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COVID-19 (Novel Coronavirus)

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General Information

Description

  • severe acute respiratory disease (known as COVID-19) caused by a novel coronavirus (provisionally called 2019-nCoV) first identified in December 2019 in Wuhan, Hubei Province, China1
    • initial infections associated with seafood and animal market
    • human to human transmission confirmed, though route and ease of transmission are unclear
  • 2019-nCoV is a member of beta genus coronaviruses and closely related to SARS-CoV
  • common signs of COVID-19 include fever, cough, and shortness of breath1
  • there is no specific antiviral treatment for 2019-nCoV, but supportive care may help to relieve symptoms and should include support of vital organ functions in severe cases1

Also Called

  • SARS-CoV-2
  • Wuhan Virus
  • Wuhan novel coronavirus (WN-CoV)

Definitions

  • World Health Organization (WHO) case definitions for surveillance
    • based on current information available and may be revised as new information accumulates
    • suspect case - either of following
      • patients with severe acute respiratory infection (fever, cough, and requiring admission to hospital) without another etiology that fully explains clinical presentation PLUS history of travel to or residence in China within 14 days of symptom onset
      • patients with any acute respiratory illness PLUS ≥ 1 of following within 14 days of symptom onset
        • contact with confirmed or probable case of COVID-19
        • worked or attended healthcare facility where patients with confirmed or probable cases of COVID-19 were treated
    • probable case - suspect case with inconclusive test result for 2019-nCoV or positive test result on pan-coronavirus assay
    • confirmed case - laboratory confirmed infection of 2019-nCoV regardless of clinical signs and symptoms
    • Reference - WHO Global Surveillance for human infection with novel coronavirus (2019-nCoV) 2020 Jan 31OpenInNew
  • Centers for Disease Control and Prevention (CDC) clinical criteria for patients under investigation (PUI)
    • fever AND signs and symptoms of lower respiratory illness (such as cough and difficulty breathing) PLUS history of travel from Hubei Province, China, in the last 14 days before symptom onset
    • fever AND signs and symptoms of lower respiratory illness (such as cough and difficulty breathing) requiring hospitaliztion PLUS history of travel from mainland China in the last 14 days before symptom onset
    • fever OR signs and symptoms of lower respiratory illness (such as cough and difficulty breathing) PLUS close contact with patient with laboratory-confirmed 2019-nCoV infection in the last 14 days before symptom onset
    • Reference - CDC Interim Guidance for Healthcare Professionals 2020 Feb 12OpenInNew

Epidemiology

Incidence/Prevalence

  • outbreak started in December 2019 in Wuhan, Hubei Province, China
  • Critical_Care Infectious_Diseases Internal_Medicine Pulmonary_Disorders75,748 confirmed cases of coronavirus disease 2019 (COVID-19) including 2,129 deaths in 27 countries worldwide (99% from China) reported by World Health Organization (WHO) as of February 20, 2020 (WHO Situation Report 2020 Feb 20)02/21/2020 09:44:18 AM75,748 confirmed cases of coronavirus disease 2019 (COVID-19) including 2,129 deaths in 27 countries worldwide (99% from China) reported by World Health Organization (WHO) as of February 20, 2020 (WHO Situation Report 2020 Feb 20 PDFPictureAsPdf); 2019-nCoV declared public health emergency of international concern on January 30, 2020 (WHO Newsroom 2020 Jan 30OpenInNew)
  • cases reported by Chinese Center for Disease Control and Prevention (CDC) as of February 20, 2020
    • China mainland
      • 75,465 confirmed cases in 31 provinces, including 2,236 deaths
      • 5,206 suspected cases
    • confirmed cases outside China mainland include
      • 68 cases in Hong Kong
      • 24 cases in Taiwan
      • 10 cases in Macau
    • Reference - Chinese CDC 2020 Feb 21 (Chinese)OpenInNew
  • 15 confirmed cases of 2019-nCoV reported in United States as of February 19, 2020 (CDC 2019 Novel Coronavirus 2020 Feb 19OpenInNew)
  • level 3 travel warning issued by U.S. Centers for Disease Control and Prevention, avoid nonessential travel to China (CDC Travelers' Health 2020 Jan 27OpenInNew)
  • real-time dashboard of 2019-nCoV cases can be found at Johns Hopkins Center for Systems Science and Engineering (CSSE)OpenInNew

Risk factors

  • interim exposure risk categories for persons in United States established by Centers for Disease Control and Prevention (CDC)
    • guidance applies to United States-bound travelers and people in U.S. who may have been exposed to 2019-nCoV
    • high risk persons include those
      • living in same household as, being intimate partner of, or providing care in nonhealthcare setting (such as home) for a person with symptomatic laboratory-confirmed 2019-nCoV infection without using recommended precautions for home care and home isolation
      • traveling from Hubei Province, China
    • medium risk persons include those
      • with close contact with a person with symptomatic laboratory-confirmed 2019-nCoV infection not meeting high risk category
        • same risk assessment applies for close contacts with clinical diagnosis of 2019-nCoV infection outside of United States without laboratory testing
        • on an aircraft, being seated within 6 feet (2 meters) or within 2 seats in any direction of a traveler with symptomatic laboratory-confirmed 2019-nCoV infection
      • living in same household as, intimate partner of, or providing care in nonhealthcare setting (such as home) for a person with symptomatic laboratory-confirmed 2019-nCoV infection while consistently using recommended precautions for home care and home isolation
      • traveling from mainland China outside Hubei Province and not having any exposures that meet definition of high risk
    • low risk persons include those
      • in same indoor environment (such as a classroom or healthcare waiting room) with a person with symptomatic laboratory-confirmed 2019-nCoV infection for prolonged period of time but not meeting the definition for close contact
      • on an aircraft, being seated within 2 rows of a traveler with symptomatic laboratory-confirmed 2019-nCoV infection but not within 6 feet (2 meters) and not having any exposures that meet a definition of medium or high risk
    • no identifiable risk for persons with interaction with patients with symptomatic laboratory-confirmed 2019-nCoV that does not meet high, medium, or low risk categories
    • Reference - CDC Interim US Guidance for Risk Assessment 2020 Feb 8OpenInNew

Etiology and Pathogenesis

Pathogen

  • 2019-nCoV is a betacoronavirus like Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV)1
  • PubMed31987001Emerging microbes & infectionsEmerg Microbes Infect2020120191221-236221sequence homology 89% to bat SARS-like coronavirus ZXC21 and 82% to human SARS-CoV reported (Emerg Microbes Infect 2020 Dec;9(1):221OpenInNew)
  • International Committee on Taxonomy of Viruses provisionally designates novel coronavirus as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (bioRxiv 2020 Feb 11OpenInNew)

Transmission

  • first cases associated with live animal market in Wuhan, China suggest initial animal-to-human spillover1
  • increase in cases not associated with live animal market, particularly among family members and healthcare workers, indicate person-to-person spread1
  • while it is unclear how 2019-nCoV is transmitted, person-to-person spread of related coronaviruses occurs via respiratory droplets among close contacts1
  • 2019-nCoV reported to have mean incubation period of 5.2 days with each case estimated to transmit infection to mean 2.2 other people in Wuhan, China
    Family_Medicine Infectious_Diseases Internal_Medicine Primary_Care Pulmonary_Disorders2019-nCoV reported to have mean incubation period of 5.2 days with each case estimated to transmit infection to mean 2.2 other people in Wuhan, China (N Engl J Med 2020 Jan 29 early online)02/11/2020 03:13:49 PMstudySummary
    • Cohort Study based on noncomparative data from cohort study
    • 425 adolescents and adults aged 15-89 years (median age 59 years, 38% ≥ 65 years old, 56% men) with first confirmed 2019-nCoV pneumonia in Wuhan, China, were assessed
      • 47 patients had illness onset before closure (January 1) of Huanan Seafood Wholesale Market (64% had exposure to wet market [Huanan Seafood Wholesale Market or other])
      • 248 patients had illness onset between closure of Huanan Seafood Wholesale Market and January 11, 2020, when real time-polymerase chain reaction reagents for identification were provided to Wuhan (16% had exposure to wet market)
      • 130 patients had illness onset during January 12-22, 2020 (6% had exposure to wet market)
    • incubation period assessed in 10 patients
      • mean incubation period 5.2 days (95% CI 4.1-7 days)
      • 95th percentile of distribution of incubation period 12.5 days (95% CI 9.2-18 days)
      • mean time between successive cases (mean serial interval) 7.5 days (95% CI 5.3-19 days)
    • mean duration from illness onset to first medical visit
      • 5.8 days (95% CI 4.3-7.5 days) in 45 patients with onset before January 1, 2020
      • 4.6 days (95% CI 4.1-5.1 days) in 207 patients with onset between January 1-11, 2020
    • assessment of epidemic curve up to January 4, 2020
      • on average, each patient spreads infection to 2.2 other people (basic reproductive number)
      • mean epidemic growth rate 0.1 per day (95% CI 0.05-0.16 per day)
      • mean doubling time 7.4 days (95% CI 4.2-14 days)
    • PubMed31995857The New England journal of medicineN Engl J Med20200129Reference - N Engl J Med 2020 Jan 29 early onlineOpenInNew

History and Physical

History and Physical

Clinical Presentation

  • COVID-19 may range from mild disease to severe illness1
  • common symptoms include1
    • fever
    • cough
    • shortness of breath
  • fever, fatigue, and cough most common clinical features in adults with 2019-nCoV pneumonia
    Critical_Care Infectious_Diseases Internal_Medicine Pulmonary_Disordersfever, fatigue, and cough most common clinical features in adults with 2019-nCoV pneumonia (JAMA 2020 Feb 7 early online)02/13/2020 12:35:56 PMstudySummary
    • Cohort StudyCohort StudyCohort Study based on 3 cohort studies
    • cohort admitted January 1-28, 2020
      • 138 adults aged 22-92 years (median age 56 years, 54% men) with confirmed 2019-nCoV pneumonia consecutively admitted to Zhongnan Hospital in Wuhan, China, between January 1-28, 2020, were evaluated through February 3, 2020
        • 29% were medical staff, 12.3% were already hospitalized patients, and 8.7% had exposure to Huanan seafood market
        • 46.4% had ≥ 1 comorbidity, most commonly hypertension (31.2%), cardiovascular disease (14.5%), diabetes (10.1%), malignancy (7.2%), and cerebrovascular disease (5.1%)
      • median duration from first symptoms to
        • dyspnea 5 days
        • hospital admission 7 days
        • acute respiratory distress syndrome (ARDS) 8 days
      • clinical features included
        • fever in 98.6%
        • fatigue in 69.6%
        • dry cough in 59.4%
        • anorexia in 39.9%
        • myalgia in 34.8%
        • dyspnea in 31.2%
        • expectoration in 26.8%
        • pharyngalgia in 17.4%
        • diarrhea in 10.1%
        • nausea in 10.1%
        • dizziness in 9.4%
        • headache 6.5%
        • vomiting in 3.6%
        • abdominal pain in 2.2%
      • 100% had bilateral patchy shadows or ground glass opacity in lungs on chest computed tomography
      • laboratory testing revealed
        • lymphopenia (lymphocyte count < 1.1 × 109 cells/L) in 70.3%
        • prolonged prothrombin time (> 12.5 seconds) in 58%
        • elevated lactate dehydrogenase (> 243 units/L) in 39.9%
      • severity of illness median scores in 36 patients in intensive care unit
        • Acute Physiology and Chronic Health Evaluation II (APACHE II) 12 points
        • Sequential Organ Failure Assessment (SOFA) 5 points
        • Glasgow Coma Scale 15 points
      • complications included
        • ARDS in 19.6%
        • arrhythmia in 16.7%
        • shock in 8.7%
        • acute cardiac injury in 7.2%
        • acute kidney injury in 3.6%
      • 12.3% required invasive ventilation (4 switched to extracorporeal membrane oxygenation)
      • 1.4% required continuous renal replacement therapy
      • 34.1% discharged from hospital (median hospital stay 10 days)
      • 4.3% died
      • PubMed32031570JAMAJAMA20200207Reference - JAMA 2020 Feb 7 early onlineOpenInNew, commentary can be found in JAMA 2020 Feb 5 early onlineOpenInNew
    • cohort admitted by January 2, 2020
      • 41 patients (mean age 49 years, 73% male) with confirmed 2019-nCoV pneumonia admitted to Jinyintan Hospital in Wuhan, China, by January 2, 2020, were evaluatedCritical_Care Infectious_Diseases Internal_Medicine Pulmonary_Disordersfever and cough most common clinical features in patients with 2019-nCoV pneumonia (Lancet 2020 Jan 24 early online)01/28/2020 08:59:32 AM
        • 66% had exposure to Huanan seafood market
        • 32% had ≥ 1 comorbidity, most commonly diabetes (20%), hypertension (15%), and/or cardiovascular disease (15%)
        • median duration from first symptoms to hospital admission 7 days
      • clinical features included
        • fever in 98%
        • cough in 76%
        • dyspnea in 55%
        • myalgia or fatigue in 44%
        • sputum production in 28%
        • headache in 8%
        • hemoptysis in 5%
        • diarrhea in 3%
      • bilateral multiple lobular and subsegmental areas of consolidation were common findings on chest computed tomography
      • laboratory testing revealed
        • lymphopenia (lymphocyte count < 1 × 109 cells/L) in 63%
        • elevated aspartate aminotransferase levels in 37%
        • leukopenia (white blood cell count < 4 × 109 cells/L) in 25%
        • viremia in 15%
      • complications included
        • ARDS in 29%
        • acute cardiac injury in 12%
        • secondary infection in 10%
      • 10% required invasive mechanical ventilation
      • 15% died
      • PubMed32004427The New England journal of medicineN Engl J Med20200131Reference - Lancet 2020 Jan 24 early onlineOpenInNew
    • cohort admitted January 1-20, 2020
      • 99 adults aged 21-82 years (mean age 55 years, 68% men) with confirmed 2019-nCoV pneumonia admitted to Jinyintan Hospital in Wuhan, China, from January 1-20, 2020, were evaluated up to January 25, 2020
        • 49% had exposure to Huanan seafood market
        • 51% had ≥ 1 comorbidity, most commonly cardiovascular and cerebrovascular disease (40%), digestive system disease (11%), and endocrine system disease (13%)
      • clinical features included
        • fever in 83%
        • cough in 82%
        • dyspnea in 31%
        • muscle ache in 11%
        • confusion in 9%
        • headache in 8%
        • sore throat in 5%
        • rhinorrhea in 4%
        • chest pain in 2%
        • diarrhea in 2%
        • nausea and vomiting in 1%
      • chest x-ray and computed tomography findings
        • bilateral pneumonia in 75%
        • multiple mottling and ground-glass opacity in 14%
        • pneumothorax in 1%
      • laboratory testing revealed
        • increased lactate dehydrogenase (> 250 units/L) in 76%
        • decreased hemoglobin (< 130 g/L) in 51%
        • neutrophilia (neutrophil count > 6.3 × 109 cells/L) in 38%
        • lymphopenia (lymphocyte count < 1.1 × 109 cells/L) in 35%
        • leukocytosis (white blood cell count > 9.5 × 109 cells/L) in 24%
        • thrombocytopenia (platelet count < 125 × 109 platelets/L) in 12%
        • leukopenia (white blood cell count < 3.5 × 109 cells/L) in 9%
        • thrombocytosis (platelet count > 350 × 109 platelets/L) in 4%
      • complications included
        • ARDS in 17%
        • ventilator-associated pneumonia in 11%
        • acute respiratory injury in 8%
        • septic shock in 4%
        • acute kidney injury in 3%
      • 4% required invasive mechanical ventilation
      • 3% required extracorporeal membrane oxygenation
      • 9% required continuous renal replacement therapy
      • 31% discharged from hospital
      • 11% died
      • PubMed32007143Lancet (London, England)Lancet20200130Reference - Lancet 2020 Jan 30 early onlineOpenInNew
  • clinical presentation of PubMed32004427The New England journal of medicineN Engl J Med20200131first patient with 2019-nCoV in United States described in case report (N Engl J Med 2020 Jan 31 early onlineOpenInNew) full-textOpenInNew

History

  • ask about recent travel to China, particularly Wuhan City1
  • ask about exposure to patients with confirmed or suspected COVID-19, such as within household or healthcare facility1

Diagnosis

DiagnosisDiagnosis

Making the Diagnosis

  • World Health Organization (WHO) interim guidance for diagnosis and testing for 2019-nCoV infection
    • consider 2019-nCoV infection in patients with either
      • severe acute respiratory infection (fever, cough, and requiring admission to hospital) without another etiology that fully explains clinical presentation PLUS history of travel to or residence in China 14 days prior to symptom onset
      • any acute respiratory illness PLUS ≥ 1 of following in the 14 days prior to symptom onset
        • contact with confirmed or probable case of 2019-nCoV infection
        • work or attendance in healthcare facility where patients with confirmed or probable 2019-nCov infections were treated
      • diagnosis confirmed by laboratory testing of 2019-nCoV
      • Reference - WHO Global Surveillance for human infection with novel coronavirus (2019-nCoV) 2020 Jan 31OpenInNew
    • WHO interim guidance on laboratory testing for 2019-nCoV infection
      • recommended specimens include
        • respiratory samples
          • sputum (if produced)
          • endotracheal aspirate or bronchoalveolar lavage in patients with severe respiratory disease
          • nasopharyngeal and oropharyngeal swabs in patients without signs of lower respiratory tract disease or in whom lower respiratory tract sample collection is not possible
        • serum in both acute and convalescent phases (for serologic testing when assay is available)
        • if initial testing is negative, but patient is strongly suspected to have 2019-nCoV
          • resample patient, collecting samples from multiple respiratory tract sites
          • consider additional blood, urine, and stool sampling
      • tests for 2019-nCoV in select reference laboratories
        • sequence information used to develop polymerase chain reaction (PCR) assays
        • 2019-nCoV PCR confirms diagnosis
        • pan-coronavirus PCR assays may be used in addition to 2019-nCoV specific assay
        • whole genome sequencing may be considered
      • cases should be reported to relevant public health authorities; laboratories should follow their regional reporting requirements
      • Reference - WHO Laboratory testing for 2019 novel coronavirus in suspected human cases 2020 Jan 17OpenInNew
  • Centers for Disease Control and Prevention (CDC) interim guidance for evaluation of patients under investigation (PUI)
    CDC Flowchart to Identify and Assess 2019 Coronavirus
    Image 1 of 1

    CDC Flowchart to Identify and Assess 2019 Coronavirus

    • evaluate patients for 2019-nCoV infection if any of following
      • fever AND signs and symptoms of lower respiratory illness (such as cough and difficulty breathing) PLUS history of travel from Hubei Province, China, in the last 14 days before symptom onset
      • fever AND signs and symptoms of lower respiratory illness (such as cough and difficulty breathing) requiring hospitaliztion PLUS history of travel from mainland China in the last 14 days before symptom onset
      • fever OR signs and symptoms of lower respiratory illness (such as cough and difficulty breathing) PLUS close contact with patient with laboratory-confirmed 2019-nCoV infection in the last 14 days before symptom onset
    • report PUI for 2019-nCoV
      • immediately notify both infection control personnel at healthcare facility and local or state health department
      • state health departments that have identified a PUI should immediately
        • contact CDC’s Emergency Operations Center (EOC) at 770-488-7100 and
        • complete a 2019-nCoV PUI case investigation available by CDC PictureAsPdf
    • collect clinical specimens from PUIs for routine testing of respiratory pathogens at either clinical or public health labs
    • diagnostic testing for 2019-nCoV can be conducted only at CDC in United States
      • CDC’s EOC will assist local/state health departments to collect, store, and ship specimens appropriately to CDC, including after hours and holidays
      • do not delay specimen shipping to CDC when testing for other respiratory pathogens
      • do not attempt viral isolation from specimens collected from 2019-nCoV PUIs
    • interim guidelines for collecting, handling, and testing clinical specimens in United States can be found at CDC 2020 Feb 2OpenInNew
    • Reference - CDC Interim Guidance for Healthcare Professionals 2020 Feb 2OpenInNew
  • Critical_Care Infectious_Diseases Internal_Medicine Pulmonary_DisordersFDA issues emergency use authorization for 2019-nCoV real-time PCR diagnostic panel at qualified laboratories designated by CDC (FDA News Release 2020 Feb 4)02/05/2020 10:31:33 AMFDA issues emergency use authorization for 2019-nCoV real-time PCR diagnostic panel at qualified laboratories designated by CDC (FDA News Release 2020 Feb 4OpenInNew)

Management

ManagementManagement
  • in patients with suspected COVID-19, triage and initiate emergency management based on disease severity
    • give supplemental oxygen to patients with severe acute respiratory illness and respiratory distress, hypoxemia, or shock
    • use conservative fluid management in patients with severe acute respiratory illness, but without evidence of shock
    • provide empiric antimicrobials within 1 hour based on clinical diagnosis, local epidemiology and susceptibility data, and regional guidelines
    • do not routinely give corticosteroids for viral pneumonia or acute respiratory distress syndrome (ARDS)
    • closely monitor patients with severe acute respiratory failure for clinical deterioration such as rapidly progressive respiratory failure and sepsis, and apply supportive care for these situations immediately
    • tailor supportive management based on comorbidities
    • communicate with patients and families
    • Reference - WHO Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected 2020 Jan 28OpenInNew
  • management of hypoxemia and ARDS
    • recognize severe hypoxemic respiratory failure when a patient is failing standard oxygen therapy
    • high-flow nasal oxygen (HFNO) or non-invasive ventilation (NIV) should only be used for select patients with hypoxemic respiratory failure
      • treatment failure is high in patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV) treated with NIV
      • closely monitor patients treated with HFNO or NIV for clinical deterioration
    • endotracheal intubation should be performed by a trained and experienced provider using airborne precautions
    • for adults with ARDS receiving mechanical ventilation
      • implement mechanical ventilation using lower tidal volumes (4-8 mL/kg body weight) and lower inspiratory pressures (plateau pressure < 30 cmH2O)
      • prone ventilation for > 12 hours recommended for patients with severe ARDS
      • use conservative fluid management in patients with ARDS without tissue hypoperfusion
      • in patients with moderate or severe ARDS
        • higher positive end-expiratory pressure (PEEP) recommended over lower PEEP
        • neuromuscular blockade by continuous infusion should not be routinely used
      • consider extracorporeal life support for patients with refractory hypoxemia despite lung protective ventilation in centers with access to expertise
    • Reference - WHO Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected 2020 Jan 28OpenInNew
    • see also
  • management of septic shock
    • recognize septic shock
      • in adults with all of
        • suspected or confirmed infection
        • vasopressors needed to maintain mean arterial pressure (MAP) ≥ 65 mg Hg, AND lactate level is ≥ 2 mmol/L
        • absence of hypovolemia
      • in children with hypotension or ≥ 2 of
        • altered mental state
        • tachycardia or bradycardia
        • prolonged capillary refill > 2 seconds or warm vasodilation with bounding pulses
        • tachypnea
        • mottled skin or petechial or purpuric rash
        • increased lactate
        • oliguria
        • hyperthermia or hypothermia
    • in resuscitation from septic shock, give isotonic crystalloid
      • 30 ml/kg in first 3 hours for adults
      • 20 mL/kg as rapid bolus and up to 40-60 mL/kg in first hour for children
    • do not use hypotonic crystalloids, starches, or gelatins for resuscitation
    • reduce or discontinue fluid administration if no response to fluid loading and signs of volume overload appear
    • administer vasopressors when shock persists during or after fluid resuscitation
    • vasopressors may be administered via peripheral IV if central venous catheters are not available; use large vein and closely monitor for signs of extravasation and local tissue necrosis
      • stop infusion if extravasation occurs
      • vasopressors may also be administered through intraosseous needles
    • consider inotrope such as dobutamine if signs of poor perfusion and cardiac dysfunction persist despite achieving MAP target with fluids and vasopressors
    • Reference - WHO Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected 2020 Jan 28OpenInNew
    • see also Sepsis Treatment in Adults or Sepsis Treatment in Children
  • specific antiviral treatment for 2019-nCoV not currently available1

Infection Control

Prevention and Screening
  • World Health Organization (WHO) interim guidance on infection prevention and control when novel coronavirus (nCoV) infection is suspected
    • early recognition and source control
      • recognize and place patients in separate area from other patients during clinical triage
        • encourage healthcare workers to have high level of clinical suspicion
        • establish triage station at entrance of healthcare facility
        • use screening questionnaire
        • post signage in public areas reminding symptomatic patients to alert healthcare workers
      • promote hand and respiratory hygiene
    • standard precautions for all patients at all times
      • hand and respiratory hygiene
        • offer medical mask for suspected nCoV infection
        • cover nose and mouth during coughing or sneezing with tissue or flexed elbow
        • wash hands after contact with respiratory secretions
      • use personal protective equipment (PPE)
      • clean and disinfect environment
      • practice safe waste management
      • sterilize patient-care equipment, linen, and food utensils
    • additional precautions for suspected nCoV infection
      • contact and droplet precautions
        • apply to all patients, family members, visitors, and healthcare workers in addition to standard precautions
        • continue until patient is asymptomatic
        • place patients in adequately ventilated single rooms (air flow ≥ 160 L/second/patient for naturally ventilated general ward rooms)
        • group patients suspected of nCoV infection together if single room unavailable, with patient beds ≥ 1 meter apart
        • group healthcare workers to exclusively care for suspected nCoV cases if possible
        • wear the following PPE
          • medical mask
          • eye/face protection, such as goggles or face shield
          • clean, nonsterile, long-sleeved gown
          • gloves
        • appropriately doff and dispose of all PPE after patient care and practice hand hygiene, use a new set of PPE when caring for different patient
        • do not touch eyes, nose, or mouth with potentially contaminated hands
        • use either single-use disposable equipment or dedicated equipment (such as with stethoscopes, blood pressure cuffs, and thermometers)
        • for shared equipment, clean and disinfect between each patient
        • do not move or transport patients out of room or area unless medically necessary
          • use designated portable diagnostic equipment, such as portable X-ray equipment
          • use predetermined transport routes if transportation required, and apply medical mask to patient
          • during transport, wear proper PPE and perform hand hygiene for healthcare workers
          • notify receiving area of necessary precautions as soon as possible before patient's arrival
        • clean and disinfect patient-contact surfaces routinely
        • limit number of healthcare workers, family members, and visitors in contact with patient with suspected nCoV infection
        • maintain record of all persons entering patient's room
      • airborne precautions for aerosol-generating procedures
        • examples of aerosol-generating procedures include tracheal intubation, noninvasive ventilation, tracheotomy, cardiopulmonary resuscitation, manual ventilation before intubation, and bronchoscopy
        • when performing aerosol-generating procedures
          • use particulate respirator at least as protective as a NIOSH-certified N95, EU FFP2, or equivalent
          • always perform seal-check when putting on disposable particulate respirator, and note that facial hair may prevent proper fit
          • wear eye protection, such as goggles or face shield
          • wear clean, nonsterile, long-sleeved gown and glove; use waterproof apron for procedures with expected high fluid volumes if gowns are not fluid resistant
          • perform procedures in adequately ventilated room
            • natural ventilation with ≥ 160 L/second/patient air flow, or
            • negative pressure rooms with ≥ 12 air changes per hour (ACH) with controlled direction of air flow when using mechanical ventilation
          • limit number of persons present in the room
    • administrative controls
      • establish sustainable infection prevention and control infrastructures and activities
      • educate patient's caregivers
      • establish policies on early recognition of acute respiratory infection potentially due to nCoV
      • obtain access to prompt laboratory testing for identification of etiologic agent
      • prevent overcrowding, especially in Emergency Department
      • provide dedicated waiting areas for symptomatic patients
      • appropriately isolate hospitalized patients
      • ensure adequate supplies of PPE
      • establish policies and procedures to ensure adherence for all facets of healthcare provisions, with emphasis on
        • training healthcare workers
        • promoting adequate patient-to-staff ratio
        • establishing surveillance process for acute respiratory infections potentially due to nCoV among healthcare workers
        • stressing importance of seeking medical care
        • monitoring compliance and providing mechanisms for improvements as needed
    • collection and handling of laboratory specimens from patient with suspected nCoV
      • all specimens should be considered as potentially infectious
      • use standard precautions to minimize potential pathogen exposure
      • healthcare workers collecting specimens should
        • use appropriate PPE including eye protection, medical mask, long-sleeved gown, and gloves
        • wear particulate respirator at least as protective as a NIOSH-certified N95, EU FFP2, or equivalent during aerosol generating procedures
      • train all personnel who transport specimens on safe-handling practices and spill decontamination procedures
      • place specimens for transport in leak-proof specimen bags (secondary container) with separate sealable pocket, with label on primary specimen container, and with clearly written laboratory request form
      • adhere to appropriate biosafety practices and transport requirements for healthcare facility laboratories
      • deliver all specimens by hand whenever possible; do not use pneumatic-tube systems
      • document patients full name, date of birth, and potential concern of suspected nCoV clearly on accompanying laboratory request form, and notify laboratory as soon as possible of specimen being transported
    • basic principles of infection prevention and control should also be applied in outpatient care settings, including
      • triage and early recognition
      • emphasize hand and respiratory hygiene
      • offer medical masks to patients with respiratory symptoms
      • use appropriate contact and droplet precautions for all suspected cases
      • prioritize care for symptomatic patients
      • ensure separate waiting area for symptomatic patients
      • educate patients and family about early recognition, precautions to use, and which healthcare facility to refer to
    • Reference - WHO Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected 2020 Jan 25OpenInNew
  • Centers for Disease Control and Prevention (CDC) interim recommendations for infection prevention and control for patients with confirmed 2019-nCoV infection or under investigation (PUI) for 2019-nCoV
    • guidance intended for United States healthcare settings only
    • minimize chance for exposures
      • before arrival
        • instruct patients with symptoms of respiratory infection to wear face mask upon entry and follow triage procedures
        • for patients arriving via transport by emergency medical services, alert receiving emergency department or healthcare facility to prepare for patient
      • upon arrival
        • ensure patients adhere to respiratory hygiene and cough etiquette, hand hygiene, and triage procedures
        • separate patients with respiratory symptoms from other patients in a well-ventilated space that allows separation by ≥ 6 feet with access to respiratory hygiene supplies
        • ensure rapid triage and isolation of patients with suspected 2019-nCoV infection
          • identify patient risk
          • implement respiratory hygiene and cough etiquette and isolate in airborne infection isolation room (AIIR) if available
          • inform infection prevention and control services, local and state public health authorities, and other healthcare staff as appropriate
        • at entrances, waiting rooms, patient check in areas, etc, provide supplies for respiratory hygiene and cough etiquette including 60%-95% alcohol-based hand sanitizer, tissues, no touch receptacles for disposal, and facemasks
      • adherence to standard, contact, and airborne precautions
        • patient placement
          • patients with confirmed or suspected 2019-nCoV infection should be placed in AIIR in accordance with current guidelines
          • once in AIIR, patient facemask can be removed
          • limit transport or movement of patient out of AIIR, and have patients wear facemask to contain secretions when outside AIIR
          • personnel entering room should wear proper personal protective equipment (PPE) including respiratory protection
          • only essential personnel should enter room
          • keep a log of all persons who care for or enter rooms
          • used dedicated or disposable noncritical patient-care equipment such as blood pressure cuffs
          • use respiratory protection if entering a room recently vacated
        • hand hygiene
          • healthcare personnel should use alcohol-based hand sanitizer before and after all patient contact, contact with potentially infectious material, and before donning or removing PPE
          • hand hygiene supplies should be readily available in every care location
        • PPE includes
          • gloves
          • gowns
          • respiratory protection at least as protective as NIOSH-certified disposable N95 filtering facepiece respirator
          • eye protection
        • specimen collection
          • procedures should take place in AIIR
          • use caution when performing aerosol-generating procedures and adhere to standard, contact, and airborne precautions
          • limit number of healthcare personnel present during procedure
          • clean and disinfect surfaces promptly
        • duration of isolation precautions for persons under investigation and patients with confirmed 2019-nCoV
          • discontinuation of isolation precautions determined on case-by-case basis in conjunction with local, state, and federal health authorities
          • factors to consider include
            • presence of symptoms
            • date of symptom resolution
            • other conditions requiring specific precautions, such as coinfections
            • other laboratory findings reflecting clinical status
            • alternatives to inpatient isolation
      • manage visitor access and movement within facility
        • establish procedures for monitoring, managing, and training visitors
        • restrict visitors from entering room of patients with known or suspected 2019-nCoV infection
        • visitors should be scheduled and controlled
          • screen visitors for symptoms of acute respiratory illness prior to entry
          • evaluate risk to health of visitor
          • provide instruction on hand hygiene, limiting surfaces touched, and use of PPE prior to entering patient room
          • maintain record of visitors who enter patient rooms
          • prevent visitors from access during aerosol-generating procedures
          • instruct visitors to limit movement within facility
          • advise exposed visitors (such as those with contact with patient prior to admission) to self-monitor and report any signs and symptoms of acute illness for 14 days after last known exposure
          • Info
            Stethoscope

            CLINICIANS' PRACTICE POINT

            Asymptomatic high risk individuals should remain quarantined in a location determined by public health officials. Asymptomatic medium risk individuals should remain at home or comparable setting, avoid congregate settings, limit public activities, and practice social distancing to the extent possible.

        • ensure visitors follow respiratory hygiene and cough etiquette while in common areas
      • consider designing and installing engineering controls to reduce or eliminate exposures
      • monitor and manage ill healthcare personnel in consultation with public health authorities
      • train and educate healthcare personnel
      • implement environmental infection control
        • use dedicated medical equipment for patient care
        • clean and disinfect all non-dedicated, non-disposable equipment to manufacturer's instructions and facility policies
        • ensure environmental cleaning and disinfection procedures are followed
        • EPA-approved products for emerging viral pathogens are recommended for routine cleaning and disinfection procedures
        • manage laundry, food service, and medical waste in accordance with routine procedures
      • establish reporting within healthcare facilities and to public health authorities
        • implement mechanisms and policies to alert key facility staff
        • communicate and collaborate with public health authorities
    • Reference - CDC interim guidance on infection prevention and control for PUI for 2019 novel coronavirus 2020 Feb 3OpenInNew
  • CDC interim guidance on movement restrictions and public activities for persons with potential 2019-nCoV exposure based on risk category and symptoms
    • for symptomatic persons
      • high and medium risk individuals should be immediately isolated
      • low risk individuals should avoid contact with others and public activities while symptomatic
    • for asymptomatic persons
      • high risk individuals should remain quarantined in a location determined by public health officials
      • medium risk individuals should remain at home or comparable setting, avoid congretage settings, limit public activities, and practice social distancing to the extent possible
      • no restrictions for low risk individuals
    • Reference - CDC Interim US Guidance for Risk Assessment 2020 Feb 8OpenInNew

Guidelines and Resources

Guidelines and Resources

Guidelines

International Guidelines

United States Guidelines

  • Centers for Disease Control and Prevention (CDC)
    • interim guidance on coronavirus disease (COVID-19) can be found at CDC Coronavirus Disease 2019OpenInNew or in ChineseOpenInNew or in SpanishOpenInNew
    • interim guidance on evaluating and reporting persons under investigation (PUI) can be found at CDC 2020 Feb 13OpenInNew
    • flowchart to identify and assess 2019 novel coronavirus can be found at CDC 2020 Feb 12OpenInNewPDFPictureAsPdf
    • interim infection prevention and control recommendations for patients with confirmed 2019 novel coronavirus (2019-nCoV) or patients under investigation for 2019-nCoV in healthcare settings can be found at CDC 2020 Feb 12OpenInNew
    • interim infection prevention and control recommendations for patients of coronavirus disease (COVID-19) in inpatient obstetric healthcare settings can be found at CDC 2020 Feb 18OpenInNew
    • interim clinical guidance for management of patients with confirmed 2019 novel coronavirus (2019 n-CoV) infection can be found at CDC 2020 Feb 12OpenInNew
    • interim considerations for disposition of hospitalized patients with 2019-nCoV infection can be found at CDC 2020 Feb 12OpenInNew
    • interim United States guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with 2019 novel coronavirus (2019-nCov) can be found at CDC 2020 Feb 12 OpenInNew
    • interim guidance for implementing home care of people not requiring hospitalization for 2019 novel coronavirus (2019 n-CoV) can be found at CDC 2020 Feb 12OpenInNew
    • interim guidance for preventing the spread of coronavirus disease (COVID-19) in homes and residential communities can be found at CDC 2020 Feb 18OpenInNew or in ChineseOpenInNew or in SpanishOpenInNew
    • interim guidance for emergency medical services (EMS) systems and 911 public safety answering points (PSAPs) for COVID-19 in United states can be found at CDC 2020 Feb 15OpenInNew
    • interim guidelines for collecting, handling, and testing clinical specimens from patients under investigation (PUIs) for coronavirus disease 2019 (COVID-19) can be found at CDC 2020 Feb 14OpenInNew
    • interim laboratory biosafety guidelines for handling and processing specimens associated with coronavirus disease 2019 (COVID-19) can be found at CDC 2020 Feb 16OpenInNew

United Kingdom Guidelines

Canadian Guidelines

European Guidelines

  • European Centre for Disease Prevention and Control (ECDC) information on COVID-19 can be found at ECDC COVID-19OpenInNew

Asian Guidelines

  • Chinese Center for Disease Control and Prevention guidance on new coronavirus pneumonia can be found at Chinese CDCOpenInNew [Chinese]
  • Japanese National Institute of Infectious Diseases (NIID)
  • Japanese Association for Infectious Diseases (JAID) information on new coronavirus infection (COVID-19) can be found at JAID 2020 Feb 21OpenInNew [Japanese]

Australian and New Zealand Guidelines

Additional Resources

References

General References Used

  1. Centers for Disease Control and Prevention (CDC). 2019 Novel Coronavirus, Wuhan, China. (CDC 2020 Jan 29OpenInNew)

DynaMed Editorial Process

Special Acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the DynaMed internal Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T1579903929505, COVID-19 (Novel Coronavirus); [updated 2020 Jan 27, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T1579903929505. Registration and login required.

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