Correspondence

ease of unknown origin is endemic. Further Penny Vlahos, Ph.D.

studies could ascertain data with respect to University of Connecticut
lifelong residence and work history and, when Groton, CT
Disclosure forms provided by the authors are available with
linked to environmental surveillance data avail- the full text of this letter at NEJM.org.
able in the United States, generate estimates for
1. Bragg-Gresham J, Morgenstern H, Shahinian V, Robinson B,
individual-level environmental exposures and risks Abbott K, Saran R. An analysis of hot spots of ESRD in the
of incident ESRD. United States: potential presence of CKD of unknown origin in
the USA? Clin Nephrol 2019 September 9 (Epub ahead of print).
Shuchi Anand, M.D. 2. Wick K, Heumesser C, Schmid E. Groundwater nitrate con-
Stanford University School of Medicine tamination: factors and indicators. J Environ Manage 2012;​111:​
Palo Alto, CA 178-86.
sanand2@​­stanford​.­edu 3. Mendley SR, Levin A, Correa-Rotter R, et al. Chronic kidney
diseases in agricultural communities: report from a workshop.
Allison Staniec, B.A. Kidney Int 2019;​96:​1071-6.
4. Caplin B, Yang CW, Anand S, et al. The International Society
University of Connecticut of Nephrology’s International Consortium of Collaborators on
Groton, CT Chronic Kidney Disease of Unknown Etiology: report of the
working group on approaches to population-level detection
Maria Montez‑Rath, Ph.D. strategies and recommendations for a minimum dataset. Kidney
Stanford University School of Medicine Int 2019;​95:​4-10.
Palo Alto, CA DOI: 10.1056/NEJMc2001023

Death from Covid-19 of 23 Health Care Workers in China

To the Editor: The National Health Commis-
sion of the People’s Republic of China has re-
ported that as of February 24, 2020, a total of
3387 of 77,262 patients with Covid-19 (4.4%) in
China were health care workers or others who
worked in medical facilities.1,2 According to the
Chinese Red Cross Foundation, the National
Health Commission of the People’s Republic of
China, and public media, as of April 3, a total of
23 of the health care professionals among these
3387 persons had died from Covid-19 after they
became infected during the practice of medicine
in Wuhan and elsewhere in China.3,4
The median age of the 23 health care workers
who died was 55 years (range, 29 to 72); 17 were
men and 6 were women. Eighteen of the health
care workers were from Wuhan, 4 were from areas
of Hubei Province outside Wuhan, and 1 was
from Hainan Province (see Table S1 in the Sup-
plementary Appendix, available with the full text
of this letter at NEJM.org). Eleven of these per-
sons had been rehired after retirement, and at
least 5 were known to have had a chronic condi-
tion such as hypertension, atrial fibrillation, or
post-polio syndrome. Thirteen were physicians
who provided direct patient care (5 practiced in
community health centers or in private clinics,
3 practiced Chinese medicine, 2 were internal
medicine physicians, 2 were physicians in respi-
ratory medicine, and 1 was a gastroenterologist);
8 were surgeons (including 3 ophthalmologic
surgeons); 1 was an electrocardiography techni-
cian; and 1 was a nurse.
The median period from the onset of symp-
toms of Covid-19 to hospital admission in the 19
health care workers for whom these data were
available in public media reports was 6 days
(range, 0 to 15). Three of them died in late Janu-
ary, 17 died in February, and 3 died in early
March. The median period from hospital ad-
mission to death in all 23 health care workers
was 19 days (range, 1 to 47). In 16 of the health
care workers, acute respiratory distress syndrome
(ARDS) rapidly progressed, and their condition
then deteriorated quickly; all but 3 of these per-
sons were 50 years of age or older. After their
condition deteriorated, 12 of the 23 health care
workers were transferred from the hospitals where
they were first admitted to specialized intensive
care units in other hospitals or to hospitals that
specialize in infectious diseases. In addition to
ARDS, the complications of Covid-19 in these
patients included cardiac injury, septic shock, mul-
tiple organ dysfunction syndrome, hypercoagu-
lability, intracardiac thrombus, and bacteremia.
Only 2 of the 23 health care workers were

n engl j med 382;23  nejm.org  June 4, 2020 2267

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Copyright © 2020 Massachusetts Medical Society. All rights reserved.
 The n e w e ng l a n d j o u r na l of m e dic i n e

physicians in respiratory medicine who had been Yaxun Qin, Ph.D.

specifically assigned to treat patients with Chang’an University
Covid-19. None of the 23 patients who died were Xi’an, China
from hospital divisions of infectious diseases or Xiang Xue, Ph.D.
worked in hospitals that specialized in infec- University of New Mexico
Albuquerque, NM
tious diseases. The infections in these patients
may have resulted from inadequate precautions Shuaijun Zhu, M.Med.
and insufficient protection in the early stages of Fujian Medical University Union Hospital
Fuzhou, China
the epidemic. zhushuaijun@​­f jmu​.­edu​.­cn
As of March 31, none of the 42,600 health All four authors contributed equally to this letter.
care workers who went to Hubei Province to care Disclosure forms provided by the authors are available with
for patients with Covid-19 were known to have the full text of this letter at NEJM.org.
been infected with severe acute respiratory syn- This letter was published on April 15, 2020, at NEJM.org.
drome coronavirus 2 (SARS-CoV-2).5 The 42,600 1. National Health Commission of the People’s Republic of
workers included one of us, an intensive care China. Transcript of the press conference of the China-WHO
physician from Fujian Province who cared for Joint Expert Investigation Team on Covid-19 on February 25,
patients with Covid-19 from January 29 to March 2020. (In Chinese) (http://www​.nhc​.gov​.cn/​xcs/​f kdt/​202002/​
1575db9286f943f4aa00d9e24e9ed0ba​.shtml).
23, first in Wuhan Central Hospital, and then in 2. National Health Commission of the People’s Republic of Chi-
Wuhan Jinyintan Hospital. These data suggest na. Update on the epidemic of Covid-19, as of 24:00 on February
that sufficient precautions with rigorous enforce- 23, 2020. February 24, 2020. (In Chinese) (http://www​.nhc​.gov​.cn/​
xcs/​yqtb/​202002/​945bd98a9d884aeeb54d76afa02ca813​.shtml).
ment can prevent health care workers from be- 3. National Health Commission of the People’s Republic of
coming infected with SARS-CoV-2 and the sub- China. Decision of awarding outstanding groups and in­
dividuals in the National Health System for excellent work
sequent risk of death. The 23 health care heroes in the prevention and control of Covid-19. March 5, 2020.
described here were dedicated to saving the lives (In Chinese) (http://www​.nhc​.gov​.cn/​xcs/​zhengcwj/​202003/​
of others in a catastrophic pandemic that has 28cc60d7e33b4dc7bd77af485fab1a58​.shtml).
4. Chinese Red Cross Foundation. Public announcement. 2020.
been plaguing our country and many others April 3, 2020. (In Chinese) (https://new​.crcf​.org​.cn/​article/​20099).
around the globe. 5. National Health Commission of the People’s Republic of China.
Transcript of the press conference of the Information Office of
Mingkun Zhan, M.Med. the State Council on March 31, 2020. March 31, 2020. (In Chinese)
Fujian Medical University Union Hospital (http://www​.nhc​.gov​.cn/​xcs/​yqfkdt/​202003/​
Fuzhou, China 26403157baf8418292f3f69110af1d1e​.shtml).
zhanmk@​­f jmu​.­edu​.­cn DOI: 10.1056/NEJMc2005696

Neurologic Features in Severe SARS-CoV-2 Infection

To the Editor: We report the neurologic fea-
tures in an observational series of 58 of 64 con-
secutive patients admitted to the hospital be-
cause of acute respiratory distress syndrome
(ARDS) due to Covid-19. The patients received
similar evaluations by intensivists in two inten-
sive care units (ICUs) in Strasbourg, France, be-
tween March 3 and April 3, 2020.
Six patients were excluded because of para-
lytic neuromuscular blockade when neurologic
data were collected or because they had died
without a neurologic examination having been
performed. In all 58 patients, reverse-transcrip-
tase–polymerase-chain-reaction (RT-PCR) assays
of nasopharyngeal samples were positive for se-
vere acute respiratory syndrome coronavirus 2
(SARS-CoV-2). The median age of the patients
was 63 years, and the median Simplified Acute
Physiology Score II at the time of neurologic
examination was 52 (interquartile range, 37 to
65, on a scale ranging from 0 to 163, with
higher scores indicating greater severity of ill-
ness). Seven patients had had previous neuro-
logic disorders, including transient ischemic
attack, partial epilepsy, and mild cognitive im-
pairment.
The neurologic findings were recorded in 8 of
the 58 patients (14%) on admission to the ICU

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The New England Journal of Medicine

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