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Confirmed the coronavirus in a German tourist in La Gomera This is the analysis performed on one of the samples sent from La Gomera (Canary Islands). The patient is admitted and isolated in a hospital of the island. IN SUMMARY The affected had had direct contact with a person infected in Germany First case of coronavirus in Spain. The National Center for Microbiology has confirmed its presence in samples sent from La Gomera (Canary Islands). The patient is admitted and isolated in a hospital of the island. It is part of the group of five tourists who were already under observation on the island. Two of them had been in contact in Germany with a patient diagnosed with coronavirus infection. These people were located on the afternoon of Wednesday once the Ministry of Health of the Canary Islands Government was alerted by Health that these two people were in the Canary Islands. As foreseen in the protocol that has been explained these days, this Saturday there will be a ministerial meeting of evaluation and monitoring of the coronavirus, chaired by the minister, Salvador Illa, after which all available information on the case will be offered. There are currently more than 75,000 cases under study in Wuhan. In Europe there are already positives in the United Kingdom, France. Germany, Italy, Sweden and Finland. https://www.antena3.com/noticias/sociedad/confirmado-caso-coronavirus-gomera_202001315e34a9380cf2cfb788f47b07.html

Virus detail Virus name: BetaCoV/Germany/BavPat1/2020 Accession ID: EPI_ISL_406862 Type: betacoronavirus Passage details/history: Original Sample information Collection date: 2020-01-28 Location: Germany / Bavaria / Munich Host: Human Additional location information: Gender: male Patient age: NA Patient status: hospitalized Specimen source: Sputum Additional host information: Outbreak: Bavaria cluster patient 1 Last vaccinated: Treatment: Sequencing technology: Illumina MiSeq, Nanopore MinION Assembly method: Geneious v9 Coverage: Institute information Originating lab: Charité Universitätsmedizin Berlin, Institute of Virology; Institut für Mikrobiologie der Bundeswehr, Munich Address: Institute of Virology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Institut für Mikrobiologie der Bundeswehr, Neuherbergstraße 11, 80937 Munich, Germany Sample ID given by the sample provider: Submitting lab: Charité Universitätsmedizin Berlin, Institute of Virology Address: Charitéplatz 1, 10117 Berlin, Germany Sample ID given by the submitting laboratory: ChVir929 Authors: Victor M Corman, Julia Schneider, Talitha Veith, Barbara Mühlemann, Markus Antwerpen, Christian Drosten, Roman Wölfel Submitter information Submitter: Barbara Muehlemann Submission Date: 2020-01-31 Address: Institute of Virology, Charité Universitätsmedizin Berlin FASTA >BetaCoV/Germany/BavPat1/2020|EPI_ISL_406862

CORRESPONDENCE Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany TO THE EDITOR: The novel coronavirus (2019-nCoV) from Wuhan is currently causing concern in the medical community as the virus is spreading around the world.1 Since its identification in late December 2019, the number of cases from China that have been imported into other countries is on the rise, and the epidemiologic picture is changing on a daily basis. We are reporting a case of 2019-nCoV infection acquired outside of Asia in which transmission appears to have occurred during the incubation period in the index patient. A 33-year-old otherwise healthy German businessman (Patient 1) became ill with a sore throat, chills, and myalgias on January 24, 2020. The following day, a fever of 39.1°C (102.4°F) developed, along with a productive cough. By the evening of the next day, he started feeling better and went back to work on January 27. Figure 1.Timeline of Exposure to Index Patient with Asymptomatic 2019-CoV Infection in Germany. Before the onset of symptoms, he had attended meetings with a Chinese business partner at his company near Munich on January 20 and 21. The business partner, a Shanghai resident, had visited Germany between Jan. 19 and 22. During her stay, she had been well with no signs or symptoms of infection but had become ill on her flight back to China, where she tested positive for 2019-nCoV on January 26 (index patient in Figure 1). On January 27, she informed the company about her illness. Contact tracing was started, and the above-mentioned colleague was sent to the Division of Infectious Diseases and Tropical Medicine in Munich for further assessment. At presentation, he was afebrile and well. He reported no previous or chronic illnesses and had no history of foreign travel within 14 days before the onset of symptoms. Two nasopharyngeal swabs and one sputum sample were obtained and were found to be positive for 2019-nCoV on quantitative reverse-transcriptase–polymerase-chain-reaction (qRT-PCR) assay.2 Follow-up qRT-PCR assay revealed a high viral load of 108 copies per milliliter in his sputum during the following days, with the last available result on January 29. On January 28, three additional employees at the company tested positive for 2019-nCoV (Patients 2 through 4 in Figure 1). Of these patients, only Patient 2 had contact with the index patient; the other two patients had contact only with Patient 1. In accordance with the health authorities, all the patients with confirmed 2019-nCoV infection were admitted to a Munich infectious diseases unit for clinical monitoring and isolation. So far, none of the four confirmed patients show signs of severe clinical illness. This case of 2019-nCoV infection was diagnosed in Germany and transmitted outside of Asia. However, it is notable that the infection appears to have been transmitted during the incubation period of the index patient, in whom the illness was brief and nonspecific.3 The fact that asymptomatic persons are potential sources of 2019-nCoV infection may warrant a reassessment of transmission dynamics of the current outbreak. In this context, the detection of 2019-nCoV and a high sputum viral load in a convalescent patient (Patient 1) arouse concern about prolonged shedding of 2019-nCoV after recovery. Yet, the viability of 2019-nCoV detected on qRT-PCR in this patient remains to be proved by means of viral culture. Despite these concerns, all four patients who were seen in Munich have had mild cases and were hospitalized primarily for public health purposes. Since hospital capacities are limited — in particular, given the concurrent peak of the influenza season in the northern hemisphere — research is needed to determine whether such patients can be treated with appropriate guidance and oversight outside the hospital. Camilla Rothe, M.D. Mirjam Schunk, M.D. Peter Sothmann, M.D. Gisela Bretzel, M.D. Guenter Froeschl, M.D. Claudia Wallrauch, M.D. Thorbjörn Zimmer, M.D. Verena Thiel, M.D. Christian Janke, M.D. University Hospital LMU Munich, Munich, Germany [email protected] Wolfgang Guggemos, M.D. Michael Seilmaier, M.D. Klinikum München-Schwabing, Munich, Germany Christian Drosten, M.D. Charité Universitätsmedizin Berlin, Berlin, Germany Patrick Vollmar, M.D. Katrin Zwirglmaier, Ph.D. Sabine Zange, M.D. Roman Wölfel, M.D. Bundeswehr Institute of Microbiology, Munich, Germany Michael Hoelscher, M.D., Ph.D. University Hospital LMU Munich, Munich, Germany Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. This letter was published on January 30, 2020, at NEJM.org. 3 References 1.Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. DOI: 10.1056/NEJMoa2001017. Free Full Text Google Scholar. opens in new tab 2.Corman V, Bleicker T, Brünink S, et al. Diagnostic detection of Wuhan coronavirus 2019 by real-time RT-PCR. Geneva: World Health Organization, January 13, 2020 (https://www.who.int/docs/default-source/coronaviruse/wuhan-virus-assay-v1991527e5122341d99287a1b17c111902.pdf. opens in new tab). Google Scholar. opens in new tab 3.Callaway E, Cyranoski D. China coronavirus: six questions scientists are asking. Nature 2020;577:605-607. Crossref. opens in new tab Medline. opens in new tab Google Scholar https://t.co/jzMvGHBmiV?amp=1

Massachusetts’ First Case of New Coronavirus Diagnosed in Boston Student It's the eighth case in the United States amid an outbreak that has prompted public health emergency declarations around the world By Josh Sullivan and Asher Klein • Published 4 hours ago • Updated 24 mins ago A university student who recently traveled back to Boston from Wuhan, China, has been diagnosed as the first Massachusetts resident with the new coronavirus, state health officials said Saturday. It's the eighth diagnosis of the illness in the U.S. and the first on the East Coast. The man is in his 20s and lives in Boston, according to a news release from the Massachusetts Department of Public Health. He sought medical soon after his return to Massachusetts and has been isolated since then. He is currently quarantined at his home and will continue to be isolated until he is cleared by public health officials, according to Saturday's news release. His "few close contacts" have been identified and are being monitored for any sign of symptoms. The risk to the public in Massachusetts still remains low, state and local public health officials said in a conference call Saturday. "We are grateful that this young man is recovering and sought medical attention immediately," said Massachusetts Public Health Commissioner Monica Bharel in the written statement Saturday. "Massachusetts has been preparing for a possible case of this new coronavirus, and we were fortunate that astute clinicians took appropriate action quickly." UMass Boston confirmed in an email message to its community Saturday afternoon that a student had tested positive for the novel coronavirus. That case was confirmed late Friday night, health officials said. The student returned from China on Jan. 28, and sought medical attention for a runny nose the following day. The same day he arrived back in Boston, the Centers for Disease Control and Prevention announced a plan to screen passengers arriving from China at 20 different airports—including Logan Airport. Those screenings did not happen because of a "timing" issue, however, health officials said in the call on Saturday. They said that the CDC did not manage to get staff to the airports quickly enough. American public health officials have cautioned that the flu remains more dangerous for people in the United States, and no one has died from the virus in the U.S. "People should take the same precautions they do to prevent the spread of the cold and flu, and [the Massachusetts Department of Public Health] will continue to work with medical professionals across the Commonwealth," Gov. Charlie Baker tweeted. But on Friday, the White House declared a public health emergency over the outbreak, which is centered in Wuhan, China. The country has seen 259 people die and over 11,000 infected so far. Travel restrictions to the U.S. were announced for some foreign nationals on Friday as well, with screening boosted at airports around the country, including Boston Logan International Airport. China has severely restricted internal travel as it attempts to stop the spread of the virus. The World Health Organization also declared a global health emergency over the outbreak. Prepare for Coronavirus Boston Mayor Marty Walsh addressed the illness to the public on Jan. 27. "We are in the best position to respond if the virus does spread" to Boston, Walsh said, noting its many world-class hospitals. The respiratory virus spreads through close face-to-face contact over time, not simply with casual contact, according to state and local health officials. He said that the Boston Public Health Commission set up an internal incident command system to quickly address any possible cases that arise and to advise local health care groups ahead of time on the best ways to prepare. https://www.nbcboston.com/news/local/first-reported-case-of-coronavirus-in-massachusetts/2070535/

Eighth Corona Virus Case in Bavaria There is another employee of the company Webasto ++ Tests of further employees still pending ++ Air force jet from Wuhan back in Germany ++ Eleven people in university clinic Source: BILD0:42 min. divide Tweet send by mailpublished on02/01/2020 - 07:49 PM It is the eighth case - and again it is an employee of the Webasto company. In Bavaria, the coronavirus has once again been detected in a human. The infected person is a 33-year-old man from Munich, said the Bavarian Ministry of Health on Saturday evening. He is like six other Corona sick employees of the Webasto company in Stockdorf in the Starnberg district. In addition to the company's seven employees, a child of one of the patients had also been tested positive for the new lung disease. The Webasto company had carried out extensive tests in the past few days, the results of which are still pending.

Confirmation of nCoV in a Webasto company employee, 33M, from Munich increases the cluster to 10 including a business associate in Shanghai, a child of one of the employees, and an employee/tourist in the Canary Islands. The 10 person cluster is spread over six cities (Shanghai, Stockdorf, Fürstenfeldbruck, Traustein, Munich, La Gomera) in three countries (China ,Germany, Spain) https://www.bild.de/news/inland/news-inland/coronavirus-usa-verhaengen-einreiseverbote-der-live-ticker-68532120.bild.html

Distributed via the CDC Health Alert Network February 1, 2020, 0900 ET (9:00 AM ET) CDCHAN-00427 Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-nCoV) Summary The Centers for Disease Control and Prevention (CDC) continues to closely monitor an outbreak of respiratory illness caused by a novel coronavirus (2019-nCoV) that was initially detected in Wuhan City, Hubei Province, China in December 2019. This CDC Health Alert Network (HAN) Update provides a situational update and interim guidance to state and local health departments that supersedes guidance in CDC’s HAN 426 distributed on January 17, 2020. It also adds guidance for clinicians caring for patients with 2019-nCoV (https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html), and for public health officials on the evaluation and testing of patients under investigation (PUIs) for 2019-nCoV (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html), and updated infection prevention and control guidance specific to 2019-nCoV (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html). Early in the outbreak, many of the patients with respiratory illness caused by 2019-nCoV in China had exposure to a large seafood and live animal market, suggesting animal-to-human transmission. More recently, cases have been confirmed with no exposure to animal markets, indicating that person-to-person spread of the virus has occurred. Chinese officials report that sustained person-to-person spread in the community is occurring in China. The first US case-patient was identified on January 21, 2020, and had recently traveled from Wuhan, China. Since that time, six additional cases have been confirmed in the United States, four among persons who traveled from Wuhan, and one a close contact of a confirmed case. Globally, reported illnesses in people with 2019-nCoV have ranged from mild (no or few signs and symptoms), to severe, including death. These findings are consistent with other coronaviruses, including Severe Acute Respiratory Syndrome (SARS) (https://www.cdc.gov/sars/) and Middle East Respiratory Syndrome (MERS) (https://www.cdc.gov/coronavirus/mers/index.html). Additional information about 2019-nCoV is needed to better understand transmission, disease severity, and risk to the general population. The goal of the ongoing US public health response is to identify and contain this outbreak and prevent sustained spread of 2019-nCoV in the United States. Recommendations for Screening of Patients for 2019-nCoV in Healthcare Facilities Recommendations for screening of patients for possible 2019-nCoV infection are based on (1) current knowledge of the characteristics of clinical illness observed in early cases, and (2) the geographic distribution of current cases. They reflect the current public health goal of rapidly containing and preventing transmission of 2019-nCoV illness. Patients presenting to healthcare facilities should be assessed for exposures associated with risk of 2019-nCoV infections (e.g., travel to China or close contact with a confirmed case) and for symptoms consistent with 2019-nCoV infection (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html). The assessment is intended to allow healthcare providers to make decisions about appropriate infection control and management of patients. Note that the signs and symptoms of 2019-nCoV overlap with those associated with other viral respiratory tract infections. Given the time of year, common respiratory illnesses, including influenza, should also be considered in patients who are screened. (Figure 1) Clinicians should ask: Does the person have fever or symptoms of lower respiratory infection, such as cough or shortness of breath? AND Has the patient traveled to mainland China within 14 days of symptom onset? OR Has the patient had close contact1 with a person confirmed with 2019-nCoV infection? Figure 1. If a patient meets these criteria: To minimize the risk that other people will be exposed to individuals who may have 2019-nCoV, patients who report having these symptoms should be asked to wear a surgical mask as soon as they are identified and directed to a separate area, if possible, with at least 6 feet (2 meters) separation from other persons. Patients should be evaluated in a private room with the door closed, ideally an airborne infection isolation room (AIIR), if available. Healthcare personnel entering the room should use standard precautions, contact precautions, airborne precautions, and use eye protection (e.g., goggles or a face shield). For more information about this, see CDC’s Interim Infection Prevention and Control Recommendations for Patients with Known or Patients Under Investigation for 2019 Novel Coronavirus (2019-nCoV) in a Healthcare Setting (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html). Clinicians should immediately notify the healthcare facility’s infection control personnel and local health department. The health department will determine if this patient needs to be considered a PUI for 2019-nCoV and be tested for infection. Criteria to Guide Evaluation and Testing of Patients Under Investigation (PUI) for 2019-nCoV Local health departments, in consultation with clinicians, should determine whether a patient is a PUI for 2019-nCoV. The CDC clinical criteria for 2019-nCoV PUIs have been developed based on available information about this novel virus, as well as what is known about SARS and MERS. These criteria are subject to change as additional information becomes available. Clinical Features AND Epidemiologic Risk Fever2 or signs/symptoms of lower respiratory illness (e.g. cough or shortness of breath) AND Any person, including health care workers, who has had close contact1with a laboratory-confirmed3 2019-nCoV patient within 14 days of symptom onset Fever2 andsigns/symptoms of a lower respiratory illness (e.g., cough or shortness of breath) AND A history of travel from Hubei Province, China within 14 days of symptom onset Fever2 and signs/symptoms of a lower respiratory illness (e.g., cough or shortness of breath) requiring hospitalization4 AND A history of travel from mainland China within 14 days of symptom onset These criteria are intended to serve as guidance for evaluation and testing. Patients should be evaluated and discussed with public health departments on a case-by-case basis for possible 2019-nCoV infection. Testing decisions might be further informed by the clinical presentation or exposure history (e.g., uncertain travel or exposure), and the presence of an alternative diagnosis that explains their clinical presentation. Recommendations for Reporting, Testing, and Specimen Collection Healthcare providers should immediatelynotify infection control personnel at their healthcare facility if a patient is classified a PUI for 2019-nCoV. State health departments that have identified a PUI should immediately contact CDC’s Emergency Operations Center (EOC) at 770-488-7100 and complete a 2019-nCoV PUI case investigation form (https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html#reporting-testing-specimen-collection). CDC’s EOC will assist local and state health departments with obtaining, storing, and shipping appropriate specimens to CDC, including afterhours or on weekends or holidays. Currently, diagnostic testing for 2019-nCoV can be done only at CDC. Testing for other respiratory pathogens should not delay specimen shipping to CDC. For initial diagnostic testing for 2019-nCoV, CDC recommends collecting and testing upper respiratory (nasopharyngeal ANDoropharyngeal swabs), and lower respiratory (sputum, if possible)) for those patients with productive coughs. Induction of sputum is not indicated. Specimens should be collected as soon as possible once a PUI is identified, regardless of the time of symptom onset. See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for 2019 Novel Coronavirus (2019-nCoV)(https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html). Recommendations for Healthcare Providers No vaccine or specific treatment for 2019-nCoV infection is available. At present, medical care for patients with 2019-nCoV is supportive. Persons with confirmed or suspected 2019-nCoV infection who are hospitalized should be evaluated and cared for in a private room with the door closed, ideally an airborne infection isolation room, if available. For more information, see Interim Infection Prevention and Control Recommendations for Patients with Known or Patients Under Investigation for 2019 Novel Coronavirus (2019-nCoV) in a Healthcare Setting (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html). Home care and isolation may be an option, based on clinical and public health assessment, for some persons. Please see Interim Guidance for Preventing the Spread of 2019 Novel Coronavirus (2019-nCoV) in Homes and Communities (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-prevent-spread.html). Those isolated at home should be monitored by public health officials to the extent possible. Refer to Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for 2019 Novel Coronavirus (2019-nCoV) (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html) for more information. Notes 1Close contact is defined as: a) being within approximately 6 feet (2 meters), or within the room or care area, of a 2019-nCoV case for a prolonged period of time while not wearing recommended personal protective equipment or PPE (e.g., gowns, gloves, NIOSH-certified disposable N95 respirator, eye protection); close contact can include caring for, living with, visiting, or sharing a health care waiting area or room with a 2019-nCoV case - or - b) having direct contact with infectious secretions of a 2019-nCoV case (e.g., being coughed on) while not wearing recommended personal protective equipment. 2Fever may be subjective or confirmed See CDC’s updated Interim Infection Prevention and Control Recommendations for Patients with Known or Patients Under Investigation for 2019 Novel Coronavirus (2019-nCoV) in a Healthcare Setting (https://www.cdc.gov/coronavirus/2019-ncov/infection-control.html). Data to inform the definition of close contact are limited. Considerations when assessing close contact include the duration of exposure (e.g., longer exposure time likely increases exposure risk) and the clinical symptoms of the person with 2019-nCoV (e.g., coughing likely increases exposure risk as does exposure to a severely ill patient). Special consideration should be given to those exposed in health care settings. 3 Documentation of laboratory-confirmation of 2019-nCoV may not be possible for travelers or persons caring for patients in other countries. 4 Category also includes any member of a cluster of patients with severe acute lower respiratory illness (e.g., pneumonia, ARDS) of unknown etiology in which 2019-nCoV is being considered that requires hospitalization. Such persons should be evaluated in consultation with state and local health departments regardless of travel history. For More Information More information is available at the 2019 Novel Coronavirus website (https://www.cdc.gov/coronavirus/2019-ncov/index.html) or by calling 800-CDC-INFO | (800-232-4636) | TTY: (888) 232-6348 The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations. Categories of Health Alert Network messages: Health Alert - Requires immediate action or attention; highest level of importance Health Advisory - May not require immediate action; provides important information for a specific incident or situation Health Update - Unlikely to require immediate action; provides updated information regarding an incident or situation HAN Info Service - Does not require immediate action; provides general public health information ##This message was distributed to state and local health officers, state and local epidemiologists, state and local laboratory directors, public information officers, HAN coordinators, and clinician organizations## You have received this message based upon the information contained within our emergency notification data base. If you have a different or additional e-mail or fax address that you would like us to use please contact your State-based Health Alert Network program at your State or local health department.

The Centers for Disease Control and Prevention (CDC) continues to closely monitor an outbreak of respiratory illness caused by a novel coronavirus (2019-nCoV) that was initially detected in Wuhan City, Hubei Province, China in December 2019. CDC Health Alert Network (HAN) Update provides a situational update and interim guidance to state and local health departments

Virus detail Virus name: BetaCoV/Germany/BavPat1/2020 Accession ID: EPI_ISL_406862 Type: betacoronavirus Passage details/history: Original Sample information Collection date: 2020-01-28 Location: Germany / Bavaria / Munich Host: Human Additional location information: Gender: male Patient age: NA Patient status: hospitalized Specimen source: Sputum Additional host information: Outbreak: Bavaria cluster patient 1 Last vaccinated: Treatment: Sequencing technology: Illumina MiSeq, Nanopore MinION Assembly method: Geneious v9 Coverage: Institute information Originating lab: Charité Universitätsmedizin Berlin, Institute of Virology; Institut für Mikrobiologie der Bundeswehr, Munich Address: Institute of Virology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; Institut für Mikrobiologie der Bundeswehr, Neuherbergstraße 11, 80937 Munich, Germany Sample ID given by the sample provider: Submitting lab: Charité Universitätsmedizin Berlin, Institute of Virology Address: Charitéplatz 1, 10117 Berlin, Germany Sample ID given by the submitting laboratory: ChVir929 Authors: Victor M Corman, Julia Schneider, Talitha Veith, Barbara Mühlemann, Markus Antwerpen, Christian Drosten, Roman Wölfel Submitter information Submitter: Barbara Muehlemann Submission Date: 2020-01-31 Address: Institute of Virology, Charité Universitätsmedizin Berlin FASTA >BetaCoV/Germany/BavPat1/2020|EPI_ISL_406862

World Coronavirus Spreading in Munich Shows Difficulty Halting New Bug By Jason Gale and Birgit Jennen January 30, 2020, 11:50 PM EST Updated on January 31, 2020, 2:52 PM EST Shanghai visitor who didn’t have symptoms led to new cluster Infections widen to seven with two additional 2019-nCoV cases SHARE THIS ARTICLE Share Tweet Post Email In this article 1006204D WEBASTO SE Private Company A business event in Munich set off a chain of coronavirus infections that began with an infected colleague from Shanghai who showed no symptoms during a trip to the German city. It’s the largest reported cluster of cases caused by human-to-human spread outside China. According to auto-parts supplier Webasto SE, seven of its employees -- five German and two Chinese -- have been infected with the new coronavirus, the cause of a massive pneumonia outbreak in China that the World Health Organization declared a global emergency on Thursday. The Schwabing hospital, where four people are being treated for coronavirus, in Munich, Germany, Jan. 29. Photographer: Michaela Handrek-Rehle/Bloomberg The infection appears to have been transmitted while a Shanghai-based colleague was still incubating the virus. The woman attended meetings from Jan. 19 to 22 at Webasto’s headquarters in Stockdorf, on Munich’s outskirts, with no signs or symptoms of infection, but she became unwell on her Jan. 22 flight back to China. She tested positive for the 2019-nCoV virus four days later, doctors said in the New England Journal of Medicine on Thursday. ADVERTISING The cases show the difficulty of controlling the contagion using methods such as fever-screening at airports. Almost 10,000 people across 20 countries are confirmed to have been infected with the new virus, which was first reported in the central Chinese city of Wuhan a month ago. Mitigation strategies for halting the spread of 2019-nCoV have been informed by experiences combating coronaviruses that cause severe acute respiratory syndrome, or SARS, and Middle East respiratory syndrome. People don’t typically transmit those infections unless they have symptoms, said Benjamin Cowie, a professor of medicine at the University of Melbourne and an epidemiologist with the Peter Doherty Institute for Infection and Immunity. 10-Year-Old Boy Cases like the ones in Germany, and that of a 10-year-old boy in Shenzhen whose case was described last week, have complicated control measures, Cowie said in an interview Friday. Read More: 10-Year-Old Boy Raises Fears Wuhan Virus Could Spread Undetected “With this information suggesting that there is at least the ability to isolate or detect the virus in asymptomatic or apparently asymptomatic individuals, that’s got significant implications for epidemiological control measures,” he said. “If we’re trying to identify cases when they’re not symptomatic, that’s impossible on a clinical basis, and that then becomes a lot harder to control.” An analysis by U.S. researchers of screening travelers found the strategy will, at best, detect less than half of infected travelers. Those who are incubating their infection may feel healthy enough to travel but show no detectable symptoms, they said in a Jan. 28 study. Need for Reassessment? “The fact that asymptomatic persons are potential sources of 2019-nCoV infection may warrant a reassessment of transmission dynamics of the current outbreak,” Camilla Rothe and colleagues at the University Hospital LMU Munich, who investigated the cluster in Germany, said in a letter to the New England Journal of Medicine. The first four cases in Germany had “mild” symptoms and were hospitalized primarily for public health purposes, the doctors said. They queried “whether such patients can be treated with appropriate guidance and oversight outside the hospital.” Pedestrians wearing protective masks walk along a street near the Bund in Shanghai, Jan. 30. Photographer: Qilai Shen/Bloomberg The first of the German cases occurred in an otherwise healthy 33-year-old businessman, who became ill with a sore throat, chills, and muscle ache on Jan. 24. He had a fever and a cough the next day, but by the evening of the following day, he started feeling better and went back to work on Jan. 27, the same day his China-based colleague told company officials that she was ill. Swabs of the back of the man’s nose and throat, and a sputum sample tested positive for 2019-nCoV. Follow-up tests found he still harbored high levels of the virus in his sputum on Jan. 29, a day after three other employees tested positive, including two who hadn’t been in contact with the colleague from China. Patients with confirmed 2019-nCoV were isolated in a Munich infectious diseases unit. All seven people attended various meetings together in Stockdorf, the company said in a statement Friday. Employees Spurned Some 122 staffers have returned negative tests for the coronavirus, with a few test results still pending, according to the company. Webasto, which has about 13,000 workers in 50 different locations, said it will keep its headquarters closed until next Monday. The company is preparing for employees to return to work Tuesday, Feb. 4, amid reports that its workforce is being subjected to discriminating behavior. “We are receiving an increasing number of reports from employees that they and their families are being turned away from institutions, companies or businesses when it becomes known that they work for Webasto,” Chairman Holger Engelmann said. “We understand that the current situation is unsettling and also frightening for people, but it cannot be that normal everyday life is no longer possible for people who do not belong to the risk group. This is an enormous burden for the families of our employees.” Read more: Here’s How the Fight Against China Coronavirus Works: QuickTake — With assistance by Tim Loh, and Sybilla Gross (Adds additional workers infected in second paragraph; company comments from 14th.)

According to auto-parts supplier Webasto SE, seven of its employees -- five German and two Chinese -- have been infected with the new coronavirus, the cause of a massive pneumonia outbreak in China that the World Health Organization declared a global emergency on Thursday. https://www.bloomberg.com/news/articles/2020-01-31/coronavirus-spreading-in-munich-shows-difficulty-halting-new-bug?utm_source=dlvr.it&utm_medium=twitter

According to auto-parts supplier Webasto SE, seven of its employees -- five German and two Chinese -- have been infected with the new coronavirus, the cause of a massive pneumonia outbreak in China that the World Health Organization declared a global emergency on Thursday. https://www.bloomberg.com/news/articles/2020-01-31/coronavirus-spreading-in-munich-shows-difficulty-halting-new-bug?utm_source=dlvr.it&utm_medium=twitter

PRESS RELEASE Press Release Man returning from Wuhan, China is first case of 2019 Novel Coronavirus confirmed in Massachusetts FOR IMMEDIATE RELEASE: 2/01/2020 Department of Public Health BOSTON — The first case of the 2019 novel coronavirus in Massachusetts has been confirmed in a man returning from Wuhan, China who is in his 20s and lives in Boston. The Massachusetts Department of Public Health (DPH) and the Boston Public Health Commission (BPHC) were notified by the US Centers for Disease Control and Prevention (CDC) of the positive test results late Friday evening. This is the eighth case of infection with 2019 novel coronavirus reported in the United States. The risk to the public from the 2019 novel coronavirus remains low in Massachusetts. The man recently traveled to Wuhan, China, and sought medical care soon after his return to Massachusetts. He has been isolated since that time and will continue to remain isolated until cleared by public health officials. His few close contacts have been identified and are being monitored for any sign of symptoms. “We are grateful that this young man is recovering and sought medical attention immediately,’’ said Massachusetts Public Health Commissioner Monica Bharel, MD. MPH. ``Massachusetts has been preparing for a possible case of this new coronavirus, and we were fortunate that astute clinicians took appropriate action quickly. Again, the risk to the public from the 2019 novel coronavirus remains low in Massachusetts.” “Our priority is not only to protect and inform the residents of Boston but also to help this man continue to recover. We are pleased that he is doing well,” said BPHC Executive Director Rita Nieves. “Right now, we are not asking Boston residents to do anything differently. The risk to the general public remains low. And we continue to be confident we are in a good position to respond to this developing situation.” DPH and BPHC continue to work closely with the CDC to maintain vigilance during this virus outbreak. The novel coronavirus has resulted in thousands of confirmed human infections in more than 20 countries, with more than 99 percent of cases in China. To date, eight cases have been confirmed in the US: three people in California, two in Illinois and one individual each in Massachusetts, Washington State, and Arizona. On Friday, US Health and Human Services Secretary Alex Azar declared the 2019 novel coronavirus a public health emergency and ordered any US citizens returning from the center of the outbreak in China to be quarantined for two weeks as a precaution. This followed a declaration Thursday by the World Health Organization that the coronavirus outbreak is a Public Health Emergency of International Concern. Also that day the CDC reported the first case of person-to-person transmission in Illinois between household members. Massachusetts state health officials, in conjunction with Massport, local health departments, and other medical partners, have responded to prevent the spread of the virus. Among the steps taken by the Department of Public Health: Established an Incident Command Structure to facilitate regular dissemination of information from federal and state partners to statewide stakeholders. Launched a new website that provides up-to-date information on the status of novel coronavirus for all residents: https://www.mass.gov/2019coronavirus. Developed and disseminated clinical advisories to all Massachusetts health care providers and issued guidance to hospitals, health systems, and Emergency Medical Services. Scheduled calls with other key health care partners including local boards of health. Coronaviruses are respiratory viruses and are generally spread through respiratory secretions (droplets from coughs and sneezes) of an infected person to another person. Symptoms of novel coronavirus include fever, cough and shortness of breath, and, in severe cases, pneumonia (fluid in the lungs). Information about how this novel coronavirus spreads is still limited. Although the risk of the coronavirus to Massachusetts residents remains low, people are advised to take many of the same steps they do to help prevent colds and the flu, including: Wash hands often with soap and warm water for at least 20 seconds. Cover coughs and sneezes. Stay home when feeling sick. Clinicians who see patients with recent travel in China, especially Hubei Province, who have a fever, lower respiratory tract symptoms (such as shortness of breath and cough), and/or contact with a known novel coronavirus patient, should contact DPH 24/7 at (617) 983-6800 for assistance. In Boston, providers should contact BPHC at 617-534-5611. The new DPH website provides relevant up-to-date information on the state of the novel coronavirus for all residents: mass.gov/2019coronavirus. Additional details and guidance regarding the novel coronavirus, is available from the CDC: 2019 Novel Coronavirus. https://www.mass.gov/news/man-returning-from-wuhan-china-is-first-case-of-2019-novel-coronavirus-confirmed-in

BOSTON — Officials with the Massachusetts Department of Public Health confirmed the first case of the Wuhan coronavirus in the state Saturday. Health officials said a Boston man in his 20s is confirmed to have the virus after he recently traveled to Wuhan, China. The DPH and the Boston Public Health Commission were notified by the U.S. Centers for Disease Control and Prevention of the positive test results late Friday evening. The man sought medical care soon after his return to Massachusetts, according to officials. He has been isolated since that time and will continue to remain isolated until he is cleared by public health officials. “We are grateful that this young man is recovering and sought medical attention immediately,’’ said Dr. Monica Bharel, Massachusetts Public Health Commissioner. "Massachusetts has been preparing for a possible case of this new coronavirus, and we were fortunate that astute clinicians took appropriate action quickly. Again, the risk to the public from the 2019 novel coronavirus remains low in Massachusetts.” Officials said his few close contacts have been identified and are being monitored for any sign of symptoms. “Our priority is not only to protect and inform the residents of Boston, but also to help this man continue to recover. We are pleased that he is doing well,” said BPHC Executive Director Rita Nieves. “Right now, we are not asking Boston residents to do anything differently. The risk to the general public remains low. And we continue to be confident we are in a good position to respond to this developing situation.”

nCoV was confirmed Friday night in Boston ex-Wuhan patient. https://www.wcvb.com/article/first-case-of-wuhan-coronavirus-confirmed-in-boston-man-massachusetts-health-officials-say/30737921#

Second Illinois 2019 Novel Coronavirus Case Identified Risk to general public in Illinois remains low Andy Buchanan [email protected] Download this News Release CHICAGO – The Illinois Department of Public Health (IDPH), Chicago Department of Public Health (CDPH), and Cook County Department of Public Health (CCDPH), along with the Centers for Disease Control and Prevention (CDC), are reporting the second confirmed case of 2019 novel coronavirus (2019-nCov) in Illinois. The individual is a man in his 60s and is the spouse of the first confirmed travel-related case in Illinois. He had not traveled overseas but interacted with his wife upon her return from China. This is the first person-to-person spread of the virus in the United States. “I want to emphasize that the risk of this novel coronavirus to the general public in Illinois remains low. Local, state, and federal health officials are working to identify those who have had close contact with the individual I order to take protective measures to minimize further spread of the virus,” said IDPH Director Dr. Ngozi Ezike. “We will continue to keep the public fully informed as additional information becomes available.” On Friday, January 24, 2020, CDC, IDPH, and CDPH announced the first confirmed Illinois case of 2019-nCoV in a Chicago resident, a woman in her 60s who returned from Wuhan, China on January 13, 2020. The woman remains in the hospital in stable condition and is doing well. The second patient is also hospitalized in stable condition. “We know coronaviruses are most likely to spread through close personal contact, and we know this second patient had close contact with his wife after she began to develop symptoms, so it’s not totally unexpected that he acquired the virus,” said Allison Arwady, MD, MPH, Commissioner of CDPH. “This is exactly why public health has been monitoring him closely, and why we monitor any close contacts of confirmed cases. This does not change our guidance that the risk to the general public remains low at this time. People in the community do not need to change their behavior based on this news; for example, they don’t need to cancel events, avoid mass gatherings, or wear gloves and masks in public.” Public health officials are investigating locations where this second patient has visited in the last two weeks and any close contacts who were possibly exposed. Public health and medical professionals are taking an aggressive approach in identifying and actively monitoring individuals who were in contact with both confirmed cases in an effort to reduce the risk of additional transmission. A CDC team continues to be deployed to Illinois to support these efforts. “If you have traveled to China or come into contact with a confirmed case and are experiencing fever, cough, or shortness of breath, contact your healthcare provider,” said Cook County Department of Public Health Chief Operating Officer Dr. Terry Mason. “We encourage everyone to practice the same germ prevention as with flu, which last year caused 35 million illnesses and just over 34,000 deaths.” CDC is closely monitoring the outbreak of respiratory illness caused by 2019-nCoV that was first detected in Wuhan City, Hubei Province, China and which continues to expand. There have been hundreds of cases worldwide, including two in Illinois, and more than 50 deaths. Symptoms reported among patients with 2019-nCoVhave included mild to severe respiratory illness with fever, cough, and difficulty breathing. Although this is the first person-to-person transmission in the U.S., it is still not yet clear how easily 2019-nCoV spreads from one person to another. With MERS and SARS, also novel coronaviruses, the virus was thought to have spread mainly through sneezing and coughing, similar to the flu. In general, it was spread between close contacts. There is currently no vaccine to prevent 2019-nCoV infection. Right now, 2019-nCoV has not been found to be spreading widely in the United States, so there are no additional precautions recommended for the general public to take. However, the following everyday preventive actions can help prevent the spread of several viruses, including seasonal flu. Wash your hands often with soap and water for at least 20 seconds Avoid touching your eyes, nose, and mouth with unwashed hands. Avoid close contact with people who are sick. Stay home when you are sick. Cover your cough or sneeze with a tissue, then throw the tissue in the trash. Clean and disinfect frequently touched objects and surfaces. This is a rapidly evolving situation and information will be updated as it becomes available. More information can be found on the IDPH website, the CDPH website, and the CDC website. https://www.chicago.gov/city/en/depts/cdph/provdrs/health_protection_and_response/news/2020/january/second-illinois-2019-novel-coronavirus-case-identified.html

A 33-year-old otherwise healthy German businessman (Patient 1) became ill with a sore throat, chills, and myalgias on January 24, 2020. The following day, a fever of 39.1°C (102.4°F) developed, along with a productive cough. By the evening of the next day, he started feeling better and went back to work on January 27. https://www.nejm.org/doi/full/10.1056/NEJMc2001468

The employee/business associate from Shanghai visited headquarters in Bavaria (near Munich). Those at the headquarters near Munich are German, based on initial reports on index case. Most recent case in Canary Island is described as tourist with contact with confirmed cases in Germany. Also traveling with others from Germany.

Jan 31 Jump in PCR confirmed cases to 29,779 Expansion of Germany cluster to nine victims in six cities in three countries New Countries Russia Finland Philippines India Italy Sweden Spain Taxi Driver Thailand Van Driver Japan Pre-print on HIV sequences (False) http://mediaarchives.gsradio.net/rense/special/rense_013120_hr3.mp3

References (20) 1.World Health Organization. Pneumonia of unknown cause — China. 2020(https://www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/. opens in new tab). Google Scholar. opens in new tab 2.World Health Organization. Novel coronavirus — China. 2020(https://www.who.int/csr/don/12-january-2020-novel-coronavirus-china/en/. opens in new tab). Google Scholar. opens in new tab 3.Chan JF-W, Yuan S, Kok K-H, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet 2020 January 24 (Epub ahead of print). Crossref. opens in new tab Medline. opens in new tab Google Scholar. opens in new tab 4.Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020 January 24 (Epub ahead of print). Crossref. opens in new tab Medline. opens in new tab Google Scholar. opens in new tab 5.Centers for Disease Control and Prevention. 2019 Novel coronavirus, Wuhan, China: 2019-nCoV situation summary. January 28, 2020 (https://www.cdc.gov/coronavirus/2019-nCoV/summary.html. opens in new tab). Google Scholar. opens in new tab 6.Phan LT, Nguyen TV, Luong QC, et al. Importation and human-to-human transmission of a novel coronavirus in Vietnam. N Engl J Med. DOI: 10.1056/NEJMc2001272. Free Full Text Google Scholar. opens in new tab 7.Johns Hopkins University CSSE. Wuhan coronavirus (2019-nCoV) global cases (https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6. opens in new tab). Google Scholar. opens in new tab 8.Centers for Disease Control and Prevention. Interim guidance for healthcare professionals: criteria to guide evaluation of patients under investigation (PUI) for 2019-nCoV. 2020(https://www.cdc.gov/coronavirus/2019-nCoV/clinical-criteria.html. opens in new tab). Google Scholar. opens in new tab 9.Centers for Disease Control and Prevention. Infection control. 2019 Novel coronavirus, Wuhan, China. 2020 (https://www.cdc.gov/coronavirus/2019-nCoV/infection-control.html. opens in new tab). Google Scholar. opens in new tab 10.Mulangu S, Dodd LE, Davey RT Jr, et al. A randomized, controlled trial of ebola virus disease therapeutics. N Engl J Med 2019;381:2293-2303. Free Full Text Web of Science. opens in new tab Medline. opens in new tab Google Scholar. opens in new tab 11.Sheahan TP, Sims AC, Leist SR, et al. Comparative therapeutic efficacy of remdesivir and combination lopinavir, ritonavir, and interferon beta against MERS-CoV. Nat Commun 2020;11:222-222. Crossref. opens in new tab Medline. opens in new tab Google Scholar. opens in new tab 12.Centers for Disease Control and Prevention. Interim guidelines for collecting, handling, and testing clinical specimens from patients under investigation (PUIs) for 2019 novel coronavirus (2019-nCoV). 2020 (https://www.cdc.gov/coronavirus/2019-nCoV/guidelines-clinical-specimens.html. opens in new tab). Google Scholar. opens in new tab 13.Centers for Disease Control and Prevention, Respiratory Viruses Branch, Division of Viral Diseases. Real-time RT-PCR panel for detection 2019-novel coronavirus. 2020(https://www.cdc.gov/coronavirus/2019-ncov/downloads/rt-pcr-panel-for-detection-instructions.pdf. opens in new tab). Google Scholar. opens in new tab 14.Centers for Disease Control and Prevention, Respiratory Viruses Branch, Division of Viral Diseases. 2019-novel coronavirus (2019-nCoV) real-time rRT-PCR panel primers and probes. 2020 (https://www.cdc.gov/coronavirus/2019-ncov/downloads/rt-pcr-panel-primer-probes.pdf. opens in new tab). Google Scholar. opens in new tab 15.Centers for Disease Control and Prevention. Information for laboratories. 2019 novel coronavirus, Wuhan, China. 2020 (https://www.cdc.gov/coronavirus/2019-nCoV/guidance-laboratories.html. opens in new tab). Google Scholar. opens in new tab 16.National Institutes of Health. GenBank overview (https://www.ncbi.nlm.nih.gov/genbank/. opens in new tab). Google Scholar. opens in new tab 17.GISAID (Global Initiative on Sharing All Influenza Data) home page (https://www.gisaid.org/. opens in new tab). Google Scholar. opens in new tab 18.Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. DOI: 10.1056/NEJMoa2001017. Free Full Text Google Scholar. opens in new tab 19.Washington State Department of Health. Novel coronavirus outbreak 2020 (https://www.doh.wa.gov/Emergencies/Coronavirus. opens in new tab). Google Scholar. opens in new tab 20.Chen N, Zhou M, Dong X Jr, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020January 30 (Epub ahead of print). Crossref. opens in new tab Google Scholar

Results SPECIMEN TESTING FOR 2019-NCOV Table 2.Results of Real-Time Reverse-Transcriptase–Polymerase-Chain-Reaction Testing for the 2019 Novel Coronavirus (2019-nCoV). The initial respiratory specimens (nasopharyngeal and oropharyngeal swabs) obtained from this patient on day 4 of his illness were positive for 2019-nCoV (Table 2). The low cycle threshold (Ct) values (18 to 20 in nasopharyngeal specimens and 21 to 22 in oropharyngeal specimens) on illness day 4 suggest high levels of virus in these specimens, despite the patient’s initial mild symptom presentation. Both upper respiratory specimens obtained on illness day 7 remained positive for 2019-nCoV, including persistent high levels in a nasopharyngeal swab specimen (Ct values, 23 to 24). Stool obtained on illness day 7 was also positive for 2019-nCoV (Ct values, 36 to 38). Serum specimens for both collection dates were negative for 2019-nCoV. Nasopharyngeal and oropharyngeal specimens obtained on illness days 11 and 12 showed a trend toward decreasing levels of virus. The oropharyngeal specimen tested negative for 2019-nCoV on illness day 12. The rRT-PCR results for serum obtained on these dates are still pending. GENETIC SEQUENCING The full genome sequences from oropharyngeal and nasopharyngeal specimens were identical to one another and were nearly identical to other available 2019-nCoV sequences. There were only 3 nucleotides and 1 amino acid that differed at open reading frame 8 between this patient’s virus and the 2019-nCoV reference sequence (NC_045512.2). The sequence is available through GenBank (accession number MN985325).16 DISCUSSION Our report of the first confirmed case of 2019-nCoV in the United States illustrates several aspects of this emerging outbreak that are not yet fully understood, including transmission dynamics and the full spectrum of clinical illness. Our case patient had traveled to Wuhan, China, but reported that he had not visited the wholesale seafood market or health care facilities or had any sick contacts during his stay in Wuhan. Although the source of his 2019-nCoV infection is unknown, evidence of person-to-person transmission has been published. Through January 30, 2020, no secondary cases of 2019-nCoV related to this case have been identified, but monitoring of close contacts continues.19 Detection of 2019-nCoV RNA in specimens from the upper respiratory tract with low Ct values on day 4 and day 7 of illness is suggestive of high viral loads and potential for transmissibility. It is notable that we also detected 2019-nCoV RNA in a stool specimen collected on day 7 of the patient’s illness. Although serum specimens from our case patient were repeatedly negative for 2019-nCoV, viral RNA has been detected in blood in severely ill patients in China.4 However, extrapulmonary detection of viral RNA does not necessarily mean that infectious virus is present, and the clinical significance of the detection of viral RNA outside the respiratory tract is unknown at this time. Currently, our understanding of the clinical spectrum of 2019-nCoV infection is very limited. Complications such as severe pneumonia, respiratory failure, acute respiratory distress syndrome (ARDS), and cardiac injury, including fatal outcomes, have been reported in China.4,18,20 However, it is important to note that these cases were identified on the basis of their pneumonia diagnosis and thus may bias reporting toward more severe outcomes. Our case patient initially presented with mild cough and low-grade intermittent fevers, without evidence of pneumonia on chest radiography on day 4 of his illness, before having progression to pneumonia by illness day 9. These nonspecific signs and symptoms of mild illness early in the clinical course of 2019-nCoV infection may be indistinguishable clinically from many other common infectious diseases, particularly during the winter respiratory virus season. In addition, the timing of our case patient’s progression to pneumonia on day 9 of illness is consistent with later onset of dyspnea (at a median of 8 days from onset) reported in a recent publication.4Although a decision to administer remdesivir for compassionate use was based on the case patient’s worsening clinical status, randomized controlled trials are needed to determine the safety and efficacy of remdesivir and any other investigational agents for treatment of patients with 2019-nCoV infection. We report the clinical features of the first reported patient with 2019-nCoV infection in the United States. Key aspects of this case included the decision made by the patient to seek medical attention after reading public health warnings about the outbreak; recognition of the patient’s recent travel history to Wuhan by local providers, with subsequent coordination among local, state, and federal public health officials; and identification of possible 2019-nCoV infection, which allowed for prompt isolation of the patient and subsequent laboratory confirmation of 2019-nCoV, as well as for admission of the patient for further evaluation and management. This case report highlights the importance of clinicians eliciting a recent history of travel or exposure to sick contacts in any patient presenting for medical care with acute illness symptoms, in order to ensure appropriate identification and prompt isolation of patients who may be at risk for 2019-nCoV infection and to help reduce further transmission. Finally, this report highlights the need to determine the full spectrum and natural history of clinical disease, pathogenesis, and duration of viral shedding associated with 2019-nCoV infection to inform clinical management and public health decision making. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. This article was published on January 31, 2020, at NEJM.org. We thank the patient; the nurses and clinical staff who are providing care for the patient; staff at the local and state health departments; staff at the Washington State Department of Health Public Health Laboratories and at the Centers for Disease Control and Prevention (CDC) Division of Viral Disease Laboratory; CDC staff at the Emergency Operations Center; and members of the 2019-nCoV response teams at the local, state, and national levels. Author Affiliations From the Epidemic Intelligence Service (M.L.H.), the National Center for Immunizations and Respiratory Diseases (A.C., L.F., A.P.), the Division of Viral Diseases (S.I.G., L.K., S.T., X.L., S. Lindstrom, M.A.P., W.C.W., H.M.B.), the Influenza Division (T.M.U.), and the Division of Preparedness and Emerging Infections (S.K.P.), Centers for Disease Control and Prevention, Atlanta; and the Washington State Department of Health, Shoreline (M.L.H., C.D., S. Lindquist, K.H.L., J.W.), Snohomish Health District (H.B., C.S.), Providence Medical Group (K.E.), and Providence Regional Medical Center (S.W., A.T., G.D.), Everett, and Department of Medicine, University of Washington School of Medicine, Seattle (C.S.) — all in Washington. Address reprint requests to Ms. Holshue at the Washington State Department of Health Public Health Laboratories, 1610 NE 150th St., Shoreline, WA 98155, or at [email protected]. A full list of the members of the Washington State 2019-nCoV Case Investigation Team is provided in the Supplementary Appendix, available at NEJM.org.

Methods SPECIMEN COLLECTION Clinical specimens for 2019-nCoV diagnostic testing were obtained in accordance with CDC guidelines.12 Nasopharyngeal and oropharyngeal swab specimens were collected with synthetic fiber swabs; each swab was inserted into a separate sterile tube containing 2 to 3 ml of viral transport medium. Serum was collected in a serum separator tube and then centrifuged in accordance with CDC guidelines. The urine and stool specimens were each collected in sterile specimen containers. Specimens were stored between 2°C and 8°C until ready for shipment to the CDC. Specimens for repeat 2019-nCoV testing were collected on illness days 7, 11, and 12 and included nasopharyngeal and oropharyngeal swabs, serum, and urine and stool samples. DIAGNOSTIC TESTING FOR 2019-NCOV Clinical specimens were tested with an rRT-PCR assay that was developed from the publicly released virus sequence. Similar to previous diagnostic assays for severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), it has three nucleocapsid gene targets and a positive control target. A description of this assay13 and sequence information for the rRT-PCR panel primers and probes14 are available on the CDC Laboratory Information website for 2019-nCoV.15 GENETIC SEQUENCING On January 7, 2020, Chinese researchers shared the full genetic sequence of 2019-nCoV through the National Institutes of Health GenBank database16 and the Global Initiative on Sharing All Influenza Data (GISAID)17 database; a report about the isolation of 2019-nCoV was later published.18 Nucleic acid was extracted from rRT-PCR–positive specimens (oropharyngeal and nasopharyngeal) and used for whole-genome sequencing on both Sanger and next-generation sequencing platforms (Illumina and MinIon). Sequence assembly was completed with the use of Sequencher software, version 5.4.6 (Sanger); minimap software, version 2.17 (MinIon); and freebayes software, version 1.3.1 (MiSeq). Complete genomes were compared with the available 2019-nCoV reference sequence (GenBank accession number NC_045512.2).

Case Report On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever. On checking into the clinic, the patient put on a mask in the waiting room. After waiting approximately 20 minutes, he was taken into an examination room and underwent evaluation by a provider. He disclosed that he had returned to Washington State on January 15 after traveling to visit family in Wuhan, China. The patient stated that he had seen a health alert from the U.S. Centers for Disease Control and Prevention (CDC) about the novel coronavirus outbreak in China and, because of his symptoms and recent travel, decided to see a health care provider. Figure 1.Posteroanterior and Lateral Chest Radiographs, January 19, 2020 (Illness Day 4). Apart from a history of hypertriglyceridemia, the patient was an otherwise healthy nonsmoker. The physical examination revealed a body temperature of 37.2°C, blood pressure of 134/87 mm Hg, pulse of 110 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation of 96% while the patient was breathing ambient air. Lung auscultation revealed rhonchi, and chest radiography was performed, which was reported as showing no abnormalities (Figure 1). A rapid nucleic acid amplification test (NAAT) for influenza A and B was negative. A nasopharyngeal swab specimen was obtained and sent for detection of viral respiratory pathogens by NAAT; this was reported back within 48 hours as negative for all pathogens tested, including influenza A and B, parainfluenza, respiratory syncytial virus, rhinovirus, adenovirus, and four common coronavirus strains known to cause illness in humans (HKU1, NL63, 229E, and OC43). Given the patient’s travel history, the local and state health departments were immediately notified. Together with the urgent care clinician, the Washington Department of Health notified the CDC Emergency Operations Center. Although the patient reported that he had not spent time at the Huanan seafood market and reported no known contact with ill persons during his travel to China, CDC staff concurred with the need to test the patient for 2019-nCoV on the basis of current CDC “persons under investigation” case definitions.8 Specimens were collected in accordance with CDC guidance and included serum and nasopharyngeal and oropharyngeal swab specimens. After specimen collection, the patient was discharged to home isolation with active monitoring by the local health department. On January 20, 2020, the CDC confirmed that the patient’s nasopharyngeal and oropharyngeal swabs tested positive for 2019-nCoV by real-time reverse-transcriptase–polymerase-chain-reaction (rRT-PCR) assay. In coordination with CDC subject-matter experts, state and local health officials, emergency medical services, and hospital leadership and staff, the patient was admitted to an airborne-isolation unit at Providence Regional Medical Center for clinical observation, with health care workers following CDC recommendations for contact, droplet, and airborne precautions with eye protection.9 On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges. On physical examination, the patient was found to have dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea. Figure 2.Symptoms and Maximum Body Temperatures According to Day of Illness and Day of Hospitalization, January 16 to January 30, 2020. On days 2 through 5 of hospitalization (days 6 through 9 of illness), the patient’s vital signs remained largely stable, apart from the development of intermittent fevers accompanied by periods of tachycardia (Figure 2). The patient continued to report a nonproductive cough and appeared fatigued. On the afternoon of hospital day 2, the patient passed a loose bowel movement and reported abdominal discomfort. A second episode of loose stool was reported overnight; a sample of this stool was collected for rRT-PCR testing, along with additional respiratory specimens (nasopharyngeal and oropharyngeal) and serum. The stool and both respiratory specimens later tested positive by rRT-PCR for 2019-nCoV, whereas the serum remained negative. Treatment during this time was largely supportive. For symptom management, the patient received, as needed, antipyretic therapy consisting of 650 mg of acetaminophen every 4 hours and 600 mg of ibuprofen every 6 hours. He also received 600 mg of guaifenesin for his continued cough and approximately 6 liters of normal saline over the first 6 days of hospitalization. Table 1.Clinical Laboratory Results. The nature of the patient isolation unit permitted only point-of-care laboratory testing initially; complete blood counts and serum chemical studies were available starting on hospital day 3. Laboratory results on hospital days 3 and 5 (illness days 7 and 9) reflected leukopenia, mild thrombocytopenia, and elevated levels of creatine kinase (Table 1). In addition, there were alterations in hepatic function measures: levels of alkaline phosphatase (68 U per liter), alanine aminotransferase (105 U per liter), aspartate aminotransferase (77 U per liter), and lactate dehydrogenase (465 U per liter) were all elevated on day 5 of hospitalization. Given the patient’s recurrent fevers, blood cultures were obtained on day 4; these have shown no growth to date. Figure 3.Posteroanterior and Lateral Chest Radiographs, January 22, 2020 (Illness Day 7, Hospital Day 3).Figure 4.Posteroanterior Chest Radiograph, January 24, 2020 (Illness Day 9, Hospital Day 5). A chest radiograph taken on hospital day 3 (illness day 7) was reported as showing no evidence of infiltrates or abnormalities (Figure 3). However, a second chest radiograph from the night of hospital day 5 (illness day 9) showed evidence of pneumonia in the lower lobe of the left lung (Figure 4). These radiographic findings coincided with a change in respiratory status starting on the evening of hospital day 5, when the patient’s oxygen saturation values as measured by pulse oximetry dropped to as low as 90% while he was breathing ambient air. On day 6, the patient was started on supplemental oxygen, delivered by nasal cannula at 2 liters per minute. Given the changing clinical presentation and concern about hospital-acquired pneumonia, treatment with vancomycin (a 1750-mg loading dose followed by 1 g administered intravenously every 8 hours) and cefepime (administered intravenously every 8 hours) was initiated. Figure 5.Anteroposterior and Lateral Chest Radiographs, January 26, 2020 (Illness Day 10, Hospital Day 6). On hospital day 6 (illness day 10), a fourth chest radiograph showed basilar streaky opacities in both lungs, a finding consistent with atypical pneumonia (Figure 5), and rales were noted in both lungs on auscultation. Given the radiographic findings, the decision to administer oxygen supplementation, the patient’s ongoing fevers, the persistent positive 2019-nCoV RNA at multiple sites, and published reports of the development of severe pneumonia3,4 at a period consistent with the development of radiographic pneumonia in this patient, clinicians pursued compassionate use of an investigational antiviral therapy. Treatment with intravenous remdesivir (a novel nucleotide analogue prodrug in development10,11) was initiated on the evening of day 7, and no adverse events were observed in association with the infusion. Vancomycin was discontinued on the evening of day 7, and cefepime was discontinued on the following day, after serial negative procalcitonin levels and negative nasal PCR testing for methicillin-resistant Staphylococcus aureus. On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.

Summary An outbreak of novel coronavirus (2019-nCoV) that began in Wuhan, China, has spread rapidly, with cases now confirmed in multiple countries. We report the first case of 2019-nCoV infection confirmed in the United States and describe the identification, diagnosis, clinical course, and management of the case, including the patient’s initial mild symptoms at presentation with progression to pneumonia on day 9 of illness. This case highlights the importance of close coordination between clinicians and public health authorities at the local, state, and federal levels, as well as the need for rapid dissemination of clinical information related to the care of patients with this emerging infection. On December 31, 2019, China reported a cluster of cases of pneumonia in people associated with the Huanan Seafood Wholesale Market in Wuhan, Hubei Province.1 On January 7, 2020, Chinese health authorities confirmed that this cluster was associated with a novel coronavirus, 2019-nCoV.2 Although cases were originally reported to be associated with exposure to the seafood market in Wuhan, current epidemiologic data indicate that person-to-person transmission of 2019-nCoV is occurring.3-6 As of January 30, 2020, a total of 9976 cases had been reported in at least 21 countries,7 including the first confirmed case of 2019-nCoV infection in the United States, reported on January 20, 2020. Investigations are under way worldwide to better understand transmission dynamics and the spectrum of clinical illness. This report describes the epidemiologic and clinical features of the first case of 2019-nCoV infection confirmed in the United States.

ORIGINAL ARTICLEBRIEF REPORT First Case of 2019 Novel Coronavirus in the United States List of authors. Michelle L. Holshue, M.P.H., Chas DeBolt, M.P.H., Scott Lindquist, M.D., Kathy H. Lofy, M.D., John Wiesman, Dr.P.H., Hollianne Bruce, M.P.H., Christopher Spitters, M.D., Keith Ericson, P.A.-C., Sara Wilkerson, M.N., Ahmet Tural, M.D., George Diaz, M.D., Amanda Cohn, M.D., et al., for the Washington State 2019-nCoV Case Investigation Team*