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10 1056@NEJMp2000929
10 1056@NEJMp2000929
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A Novel Coronavirus Emerging in China
Table 1. Pathogenicity and Transmissibility Characteristics of Recently Emerged Viruses in Relation to Outbreak Containment.
Case Fatality
Virus Rate (%) Pandemic Contained Remarks
2019-nCoV Unknown* Unknown No, efforts ongoing
pH1N1 0.02–0.4 Yes No, postpandemic circulation and es-
tablishment in human population
H7N9 39 No No, eradication efforts in poultry res-
ervoir ongoing
NL63 Unknown Unknown No, endemic in human population
SARS-CoV 9.5 Yes Yes, eradicated from intermediate ani- 58% of cases result from nos-
mal reservoir ocomial transmission
MERS-CoV 34.4 No No, continuous circulation in animal 70% of cases result from nos-
reservoir and zoonotic spillover ocomial transmission
Ebola virus (West 63 No Yes
Africa)
* Number will most likely continue to change until all infected persons recover.
es raise an additional question: ing the relationship between SARS-CoV — cause disease of
How widespread is the virus in transmissibility and pathogenici- different severity. Whereas NL63
its reservoir? Currently, epidemi- ty of respiratory viruses has been usually causes mild upper respi-
ologic data that would allow us influenced by our understanding ratory tract disease and is en-
to draw this pyramid are largely of influenza A virus: the change demic in the human population,
unavailable (see diagram). in receptor specificity necessary SARS-CoV induced severe lower
Clearly, efficient human-to- for efficient human-to-human respiratory tract disease with a
human transmission is a require- transmission of avian influenza case-fatality rate of about 11%
ment for large-scale spread of this viruses leads to a tropism shift (see table). SARS-CoV was even-
emerging virus. However, the se- from the lower to the upper respi- tually contained by means of
verity of disease is an important ratory tract, resulting in a lower syndromic surveillance, isolation
indirect factor in a virus’s ability disease burden. Two primary — of patients, and quarantine of their
to spread, as well as in our ability and recent — examples are the contacts. Thus, disease severity is
to identify those infected and to pandemic H1N1 virus and the avi- not necessarily linked to transmis-
contain it — a relationship that an influenza H7N9 virus. Whereas sion efficiency.
holds true whether an outbreak the pandemic H1N1 virus — Even if a virus causes subclini-
results from a single spillover binding to receptors in the upper cal or mild disease in general,
event (SARS-CoV) or from repeat- respiratory tract — caused rela- some people may be more suscep-
ed crossing of the species barrier tively mild disease and became tible and end up seeking care. The
(MERS-CoV). endemic in the population, the majority of SARS-CoV and MERS-
If infection does not cause se- H7N9 virus — binding to recep- CoV cases were associated with
rious disease, infected people prob- tors in the lower respiratory tract nosocomial transmission in hos-
ably will not end up in health care — has a case-fatality rate of ap- pitals,5 resulting at least in part
centers. Instead, they will go to proximately 40% and has so far from the use of aerosol-generat-
work and travel, thereby potential- resulted in only a few small clus- ing procedures in patients with
ly spreading the virus to their con- ters of human-to-human trans- respiratory disease. In particular,
tacts, possibly even internationally. mission. nosocomial super-spreader events
Whether subclinical or mild dis- It is tempting to assume that appear to have driven large out-
ease from 2019-nCoV is also as- this association would apply to breaks within and between health
sociated with a reduced risk of other viruses as well, but such a care settings. For example, travel
virus spread remains to be deter- similarity is not a given: two from Hong Kong to Toronto by
mined. coronaviruses that use the same one person with SARS-CoV result-
Much of our thinking regard- receptor (ACE2) — NL63 and ed in 128 SARS cases in a local
naviruses. In addition to the vul- complicated by violent conflict, From the Laboratory of Virology, National
nerability of health care settings all previous outbreaks were con- Institute of Allergy and Infectious Diseases,
to outbreaks of emerging coro- tained through identification of National Institutes of Health, Hamilton, MT
(V.J.M., N.D., E.W.); and the Department of
naviruses, hospital populations cases and tracing of contacts, de- Viroscience, Erasmus Medical Center, Rot-
are at significantly increased risk spite the virus’s efficient person- terdam, the Netherlands (M.K., D.R.).
for complications from infection. to-person transmission. This article was published on January 24,
Age and coexisting conditions We currently do not know 2020, at NEJM.org.
(such as diabetes or heart dis- where 2019-nCoV falls on the scale 1. Disease outbreak news (DONs). Geneva:
ease) are independent predictors of human-to-human transmissi- World Health Organization, 2020 (https://
of adverse outcome in SARS-CoV bility. But it is safe to assume that www.who.int/csr/don/en/).
2. de Wit E, van Doremalen N, Falzarano
and MERS-CoV. Thus, emerging if this virus transmits efficiently, D, Munster VJ. SARS and MERS: recent in-
viruses that may go undetected its seemingly lower pathogenicity sights into emerging coronaviruses. Nat Rev
because of a lack of severe dis- as compared with SARS, possibly Microbiol 2016;14:523-34.
3. Laboratory testing for 2019 novel corona-
ease in healthy people can pose combined with super-spreader virus (2019-nCoV) in suspected human cases.
significant risk to vulnerable pop- events in specific cases, could al- Geneva: World Health Organization, 2020
ulations with underlying medical low large-scale spread. In this (https://www.who.int/publications-detail/
laboratory-testing-for-2019-novel-coronavirus
conditions. manner, a virus that poses a low -(2019-ncov)-in-suspected-human-cases).
A lack of severe disease mani- health threat on the individual 4. Gibbons CL, Mangen M-JJ, Plass D, et al.
festations affects our ability to level can pose a high risk on the Measuring underreporting and under-ascer-
tainment in infectious disease datasets: a
contain the spread of the virus. population level, with the poten- comparison of methods. BMC Public Health
Identification of chains of trans- tial to cause disruptions of global 2014;14:147.
mission and subsequent contact public health systems and eco- 5. Chowell G, Abdirizak F, Lee S, et al.
Transmission characteristics of MERS and
tracing are much more complicat- nomic losses. This possibility SARS in the healthcare setting: a compara-
ed if many infected people remain warrants the current aggressive tive study. BMC Med 2015;13:210.
asymptomatic or mildly sympto- response aimed at tracing and DOI: 10.1056/NEJMp2000929
matic (assuming that these peo- diagnosing every infected patient Copyright © 2020 Massachusetts Medical Society.
A Novel Coronavirus Emerging in China