Clinical Characeteristics of COVID-19 Disease in China
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The new england journal of medicine Original Article Clinical Characteristics of Coronavirus Disease 2019 in China W. Guan, Z. Ni, Yu Hu, W. Liang, C. Ou, J. He, L. Liu, H. Shan, C. Lei, D.S.C. Hui, B. Du, L. Li, G. Zeng, K.-Y. Yuen, R. Chen, C. Tang, T. Wang, P. Chen, J. Xiang, S. Li, Jin-lin Wang, Z. Liang, Y. Peng, L. Wei, Y. Liu, Ya-hua Hu, P. Peng, Jian-ming Wang, J. Liu, Z. Chen, G. Li, Z. Zheng, S. Qiu, J. Luo, C. Ye, S. Zhu, and N. Zhong, for the China Medical Treatment Expert Group for Covid-19* ABSTRACT BACKGROUND Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan The authors’ full names, academic de- city and rapidly spread throughout China, data have been needed on the clinical grees, and affiliations are listed in the Appendix. Address reprint requests to characteristics of the affected patients. Dr. Zhong at the State Key Laboratory of Respiratory Disease, National Clinical METHODS Research Center for Respiratory Disease, We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland Medical University, 151 Yanjiang Rd., China through January 29, 2020. The primary composite end point was admission Guangzhou, Guangdong, China, or at to an intensive care unit (ICU), the use of mechanical ventilation, or death. nanshan@ vip . 163 . com. *A list of investigators in the China Medi- RESULTS cal Treatment Expert Group for Covid-19 The median age of the patients was 47 years; 41.9% of the patients were female. study is provided in the Supplementary The primary composite end point occurred in 67 patients (6.1%), including 5.0% Appendix, available at NEJM.org. who were admitted to the ICU, 2.3% who underwent invasive mechanical ventila- Drs. Guan, Ni, Yu Hu, W. Liang, Ou, He, tion, and 1.4% who died. Only 1.9% of the patients had a history of direct contact L. Liu, Shan, Lei, Hui, Du, L. Li, Zeng, and Yuen contributed equally to this article. with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms This article was published on February 28, 2020, and last updated on March 6, 2020, were fever (43.8% on admission and 88.7% during hospitalization) and cough at NEJM.org. (67.8%). Diarrhea was uncommon (3.8%). The median incubation period was 4 days DOI: 10.1056/NEJMoa2002032 (interquartile range, 2 to 7). On admission, ground-glass opacity was the most Copyright © 2020 Massachusetts Medical Society. common radiologic finding on chest computed tomography (CT) (56.4%). No radio- graphic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission. CONCLUSIONS During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.) n engl j med nejm.org 1 The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF COLORADO HOSPITAL on March 8, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. The new england journal of medicine n early December 2019, the first pneu- throughput sequencing or real-time reverse-tran- monia cases of unknown origin were identi- scriptase–polymerase-chain-reaction (RT-PCR) fied in Wuhan, the capital city of Hubei assay of nasal and pharyngeal swab specimens.1 I 1 province. The pathogen has been identified as a Only laboratory-confirmed cases were included novel enveloped RNA betacoronavirus2 that has in the analysis. currently been named severe acute respiratory We obtained data regarding cases outside syndrome coronavirus 2 (SARS-CoV-2), which Hubei province from the National Health Com- has a phylogenetic similarity to SARS-CoV.3 Pa- mission. Because of the high workload of clini- tients with the infection have been documented cians, three outside experts from Guangzhou both in hospitals and in family settings.4-8 performed raw data extraction at Wuhan Jinyin- The World Health Organization (WHO) has re- tan Hospital, where many of the patients with cently declared coronavirus disease 2019 (Covid-19) Covid-19 in Wuhan were being treated. a public health emergency of international con- We extracted the recent exposure history, cern.9 As of February 25, 2020, a total of 81,109 clinical symptoms or signs, and laboratory find- laboratory-confirmed cases had been document- ings on admission from electronic medical rec- ed globally.5,6,9-11 In recent studies, the severity of ords. Radiologic assessments included chest radi- some cases of Covid-19 mimicked that of SARS- ography or computed tomography (CT), and all CoV.1,12,13 Given the rapid spread of Covid-19, we laboratory testing was performed according to determined that an updated analysis of cases the clinical care needs of the patient. We deter- throughout mainland China might help identify mined the presence of a radiologic abnormality the defining clinical characteristics and severity of on the basis of the documentation or description the disease. Here, we describe the results of our in medical charts; if imaging scans were avail- analysis of the clinical characteristics of Covid-19 able, they were reviewed by attending physicians in a selected cohort of patients throughout China. in respiratory medicine who extracted the data. Major disagreement between two reviewers was Methods resolved by consultation with a third reviewer. Laboratory assessments consisted of a complete Study Oversight blood count, blood chemical analysis, coagula- The study was supported by National Health tion testing, assessment of liver and renal func- Commission of China and designed by the in- tion, and measures of electrolytes, C-reactive vestigators. The study was approved by the insti- protein, procalcitonin, lactate dehydrogenase, tutional review board of the National Health and creatine kinase. We defined the degree of Commission. Written informed consent was severity of Covid-19 (severe vs. nonsevere) at the waived in light of the urgent need to collect time of admission using the American Thoracic data. Data were analyzed and interpreted by the Society guidelines for community-acquired pneu- authors. All the authors reviewed the manuscript monia.15 and vouch for the accuracy and completeness of All medical records were copied and sent to the data and for the adherence of the study to the data-processing center in Guangzhou, under the protocol, available with the full text of this the coordination of the National Health Com- article at NEJM.org. mission. A team of experienced respiratory clini- cians reviewed and abstracted the data. Data Data Sources were entered into a computerized database and We obtained the medical records and compiled cross-checked. If the core data were missing, data for hospitalized patients and outpatients requests for clarification were sent to the coor- with laboratory-confirmed Covid-19, as reported dinators, who subsequently contacted the attend- to the National Health Commission between ing clinicians. December 11, 2019, and January 29, 2020; the data cutoff for the study was January 31, 2020. Study Outcomes Covid-19 was diagnosed on the basis of the The primary composite end point was admission WHO interim guidance.14 A confirmed case of to an intensive care unit (ICU), the use of me- Covid-19 was defined as a positive result on high- chanical ventilation, or death. These outcomes 2 n engl j med nejm.org The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF COLORADO HOSPITAL on March 8, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved. Characteristics of Coronavirus Disease 2019 in China were used in a previous study to assess the se- descriptive only. We used ArcGIS, version 10.2.2, verity of other serious infectious diseases, such to plot the numbers of patients with reportedly as H7N9 infection.16 Secondary end points were confirmed cases on a map. All the analyses were the rate of death and the time from symptom performed with the use of R software, version onset until the composite end point and until 3.6.2 (R Foundation for Statistical Computing). each component of the composite end point. Results Study Definitions The incubation period was defined as the inter- Demographic and Clinical Characteristics val between the potential earliest date of contact Of the 7736 patients with Covid-19 who had been of the transmission source (wildlife or person hospitalized at 552 sites as of January 29, 2020, with suspected or confirmed case) and the poten- we obtained data regarding clinical symptoms tial earliest date of symptom onset (i.e., cough, and outcomes for 1099 patients (14.2%). The fever, fatigue, or myalgia). We excluded incuba- largest number of patients (132) had been ad- tion periods of less than 1 day because some mitted to Wuhan Jinyintan Hospital. The hospi- patients had continuous exposure to contamina- tals that were included in this study accounted tion sources; in these cases, the latest date of for 29.7% of the 1856 designated hospitals exposure was recorded. The summary statistics where patients with Covid-19 could be admitted of incubation periods were calculated on the in 30 provinces, autonomous regions, or munici- basis of 291 patients who had clear information palities across China (Fig.