Updated as of Feb. 2021

COVID-19 Vaccines

See the SHEA Statement for Healthcare Settings (pdf; Jan. 2021)

State of the Pandemic

Authored by SHEA Board of Trustees, published in ICHE

Transmission

Q1: How contagious is SARS-CoV-2, the virus that causes COVID-19?

A1: The SARS-CoV-2 virus is transmitted from person-to-person, most frequently by droplets spread during close contact, similar to the epidemiology of influenza. Close contact has been defined by CDC as being within about six feet of someone for a prolonged period of time (10-15 minutes, including recurring, intermittent brief contacts) while not wearing recommended personal protective equipment.

In certain circumstances (e.g., being unmasked in a closed, poorly ventilated room in proximity to an unmasked, infected individual) airborne spread may occur. The potential for airborne transmission is also increased if the infected individual is coughing, sneezing, singing, or shouting, which facilitate aerosolization of the droplets emitted. Based on the national and international epidemiology, substantial evidence documents that COVID-19 is not operating as a classical airborne infectious disease (e.g., measles, varicella, etc.); however, as is the case for virtually all biological systems, the distinction between airborne and droplet spread is not dichotomous. Unlike measles or varicella, airborne transmission from person-to-person over long distances is unlikely.

In terms of contagion, early evidence suggests that, in the absence of mitigating strategies (e.g., masking, social distancing, etc.) a single case will likely give rise to approximately two to three additional cases, although this depends on mitigation measures in place.

Research is ongoing to study the transmissibility of SARS-CoV-2 variants of concern (VOCs) B117 and 501YV2, with estimates of B117 being at least 40% more transmissible than the wild-type virus.

Signs and Symptoms

Q2: What are the signs and symptoms associated with infection with the COVID-19?

A2: Signs and symptoms associated with COVID-19 infection are relatively nonspecific, but include cold-like symptoms, fever, chills, headache, cough, shortness of breath, and myalgia. Some patients experience anosmia, dysgeusia, sore throat, nausea, vomiting, diarrhea, and abdominal pain, and a variety of neurological symptoms.

Some patients may experience myocarditis that can be accompanied by life-threatening arrhythmias. Patients who develop persistent infection may progress to severe pneumonia and an acute respiratory distress syndrome (ARDS)-like illness thought to be caused by a cytokine storm. Many such patients require prolonged ventilatory support. Patients who become seriously ill often have serious problems with thrombotic events (e.g., pulmonary emboli, stroke, etc.).

Some patients, including young survivors, have reported symptoms after acute illness. CDC describes COVID-19 sequelae following resolution of infection as involving fatigue, dyspnea, cough, arthralgia, and chest pain, as well as cognitive impairment and depression, myalgia, headache, fever, and palpitations. Additional serious complications have been reported, including myocardial inflammation, ventricular dysfunction, pulmonary function abnormalities, acute kidney injury, skin rash, alopecia, olfactory and gustatory dysfunction, sleep dysregulation, altered cognition, memory impairment, depression, anxiety, and changes in mood. Post-COVID-19 care centers have opened in medical centers around the US to provide comprehensive and coordinated treatment for individuals suffering from COVID-19 sequelae.

Q3: Can an asymptomatic person with SARS-CoV-2 infection transmit the virus to others?

A3: Asymptomatic COVID-19 infection occurs commonly, with current estimates suggesting that 25-80% of individuals who become infected remain asymptomatic. In addition, patients may have atypical, insidious, minimal, or mild symptoms. Data now demonstrate that asymptomatic or pre-symptomatic patients often have viral burdens that may be equivalent to those of symptomatic patients. Transmission by individuals who are not showing symptoms is well-documented and has been a major factor in fueling the pandemic. Transmission associated with asymptomatic, pre-symptomatic, or mild infections likely represents one of the differences between the way that SARS-CoV-2 and the original SARS and MERS coronaviruses operated in society.

Healthcare Personnel and Individual Protection

Q4: What personal protective equipment (PPE) should healthcare professionals use to provide care for a patient infected with COVID-19?

A4: CDC provides interim guidance for the use of PPE (last updated Feb. 10, 2021), advising healthcare personnel (HCP) to follow standard precautions if interacting with patients NOT suspected to have SARS-CoV-2 infection or transmission-based precautions based on the suspected diagnosis (e.g. tuberculosis). HCP should use N95 respirators or higher for aerosol-generating procedures and surgical procedures that may pose higher risk for transmission if the patient has COVID-19. For source control, HCP should use an N95 respirator, a respirator approved under standards similar to NIOSH-approved N95 filtering facepiece respirators, or a well-fitting facemask. Eye protection should be worn during patient care encounters. WHO provides recommendations for PPE (PDF; Feb. 2, 2021) from low to high risk healthcare roles, with N95 or equivalent respirators, eye protection, and gown/apron recommended for those working with COVID-19 patients and frequently performing aerosol-generating procedures.

In the US, the rapidly escalating pandemic initially resulted in a shortage of some elements of PPE. For this reason, SHEA advises facilities to adopt a risk-based approach for the use of PPE, particularly for institutions that have limited supplies of N95 respirators and/or PAPRs. CDC provides guidance for optimizing the supply of N95 respirators (updated Feb. 10, 2021).Based on infection prevalence and incidence in the community and local and institutional risk assessments by the healthcare epidemiology team, institutions should reserve N95 respirators and/or PAPRs for procedures or clinical instances where the risk for aerosolization or potential for airborne spread is highest. For procedures adjudged to be associated with a lower risk for aerosol or airborne transmission (e.g., outdoor nasopharyngeal swabbing), a surgical mask with a face shield is a reasonable alternative to an N95.

Most instances of healthcare-associated transmission of these types of pathogens historically have been associated with breaches in infection control precautions that are in place. For example, several case clusters among HCP have been associated with shared lunch breaks, etc. – circumstances in which the HCP have removed their masks and protective eyewear. Whatever set of precautions your institution elects to follow, meticulous adherence to those recommendations is critical to success.

The use of universal pandemic precautions has been associated with extremely low rates of infection among healthcare workers.

Q5: How can I protect myself from COVID-19?

A5: For virtually all infectious diseases the best way to avoid infection is to minimize the risk for exposure. The mitigation strategies that have proven effective in minimizing the risk for COVID-19 transmission include: vaccination, face coverings, physical distancing by at least 6 feet, avoiding crowds and congregate settings, interacting with others outdoors when this is possible, the frequent use of hand hygiene and hand sanitizer. For the general public, source control masking when in public spaces and physical distancing are the keys to avoiding exposure to people who are carrying SARS-CoV-2. Frequently clean hands and avoiding touching your eyes, nose, and mouth with un-sanitized hands. For healthcare workers, follow the precautions outlined in the above questions, including the use of appropriate PPE.

Q6: How should HCP identify and initially manage patients who are suspected to have COVID-19 infection?

A6: SHEA advocates the routine use of universal pandemic precautions (i.e., face coverings and protective eyewear for all patient care). For patients who are not planned admissions, in instances in which a patient presents unexpectedly with a fever and respiratory symptoms, the HCP should place a facemask on the patient, notify the hospital epidemiology program, move the patient 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). If the HCP is not already using universal pandemic precautions, healthcare staff providing care for the patient should don appropriate personal protective equipment (discussed above). In most facilities, restrictions are placed on visitors and family members.

Ideally, the HCP will be notified before the patient arrives that an arriving patient is someone who may be at risk for COVID-19 infection. 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 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.

Q7: What processes are effective in disinfecting/decontaminating N95 respirators?

A7: CDC provides a bibliography of several strategies have been used throughout the pandemic to disinfect/decontaminate respirators. Among techniques are vaporous hydrogen peroxide (VHP), ultraviolet germicidal irradiation (UVGI, also called GUV), and moist heat. FDA Emergency Authorization Use (EUA) has been granted for several VHP and UVGI companies. Reprocessing disposable PPE is not standard practice, but for “Crisis Standards of Care.”

Ambulatory Care

Q8: How should an ambulatory care office manage a patient who presents with symptoms consistent with SARS-CoV-2 infection?

A8: Place a mask on a patient and implement droplet and contact precautions. Notify the hospital epidemiology program, move the patient to the best available room for maintaining isolation (e.g. 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.

Diagnosis

Q9: How are patients evaluated for COVID-19 infection?

A9: In addition to screening all patients for signs and symptoms of respiratory infection or exposure to someone who is known or suspected to be infected with SARS-CoV-2, patients suspected of SARS-CoV-2 infection will undergo laboratory testing, most frequently via molecular tests (PCR, NAAT, or LAMP). Antigen tests are widely available and used; however, a patient with a high pre-test probability for COVID-19 should be retested if they receive a negative result. Antigen tests are not as sensitive or specific as molecular tests.

In general, molecular tests that uses different sample location sites (e.g. NP, mid-turbinate, nostril, saliva, throat) perform similarly if collected and processed by trained personnel. Nonetheless, facilities should understand the sensitivity/specificity of tests they purchase, available in the FDA EUA and validation data, if available. Nasopharyngeal samples have somewhat higher sensitivity for detection of SARS CoV-2 compared to other samples. Lower respiratory samples from patients who have documented, established lower respiratory infections are occasionally positive when upper respiratory samples have become negative. Sputum induction is not indicated.

Collecting diagnostic respiratory may cause coughing or sneezing. For this reason, only the patient and the appropriately garbed HCP who is following the isolation protocol outlined above should be in the room when obtaining the sample.

For low-volume, in-hospital testing, ideally sample collection occurs in a private room in an area away from other patients and staff. Many centers have deployed drive-through testing sites, where the individuals being tested do not have to leave their vehicles. Most of these are testing sites are outdoors which decreases the risk for HCP exposure.

Although initially testing resources and reagents were limited, now all state health departments, several commercial laboratories and most academic centers offer tests. Although generally much more available than early in the pandemic, because of the major surges in infection that occurred in New England in April 2020, in the South and Southwest in July, and the Midwest surge in October/November, both the platforms for performing the test and reagents for some of the marketed tests are still in short supply.

Q10: What is the role of serologic testing?

A10: Serologic testing should not be used for diagnosis of active infection. Broader use of all of these tests will help better our understanding of the epidemiology of this complex disease, and at this time are used primarily by public health agencies to study the prevalence of the disease in certain locations.

Currently, an individual’s positive test does not definitively indicate that the person has immunity to the disease, as important questions remain to be answered include whether the antibodies that are detected by these tests confer protective immunity, and if so, how long the immunity will last.

Case Fatality

Q11: How serious are infections with COVID-19, and what is the case fatality rate?

A11: In the US, approximately 6% of COVID-19 cases require hospitalization. As of Feb. 2021, the case fatality rate in the US is 1.8%, with 149 deaths per 100,000.

The risk of dying from COVID-19 varies substantially depending on age, socioeconomic status, ethnicity, access to healthcare, and underlying health conditions (many of which are confounding). Because many mild infections may have gone undiagnosed, the case fatality rate may be artificially high.

Treatment

Q12: How are patients with serious COVID-19 infections treated?

A12: 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. IDSA Guideline on the Treatment and Management Patients Infected with COVID-19 (reviewed and endorsed by SHEA) is frequently updated as new evidence emerges.

Decontamination

Q13: When a confirmed or suspected COVID-19 patient is evaluated in a regular exam room (i.e., not an airborne infection isolation room), how should the room be managed?

A13: CDC recommends use of dedicated medical equipment when caring for patients with suspected or confirmed SARS-CoV-2 infection, with all non-dedicated, non-disposable equipment cleaned and disinfected according to the manufacturer's instructions for use (IFUs) and the facility's policies. Routine cleaning and disinfection procedures may be used for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed.

Q14: What are the recommended disinfectants for cleaning surfaces following possible exposure to patients who have COVID-19 infection?

A14: Though it is likely that all disinfectants registered by the EPA as viricidal will be effective when used following the manufacturer’s IFUs, CDC recommends List N EPA-registered, hospital-grade disinfectants that has an ‘emerging viral pathogens’ claim of efficacy.

Background

Q15: What is COVID-19 and the virus that causes it, SARS-CoV-2?

A15: The 2019 novel coronavirus, named SARS-CoV-2, is a respiratory virus first detected in late 2019 in the city of Wuhan, in the Hubei Province, of China.

The coronaviruses with which we were most familiar prior to the emergence of SARS-CoV-2 generally cause cold-like, very mild respiratory illnesses. The SARS-CoV-2 virus 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 virus, likely of animal origin, had 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 these three novel coronaviruses are all quite distinct from each other, evidence suggests that SARS-CoV-2 likely evolved from a virus related to the SARS coronavirus.