Singapore : Gatherings of 10 or more people are prohibited. All bars and entertainment venues are closed, religious services and congregations, and organized tours are suspended. Malls, museums, and other attractions and restaurants may remain open with appropriate distancing measures in place. South Korea : The southern cities of Cheongdo, Daegu, and Gyeongsan have been declared "special care zones," with schools, markets, and restaurants closing in some neighborhoods and a ban on all large public gatherings.
Travel has not been restricted to and from Daegu and Cheongdo, although residents have been asked to stay home and wear face masks even indoors if possible. In Seoul, large public gatherings and protests have been banned. All individuals who have come within 2 m 6 ft of a symptomatic COVID case have been asked to self-quarantine for 14 days. Other states have closed schools, museums, bars, restaurants, houses of worship, and large gathering places. Many universities have moved to online classes. CDC is recommending that all events and mass gatherings with 50 or more people should be canceled; local and state guidelines may differ.
Professional and college sporting events have been canceled or postponed indefinitely. People with underlying medical conditions and older persons should avoid large gatherings, air travel, and cruise travel. Shortages of medical supplies and protective gear are already hampering care in heavily affected states. Department of Defense has now halted all domestic travel for service members, Department of Defense civilians, and their families until May Domestic travel to New York City is discouraged.
The detailed epidemiology of possible causative animal exposures and zoonotic transmission at the outset of the outbreak remains unclear. Thirty-three environmental samples from the market tested positive for SARS-CoV-2, indicating that the market was an—or the—origin or amplification point of the large-scale outbreak. No samples taken directly from live animals have been reported as positive.
The symptom-onset date of the first case identified in the outbreak was December 1, ; the case reported no exposure to the market. No epidemiological link has been detected between this case and later cases. An initial single jump of SARS-CoV-2 directly from bat to human, or from an intermediate animal host to a human, with subsequent initial human-to-human propagation within the seafood market, is likely. Infected intermediate animal hosts, if they exist, may still be present, but the sale of live animals in markets in China has officially ceased.
Preliminary data, not yet peer-reviewed and published, indicate pangolins may be a leading candidate. All evidence to date suggests that the main route of transmission is via respiratory droplets or close contact with an infected person. Aerosolized transmission may occur during medical procedures, but no data are available to implicate this mode of transmission. A reproductive number, R 0 , is estimated at 2—3 both by Chinese authorities and by multiple other international estimates.
R 0 is not a constant number and changes with the ongoing circumstances and evolution of an outbreak. In serial nose and throat swabs in several cohorts, the highest viral loads were detected within 3 days after symptom onset, with higher viral loads detected in the nose than in the throat, especially in the early stage of illness.
Viral loads peaked between 6 and 12 days after symptom onset and were highest in those most severely ill. Additionally, the viral load in asymptomatic persons is similar to that in the symptomatic persons. These findings support possible transmission early in illness in a pattern similar to influenza.
However, how the SARS-CoV-2 viral load correlates with culturable or transmissible virus either in symptomatic or asymptomatic persons remains to be determined. Most case clusters in China occurred in families. SARS-CoV-2 was grown in culture from nasopharyngeal swabs from 9 pre- or minimally symptomatic infected contacts of a minimally symptomatic index case from Wuhan at a Munich business meeting. Such minimally symptomatic persons have had an unknown importance in transmission. No virus was culturable more than 8 days after symptom onset, even with continued high levels of viral RNA detected by RT-PCR, which remained positive for up to 20 days.
Viral loads by PCR peaked between 1 and 5 days after the onset of symptoms, validating other studies.
The clinical courses in subjects under study were mild, all being young to middle-aged professionals without significant underlying disease; these findings are reflective of potential community carriers of SARS-CoV-2 but should not be extrapolated to patients with severe COVID disease.
During 14 days of active symptom monitoring of close contacts of the initial 12 imported confirmed U.
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Two persons who were household contacts tested positive for SARS-CoV-2, for an overall symptomatic secondary attack rate of 0. Close contact was defined as either at least 10 minutes spent within 2 m 6 ft of the patient or having spent time in the same air space e. Several published cluster studies indicate at least asymptomatic shedding but not necessarily transmission. Asymptomatic transmission is reported in family clusters or in travel groups.
When occurring in areas where local transmission is occurring at the same time, these reports must be considered with caution because any of the COVID cases may possibly have been infected outside of the family or group cluster. Reports of asymptomatic infection in countries with no community-based infection are more credible. After a repatriation flight to Japan, officials there screened and tested every passenger; 8 tested positive for SARS-CoV-2, but 4 of those were asymptomatic.
On a German repatriation flight, 2 asymptomatic individuals tested positive, both by PCR and by viral culture. The frequency of asymptomatic transmission is unclear and, so far, appears to be an outlier or rare event, especially if super-spreaders with high viral loads early in the incubation phase exist. Chinese researchers followed people who were diagnosed with COVID based on their symptoms and 1, of their close contacts to see whether the contacts would test positive for the virus even if they had not shown symptoms.
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Whether children are important in transmitting the virus, as they are with influenza, is not addressed by this study. Studies using Chinese data to infer high levels of asymptomatic transmission during the outbreak in China should be viewed in the context of a lack of testing, meaning that most transmission was undocumented.
Differentiating between asymptomatic and symptomatic transmission is not possible in this setting. Prior to the January 23 lockdown, Wuhan and Hubei had almost no testing and most "cases" were being confirmed clinically. Public health was overwhelmed little contact tracing was done , and most hospitals were already overwhelmed so many untested, symptomatic people were in the community causing undocumented transmission. Detailed, published data from Singapore indicate that transmission control was accomplished by intense contact tracing and enforcing strict testing and heavily monitored quarantine multiple, daily webcam checks on every contact; this kept the next generation out of the general community.
Detailed contact tracing and rapid testing indicated almost all transmission to be via close contacts. Early testing of contacts identifies persons who are incubating and presymptomatic as well as persons who are incubating and will never be symptomatic; all these persons are not necessarily transmitting while asymptomatic.
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Quarantining these individuals keeps potential next-generation transmitters out of the population. In severely ill patients, intubation is considered "source control" equal to a patient wearing a face mask, greatly diminishing transmission risk. Limited experience indicates that no vertical transmission from mother to fetus or newborn before, during, or immediately after delivery of SARS-CoV-2 has been reported; SARS-CoV-2 was not detected in samples of amniotic fluid, and all infants tested negative.
Symptomatic mothers well enough to breastfeed should do so and wear a face mask and observe hand hygiene; symptomatic mothers not well enough to breastfeed should wear a face mask and observe hand hygiene while expressing milk for bottle feeding. A study from the U.
SARS-CoV-1 remained culturable for up to 72 hours on plastic, for 48 hours on stainless steel, and for 8 hours on either cardboard or copper. Variations of heat and humidity and viability in different matrices such as nasal secretions, sputum and fecal matter were not examined. Historically, studies have demonstrated survivability of zoonotic coronaviruses on different surfaces ranging from a few hours up to 9 days longest on plastic depending on ambient conditions, including temperature, humidity, and the specific infected bodily fluid contaminating the surface.
The risk of spread is very low from items shipped at ambient temperatures over several days. No evidence exists of SARS-CoV-2 transmission associated with imported goods; no associated cases have been reported to date. See Survival on Surfaces. Disinfection processes that are effective for other zoonotic coronaviruses should be followed for now. Clean daily all "high-touch" surfaces, such as counters, tabletops, hard-backed chairs, doorknobs, light switches, handles, desks, bathroom fixtures, toilets, phones, remote controls, keyboards, tables, and bedside tables.
After cleaning solid materials using a detergent, use a diluted bleach solution or a household disinfectant with a label that says "EPA-approved. Alcohol-based hand disinfectants and common hospital personal disinfectants are all effective against SARS-CoV-2 but provide no ongoing protection between uses. Modeling data from a leading group in the U. The model shows that relaxation of suppression could lead to an immediate rebound to peak epidemic levels. Suppression, as defined, includes social distancing in all community settings remaining out of congregate settings [crowded places such as shopping centers, movie theaters, and stadiums], avoiding mass gatherings and public transportation, and maintaining a distance of 2 m [6 ft] from others for the entire population, home isolation of all cases, isolation of all household members, and rigorous and rapid testing capability.
Models are useful tools but are only as good as each of their multiple 5 to dozens assumptions; 1 or more weak assumptions based on the lack of significant knowledge of a parameter at the time the model is run can dramatically change the findings. Several assumptions in all the current models are based on data made available from the Chinese outbreak; the data suffer from weak initial testing capability and case ascertainment, and some data components may be partially fictionalized.
Assumptions on asymptomatic infection rates are not based on population-based antibody studies, and assumptions on asymptomatic transmission are based largely on household transmission and not random community transmission. Robust data from Singapore that included meticulous, state-of-the-art electronic contact tracing and rapid testing indicated almost all transmission to be via close contacts.
Many of the models assume much higher asymptomatic transmission rates in the community. Variables and intangibles for which no current data exist are only possible to include in future runs of the particular model. Other nonpharmaceutical and pharmaceutical preventions and treatments may come into play at uncertain times in the future, testing capacity will become more robust, and the rate of rise of immune individuals within a community is impossible to predict with a new organism. In general, models can be regarded as bases for worst case scenarios for planning given current knowledge and need to be frequently rerun as knowledge evolves.
An incubation period of 2 to 7 days appears most common 5 days typical across many studies , with an upper range of 14 days. As with any infection, very small numbers of outliers with longer incubation periods have been reported. Loss of the senses of smell and taste as the first symptom of infection has been anecdotally reported with increasing frequency; no data has been published to date.
CT scan findings include ground-glass opacification, consolidation, bilateral involvement in most, and peripheral and diffuse distribution. The sequence and evolution of these radiologic findings is not yet clear. Asymptomatic patients with CT scan abnormalities have been reported.
CT scans may not offer information beyond what is in the chest x-ray in a patient in an intensive care unit. Mild illness may occur for up to 14 days, with late onset of severe respiratory compromise; influenza has a much more sudden onset. White blood cell counts are typically normal and a lymphocyte count of less than 1.
Abnormal liver function tests, especially LDH, appear to be common and may be a poor prognostic sign. Diarrhea may occur, but incidence has been highly variable in several cohorts. Recovery time is about 2 weeks for persons with mild disease and 3 to 6 weeks for persons with severe or critical disease, many of whom require intensive care. Based on available information as of March 24, more than 9, cases of severe disease and 14, deaths have been reported in cases exported from China or in cases acquired outside of China.
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Two uncontrolled trials in a small number of patients, 1 in China and 1 in France, indicate dramatic effects of hydroxychloroquine or chloroquine on viral replication in humans. Data on eventual outcomes are unclear but no other drug data have been published to indicate viral suppression in humans. CDC guidance now lists dosing for hydroxychloroquine sulfate, with the following options pending results of more detailed ongoing clinical trials: mg 2 times per day on day 1, then daily for 5 days; mg 2 times per day on day 1, then mg 2 times per day for 4 days; mg 2 times per day on day 1, then mg daily on days 2 through 5.
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