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Diagnosis and Management of COVID-19 Disease: Public Health
Diagnosis and Management of COVID-19 Disease: Public Health
are possible as the virus can persist on surfaces Attack rate: 30-40% (community, in China)
and is shed in feces, but it is unclear if these are R0: 2-4 (lower with containment)
2,3
Case fatality rate 1.5% USA, 3.4% overall
There is evidence of transmission by asymptomatic worldwide
individuals4. Incubation time 3-14 days
The virus binds to the ACE2 receptor on type II Viral shedding Median 20 days
pneumocytes. However, the role of Angiotensin
Clinical Presentation
Converting Enzyme Inhibitors and Angiotensin
Receptor Blockers (ARBs) as treatments or risk Symptoms may vary from mild cough to fulminant
factors for disease is unclear5. respiratory failure. Positive tests have also been
obtained from asymptomatic patients. Table 2 lists
The reported incubation time is 3-12 days with a
the estimated frequency of symptoms observed to
median duration of viral shedding of 20 days6,7.
date10:
There is evidence that the virus changes over time.
Table 2: Frequency of Symptoms in COVID-19
There may be multiple strains of SARS-CoV-2 in
Symptom Percent of patients with symptom
circulation8.
Cough 50-80%
Epidemiology
Fever 85% (only 45% febrile on
Characteristics such as the attack rate (% of presentation)
individuals in an at-risk population who acquire the Fatigue 69.6%
infection), R0 (R naught, the expected number of
Dyspnea 20-40%
cases directly generated by one case in a population
URI symptoms 15%
where all individuals are susceptible to infection),
and case fatality rate (CFR, % of infected individuals GI symptoms (nausea, 10%
who die) are contextual. That is, they depend on vomiting, diarrhea)
Laboratory Findings
The following lab abnormalities have been observed
in patients with COVID-1910: respiratory viruses is important, particularly
Complete blood count: normal WBC, leukopenia,
lymphopenia (80%+), thrombocytopenia respiratory pathogens. Co-infection has also been
Chemistries: elevated BUN/creatinine, elevated reported
AST, ALT, and Total bilirubin Do not order sputum induction
Avoid bronchoscopy unless absolutely indicated
high C-reactive protein and ferritin ◆ If indicated, follow current recommendations
testing capacity is increasing quickly. The following ◆ Droplet precautions with eye protection
recommendations have been made regarding ◆ PLUS airborne precautions for aerosolizing
diagnostic testing and reporting11,12. procedures such as intubation, extubation, non-
Send nasopharyngeal swab for SARS-CoV-2 invasive positive pressure ventilation (NIPPV),
polymerase chain reaction testing (RT-PCR). open circuit suctioning, bronchoscopy, and
Check with your local facility regarding test aerosol treatments
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AJRCCM Articles in Press. Published March 30, 2020 as 10.1164/rccm.2020C1
Copyright © 2020 by the American Thoracic Society
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American Thoracic Society
PUBLIC HEALTH | INFORMATION SERIES
HEALTHCARE PROVIDER EDUCATION RAPID RESPONSE
15
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AJRCCM Articles in Press. Published March 30, 2020 as 10.1164/rccm.2020C1
Copyright © 2020 by the American Thoracic Society
Page 4 of 4
American Thoracic Society
PUBLIC HEALTH | INFORMATION SERIES
HEALTHCARE PROVIDER EDUCATION RAPID RESPONSE
Increasing age 6. Lauer S, et al. “The Incubation Period of Coronavirus Disease 2019
Comorbidities including diabetes, cardiovascular and Application.” Annals of Internal Medicine: 10 March 2020.
disease (including hypertension), and chronic lung 7. Zhou F, et al. “Clinical course and risk factors for mortality of
disease adult inpatients with COVID-19 in Wuhan, China: a restrospective
cohort study. Lancet. 2020 Mar 11. pii: S0140-6736(20)30566-3. doi:
Higher admission sequential organ failure 10.1016/S0140-6736(20)30566-3.
assessment (SOFA) score 8. Xiaolu Tang, Changcheng Wu, Xiang Li, Yuhe Song, Xinmin Yao,
Xinkai Wu, Yuange Duan, Hong Zhang, Yirong Wang, Zhaohui Qian,
Laboratory abnormalities: elevated D-dimer, Jie Cui, Jian Lu, On the origin and continuing evolution of SARS-
ferritin, and troponin CoV-2, National Science Review, nwaa036, https://doi.org/10.1093/
nsr/nwaa036
Control Strategies
9. https://www.who.int/docs/default-source/coronaviruse/situation-
The following strategies are recommended to slow reports/20200306-sitrep-46-covid-19.pdf?sfvrsn=96b04adf_2
the rate of SARS-CoV-2 spread: (accessed 3/21/2020).
10. Guan W, et al. “Clinical Characteristics of Coronavirus Disease 2019
Contact tracing in China.” NEJM. DOI: 10.1056/NEJMoa2002032.
Social /Physical distancing 11. https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-
clinical-specimens.html (accessed 3/21/2020)
Quarantine of suspected cases and exposed
12. https://aabronchology.org/2020/03/12/2020-aabip-statement-on-
individuals bronchoscopy-covid-19-infection/ (accessed 3/21/2020)
Travel restrictions 13. https://aabronchology.org/2020/03/12/2020-aabip-statement-on-
bronchoscopy-covid-19-infection/ (accessed 3/23/2020)
Authors:
14. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/
Shazia Jamil, MD, Scripps Clinic and University of control-recommendations.html (accessed 3/21/2020)
California, San Diego
15. Board on Health Sciences Policy; Institute of Medicine. The
Nick Mark, MD, University of Washington
Graham Carlos, MD, Indiana University Health Care: Workshop Summary. Washington (DC): National
Charles S. Dela Cruz, MD, PhD, Yale University Standards. Available from: https://www.ncbi.nlm.nih.gov/books/
Jane E Gross, MD, PhD, National Jewish Health NBK294223/
Susan Pasnick, MD, MidCentral DHB, New Zealand 16. Henry B. “COVID-19, ECMO, and lymphomenia: a word of caution.”
Lancet: DOI:https://doi.org/10.1016/S2213-2600(20)30119-3.
Reviewers: 17.
Vidya Krishnan, MD of 21 Critically Ill Patients With COVID-19 in Washington
State. JAMA. Published online March 19, 2020. doi:10.1001/
Marianna Sockrider, MD, DrPH jama.2020.4326
Kevin Wilson, MD 18. https://www.cdc.gov/coronavirus/2019-ncov/hcp/therapeutic-
options.html (accessed 3/23/2020)
19. Cao B, Wang Y, Wen D, et al. A trial of lopinavir–ritonavir in adults
hospitalized with severe Covid-19. N Engl J Med. DOI: 10.1056/
NEJMoa2001282.
www.thoracic.org
AJRCCM Articles in Press. Published March 30, 2020 as 10.1164/rccm.2020C1
Copyright © 2020 by the American Thoracic Society