September 23, 2020

Coronavirus disease 2019 (COVID-19) started in early December 2019 in the city of Wuhan in the Hubei province in China.1  Since the first cases, the disease has spread rapidly throughout the world, and the World Health Organization declared a pandemic on March 11, 2020. The first known case in the United States occurred in Snohomish County in the state of Washington in January 2020.2 Clinical presentation includes fever in approximately 83 to 98% of patients, cough in 76 to 82% of  patients, and myalgias or fatigue in 11 to 44% of patients.3 Nausea, vomiting, or diarrhea were not common.1 Chest radiographs may have bilateral patchy infiltrates, and chest CTs may have ground-glass opacities and patchy shadowing.1,3  Lymphocytopenia is the most common hematologic abnormality.1 Diagnostic testing involves the reverse transcriptase-polymerase chain reaction (RT-PCR) test, and the biologic specimens producing the highest rates of positivity include bronchoalveolar lavage fluid (93%), sputum (72%), nasal swabs (63%), pharyngeal swabs (29%), and fecal swabs (29%).4,5

Median incubation period is about four days, but the range is 2 to 14 days.1,4 Transmission is understood to be from person to person via respiratory droplets (which occurs when a person with infection coughs or sneezes, usually within a distance of about 6 feet).6 At present, although it may be possible for transmission to occur from contact with contaminated surfaces or items, it is most likely spread from person to person.6 Median age is in the 50s with a slim preponderance of men.3 It is estimated that 80% of patients infected have mild symptoms.7 However, older patients (age 60 years or older) are at particular risk of a more severe course and are more likely to require intensive unit, or critical, care.3,8 In addition, about 40% of patients who require critical care have co-morbid medical conditions, such as cardiac disease and diabetes.8,9 Critically ill patients with COVID-19 are likely to develop acute respiratory distress syndrome.8  There is evidence that the antiviral medication, remdesivir, has been associated with clinical improvement, however, there is currently no cure, patient care is generally supportive, and there is no vaccine currently available.10 

Community transmission (transmission with no known exposure source) has been occurring in the United States.7 Therefore, there has been a shift from containment to mitigation of the disease.7 As of September 22, 2020, there are a total of 6,825,697 cases in the United States with almost 200,000 deaths.11

Allergy and Immunology Physicians and Providers

As allergy and immunology healthcare physicians and providers, many of our patients with asthma and/or rhinitis present with similar symptoms to COVID-19, including cough. However, fever is not a common symptom in allergic rhinitis, and even acute sinusitis may not present with fever. Patients with COVID-19 may not present with fever either.1 Therefore, as symptoms of COVID-19 are similar to asthma, rhinitis, and influenza, it is recommended that each physician use clinical judgement to determine if evaluation for COVID-19 is necessary. When testing, it is recommended to collect upper respiratory specimens (nasopharyngeal and oropharyngeal swabs) as well as lower respiratory specimens, if available.12 Testing for other respiratory conditions such as influenza is advisable.11 Nucleic acid, or antigen, testing to diagnose active COVID-19 infection may be coordinated through local and state health authorities.12,13 Antibody testing may be performed also, but it is currently unknown whether presence of antibodies to COVID-19  indicates protective immunity from the disease.13

Personal protective equipment, such as N95 respirators, facemasks, and gowns, should be used by all members of the healthcare team, when available.14 Triaging patients at appointment scheduling is advisable to determine risk.14 Once at the office, patients should be provided with respiratory hygiene supplies, including alcohol-based sanitizers and tissues, as well as face masks, if available.14 At-risk patient isolation in examination rooms is advisable, as is at least six feet of separation (if private areas are unavailable) between patients in the common waiting room.14  Training and educating the staff at the allergy and immunology office is essential.14 The use of alternative patient encounters, including telemedicine, should be considered.14

Patients, Including Older Adults

Individuals at higher risk for more severe symptoms of COVID-19 include older adults and those with chronic medical conditions including heart disease, lung disease, and diabetes.15 Higher risk individuals should reduce their risk exposure.15 This can be done by avoiding non-essential travel, including cruise ships, avoiding crowds, limiting close contact with people (“social distancing”, or remaining about six feet apart), and washing hands often (20 seconds or longer, as above).15,16 Individuals, especially at higher risk, should have adequate supplies on hand including both prescription and non-prescription medications (using mail-order to obtain additional medication) as well as household and grocery items.15 Planning for a potential COVID-19 infection should include having the contact information of one’s physician as well as staying in touch with family, friends, or neighbors via phone, texting, email, or other methods of electronic communication.15 Individuals should contact their physician (or notify emergency medical services, at 911, if a medical emergency) if they have any symptoms such as fever, cough, and shortness of breath or suspect they may be exposed to COVID-19, and this should be done prior to seeking care, so adequate preparation for their visit can occur at the health facility site if necessary.15 Other practical advice if one has has symptoms includes covering all sneezes and coughs with a tissue that is then disposed of, wearing a face mask, if available, separating oneself from others in the home (in a different room from household members and pets), and washing hands often with soap and water (or using an alcohol-based hand sanitizer with at least 60% alcohol).15 Avoiding touching one’s eyes, nose, and mouth with unwashed hands (though difficult) is also advisable as is cleaning surfaces with EPA-registered disinfectants.15,17 As public places begin to reopen worldwide, practicing social distancing, wearing breathable coverings for the mouth and nose, washing hands, and cleaning and disinfecting frequently touched surfaces can still help prevent the spread of the disease.18

Physician and General Public Wellness and COVID-19

For all parties involved, including physicians, other healthcare personnel, patients, and the general public, a pandemic is a time of great stress, both physical and psychological. Acknowledging and coping with these stresses by all parties is of paramount importance.16 Pandemics can cause fear and worry about one’s own health and that of family members, as well as difficulty sleeping, and potentially increased use of alcohol or drugs.16 Addressing one’s own wellness, including psychological well-being, is important.16,19 Supportive actions for physicians, other healthcare providers, and the general public include avoiding excessive media exposure regarding COVID-19, eating healthy, exercising, and getting adequate sleep, as well as connecting socially with others and maintaining healthy relationships electronically.16,19,20 Maintaining a positive outlook and sense of humor can be useful in coping.16,19 Being aware of stigmatizing groups of people due to infection or suspected infection with COVID-19 is also crucial.21

It is important to note that the COVID-19 pandemic is currently evolving. For additional and up to date information, please visit https://www.cdc.gov.

References

1. Guan W, Ni Z, Hu Y, Liang W, Ou C, He J et al. Clinical characteristics of Coronavirus Disease 2019 in China. NEJM 2020, DOI: 10.1056/NEJMoa2002032.

2. Holshue M, DeBolt C, Lindquist S, Lofy K, Wiesman J, Bruce H et al. First case of 2019 novel Coronavirus in the United States. NEJM 2020: 382: 929-36.

3. Del Rio C, Malani P. COVID-19-New insights on a rapidly changing epidemic. JAMA 2020, doi: 10.1001/jama.2020.3072.

4. Sharfstein J, Becker S, Mello M.  Diagnostic testing for the Novel Coronavirus. JAMA 2020, doi: 10.1001/jama.2020.3864.

5. Wang W, Xu Y, Gao R, Lu R, Han K, Wu G et al. Detection of SARS-CoV-2 in different types of clinical specimens. JAMA 2020, doi: 10.1001/jama.2020.3786.

6. How COVID-19 spreads. https://www.cdc.gov. Accessed March 13, 2020.

7. Parodi S, Liu V. From containment to mitigation of COVID-19 in the US. JAMA 2020, doi: 10.1001/jama.2020.3882.

8. Murthy S, Gomersall C, Fowler R.  Care for critically ill patients with COVID-19. JAMA 2020, doi: 10.1001/jama.2020.3633.

9. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J et al. Clinical characteristics of 138 hospitalized patients with 2019 novel Coronavirus-infected pneumonia in Wuhan, China. JAMA 2020, doi: 10.1001/jama.2020.1585.

10. Grein J, Ohmagari N, Shin D, Diaz G, Asperges E, Castagna A et al.  Compassionate use of remdesivir for patients with severe Covid-19.  NEJM.  DOI: 10.156/NEJMoa2007016.

11. Coronavirus disease 2019 (COVID-19) in the U.S. https://www.cdc.gov. Accessed September 23, 2020.

12. Evaluating and testing persons for Coronavirus disease 2019 (COVID-19).  https://www.cdc.gov. Accessed March 13, 2020.

13.  Coronavirus disease 2019 (COVID-19).  Testing for COVID-19 and Guidance on interpreting COVID-19 test results.  https://www.cdc.gov. and www.whitehouse.gov.  Accessed May 29, 2020.

14. Interim infection prevention and control recommendations for patients with suspected or confirmed Coronavirus Disease 2019 (COVID-19) in healthcare settings. https://www.cdc.org.  Accessed March 13, 2020.

15. People at risk for serious illness from COVID-19. https://www.cdc.gov. Accessed March 13, 2020.

16. Mental health and coping during COVID-19. https://www.cdc.gov. Accessed March 13, 2020.

17. Coronavirus disease 2019 (COVID-19). https://www.cdc.gov. Accessed March 13, 2020.

18  Coronavirus disease 2019 (COVID-19).  How to protect yourself & others.  https://www.cdc.gov. Accessed May 29, 2020.

19. Nanda A, Wasan A, Sussman J.  Provider health and wellness. J Allergy Clin Immunol Pract 2017; 5:  1543-8.

20.Bansal P, Bingemann T, Greenhawt M, Mosnaim G, Nanda A, Oppenheimer J et al.  Clinician wellness during the COVID-19 pandemic: Extraordinary times and unusual challenges for the allergist/immunologist.  J Allergy Clin Immunol Pract 2020; in press.  https://doi.org/10.1016/j.jaip.2020.04.001.

21. Stigma and resilience. https://www.cdc.gov. Accessed March 13, 2020.