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In late December 2019 an outbreak was reported to the World Health Organization (WHO) in Wuhan, China and later identified as a novel coronavirus (2019-nCov). By 28 January 2020 the virus had killed 131 and infected at least 5494 people across 29 provinces. Rapidly, the outbreak became a pandemic with 84 cases in 17 countries including Australia.

Authorities fear >50,000 people may have been infected. Although the current mortality rate of 2019-nCoV, 2-3%, is lower than SARS-CoV, 11%, there is a potential for the absolute numbers of death to exceed SARS-CoV because of the ease of amplification and delays in isolation of the epicentre. Amplification is assisted by a large proportion of mild cases, currently estimated at 20%, the ability to transmit in the 24-hours prior to symptoms and a transmissibility rate of 1.4-2.5 persons per case.

My review of the SARS outbreak in Beijing in collaboration with the Beijing Health Bureau identified a critical failure to control the outbreak with the most effective control measures early – enforced isolation of the epicentre. With WHO classifying the global situation as ‘high’ it is beholden of us as good global citizens to cooperate with amplification reduction efforts by using social distancing for 14 days after international travel and even after ‘casual’ exposure to a case. Other measures include thorough cleaning and disinfection of surfaces, frequent hand hygiene with alcohol based hand rub and correct cough etiquette, responsible disposal of used tissues and of course remain in isolation when requested.

During my review of the Hong Kong SARS designated hospital, the critical items to keep staff safe included ramping-up of hospital-wide environmental cleaning schedules, use of hand hygiene champions to actively remind staff in critical wards when to perform hand hygiene and correct donning and doffing of PPE. Don’t wait for a 2019-nCoV patient or staff acquisition of the disease to ramp up prevention. Act now!

Update 1: By 31st January 2020 the virus had killed 171 and infected over 8,200 people. Rapidly, the outbreak became a pandemic with 112 cases in 21 countries including Australia. Finally, today WHO called a state of emergency!  The WHO committee was split 50:50 about making this declaration while it considers among factors including economic impact to closed borders and required resources. Having seen the missed opportunity during SARS it is my advice never wait for WHO to declare an emergency before ramping-up infection prevention; prevention is the best protection against economic impact, morbidity and death. To the general community please hand hygiene with soap and water or alcohol based hand rub (ABHR) if water washing is not available. To healthcare workers please be even more mindful about your ABHR hand hygiene and ramp up environmental cleaning schedules. Stay safe.

Update 2: It is now 3rd Feb 2020. Transmission of the virus is following a geometric pattern and sadly there are 362 deaths and over 17,300 infected persons (181 of whom are from 26 countries including Australia). The death rate is around 2% and we can’t predict who will die, who will require hospital admission or who will have a mild infection. Many argue the death rate is much lower than SARS CoV (9.6% globally) that killed 774 people. So why are we worried? To date, the number of infections exceeds SARS (8,100), 20% of 2019-nCoV cases are mild, and infectivity 24 hour prior to symptoms means the absolute number of deaths may exceed SARS (744; 9.6% global death rate). It is my experience ramping-up infection prevention early saves healthcare workers’ and patients’ lives. Please be vigilant with your hand hygiene, be vigilant with hand hygiene associated with correct donning and doffing of masks and environmental cleaning schedules. Stay safe.

Update 3: It is now 10th February 2020 and in just seven days since my previous update there has been close to a tripling of cases and deaths globally; 42,767 cases and 1,013 deaths. Quarantining is the preferred containment strategy by epidemiologists for disease outbreaks associated with high transmissibility regardless of mortality rate. Understandably, over the past few weeks there has been speculation about the need for strict containment given an estimated 20% (and likely more) of cases are mild, death rates of around 2% (lower than SARS but higher in absolute numbers) and the potential for severe economic and diplomatic impact. Quarantining of epicentres is the preferred option over free movement of populations where the treatment options are uncertain and outcomes of the disease are not always straightforward especially for older susceptible persons with comorbidities. The rationale is simple; widespread morbidity is undesirable on a humanitarian level and neither is mortality. The safety is of central concern and the leadership of countries have to balance the risk with productivity of their community. Practice good hand hygiene and safe coughing etiquette, and frequent environmental cleaning paying attention to high touch areas. Stay safe!

Update 4:

Update 5: Professor Mary Louise McLaws featured on ‘@A Current Affair’ last night discussing the importance of hand hygiene and the technique for hand washing. Click here to view the story.

Update 6:

The COVID-19 outbreak in Australia started in January with three cases and steadily increased. Australian’s were advised that it was business as usual. The Australian border was closed to China while remaining open to Europe, UK and USA even as cases were rapidly increasing in these countries. In early February, Australians returning from Wuhan were held in isolation on Christmas Island. Many Australians were uncomfortable with this approach but in early February the total cases (old and new) in China were close to 20,000. Christmas Island was a humane holding centre with open-air and room to exercise compared with the Diamond Princess cruise ship where passengers were confined mostly to their small cabins before finally disembarking on 27th February. Australia’s epidemic curve continued to rise as returning Australians and international travellers arrived from around the world and constituted our largest risk group.The second largest risk group for Australia was contact with travellers as the new cases (incidence) in this group rose in numbers. Travellers were advised to self-isolate however the compliance of this was never monitored or checked and contacts from travellers increased.Action was taken to cancel spectators to the Grand Prix and other sporting events were eventually banned. Nine weeks after the first cases on January 25th the borders have now been tightly secured with travellers mandatorily held in isolation for 14 days. We should now experience an improvement in imported and transmitted cases into the community but this will not be reflected in the epidemic curve for at least 7-14 days (the average and long incubation periods). I have been tracking the epidemic curve and the doubling time has slowed from every 3-4 days to around 5-6 days. Because this new pattern has only just begun it is still too soon to say if it is a new trend. So keep up your hand hygiene practice, increase environmental cleaning (hospitals, business and public) and if someone in the public is not in your ‘family germ bubble” keep your distance. Stay healthy.

Update 7:

Hand hygiene and environmental cleaning are effective actions to reduce the spread of pathogens and prevent infections, including the SARS-CoV-2 virus. Read the latest update from Professor Mary-Louise McLaws:

Forget about the nah sayers. Total elimination is possible and zero should be our aim. Today we have nationally 16 new cases (1 in Queensland, 1 in Tasmania, 7 in Victoria and 9 in NSW).

The threat from incoming international travellers has ceased and a third of our cases have been locally acquired (N=2434) of whom 10% (N=678) have an ‘unknown’ contact. The proportion of cases with an unknown source of infection has remained stable (10%) and may represent an inability by the Departments of Health to find contacts and failure or refusal of the case to recall their contacts.

Are we there yet?

The ‘tail’ of any large outbreak (see graph below) is always long when the R0 (number susceptible who can be infected by a single case) is 2 or greater. It will just take patience to get to zero new daily cases nationally. But it has already happened for four States/Territories: Congratulations NT (for more than 3 average incubation periods), SA (since 26 April), ACT (since 28 April) and WA (since 29 April).

We have gone from doubling every 2-3 days to flattening the curve by day-20 for NT, ACT, SA and WA. NSW, QLD and SA flattened their curves later, by around day-30, as these three States continued to acquire new incoming cases from international travellers/cruise ships and their secondary cases continued to occur until mandatory supervised quarantining came into effect on 27 March.

image credit: Pool Boy Graphics

We are competitive so how are we doing?

New Zealand’s COVID-19 outbreak is comparable to ours; their population is a fifth and their cases are a fifth of ours. They call for a lockdown and introduced paper diaries for contact tracing. Yesterday they had a fifth of our new cases. I think it’s a tie! (Declaration of Conflict of Interest: I love NZ).

Take one for the country. Get the flu shot; we are entering Influenza season. Annually, there are surges on our health services nationally with an average of 300,000 influenza related presentations to general practitioners and 180,000 hospitalisations (Immunisation Coalition). Young children drive the influenza season so vaccinate them and yourself. This will not only save the health services from preventable presentations, transmission of a preventable disease but help to keep you healthier during the pandemic.

Clean? When in doubt perform hand hygiene please. May 5 is World Hand Hygiene Day. This year it is particularly poignant – not only do patients and healthcare workers benefit from hand hygiene but it’s a win-win for everyone. During May 5 remember to hand hygiene (alcohol based hand rub or soap and water wash) in the healthcare setting and residential aged care facilities (RACFs) where our most vulnerable have become even more vulnerable as cases of COVID-19 are cared for in the same facility. This is the time to aim for a personal goal of 100% compliance, even if you are not on the ward or zone for COVID-19 patients in RACFs and hospitals. There have been several publications recently of COVID-19 expelled by patients as droplet and airborne sized particles. But the likelihood of this mode of transmission is small might occur if the environmental conditions are just right (like aerosol generating procedures, small unventilated rooms etc that enables small particles to remain in the air. We touch our faces on average 23 times an hour, 11 of these are to our nose, eyes, mouth or a combination (Kwok, Gralton, McLaws. Am J Infect Control). The mode of transmission will be droplet in the majority of cases. Transmission can be prevented with physical distancing, not touching your face with unclean hands, hand hygiene and environmental cleaning. The outbreak in the RACFs in NSW and Tasmania is a brutal reminder that a mask and gloves can not be relied on instead of hand hygiene and environmental cleaning.

When do we celebrate the end of an Australian COVID-19 epidemic? The definition that starts with the date from the last case testing negative (or dies or fulfils a criterion for negative status) plus twice the maximum incubation period (World Health Organization). WHO recommends a heightened surveillance period continues thereafter to ensure human-to-human transmission has ceased to occur.

But we can celebrate our heroes. We all love firefighters, ambulance officers and healthcare workers. They are our national heroes. I’d like to include environmental cleaners to this list. Without them our healthcare workers, vulnerable patients and visitors would be surrounded by risk of acquiring a pathogen. SARS-CoV-1 has been tested in the laboratory to survive for hours (Kampf et al. J Hosp Infect 2020). So, the next time we are asked to salute our healthcare workers take a moment to think of the cleaning staff who care for our environment.

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