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Covid-19 (Coronavirus) Clinical Alert

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This page is updated often to help keep emergency physicians prepared and save time.

 

Feb. 15, 2020

A JAMA report found that the spread of coronavirus, also known as Covid-19, to health care workers appears to be relatively common.

Of the 138 patients in the report, about 40% appear to have been infected in the hospital. Less than 20% of the infected health care workers were from the Emergency Department. The majority were from inpatient wards. It appears that infection may be associated with immune deficiency, activation of the coagulation system, and injury to the myocardium, liver and kidney.

There are new CDC guidelines for optimizing the supply of N95 respirators, including minimizing the number of healthcare personnel who need to use respiratory protection, using alternatives to N95 respirators when feasible, implementing practices to allow extended use and/or limited reuse of N95 respirators when possible, and prioritizing the use of N95 respirators for those personnel at highest risk of acquiring infection or experiencing complications of infection.

The CDC has new recommendations around the annual ‘fit’ testing. Where possible an airborne infection isolation room should be used for patients potentially infected with Covid-19. This type of room can reduce the exposure of personnel. Barriers such as glass/plastic window between patients and intake desks, information booths, pharmacy pick-up can reduce airborne spread.

As of Feb. 15, there were more than 67,000 confirmed cases in more than two dozen countries, includingmore than 66,000 in Mainland China and 15 in the United States. There have been more than 1,500 deaths, including more than 1,400 in China. 

Feb. 18 Coronavirus Webinar: Impact, Containment, Treatment
ACEP is partnering with the Emergency Nurses Association (ENA) and the Association of American Medical Colleges (AAMC) to provide a free coronavirus webinar at 2 p.m. EST on Feb. 18. The National Ebola Training and Education Center will discuss the nature and impact of the virus, along with suggestions for containment and treatment. Representatives from the HHS, CDC, ASPR and HPP will be available to answer your questions. Register now. 

For patient-facing information about Covid-19, visit emergencyphysicians.com

Earlier, the CDC released interim guidance for EMS professionals.

According to the JAMA report, the in-hospital mortality rate was 4.3%, and 26% required ICU care. In this case series the average age was 56, and 54.3% were men.

Median duration from first symptoms to dyspnea was 5 days, from first symptoms to ARDS was 8 days and from first symptoms to ICU care 10 days. ICU patients displayed shock, acute cardiac injury, dysrhythmias, ARDS and AKI.

Leukopenia was more severe in non-survivors. The most common symptoms at the onset were fever (nearly 100%), fatigue (~70%) and cough (~60%). Patients who developed severe disease were older and more likely to have underlying conditions.

Of the 138 patients, 41% appeared to have been infected in the hospital. This included patients hospitalized for other reasons and healthcare workers. Read the JAMA paper here.

While human-to-human transmission is occurring, early reports that asymptomatic individuals could spread the disease are now being questioned. It appears now that the ‘asymptomatic’ patient reported actually had some symptoms, including fatigue and body aches.

Risk for acquiring Covid-19

The CDC also laid out guidance for assessing a person's risk for acquiring coronavirus. The following U.S. people are considered at high risk:

  • Those who've been in Hubei Province, China, in the past 14 days.
  • Those living in the same house as, being an intimate partner of, or caring for a person with symptomatic, lab-confirmed coronavirus infection without consistently following recommended precautions. (The same applies in cases where coronavirus was diagnosed clinically outside the U.S. but wasn't lab-confirmed.)

Symptomatic, high-risk people should be put in immediate isolation with recommended medical evaluation. Asymptomatic, high-risk people should be quarantined and monitored daily. The recommended quarantine period is 14 days.

Those at medium risk for acquiring the virus include:

  • Those with close contact with a person with symptomatic, lab-confirmed infection (without the high-risk exposures listed above). This could include being seated within 6 feet of a symptomatic, lab-confirmed person on an airplane (roughly two seats in each direction).
  • Those with close contact with a lab-confirmed patient at home while using recommended precautions.
  • Those who've traveled from other parts of China.

People at medium risk and with no symptoms should still try to limit their public activities.

News & Updates

Epidemiological modeling suggests that cases will double every 6-7 days. Consistent with this, there were just over 3000 cases confirmed in China in one day.

It should be noted that the CDC announced there have been at least 15 million cases of influenza in the United States with 8,200 deaths, 54 of them in children.

Exposure to disease about 5 days (2-14 range). Patients present with fever cough and shortness of breath. Older patients, those with chronic illness and possibly pregnant women are at potentially higher risk.

The previous report of male predominance appears to be because of the high number of male workers in the seafood market where the virus first noted. Later reports suggest an equal distribution of male and female. 

Deaths continue to occur primarily in patients with co-morbidities. 

Patients with severe disease have multilobar pneumonia and often leukopenia (though leukocytosis has been seen). Hepatic enzymes are elevated in some patients. About 1/3 - 1/2 of patients with underlying disease. Pneumonia appears around the 2nd week of symptoms.

The CDC website has a chart to guide evlaution of patients under investigation.

Consider 2019-nCoV if

  • Fever or signs/symptoms of lower respiratory illness (cough/short of breath) AND any close contact with confirmed 2019-nCoV within 14 days
  • Fever AND signs/symptoms of lower respiratory illness AND a history of travel from Hubei Province within 14 days of symptoms
  • Fever AND signs/symptoms of lower respiratory illness requiring hospitalization AND travel from Mainland China within 14 days

If a patient meets the above criteria immediately notify both infection control personnel at the facility and the local/state health department.

Airborne and contact precautions, along with eye protection should be used when treating a patient with fever plus symptoms of lower respiratory illness who has travelled from Wuhan City, China, or who has had close contact with a person under investigation for the novel coronavirus while that person was ill. Reserve use of an N95 mask for patients at very high risk for coronavirus. 

The same precautions apply to patients who have fever or lower respiratory illness who have had contact with a laboratory confirmed case in the past 14 days. 

Cases should be reported to the hospital’s infection control department and to the local or state health department.


  1. IDENTIFY: Screening must be implemented. See the CDC site for screening criteria.

    The first step of controlling the disease is identify. Patients should be screened for travel to mainland China within the past 14 days and for the presence of respiratory disease and/or fever. In addition patients who have had exposure to patients with Novel Coronavirus with symptoms should be identified.

    The CDC website updates screening criteria nearly daily so if there is any question, consult their website.

    ALL facilities need to be screening (hospitals, clinics, urgent cares, ambulatory surgery centers, etc.).
      
  2. ISOLATE: Review your isolation plans, please. 

    Those patients should be isolated and have a facemask applied. Patients should be placed in an airborne precaution room, or if that is not available, in a private room with a door.

    Healthcare workers should don typical PPE for contact, airborne protection including eye. N95 masks should be used. Contact the local health department or state health department if the patient screens positive.
     
    Patients under investigation (PUI) for novel coronavirus will require isolation but in some cases that can be done at home. That decision should be made with the Health Department and/or the CDC.

  3. INFORM: Bottom line - notify your institution’s Infection Control and call your local health office (LHO). The CDC links to this directory of local health departments.

    Isolate and call your local health office (LHO) BEFORE testing to confirm true patient under investigation (PUI) status.

  4. TESTING: CDC has a very detailed explanation of what testing to obtain, how to ship, who to contact. The local health office (LHO) and department of health (DOH), with the CDC, will guide clinicians as what type of testing is needed. The CDC site has a directory of local health departments

    The CDC recommends nasopharyngeal and oropharyngeal swabs as well as sputum be collected. They may also recommend blood, urine and stool.
     
  5. TREATMENT: Treatment is symptomatic. There is no antiviral known to be effective. Of the cases with pneumonia in China, most have been older men with comorbidities. Pneumonia appears around day 7. ARDS appears in about 17-29%. Secondary infection appears in about 10%.

    About 25-30% require ICU with some receiving mechanical ventilation and a few have been treated with ECMO. Some patients have had acute cardiac or kidney injury during the course of the disease.

    The commercial panel that screens for coronavirus and other respiratory viruses such as RSV do not detect coronavirus.

    It is unclear how long patients may shed the virus and may be infectious. That should be known as the disease is further studied.

    Media reports about a "cure" or "treatment" are not correct. There was one patient that received a combination of anti-virals and did recover, however that is not evidence in favor of any treatment. Treatment remains supportive.

EMS and other first responders should provide a face mask to all patients who screen for possible coronavirus. In addition, EMS personnel who travel in the compartment with the patient should have an N95 mask, eye protection, gloves and, if possible, gown.

In short, screen patients to IDENTIFY potential patients with novel coronavirus. ISOLATE them within your department. INFORM your health department as early as possible. Consult the CDC website for further information.

For more information:

Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. Wang D, Hu B, Hu C, et al. JAMA. Published online February 7, 2020.

National Ebola Training and Education Center has information and PPE recommendations - https://repository.netecweb.org/exhibits/show/ncov/ncov 

Initial Public Health Response and Interim Clinical Guidance for the 2019 Novel Coronavirus Outbreak — United States, December 31, 2019–February 4, 2020 - CDC Morbidity and Mortality Weekly Report (MMWR)

2019-nCoV: The Identify-Isolate-Inform (3I) Tool Applied to a Novel Emerging Coronavirus - Kristi L. Koenig, MD; Christian K. Beÿ, BS; Eric C. McDonald, MD, MPH; Western Journal of Emergency Medicine, articles in press

CDC Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-nCoV) in Wuhan, China

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