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      Nursing and the novel coronavirus: Risks and responsibilities in a global outbreak

      , PhD, MS, RN 1 , 2 , , , PhD, RN, PHN 1 , 3 , , PhD, WHNP‐BC, FAAN 4
      Journal of Advanced Nursing
      John Wiley and Sons Inc.

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          In December 2019, reports emerged of pneumonia clusters of unknown cause at health facilities in Wuhan, China. These cases were linked to a wet animal wholesale market in the region and, after extensive epidemiologic investigation, led to identification of a novel coronavirus (COVID‐19). COVID‐19 is among a family of viruses – called coronaviruses – that can affect both humans and animals (Zhu et al., 2020). Coronavirus infections are respiratory in nature and can range from the common cold with mild symptoms to more severe infections, such as severe acute respiratory syndrome and Middle East respiratory syndrome (Perlman, 2020; World Health Organization [WHO], 2020). The newly identified COVID‐19 infection typically presents as fever, tiredness, fatigue, and dry cough (Huang et al., 2020). However, more severe symptoms such as dyspnoea, diarrhoea, pneumonia, and others have been reported. As of 9 March 2020, cases of COVID‐19 have been reported in countries across the world. The global number of reported cases has surpassed 100,000 with almost 4,000 deaths (WHO, 2020). China remains the highest risk area but, clearly, COVID‐19 is a global health problem. Nurses are central to COVID‐19 prevention and response efforts. Nursing is the largest healthcare profession in the US and the world, with approximately 3.8 million nurses in the US and over 20 million nurses worldwide. Nurses are providing front‐line care in the most patient‐facing role to complex COVID‐19 cases that require hospitalization. Individuals who have preexisting health vulnerabilities are at greatest risk for COVID‐19 complications or mortality and nursing resources are critical to managing this population. Public health experts predict that healthcare and hospital resources will become even more urgently needed as COVID‐19 spreads in communities (Jiang et al., 2020; Pan, Wang, & Huang, 2020). As one of the most trusted health professional groups, nurses also play a key role in providing public education on disease prevention and reducing the spread of misinformation around the outbreak. There has been widespread misinformation on how COVID‐19 is transmitted, who is at risk of transmitting or receiving the virus and where outbreaks are occurring (Wen, Aston, Liu, & Ying, 2020). For example, in some cases, Chinese and other Asian individuals have been assumed to be at higher risk for being infected with COVID‐19 simply because of their nationality or race, resulting in stigma and xenophobia (Wen et al., 2020). There has also been misinformation about appropriate use of face masks. Some individuals have assumed that they are protected from COVID‐19 by wearing a face mask – even though evidence is mixed from studies of other viral infections – and may neglect more efficacious infection prevention measures (e.g., handwashing) while also limiting the availability of face masks for response professionals who need them (Cowling, Zhou, Ip, Leung, & Aiello, 2010; WHO, 2020). Such misinformation may be spread via traditional media, social media, or in communities and can interfere with public health response efforts. Because of the unique patient‐facing nature of nursing work in community, outpatient, and acute care settings, there are occupational risks to providing care during the COVID‐19 outbreak. It is essential that nurses are supported to protect themselves during the management of COVID‐19 in clinical care with clear infection control protocols (standard, contact, and airborne) and adequate availability of personal protective equipment at their place of work, including/N95 respirators, masks, gowns, eye protection, face shields, and gloves (American Nurses Association [ANA], 2020). Healthcare facilities employing nurses must ensure consistent availability and use of hand hygiene supplies; provide updated information on screening, isolation, quarantine, and triage procedures based on guidance from the Centers for Disease Control and Prevention or other appropriate public health agencies; and coordinate with local, state, or national outbreak management efforts (ANA, 2020). Healthcare leaders should closely monitor the well‐being, occupational health, and safety of their clinical nursing staff. Nurses have a responsibility to stay home if they have travelled to areas that have declared states of emergency or contract COVID‐19 in their work. Healthcare leaders must support and provide resources for nurses who are exposed to COVID‐19 or experience other outbreak‐related harm as a result of their work, even if nursing resources become strained. Despite these occupational risks and the immediate need for health system interventions to support nurses, nursing also has unique responsibilities in the COVID‐19 outbreak. Nurses will continue to be at the front line of patient care in hospitals and closely involved with assessment and monitoring in outpatient and community settings. They must ensure that all patients receive individualized, high‐quality care regardless of their infection status and participate in preparation for increased nursing and health system demand related to COVID‐19. Nurses also must continue to provide education to patients and the public about the outbreak. This includes confronting misinformation, directing communities to reputable public health resources such as the World Health Organization and Centers for Disease Control and Prevention and promoting evidence‐based infection prevention measures (Centers for Disease Control & Prevention, 2020; WHO, 2020). Leaders and educators in nursing should provide education to clinical nurses and support staff about current COVID‐19 issues and risks specific to their practice area (e.g., paediatrics, maternal–infant health, nursing homes, schools, places of worship). This education should extend to nursing students, who may have additional considerations related to being in a campus environment. Finally, nurses should advocate for local, state, and national policy response to the COVID‐19 outbreak and support local preparedness and prevention efforts (International Council of Nurses, 2020; National Nurses United, 2020). Particularly, there is a need for care coordination across public health departments, communities, and healthcare systems that nurses are ideally suited to providing. A global outbreak requires the active participation of the nursing workforce in clinical care, education and information sharing, public health, and policy. Nurses are already fully engaged in COVID‐19 response and, with appropriate support, will be key players in ending the outbreak. CONFLICT OF INTEREST No conflict of interest was declared by the authors in relation to the study itself. Note that M. Cynthia LOGSDON is a JAN editor but, in line with usual practice, this paper was edited by another editor. Funding information This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.

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          Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

          Summary Background A recent cluster of pneumonia cases in Wuhan, China, was caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). We report the epidemiological, clinical, laboratory, and radiological characteristics and treatment and clinical outcomes of these patients. Methods All patients with suspected 2019-nCoV were admitted to a designated hospital in Wuhan. We prospectively collected and analysed data on patients with laboratory-confirmed 2019-nCoV infection by real-time RT-PCR and next-generation sequencing. Data were obtained with standardised data collection forms shared by WHO and the International Severe Acute Respiratory and Emerging Infection Consortium from electronic medical records. Researchers also directly communicated with patients or their families to ascertain epidemiological and symptom data. Outcomes were also compared between patients who had been admitted to the intensive care unit (ICU) and those who had not. Findings By Jan 2, 2020, 41 admitted hospital patients had been identified as having laboratory-confirmed 2019-nCoV infection. Most of the infected patients were men (30 [73%] of 41); less than half had underlying diseases (13 [32%]), including diabetes (eight [20%]), hypertension (six [15%]), and cardiovascular disease (six [15%]). Median age was 49·0 years (IQR 41·0–58·0). 27 (66%) of 41 patients had been exposed to Huanan seafood market. One family cluster was found. Common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhoea (one [3%] of 38). Dyspnoea developed in 22 (55%) of 40 patients (median time from illness onset to dyspnoea 8·0 days [IQR 5·0–13·0]). 26 (63%) of 41 patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα. Interpretation The 2019-nCoV infection caused clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus and was associated with ICU admission and high mortality. Major gaps in our knowledge of the origin, epidemiology, duration of human transmission, and clinical spectrum of disease need fulfilment by future studies. Funding Ministry of Science and Technology, Chinese Academy of Medical Sciences, National Natural Science Foundation of China, and Beijing Municipal Science and Technology Commission.
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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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              Another Decade, Another Coronavirus

              For the third time in as many decades, a zoonotic coronavirus has crossed species to infect human populations. This virus, provisionally called 2019-nCoV, was first identified in Wuhan, China, in persons exposed to a seafood or wet market. The rapid response of the Chinese public health, clinical, and scientific communities facilitated recognition of the clinical disease and initial understanding of the epidemiology of the infection. First reports indicated that human-to-human transmission was limited or nonexistent, but we now know that such transmission occurs, although to what extent remains unknown. Like outbreaks caused by two other pathogenic human respiratory coronaviruses (severe acute respiratory syndrome coronavirus [SARS-CoV] and Middle East respiratory syndrome coronavirus [MERS-CoV]), 2019-nCoV causes respiratory disease that is often severe. 1 As of January 24, 2020, there were more than 800 reported cases, with a mortality rate of 3% (https://promedmail.org/). As now reported in the Journal, Zhu et al. 2 have identified and characterized 2019-nCoV. The viral genome has been sequenced, and these results in conjunction with other reports show that it is 75 to 80% identical to the SARS-CoV and even more closely related to several bat coronaviruses. 3 It can be propagated in the same cells that are useful for growing SARS-CoV and MERS-CoV, but notably, 2019-nCoV grows better in primary human airway epithelial cells than in standard tissue-culture cells, unlike SARS-CoV or MERS-CoV. Identification of the virus will allow the development of reagents to address key unknowns about this new coronavirus infection and guide the development of antiviral therapies. First, knowing the sequence of the genome facilitates the development of sensitive quantitative reverse-transcriptase–polymerase-chain-reaction assays to rapidly detect the virus. Second, the development of serologic assays will allow assessment of the prevalence of the infection in humans and in potential zoonotic sources of the virus in wet markets and other settings. These reagents will also be useful for assessing whether the human infection is more widespread than originally thought, since wet markets are present throughout China. Third, having the virus in hand will spur efforts to develop antiviral therapies and vaccines, as well as experimental animal models. Much still needs to be learned about this infection. Most important, the extent of interhuman transmission and the spectrum of clinical disease need to be determined. Transmission of SARS-CoV and MERS-CoV occurred to a large extent by means of superspreading events. 4,5 Superspreading events have been implicated in 2019-nCoV transmission, but their relative importance is unknown. Both SARS-CoV and MERS-CoV infect intrapulmonary epithelial cells more than cells of the upper airways. 4,6 Consequently, transmission occurs primarily from patients with recognized illness and not from patients with mild, nonspecific signs. It appears that 2019-nCoV uses the same cellular receptor as SARS-CoV (human angiotensin-converting enzyme 2 [hACE2]), 3 so transmission is expected only after signs of lower respiratory tract disease develop. SARS-CoV mutated over the 2002–2004 epidemic to better bind to its cellular receptor and to optimize replication in human cells, enhancing virulence. 7 Adaptation readily occurs because coronaviruses have error-prone RNA-dependent RNA polymerases, making mutations and recombination events frequent. By contrast, MERS-CoV has not mutated substantially to enhance human infectivity since it was detected in 2012. 8 It is likely that 2019-nCoV will behave more like SARS-CoV and further adapt to the human host, with enhanced binding to hACE2. Consequently, it will be important to obtain as many temporally and geographically unrelated clinical isolates as possible to assess the degree to which the virus is mutating and to assess whether these mutations indicate adaptation to the human host. Furthermore, if 2019-nCoV is similar to SARS-CoV, the virus will spread systemically. 9 Obtaining patient samples at autopsy will help elucidate the pathogenesis of the infection and modify therapeutic interventions rationally. It will also help validate results obtained from experimental infections of laboratory animals. A second key question is identification of the zoonotic origin of the virus. Given its close similarity to bat coronaviruses, it is likely that bats are the primary reservoir for the virus. SARS-CoV was transmitted to humans from exotic animals in wet markets, whereas MERS-CoV is transmitted from camels to humans. 10 In both cases, the ancestral hosts were probably bats. Whether 2019-nCoV is transmitted directly from bats or by means of intermediate hosts is important to understand and will help define zoonotic transmission patterns. A striking feature of the SARS epidemic was that fear played a major role in the economic and social consequences. Although specific anticoronaviral therapies are still in development, we now know much more about how to control such infections in the community and hospitals, which should alleviate some of this fear. Transmission of 2019-nCoV probably occurs by means of large droplets and contact and less so by means of aerosols and fomites, on the basis of our experience with SARS-CoV and MERS-CoV. 4,5 Public health measures, including quarantining in the community as well as timely diagnosis and strict adherence to universal precautions in health care settings, were critical in controlling SARS and MERS. Institution of similar measures will be important and, it is hoped, successful in reducing the transmission of 2019-nCoV.

                Author and article information

                Role: Assistant Professor, Adjunct Investigatorkrchoi@ucla.edu
                Role: Assistant Professor
                Role: Professor
                J Adv Nurs
                J Adv Nurs
                Journal of Advanced Nursing
                John Wiley and Sons Inc. (Hoboken )
                15 April 2020
                : 10.1111/jan.14369
                [ 1 ] School of Nursing UCLA Los Angeles CA USA
                [ 2 ] Department of Research & Evaluation Kaiser Permanente Southern California Pasadena CA USA
                [ 3 ] Center for the Study of Racism Social Justice & Health, Fielding School of Public Health UCLA Los Angeles CA USA
                [ 4 ] School of Nursing University of Louisville Louisville KY USA
                Author notes
                [*] [* ] Correspondence

                Kristen R. Choi, School of Nursing, UCLA, Los Angeles, CA, USA

                Email: krchoi@ 123456ucla.edu

                Author information
                © 2020 John Wiley & Sons Ltd

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                : 10 March 2020
                : 19 March 2020
                Page count
                Figures: 0, Tables: 0, Pages: 2, Words: 3373
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