Editorials

COVID-19 – Brace for impact

Ahmed Adel Eladely, M.D., Steven Lippmann, M.D.

Introduction

SARS-CO-2 is a coronavirus causing a worldwide pandemic (1). First recognized in China, it spread, and in just three months has reached at least 199 countries. With an increasing number of people affected, by late-March there were well over 465,000 patients known to exhibit COVID-19 infections and which caused about 21,000 deaths around the globe (2). These numbers are constantly evolving.

Transmission is primarily via breathing in aerosolized droplets; direct physical contact or toughing contaminated surfaces are other means of spread. The incubation period seems to be about 14 days. Infection can be passed to other persons while an individual is asymptomatic or during overt illness (3).

Clinical

COVID-19 may present with a wide range of presentations from asymptomatic, to mild, or severe cases, even potentially inducing death. Symptoms commonly include cough, shortness of breath, and myalgia. Being febrile is the main sign of illness. Sick patients may develop pneumonia, requiring ventilatory support (4). Chest tomography yields higher diagnostic sensitivity (98%) than real-time polymerase chain reaction testing (71%) as a screening tool (5). Tomography documents changes like a ground glass appearance, crazy-paving patterns, or consolidation; these peak about 10 days after symptom onset (6). So far, there is no substantiated corona-induce outcome differences during pregnancies as compared to uninfected gestations (7). There is no known evidence for vertical or perinatal transmission during labor (8).

Practical

What about management of suspected cases in pre-clinical settings? Start by not making new appointments and postponing already scheduled ones for all circumstances considered elective. Many clinics are calling patients ahead of their appointment days to evaluate the need for and timing of future office visits. For example, a patient doing well and only requiring a pharmaceutical refill can be often handled remotely. Initial screening can be completed by phone-triage; when possible, conduct this interview, inquiring about fever and potential symptoms. Such a review can be remotely facilitated by telemedicine, as in text monitoring or video conferencing.

Facilities not equipped to manage COVID-19 cases and those with few test kits, should refer all patients of concern to institutions prepared for such higher levels of care. Sick patients are immediately sent to appropriate facilities; a telephoned report to the receiving instruction is warranted. Healthcare personnel examinations at someone’s home are recommended only with full personal protective equipment before entering, along with ideally maintaining six feet of distance from the patient (9).

Handling suspected or confirmed, and even the-not-sick cases, in healthcare settings also begins by minimizing exposure through rescheduling appointments for elective matters. However, anyone reporting clinical illness and especially those with fever or respiratory symptoms, requires a prompt evaluation. On entry to the facility during triage of persons suspected to have contracted this ailment, even without respiratory symptoms, use masks on patients and staff. Isolate contact from others. Best is to limit movement and sequester such cases in a specially designated place with health care professionals dedicated to deal with suspected or confirmed COVID-19 infections; this diminishes wider exposure and/or contagion. Apply standard precautions of hand hygiene, face mask, gowns, gloves, and eye protection; conventional eyeglasses are not adequate eye protection. Social-distance when feasible. Overt case management mandates protective suits for medical staff.  Limit visitors and monitor them for symptoms. Visitors are only allowed when critically necessary for patient well-being. COVID-19 education is provided. Healthcare workers also need consistent reeducation and repeated training about infection control guidelines (10). After completion of each patient contact, staff should perform room and surface cleaning.

Hospital discharge of patients must be individualized. Guidelines that are recommend for sending someone home include that the clinical status evidences safety, being afebrile, without using antipyretic medications, and/or negative results on two consecutive nasopharyngeal or throat swabs collected 24 hours apart (11).

Discussion

The COVID-19 situation is consistently evolving. Clinicians and health care facilities should keep monitoring new data and update their knowledge regularly. The hope of population self-quarantine and of hospital isolation is to prevent a spike of COVID-19 infections that overwhelms the health care system with too many at-a-time affected persons or too numerous very sick ones.

References

  1. WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19-11-March-2020  Last accessed March 15, 2020.
  2. Novel Coronavirus( COVID-19) Situation https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd Last accessed: March 26, 2020
  3. Hassan S, Sheikh F N, Jamal S, et al. Coronavirus (COVID-19): A Review of Clinical Features, Diagnosis, and Treatment. Cureus 2020; 12(3): e7355. DOI:10.7759/cureus.7355
  4. Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html Last accessed: March 15, 2020
  5. Fang Y, Zhang H, Xie J, et al. Sensitivity of Chest CT for COVID-19: Comparison to RT-PCR. [ Published online February, 2020]. RSNA DOI: 10.1148/radiol.2020200432  Last Accessed: March 17, 2020
  6. Pan F, Ye T, Sun P, et al. Time Course of Lung Changes on Chest CT During Recovery From 2019 Novel Coronavirus (COVID-19) Pneumonia. [ Published online February 2020]. RSNA       DOI: 10.1148/radiol.2020200370  Last Accessed: March 17, 2020
  7. Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. The Lancet 2020; 395:809-815
  8. Lack of Vertical Transmission of SARS-CoV-2 — Maybe. https://www.jwatch.org/na51081/2020/03/10/lack-vertical-transmission-sars-cov-2-maybe Last Accessed: March 17, 2020   
  9. Interim Guidance for Public Health Personnel Evaluating Persons Under Investigation (PUIs) and Asymptomatic Close Contacts of Confirmed Cases at Their Home or Non-Home Residential Settings. https://www.cdc.gov/coronavirus/2019-ncov/php/guidance-evaluating-pui.html Last Accessed: March 15, 2020.
  10. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings Last Accessed: March 15, 2020. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Finfection-control.html  Last Accessed: March 15, 2020
  11. Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of Hospitalized Patients with COVID-19 https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html  Last Accessed: March 15, 2020
 

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