Dr Toni Hazell summarises the recent guidance on how to identify possible cases of novel coronavirus and why suspected cases must be isolated immediately
Read this article to learn more about:
- who is at risk of novel coronavirus (2019-nCoV)
- rapidly isolating a patient in primary care premises to reduce risk of transmission
- communicating with patients and obtaining specialist advice.
Four-letter acronyms seem to be all the rage when it comes to viruses that arrive from the East. In 2003 we had SARS (severe acute respiratory syndrome), which came from the Guangdong province in China. There were 8098 cases and 774 deaths worldwide.1,2 More recently, MERS (Middle East respiratory syndrome) caused 858 deaths between 2012 and 2019.3 Both SARS and MERS were caused by a coronavirus and now we have a new virus in this family to worry about. Going by the slightly less catchy name of 2019-nCoV (novel coronavirus), it originates from Wuhan City in the Hubei province of China.4
Concern was first raised on 31 December 2019, when a cluster of diagnoses of pneumonia of unknown cause was identified. Within a fortnight a novel coronavirus had been sequenced and as of 11 February there had been 42,638 cases and 1,016 deaths officially reported in China, with a mortality rate of around 2%.5 On 31 January 2020, the first two cases were confirmed in the UK and as of 11 February the total number of confirmed cases had risen to eight, including two GPs. All of the new cases were known contacts of a previously confirmed case and were passed on in France.6
Suspected novel coronavirus—basic principles for primary care
2019-nCoV presents in the same way as most respiratory tract infections—patients may have a temperature, cough, shortness of breath, runny nose, general malaise, and headache.7 Upper respiratory tract symptoms are most common although it can also cause lower respiratory tract symptoms. Those with pre-existing cardiorespiratory conditions, or people with weakened immune systems, infants, and older adults, are more likely to have symptoms in the lower respiratory tract.7
In February, UK GPs will be dealing with patients who have respiratory tract symptoms every day, so the symptoms alone will not help identify who might have 2019-nCoV. This coronavirus is classified as an airborne high consequence infectious disease (HCID)8 due to its acute infectiousness and high fatality rate.9 HCIDs are difficult to recognise, can spread easily within the community and healthcare settings, and may not have effective prophylaxis or treatment.9 For this reason it is vital to rapidly recognise a patient who may be at risk of 2019-nCoV so that they can be isolated to reduce the risk of spread. Advice from Public Health England (PHE) is changing daily—the advice in this article is correct as of 11 February 2020 and the key reference for those wanting to update themselves on any changes is PHE’s interim guidance for primary care,10 the principles of which are outlined in Box 1 below.
Box 1: Principles of primary care management of a suspected case of 2019-nCoV10
- Identify possible cases as soon as possible
- Prevent potential transmission to other patients and staff
- Avoid direct physical contact
- Isolate the patient
- Obtain specialist advice
- Inform the local health protection team.
Adapted from: Public Health England. Novel coronavirus (2019-nCoV): interim guidance for primary care. Available at: www.gov.uk/government/publications/wn-cov-guidance-for-primary-care/wn-cov-interim-guidance-for-primary-care Updated 11 February 2020.
Contains public sector information licensed under the Open Government Licence v3.0.
Who is currently considered to be at risk of contracting the virus?
To implement this advice in practice, the first thing is to know which patients should make you concerned about 2019-nCoV. An estimated 42% of UK working-age adults are ‘unable to understand or make use of everyday health information’11 and so we can probably expect calls from people who are worried that they may have the virus, when in fact they are at no risk at all. The PHE criteria are straightforward—to be a ‘possible case’, the patient has to meet both epidemiological and clinical criteria shown in Box 2.12
Box 2: Public Health England criteria for a possible case of 2019-nCoV12
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 or
- contact with a confirmed case of 2019-nCoV.
A contact is defined as:
- someone who is living in the same household or
- direct contact with the case or with their bodily fluids or laboratory specimens, or has been in the same room of a healthcare setting when an aerosol generating procedure is undertaken on the case without appropriate PPE or
- direct or face-to-face contact with a case, for any length of time or
- has been within 2 metres of the case for any other exposure not listed above, for longer than 15 minutes or
- being otherwise advised by a public health agency that contact with a confirmed case has occurred.
2. Clinical criteria
The clinical criteria for a potential case of 2019-nCoV are:
- severe acute respiratory infection needing admission to hospital with clinical or radiological evidence of pneumonia or acute respiratory distress syndrome or
- acute respiratory infection of any degree of severity which includes at least one of: shortness of breath (difficult breathing in children), or cough (with or without fever) or
- fever with no other symptoms.
Clinicians should be aware that immunocompromised patients may present atypically.
Any individual reporting any contact with a confirmed case of 2019-nCoV, even if asymptomatic, should be reported to the local health protection team immediately.
Adapted from: Public Health England. Investigation and initial clinical management of possible cases of novel coronavirus (2019-nCoV) infection. Available at: www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases Updated 11 February 2020.
Contains public sector information licensed under the Open Government Licence v3.0.
Patients at risk should not be examined or diagnosed in primary care
If phone triage is possible, this may be preferable as a suspected case is easier and safer to manage if the patient is on the phone rather than in your surgery. The key thing to remember is that 2019-nCoV is not something we should be attempting to diagnose or manage in primary care, and we should be staying as far away from the patient as possible.
The advice to the general public is that they should phone 111 (or 0300 200 7885 if in Northern Ireland) if they have returned from Wuhan or Hubei province in the last 14 days (even those without symptoms), or from other parts of China, Macau, Hong Kong, Thailand, Japan, Republic of Korea, Taiwan, Singapore, or Malaysia if they have symptoms,4 but patients may phone the GP surgery instead of 111. If after carrying out a phone risk assessment, the patient meets the criteria in Box 2, do not advise them to come down to the surgery or out-of-hours centre for a face-to-face assessment.10 They should stay indoors and avoid contact with other people13 and you should ‘call the local secondary care infection specialist to discuss safe assessment, which may require assessment in hospital’.10 You should also inform your local health protection team (HPT).14
What if a patient with possible novel coronavirus comes to the surgery?
If the patient comes to the surgery without phoning ahead, then ideally they should be identified at reception and immediately placed into an isolation room away from other patients and staff. They should be told not to touch anything and no one should enter the room, all communication with the patient thereafter being by phone. Ask the patient to call NHS 111 from their room, on their mobile (or GP surgery landline if mobile unavailable). 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. The guidance is somewhat inconsistent here, as it isn’t clear how a patient is meant to use the toilet and wash their hands without touching anything or any assistance! As above, you need to talk to secondary care to find out where to send them and inform the HPT, who should be involved in any decision on transferring the patient and the mode of transport. Patients with suspected 2019-nCoV should be instructed not to use public transport or taxis to get to hospital.10
What if the consultation has already started?
If you become aware during a consultation that a patient is at risk of 2019-nCoV then the same principles apply, but the patient should be isolated in the consultation room. 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 does not specify what we should do 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, and the HPT informed.10
Cleaning and disinfecting following a possible case
Once all the phone calls have been made and the patient has left your premises, and you have all taken a deep breath and had a strong cup of coffee, thoughts should turn to the safe use of the premises for ongoing patient care. PHE tell us that:10
‘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.’
The 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.10
Information for the public will be updated every day until further notice on gov.uk’s Coronavirus: latest information and advice page.13
Dr Toni Hazell
Part-time GP, Greater London
The advice in this article is correct as of 11 February 2020.
For more up-to-date information, refer to PHE’s interim guidance for primary care.
Implementation actions for clinical pharmacists in general practice
written by Gupinder Syan, Training and Clinical Outcomes Manager, Soar Beyond Ltd
The following implementation actions are designed to support clinical pharmacists in general practice with implementing the guidance at a practice level.
- Understand the principles of primary care management and criteria for identifying a case of suspected 2019-nCoV and apply these when with patients in clinics, minor illness clinics, or when undertaking telephone triage or talking to patients on the phone; or whenever patients volunteer information or voice concerns
- Know what to do if you suspect a case of 2019-nCoV. If you come across a patient with suspected 2019-nCoV, you must:
- ensure that you know the correct advice to give patients face to face as well as over the phone. Check whether the patient meets the criteria outlined in the article. If speaking to them by phone, ensure you give the correct advice about staying indoors and not coming into the surgery or into contact with others, and ensure that you seek further specialist advice from a local microbiologist, virologist, or infectious diseases specialist and inform your local health protection team
- know the pathway and procedure for what to do if a suspected case presents in the practice, including how to clean up the premises once the patient has left. Make sure you and all staff and healthcare professionals in your surgery are aware of these procedures
- avoid creating further undue panic for your patients and the public, including the staff at the practice, by ensuring that you follow the policies and procedures in a professional manner and provide reassurance to all
- keep updated with the latest information via Public Health England’s Novel coronavirus (2019-nCoV): interim guidance for primary care.10
2019-nCoV=2019 novel coronavirus
- World Health Organization. SARS (Severe acute respiratory syndrome). www.who.int/ith/diseases/sars/en/ (accessed 12 February 2020).
- NHS website. SARS (severe acute respiratory syndrome). www.nhs.uk/conditions/sars/ (accessed 12 February 2020).
- World Health Organization. Middle East respiratory syndrome coronavirus (MERS-CoV). www.who.int/emergencies/mers-cov/en/ (accessed 12 February 2020).
- NHS website. Coronavirus (2019-nCoV). www.nhs.uk/conditions/wuhan-novel-coronavirus/ (accessed 12 February 2020).
- Public Health England. Novel coronavirus (2019-nCoV): epidemiology, virology and clinical features. Updated 11 February 2020. www.gov.uk/government/publications/wuhan-novel-coronavirus-background-information/wuhan-novel-coronavirus-epidemiology-virology-and-clinical-features (accessed 12 February 2020).
- Witty C. Chief Medical Officer for England announces four further coronavirus cases. DHSC, 10 February 2020. www.gov.uk/government/news/chief-medical-officer-for-england-announces-four-further-coronavirus-cases (accessed 12 February 2020).
- Centers for Disease Control and Prevention. Coronavirus. Symptoms and diagnosis. www.cdc.gov/coronavirus/about/symptoms.html (accessed 12 February 2020).
- Public Health England. Novel coronavirus (2019-nCoV). www.gov.uk/government/collections/wuhan-novel-coronavirus (accessed 12 February 2020).
- Public Health England. High consequence infectious diseases (HCID). Updated 11 February. www.gov.uk/guidance/high-consequence-infectious-diseases-hcid#classification-of-hcids (accessed 9 February 2020).
- Public Health England. 2019-nCoV: interim guidance for primary care. Updated 11 February. www.gov.uk/government/publications/wn-cov-guidance-for-primary-care/wn-cov-interim-guidance-for-primary-care (accessed 12 February 2020).
- Public Health England. Local action on health inequalities: improving health literacy to reduce health inequalities. PHE, 2015. Available at: 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. Updated 11 February 2020. 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 (accessed 12 February 2020).
- Department of Health and Social Care, Public Health England. Coronavirus: latest information and advice. Updated 11 February 2020. www.gov.uk/guidance/wuhan-novel-coronavirus-information-for-the-public (accessed 12 February 2020).
- Public Health England. Find your local health protection team in England. 2020. www.gov.uk/health-protection-team (accessed 12 February 2020).