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      Lessons for managing high-consequence infections from first COVID-19 cases in the UK

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          Abstract

          Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of an ongoing international outbreak of respiratory illness, known as coronavirus disease 2019 (COVID-19).1, 2, 3 In the week commencing Jan 27, 2020, the first two cases were diagnosed in England. Both patients were identified as being at risk while still in the community, and transported directly from their hotel to the regional Infectious Disease Unit at Hull University Teaching Hospitals. The patients were met on arrival by medical and nursing staff using enhanced personal protective equipment, in accordance with national guidance. They were placed in separate negative pressure rooms with antechambers, and managed there until the results of tests were available. Once both patients were confirmed to have SARS-CoV-2, they were transferred to the designated High-Consequence Infectious Diseases (HCID) Unit in Newcastle, UK. These first UK cases of COVID-19 raise important points about the management of cases of HCID in England. The decision to test for SARS-CoV-2 is based on a clinical and epidemiological case definition, and testing is only approved if this is met. When tested, neither of these people clearly met the current case definition, and had criteria been strictly applied, testing might not have been done. A decision to test was made because of high clinical suspicion and in response to latest available information about the distribution of infection. It is important that testing is appropriately targeted, and this is best done by applying clear case definitions. However, with any newly emerging infection, case definitions must evolve rapidly as information accrues. There should also be room for flexibility on the basis of discussion with clinical and public health experts. These patients were identified in the community and were transferred directly to a specialist isolation facility for assessment. Once the diagnosis was confirmed, the patients were moved to one of the HCID Units commissioned by National Health Service (NHS) England. These units are funded centrally and have to comply with a national specification for the management of confirmed HCID. However, the management and assessment of possible cases of HCID (when the risk of nosocomial transmission may be higher, as has been shown elsewhere in the current outbreak, and in other cases of HCID in England 4 ) remains locally commissioned, with no central funding or specification. There is little incentive for acute NHS Trusts or Clinical Commissioning Groups to commission isolation facilities, or to maintain a pool of trained staff, as funding mechanisms are unlikely to cover the significant investment required. Although many areas (as in this case) do have effective local arrangements based on locally commissioned isolation facilities, there are other parts of the country where there are no such facilities and expertise in managing highly transmissible infections is limited. The HCID Units should be supported by a second tier of appropriately commissioned regional facilities so that high-risk suspected cases can be assessed safely and risk of nosocomial transmission minimised.

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          A Novel Coronavirus from Patients with Pneumonia in China, 2019

          Summary In December 2019, a cluster of patients with pneumonia of unknown cause was linked to a seafood wholesale market in Wuhan, China. A previously unknown betacoronavirus was discovered through the use of unbiased sequencing in samples from patients with pneumonia. Human airway epithelial cells were used to isolate a novel coronavirus, named 2019-nCoV, which formed a clade within the subgenus sarbecovirus, Orthocoronavirinae subfamily. Different from both MERS-CoV and SARS-CoV, 2019-nCoV is the seventh member of the family of coronaviruses that infect humans. Enhanced surveillance and further investigation are ongoing. (Funded by the National Key Research and Development Program of China and the National Major Project for Control and Prevention of Infectious Disease in China.)
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            Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study

            Summary Background Since Dec 31, 2019, the Chinese city of Wuhan has reported an outbreak of atypical pneumonia caused by the 2019 novel coronavirus (2019-nCoV). Cases have been exported to other Chinese cities, as well as internationally, threatening to trigger a global outbreak. Here, we provide an estimate of the size of the epidemic in Wuhan on the basis of the number of cases exported from Wuhan to cities outside mainland China and forecast the extent of the domestic and global public health risks of epidemics, accounting for social and non-pharmaceutical prevention interventions. Methods We used data from Dec 31, 2019, to Jan 28, 2020, on the number of cases exported from Wuhan internationally (known days of symptom onset from Dec 25, 2019, to Jan 19, 2020) to infer the number of infections in Wuhan from Dec 1, 2019, to Jan 25, 2020. Cases exported domestically were then estimated. We forecasted the national and global spread of 2019-nCoV, accounting for the effect of the metropolitan-wide quarantine of Wuhan and surrounding cities, which began Jan 23–24, 2020. We used data on monthly flight bookings from the Official Aviation Guide and data on human mobility across more than 300 prefecture-level cities in mainland China from the Tencent database. Data on confirmed cases were obtained from the reports published by the Chinese Center for Disease Control and Prevention. Serial interval estimates were based on previous studies of severe acute respiratory syndrome coronavirus (SARS-CoV). A susceptible-exposed-infectious-recovered metapopulation model was used to simulate the epidemics across all major cities in China. The basic reproductive number was estimated using Markov Chain Monte Carlo methods and presented using the resulting posterior mean and 95% credibile interval (CrI). Findings In our baseline scenario, we estimated that the basic reproductive number for 2019-nCoV was 2·68 (95% CrI 2·47–2·86) and that 75 815 individuals (95% CrI 37 304–130 330) have been infected in Wuhan as of Jan 25, 2020. The epidemic doubling time was 6·4 days (95% CrI 5·8–7·1). We estimated that in the baseline scenario, Chongqing, Beijing, Shanghai, Guangzhou, and Shenzhen had imported 461 (95% CrI 227–805), 113 (57–193), 98 (49–168), 111 (56–191), and 80 (40–139) infections from Wuhan, respectively. If the transmissibility of 2019-nCoV were similar everywhere domestically and over time, we inferred that epidemics are already growing exponentially in multiple major cities of China with a lag time behind the Wuhan outbreak of about 1–2 weeks. Interpretation Given that 2019-nCoV is no longer contained within Wuhan, other major Chinese cities are probably sustaining localised outbreaks. Large cities overseas with close transport links to China could also become outbreak epicentres, unless substantial public health interventions at both the population and personal levels are implemented immediately. Independent self-sustaining outbreaks in major cities globally could become inevitable because of substantial exportation of presymptomatic cases and in the absence of large-scale public health interventions. Preparedness plans and mitigation interventions should be readied for quick deployment globally. Funding Health and Medical Research Fund (Hong Kong, China).
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              Human-to-Human Transmission of Monkeypox Virus, United Kingdom, October 2018

              In September 2018, monkeypox virus was transmitted from a patient to a healthcare worker in the United Kingdom. Transmission was probably through contact with contaminated bedding. Infection control precautions for contacts (vaccination, daily monitoring, staying home from work) were implemented. Of 134 potential contacts, 4 became ill; all patients survived.
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                Author and article information

                Contributors
                Journal
                Lancet
                Lancet
                Lancet (London, England)
                Elsevier Ltd.
                0140-6736
                1474-547X
                27 February 2020
                14-20 March 2020
                27 February 2020
                : 395
                : 10227
                : e46
                Affiliations
                [a ]Department of Infection, Hull University Teaching Hospitals NHS Trust, Hull HU16 5JQ, UK
                Article
                S0140-6736(20)30463-3
                10.1016/S0140-6736(20)30463-3
                7133597
                32113507
                245a7372-4600-4bf6-96f6-7bdd7f4f6042
                © 2020 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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