Editorial
Li
Wenliang,
a
face
to
the
frontline
healthcare
worker.
The
first
doctor
to
notify
the
emergence
of
the
SARS-CoV-2,
(COVID-19),
outbreak
DrLiWenliang,wholosthislifetothenovelcoronavirus, SARS-CoV-2,becamethefaceofthethreatofSARS-CoV-2tofrontline workers, the clinicians taking care of patients. Li, 34, was an ophthalmologistatWuhanCentral Hospital.On30thDecember, 2019,whentheWuhanmunicipalhealthservicesentoutanalert, he reportedly warned a closed group of ex-medical school classmatesonthe WeChat social mediasite of “Sevencases of severeacuterespiratorysyndrome(SARS)likeillnesswithlinks withtheHuananSeafoodWholesaleMarket”athishospital.He was among eight people reprimanded by security officers for “spreadingrumours”.Inatragicturnofevents,hesubsequently contractedSARS-CoV-2and,afteraperiodinintensivecare,died onthemorningofFriday7thFebruary,2020(SouthChinaMorning Post,2020).
Thiscaseisastarkreminderoftherisksofemergingdisease outbreaksforhealthcareworkers(HCWs).DrLiWenliang’snameis addedtothelonglistofHCWthatwereattheforefrontofoutbreaks of SARS, Ebola, MERS and now SARS-CoV-2. It is important to recognisethatitwasthecliniciansinWuhan whosoundedthealarm abouttheemergenceofSARS-CoV-2whichwasrapidlyidentified aftertheseclinicianssentsamplestoareferencelaboratoryfornext generationsequencing(NGS)(Zhouetal.,2020).
Global public health security is of primary importance to preventoutbreaksofdiseaseswithepidemicpotentialandevery effort to detect, report, and institute infection prevention and control measures should be made. Astute clinicians, access to laboratorieswithstateofthearttools,andopenness,transparency and quick reporting are crucial components of this response (Kavanagh,2020).Thisrequiresanopenflowofinformationand collaborationbetween laboratory experts and clinicians on the frontlinewhomaybethefirsttoobserveunusualclusteringof casesoruncommonclinicalpresentations,bothofwhichshouldbe reportedimmediately.
Healthcareworkersarealsooneofthegroupsmostatriskfrom outbreaksduetoreemergingandnovelpathogens.Thishasbeen seeninthecurrentSARS-CoV-2outbreakinChinawhereasmany as1716healthworkershavebeenreportedtobeinfectedbythe viruswith6deathsason14thFebruary,2020(WHO,2020a).Ina singlecentercase series ofSARS-CoV-2 fromWuhanpublished recently, almost 29% of all patients were healthcare workers
presumed to have been infected in the hospital (Wang et al., 2020b).
The preliminary sequence data on the case cluster were obtainedbyNGSofspecimenscollectedon26thDecember2019 through7January2020(Luetal.,2020).TheChineseauthorities ruled out SARS-CoV and MERS-CoV, and confirmed a novel coronavirus as the probable cause on 9th January, 2020 (Hui etal.,2020;Wangetal.,2020a).Thefirstgenomesequencewas releasedonvirological.orgthe12thJanuary2020,seventeendays afterobtainingthefirstspecimenandseveraladditionalgenomic sequenceswerethensharedonGISAID(Wangetal.,2020c).Thisis animpressiverapidprogressionfrominitialoutbreaknotification toidentificationofanovelpathogen.
The rapid identification of the SARS-CoV-2 virus by NGS illustratestheadvancesinmolecularidentificationsincethe SARS-CoV(2003)andMERS-CoV(2012)outbreaks,wherebothviruses wereinitiallyidentifiedbyinvitrocellculture.Thus,clinicianof thepossibilityofanewinfectiousdiseasecoupledwithNGScan servetoquicklyidentifynovelpathogensandallowfortherapid initiation of control measures to reduce further spread and potentiallypreventlarge-scaleoutbreaks.
The SARS-CoVoutbreakoriginating fromChinain 2003was firstreportedtotheglobalhealthcommunitybyProMED(ProMED, 2003; CarrionandMadoff,2017;Hameretal.,2017).Ittook six weeksfortheauthoritiestoacknowledgetheoutbreakhadspread significantlyfromGuangdongthroughoutChinaaftercaseswere reportedfromHongKong,Hanoi,Singapore,andToronto.
Inreportingtheexistenceofanewrespiratorydiseasetothe WHO on December 31 st, the Chinese authorities formally acknowledged the outbreakmuch soonerthis time, perhaps in partbecauseof theongoing spread of information oninformal social medianetworks.ProMEDposted theinitialreportof the unknownpneumoniaoutbreakinWuhanon30December2019 (ProMED,2019).Sincethen,transmissionofinformationhasbeen relativelytransparent,withthepromptsharingofthesequenceof thevirusandactualnumbersofcasesreportedonadailybasis.The casefigureshavedemonstratedtheupwardtrajectoryoftherapid spreadofSARS-CoV-2fromWuhanandHubeiProvincetoallof China.
On 13thFebruary 2020theChinese authorities changedthe casedefinitionandthenumberofnewlyreportedcasesoverthe
https://doi.org/10.1016/j.ijid.2020.02.052
1201-9712/©2020PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
InternationalJournalofInfectiousDiseases93(2020)205–207
ContentslistsavailableatScienceDirect
International
Journal
of
Infectious
Diseases
prior24hjumpedto14,886fromaprevioushighof4370on6th February 2020. This was not a real increase, but reflectedthe additionofthecumulativenumberofclinicallydiagnosedcases (without laboratory confirmation) to the reported number of laboratoryconfirmed casesanddemonstrates howeasilya case definition can influence numbers. On 19 February 2020, the Chinese authorities changed the case definition to include laboratoryconfirmed casesonlyand designatingclinically diag-nosedcasesassuspectedcases.Thisresultedinarapiddropof dailynewlyconfirmedcases,againdemonstratingtheimpactof casedefinitiononreportedcasenumbers.Asof23February2020, WHO has reported a total of 78,007 cases with 2,462 deaths globallywithreportsofcasesfrom29countries(WHO,2020a,b). A key questionremains “whatis therealnumber ofpeople infectedsincemanycasesmaybemildorasymptomatic?”Arecent modellingestimatedthepopulationattackratetobebetween0.75 per100,000to15.8per100,000analysingratesdowntoprefecture levelinChina(Yangetal.,2020).Anydeterminationofincidence willlikelybeanunderestimatesinceitwillnotincludemildand asymptomaticcases.Accuracyofsuchestimateswilldependon thedevelopmentofsensitiveandspecificserologictests.
Recognizing disease in travelers is a particularly important aspectofsurveillancefortheimportationofemerginginfections. Multi-site collaborations such as the GeoSentinel Surveillance Network(Wilder-Smith and Boggild, 2018) can act as sentinel systemstorecognize newpatternsof diseasein travelersfrom specific areas. Previous GeoSentinel data showed that despite receivingcareatspecializedpost-travelmedicinesites,upto40% of returning ill travellers with febrile illness do not have a confirmed etiology;frequently nospecific diagnostictesting is availabletoidentifyacause(Freedmanetal.,2006;Wilsonetal., 2007;Leder etal., 2013).Thecurrent large-scaleoutbreak of a novelpathogen,SARS-CoV-2,highlightsthecriticalimportanceof prioritizingtheidentificationofdiseaseetiologythroughclinician awarenessandmodernlaboratorytechniquessuchasNGS.
TherehasbeenwidespreadmourningofthesaddemiseofDrLi fromCOVID-2019.DrLiWenliang’sexampleasanastuteclinician shouldinspire all of us tobe vigilant, bold and courageous in reportingunusualclinicalpresentations.TheSARS-CoV-2outbreak underscorestheresponsibilitiesandthevulnerabilitiesoffrontline health care workersin tackling novel and highlytransmissible pathogens.Wemustuseourknowledgeandskills,withthebackup oflaboratorysupport,torapidlydetectandreportanysuspicionof emerginginfections. Rapid,transparentcommunicationis para-mountwheninfectiousdiseasesemerge.Thisistheonlywayto preventmajoroutbreaksandwillsavemanylives.
Conflictofinterests
Theauthorsdeclarethattheyhavenoconflictofinterests. References
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EskildPetersena,b,c,* aDirectorateGeneralforDiseaseSurveillanceandControl,Ministryof
Health,Muscat,Oman
bEuropeanSociatyforClinicalMicrobiologyandInfectiousDiseases,
Basel,Switzerland
c
InstituteforClinicalMedicine,FacultyofHealthSciences,University ofAarhus,Denmark DavidHui DepartmentofMedicine&Therapeutics,ChineseUniversityofHong Kong,PrinceofWalesHospital,Shatin,NewTerritories,HongKong, China DavidsonH.Hamera,b
aDepartmentofGlobalHealth,BostonUniversitySchoolofPublic
Health,Boston,MA,USA
bSectionofInfectiousDisease,DepartmentofMedicine,Boston
UniversitySchoolofMedicine,Boston,MA,USA LucilleBlumberg NationalInstituteforCommunicableDiseases,ADivisionofthe NationalHealthLaboratoryService,Johannesburg,SouthAfrica LawrenceC.Madoffa,b
aInternationalSocietyforInfectiousDiseases,Boston,MA,USA bUniversityofMassachusetts,DivisionofInfectiousDiseases,
Worcester,MA,USA
MarjoriePollack InternationalSocietyforInfectiousDiseases,Boston,MA,USA ShuiShanLee StanleyHoCentreforEmergingInfectiousDiseases,TheChinese UniversityofHongKong,Shatin,HongKong,China SusanMcLellan BiocontainmentTreatmentUnit,BiosafetyforResearch-Related InfectiousPathogens,UniversityofTexasMedicalBranch,Galveston, TX,USA ZiadMemisha,b,c
a
ResearchCentre,KingSaudMedicalCity,MinistryofHealth,Riyadh, SaudiArabia
bCollegeofMedicine,AlfaisalUniversity,Riyadh,SaudiArabia c
HubertDepartmentofGlobalHealth,RollinsSchoolofPublicHealth, EmoryUniversity,Atlanta,GA,USA IraPraharaj IndianCouncilofMedicalResearch,DepartmentofHealthResearch, NewDelhi,India SeanWassermanq
qDivisionofInfectiousDiseasesandHIVMedicine,Departmentof
Medicine,GrooteSchuurHospitalandUniversityofCapeTown,Cape Town,SouthAfrica FrancineNtoumi FondationCongolaisepourlaRechercheMédicale/UniversitéMarien Ngouabi,RepublicofCongoandInstituteforTropicalMedicine, UniversityofTübingen,Germany EsamIbraheemAzhar KingFahdMedicalResearchCenter(KFMRC),MedicalLaboratory TechnologyDepartment,FacultyofAppliedMedicalSciences,King AbdulazizUniversity,Jeddah,SaudiArabia
TimothyD.Mchugh CenterforClinicalMicrobiology,DivisionofInfectionandImmunity, UniversityCollegeLondon,UnitedKingdom RichardKock TheRoyalVeterinaryCollege,UniversityofLondon,Hatfield, Hertfordshire,UnitedKingdom GuiseppeIppolito NationalInstituteforInfectiousDiseases,LazzaroSpallanzani,Rome, Italy AliZumla CenterforClinicalMicrobiology,DivisionofInfectionandImmunity, UniversityCollegeLondon,andNIHRBiomedicalResearchCentre, UCLHospitalsNHSFoundationTrust,London,UnitedKingdom MarionKoopmans DepartmentofViroscience,ErasmusMedicalCenter,University MedicalCenter,Rotterdam,Netherlands *Correspondingauthorat:DirectorateGeneralforDisease SurveillanceandControl,MinistryofHealth,Muscat,Oman. E-mailaddress:eskild.petersen@gmail.com(E.Petersen). Received25February2020
