FAQ Coronavirus on symptoms, viabililty on surfaces and in aerosols, prolonged faecal shedding and the need for serological testing

What symptoms of SARS-CoV-2 are common?
Of 99 patients, 83% presented with fever, 82% with a cough and 31% with shortness of breath. Symptoms such as muscle ache, confusion, headache, sore throat, diarrhoea, nausea and vomiting were also observed. The NHS, RIVM and other health autorities seem to present rhinorrhoea and sneezing as main symptoms of COVID. Rhinorrhoea was observed in 4% of COVID cases (Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, The Lancet, 30 January 2020).

Another case study, Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study, confirms the abovementioned. Of 30 patients, the most common symptom was fever (96%), followed by cough (22%) and dyspnoea (17%). In severe cases, serum alkaline phosphatase was significantly higher than in mild cases. Multifocal ground-glass lung opacities were seen in 74%.

According to a study involving 191 patients the median time from illness onset until discharge is 22 days. The median duration of viral shedding for survivors is 20 days. Among 29 patients receiving lopinavir/ritonavir treatment, the median time of viral shedding is 22 days. In critical patients, the median duration of viral shedding is 24 days, the longest viral shedding observed being 30 days (Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study, The Lancet, published online on 9 March 2020).

How viable is SARS-CoV-2 on materials and in aerosols?
Viability refers to the time a virus can 'survive' on materials and in aerosols. Airborne transmission is the transmission route of viral particles through air. In aerosols, SARS-CoV-2 proved to remain stable up to 3 hours. The virus remains stable for up to 72 hours on plastic, up to 48 hours on stainless steel,  24 hours on cardboard and 4 hours on copper (Aerosol and Surface Stability of SARS-CoV-2 as compared to SARS-CoV-1, The New England Journal of Medicine, 17 March 2020).

Air samples taken from airborne infection isolation rooms in Singapore were all negative (Air, Surface, Environmental and Personal Protective Equipment Contamination by SARS-CoV-2 From a Symptomatic Patient, JAMA, 4 March 2020), indicating that inducing air flow by regular ventilation of rooms is important. A preprint claims that air samples taken at the Nebraska Medical Center contained SARS-CoV-2. The highest concentration was recovered from an air handling grate. Air samples were found to be 63.2% positive by RT-PCR, while none of the patients were observed to cough. The highest airborne concentration was observed while a patient was receiving oxygen through a nasal cannula (Transmission potential of SARS-CoV-2 in viral shedding observed at the University of Nebraska Medical Center, preprint available via MedRxiv).

Caution is recommended. What has to be proven yet is:
1. The infection of in vivo cells through airborne transmission;
2. Given that airborne transmission proves to be a route to infect hosts' cells, how concentration of viable loads, expelled through aerosols, relates to severity of SARS-CoV-2.

Why is hand hygiene important?
The fecal-oral route and respiratory droplet-oral route are two possible transmission routes. Note that contamination through surfaces and faeces is not the only transmission route, but the fecal route must not be understated as a shedding route of SARS-CoV-2 (Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes, Emerging Microbes and Infections, 17 February 2020).

One study supplied evidence that some SARS-CoV-2-infected patients can harbor the virus in the intestines during the early stage of the infection, whereas in SARS-infected patients, intestinal infection was observed during the late stage of the infection. A study involving 1099 patients confirms that asymptomatic people might be shedding virus through stool. Eight out of ten children tested positive on rectal swabs, even after testing negative on nasopharyngael surveillance (COVID-19: faecal-oral transmission?, Nature Reviews Gastroenterology & Hepatology, 25 March 2020).

There is evidence for prolonged presence of SARS-CoV-2 in feces. For 5 weeks after the patients' respiratory samples tested negative for viral RNA, virus was detected on faecal sampling. One patient had positive faecal samples for 33 days after testing negative on respiratory sampling; another patient had a prolonged faecal shedding for 47 days after first symptom onset (Prolonged presence of SARS-CoV-2 viral RNA in faecal samples, The Lancet Gastroenteroloy & Hepatology, 19 March 2020).

Is routine surveillance sufficient?
No: routine surveillance typically involves oral sampling, which is not accurate in respect of the difference in viral loads during different stages of a SARS-CoV-2 infection. In a January 2020 molecular study, of the patients with viremia blood, none tested oral or anal positive, indicating that patients should not be discharged on oral negative swabbing alone. This confirms the necessity of serological testing using IgM and IgG (Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes, Emerging Microbes and Infections, 17 February 2020).

Moreover, in a SARS-CoV-2 infected patient with mild symptoms, ASC peaked on day 8 after onset. Antibodies are observed until day 20 (Breadth of concomitant immune responses prior to patient recovery: a case report of non-severe COVID-19, Nature Medicine, 16 March 2020). Rebound of viral load after 5 days was observed in one cohort study (Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2, The Lancet, 23 March 2020).

Thus: a policy that demands discharging a patient on oral negative swabbing is contrary to findings concerning patients testing positive on viremia blood sampling. Add a health policy of anal swabbing and serological testing. One should be aware of the fact that feces of a SARS-CoV-2 patient might test positive until a median of 5 weeks after onset. Awareness and adjustment of health policies should reduce the risk of contamination with faecal shedding of SARS-CoV-2.

How coronaviruses have spread from bats to humans

2019-nCoV = novel coronavirus 2019 = SARS-CoV-2 (Severe Acute Respiratory Syndrome)
COVID-19 =  disease caused by infection with SARS-CoV-2/2019-nCoV

2019-nCoV and bats
Coronavirus 2019-nCoV is 88% identical to two bat-related corona viruses found in South China in 2018. 2019-nCoV shows 79.5% similarity to the genome of SARS-CoV. For 96%, 2019 nCoV is identical to a bat coronavirus. Coronavirus 2019 nCoV is likely to share a common precursor with bat coronavirus RaTG13. Viruses that have sprung from the strain of RaTG13 may have taken decades to mutate into the current coronavirus 2019-nCoV (Mining coronavirus genomes for clues to the outbreak's origins, AAAS Science, January 31, 2020).

Almost with certainty, the bat can be identified as the original source of the current coronavirus 2019 nCoV (Bat Coronaviruses in China, MDPI Viruses, March 2019, 11 (3): 210, published March 2, 2019). The prediction of the 2019 nCoV outbreak in China was made in March 2019. Typical for coronaviruses is that the genome of a bat coronavirus does not have to adapt to the human host's DNA first; the S protein in coronaviruses (including SARSr-CoVs) can attach to the human receptor ACE2 (involved in the circulatory and gastrointestinal systems).
 

Contrary to popular belief: coronaviruses are BAT viruses, they are not mutations of influenza. Both coronaviruses and influenza mutants put individuals with a weakened immune system at risk. Prevention and minimization of the spread of coronaviruses is urgent. Firstly, no vaccine is available yet. Second, coronaviruses among the human population should not mutate into common coronavirus.

Transmission from bat to human
The September 2019 edition of Elsevier Biosafety and Health contains a comprehensive study of the cross-contamination between bat and human in southern China. The bat caves in the South of China are the main shelter of SARS-CoV. Bats' immune systems are likely to work great. A bat's cells have evolved to exclude coronaviruses. Bats are capable of storing viruses outside the cells, though still inside the body. Outside of the body, coronaviruses survive for up to 9 days (Persistence of coronaviruses on inanimate surfaces and their inactivation within biocidal agents, Journal of Hospital Infection, vol. 104 issue 3, March 2020). Coronaviruses can be transferred via bat droppings and urine to a host that does not have such a strong immune system. This can be an intermediate host in the form of a wild animal or a slaughter pig.

The human population's interactions with wild animals, domestic animals and the immediate environment are the catalysts for the spread of coronaviruses. Research has shown that there has been no direct contact between the inhabitants of the rural South and the bats. The coronaviruses have been distributed through intermediate hosts at first. Among the intermediate hosts are civets, porcupines, ferrets, pigs, poultry. The seropositive respondents were exposed to coronaviruses via domesticated animals and agricultural goods. The respondents in the study indicated that they had not taken any measures to limit exposure to pathogens. In addition, the bat caves in southern China attract lots of people during the summer months (New research: Bats harbor hundreds of coronaviruses, and spillovers aren't rare, NPR, February 20, 2020).

The source of contamination (not: place of origin, which is still unclear in March 2020) of 2019-nCoV is the Wuhan Wholesale Seafood Market, where probably contaminated imported goods are traded. Wuhan's population density, the rate at which infected persons, animals and goods are transported, and hygiene are factors that have all contributed to the rapid spread of the most recent Corona virus.

The bat cave that is the breeding ground for 2019-nCoV and a multitude of other (corona) viruses was discovered as early as 2005, but due to a lack of financial resources, further research was forced to be canceled (Cave full of bats in China identified as source of virus almost identical to 2019-nCoV, National Post, February 6, 2020).

Could this dramatic spread have been prevented?
An inconvenient notion is that the spread could have been prevented by isolating vacationers and commuters from the Wuhan area as soon as people were tested positive for 2019-nCoV. Governments of other areas and states could have refused to admit persons from this initial contamination area.

Governments have allowed tourists and commuters to travel during the incubation period, thereby creating major risks for the population. First, an estimation error has been made with regard to the incubation period, which was initially set at 14 days and appears to be more than 21 days. Secondly, it was assumed that the virus would not spread until symptoms occur, while infected hosts are also contagious without showing symptoms (Feasability of controlling COVID-19 outbreaks by isolation of cases and contacts, The Lancet, on published on February 28, 2020).

Isolating infected persons or persons from risk areas is dismissed as "treating people like a Pariah." For the sake of avoiding discrimination, no isolation measures have been and will not be taken to limit the spread. In addition, economic interests play the largest role in balancing protection of a nation's human population and the interest of stimulating the economy in the short term. After the discovery of the first seat of fire and subsequent incubators of 2019-nCoV, the officer in charge could have already decided to issue negative travel advice and to immediately apply professional quarantine.

The 2003 SARS epidemic was successfully brought under control by isolating and providing medical care to infected individuals as soon as possible, by applying travel restrictions and screening passengers at airports. The curbing of the SARS epidemic serves as a standard for the current 2019 nCoV epidemic (Coronavirus latest: global infections pass 90,000, Nature, updates on 2019-nCoV). Researchers recommend taking draconian isolation measures in affected areas to prevent further spread of 2019 nCoV. To prevent and minimize contamination within one area, it is prescribed to cancel meetings, close schools and work from home (Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modeling study, The Lancet, vol. 395, issue 10225, February 29, 2020 (published on the Internet on January 31, 2020). The role of children as spreaders of the virus is being investigated. Children are equally likely to become infected with the virus, but seem to be less troubled by the symptoms. It is recommended that primary schools and childcare be closed (Coronavirus latest: global infections pass 90,000, Nature, updates on 2019-nCoV).

The role of high-density modalities in the spread of 2019-nCoV

2019-nCoV has spread across the world at lightning speed by transporting travelers from Wuhan to the international community within a relatively short period of time. Aviation and shipping are main intermediaries in the distribution of 2019-nCoV. Coronaviruses have a lifespan of up to 9 days outside the body. Where groups of people are concentrated (plane or boat), viruses can successfully spread to multiple hosts within a short period of time. In the immediate living environment, public transport, lecture halls and other locations that house many people at the same time contribute to the spread of viruses.

Corona and responsible actors- and what should be done now

To allow people to travel to affected areas and back is irresponsible, here's why
One argument reads that this virus is a rich man's disease. Yes, it is true that people who can afford themselves to travel and who did so during Sprink Break, have taken this infection with them from nothern Italy and other massively affected areas following the Wuhan outbreak of December 2019. One cannot hold someone accountable for traveling abroad when no one was noticed about the virus emerging in what would soon become high risk areas. But when a warning was emitted in our country, people still travelled to affected areas in order to return home, fallen ill to COVID-19.

People are always affected by other people's actions. To travel abroad to an epicentre is a choice that puts others at risk. A risk nobody has asked for and made many of us powerless. People with chronic diseases did not have a choice. They are, to a great extent, dependent on how others behave after contracting an infection. Furthermore, it has been very irresponsible to allow people to travel to affected areas. 

The thought alone of limiting physical freedom by imposing travel restrictions, seemed not negotiable to many of our governments. It was decided to not impose travel restrictions from an economical point of view. Short term economical benefits prevailed over taking measures to ward off this virus as much and as long as possible. Also, a fear of acting discriminative has withheld governments from enforcing restrictive measures, such as containment. 

Blame is only natural if institutions with authority and responsibility fail or refuse to take measures to prevent unnecessary damage. Delay leads to unnecessary damage. Unnecessary is damage evidently caused by leaning back and not acting upon a serious threat. An authority that trivializes problems and takes a wait-and-see-attitude, intervenes deeply in the lives of citizens. What's more: authorities have been acting contrary to containment. The prevention phase was a crucial phase, during which containment should have been the foremost strategy to keep the curve of patients falling ill to COVID-19 as flat as possible.

"Anything we say in advance of a pandemic is alarmist; anything we say afterwards is inadequate"- Michael Leavitt, 2006
Some say: scientists try to evoke panic and mass hysteria. How's that? People did not want their perception of freedom to be limited. How much is this perceived kind of freedom worth on a scale of life? People will actually experience what freedom really means to them, once they will have to live in a vacuum. The problem with people in general is that awareness before any kind of disaster is deemed "hysteria". Some of them say "we should not go overboard with measures" even before having taken any measures at all. Those people need to see it happen before their eyes to realise it might be mean. Ask yourself: is awareness really worse than neglect? 

I'll tell you this: it's been 20 years since scientists have been warning the world for this outbreak. A virus is not a matter of revolution, it's evolution. Researchers have observed developments, in case mutations to RaTG13, and estimated an outbreak would happen in the course of 2019. I pulled my ACP Medicine out and searched for biochemical information on coronaviruses. A study written in 2007 reads that "Future outbreaks of nCoV should be limited by isolation of patients with suspected SARS for at least 10 days. In case of documented SARS, patients should be isolated for at least 20 days to prevent a spread." Sadly, to this date none of these recommendations have been taken to heart by governments, except for a few, like China. To come awake too late is bad. Being fully aware and not taking the right measures is downward terrible. By ignoring recommendations backed by scientific practice that has been developed for over the past 20 years, you, as an authority, are responsible for every death that occurs due to your negligence.

Taking recommendations backed by scientific evidence is not born out of a sense of panic, but very realistic and useful. We, as citizens, are responsible for taking measures to prevent further transmission.

ACP Medicine, a 2007 SARS study: prevention is key. Patients with suspected SARS should be isolated for at least 10 days. In cases with confirmed SARS, patients should be isolated for 10 days after the abatement of fever.

Containment: what should be done now
Many West European people, especially the Dutch and German, praise themselves for having  phlegmatic temperament. While being sensible would be recommendable, it is in fact indifference that a good amount of Dutch people consider to be 'nuchter'. Indifference, as in "lean back, wait and we'll see, because it is just another storm that will pass by itself" is not going to help society out of this epidemic. It is not going to contribute to containment. 
The government has decided (well actually it did not make any 'decisions') to leave it up to people whether they want to restrict their daily activities. "Just use your common sense". 

What does "common sense" mean with regards to COVID-19? People have to decide whether to stay at home or to continue their activities while being infected. People have visited hospitals and general practitioners after being infected with 2019-nCoV. One man has mentioned to have been tested seropositive for COVID-19 on 1 March 2020. He used public transport to visit the city's hospital, in order to be tested positive for COVID on 9 March 2020. Hence, people are given a responsibility that they cannot handle or understand.

Everything should be done to enable hospitals to treat their patients, without getting stuck in an overflow of people falling ill to COVID-19. A shortage of ICU beds (Intensive Care Unit) and ventilators is a threat that has to be avoided right now. If our governments fail to enforce all restrictions needed, hospitals will be faced by abhorrent questions of triage. Similar to wartime, people with compromised immune systems and relatively older people will have to be sacrificed to treat relatively younger, non-compromised patients. This is why there is no time left to overthink possible scenarios.

Rules of containment
- The government should suspend all flights, except for cargo. As of today, an impossible threat is still imposed on all of us, by admitting flights and travelers from high-risk areas in this country. This is a threat for for everyone within our borders. Do not consider the suspension of flights and other forms of travel too much of a draconian measure. It is sheer necessity to prohibit flights and travel in order to flatten the curve;
- Close the borders;
- All schools should be closed right now;
- Quarantine people who have been exposed to 2019-nCoV right now. Do not leave it up to people whether they should continue their daily activities and social commitmens;
- A regulation that reads that "gathering with hundreds of people or more is discouraged, gathering with a maximum of 20 people is recommended" is insufficient and does not comply with containment, nor does it comply with mitigation. It was estimated that every infected individual, asymptomatic cases included, has the potential to infect approximately three persons. Thus, a regulation limiting the number of people participating in meetings should be replaced by a rule of conduct stipulating that meetings should be avoided.

Coronavirus SARS-CoV-2: awareness. On complications of 2019-nCoV and transmission routes

People finally realize that coronavirus 2019-nCoV/SARS-CoV-2 is not a flu, but a virus of a completely different nature ('analogies create blind spots', to quote Peckham in his commentary in The Lancet of 2 March 2020). This virus, like any virus, should be taken seriously. Realism has nothing to do with panic. Some people let themselves be soothed by trusting that everything will function properly and that it will end with a hiss. I am in favor of more people being critical. A critical attitude is different from unfounded panic. 

What is evident in the media storm that blows over our country is the need of the population for transparency about the risks of the virus, the measures being taken to limit further spread and the seriousness of the situation. Reports that people who transmit symptoms and despite submitting a request are not tested, reports that people coming from risk areas are not restricted from having intensive contact with third parties and the fact that 'privacy' is used as an excuse. People don't need numbers and statistics made up to provide them with a false sense of safety. People need transparency, even if the number of cases might be a shock. It's patronizing to hide truths and laugh actual threats off. Mystery must give the impression that everything is under control, but a lack of transparency causes suspicion.

I will illustrate this with two examples. In the initial phase, the responsible authorities issued the message that people from risk areas are only contagious when they show symptoms such as a high fever. It was already clear at the time of reporting that infected people were already contagious before the onset of the first symptoms. Also, people were not checked if they reported a sore throat, while they were indeed infected and a sore throat is listed as one of the first symptoms of infection with 2019-nCoV as well. The RIVM cites fever as the main factor to report a suspected infection, while fever can occur up to 8 days later in 11.5% of seriously ill patients.

In this report, I will discuss the importance of limitation and prevention of 2019-nCoV and its L and S strains, the complications caused by 2019-nCoV and the transmission routes of coronaviruses. Lastly, I will discuss to what extent governments have acted too late upon the global spread. I base my reporting solely on empirical and clinical studies that have been published in scientific journals such as The Lancet, Nature Magazine and AAAS.

Why is it so important to limit the spread of the virus?
First, there is currently no vaccine against coronaviruses. Secondly, the spread of viruses must be limited to prevent successful mutations as much as possible. Coronavirus 2019-nCoV is a loot to the strain of a precursor that, according to calculations, existed 65 years earlier. 2019-nCoV most likely has this precursor in common with bat coronavirus RaTG13 (Mining coronavirus genomes for clues to the outbreak's origins, AAAS, January 31, 2020). On March 3, 2020, it is known that an L and S variant of the corona virus are active (On the origin and continuing evolution of SARS-CoV-2, National Science Review, nwaa036, published on March 3, 2020). 

Pathogenecity and transmissibility are intertwined. Substantial and consistent interruption of transmission from one person to another (R < 1) is key to control and eradication of 2019-nCoV (Pathogenecity and transmissibility of 2019-nCoV- A quick overview and comparison with other emerging viruses, Microbes and Infection, published online on 4 Februari 2020).

Complications of SARS-CoV-2
The extent of the worldwide influence of the active virus mutations cannot be estimated right now. It is clear that SARS-CoV-2 can cause serious complications. In a patient population with severe symptoms, damage to the organ functions occurs: in a control group, 67% had ARDS (Acute Respiratory Distress Syndrome), 15% kidney failure, 23% heart failure and 29% liver failure. X-rays of the group examined show lesions in the tissue of both lungs (Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study, The Lancet, published on 24 February 2020). Edema occurs at an early stage of ARDS, characterized by the presence of nucleoli in the vesicles.

Coronaviruses have neuroinvasive capacities. Like respiratory viruses in general, they can cause permanent damage to the central nervous system. Coronaviruses can lead to encephalitis via the blood-brain barrier, as accumulation of interleukin-6 increases the permeability of the blood-brain barrier. The rapid replication of the pathogens of SARS-CoV-2 is a risk factor for initiating overreaction of the human immune system, where viral meningitis can occur (Human Coronaviruses and other respiratory viruses: Underestimated opportunistic pathogens of the Central Nervous System ?, Viruses 2020, 12 (1), 14, published December 20, 2019). In a young patient group with CoV, a slight accumulation of IL-6, IL-8 and MCP-1 in the brain fluid was observed. MCP-1 is involved in initiating inflammatory responses in the brain (Coronavirus infections in the Central Nervous System and respiratory tract show distinct features in hospitalized children, Intervirology 2016, vol. 59, no. 3, published in February 2017).

Based on pathological examination of one case of ARDS, it is recommended to treat severe cases with corticosteroids and artificial respiration (Pathological findings or COVID-19 associated with acute respiratory distress syndrome, The Lancet, published on February 18, 2020). The downside to medical treatment is that liver damage can occur, in addition to the risk of liver damage due to coronavirus infection (Liver injury in COVID-19: management and challenges, The Lancet, published March 4, 2020). Data on previous corticosteroid treatments of lung disease (including Dexamethasone) caused by SARS-CoV and MERS-CoV do not provide conclusive information on the effectiveness of corticosteroids. Because the potential benefits do not outweigh the damage caused by corticosteroids, researchers do not recommend treatment with corticosteroids (Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury, The Lancet, vol. 395, issue 10223, P473-475, 15 February 2020).

What are the transmission routes for SARS-CoV-2?
Contamination with 2019-nCoV can occur through the eyes (2019-nCoV transmission through the ocular surface must not be ignored, The Lancet, vol. 395, issue 10224, PE39, February 22, 2020). Because only 1 in 5 people wash their hands sufficiently, there is a high risk of people getting infected as a result of poo getting into the mouth (Enteric involvement or coronaviruses: is faecal-oral transmission or SARS-CoV-2 possible? The Lancet Gastroenterology & Hepatology, published on February 19, 2020). Breathing drops and poop particles end up on surfaces. Coronaviruses can remain active on surfaces for up to 9 days (Persistence of coronaviruses on inanimate surfaces and their inactivation within biocidal agents, Journal of Hospital Infection, vol. 104 issue 3, March 2020). But there's another, less visible transmission route: that of the aerosol transmission. Tiny particles may reach the tract of the host. The airborne or aerosol transmission route was also a major contributor to the SARS-CoV-1 epidemic in 2003, as a tower in the Amoy Gardens in Hong Kong was discovered to be a SARS-transmitting housing complex due to faulty ventilation.

Have international governments acted too late? Yes: delayed detection and reporting and a lack of restrictions in the first phase have seriously damaged global prevention
It is always easy talking in hindsight, but that is not the case this time: beforehand it was clear that unnecessary risks would be taken by not acting directly, but waiting, relying on sheer hope instead of taking measures. Lessons had already been learned from the SARS and MERS epidemics. 

Containment must be applied immediately to curb the spread of corona viruses. Early detection and reporting of 2019-nCoV cases was delayed, the public was not informed in time about the first phase of the outbreak (Early lessons from the frontline of the 2019-nCoV outbreak, The Lancet, vol. 395, issue 10225, P687, February 29, 2020). A lack of medical resources and hospital beds has contributed to the inability to curb the outbreak of the virus in the first phase.

During Chinese New Year, 5 million people from the Wuhan epicentre were able to travel to other countries and to other areas within China. Outside of China, traveling to high-risk areas, traveling people from high-risk provinces in China to other countries (including northern Italy), the Venetian Carnival, German and Dutch Carnival, and other massive occasions have contributed to the worldwide spread of the 2019 coronavirus. After it was announced that northern Italy and South Tyrol were risky areas, tourists were still allowed to travel to these areas and return to their home country. Governments should have acted at this crucial stage. Only rapid detection and isolation of infected persons, including those with mild symptoms, can limit the further spread of the virus. It is not appropriate for a government agency to advise people to remain silent, to refuse to test people who show symptoms of SARS-CoV-2 and to resort to ill advice such as 'do not shake hands'.