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| ==Introduction==
| | #REDIRECT[[COVID-19]] |
| * Disease name = COVID-19
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| * Virus = SARS-CoV-2 (previously 2019-nCoV
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| === Virology ===
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| * Coronaviruses are a common human pathogens (discovered in the1960s to cause the common cold).
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| ** During epidemics, they are the cause of up to one-third of community-acquired upper respiratory tract infections in adults; may cause diarrhea in infants and children as well)
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| * SARS-CoV-2 is a novel coronavirus (a new strain not previously identified in humans)
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| ** Likely primary source = bats
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| ** A betacoronavirus in the same subgenus as the severe acute respiratory syndrome (SARS) virus
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| ** Receptor-binding gene region is very similar to that of the SARS coronavirus (uses angiotensin-converting enzyme 2 [ACE2] for cell entry)
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| ** Middle East respiratory syndrome (MERS) virus, another betacoronavirus, appears more distantly related
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| * Viral survival time of SARS-CoV-2:
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| ** Stainless steel: persists for 3 hours (or longer)
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| ** Underscores the importance of environmental cleaning / disinfection
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| *** Cleaning gets rid of the proteins that would interfere with a disinfectants effectiveness
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| ** Note: studied in a simulated lab environment. Lab virions not covered in protein and mucus and other things that would mimic real life and that could prolong survival
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| === Basic Epidemiology/Infectivity Data ===
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| * Expected patient outcomes (from data so far):
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| ** 80% have mild symptoms
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| ** 15% have severe disease requiring hospitalisation
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| ** 5% require mechanical ventilation
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| * Case fatality rate (CFR) = 2-4% (from Hubei data)
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| ** SARS ~ 10%
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| ** MERS ~ 35%
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| ** Seasonal flu ~ 0.1-0.2%
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| ** 1918 Pandemic Influenza ~ 2-3%
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| * R0 = 2.2 - 4.2
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| ** Where R0 = expected number of secondary cases produced by a single typical infection in a susceptible population (basic reproductive rate)
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| ** R0 for seasonal flu ~ 1.3
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| ** R0 for pandemic flu ~ 1.5-1.8
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| * Incubation: 5 days (median); range of 2-14 days
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| * Serial interval duration = 7.5 days
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| ** Serial interval refers to the time from illness onset in successive cases in a transmission chain
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| [[File:Ro example.png|thumb|center|Ro Example]] | |
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| === Clinical Findings ===
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| * At onset: fever, dry cough, myalgias, fatigue, shortness of breath
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| ** Fever and cough start early, SOB noted about 9 days into illness
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| ** Fever not present in all adults (less common in vulnerable populations)
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| ** Less common: cough with sputum, sore throat, headache, congestion, GI symptoms
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| * Most common complications: pneumonia, ARDS (avg 8 days from onset, 20% of patients in China)
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| ** Decompensation risk occurs during 2nd week of illness
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| * Risk factors: older adults, underlying conditions (lung disease, heart disease, diabetes)
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| ** Children: milder disease (see Children)
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| ** Pregnant patients: don’t appear to be at increased risk of infection or adverse outcomes (limited data - see Pregnant Women)
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| ==== Laboratory Findings ====
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| * Lymphopenia most common in critically ill; mildly elevated ALT, AST; normal pro-calcitonin on admission
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| ** Elevated d-dimer and severe lymphopenia are associated with increased mortality
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| ** RT-PCR is currently test of choice for confirming cases
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| *** Test kit availability is currently limited as of mid March
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| *** Consider influenza/viral respiratory panel to identify alternative diagnoses
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| **** Although co-infection is possible
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| ==== Imaging ====
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| * XRay:
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| ** Portable CXR preferred in PUI to prevent spread of infection
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| ** May be normal in early disease
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| ** Typical pattern is peripheral patchy ground glass opacities (GGO)
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| ** More opacities correlates with worse disease
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| ** GGOs may coalesce and appear as infiltrates
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| * CT:
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| * Many have normal imaging early on (so CDC DOES not recommend CT for diagnostic purposes at this time)
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| ** CT (86%) more sensitive than CXR (59%) for detecting GGOs
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| ** Radiopaedia COVID-19 Resources (https://radiopaedia.org/articles/covid-19)
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| ** From the American College of Radiology (3/11/20): “Generally, the findings on chest imaging in COVID-19 are not specific, and overlap with other infections, including influenza, H1N1, SARS and MERS. Being in the midst of the current flu season with a much higher prevalence of influenza in the U.S. than COVID-19, further limits the specificity of CT.”
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| * Reinfection (after recovery from COVID19): unclear if possible
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| ** Limited data. Unlikely to be reinfected shortly after but unknown about later on
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| ==General Prevention Recommendations==
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| * Exercise general infection precautions
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| ** Person-to-person transmission occurs with close contact (6 feet)
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| *** Direct contact with mucous membranes or respiratory droplets
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| *** Indirect: cough —> secretions left on surface —> 2nd person touches surface secretions and touches face & mucous membranes
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| ** Avoid touching your face (try it, it’s not easy)
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| ** Frequent Handwashing
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| *** Alcohol based hand sanitizer
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| *** Diligent hand wasing
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| **** 20 seconds minimum
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| **** Image shows commonly forgotten areas: thumb (ulnar aspect), fingertips, WRIST (Borrowed from WHO Hand Hygiene for Healthcare)
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| ** Wear a mask if you develop respiratory symptoms (fever, cough, rhinorrhea, congestion) to prevent spread
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| * Avoid unnecessary travel
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| * Stay home if symptomatic
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| ** Home care does not mean being out in the parks with other groups of people
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| ** Contact your supervisor: due to expected HCW shortages, minor symptoms may be allowed to continue working with adequate PPE to prevent infection spread
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| [[File:Hand Hygiene.png|thumb|center]]
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| ==Precautions For Healthcare Workers==
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| === PPE Bottom Line: Per CDC and LADPH (3.12.20) ===
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| * “Can collect specimens (e.g., nasopharyngeal swabs) for COVID-19 observing standard, contact, and droplet precautions including eye protection in a normal examination room with the door closed”
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| * No airborne isolation required (unless aerosol-generating procedure)
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| === Transmission ===
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| * Simply walking into a room is NOT a recognized risk of transmission. Must make contact with respiratory droplet (directly or indirectly)
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| * Masks: MOST IMPORTANT utility is to put on the coughing individual
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| ** Research clearly demonstrates it decreases shedding of infectious material in the environment
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| ** This is more effective than HCWs wearing masks prophylactically to prevent catching the infection when not actually performing close contact patient care
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| * How long to shut a patient room down after a COVID patient is in there?
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| ** It’s not about the risk of contracting the infection but about the ability to clean room safely without respiratory protection precautions by the cleaner
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| ** 30-40 minutes usually sufficient (for most modern facilities) as long as no aerosol-generating procedure performed (longer, time not clearly stated at this time)
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| *** Most modern rooms designed to have 12 air exchanges per hour
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| *** Ventilation symptoms vary. So, older / fewer exchanges per hour => more time.
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| === PPE Guidelines ===
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| * EVERY PATIENT CONTACT: Respiratory droplet precautions. Contact precautions also recommended but if gowns in short supply consider reserving for aerosol-generating procedures
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| ** Droplet = surgical mask, eye protection
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| ** Contact = gown and gloves
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| ** Technique:
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| *** Mask donning (often incorrectly done):
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| **** Wash hands BEFORE touching mask
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| **** Grip mask by loops/bands/ties only
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| **** Coloured portion typically faces outward
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| **** Mold / pinch the stiff edge to the shape of your nose
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| **** Pull the bottom of the mask over your mouth AND chin
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| **** Make sure you are up to date with fit testing
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| *** Mask removal:
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| **** Wash hands BEFORE touching mask
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| **** Only make contact with the loops/bands/ties. DON’T TOUCH THE MASK ITSELF!
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| * For AEROSOL GENERATING procedures: airborne precautions (N95/PAPR)
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| ** Due to higher risk of aerosolizing droplets-- infection itself doesn’t seem to be spread via airborne route)
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| ** Aerosol generating procedures (avoid when possible)
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| *** Bag-valve mask (BMV)
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| *** CPAP/BiPAP
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| *** Intubation
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| *** Nebulizer administration (COMMONLY FORGOTTEN) - use MDI instead. E.g. 8-12 MDI puffs instead of albuterol 2.5-5mg INH.
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| *** Bronchoscopy
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| *** Chest PT
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| === PPE Shortage/Limiting Usage Guidelines ===
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| In case of PPE shortage or in an attempt to save on PPE supplies, the following guidelines were approved by CDC 3/13/20
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| * Same respirator can be worn for multiple serial patient contacts (e.g. in between successive COVID/PUI (patients under investigation) without exchanging respirator. Therefore, in between each patient:
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| * No need to change mask or eye protection
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| * BUT need to change gown and gloves
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| * Respirator reuse possible? Higher risk because of having to touch the mask and either self-inoculate or transmit to another patient (e.g. wear it for a patient, then you remove, and then you put it back on)
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| * If you must do this because of limited supplies, don and doff properly and perform proper hand hygiene in between
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| * CDC / NIOSH will allow certain N95s to be used beyond manufacture-designated shelf life
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| ** See list of appropriate models here (manufactured between 2003-2013)
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| * N95 Reuse? Probably okay to re-use same N95 during an 8 hour shift as long as no tears or visible contamination. Store facedown in labeled re-sealable bag/container.
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| ** Based on non peer reviewed reports from Washington State
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| === Healthcare Worker Monitoring ===
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| * Every HCW should be keeping a thermometer at home
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| * Self-monitor BID (and especially before work). Facilities should screen their HCW prior to shifts.
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| * If symptomatic, notify supervisor.
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| * If febrile, STAY HOME.
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| * If other symptoms, discuss with supervisor / clinical experts. Due to expected HCW shortages, minor symptoms may be allowed to continue working with adequate PPE to prevent infection spread
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| ==Isolation==
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| * Persons diagnosed with COVID-19 are considered cleared after 14 days from symptom onset or 3 days after resolution of fever and improvement of other symptoms, whichever is longer.
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| * CDC: Reasonable to isolate patients with unexplained fever and respiratory symptoms (and no travel history) at this time
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| ==Testing==
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| * LA County DPH checklist (http://publichealth.lacounty.gov/acd/ncorona2019/checklist.htm)
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| * Mild illness: DO NOT send for testing (increased risk of exposure to COVID-19)
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| * ER: DO NOT go unless hospital level of care is needed (increased exposure of other patients and staff)
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| * Testing can be done in ambulatory setting if absolutely needed (see precautions)
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| === Guidelines: Epidemiologic Factors ===
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| * Persons (including HCW) within 14 days of travel (domestic/international), or
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| * Close contacts with lab-confirmed COVID19 patient within 14 days
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| [[File:Screen Shot 2020-03-17 at 7.27.23 PM.png|thumb|center|LAC DPH Public Health Lab (PHL) COVID-19 Testing Criteria]]
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| ==Disposition==
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| ==See Also==
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| ==External Links==
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| ==References==
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| <references/>
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| [[Category:Admin]]
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