Fears of asymptomatic coronavirus transfer grow

Matt Woodley

30/01/2020 4:40:54 PM

Australian health authorities have issued new advice based on reported instances of viral transfer by asymptomatic carriers.

Travellers wearing facemasks
The Australian Health Protection Principal Committee is now directing travellers who have recently been to Hubei Province to self-isolate for a period of 14 days.

The updated advice from the Australian Health Protection Principal Committee (AHPPC) directs travellers who have recently been to Hubei Province to self-isolate for a period of 14 days.
The new directive is based on very recent cases of coronavirus that are asymptomatic or minimally symptomatic, and reports of one case of probable transmission from a pre-symptomatic case to other people, two days prior to the onset of symptoms. Referred to as the ‘German cluster case’, it involved an asymptomatic Chinese national who infected four German people with no travel history to China.
A second potential case involved a Japanese bus driver with no history of international travel who contracted coronavirus from a group of Chinese passengers from Wuhan. None of the passengers are known cases.
The AHPPC has said it ‘still believes that most infections are transmitted by people with symptomatic disease’.
However, the revelations of asymptomatic transfer combined with the ‘significant’ increase in the number of cases and additional countries where the virus’ presence has been confirmed, have prompted the World Health Organization (WHO) to declare a global health emergency.

Emeritus Professor John Mackenzie, an expert on global aspects of infectious disease surveillance and response, particularly emerging zoonotic diseases, is on the emergency committee convened by the WHO to assess the threat of the virus. Prior to the meeting, he told newsGP the committee would consider ‘everything relevant to the disease’, including its spread, transmission and pathogenesis.
‘Perhaps most important is that there is now greater clarity on transmissibility – that all levels of infection occur from sub-clinical to severe infections, that transmission can occur from mild and sub-clinical infections, and that infected persons are contagious from during incubation and prior to clinical symptoms,’ he said.
‘These issues are all different from SARS, where most cases were severe and transmission only occurred after onset of symptoms. This indicates that containment is much more difficult, but there is little or no upper respiratory-tract involvement in most patients.
‘We still don’t have any idea of the denominator in understanding transmission dynamics or metrics – how many mild or sub-clinical cases compared to more severe cases – but mortality is definitely less than SARS or MERS.’
Meanwhile, a Sydney-based GP who helped identify one of the first confirmed cases in Australia is worried infected carriers have been slipping through the net due to a policy of only testing people who have recently returned from Hubei Province or been in contact with confirmed cases.
The doctor, who wishes to remain anonymous, told newsGP they have had multiple requests for coronavirus testing denied on the basis that the patient had no history of travel in the area that the virus is thought to have originated.
‘My fear is that the number of cases in Australia is getting much, much higher. But, unfortunately, we have set an artificial barrier for confirming the actual number,’ the GP said.
‘We have been calling the public health unit for many patients who have symptoms, such as a fever, coughing and sore throat, runny nose … [but] they have only approved cases who have come in from Wuhan.
‘We’ve had patients with symptoms from Shanghai, Shenzen, Guangzhou or Beijing. They don’t do it.
‘The policy needs to be changed immediately.’
RACGP Harry Nespolon has said GPs are ‘fully prepared to manage patients who present with symptoms consistent with the virus’.
‘If a GP refers a patient to undertake a pathology test it should obviously take place,’ he said.
‘GPs don’t order tests unnecessarily and it would be disappointing if pathologists, who don’t have the full picture of a person’s health, were making decisions on which tests to process without consulting the GP.’
The number of confirmed cases in Australia reached nine overnight, with new cases emerging in Victoria and Queensland.  
The Queensland case, a 42-year-old woman from Wuhan, is thought to have contracted the virus after travelling on a flight from Melbourne to Gold Coast with another Chinese national from Wuhan, a 44-year-old man.

The man was reportedly asymptomatic upon entering Australia but became unwell during the Melbourne to Gold Coast flight on 23 January. A number of other people in the same travelling group have also fallen ill and are being held under surveillance at Gold Coast University Hospital.
Melbourne and Sydney have been identified by University of Southampton researchers in a list of cities which pose the highest risk of spreading the deadly coronavirus outbreak.
NSW Chief Health Officer Dr Kerry Chant told reporters on Wednesday the state had previously only been testing about six people a day, but that it was ‘ramping up’ efforts to broaden testing to those with more mild symptoms.
‘NSW Health recommends that GPs refer patients who require testing to the local emergency department [ED],’ a NSW Health spokesperson told newsGP.
‘The ED will seek advice from infectious diseases or public health experts to assess the risks of the patient and recommend testing based on the latest information.’
This advice differs from information initially provided by NSW Health, which directed GPs to ‘collect nasopharyngeal, nasal, and/or throat swabs’, but is consistent with a 28 January update that states GPs ‘should not take samples for 2019-nCoV [novel coronavirus] testing themselves unless there is no alternative option’.
newsGP attempted to clarify how and when NSW Health’s updated information was communicated with GPs, but did not receive a response prior to publication.
The latest NSW Health information sheet indicates patients should only be referred for coronavirus testing if they have a history of travel in Hubei Province in the 14 days before illness onset, or if they have had close contact with a confirmed case.
This advice differs to that provided by Queensland Health, with a spokesperson telling newsGP criteria for coronavirus testing includes people who have travelled anywhere in China in the past 14 days and developed fever or respiratory symptoms.
It also appears to contradict Commonwealth Department of Health advice, which states ‘consider novel coronavirus (2019-nCoV) infection in patients with fever and respiratory symptoms who recently travelled to anywhere in China but in particular Wuhan’.
Likewise, it also conflicts with a directive from the NSW Health and Education Departments to keep any student away from school for two weeks after travelling anywhere in China.
GPs have expressed concern about inconsistent messaging and an overall lack of coordination among public health authorities, and called for clarity to help efforts to curtail the virus.
The anonymous Sydney doctor said they had been frustrated by fruitless efforts to acquire appropriate personal protective equipment (PPE) including P2/N95 facemasks, as well as uncertainty over room sterilisation following the confirmed case in their clinic.
‘We only have a handful of masks. We have zero P2 masks – we can’t buy any. We order, we order, but we can’t buy a single one,’ the GP said.
‘We’re a well-developed nation, we should have that sort of equipment straight away. These are basic things.
‘It’s putting the patient, the community, doctors and the health profession at large at grave risk.’
According to the GP, the lack of access to resources is complicated by public health messaging that directs potential cases to visit general practice clinics. They said one suspected case was in the waiting room for two hours, and the GP who assessed the initial confirmed case has had to be placed in quarantine for two weeks.
The GP believes a better approach would be to establish dedicated centres to assess and refer suspected cases for testing and treatment.
‘NSW Health has said patients with a fever or upper respiratory-tract infection who have been to China, Hong Kong or other affected areas should go to their GP, but the thing is that we have really limited resources,’ they said.
‘We [also] deal with many patients who have chronic conditions, elderly patients. It’s putting them in a really vulnerable situation.
‘Every single potential case requires at least half an hour or more, so it puts a lot of stress on the GPs … we’re already over-stretched.’
There have been seven confirmed cases of coronavirus in Australia to date, with dozens more referred for testing.
At the time of publication, there had been more than 7000 confirmed cases of coronavirus globally, and at least 170 deaths.
The RACGP has more information on coronavirus available on its website.
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Dr Ian Mark Light   31/01/2020 10:38:12 AM

Could well be infective in the late incubation period 1-2 days before symptoms when there is asymptomatic shedding as in many illnesses .
Nasopharyngeal Pharyngeal and through swans could well diagnose then .
As for patients in waiting rooms phone triage is vital as well as a warning on online appointments .
In measles outbreaks doctors often met patients outside the clinics in some areas or there was a heath professional at the entrance to a clinic particularly in packed waiting rooms .
House visiting by a team of protected medical personnel is also an option .
But this crises is in a warming to contain a potentially more dangerous outbreak in the future .

Dr Peter James Strickland   31/01/2020 12:29:37 PM

This is amazing to see this coronavirus episode unravel! Incompetent advice on allowing travellers to come in from affected areas, putting the blame at one stage on GPs here in Australia who deal with thousands of other respiratory-type infections daily, i.e when the flights from China should have ceased as I personally recommended about one week ago. How do you stop an infection spreading? Isolate those with potential to spread it NOW, and NOT later --it is basic public health and commonsense isn't it? To be flying people in from China now is a bungle, and threatens to extend the problem even further. Stop moving potentially infected (and infective) people around the world, and in our case into Australia. The RACGP and AMA should be firm in that policy, and not fence-sitters.

Dr Caroline Meredith Cornwallis   1/02/2020 7:00:39 PM

This is precisely the kind of departmental incompetence that GPs have to deal with, obstructing critical work, delaying diagnoses and putting staff at risk. Exactly the same rubbish wrapped up in bizarre directives happened in 2009 with H1N1. Perhaps the people writing today's policies have no coalface experience or were only in school in 2009 and haven't bothered to ask any one who actually worked through it. Certainly no one asked us or listened at the time! So we just sent off our own tests and confirmed, isolated and treated hundreds more cases than would have been found through the recommended procedure. It defies logic and basic virology to only test people from Hubei. Anyone, Chinese or locals returning from holidays, out of any affected city, sharing air and communal surfaces on a plane for 12 hours is now a "contact". If the patient has been in China, has fever and cough , just say they are from Hubei, case find, fix the data later. Our duty is to our patient and community

Dr Aline Suan Lin Smith   2/02/2020 8:01:45 AM

In the swine flu crisis including SARS , MERS outbreak, my recollection is that NSW advise to GPs and community was to if sick attend hospital dedicated clinic located next to EDs of public hospitals to get tested. They were discouraged from going to GPs and asked to stay home.
GPs also got swabs to test early mild cases and national stockpile of antivirals was released.
Our clinic is throwing the net wide to screen ALL overseas travellers - we cannot be too careful and restrictions to just Wuhan, hubei or even China is not quite enough as a strategy..