Q: What is the 2019 Novel Coronavirus (COVID-19)?

A: The 2019 Novel Coronavirus, now known as COVID-19, is a newly identified respiratory virus that was first detected in the city of Wuhan, in the Hubei Province, of China.

 

Q: Why is the virus called a “Novel Coronavirus?”

A: The coronaviruses with which we are most familiar generally cause cold-like very mild respiratory illnesses. The COVID-19 is not closely related to these common viruses and is more like the coronavirus agents that caused the Severe Acute Respiratory Syndrome (SARS) in 2003 and the Middle East Respiratory Syndrome (MERS) in 2012. Similar to the SARS and MERS coronaviruses, the COVID-19 is a virus, likely of animal origin, that has not been previously associated with disease in humans. The SARS coronavirus was most closely associated with civets and bats, and the MERS coronavirus was most closely associated with camels and bats. Although the precise animal reservoir for the COVID-19 is not yet certain, recent evidence suggests that both bats and the pangolin, a scaled, anteater-like animal that is consumed a food in China and that has scales used in traditional medicine, may be the reservoir. A virus that has a genome that is more than 99% similar to the COVID-19 has recently been isolated from pangolins. Although these three novel coronaviruses are all quite distinct from each other, emerging evidence suggests that the COVID-19 likely evolved from a virus related to the SARS coronavirus.

 

Q: How is the COVID-19 being spread and how contagious is the virus?

A: The COVID-19 is being spread from person-to-person. Precise mechanisms for how the virus is being spread are not yet entirely clear. Based on the viral epidemiology, one can safely assume that the spread appears to be similar to the spread of influenza (i.e., by droplet and direct/close contact). Close contact has been defined by CDC as being within about six feet of someone for a prolonged period of time without wearing recommended personal protective equipment. In terms of contagion, early evidence suggests that a single case will likely give rise to approximately two to three additional cases.

 

Q: What are the signs and symptoms associated with infection with the COVID-19?

A: Signs and symptoms associated with infection with the COVID-19 are relatively nonspecific, but include: cold-like symptoms, fever, chills, headache, cough, shortness of breath, and myalgia. Some patients experience sore throat, nausea, vomiting, diarrhea, and abdominal pain.

 

Q: How serious are infections with COVID-19, and what is the case fatality rate?

A: Analysis of the cases that have been diagnosed to date in China suggests that more than 80% of cases were mild. About 14% of cases were severe, including pneumonia, and about 5% of patients diagnosed with COVID-19 became critically ill, requiring ICU care. The case-fatality rate (the percentage of people with diagnosed COVID-19 who died) was approximately 2.3%. A major caveat is that fact that many mild infections may have gone undiagnosed, which would mean that the case fatality rate may be artificially high.

 

Q: How should healthcare practitioners identify and initially manage patients at risk for infection with the COVID-19?

A: Ideally, the healthcare practitioner will be notified before the patient arrives that an arriving patient is someone who may be at risk for COVID-19 infection. In that instance, the provider should first notify the Hospital Epidemiology program, second, with Hospital Epidemiology assistance, make certain that institutional policies and practices are followed in order to minimize the potential for exposures. These practices include managing ingress and egress appropriately, placing a tight-fitting mask on the patient at arrival, and ensuring that the patient and those accompanying the patient follow institutional policies concerning adherence to appropriate respiratory hygiene practices, cough etiquette, hand hygiene, and institutional triage procedures. The patient should be moved to the best available room for maintaining isolation (ideally, a negative pressure airborne infection isolation room, or, if not available, a private room or an area away from other patients and staff). Healthcare staff providing care for the patient should don appropriate personal protective equipment (discussed below). For patients who are not planned admissions, in instances in which a patient presents unexpectedly with a fever and respiratory symptoms, healthcare professionals should obtain a careful travel history, including whether the patient within the past 14 days has traveled from China or another area with sustained transmission of COVID-19 (e.g., or possibly has been exposed to a person known or suspected to have infection with the COVID-19. If the patient has signs and symptoms of a respiratory infection and the travel or exposure histories suggest possible COVID-19 infection, the provider should place a facemask on the patient, notify the hospital epidemiology program, move the patient to the best available room for maintaining isolation (e.g., optimally, a negative pressure airborne infections isolation room, alternatively, a private room or an area apart from other patients and staff) and don appropriate personal protective equipment (discussed below).

 

Q: What Personal Protective Equipment (PPE) should healthcare professionals don to provide care for a patient infected with COVID-19?

A: The Centers for Disease Control and Prevention (CDC) has provided interim guidance for the use of PPE (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html), These guidelines suggest the use of Standard, Contact, and Airborne Precautions, including the use of eye protection. A healthcare worker should wear a gown, gloves, and either an N-95 respirator plus either a face shield or goggles or, alternatively, powered, air-purifying respirator (PAPR). SHEA endorses this initially conservative approach. These recommendations are made out of an abundance of caution, as we are continuing to learn about the epidemiology and transmission risks associated with this new disease. Many hospitals in the US have the appropriate infrastructure to provide care for patients on airborne isolation. The WHO guidelines emphasize that transmission is primarily associated with droplet and direct contact spread. Their guidelines currently recommend only droplet and contact precautions. Irrespective of the guidelines followed, most instances of healthcare-associated transmission of these types of pathogens have been associated with breaches in infection control precautions, so whatever precautions are followed, adherence to the guidelines are critical to success.

 

Q: Why are American academic hospitals recommending different personal protective equipment than we are seeing in news reports from China?

A: Most American hospitals follow all the recommendations for personal protective equipment advocated by the US CDC. These recommendations include a gown and gloves to protect against direct contact with the virus in respiratory secretions or on surfaces in the patient room. The use of a respirator (usually an N95, or a PAPR/CAPR) protects against inhaling airborne droplets from the patient that may contain active virus and keeps those droplets from landing on the nose or mouth. Usually coronaviruses are carried in larger respiratory droplets that a simple isolation mask can protect against, but until we are sure the new strain of coronavirus doesn’t have the ability to survive in smaller droplets that might get around or through an isolation mask, we are using respirators. Facemasks (or goggles) protect the eyes against respiratory droplets that might contain active virus. Together with the respirator, they also keep healthcare workers from touching their eyes, nose or mouth with possibly contaminated hands. Combined, this personal protective equipment provides full protection against coronavirus. In China, different equipment may be used more commonly leading to different recommendations. In addition, news reports have implied that there are shortages, so that healthcare personnel are wearing the same equipment all day with multiple different patients, which can also lead to different decisions about which equipment is easier to keep on all day.

 

Q: How can I protect myself from the COVID-19?

A: For virtually all infectious diseases the best way to avoid infection is to minimize the risk for exposure. For the general public, avoiding close contact with people who are sick, washing your hands with either soap and water for 20 seconds or using an alcohol-based hand sanitizer for 20 seconds as often as is practical, and avoiding touching your eyes, nose, and mouth with unsanitized hands. For healthcare workers, follow the precautions outlined above, including the use of appropriate PPE.

 

Q: How are patients evaluated for COVID-19 infection?

A: In addition to screening all patients for signs and symptoms of respiratory infection and recent travel to China, Japan, South Korea, Italy, Iran or another area that develops sustained transmission of COVID-19 or exposure to someone who is known or suspected to be infected with the COVID-19, patients suspected of being infected with the COVID-19 will undergo laboratory testing. Currently this testing (a polymerase chain reaction test for COVID-19 ribonucleic acid [RNA]) is done at the Centers for Disease Control and Prevention (CDC), but the test will soon be available from each state health department.

 

Q: How should samples be collected and what samples should be submitted to evaluate a patient for COVID-19 infection?

A: CDC recommends collecting upper respiratory – both nasopharyngeal and oropharyngeal swabs – as well as lower respiratory secretions (sputum, if possible, for patients who have productive coughs). Sputum induction is not indicated. Collecting diagnostic respiratory may cause coughing or sneezing. For this reason, only the patient and the appropriately garbed healthcare provider who is following the isolation protocol outlined above should be in the room when obtaining the sample. Ideally sample collection should occur in an airborne infection isolation room (AIIR). The patient should not be placed in a room from which room exhaust is recirculated within the building without HEPA filtration. Before attempting to collect any specimens from these patients, please notify the Hospital Epidemiology Program for direction

 

Q: How are patients with serious COVID-19 infections treated?

A: As is the case for many viral infections, most aspects of care for patients infected with COVID-19 are supportive, including respiratory support with a ventilator, if needed. No pharmaceutical products are approved to treat COVID-19 infection; however, many drugs are being evaluated in clinical trials in China. Among them are remdesivir (a nucleotide prodrug with in vitro activity against SARS-CoV and MERS-CoV) and lopinavir/ritonavir (an HIV protease inhibitor combination). Should additional data about the activity of these agents in vitro against the COVID-19 and/or apparent in vivo activity become available, this site will be updated.

 

Q. How should a patient who meets the COVID-19 case definition for a PUI and who presents to an ambulatory care office, be managed?

A. A mask should be placed on a patient and the patient should be managed with droplet and contact precautions as an isolation patient. The patient should be placed as far from other patients as is practical. The provider should notify the Hospital Epidemiology Program, move the patient to the best available room for maintaining isolation (ideally a negative-pressure airborne infection isolation room [AIIR], or, if not available, a private room or an area away from other patients and staff). The patient should not be sent to other hospital locations (e.g., phlebotomy, laboratory, imaging, etc.) Staff should make every effort to collect as much information, and as many specimens in the isolated location.

 

Q. When a patient who is, or might be, a PUI is being evaluated in a clinical setting in a regular exam room (i.e., not an airborne infection isolation room), how should the room be managed after the patient has been evaluated and leaves the room?

A. The room should be cleaned as if it has been used an airborne infectious disease isolation room. Environmental services staff should defer entry into the room until sufficient time has elapsed for air changes to remove potentially infectious particles, similar to the approach used for cleaning a room that has been occupied by a patient with measles, tuberculosis). Cleaning personnel should wear a gown and gloves and a facemask and eye protection should be donned if staff anticipate splashes or sprays.

 

Q. What are the recommended disinfectants for cleaning surfaces following possible exposure to COVID-19?

A. Though it is likely that all disinfectants registered by the EPA as viricidal will be effective when used following the manufacturer’s instructions, CDC currently recommends using an EPA-registered, hospital-grade disinfectant that has an emerging viral pathogens claim of efficacy.

 

Q. Should staff do anything anything specific regarding the disposal of waste from patients with coronavirus?

A. Waste from these patients should be managed following the institution’s medical pathological waste protocol.