Updated 4/15/2020

Q1: What is the 2019 Novel Coronavirus (COVID-19)?

A1: The 2019 Novel Coronavirus, now known as SARS-CoV-2, is a newly identified respiratory virus that was first detected in the city of Wuhan, in the Hubei Province, of China.

 

Q2: Why is the virus called a “Novel Coronavirus?”

A2: The coronaviruses with which we are most familiar 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 is a virus, likely of animal origin, 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 virus causing COVID-19 is not yet certain, recent evidence suggests that both bats and the pangolin, a scaled, anteater-like animal that is consumed as food in China and has scales used in traditional medicine, may be the reservoir. A virus that has a genome that is more than 99% similar to SARS-CoV-2 has recently been isolated from pangolins. Although these three novel coronaviruses are all quite distinct from each other, emerging evidence suggests that SARS-CoV-2 likely evolved from a virus related to the SARS coronavirus.

 

Q3: How is the COVID-19 being spread and how contagious is the SARS-CoV-2 virus?

A3: The SARS-CoV-2 virus spreads from person-to-person, but the precise mechanisms defining how it is spread are not yet entirely clear. Most experts agree that the primary routes appear to be by direct contact and droplets, similar to the epidemiology of influenza (i.e., transmitted 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. 

Nonetheless, concerns continue to be raised about the potential for airborne transmission of this newly identified disease. Based on the national and international epidemiology, COVID-19 is clearly 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 truly dichotomous. Whereas COVID-19 is not classically airborne, the extent to which droplets may carry SARS-CoV-2 over a short distance across a closed room to present an airborne risk remains uncertain. Airborne transmission from person-to-person over long distances is unlikely.

In terms of contagion, early evidence suggests that a single case will likely give rise to approximately two to three additional cases.

 

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

A4: The Centers for Disease Control and Prevention (CDC) provided initial interim guidance for the use of PPE (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html) when caring for patients with confirmed or suspected COVID-19. This guidance recommended 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 N95 respirator plus either a face shield or goggles or, alternatively, a powered, air-purifying respirator (PAPR) (see below if N95s or PAPRs are not available). SHEA recognizes that these recommendations were made out of an abundance of caution, as we were just beginning to learn about the epidemiology and transmission risks associated with this new disease.

The World Health Organization (WHO) guidance recommends droplet and contact precautions. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infection-prevention-and-control

In the US, the rapidly escalating pandemic resulted in a shortage of some elements of PPE, particularly a critical shortage of N95 respirators. 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. Based on local 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.

Irrespective of the whether your institution elects to follow the CDC or WHO recommendations, 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. Whatever set of precautions your institution elects to follow, meticulous adherence to those recommendations is critical to success.

 

Q5: Why have some facilities, particularly hospitals in areas that have a high rate of community spread, asked their healthcare workers to wear surgical or isolation masks at all times?

A5: The reason that some facilities and institutions have asked all clinical staff to wear surgical masks is to prevent the individual who is wearing the mask from transmitting COVID-19 infection to other staff or patients (i.e., these masks are not intended as protection for the individual wearing the mask, but rather as ‘source control’).

This is the same reason that CDC is now advocating that people in society wear cloth masks when they are out in public. This strategy is perhaps even more important in locations where community transmission is common and providers are at increased risk for infection in their communities. The strategy also makes sense for a disease that may cause asymptomatic infection in a substantial fraction (perhaps up to 25%) of instances of infection. Thus, healthcare workers could be completely asymptomatic or only mildly symptomatic and be at risk to transmit infection to their patients or their coworkers.

 

Q6: What are the signs and symptoms associated with infection with the COVID-19?

A6: 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, 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.

 

Q7: Does asymptomatic COVID-19 infection occur, and if so, can people who have asymptomatic infection transmit the disease to others?

A7: Though published data about the extent of asymptomatic infection and transmission are limited, asymptomatic transmission of SARS-CoV-2 has been well documented in several studies. As we have gained more experience with the disease in the US, we have become increasingly aware that patients who have atypical, insidious, minimal, or mild symptoms are far more common than originally thought. Asymptomatic infections were originally thought to account for approximately 10% of all cases, but more recent estimates place that fraction closer to 25%.

Models suggest that asymptomatically infected people are likely less contagious than individuals who have symptomatic disease. In one modeling study, ‘undocumented infections’ (defined in the study as individuals who experienced mild, limited or no symptoms and hence go unrecognized) were responsible for a substantial fraction of the spread of COVID-19 in China. Asymptomatic infection and transmission associated with asymptomatic infections likely represent some of the major differences between the way that SARS-CoV-2 and the original SARS and MERS coronaviruses operated in society.

 

Q8: How serious are infections with COVID-19, and what is the case fatality rate?

A8: 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 in China (the percentage of people with diagnosed COVID-19 who died) was approximately 2.3%. In the US through the end of March, approximately 6% of nearly 400,000 COVID-19 infections produced critical illnesses, and the mortality rate was approximately 3.2%, keeping in mind that the fatality rate will increase, because the denominator includes recently diagnosed cases. Conversely, 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.

 

Q9: How should healthcare practitioners identify and initially manage patients at risk for infection with the COVID-19?

A9: 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 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 above). 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 history, including whether the patient within the past 14 days has traveled from China or another area with sustained transmission of COVID-19 infection. Most areas in the US have community cases of COVID-19, so travel to a more affected area can indicate increased risk of infection, but lack of travel does not indicate no risk of infection. If the patient has signs and symptoms of a respiratory infection and the history suggests 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. a private room or an area apart from other patients and staff) and don appropriate personal protective equipment (discussed above).

 

Q10: Why are American academic hospitals recommending different personal protective equipment (PPE) than we are seeing in news reports from China?

A10: 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 small 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, CDC recommends using. In circumstances in which respirators are not available, CDC recommends procedure or surgical masks as the next best available alternative. Face shields (or goggles) protect the eyes against respiratory droplets that might contain active virus and 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.

 

Q11: How can I protect myself from the COVID-19?

A11: For virtually all infectious diseases the best way to avoid infection is to minimize the risk for exposure. For the general public, social distancing is key to avoiding close contact with people who are carrying SARS-CoV-2. In addition, you should wash your hands with either soap and water for 20 seconds or use an alcohol-based hand sanitizer for 20 seconds as often as is practical, and avoid touching your eyes, nose, and mouth with unsanitized hands. For healthcare workers, follow the precautions outlined in the above questions, including the use of appropriate PPE.

 

Q12: How are patients evaluated for COVID-19 infection?

A12: In addition to screening all patients for signs and symptoms of respiratory infection and recent travel to areas that are known to be harboring sustained transmission of COVID-19 infection or exposure to someone who is known or suspected to be infected with SARS-CoV-2, patients suspected of being infected with SARS-CoV-2 will undergo laboratory testing.

Although initially testing resources were quite limited, now all state health departments, several commercial laboratories and most academic centers offer the test. In addition, in early April of 2020, the first antibody test received an emergency use authorization (EUA) from the FDA, with the expectation that several additional antibody tests would also soon become available. Broader use of all of these tests will help better our understanding of the epidemiology of this complex disease. Important questions that 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.

 

Q13: How should samples be collected and what samples should be submitted to evaluate a patient for COVID-19 infection?

A13: CDC and FDA recommend collecting upper respiratory samples. Swab samples of either the nasopharynx, middle turbinate, anterior nares, or oropharynx are acceptable, although nasopharyngeal samples have somewhat higher sensitivity for detection of SARS CoV-2 compared to other samples. Lower respiratory secretions (sputum, if possible, for patients who have productive coughs, bronchoalveolar lavage fluid, or tracheal aspirates can be tested in patients with COVID-19 pneumonia). 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.

For low-volume, in-hospital testing, ideally sample collection should occur in a private room in an area away from other patients and staff. The patient should not be placed in a room from which room exhaust is recirculated within the building without HEPA filtration. Some facilities have developed creative strategies for making swabbing sites negative pressure and avoiding recirculation of air from the swabbing location. Many centers have now 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 healthcare personnel exposure.

 

Q14: How are patients with serious COVID-19 infections treated?

A14: 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. Among them are remdesivir (a nucleotide prodrug with in vitro activity against SARS-CoV and MERS-CoV), favipiravir (a nucleotide prodrug with marketed in Japan and China as an anti-influenza agent) and lopinavir/ritonavir (an HIV protease inhibitor combination). The antimalarial drugs chloroquine and hydroxychloroquine are being aggressively evaluated. In addition, drugs, such as Tocilizumab and Baricitinib, that are aimed at modulating the cytokine release syndrome, (thought to be a major effector of the acute respiratory distress syndrome seen in COVID patients) are also in Phase III clinical trials. More than 70 candidate vaccine preparations are also being evaluated.

IDSA Guideline on the Treatment and Management Patients Infected with COVID-19 (reviewed and endorsed by SHEA) https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/

 

Q15. How should a patient who meets the COVID-19 case definition for a PUI and who presents to an ambulatory care office, be managed?

A15. 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 (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.

 

Q16: When a patient who is a PUI or confirmed to be infected with SARS-CoV-2 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?

A16: 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 or tuberculosis), though it is likely that the SARS-CoV-2 agent does not present the same magnitude of risk for airborne persistence as measles, varicella, or tuberculosis. For this latter reason, when cleaning a room that has not been used for a procedure considered to be aerosol-generating, many institutions follow cleaning procedures used for droplet isolation rooms. Cleaning personnel should don a gown and gloves, as they would for other rooms with patients on contact precautions and add a facemask and eye protection if staff anticipate splashes or sprays.

 

Q17: In settings in which shortages of N95 masks or surgical mask occur, are there protocols for extended use or reuse of these devices?

A17: CDC has provided clear recommendations about the extended use of N95 respirators in epidemic/pandemic circumstances https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html. Similarly, CDC has published strategies for optimizing the supply of N95 respirators https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html. Due to the shortage of all kinds of kinds of PPE in various locations where exponential spread of COVID-19 infection is occurring, creative conservation of PPE devices is ongoing.

A major theme throughout the pandemic has been efforts by institutions to provide healthcare personnel with the best possible protective devices available at the moment. Whereas some strategies may not precisely hit ideal targets set by CDC recommendations, this is outweighed by the crucial need to assure PPE for healthcare personnel on the front line during the pandemic.

CDC has proffered the following approach: institutions may wish to issue five N95 respirators to each individual who is providing care for patients who have COVID-19 infection. Each respirator will be used on a particular day of the week and, after use, would be placed in a (breathable) paper bag for the remainder of the week. The five or six days that elapse from the time a respirator is used to the time it would be reused far exceeds the putative 72-hour expected survival time for SARS-CoV-2.

Some institutions have elected to disinfect/decontaminate used respirators (see question immediately following).

 

Q18: Is it possible to disinfect/decontaminate N95 respirators? If so, what processes are effective?

A18: Several strategies have been used to disinfect/decontaminate respirators. Among techniques are vaporous hydrogen peroxide (VHP), ultraviolet germicidal irradiation (UVGI), and moist heat. FDA Emergency Authorization Use (EUA) has been granted for several VHP and UGHI companies. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html

Processes that have been described as ‘unsuitable’ include ethyl alcohol (can degrade efficiency of filtration), soap and water (also degrades filtration efficacy), immersion of the respirator in bleach solutions (also degrades filtration efficacy), and 24-hour oversight storage (virus has been shown to be viable for at least 72 hours).

A bibliography relating to differing decontamination strategies is available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html

 

Q19. What are the recommended disinfectants for cleaning surfaces following possible exposure to patients who have COVID-19 infection?

A19. 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.