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Reply of “The outbreak of COVID-19 -An overview”

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Yi-Chi Wu
Yi-Chi Wu
Yi-Chi Wu
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Ching-Sung Chen
Ching-Sung Chen
Ching-Sung Chen
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Yu-Jiun Chan
Yu-Jiun Chan
Yu-Jiun Chan
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Letter to the editor
J Chin Med Assoc
www.ejcma.org 1
*Address Correspondence. Dr. Yu-Jiun Chan, Division of Microbiology,
Department of Pathology and Laboratory Medicine, Taipei Veterans General
Hospital, Taipei Veterans General Hospital, 201, Section 2, Shi-Pai Road, Taipei
112, Taiwan, ROC. E-mail address: yjchan@vghtpe.gov.tw (Y.-J. Chan).
Conflicts of interest: The authors declare that they have no conflicts of interest
related to the subject matter or materials discussed in this article.
Journal of Chinese Medical Association. (2020) XXX: 00-00.
Received April 10, 2020; accepted April 10, 2020.
doi: 10.1097/JCMA.0000000000000331.
Copyright © 2020, the Chinese Medical Association. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/)
Reply to “The outbreak of COVID-19: An overview”
Yi-Chi Wua, Ching-Sung Chena, Yu-Jiun Chana,b,c,*
aDivision of Microbiology, Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei,
Taiwan, ROC; bDivision of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC;
cInstitute of Public Health, National Yang-Ming University, Taipei, Taiwan, ROC
DEAR EDITOR,
We appreciate the comments by Tseng et al1 on our recent
article Wu et al2 published in the current issue of the Journal
of the Chinese Medical Association. Indeed, it is very crucial to
protect health care workers (HCWs) in this pandemic. Not only
HCWs safeguard patient care, but also they are at high risk of
contracting this contagious disease. Studies indicate that 3.8%
(1716/44 672) of HCWs during the outbreak in China (as of
February 11, 2020) were infected and 14.8% of conrmed cases
were classied as severe or critical.3,4 A random sample survey
in March 2020, in Noord-Brabant, Netherlands, revealed nearly
4% of the hospital staff is infected with this novel coronavirus,
but the percentages vary per hospital (0%-10%).5 Mortality did
happen even among young doctors. As we emphasized in pre-
vious overview and the authors concur that “stringent protec-
tion procedures should be conducted for high-risk procedures.”2
Endotracheal tube intubation by all means is one of the most
dangerous maneuver. It has been shown that aerosol might be
generated during intubation and viral-containing droplets can
oating or contaminate different surfaces for many hours.6
Particularly, viral loads are high in the early stage of symptom
onset and lung-derived samples (such as sputum or aspirate)
contain high viral load when the patient’s condition deteriorates
and need intubation.7,8
It has been shown that surgical face masks can effectively
prevent viral spreading of many respiratory viruses, including
the severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2).9 However, surgical face masks need to be removed
during intubation. The authors invented a transparent acrylic
“aerosol box” to protect the person who conducts intubation
from aerosol spreading or droplet contamination. This device
seems promising in reducing the chance of infection during intu-
bation. It would be very informative if the authors could dem-
onstrate or show experimental data that how effective “the box”
can contain viral-containing droplets inside the box and protect
people from infection.
REFERENCES
1. Tseng YJ, Lai HY. Protecting against COVID-19 aerosol infection during
intubation. J Chin Med Assoc 2020;83:(in press)
2. Wu YC, Chen CS, Chan YJ. The outbreak of COVID-19: an overview. J
Chin Med Assoc 2020;83:217–20.
3. Chang D, Xu H, Rebaza A, Sharma L, Cruz CSD. Protecting health-
care workers from subclinical coronavirus infection. Lancet Respir Med
2020;8:e13.
4. Wu Z, McGoogan JM. Characteristics of and important lessons from the
coronavirus disease 2019 (COVID-19) outbreak in China. JAMA 2020.
[Epub ahead of print]
5. Results of Random Sample Test: 4% of Hospital Staff Infected With
Coronavirus. RIVM Committed to health and sustainability. 2020. Available
at https://www.rivm.nl/en/news/result-of-random-sample-4-hospital-staff-
infected-with-coronavirus
6. Doremalen NV, Bushmaker T, Morris DH, Holbrook MG, Gamble A,
Williamson BN, et al. Aerosol and surface stability of SARS-CoV-2 as
compared with SARS-CoV-1. N Engl J Med 2020;382:1564–7.
7. Wolfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Muller
MA, et al. Virological assessment of hospitalized patients with COVID-
2019. Nature 2020. [Epub ahead of print]
8. Liu Y, Yan LM, Wan L, Xiang TX, Le A, Liu JM, et al. Viral dynamics
in mild and severe cases of COVID-19. Lancet Infect Dis 2020. [Epub
ahead of print]
9. Leung HL, Chu KW, Shiu YC, Chan KH, McDevitt JJ, Hau JP, et al.
Respiratory virus shedding in exhaled breath and efcacy of face masks.
Nat Med 2020. [Epub ahead of print]
<zdoi:doi: 10.1097/JCMA.0000000000000331>
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We noted that the DCt values of severe cases were significantly lower than those of mild cases at the time of admission (appendix). Nasopharyngeal swabs from both the left and right nasal cavities of the same patient were kept in a sample collection tube containing 3 mL of standard viral transport medium. All samples were collected according to WHO guidelines.5 The mean viral load of severe cases was around 60 times higher than that of mild cases, suggesting that higher viral loads might be associated with severe clinical outcomes. We further stratified these data according to the day of disease onset at the time of sampling. The DCt values of severe cases remained significantly lower for the first 12 days after onset than those of corresponding mild cases (figure A). We also studied serial samples from 21 mild and ten severe cases (figure B). Mild cases were found to have an early viral clearance, with 90% of these patients repeatedly testing negative on RT-PCR by day 10 post-onset. By contrast, all severe cases still tested positive at or beyond day 10 post-onset. Overall, our data indicate that, similar to SARS in 2002–03,6 patients with severe COVID-19 tend to have a high viral load and a long virus-shedding period. This finding suggests that the viral load of SARS-CoV-2 might be a useful marker for assessing disease severity and prognosis.
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Protecting healthcare workers from subclinical coronavirus infection
  • Jan 2020
  • 13
  • D Chang
  • H Xu
  • A Rebaza
  • L Sharma
  • Csd Cruz
Chang D, Xu H, Rebaza A, Sharma L, Cruz CSD. Protecting healthcare workers from subclinical coronavirus infection. Lancet Respir Med 2020;8:e13.
Respiratory virus shedding in exhaled breath and efficacy of face masks
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  • NAT MED
  • H L Leung
  • K W Chu
  • Y C Shiu
  • K H Chan
  • J J Mcdevitt
  • J P Hau
Leung HL, Chu KW, Shiu YC, Chan KH, McDevitt JJ, Hau JP, et al. Respiratory virus shedding in exhaled breath and efficacy of face masks. Nat Med 2020. [Epub ahead of print] <zdoi:doi: 10.1097/JCMA.0000000000000331>
The outbreak of COVID-19: an overview.
  • Jan 2020
  • 217
  • Wu