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What Healthcare Providers Should Know About Novel Coronavirus COVID-19

Originally published 4/3/20.

The global death toll from the coronavirus, which first struck Wuhan, China, in late December 2019, has surpassed 100,000. To date, there are more than one million known cases of the virus, which has spread to at least 180 countries and territories.

While the outbreak appears to be slowing down in China, it’s picking up elsewhere, especially in the U.S, where cases have soared past 520,000. To date, more than 18,000 Americans have died from the virus. States have shut down schools and gyms, restricted restaurants to take-out or delivery only and barred mass gatherings.

Here are important updates on the COVID-19 outbreak for healthcare professionals.

Know the symptoms of coronavirus.

The clinical presentation of SARS-CoV-2, novel coronavirus’ official name, includes a range of symptoms, from light coughing to severe pneumonia resulting in death. Fever, coughing and shortness of breath are most common. Symptoms usually appear from two days to two weeks after exposure.

The virus likely moves from person to person through the respiratory droplets in an infected individual’s cough or sneeze. According to the Centers for Disease Control and Prevention, it spreads “easily and sustainably … in some affected geographic areas.” Research places the novel coronavirus’ R0 (the number of people who will catch the disease from an infected person in a population that’s never seen the disease before) between two and three.

Transmission by asymptomatic patients is possible.

Research shows patients can transmit the virus when they’re not showing symptoms, but it’s unclear how often this actually happens. The CDC has said this is not the main way the virus spreads and current data shows people are at their most contagious when they’re the sickest.

There is no vaccine for novel coronavirus 2019-nCoV.

Various biotech companies are attempting to develop a vaccine for novel coronavirus 2019-nCoV as quickly as possible, but it will likely be several months at a minimum before it’s available to the public.

For now, the best way to prevent the disease is to avoid contact with infected individuals. The CDC also recommends:

  • Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom, before eating, and after blowing your nose, coughing and sneezing. If soap and water are not available, use hand sanitizer with 65-to-95-percent alcohol.
  • Avoid touching your eyes, nose and mouth.
  • Stay home when you are sick.
  • Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
  • Regularly disinfect frequently touched objects and surfaces.

Take a detailed travel history for patients with fever and acute respiratory illness.

It’s important to assess if the patient has been in a country with coronavirus or nearby within two weeks of symptom onset, according to CDC. That said, as community spread in the U.S. grows, don’t dismiss patients showing possible COVID-19 symptoms because they don’t have relevant travel history or exposure to a confirmed patient. Clinical judgement is key.

As soon as possible, evaluate patients for COVID-19 based on the following criteria:

  • Patients with symptoms compatible with COVID-19, especially fever and lower respiratory illness (cough, difficulty breathing, etc.)
  • Within 14 days of symptom onset, a history of travel to areas with sustained community transmission (China, Iran, Italy, Japan, South Korea)
  • Within 14 days of symptom onset, close contact with a lab-confirmed COVID-19 patient
  • Fever AND severe acute lower respiratory illness requiring hospitalization without any alternative, explanatory diagnosis (regardless of travel history or contact with COVID-19 patients)

Consider anyone with symptoms and possible exposure to the virus or anyone with severe symptoms and no other explanation “a patient under investigation (PUI),” per the CDC.

Immediately notify local authorities of suspected COVID-19 cases.

If you encounter a PUI for COVID-19, immediately notify your employer’s infection control office and the local and state health departments. This way, the health department can contact the CDC’s Emergency Operations Center (EOC) and assist with collecting samples for testing. Currently, diagnostic testing is being performed at the CDC headquarters and various, vetted labs around the country.

Collect specimens for coronavirus testing as soon as possible.

Include upper respiratory (nasopharyngeal AND oropharyngeal swabs) and lower respiratory (sputum, if possible) for those patients with productive coughs. Do not try to induce sputum. For patients for whom it is clinically indicated (for example, those receiving invasive mechanical ventilation), take a lower respiratory tract aspirate or broncho-alveolar lavage sample.

Collect the samples as soon as you can, regardless of when symptom onset took place. The CDC offers in-depth guidelines for collecting and handling specimens for coronavirus testing.

The CDC has said that a positive test result indicates a likely infection, but a negative one doesn’t necessarily mean the patient does not have COVID-19. Develop all management decisions based on clinical observations, patient history and epidemiological information.

Follow infection control procedures with any patients under investigation.

Per WHO recommendations, ask patients to wear a medical mask, cover their nose and mouth while coughing or sneezing with a tissue or flexed elbow, and wash their hands after any contact with respiratory secretions. When scheduling appointments, ask patients if they have symptoms of a respiratory infection; if so, request they take appropriate preventive actions (for example, wearing a mask) when seeking healthcare, and keep them in a separate waiting room. Enforce preventive behavior among suspected COVID-19 and respiratory-infection patients for their entire visit.

Try to keep possible novel coronavirus patients in Airborne Infection Isolation Rooms (AIIRs). Make sure all patients have equipment to practice prevention behavior at their disposal. This includes: 60-to-95-percent alcohol-based hand sanitizer, tissues, no-touch receptacles for disposal, and face masks at entrances, patient check-ins, in waiting rooms, etc. Patients do not have to wear masks inside the AIIR.

Only essential personnel should enter AIIRs with possible COVID-19 patients. Follow standard contact and airborne precautions to prevent infection. This includes wearing personal, protective equipment: NIOSH-approved N95 respirators (surgical or otherwise), gowns, gloves, face shield/eye protection, etc. PPE is especially important when collecting samples for testing, as swabbing often triggers coughing.

Follow CDC protocol for donning and doffing protective clothing. For example:

  • Perform hand hygiene, then put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated.
  • Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene.
  • Disposable respirators should be removed and discarded after exiting the patient’s room or care area and closing the door. Perform hand hygiene after discarding the respirator.
  • Reusable respirators (such as PAPR) must be cleaned and disinfected according to manufacturer’s reprocessing instructions prior to re-use.

For more information, review the CDC guidelines, which also address triage areas, managing exposed HCPs, training, education, and special precautions for pregnant patients with suspected COVID-19.

Provide supportive care for coronavirus.

No specific treatment for COVID-19 is currently available. As a result, the CDC recommends supportive care to relieve symptoms. Avoid using steroids, unless the patient develops another condition that requires them for treatment, such as septic shock. If a patient develops a bacterial coinfection, use antibiotics. Whenever possible, care for patients in AIIRs.

Not every patient will require hospitalization. Just keep in mind that COVID-19 symptoms often worsen during the second week after onset. Unconfirmed but possible risk factors for more severe illness include: older age, underlying chronic medical conditions (lung disease, cancer, heart failure, cerebrovascular disease, renal disease, liver disease, diabete) immuno-compromising conditions and pregnancy.

Learn more from the CDC about investigational therapeutics.

Monitor your own exposure risk.

The CDC divides healthcare workers’ risk of exposure to novel coronavirus into five categories: high, medium, low, no identifiable risk, and community/travel exposures. Each depends on what procedures you’ve been present for relating to COVID-19 patients and what personal, protective equipment you were wearing. Different degrees of risk also require different degrees of monitoring and possible isolation.

Follow the CDC’s preparedness checklist for healthcare providers.

Stay up to date on the signs and symptoms of coronavirus, diagnostic testing practices, and case definitions for MERS-CoV disease. Also, follow infection control policies, be alert for patients who meet the case definition and more.

Share with patients the CDC guidelines on preventing the virus from spreading to others at home and in communities.

It includes recommendations for ill patients such as, “stay at home except to get medical care,” “separate yourself from other people in your home,” and “wear a face mask.” At this time, the general (healthy) public should not wear face masks because it could aggravate a possible shortage of PPE for health workers and others who need them.

References:

Report 2: Estimating the potential total number of novel Coronavirus cases in Wuhan City, China, Imperial College London.

First Travel-related Case of 2019 Novel Coronavirus Detected in United States, CDC.

2019 Novel Coronavirus (2019-nCoV), Wuhan, China, CDC.

2019 Novel Coronavirus, Wuhan, China: Interim Guidance for Healthcare Professionals, CDC.

Interim Healthcare Infection Prevention and Control Recommendations for Patients Under Investigation for 2019 Novel Coronavirus, CDC.

Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected, WHO.

Interim Guidance for Preventing 2019 Novel Coronavirus (2019-nCoV) from Spreading to Others in Homes and Communities, CDC.

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