NOTE: Information and guidelines may change rapidly. Check in with listed references in ‘Learn More – Primary Sources’ to best keep up to date

SUMMARY:

The novel coronavirus, named SARS-CoV-2, is the pathogen underlying the pandemic (a global outbreak of disease). The disease associated with this virus has been officially named COVID-19. Coronaviruses represent a large family of viruses. They can cause human illness, but many are found in animals and, rarely, animal coronaviruses can evolve and infect people as was the case in previous infectious outbreaks such as MERS and SARS.

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• Those at Risk
• Travel Warnings
• Criteria to Guide Evaluation of PUIs for COVID-19
• Priorities for COVID-19 Testing
• Recommendations for Reporting, Testing, and Specimen Collection
• Healthcare Personnel: Infection Prevention
• Discontinuation of Transmission-Based Precautions – COVID-19 With Symptoms
• Discontinuation of Transmission-Based Precautions – Asymptomatic Patients who Tested Positive
• Hospital Discharge

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Symptoms

• Incubation period
  • Time from exposure to development of symptoms: 2 to 14 days
  • 97.5% of persons with COVID-19 who develop symptoms will do so within 11.5 days of SARS-CoV-2 infection (see ‘Related ObG Topics’ below)
  • Median time from exposure to symptoms onset: 4-5 days

• Signs and Symptoms
  • Fever (83% to 99%)
  • Cough (59% to 82%)
  • Fatigue (44% to 70%)
  • Anorexia (40% to 84%)
  • Shortness of breath (31% to 40%)
  • Sputum production (28% to 33%)
  • Myalgias (11% to 35%)

• Atypical presentations
  • Older adults: Especially those with comorbidities may have delayed presentation of fever and respiratory symptoms.
• Other symptoms that have been described in the literature (<10%)
  • Headache | Confusion | Rhinorrhea | Sore throat | Hemoptysis | Vomiting | Diarrhea
  • GI symptoms (diarrhea and nausea) may present prior to developing fever and lower respiratory tract signs | Anosmia or ageusia (taste) have also been reported (see ‘Related ObG Topics’ below) | CDC also lists chills and repeated shaking with chills as symptoms

Those at Risk

CDC currently considers the following individuals to be at higher risk

• ≥ 65 years
• Nursing home or long-term care facility resident
• Respiratory: Chronic lung disease or moderate to severe asthma
• Cardiac: Heart disease with complications
• Immunocompromised: Including cancer treatment
• Severe obesity: BMI ≥40
• Certain underlying medical conditions (particularly not well controlled): e.g., Diabetes | Renal failure | Liver disease
• Pregnancy: CDC states that pregnant women “should be monitored” based on experience from previous outbreaks but as of yet, data has not demonstrated increased risk

Travel Warnings

• Updated travelers’ warnings can be found within the CDC Novel Coronavirus Summary page below (‘Learn More – Primary Sources’)

KEY POINTS:

Criteria to Guide Evaluation of Patients Under Investigation (PUI) for COVID-19

• The CDC states that “Clinicians should use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested”
• Clinicians are strongly encouraged to test for other causes of respiratory illness, including infections such as influenza
• Decisions on which patients receive testing should be based on the local epidemiology of COVID-19, as well as the clinical course of illness
• Epidemiologic factors that may help guide decisions on whether to test include
  • Healthcare Personnel: Even mild signs and symptoms (e.g., sore throat) should be evaluated
  • Known exposure to an individual who has tested positive for SARS-CoV-2
  • Occurrence of local community transmission or transmission within a specific setting/facility (e.g., nursing homes) of COVID-19

Priorities for COVID-19 Testing

High Priority

• Hospitalized patients with symptoms
• Healthcare facility workers, workers in congregate living settings, and first responders with symptoms
• Residents in long-term care facilities or other congregate living settings, including prisons and shelters, with symptoms

Priority

• Persons with symptoms of potential COVID-19 infection, including
  • Fever | Cough | Shortness of breath | Chills | Muscle pain | New loss of taste or smell | Vomiting or diarrhea | Sore throat.
• Persons without symptoms who are prioritized by health departments or clinicians, for any reason, including but not limited to
  • Public health monitoring | Sentinel surveillance | Screening of other asymptomatic individuals according to state and local plans

Recommendations for Reporting, Testing, and Specimen Collection

Diagnostic Testing – Specimen Collection

• Obtain an upper respiratory specimen for initial diagnostic testing
  • A nasopharyngeal (NP) specimen collected by a healthcare professional or
  • An oropharyngeal (OP) specimen collected by a healthcare professional or
  • A nasal mid-turbinate swab collected by a healthcare professional or by a supervised onsite self-collection (using a flocked tapered swab) or
  • An anterior nares (nasal swab) specimen collected by a healthcare professional or by onsite or home self-collection (using a flocked or spun polyester swab) or
  • Nasopharyngeal wash/aspirate or nasal wash/aspirate (NW) specimen collected by a healthcare professional
• Lower respiratory tract specimens
  • Collect and test sputum in patients who develop a productive cough | Induction of sputum is not recommended
  • Under certain clinical circumstances (e.g., those receiving invasive mechanical ventilation), a lower respiratory tract aspirate or bronchoalveolar lavage sample should be collected and tested as a lower respiratory tract specimen

Note: CDC does not recommend using antibody testing to diagnose acute infection | Use a viral (nucleic acid or antigen) test to diagnose acute infection

Healthcare Personnel: Infection Prevention

• Healthcare personnel: CDC advises use of
  • Gloves
  • Gowns
  • Airborne precautions
  • Eye protection (e.g., goggles or a face shield)
• Face masks are an acceptable alternative when the supply chain of N95 respirators (or similar respirators that filter inspired air and offer respiratory protection) cannot meet the demand
• If respirators are in short supply, priority should be given to aerosol-generating procedures
• CDC addresses alternatives in the setting of face mask shortages on the page entitled Strategies for Optimizing the Supply of Facemasks (see ‘Learn More – Primary Sources’)
  

Discontinuation of Transmission-Based Precautions – COVID-19 With Symptoms

Symptom-Based Strategy

• At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and
• At least 10 days have passed since symptoms first appeared

Test-Based Strategy

• Resolution of fever without the use of fever-reducing medications and
• Improvement in respiratory symptoms (e.g., cough, shortness of breath) and
• Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens)

Discontinuation of Transmission-Based Precautions – Asymptomatic Patients who Tested Positive

Time-Based Strategy

• No symptoms have developed during isolation period
  • At least 10 days have passed since the date of their first positive COVID-19 diagnostic test
• Symptoms developed during isolation period
  • Use symptom-based or test-based strategy

Test-Based Strategy

• Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens)

Hospital Discharge

• Patient can be discharged from hospital with COVID-19 when clinically indicated even if not having met criteria for discontinuation of Transmission-Based Precautions
• If not yet met criteria for discontinuation of Transmission-Based Precautions
  • Decision should be made with clinical care team and local or state public health departments
  • Take in to consideration patient’s home situation and whether it is appropriate for home isolation recommendations (e.g., separate bedroom, appropriate caregivers, access to PPE, potential risk to others in the home who may be at risk)

Learn More – Primary Sources:

CDC: 2019 Cases, Data, & Surveillance

CDC Coronavirus Disease 2019: Evaluation & Testing

CDC: Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19)

CDC Coronavirus Disease 2019: Guidelines for Clinical Specimens

CDC: Interim U.S. Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19

CDC: Coronavirus Disease 2019 Information for Travel

CDC FAQs for Healthcare Professionals

CDC: People Who Are at Higher Risk for Severe Illness

CDC: Strategies for Optimizing the Supply of Facemasks

CDC: Disposition of Hospitalized Patients with COVID-19

CDC: Implementing Home Care

WHO: Novel coronavirus Information Page

https://assets.acponline.org/coronavirus/scormcontent/?&_ga=2.108739588.707318761.1590898566-244366264.1584740301#/COVID-19: An ACP Physician’s Guide + Resources

BMJ: Coronavirus Updates

Lancet: Coronavirus Hub

NEJM: 2019 Novel Coronavirus

Annals of Internal Medicine: Content Related to Coronavirus in Annals of Internal Medicine

CDC: Standard Precautions

CDC: Contact and Airborne Precautions

CDC: Middle East Respiratory Syndrome (MERS)

CDC: Severe acute respiratory syndrome (SARS)

JAMA: What Is a Pandemic?

Related ObG Topics: