CHARACTERISTICS OF CORONAVIRUS DISEASE 2019 IN CHINA creatine kinase.and p-dimer.Patients with severe findings and in the severity of disease at the disease had more prominent laboratory abnor-time of presentation.Fever was identified in malities (including lymphocytopenia and leuko- penia)than those with nonsevere disease. oped in 88.7% e 109) No e lost to folloy oitend-pon patients with seve event occurred in67patients (.1%),including with nonsevere disease.Despite the number of 5.0%who were admitted to the ICU,2.3%who deaths associated with Covid-19,SARS-CoV-2 underwent invasive mechanical ventilation,and appears to have a lower case fatality rate than mposite end-poin drome-related isk of t山 omg ite end point was%among those with severe ed with worse outcomes disease the cumulative risk was 206% Approximately 2%of the patients had a history of direct contact with wildlife,whereas more than TREATMENT AND COMPLICATIONS the patients () the city,or had contact with city therapy,and35.8% out an as 6.1%higher percentages of patients with severe disease received these therapies (Table 3).Me- study cannot preclude the presence of patients chanical ventilation was initiated in more pa who have been termed "super-spreaders. tients with severe disease than in those with entional rot utes of transmission of SARS Cov, S-Cov,an influenz tha plets (18.6%),with a higher percentage among those SARS-CoV-2 well.SARS-Cov-2 can be with severe disease than nonsevere disease (44.%detected in the gastrointestinal tract,saliva,and vs.13.7%).Of these 204 patients,33 (16.2%)urine,these routes of potential transmission were admitted to the ICU,17(8.3%)underwent need to be investigated (Tables $1 and S2). invasi and 5)die d-1 has been applied to pa oratory-co (0 59 12.0 days (mean,12.8).During of the disease is needed.sincein of the sion,most of the patients received a diagnosis of patients,SARS-CoV-2 infection was detected be- pneumonia from a physician (91.1%),followed fore the development of viral pneumonia or viral by ARDS (3.4%)and shock (11%).Patients with pneumonia did not develop. 99.4%s.89.5% those ARS-Cov. teristics dominant symptoms and ga rointestinal sy DISCUSSION ence in viral tropism as compared with SARS-CoV. During the initial phase of the Covid-19 out MERS-CoV,and seasonal influenza.2 The ab- maging Co and RCo im SAR-CovdMR- N ENGLJ MED NEJM.ORG e0UE MEDICL6于 Dow n engl j med nejm.org 5 Char acteristics of Coronavirus Disease 2019 in China creatine kinase, and d-dimer. Patients with severe disease had more prominent laboratory abnor￾malities (including lymphocytopenia and leuko￾penia) than those with nonsevere disease. Clinical Outcomes None of the 1099 patients were lost to follow-up during the study. A primary composite end-point event occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died (Table 3). Among the 173 patients with severe disease, a primary composite end-point event occurred in 43 patients (24.9%). Among all the patients, the cumulative risk of the compos￾ite end point was 3.6%; among those with severe disease, the cumulative risk was 20.6%. Treatment and Complications A majority of the patients (58.0%) received intra￾venous antibiotic therapy, and 35.8% received oseltamivir therapy; oxygen therapy was admin￾istered in 41.3% and mechanical ventilation in 6.1%; higher percentages of patients with severe disease received these therapies (Table 3). Me￾chanical ventilation was initiated in more pa￾tients with severe disease than in those with nonsevere disease (noninvasive ventilation, 32.4% vs. 0%; invasive ventilation, 14.5% vs. 0%). Sys￾temic glucocorticoids were given to 204 patients (18.6%), with a higher percentage among those with severe disease than nonsevere disease (44.5% vs. 13.7%). Of these 204 patients, 33 (16.2%) were admitted to the ICU, 17 (8.3%) underwent invasive ventilation, and 5 (2.5%) died. Extracor￾poreal membrane oxygenation was performed in 5 patients (0.5%) with severe disease. The median duration of hospitalization was 12.0 days (mean, 12.8). During hospital admis￾sion, most of the patients received a diagnosis of pneumonia from a physician (91.1%), followed by ARDS (3.4%) and shock (1.1%). Patients with severe disease had a higher incidence of physi￾cian-diagnosed pneumonia than those with non￾severe disease (99.4% vs. 89.5%). Discussion During the initial phase of the Covid-19 out￾break, the diagnosis of the disease was compli￾cated by the diversity in symptoms and imaging findings and in the severity of disease at the time of presentation. Fever was identified in 43.8% of the patients on presentation but devel￾oped in 88.7% after hospitalization. Severe ill￾ness occurred in 15.7% of the patients after ad￾mission to a hospital. No radiologic abnormalities were noted on initial presentation in 2.9% of the patients with severe disease and in 17.9% of those with nonsevere disease. Despite the number of deaths associated with Covid-19, SARS-CoV-2 appears to have a lower case fatality rate than either SARS-CoV or Middle East respiratory syn￾drome–related coronavirus (MERS-CoV). Com￾promised respiratory status on admission (the primary driver of disease severity) was associat￾ed with worse outcomes. Approximately 2% of the patients had a history of direct contact with wildlife, whereas more than three quarters were either residents of Wuhan, had visited the city, or had contact with city residents. These findings echo the latest reports, including the outbreak of a family cluster,4 transmission from an asymptomatic patient,6 and the three-phase outbreak patterns.8 Our study cannot preclude the presence of patients who have been termed “super-spreaders.” Conventional routes of transmission of SARS￾CoV, MERS-CoV, and highly pathogenic influenza consist of respiratory droplets and direct con￾tact,18-20 mechanisms that probably occur with SARS-CoV-2 as well. Because SARS-CoV-2 can be detected in the gastrointestinal tract, saliva, and urine, these routes of potential transmission need to be investigated21 (Tables S1 and S2). The term Covid-19 has been applied to pa￾tients who have laboratory-confirmed symptom￾atic cases without apparent radiologic manifes￾tations. A better understanding of the spectrum of the disease is needed, since in 8.9% of the patients, SARS-CoV-2 infection was detected be￾fore the development of viral pneumonia or viral pneumonia did not develop. In concert with recent studies,1,8,12 we found that the clinical characteristics of Covid-19 mimic those of SARS-CoV. Fever and cough were the dominant symptoms and gastrointestinal symp￾toms were uncommon, which suggests a differ￾ence in viral tropism as compared with SARS-CoV, MERS-CoV, and seasonal influenza.22,23 The ab￾sence of fever in Covid-19 is more frequent than in SARS-CoV (1%) and MERS-CoV infection The New England Journal of Medicine Downloaded from nejm.org at SOUTHERN MEDICAL UNIVERSITY on March 6, 2020. For personal use only. No other uses without permission. Copyright © 2020 Massachusetts Medical Society. All rights reserved