Update on COVID-19: part 13, it giet oan?

In February many in my country just want to hear three words: “it giet oan”. This means that the famous eleven city ice-skating race will actually happen. Since 1909 this occurred 15 times (last time in 1997), as it needs about three weeks of continuous frost. No chance for that this year, but the words must have crossed many clinical microbiologists’ mind this weekend when the news on SARS-CoV-2 from Italy unfolded.

Chances that the SARS-CoV-2 could be contained in China, and other Asian countries, have decreased steadily over the last weeks, and now the virus is within our Schengen borders and we have no clue how it got there. Apparently, the case definition of symptoms and geographical linkage to SARS-CoV-2 disease areas failed to identify infected patients in Italy, and local transmission must have occurred already. As such, what happened in Italy, could have (or may have) happened in other places in Europe.

Interesting discussions today about what can be learned from reported casualties. Iran reported 50 deaths and Italy 6. Simple math: if that reflects a 1% case fatality rate, than there could be 5000 and 600 infected subjects. But if they died today (or yesterday), they got sick about 20 days ago (on average) and with 10-14 days incubation time, we might be looking at unnoticed transmission for 5-6 weeks…..  and then there might be even more infected by now. But also, many infected may have left the Italian region before this weekends lockdown.

So what to do in our hospital? We have a validated RT-PCR for SARS-CoV-2, and we routinely test for influenza in all patients with community-acquired respiratory tract infections. The case definition for patients at risk for SARS-CoV-2 infection has been broadened today, and now also includes the affected northern Italian regions and South Korea (and more). But is it – given the lack of identifiable source in Italy and the likelihood of prolonged ongoing transmission – still justified to only test patients meeting the new case definition, in settings where the test is available? I don’t think so. And so do many colleagues in our app-group of head of departments of clinical microbiology in Dutch academic hospitals, today.

In our hospital, we, therefore, decided to adapt the testing strategy. Still, all patients meeting the updated case definition will be placed in “strict viral isolation” (negative pressure with anteroom). FFP2 masks, glasses, gown and gloves will be used for protection and patients will be tested and samples will be send to a national reference lab. Patients not meeting this case definition, but eligible for routine influenza testing (because of symptoms) will also be tested for SARS-CoV-2. Such patients will be treated in contact droplet isolation (single bedroom, FFP1 mask, gown and gloves) – according to current practice – which will be withdrawn if influenza or another relevant respiratory virus is not detected. If SARS-CoV-2 is demonstrated, control measures can be implemented immediately. This policy is a trade-off between optimal safety for critically ill patients and healthcare workers, and no extra obstruction of patient flows due to pre-emptive strict isolation measures as long as the likelihood of SARS-CoV-2 infection remains low (but not zero).

The collateral benefit is that we have an additional surveillance system, which currently relies on testing subjects with respiratory infections in primary care. I heard 44 were tested last week.



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