niman

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

New England Journal of Medicine paper on first confirmed nCoV case (35M in Snohomish Co WA) 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. https://www.nejm.org/doi/full/10.1056/NEJMoa2001191#.XjSWBjmO7T4.twitter

Transcript for CDC Media Telebriefing: Update on 2019 Novel Coronavirus (2019-nCoV) Press Briefing Transcript Friday, January 31, 2020 Audio recording media icon[MP3 – 4 MB] Please Note: This transcript is not edited and may contain errors. Telebriefing Audio playstopskip-backwardskip-forwardvolume Volume Range Slider Scrub Range Slider Operator: Welcome and thank you all for standing by. All participants will be on a listen-only mode until the question and answer session of today’s call. At that time, you can press star one to ask a question from the phone line. And I’d also like to inform parties that the call is being recorded. If you have any objections you may disconnect at this time. I’d now like to turn the call over to Mr. Benjamin Haynes. You may begin. Ben Haynes: Thank you, Sarah. And thank you all for joining us for this briefing to update you on the 2019 Novel Coronavirus Response. We’re joined today by Dr. Nancy Messonnier, Director of CDC’s National Center for Immunization and Respiratory Diseases and Dr. Marty Cetron, Director of CDC’s Division of Global Migration and Quarantine. They will update you on CDC’s response to this novel coronavirus. Dr. Messonnier will give an update before taking your questions. Dr. Nancy Messonnier: Thank you for joining us today. Yesterday the World Health Organization declared a Public Health Emergency of International C oncern for this novel coronavirus outbreak, which has demonstrated the capacity to spread globally. This is a very serious public health situation, and CDC and the Federal Government has and will continue to take aggressive action to protect the public. We are coordinating closely across HHS with the whole of government and the White House. If we take strong measures now, we may be able to blunt the impact of the virus on the United States. Here are the facts as we know them today. Every day this week China has reported additional cases. Today’s numbers are a 26% increase since yesterday. Over the course of the last week, there have been nearly 7,000 new cases reported. This tells us the virus is continuing to spread rapidly throughout China. The reported deaths have continued to rise as well, and additional locations outside China have continued to report cases. There has been an increasing number of reports of person-to-person spread. And now most recently, a report from the new England journal of medicine of asymptomatic spread. While we still don’t have the full picture and we can’t predict how this situation will play out in the U.S., the current situation, the current scenario is a cause for concern. I understand how this may cause people to be worried about this new virus and how it could affect them. We must be proactive and aggressive, but we want to reassure you that our actions are evidence-based and, we believe, appropriate to the current circumstances. At this moment CDC staff are speaking with the repatriated individuals in California to let them know that CDC under statutory authority of the HHS Secretary has issued federal quarantine orders for all 195 passengers. The quarantine will last 14 days from when the plane left Wuhan, China. This decision, which has been deliberated at CDC by our most expert staff with previous experience working on multiple outbreaks and pandemics, is based on the current scientific facts. While we recognize this is an unprecedented action, we are facing an unprecedented public health threat. And this is one of the tools in our toolbox to mitigate the potential impact of this novel virus on the united states. This legal order is part of an aggressive public health response, the goal of which is to prevent, as much as possible, community spread with this novel virus in the united states. This legal order will also protect the health of the repatriated individuals and protect their families and their communities. These individuals will continue to be held at the March Air Reserve Base in Ontario, California. We do not believe their presence on the base poses a threat to the residents of Ontario. This is a respiratory virus, which means it’s spread through things like respiratory droplets. Medical staff will continue to monitor the health of each traveler including temperature checks and observation for respiratory symptoms. Medical care will be readily available at the first onset of symptoms. Even if an initial screening test comes back negative from CDC’s laboratory, it does not guarantee these individuals will not get sick. We are preparing as if this were the next pandemic, but we are hopeful still that this is not and will not be the case. This is the first time in over 50 years that CDC has issued a quarantine order. While we understand this action may seem drastic, our goal today, tomorrow, and always continues to be the safety of the American public. We would rather be remembered for overreacting than underreacting. I want to reiterate that everyone does have a role to play as we work together to contain the spread of this virus. Stay informed. CDC is updating its website daily with the latest information and advice for the public. Remember to take everyday preventive actions that are always recommended to prevent the spread of respiratory viruses. We do not currently recommend the use of face masks for the general American public. This virus is not spreading in your communities. While it is cold and flu season, we don’t routinely recommend the use of face masks by the public to prevent respiratory illness, and we are certainly not recommending that at this time for this novel virus. We understand the recent recommendations are concerning. The actions of the Federal Government – the actions that the Federal Government is taking are science-based with the aim of protecting the health and safety of all Americans. Please do not let fear or panic guide your actions. For example, please do not assume that just because someone is of Asian descent that they have this new coronavirus. There are about 4 million Chinese-Americans in this country. We recognize the uncertainty of the current situation. As always, CDC public health experts drive to make the best recommendations on the most up-to-date data which will continue to inform our guidance. We have extensive guidance and information on our website at www.cdc.gov/ncov. We’d be happy to take your questions at this time now. Operator: Thank you. At this time if you would like to ask a question, please press star one. Please be sure to unmute your phone and record your name at the prompt so that I may introduce you for your question. Also please limit to one question and one follow-up question. Once again, it is star-one to ask a question. Our first question comes from Denise Grady with New York Times, your line is now open. Denise Grady: Thank you, Dr. Messonnier. The question I’d like to ask, just to be absolutely certain of why this is being done now rather than it hasn’t been done with any of the people who came in on planes before. Is it because of the increased spread in China and also because of the asymptomatic spread? Are those really what prompted it? And did this decision originate within CDC, or did it come from some other level of government? Dr. Nancy Messonnier: Thanks for that question and the opportunity to clarify. This outbreak continues to evolve day by day, and every one of these teleconferences we’ve said that as new information becomes available, we’ll have to re-evaluate our guidance. As we have proceeded through this very long week, what has become clear is that the magnitude of the scope – magnitude and scope of this epidemic in China is increasing, and the epicenter of it continues to be Hubei. While flights from Hubei have decreased since the closure of the airport in Wuhan, these returning travelers are coming directly from the epicenter. So, it is their where they are coming from. But in addition, the emerging evidence this week of the growth and spread of this outbreak, the increase in deaths, and the incoming data about person-to-person transmission as well as concerning reports about asymptomatic spread. All of that data taken together has led CDC to make evidence-based recommendations, and this has been driven from the perspective of CDC by scientifically evidence-based recommendations from CDC experts who have been working on exactly these kinds of issues for many years. So, I’ll stop there. Ben Haynes: Next question, please. Operator: Next question comes from Andrew Joseph with STAT. Your line is open. Andrew Joseph: Hi, yeah. Can you just explain a little bit scientifically how a test can come back negative, and maybe the person still has a virus, or might get sick later? And how does the report of asymptomatic transmission from Germany, how is that changing sort of broader U.S. response beyond this quarantine measure? Thanks. Dr. Nancy Messonnier: Sure. And I think it’s really important to clarify, because I think our screening of people’s nose with this test has been misunderstood. This test was developed at CDC. It’s a test that was developed specifically to identify people who are ill with novel coronavirus. The issue is that we don’t know the sensitivity, specificity, and positive predictive value of that test when we’re using it in people who aren’t yet sick. So, we’re looking in somebody’s nose to see if they have the novel coronavirus there. But it’s possible, for example, that somebody already is asymptomatically incubating the disease. We cannot, with the testing that we have now available at CDC, identify people in that phase, and I think that makes us concerned that this test, which is a point-in-time single test shouldn’t be relied upon to make a prediction at an individual level as to whether somebody’s going to ­– as to whether we can predict that person will become ill. So that’s the answer to the first question. The answer to the second question, in addition to the issue of these repatriated travelers, we have been with our State Health Departments very forthright and aggressive in identifying potential contacts around cases. Using U.S. data, the thing that we are looking at most closely is if we can look at the contacts of confirmed cases and whether they’re spread around those contacts to help us better understand transmission dynamics. But it’s going to be equally important, and we’re very excited that there’s going to be a team now going into China to look at their data, because the data of the epicenter of disease is perhaps the best data right now that will help us know how to interpret this asymptomatic transmission. We need to know if that – how that is impacting the drivers of the outbreak and what role that has in the community transmission in China. Ben Haynes: Next question, please. Operator: Our next question comes from Mike Stobbe with Associated Press. Your line is now open. Mike Stobbe: Hi. Thank you for taking my call. I was wondering, somebody tried to leave March Air Force Base and then a county quarantine order was issued. Has anyone else tried to leave since then? Was that part of the decision making? Also, are there any more flights that are going to be routed to air force bases moving forward? Are you going to deal with every flight from now on going through a military facility and the people being quarantined in and I’m sure you all have extensive discussions about the pros and cons of quarantine, and can you talk about the cons, the things that made you hesitate to take this kind of action? And finally, I’m sorry, could you tell us, is this novel coronavirus deadlier than seasonal flu? Dr. Nancy Messonnier: Okay. So that was four questions and that’s fine, but I’m going to take two of them and then Dr. Cetron is going to take two of them. So, the question about the severity of disease, I guess is a good place to start. And what I would say in terms of severity of disease is, the information that’s coming in from China suggests that there is significant mortality associated with this disease. However, it is very difficult to use that information to calculate a case fatality ratio, and the case fatality ratio for flu differs year by year. We also know that there are biases in reporting of diseases in general. We have found that more severe disease tends to be reported first, which may throw off a calculation. We also understand that the initial case definition in China really focused on patients with pneumonia. And so, it’s not clear what the case fatality – the true case fatality ratio is right now. Therefore, it’s difficult to compare the flu. But what I would say is that there clearly are deaths being reported out of China, and that’s concerning. I’ll answer also the question of future repatriation. As I presume folks know, the State Department has already announced they will be repatriating additional travelers from Wuhan. We are working closely with them to determine how those travelers will be – will be processed and what our operations will be when they’re back in the United States. When we have that more finalized, we will definitely be providing that information, but we’re not prepared today to go in detail about how that operation will proceed. Then for your other two questions, Dr. Cetron, do you want to handle this? Dr. Marty Cetron: Sure. Thanks, Mike. You asked about the use of this measure. And, as Nancy said, we believe that this approach of having quarantine for the incubation period offers the greatest level of protection for the American public in preventing introduction and spread. And that is our primary concern. Prior epidemics actually suggest that people will be – when they’re properly informed, are usually very compliant with this request to restrict their movement. There are benefits to the individual. This allows someone who would become symptomatic to be rapidly identified. And, you know, as these symptoms are not specific, there are many other things. So, offering early rapid diagnosis of their illness could alleviate a lot of anxiety and uncertainty. In addition, this is a protective effect on family members. No individual wants to be the source of introducing or exposing a family member or a loved one to their virus. And, additionally, this is a part of their civic responsibility to protect their communities. Many of these people coming out have been diplomats that are serving America overseas. So, they understand this. In fact, when they arrived at Anchorage prior to getting to the base, they were exuberated and elated to be out of harm’s way, and the idea of the quarantine was not the thing that was troubling them. So, I think that’s the example of why this is a good thing. Clearly, there are cons. If they’re not done properly, if it induces fear and stigma of individuals, if people aren’t treated with dignity and respect and have all the supportive care, that’s not the way to implement this tool in our toolkit, and we’re taking every measure possible to make sure that these people are treated with dignity and respect. Oh, you asked if other people have tried to leave. To our knowledge, when people express some concern, we do talk to them about these risk benefit issues, and they basically say, yeah, it sounds right. This one person who tried to leave was, you know, offered a sort of a California quarantine order in order to enhance that level of protection. But that is not the driving force of this decision. So, this decision is made with deliberation about the nature of the epidemic and the virus, not about any one individual’s behavior. Thanks. Ben Haynes: Next question, please? Operator: Our next question comes from Rob Stein with NPR. Your line is now open. Rob Stein: Thanks very much for taking my call. My question is – a couple of questions. If you can give us a little bit more detail about that one person, what exactly happened with them. And the other question I had was you said this is the first time in 50 years that this quarantine order has been issued. When was the last time and what were the details and circumstances of that? And I just want you to clarify, I didn’t quite understand the question about other planes coming in. Will the same thing happen with passengers on other planes coming in? Dr. Nancy Messonnier: Again, we’re not going to provide more detail about this one individual. That is something that we’re just not going to speak to more now. In terms of the other planes, again, as we said, this situation continues to evolve, and our guidance, our operations, our implementation continues to evolve rapidly as we try to synthesize the risk. We’ve made this decision. We understand its historical significance. We are working with the State Department to fully understand these other repatriated individuals. And as we develop more concrete plans, you will certainly know them. There are active conversations going on while we are at this teleconference on this issue, and when it’s worked out in more detail, we will be communicating that. Dr. Marty Cetron: In terms of the historical context, I think maybe it’s important for people to understand the difference between isolation and quarantine. Isolation is a public health tool that’s used when we restrict the movement of someone who’s already sick with a specific illness. Quarantine is basically when we have a recommended movement, restriction, or some kind of conditions on that movement for people who are exposed and not yet sick. So, while there have been several isolation orders over the last many years, the last time the quarantine was used for a suspect case was in the 1960s for a smallpox evaluation. So, I hope that helps. Ben Haynes: Next question, please? Operator: Our next question comes from Robert Langreth with Bloomberg News. Your line is now open. Robert Langreth: Hi. I just wanted to ask, so what happens to the remaining commercial flights coming from China? What kind of screening and/or situation are you going to put on them? Is that going to be enhanced? Because I guess many of the flights are shutting down. But there are still a bunch coming in, in the next few days. And I think this virus is now in 50, 100 cities in China now. What steps are you doing for the remaining commercial flights coming in, and are you enhancing that? Dr. Marty Cetron: At this point we’re evaluating the appropriate strategy in light of the new information. There is nothing to share at this point. And when there is something to share, we will. Ben Haynes: We have time for one more question, please. Operator: Then our last question comes from Lisa Krueger with San Jose Mercury News. Lisa Krueger: Thank you. I wonder if you can clarify if all these passengers have been tested and those tests have come back negative, presumably? And then a follow-up of how the quarantine is enforced. Dr. Nancy Messonnier: I’ll take the first question. As we have tried to emphasize in my comments today, screening with a laboratory test in this setting does not help us identify people, clearly, who are going to be going on to illness. That is, a negative result on a test will not help us confirm that people are safe from this disease. No, all the test results are not back, and when we have them back, we will be communicating them first to the health care workers who are working with this community, 195 people. But please remember that we do not believe that a negative result on this test means that somebody is out of danger for developing this disease, nor for communicating it to someone else. Dr. Marty Cetron: With regard to your question about enforcement, the truth is, as I indicated before and prior experience in SARS, for example, in Toronto, in SARS over 99% of the persons, once educated and assured and reassured, didn’t need any legal enforcement. So, while that may be available to the very few people when indicated, the best way to enforce a quarantine is to educate people on its purpose and educate what the benefits are for the individuals who cooperate. These are American citizens who clearly want to do the right thing. And in contrast to their experience in Wuhan, this is a much better scenario for them. Thank you. Dr. Nancy Messonnier: And we should take the opportunity to thank them for their cooperation. We understand that this is a difficult situation for them. They’ve been through an ordeal. And we’re asking them to take the time with us to make sure that they’re protecting their families and their communities, and we really admire their flexibility and resilience. Ben Haynes: Thank you, Dr. Messonnier. And thank you, Dr. Cetron. Thank you all for joining us for today’s update. Please visit CDC’s 2019 novel coronavirus website for continued updates. And if you have further questions, please contact the main media line at 404-639-3286 or email [email protected]. Thank you. Operator: This concludes today’s call. Thank you all for participating. You may disconnect your lines at this time. https://www.cdc.gov/media/releases/2020/t0131-2019-novel-coronavirus.html

Transcript for CDC Media Telebriefing: Update on 2019 Novel Coronavirus (2019-nCoV) Press Briefing Transcript Friday, January 31, 2020 Audio recording media icon[MP3 – 4 MB] Please Note: This transcript is not edited and may contain errors. Telebriefing Audio playstopskip-backwardskip-forwardvolume Volume Range Slider Scrub Range Slider Operator: Welcome and thank you all for standing by. All participants will be on a listen-only mode until the question and answer session of today’s call. At that time, you can press star one to ask a question from the phone line. And I’d also like to inform parties that the call is being recorded. If you have any objections you may disconnect at this time. I’d now like to turn the call over to Mr. Benjamin Haynes. You may begin. Ben Haynes: Thank you, Sarah. And thank you all for joining us for this briefing to update you on the 2019 Novel Coronavirus Response. We’re joined today by Dr. Nancy Messonnier, Director of CDC’s National Center for Immunization and Respiratory Diseases and Dr. Marty Cetron, Director of CDC’s Division of Global Migration and Quarantine. They will update you on CDC’s response to this novel coronavirus. Dr. Messonnier will give an update before taking your questions. Dr. Nancy Messonnier: Thank you for joining us today. Yesterday the World Health Organization declared a Public Health Emergency of International C oncern for this novel coronavirus outbreak, which has demonstrated the capacity to spread globally. This is a very serious public health situation, and CDC and the Federal Government has and will continue to take aggressive action to protect the public. We are coordinating closely across HHS with the whole of government and the White House. If we take strong measures now, we may be able to blunt the impact of the virus on the United States. Here are the facts as we know them today. Every day this week China has reported additional cases. Today’s numbers are a 26% increase since yesterday. Over the course of the last week, there have been nearly 7,000 new cases reported. This tells us the virus is continuing to spread rapidly throughout China. The reported deaths have continued to rise as well, and additional locations outside China have continued to report cases. There has been an increasing number of reports of person-to-person spread. And now most recently, a report from the new England journal of medicine of asymptomatic spread. While we still don’t have the full picture and we can’t predict how this situation will play out in the U.S., the current situation, the current scenario is a cause for concern. I understand how this may cause people to be worried about this new virus and how it could affect them. We must be proactive and aggressive, but we want to reassure you that our actions are evidence-based and, we believe, appropriate to the current circumstances. At this moment CDC staff are speaking with the repatriated individuals in California to let them know that CDC under statutory authority of the HHS Secretary has issued federal quarantine orders for all 195 passengers. The quarantine will last 14 days from when the plane left Wuhan, China. This decision, which has been deliberated at CDC by our most expert staff with previous experience working on multiple outbreaks and pandemics, is based on the current scientific facts. While we recognize this is an unprecedented action, we are facing an unprecedented public health threat. And this is one of the tools in our toolbox to mitigate the potential impact of this novel virus on the united states. This legal order is part of an aggressive public health response, the goal of which is to prevent, as much as possible, community spread with this novel virus in the united states. This legal order will also protect the health of the repatriated individuals and protect their families and their communities. These individuals will continue to be held at the March Air Reserve Base in Ontario, California. We do not believe their presence on the base poses a threat to the residents of Ontario. This is a respiratory virus, which means it’s spread through things like respiratory droplets. Medical staff will continue to monitor the health of each traveler including temperature checks and observation for respiratory symptoms. Medical care will be readily available at the first onset of symptoms. Even if an initial screening test comes back negative from CDC’s laboratory, it does not guarantee these individuals will not get sick. We are preparing as if this were the next pandemic, but we are hopeful still that this is not and will not be the case. This is the first time in over 50 years that CDC has issued a quarantine order. While we understand this action may seem drastic, our goal today, tomorrow, and always continues to be the safety of the American public. We would rather be remembered for overreacting than underreacting. I want to reiterate that everyone does have a role to play as we work together to contain the spread of this virus. Stay informed. CDC is updating its website daily with the latest information and advice for the public. Remember to take everyday preventive actions that are always recommended to prevent the spread of respiratory viruses. We do not currently recommend the use of face masks for the general American public. This virus is not spreading in your communities. While it is cold and flu season, we don’t routinely recommend the use of face masks by the public to prevent respiratory illness, and we are certainly not recommending that at this time for this novel virus. We understand the recent recommendations are concerning. The actions of the Federal Government – the actions that the Federal Government is taking are science-based with the aim of protecting the health and safety of all Americans. Please do not let fear or panic guide your actions. For example, please do not assume that just because someone is of Asian descent that they have this new coronavirus. There are about 4 million Chinese-Americans in this country. We recognize the uncertainty of the current situation. As always, CDC public health experts drive to make the best recommendations on the most up-to-date data which will continue to inform our guidance. We have extensive guidance and information on our website at www.cdc.gov/ncov. We’d be happy to take your questions at this time now. Operator: Thank you. At this time if you would like to ask a question, please press star one. Please be sure to unmute your phone and record your name at the prompt so that I may introduce you for your question. Also please limit to one question and one follow-up question. Once again, it is star-one to ask a question. Our first question comes from Denise Grady with New York Times, your line is now open. Denise Grady: Thank you, Dr. Messonnier. The question I’d like to ask, just to be absolutely certain of why this is being done now rather than it hasn’t been done with any of the people who came in on planes before. Is it because of the increased spread in China and also because of the asymptomatic spread? Are those really what prompted it? And did this decision originate within CDC, or did it come from some other level of government? Dr. Nancy Messonnier: Thanks for that question and the opportunity to clarify. This outbreak continues to evolve day by day, and every one of these teleconferences we’ve said that as new information becomes available, we’ll have to re-evaluate our guidance. As we have proceeded through this very long week, what has become clear is that the magnitude of the scope – magnitude and scope of this epidemic in China is increasing, and the epicenter of it continues to be Hubei. While flights from Hubei have decreased since the closure of the airport in Wuhan, these returning travelers are coming directly from the epicenter. So, it is their where they are coming from. But in addition, the emerging evidence this week of the growth and spread of this outbreak, the increase in deaths, and the incoming data about person-to-person transmission as well as concerning reports about asymptomatic spread. All of that data taken together has led CDC to make evidence-based recommendations, and this has been driven from the perspective of CDC by scientifically evidence-based recommendations from CDC experts who have been working on exactly these kinds of issues for many years. So, I’ll stop there. Ben Haynes: Next question, please. Operator: Next question comes from Andrew Joseph with STAT. Your line is open. Andrew Joseph: Hi, yeah. Can you just explain a little bit scientifically how a test can come back negative, and maybe the person still has a virus, or might get sick later? And how does the report of asymptomatic transmission from Germany, how is that changing sort of broader U.S. response beyond this quarantine measure? Thanks. Dr. Nancy Messonnier: Sure. And I think it’s really important to clarify, because I think our screening of people’s nose with this test has been misunderstood. This test was developed at CDC. It’s a test that was developed specifically to identify people who are ill with novel coronavirus. The issue is that we don’t know the sensitivity, specificity, and positive predictive value of that test when we’re using it in people who aren’t yet sick. So, we’re looking in somebody’s nose to see if they have the novel coronavirus there. But it’s possible, for example, that somebody already is asymptomatically incubating the disease. We cannot, with the testing that we have now available at CDC, identify people in that phase, and I think that makes us concerned that this test, which is a point-in-time single test shouldn’t be relied upon to make a prediction at an individual level as to whether somebody’s going to ­– as to whether we can predict that person will become ill. So that’s the answer to the first question. The answer to the second question, in addition to the issue of these repatriated travelers, we have been with our State Health Departments very forthright and aggressive in identifying potential contacts around cases. Using U.S. data, the thing that we are looking at most closely is if we can look at the contacts of confirmed cases and whether they’re spread around those contacts to help us better understand transmission dynamics. But it’s going to be equally important, and we’re very excited that there’s going to be a team now going into China to look at their data, because the data of the epicenter of disease is perhaps the best data right now that will help us know how to interpret this asymptomatic transmission. We need to know if that – how that is impacting the drivers of the outbreak and what role that has in the community transmission in China. Ben Haynes: Next question, please. Operator: Our next question comes from Mike Stobbe with Associated Press. Your line is now open. Mike Stobbe: Hi. Thank you for taking my call. I was wondering, somebody tried to leave March Air Force Base and then a county quarantine order was issued. Has anyone else tried to leave since then? Was that part of the decision making? Also, are there any more flights that are going to be routed to air force bases moving forward? Are you going to deal with every flight from now on going through a military facility and the people being quarantined in and I’m sure you all have extensive discussions about the pros and cons of quarantine, and can you talk about the cons, the things that made you hesitate to take this kind of action? And finally, I’m sorry, could you tell us, is this novel coronavirus deadlier than seasonal flu? Dr. Nancy Messonnier: Okay. So that was four questions and that’s fine, but I’m going to take two of them and then Dr. Cetron is going to take two of them. So, the question about the severity of disease, I guess is a good place to start. And what I would say in terms of severity of disease is, the information that’s coming in from China suggests that there is significant mortality associated with this disease. However, it is very difficult to use that information to calculate a case fatality ratio, and the case fatality ratio for flu differs year by year. We also know that there are biases in reporting of diseases in general. We have found that more severe disease tends to be reported first, which may throw off a calculation. We also understand that the initial case definition in China really focused on patients with pneumonia. And so, it’s not clear what the case fatality – the true case fatality ratio is right now. Therefore, it’s difficult to compare the flu. But what I would say is that there clearly are deaths being reported out of China, and that’s concerning. I’ll answer also the question of future repatriation. As I presume folks know, the State Department has already announced they will be repatriating additional travelers from Wuhan. We are working closely with them to determine how those travelers will be – will be processed and what our operations will be when they’re back in the United States. When we have that more finalized, we will definitely be providing that information, but we’re not prepared today to go in detail about how that operation will proceed. Then for your other two questions, Dr. Cetron, do you want to handle this? Dr. Marty Cetron: Sure. Thanks, Mike. You asked about the use of this measure. And, as Nancy said, we believe that this approach of having quarantine for the incubation period offers the greatest level of protection for the American public in preventing introduction and spread. And that is our primary concern. Prior epidemics actually suggest that people will be – when they’re properly informed, are usually very compliant with this request to restrict their movement. There are benefits to the individual. This allows someone who would become symptomatic to be rapidly identified. And, you know, as these symptoms are not specific, there are many other things. So, offering early rapid diagnosis of their illness could alleviate a lot of anxiety and uncertainty. In addition, this is a protective effect on family members. No individual wants to be the source of introducing or exposing a family member or a loved one to their virus. And, additionally, this is a part of their civic responsibility to protect their communities. Many of these people coming out have been diplomats that are serving America overseas. So, they understand this. In fact, when they arrived at Anchorage prior to getting to the base, they were exuberated and elated to be out of harm’s way, and the idea of the quarantine was not the thing that was troubling them. So, I think that’s the example of why this is a good thing. Clearly, there are cons. If they’re not done properly, if it induces fear and stigma of individuals, if people aren’t treated with dignity and respect and have all the supportive care, that’s not the way to implement this tool in our toolkit, and we’re taking every measure possible to make sure that these people are treated with dignity and respect. Oh, you asked if other people have tried to leave. To our knowledge, when people express some concern, we do talk to them about these risk benefit issues, and they basically say, yeah, it sounds right. This one person who tried to leave was, you know, offered a sort of a California quarantine order in order to enhance that level of protection. But that is not the driving force of this decision. So, this decision is made with deliberation about the nature of the epidemic and the virus, not about any one individual’s behavior. Thanks. Ben Haynes: Next question, please? Operator: Our next question comes from Rob Stein with NPR. Your line is now open. Rob Stein: Thanks very much for taking my call. My question is – a couple of questions. If you can give us a little bit more detail about that one person, what exactly happened with them. And the other question I had was you said this is the first time in 50 years that this quarantine order has been issued. When was the last time and what were the details and circumstances of that? And I just want you to clarify, I didn’t quite understand the question about other planes coming in. Will the same thing happen with passengers on other planes coming in? Dr. Nancy Messonnier: Again, we’re not going to provide more detail about this one individual. That is something that we’re just not going to speak to more now. In terms of the other planes, again, as we said, this situation continues to evolve, and our guidance, our operations, our implementation continues to evolve rapidly as we try to synthesize the risk. We’ve made this decision. We understand its historical significance. We are working with the State Department to fully understand these other repatriated individuals. And as we develop more concrete plans, you will certainly know them. There are active conversations going on while we are at this teleconference on this issue, and when it’s worked out in more detail, we will be communicating that. Dr. Marty Cetron: In terms of the historical context, I think maybe it’s important for people to understand the difference between isolation and quarantine. Isolation is a public health tool that’s used when we restrict the movement of someone who’s already sick with a specific illness. Quarantine is basically when we have a recommended movement, restriction, or some kind of conditions on that movement for people who are exposed and not yet sick. So, while there have been several isolation orders over the last many years, the last time the quarantine was used for a suspect case was in the 1960s for a smallpox evaluation. So, I hope that helps. Ben Haynes: Next question, please? Operator: Our next question comes from Robert Langreth with Bloomberg News. Your line is now open. Robert Langreth: Hi. I just wanted to ask, so what happens to the remaining commercial flights coming from China? What kind of screening and/or situation are you going to put on them? Is that going to be enhanced? Because I guess many of the flights are shutting down. But there are still a bunch coming in, in the next few days. And I think this virus is now in 50, 100 cities in China now. What steps are you doing for the remaining commercial flights coming in, and are you enhancing that? Dr. Marty Cetron: At this point we’re evaluating the appropriate strategy in light of the new information. There is nothing to share at this point. And when there is something to share, we will. Ben Haynes: We have time for one more question, please. Operator: Then our last question comes from Lisa Krueger with San Jose Mercury News. Lisa Krueger: Thank you. I wonder if you can clarify if all these passengers have been tested and those tests have come back negative, presumably? And then a follow-up of how the quarantine is enforced. Dr. Nancy Messonnier: I’ll take the first question. As we have tried to emphasize in my comments today, screening with a laboratory test in this setting does not help us identify people, clearly, who are going to be going on to illness. That is, a negative result on a test will not help us confirm that people are safe from this disease. No, all the test results are not back, and when we have them back, we will be communicating them first to the health care workers who are working with this community, 195 people. But please remember that we do not believe that a negative result on this test means that somebody is out of danger for developing this disease, nor for communicating it to someone else. Dr. Marty Cetron: With regard to your question about enforcement, the truth is, as I indicated before and prior experience in SARS, for example, in Toronto, in SARS over 99% of the persons, once educated and assured and reassured, didn’t need any legal enforcement. So, while that may be available to the very few people when indicated, the best way to enforce a quarantine is to educate people on its purpose and educate what the benefits are for the individuals who cooperate. These are American citizens who clearly want to do the right thing. And in contrast to their experience in Wuhan, this is a much better scenario for them. Thank you. Dr. Nancy Messonnier: And we should take the opportunity to thank them for their cooperation. We understand that this is a difficult situation for them. They’ve been through an ordeal. And we’re asking them to take the time with us to make sure that they’re protecting their families and their communities, and we really admire their flexibility and resilience. Ben Haynes: Thank you, Dr. Messonnier. And thank you, Dr. Cetron. Thank you all for joining us for today’s update. Please visit CDC’s 2019 novel coronavirus website for continued updates. And if you have further questions, please contact the main media line at 404-639-3286 or email [email protected]. Thank you. Operator: This concludes today’s call. Thank you all for participating. You may disconnect your lines at this time.

Transcript We are preparing as if this were the next pandemic, but we are hopeful still that this is not and will not be the case. This is the first time in over 50 years that CDC has issued a quarantine order. While we understand this action may seem drastic, our goal today, tomorrow, and always continues to be the safety of the American public. We would rather be remembered for overreacting than underreacting. I want to reiterate that everyone does have a role to play as we work together to contain the spread of this virus. Stay informed. https://www.cdc.gov/media/releases/2020/t0131-2019-novel-coronavirus.html

Audio https://www.cdc.gov/media/releases/2020/t0131-cdc-telebriefing-2019-novel-coronavirus.mp3

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* Article Figures/Media Metrics 20 References 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. 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. 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). 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. Supplementary Material Supplementary Appendix PDF 117KB 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

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 https://www.nejm.org/doi/full/10.1056/NEJMoa2001191#.XjSWBjmO7T4.twitter

It stopped spreading in May. Wet markets were closed and lots of people stayed indoors in China, but SARS was one or two orders of magnitude smaller than nCoV.

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

https://www.stmgp.bayern.de/presse/aktuelle-informationen-zur-coronavirus-lage-in-bayern-bayerisches-gesundheitsministerium-2/ The Bavarian Ministry of Health informed on Friday about the current development of the new corona virus in Bavaria. A ministry spokesman said in Munich that, according to the State Office for Health and Food Safety (LGL), another coronavirus case in Bavaria was confirmed at noon. It is a child of the man from the district of Traunstein, the positive finding of which was published late Thursday evening. The man is an employee of the company from the district of Starnberg, which also deals with the other four cases known to date. There are a total of six coronavirus cases in Bavaria. According to doctors, all those affected are currently in a stable state of health. Tests by other people who also work for this company showed no further positive results until midday on Friday. The Bavarian Ministry of Health will provide further details later today. The contacts identified so far should isolate themselves at home and continuously report to the health department with information on their health status.

press release 01/31/2020 No. 19 / GP Download PDF Current information on the corona virus situation in Bavaria - Bavarian Ministry of Health: A new case in the Fürstenfeldbruck district confirmed The Bavarian Ministry of Health informed a third time late Friday evening about the current development of the new corona virus in Bavaria. A ministry spokesman said in Munich that, according to the State Office for Health and Food Safety (LGL), another coronavirus case in Bavaria had been confirmed. It is a man who lives in the Fürstenfeldbruck district. He is an employee of the company from the district of Starnberg, where the five first known coronavirus cases are employed. There are currently seven known coronavirus cases in Bavaria (as of 7:30 p.m.). The sixth case had been confirmed on Friday afternoon. It is a child of the man from the district of Traunstein, the positive finding of which was published late Thursday evening. This man is also an employee of the company from the district of Starnberg. A test campaign for employees had taken place there on Wednesday, Thursday and Friday. Of the 128 results currently available, 127 were negative. The positive finding comes from the man in the Fürstenfeldbruck district - details will be given to the media on Saturday. https://www.stmgp.bayern.de/presse/aktuelle-informationen-zur-coronavirus-lage-in-bayern-bayerisches-gesundheitsministerium-4/

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://www.nejm.org/doi/full/10.1056/NEJMc2001468

The Bavaria nCoV cluster, which has it's epicenter in suburban Munich, has grown to nine victims spread over six cities (Shanghai, Stockdorf, Fürstenfeldbruck, Starnberg, Traustein, La Gomera) in three countries (China, Germany, Spain)

press release 01/31/2020 No. 19 / GP Download PDF Current information on the corona virus situation in Bavaria - Bavarian Ministry of Health: A new case in the Fürstenfeldbruck district confirmed The Bavarian Ministry of Health informed a third time late Friday evening about the current development of the new corona virus in Bavaria. A ministry spokesman said in Munich that, according to the State Office for Health and Food Safety (LGL), another coronavirus case in Bavaria had been confirmed. It is a man who lives in the Fürstenfeldbruck district. He is an employee of the company from the district of Starnberg, where the five first known coronavirus cases are employed. There are currently seven known coronavirus cases in Bavaria (as of 7:30 p.m.). The sixth case had been confirmed on Friday afternoon. It is a child of the man from the district of Traunstein, the positive finding of which was published late Thursday evening. This man is also an employee of the company from the district of Starnberg. A test campaign for employees had taken place there on Wednesday, Thursday and Friday. Of the 128 results currently available, 127 were negative. The positive finding comes from the man in the Fürstenfeldbruck district - details will be given to the media on Saturday. https://www.stmgp.bayern.de/presse/aktuelle-informationen-zur-coronavirus-lage-in-bayern-bayerisches-gesundheitsministerium-4/

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 Antena 3 News Published: 01/31/2020 23:24 Updated: 01.02.2020 00:00 WhatsApp Facebook Twitter Linkedin Flipboard Share More information The Spaniards repatriated from Wuhan by the coronavirus arrive in Madrid It's that easy to cheat about the coronavirus and its terrible consequences 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

Tourist in La Gomera in Canary Islands, Spain linked to cluster in Starnberg, Germany, where there are now 7 positives in addition to the index case in Shanghai. Cluster now in three countries (China, Germany, Spain) with epicenter in Germany.

Media Statement For Immediate Release Friday, January 31, 2020 Contact: CDC Media Relations 404-639-3286 CDC Confirms Seventh Case of 2019 Novel Coronavirus CDC today confirmed another infection with 2019 Novel Coronavirus (2019-nCoV) in the United States that was detected in California. The patient recently returned from Wuhan, China, where an outbreak of respiratory illness caused by this novel coronavirus has been ongoing since December 2019. This brings the total of number of 2019-nCoV cases in the United States to seven. For the latest information on the outbreak, visit CDC’s Novel Coronavirus 2019 website.

Update on pneumonia of new coronavirus infection as of 21:00 on January 31 2020-02-01 　　1 Yue 31 Ri 0-24 , the 31 provinces (autonomous regions and municipalities) and Xinjiang Production and Construction Corps new confirmed cases reported 2102 cases of new severe cases 268 cases of new deaths in 46 cases (Hubei Province, 45 cases in Chongqing City 1 case), new cases were cured 72 cases of new suspected cases, 5019 cases. 　　As of 1 Yue 31 Ri 24 , the national health committee received 31 provinces (autonomous regions and municipalities) and Xinjiang Production and Construction Corps reported a total of confirmed cases 11791 cases (Jiangxi, Shaanxi Province, Gansu Province, each subtract 1 case), the existing There were 1795 severe cases , a total of 259 deaths, a total of 243 cured and discharged patients , and a total of 17,988 suspected cases . 　　At present, a total of 136,987 close contacts have been traced . Of the 6,509 people who were released from medical observation on the same day , a total of 118,478 people are receiving medical observation. 　　A total of 30 confirmed cases were reported in Hong Kong , Macao and Taiwan : 13 in the Hong Kong Special Administrative Region, 7 in the Macao Special Administrative Region , and 10 in Taiwan . 　　(Information comes from the official website of the National Health Commission)

1795 severe cases , a total of 259 deaths, a total of 243 cured and discharged patients http://www.chinacdc.cn/jkzt/crb/zl/szkb_11803/jszl_11809/202002/t20200201_212109.html

Epidemic situation of new coronavirus infection in Hubei Province on January 31, 2020 From 04:00 to 24:00 on January 31, 2020 , 1347 new cases of pneumonia caused by new coronavirus infection were added in Hubei Province (including: 576 in Wuhan, 41 in Huangshi, 27 in Shiyan, 61 in Xiangyang, and Yichang 109 cases, 66 cases in Jingzhou City, 24 cases in Jingmen City, 38 cases in Ezhou City, 87 cases in Xiaogan City, 153 cases in Huanggang City, 40 cases in Xianning City, 76 cases in Suizhou City, 12 cases in Enshi Prefecture, 7 cases in Xiantao City, and Tianmen City 15 cases, 15 cases in Qianjiang City, and 0 cases in Shennongjia Forest District). There were 45 new deaths in the province (among them: 33 in Wuhan, 1 in Huangshi, 1 in Jingzhou, 3 in Ezhou, 3 in Xiaogan, 2 in Huanggang, 1 in Suizhou, and 1 in Tianmen) . There were 50 new discharges (including: 36 in Wuhan, 1 in Jingzhou, 1 in Jingmen, 11 in Huanggang, and 1 in Xianning). As of 24:00 on January 31, 2020, Hubei Province has reported 7,153 cases of pneumonitis with new type of coronavirus infection (including 3215 cases in Wuhan, 209 cases in Huangshi City, 177 cases in Shiyan City, 347 cases in Xiangyang City, and 276 cases in Yichang City). 287 cases in Jingzhou, 251 in Jingmen, 227 in Ezhou, 628 in Xiaogan, 726 in Huanggang, 206 in Xianning, 304 in Suizhou, 87 in Enshi, 97 in Xiantao, and 82 in Tianmen , 27 cases in Qianjiang City, 7 cases in Shennongjia Forest District), 166 cases have been cured and 249 patients have been discharged (among them: 192 in Wuhan, 2 in Huangshi, 1 in Yichang, 4 in Jingzhou, and 5 in Jingmen (9 cases in Ezhou City, 12 cases in Xiaogan City, 14 cases in Huanggang City, 1 case in Suizhou, 1 case in Xiantao City, 7 cases in Tianmen City, and 1 case in Qianjiang City). At present, 6738 cases are still being treated in the hospital (among them: 956 cases of severe illness and 338 cases of critical illness), all of them are receiving isolation treatment at designated medical institutions. A total of 41,075 close contacts have been tracked, and 36,838 people are still undergoing medical observation.

956 cases of severe illness and 338 cases of critical illness, 166 cases have been cured and 249 patients have died http://wjw.hubei.gov.cn/fbjd/dtyw/202002/t20200201_2017100.shtml

News Release Ontario Confirms Third Case of 2019 Novel Coronavirus Province Adds New Reporting Category to More Accurately Reflect Current Status January 31, 2020 2:59 P.M. Ministry of Health TORONTO - Today, Dr. David Williams, Chief Medical Officer of Health, confirmed Ontario's third case of 2019 novel coronavirus. The case is located in London, Ontario. Given the newness of the 2019 novel coronavirus and as part of the continuing cooperative efforts between Public Health Ontario (PHO) and the Public Health Agency of Canada (PHAC), Ontario has been sharing all test samples with the National Microbiology Lab in Winnipeg. As part of the National Microbiology Lab's efforts to ensure quality control, additional testing was performed on the samples provided. As a result of this additional testing, a case that was previously deemed negative by PHO's lab has now been found to be positive by the National Microbiology Lab, which uses a more sensitive test that can identify the smallest trace presence of the virus. The majority of cases previously considered negative have been confirmed as negative by the National Microbiology Lab. To provide the public with the greatest certainty, Ontario's reporting will now include a new category that more accurately reflects the province's status: presumptive negative. That said, for any person found presumptively negative by the PHO lab, there is an extremely low risk of transmitting the virus. The newly confirmed case, a female in her 20s, arrived asymptomatic in Toronto on January 23, 2020 and was transported to London by way of a private vehicle. On January 24, 2020, the individual started to exhibit symptoms and that same day was assessed and tested at London Health Sciences Centre. She was released with follow up by the Middlesex-London Health Unit. This individual has had limited exposure to other individuals and has otherwise been in isolation since January 24, 2020, with regular contact by the Middlesex-London Health Unit to monitor her condition. She is now recovered and is well. "I want to re-emphasize that the risk to Ontarians remains low," said Dr. Williams. "It is clear that we are learning more and more about the coronavirus each day, and our testing procedures are evolving and getting more and more precise, which is good news for everyone throughout Ontario and Canada. By working hand-in-hand with our partners across the health care system we are in a very good position to contain the virus and better protect the health and wellbeing of individuals and families across the province." While requiring validation by the National Microbiology Lab, PHO's lab will continue to offer the province's public health system an early indication of a case's status, allowing the province and local public health officials to quickly and effectively implement all necessary protocols to contain and treat any individuals who have 2019 novel coronavirus. Media Contacts Travis Kann Office of the Deputy Premier & Minister of Health [email protected] 647-388-5845 David Jensen Ministry of Health [email protected] 416-314-6197 https://news.ontario.ca/mohltc/en/2020/01/ontario-confirms-third-case-of-2019-novel-coronavirus.html

Third Ontario nCoV case (20'sF) confirmed by National Lab after initial negative in Ontario Lab.

CORONAVIRUS LIVE: Coronavirus: Bay Area's 1st case confirmed in Santa Clara County, CDC says SAN JOSE, Calif. (KGO) -- The Bay Area's first case of the coronavirus from China has been confirmed in Santa Clara County, officials say. RELATED: Here's what US health officials know about coronavirus outbreak that originated in Wuhan, China The CDC says an adult male resident tested positive for the new coronavirus. He has been self-isolating since he returned from a trip to Wahun on Jan. 24, officials say. He has not been hospitalized and has not been very sick. He's currently being treated as an outpatient and has come into contact with very few individuals since he's been home, officials say. The people with whom he came into contact with are self-isolating at home for 14 days. The Santa Clara County case marks the seventh confirmed case in the United States. There are two other cases in California, one in Arizona, one in Washington state, and two in Illinois. RELATED: WHO declares global emergency over coronavirus from China While the virus has been identified in one person, Santa Clara County officials say it's not considered "circulating" in the area. The flu, however, is circulating widely. Health officials say that if you are sick, stay home, wash hands frequently, cough and sneeze into your sleeve or a tissue and avoid touching your eyes, nose and mouth. Almost 10,000 people have been infected globally in a two-month period. More than 200 people have died, all in China. The U.S. State Department has issued a "Do Not Travel" advisory to the country. Delta Airlines, American Airlines and United Airlines are suspending all flights between the U.S. and China.