April 13, 2021
Coronavirus disease 2019 (COVID-19) started in late December 2019.1 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 Loss of taste or smell also can occur. 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 4 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 six 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 Although there are current therapies available for COVID-19, there is currently no cure.10 Outpatient patient care is generally supportive.
Community transmission (transmission with no known exposure source) has been occurring in the United States since March 2020.7As of April 12, 2021, there have been a total of approximately 31,076,891 cases in the United States with approximately 559,741 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, face masks, 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 had 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 Environmental Protection Agency-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
COVID-19 Vaccines and Vaccine Hesitancy
To date, three COVID-19 vaccines have been approved under emergency use authorizations by the Food and Drug Administration (FDA): Pfizer-BioNTech COVID-19 vaccine (ages 16 and older), Moderna COVID-19 vaccine (ages 18 and older), and Janssen Biotech (Johnson and Johnson) COVID-19 vaccine (ages 18 and older).22,23,24 The Pfizer-BioNTech and Moderna vaccines are two-dose vaccines, while Janssen Biotech (Johnson and Johnson) is a one-dose vaccine.22,23,24
As of March 29, approximately 85 million people in the United States have been vaccinated.25 The vaccines have been shown to be safe and effective, with rare anaphylaxis.25,26,27 On April 13, 2021, the Centers for Disease Control and Prevention (CDC) and FDA recommended a pause in the use of Johnson & Johnson’s Janssen COVID-19 vaccine because of rare reports of blood clots post-vaccination.28 Vaccine hesitancy, unfortunately, is an issue with many in the public.29 Misinformation and disinformation both exist regarding the COVID-19 vaccines, including distrust of the healthcare system.29 At-risk populations may have higher rates of vaccine hesitancy, including potentially, older adults.30 Based on a recent AARP survey, major reasons for COVID-19 vaccine hesitancy among adults ages 50 and older include: worry about vaccine side effects (59%), concerns with vaccine effectiveness (29%), perceived risks of the COVID-19 vaccine (52%) and distrust of the government (47%).31
Addressing vaccine hesitancy requires understanding attitudes, risks and perceptions of various communities.30 Communication regarding the vaccine is essential to address any vaccine concerns and refute any misconceptions.30 In the United States, patients trust their healthcare provider more than leaders in government or the media, making this interaction a key opportunity to address vaccine hesitancy.32 The allergy/immunology physician is at the forefront of the healthcare system for many patients. Taking time during the office visit is valuable to discuss the COVID-19 vaccine, including potential risks, benefits, misinformation and disinformation. Even an extra couple minutes of physician-led education and sharing personal experiences with the vaccine can lead to a more informed and trusted decision by the patient regarding immunization. It is important to be aware of the types of vaccines and availability in your local community. If the allergy/immunology physician takes this vital time at the in-person or virtual office visit, the COVID vaccine hesitancy issue can be improved and potentially overcome.
It is important to note that the COVID-19 pandemic is currently evolving. For additional and up to date information, please visit cdc.gov.
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.
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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 April 13, 2021.
12. Overview of Testing for SARS-CoV-2 (COVID-19). https://www.cdc.gov. Accessed April 13, 2021..
13. Coronavirus disease 2019 (COVID-19). Testing for COVID-19 and Guidance on interpreting COVID-19 test results. https://www.cdc.gov and https://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.gov. 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.
22. Pfizer-BioNTech Covid-19 Vaccine. Fact sheet for healthcare providers administering vaccine. Emergency use authorization (EUA) prescribing information. Available at https://www.fda.gov. Accessed Feb. 14. 2021.
23. Moderna Covid-19 Vaccine. Fact sheet for healthcare providers administering vaccine. Emergency use authorization (EUA) prescribing information. Available at https://www.fda.gov. Accessed Feb. 14, 2021.
24. Janssen Covid-19 Vaccine. Fact sheet for healthcare providers administering vaccine. Emergency use authorization (EUA) prescribing information. Available at https://www.fda.gov. Accessed Apr. 2, 2021.
25. AAAAI COVID-19 Response Task Force email communication. March 29, 2021.
26. AAAAI COVID-19 Response Task Force email communication. March 15, 2021.
27. AAAAI COVID-19 Response Task Force email communication. February 15, 2021.
28. CDC website. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/JJUpdate.html. Accessed Apr. 19, 2021.
29. Rosenbaum L. Escaping Catch-22 - Overcoming Covid vaccine hesitancy. NEJM 2021. Doi: 10.1056/NEJMms2101220.
30. Latkin C, Dayton L, Yi G, Konstantopoulos A, Park J, Maulsby C et al. COVID-19 vaccine intentions in the United States, a social-ecological framework. Vaccine 2021. Doi: 10.1016/j.vaccine.2021.02.058.
31. McSpadden, J. Vaccine Hesitancy among Older Adults, with implications for COVID-19 Vaccination and Beyond. Washington DC: AARP Public Policy Institute, February 2021. https://doi.org/10.26419/ppi.00123.001.
32. Pew Research Center. https://www.pewresearch.org/science/2019/08/02/trust-and-mistrust-in-americans-views-of-scientific-experts/. Accessed April 19, 2020.