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Author: Kenneth McIntosh, MD

Section Editor: Martin S Hirsch, MD
Deputy Editor: Allyson Bloom, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan 2020. | This topic last updated: Feb 07, 2020.

INTRODUCTION

Coronaviruses are important human and animal pathogens. At the end of 2019, a novel
coronavirus, currently designated 2019-nCoV, was identified as the cause of a cluster of pneumonia
cases in Wuhan, a city in the Hubei Province of China. It rapidly spread, resulting in an epidemic
throughout China, with sporadic cases reported globally.

Understanding of this novel coronavirus is evolving. Interim guidance has been issued by the World
Health Organization and by the United States Centers for Disease Control and Prevention [1-3].
Links to these and other related society guidelines are found elsewhere. (See 'Society guideline
links' below.)

This topic will discuss the epidemiology, clinical features, diagnosis, management, and prevention of
2019-CoV infection. Community-acquired coronaviruses, severe acute respiratory syndrome
(SARS) coronavirus, and Middle East respiratory syndrome (MERS) coronavirus are discussed
separately. (See "Coronaviruses" and "Severe acute respiratory syndrome (SARS)" and "Middle
East respiratory syndrome coronavirus: Virology, pathogenesis, and epidemiology".)

EPIDEMIOLOGY

Geographic distribution — Since the first reports of cases from Wuhan, a city in the Hubei
Province of China, at the end of 2019, more than 30,000 laboratory-confirmed cases in China have
been reported, and the case count has been rising daily. The majority of reports are from Hubei and
surrounding provinces, but numerous cases have been reported in other provinces and
municipalities throughout China [4,5]. Sporadic but increasing cases have also been reported in
other countries globally (including countries in Asia and Europe, as well as Australia, the United
States [Washington state, Illinois, California, Arizona, Massachusetts, and Wisconsin], and
Canada), mainly among travelers from China [6-10]. Updated case counts in English can be found
on the World Health Organization and European Centre for Disease Prevention and Control
websites.

Transmission — Understanding of the transmission risk is incomplete.

Epidemiologic investigation in Wuhan identified an initial association with a seafood market where
most patients had worked or visited and which was subsequently closed for disinfection [11]. The
seafood market also sold live rabbits, snakes, and other animals.

However, as the outbreak progressed, most laboratory-confirmed cases had no contact with this
market, and cases were identified among health care workers and other contacts of patients with
2019-nCoV infection. Human-to-human transmission has been confirmed in China [12] and has also
been identified in other countries [13], including the United States. The question of whether
asymptomatic individuals infected with 2019-nCoV can transmit the virus to others remains
controversial [14,15].

VIROLOGY

Full-genome sequencing and phylogenic analysis indicated that 2019-nCoV is a betacoronavirus in

the same subgenus as the severe acute respiratory syndrome (SARS) virus (as well as several bat
coronaviruses), but in a different clade. The apparent structure of the receptor-binding gene region
was very similar to that of the SARS coronavirus, and there is speculation that it will be shown to
use the same receptor for cell entry. The Middle East respiratory syndrome (MERS) virus, another
betacoronavirus, was more distantly related [16,17]. The closest RNA sequence similarity is to two
bat coronaviruses, and it appears likely that bats are the primary source; whether 2019-nCoV is
transmitted directly from bats or through some other mechanism (eg, through an intermediate host)
is unknown [18]. (See "Coronaviruses", section on 'Viral serotypes'.)

CLINICAL FEATURES

Incubation period — The incubation period of 2019-nCoV is thought to be within 14 days following
exposure.
In a family cluster of infections, the onset of fever and respiratory symptoms occurred approximately
three to six days after presumptive exposure [19]. Similarly, in an analysis of 10 patients with
confirmed 2019-nCoV-associated pneumonia, the estimated mean incubation period was five days
[12].

Clinical presentation — Pneumonia appears to be the most frequent manifestation of infection,

characterized primarily by fever, cough, dyspnea, and bilateral infiltrates on chest imaging [20,21].
However, patients can present with a spectrum of disease, ranging from mild respiratory illnesses,
particularly in younger adults or children, to severe disease (including respiratory failure, septic
shock, or other organ failure requiring intensive care) [19,22,23]. The frequency of asymptomatic or
mild infection is unknown, but approximately 20 percent of confirmed patients have had critical
illness. The overall case fatality rate is uncertain but appears to be less than 3 percent [24]. Most of
the fatal cases have occurred in patients with underlying medical comorbidities.

In a study describing 41 of the initial cases of pneumonia identified in the outbreak, 73 percent of
cases were males, and the median age was 49 years (interquartile range 41 to 58 years) [20].
Nearly all (98 percent) reported fever, 76 percent had cough, and 44 percent had myalgias/fatigue.
Dyspnea developed in 55 percent after a median of eight days of illness, suggesting the possibility
of clinical deterioration later in the course of illness. Lymphopenia was common, and all patients
had parenchymal lung abnormalities on computed tomography of the chest, including ground glass
opacities, subsegmental consolidation, and multilobular consolidation. Acute respiratory distress
syndrome developed in 30 percent, and mechanical ventilation was implemented in 10 percent.
Upper respiratory symptoms and diarrhea were both seen but in fewer than 10 percent. Similar
clinical features were described in a cohort of 99 patients with confirmed 2019-nCoV infection
admitted to an infectious disease specialty hospital in Wuhan [21].

EVALUATION AND DIAGNOSIS

The approach to initial management should focus on early recognition of suspect cases, immediate
isolation, and institution of infection control measures. At present, the possibility of 2019-nCoV
should be considered in patients with fever and/or lower respiratory tract symptoms who reside in or
have recently (within the prior 14 days) traveled to China or who have had recent (within the prior 14
days) close contact with a confirmed or suspected case of 2019-nCoV.

When 2019-nCoV is suspected, infection control measures should be implemented and public
health officials notified. Infection control precautions are discussed elsewhere. (See 'Infection
control for suspected or confirmed cases' below.)
The specific case definitions and clinical criteria for diagnostic evaluation differ slightly between
expert groups. Suspect case definitions from the World Health Organization are found in its
technical guidance online; clinical criteria for patients under investigation from the United States
Centers for Disease Control and Prevention (CDC) are detailed in the table (table 1).

For patients who meet their criteria, in addition to testing for other respiratory pathogens, the CDC
recommends collection of specimens for 2019-nCoV testing from the upper respiratory tract
(nasopharyngeal and oropharyngeal swab) and, if possible, the lower respiratory tract (sputum,
tracheal aspirate, or bronchoalveolar lavage). Induction of sputum is not indicated. Additional
specimens (eg, stool, urine) can also be collected. 2019-nCoV is detected by polymerase chain
reaction; in the United States, testing is performed by the CDC or a CDC-qualified lab [3].

For safety reasons, specimens from a patient with suspected or documented 2019-nCoV should not
be submitted for viral culture.

MANAGEMENT

Hospital care — Management of patients with suspected or documented 2019-nCoV infections

consists of ensuring appropriate infection control, as below (see 'Infection control for suspected or
confirmed cases' below), and supportive care. Clinical guidance can be found on the World Health
Organization (WHO) and Centers for Disease Control and Prevention (CDC) websites [25,26].

Supportive care for sepsis and acute respiratory distress syndrome is discussed elsewhere. (See
"Evaluation and management of suspected sepsis and septic shock in adults" and "Acute
respiratory distress syndrome: Supportive care and oxygenation in adults".)

The WHO and CDC generally recommend glucocorticoids not be used in 2019-nCoV pneumonia
unless there are other indications (such as exacerbation of chronic obstructive pulmonary disease)
[25,26]. Glucocorticoids have been associated with an increased risk for mortality in patients with
influenza and delayed viral clearance in patients with Middle East respiratory syndrome coronavirus
(MERS-CoV) infection. Although they were widely used in management of severe acute respiratory
syndrome (SARS), there was no good evidence for benefit, and there was persuasive evidence of
adverse short- and long-term harms [27]. (See "Treatment of seasonal influenza in adults", section
on 'Adjunctive therapies' and "Middle East respiratory syndrome coronavirus: Treatment and
prevention", section on 'Treatment'.)

Investigational agents are being explored for antiviral treatment of 2019-nCoV infections. As an
example, the manufacturer of remdesivir, a novel nucleotide analogue that has activity against
related coronaviruses (including SARS and MERS-CoV) in vitro and in animal studies [28], is
planning randomized clinical trials in China to evaluate the efficacy and safety of remdesivir against
2019-nCoV [29]. The compassionate use of remdesivir through an investigational new drug
application was described in a case report of one of the first patients with 2019-nCoV infection in the
United States [30]. Any clinical impact of remdesivir on 2019-nCoV remains unknown.

Home care — Home management may be appropriate for patients with mild infection who can be
adequately isolated in the outpatient setting [25,26]. Management of such patients should focus on
prevention of transmission to others, and monitoring for clinical deterioration, which should prompt
hospitalization.

Interim recommendations on home management of patients with 2019-nCoV infections can be

found on the WHO and CDC websites [31-33].

PREVENTION

Infection control for suspected or confirmed cases — Infection control to limit transmission is an
essential component of care of patients with suspected or documented 2019-nCoV infection.

Individuals with suspected infection in the community should be advised to wear a medical mask to
contain their respiratory secretions and seek medical attention. (See 'Evaluation and diagnosis'
above.)

In the health care setting, the World Health Organization (WHO) and United States Centers for
Disease Control and Prevention (CDC) recommendations for infection control for suspected or
confirmed infections differ slightly:

● The WHO recommends standard, contact, and droplet precautions, with eye or face protection
[34]. The addition of airborne precautions is warranted during aerosol-generating procedures,
such as tracheal intubation, non-invasive ventilation, tracheotomy, cardiopulmonary
resuscitation, manual ventilation before intubation, and bronchoscopy.

● The CDC recommends standard, contact, and airborne precautions, with eye protection [35]. If
an airborne infection isolation room (ie, a single patient negative pressure room) is not readily
available, the patient should wear a mask and be placed in a private room with the door closed,
and any personnel entering the room should wear the appropriate personal protection
equipment. Patients with suspected or confirmed 2019-nCoV infection who require
hospitalization should be cared for in a facility that can provide an airborne infection isolation
room.

Elements of the different types of infection control precautions are detailed in the table (table 2).
Preventing exposure — The WHO advises general measures to reduce transmission of infection,
including diligent hand washing, respiratory hygiene, and avoiding close contact with live or dead
animals and ill individuals.

It notes that for people without respiratory symptoms, wearing a medical mask in the community is
not required, even if 2019-nCoV is prevalent in the area; wearing a mask does not decrease the
importance of other general measures to prevent infection, and it may result in unnecessary cost
and supply problems [36].

Individuals who are caring for patients with suspected or documented 2019-nCoV at home,
however, should wear a tightly fitting medical mask when in the same room as that patient.

Global public health measures — On January 30, 2020, the WHO declared the 2019-nCoV
outbreak a public health emergency of international concern.

The WHO does not recommend international travel restrictions but does acknowledge that
movement restriction may be temporarily useful in some settings. The WHO advises exit screening
for international travelers from areas with ongoing transmission of 2019-nCoV to identify individuals
with fever, cough, or potential high-risk exposure [37].

In China, health officials announced a restriction of public transportation within and a halt of air and
rail traffic out of Wuhan and other surrounding areas [4]. In the United States, the CDC
recommends that individuals avoid all nonessential travel to China [38]; United States citizens
returning from the Hubei Province are undergoing a 14-day quarantine, while those returning from
other parts of China are undergoing screening for signs of illness on arrival (with subsequent self-
monitoring) as long as there is no known high-risk exposure; foreign nationals who have been in
China in the prior 14 days are temporarily suspended from entry. Additional guidance regarding risk
assessment and management of persons with a suspected exposure to 2019-nCoV can be found
on the CDC website [39].

SPECIAL POPULATIONS

Pregnant women — Minimal information is available regarding 2019-nCoV infection during

pregnancy. One case of mother-to-child transmission has been reported [40]. The approach to
prevention, evaluation, diagnosis, and treatment of pregnant women with suspected 2019-nCoV
infection should be similar to that in nonpregnant individuals (as described above), with
consideration that pregnant women with other potentially severe respiratory infections, such as
influenza, severe acute respiratory syndrome (SARS)-CoV, or Middle East respiratory syndrome
(MERS)-CoV, appear to be more vulnerable to developing severe sequelae.
SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Novel coronavirus".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients
who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topic (see "Patient education: 2019 novel coronavirus (The Basics)")

SUMMARY AND RECOMMENDATIONS

● In late 2019, a novel coronavirus, designated 2019-nCoV, was identified as the cause of an
outbreak of acute respiratory illness. It has subsequently spread to include more than 30,000
cases in China and scattered but increasing cases worldwide, prompting the World Health
Organization (WHO) to declare a public health emergency in late January 2020. (See
'Epidemiology' above.)

● The possibility of 2019-nCoV should be considered in patients with fever and/or lower
respiratory tract symptoms who reside in or have recently (within the prior 14 days) traveled to
China or who have had recent (within the prior 14 days) close contact with a confirmed or
suspected case of 2019-nCoV (table 1). (See 'Clinical features' above and 'Evaluation and
diagnosis' above.)

● Upon suspicion, infection control measures should be implemented and public health officials
notified. In health care settings in the United States, the Centers for Disease Control and
 Prevention (CDC) recommends standard, contact, and airborne precautions (table 2), as well
as eye protection. (See 'Infection control for suspected or confirmed cases' above.)

● In addition to testing for other respiratory pathogens, upper and lower respiratory tract
specimens should be collected for 2019-nCoV testing. Additional specimens (eg, stool, urine)
can also be collected. (See 'Evaluation and diagnosis' above.)

● Management consists of supportive care. Home management may be possible for patients with
mild illness who can be adequately isolated in the outpatient setting. (See 'Management'
above.)

● The WHO has issued interim guidance on surveillance case definitions, laboratory diagnosis,
and clinical management. The CDC has also issued interim guidance. (See 'Society guideline
links' above.)

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