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COVID-19 in the U.S., One Year Later

It was one year ago — Jan. 20, 2020 — that the first case of SARS-CoV-2 infection was reported on U.S. soil.

It was still called the “novel coronavirus” at the time; at least that’s how it was referenced in a CDC statement. By the time a final New England Journal of Medicine report on the case was published March 5, it had been dubbed 2019-nCoV as well as SARS-CoV-2.

Few now believe it was really the country’s first case.

On Jan. 19, 2020, a man who’d recently returned from visiting family in Wuhan, China, presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and fever. He was aware that a novel coronavirus was circulating at the time, but he hadn’t had contact with anyone who was sick, and he hadn’t been to any seafood markets or healthcare facilities in Wuhan — at that time, the only known risk factors.

His oxygen saturation was 96% on room air, but he had no abnormalities on chest x-ray, according to Michelle Holshue, MPH, of the Washington State Department of Health, and colleagues.

Still, given his travel history, the urgent care clinic notified the local and state health departments immediately, and the latter notified the CDC — which confirmed the next day, on Jan. 20, that the patient was indeed positive for the novel coronavirus.

The patient, who’d been discharged from urgent care to home isolation with active monitoring by the local health department, was then admitted to Providence Regional Medical Center for observation. He was put in an airborne isolation unit and healthcare workers had to follow CDC recommendations for contact, droplet, and airborne precautions.

While his vitals were initially in normal ranges, by the fifth day of his hospitalization (which was the ninth day of his illness) his oxygen saturation dropped to as low as 90% on room air. A new chest x-ray revealed evidence of pneumonia in the lower lobe of his left lung.

The next day, he was started on supplemental oxygen, and another chest x-ray showed basilar streaky opacities in both lungs.

At that point, doctors advocated for compassionate use of remdesivir, which was obtained and started the following evening, the 11th day of the patient’s illness.

The man’s clinical condition then improved — so much so that supplemental oxygen was stopped, and his O2 sats improved to 94% to 96% on room air.

He was still in the hospital when the NEJM authors finished their manuscript on Jan. 30, but he had no fever and all his symptoms had resolved, except his cough, which was “decreasing in severity.”

Treatment today looks much the same for a patient experiencing the same level of moderate illness requiring hospitalization, though remdesivir (Veklury) is now FDA approved for treating COVID-19, and a handful of other therapies are available, if inconsistently effective. But critical care practices aside from drugs have improved and case fatality rates have fallen significantly, even as the number of U.S. cases has soared past 20 million with no end in sight.

Though the case occurred before COVID-19 reached pandemic proportions — the virus was declared a public health emergency of international concern by the World Health Organization on Jan. 30 — Holshue and colleagues’ NEJM report highlighted topics that still remain controversial today.

For instance, they wrote that the patient had low PCR cycle threshold (Ct) values on illness day 4, suggesting high levels of virus despite mild symptoms at the time: values of 18 to 20 in nasopharyngeal samples and 21 to 22 in oropharyngeal samples.

Holshue and colleagues also noted that the full genome sequence from oropharyngeal and nasopharyngeal specimens were nearly identical to other available 2019-nCoV sequences, with only three nucleotides and one amino acid that differed from the reference sequence. Now, a handful of potentially significant mutations have global health authorities concerned.

  • Kristina Fiore leads MedPage’s enterprise & investigative reporting team. She’s been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. Send story tips to [email protected] Follow