cov-infection#interim-definition-possible-cases
- Public Health England. Coronavirus: latest information and advice. 2020. https://www.gov.uk/guidance/wuhan-novel-coronavirus-information-for-the-public?gclid=CjwKCAiAg9rxBRADEiwAxKDTuiOYGV5KTvXsPcfZ4TGXPEQ3a3nXFnl3Dmiiq8CaXBC3qFDpxmK-mRoCxXMQAvD_BwE
- Public Health England. Find your local health protection team in England. 2020. https://www.gov.uk/health-protection-team.