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Quick Take: NEJM coronavirus paper tackles viral load, survivability

The New England Journal of Medicine rapidly published a peer-reviewed report on the first case of COVID-19 in the U.S.


Workers stand near an ambulance, Friday, March 6, 2020, at the Life Care Center in Kirkland, Wash., which has become the epicenter of the COVID-19 coronavirus outbreak in Washington state.

AP Photo/Ted S. Warren

The New England Journal of Medicine has rapidly published a peer-reviewed paper on the Snohomish County, Washington, “Patient One” – the first reported case of COVID-19 (coronavirus) in the U.S. This seminal document, given the magnitude of the case and its initial findings, is released in full here.

The work, authored by Michelle L. Holshue, MPH; Chas DeBolt, MPH; and Scott Lindquist, MD; et. al., for the Washington State 2019-nCoV Case Investigation Team, was turned around in just over 5 weeks. Following is an executive summary, as extracted from the Journal, but the paper and range of results should be read in full and is embedded below.

COVID-19 Patient One presentation

On Jan. 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 Jan. 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 healthcare provider.

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.

COVID-19 viral presence

Both upper respiratory specimens obtained on illness day 7 remained positive for COVID-19, including persistent high levels in a nasopharyngeal swab specimen (Ct values: 23 to 24).

Stool obtained on illness day 7 was also positive for COVID-19 (Ct values: 36 to 38).

Nasopharyngeal and oropharyngeal specimens obtained on illness days 11 and 12 showed a trend toward decreasing levels of virus.

Day 8: condition improves

On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94-96% while he was breathing ambient air. 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 Jan. 30, 2020, the patient remained hospitalized. He was afebrile, and all symptoms had resolved with the exception of his cough, which was decreasing in severity.

Patient history taking

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 COVID-19 infection and to help reduce further transmission.

This report highlights the need to determine the full spectrum and natural history of clinical disease, pathogenesis and duration of viral shedding associated with COVID-19 infection to inform clinical management and public health decision making.

Top takeaways from NEJM COVID-19 paper

There is little doubt that this paper is about to become a globally sited document as we continue to deal with COVID-19. As far as EMS and our first response to it goes, the paper reinforces the key actions currently being taken.

1. Emerging infectious disease identification

The work of public safety answering points in identifying potential patients through the use of emerging infectious disease protocols is vital and is the tip of our spear to ensure first responders are ready and appropriately protected before patient contact.

2. Patient history taking is key

Holshue et. al. note that a thorough history (if not obtained via a PSAP) on travel and contacts is vital in the identification and containment of COVID-19.

3. Maintaining the barrier

Specimen sampling identified the presence of COVID-19 from nasopharyngeal and oropharyngeal specimens as well as stool samples. This is a no brainer in terms of ensuring PPE is in place on approaching the patient and also the obvious need to place a mask on the patient as well. The presence of COVID-19 in fecal sampling also further reinforces the need to hand wash, hand wash, hand wash (and perhaps keep those modern day germ carriers – the smart phone – out of the bathroom).

4. Recovery and fear

As we seek to allay the fear of the outbreak and those that perceive this as a fatal encounter, we can see that COVID-19 is survivable. Patient One was a 35-year old man with no pre-existing conditions and this may have been a factor in his tolerance of the virus during the opening days of the infection and subsequent improvement.

Nevertheless this study is a sound piece of academic writing and research, and I hope more follow.

Read next: Is EMS prepared for an epidemic or pandemic?

Rob Lawrence has been a leader in civilian and military EMS for over a quarter of a century. He is currently the director of strategic implementation for PRO EMS and its educational arm, Prodigy EMS, in Cambridge, Massachusetts, and part-time executive director of the California Ambulance Association.

He previously served as the chief operating officer of the Richmond Ambulance Authority (Virginia), which won both state and national EMS Agency of the Year awards during his 10-year tenure. Additionally, he served as COO for Paramedics Plus in Alameda County, California.

Prior to emigrating to the U.S. in 2008, Rob served as the COO for the East of England Ambulance Service in Suffolk County, England, and as the executive director of operations and service development for the East Anglian Ambulance NHS Trust. Rob is a former Army officer and graduate of the UK’s Royal Military Academy Sandhurst and served worldwide in a 20-year military career encompassing many prehospital and evacuation leadership roles.

Rob is a board member of the Academy of International Mobile Healthcare Integration (AIMHI) as well as chair of the American Ambulance Association’s State Association Forum. He writes and podcasts for EMS1 and is a member of the EMS1 Editorial Advisory Board. Connect with him on Twitter.