COVID-19 | Spoon-Feed Version

March 16, 2020

Updated December 30, 2020

Written by Clay Smith

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This post compiles the most authoritative answers to your questions about COVID-19 all in one place.

Why does this matter?

COVID-19 is considered a global pandemic. In the U.S. alone, there are 330 million people. Estimates are that 60-70% of the population will become infected. That’s between 160 million and 214 million infected in the U.S., of which an estimated 200,000 to 1.7 million may die. The U.S. has only 924,000 staffed beds. These numbers assume no mitigation strategies and may be better than expected. This is a very important topic.

COVID-19 – Authoritative Answers In One Place

We have previously written about COVID-19 in a broad overview and a deep dive on the clinical presentation. This post is a quick way to find the most reliable sources of information to answer your clinical questions about COVID-19. If you see something that should be added, please help me and leave a comment or use the website’s contact form to let me know.

Basic Science

Where can I learn about the coronavirus, SARS-CoV-2, that causes the disease COVID-19?

• This article in Nature takes a deep dive into the basic science of coronaviruses. Free full text.

• Mark Denison, MD, Vanderbilt Pediatric Infectious Disease, has been researching coronaviruses for almost 30 years. See this treasure trove of publications from the Denison Lab.

• For more on taxonomy and where SARS-CoV-2 fits among other coronaviruses, see this from Nature Microbiology and the initial description of the outbreak in NEJM. Both free full text.

Epidemiology

What is the incubation period?

• It is 2-14 days (CDC); median 4-5 days.

When do we expect the disease to peak? How can we predict resource utilization?

• The IMHE model has helpful predictive analytics.

How is COVID-19 spread?

• Respiratory droplets (CDC)

• Up to 86% of all infections early on in China were undocumented. That means, the numbers of cases confirmed were the tip of the iceberg.

• We know SARS and MERS can live on surfaces for days. There was no viable SARS-CoV-2 after 4-8h on copper; 1 day on cardboard; 1-2 days on stainless steel or plastic per NEJM.

• Here is a list of EPA-approved disinfectants with activity against SARS-CoV-2.

• For an easy-to-understand tour de force on ways this is spread, you need to read this blog post.

If I am infected, can I get infected again?

• It appears so.

• If other coronaviruses are any indication, immunity wains and reinfection is common. In Iceland, there is encouraging news that antibody lasts at least 4 months.

What is the case (or infection) fatality rate for COVID-19?

• The CDC has several scenarios here.

• An Icelandic study with extensive sampling and seroprevalance data suggests the infection fatality rate was 0.3% in this homogeneous population.

• It depends on the age of the patient. There was 0% mortality in children 0-9 years and 14.8% mortality over age 80. It was a little worse than seasonal influenza in those aged 10 – 39 years, with case fatality rate of 0.2%. But case fatality steadily rose with age over ≥40.

• Case fatality among healthcare providers in China was 0.3%.

• This came from the China CDC, which loads very slowly. Here is a PDF version you can rapidly download. Citation credit: The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020[J]. China CDC Weekly, 2020, 2(8): 113-122.

Are children equally impacted by COVID-19?

• Children are certainly susceptible to COVID-19 and had high rates of infection. However, >90% were mild or moderate.

• Children were also less likely than adults to have fever, cough, or shortness of breath (just 73%) vs adults (93%).

• Severe or critically ill cases were rare but occurred most often in infants under 1 year. See this important study in Pediatrics.

• A disease entity, multisystem inflammatory syndrome in children (MIS-C) has emerged, resembling Kawasaki disease. See this JF summary for analysis of cases from Italy and several other links.

How do I protect myself as a healthcare provider?

• See this guidance from the CDC. Wear a surgical mask, gown (if possible), eye protection, and gloves.

• If intubating or doing a procedure that creates aerosols, an N-95 mask is recommended.

• Here is one recommended way to set up a healthcare facility to minimize transmission recommended by the IDSA, modeled on the response to SARS.

What are general ways to protect myself and my family?

• The basics make a big difference (CDC).

• Keys: Social distance (6 feet); wear a mask; handwashing (or hand sanitizer with 60% alcohol); don’t touch eyes, nose, or mouth; avoid close contact with sick people (obviously meant for a non-healthcare audience); stay home if sick; cover coughs and sneezes; disinfect high-touch surfaces like counters, doorknobs, etc.

Who is at higher risk from infection with COVID-19?

• Older patients and those with comorbidities are at greatest risk.

• Comorbidities may include diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease.

• It is unknown if COVID-19 is more dangerous in pregnancy. A study from China found the risk of severe disease was comparable to the general population, but the CDC notes that pregnancy may increase risk of severe disease. The WHO stated, “pregnant women do not appear to be at higher risk of severe disease. In an investigation of 147 pregnant women (64 confirmed, 82 suspected and 1 asymptomatic), 8% had severe disease and 1% were critical.” The CDC has an entire section devoted to pregnancy and breastfeeding.

How widespread is the disease, COVID-19?

• The best map is from Johns Hopkins.

• You can track the surge in the U.S. or by state here.

• The WHO map is here.

• The New York Times has a frequently updated map as does the CDC.

What are the best sites to keep informed about this emerging pandemic?

• Health organizations: CDC | WHO

• Journals: NEJM | Lancet | BMJ | JAMA

• Great resources: Hippo Education (free) | UpToDate

Clinical Pearls

What is the clinical presentation?

• The CDC now considers the following: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea.

• Acute cough is common. Fever on initial presentation was noted in 44% of patients and in almost 90% during hospitalization at some point. “Fever” was defined as an axillary temperature ≥ 37.5°C (99.5°F) in this large Chinese case series.

• Some patients had fatigue, headache, myalgia, sore throat, or shortness of breath. (NEJM).

• Around 80% have mild disease. They may be treated at home.

• Approximately 14% will develop severe disease requiring hospitalization, and 5% will need critical care (JAMA).

What labs are helpful?

• 83% of hospitalized patients with pneumonia had lymphocytopenia, <1,100. About one-third of these patients had leukopenia and thrombocytopenia.

• Procalcitonin was rarely elevated. CRP was elevated in most patients. This is from the NEJM study with 1,099 patients.

• It is reasonable to check a troponin on hospitalized patients, as elevated troponin is associated with in-hospital mortality.

• Elevated D-dimer + lymphopenia is common and is associated with increased mortality.

What are imaging options for COVID-19?

• CXR was abnormal in over half of hospitalized patients (same NEJM study above).

• Over half of early presenters (in the first 2 days) may have no CT changes. However, most hospitalized patients with pneumonia from COVID-19 develop bilateral consolidation and ground glass opacities. See these images (AJR). The American College of Radiology does not recommend CT be used to screen for COVID-19.

• Lung ultrasound may have characteristic changes summarized in this paper; and this paper is filled with images showing CT and corresponding sonographic findings.

Which patients should be tested for possible COVID-19?

• The CDC recommendations are found here. These are evolving over time.

• Patients who have symptoms and are hospitalized, those with comorbidities, and healthcare workers should be prioritized.

How do I test for it?

• This is what you need to know from the CDC. We use universal viral transport medium and FLOQSwabs in my facility.

• If collecting a nasopharyngeal specimen, you need to watch this 41 second video on proper nasopharyngeal sampling technique.

• The CDC considers bilateral anterior nasal swabs to be acceptable.

What lab test is done to test for SARS-CoV-2?

• It is a RT-PCR test.

• Here are all the details.

• Rapid molecular tests are on the market. There is increasing concern with the Abbott ID NOW device.

How is COVID-19 treated?

• See these ever-updated treatment guidelines from the NIH.

• Dexamethasone reduced death in mechanically ventilated patients by one third, 29.0% vs. 40.7% (RR 0.65, 95%CI 0.51 to 0.82). NNT to prevent 28-day mortality was 8.5.

• Remdesivir has been approved for emergency use.

• Trials of remdesivir showed that it shortened recovery time.

• For most, it is supportive care.

• ACE inhibitors and angiotensin receptor blockers did not worsen outcome and may even decrease mortality.

• NSAIDs do not appear to be harmful, despite anecdotal reports.

• Hydroxychloroquine (chloroquine) +/- azithromycin should not have have a role. Early on, a tiny study that lacked any patient-centered outcome showed possible benefit. However, both agents prolong the QT interval. Nature Medicine has proven the effect on prolonging the QTc. An observational study showed no apparent benefit on intubation or death. And a massive registry study with over 96,000 patients showed that chloroquine and (to no one’s surprise) hydroxychloroquine with or without azithromycin was independently associated with both increased risk of mortality and ventricular arrhythmia…which, of course has now been retracted.

• Hypercoagulability is a problem in hospitalized and critically ill patients.

How should we manage cardiac arrest in the COVID-19 era?

• This paper from the AHA is very helpful. You must see the new algorithms.

• Minimize exposure. Limit personnel. Use PPE.

• Use HEPA (viral) filter on exhalation ports; use video over direct laryngoscopy; minimize face mask ventilation and intubate or place a supraglottic device; have the most experienced intubator place the tube.

• Consider if CPR should be started in end-stage patients. Consider if it should be stopped in futile cases. Have plans for both in place ahead of time. Discuss goals of care with patients in advance.

How do we prepare the ED to manage the surge of patients?

• This paper in Disaster Medicine and Public Health Preparedness by physicians on the ground in Italy offers evidence-based tables to organize your thinking on how to prepare for the surge.

What if we have more patients than we have ventilators?

• See the New York State Ventilator Allocation Guidelines.

• These come by way of Dr. Reuben Strayer, EM Updates.

• EMCrit has put together a helpful list of resources.

How long do patients remain contagious?

• According to the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19), “ virus can initially be detected in upper respiratory samples 1-2 days prior to symptom onset and persist for 7-12 days in moderate cases and up to 2 weeks in severe cases.”

• The CDC has this guidance on return to normal after home isolation.

What should healthcare workers do if they are exposed to patients with confirmed COVID-19?

• It depends on the risk of the exposure.

• See this CDC guidance.

What should healthcare workers do if they develop symptoms?

• You should be tested (CDC), wear a mask, and self-isolate.

When should healthcare workers return to work if they test positive for COVID-19?

• This must be determined by your employer on a case-by-case basis at this point.

How should EMS handle confirmed or potential cases of COVID-19?

• Here are recommendations for EMS related to COVID-19.

Will there be a vaccine for COVID-19?

• There are numerous vaccine trials underway. Some have been granted emergency use. I got my first of two shots on December 19, 2020. That’s almost a miracle. Thank you to my friends and colleagues who have worked so hard to make this possible.

• The NYT has a helpful vaccine tracker.

What additional questions would you like to see answered here?

Please contact us. We would love to hear from you.