Clinical Considerations

As the numbers of confirmed cases and deaths continue to rise, clinical details of the 2019 novel coronavirus disease have become available through case reports and public health partners. (Since the nomenclature has changed, we simply note that novel coronavirus disease is now named COVID-19 and the responsible agent is SARS-CoV-2 a coronavirus related to SARS-CoV and MERS-CoV.) However, the complete clinical spectrum is still unknown, and reported illnesses have ranged from infected people with few-to-no symptoms to people who become severely ill and die. Of the confirmed cases admitted to Zhongnan Hospital in Wuhan, China in January 2020, around 26 percent ended up in the intensive care unit.a These are thought to be severe clinical presentations of COVID-19 and present in older population with underlying comorbities.a It is essential to remember that this is a rapidly developing situation that requires our healthcare providers to stay up to date on information as it becomes available.

Clinical signs and symptoms

Limited information is available at this time to characterize the spectrum of clinical illness associated with COVID-19. Patients with COVID-19 have most commonly reported symptoms of:

  1. Fever
  2. Cough
  3. Shortness of Breath
Source: CDC - About 2019-nCoV: Symptoms

Based on recent published case series of COVID-19 patients, fever will develop in the majority of symptomatic cases, and cough remains a common symptom in a majority of patients.b Other symptoms have included myalgias or fatigue and sputum production. Less commonly, headaches, diarrhea, and hemoptysis have been reported.c

A case series from China reported an average incubation time from exposure to the development of symptoms as four days (interquartile range: 2-7 days).b However, the CDC recommends monitoring for symptom development during the 2-14 days following exposure.

The spectrum of illness in patients with acute respiratory infection with SARS-CoV-2 can range from uncomplicated illness to mild pneumonia, severe pneumonia, acute respiratory distress syndrome, sepsis and septic shock.d Based on large case series of COVID-19 patients, the majority of cases are occurring in adults and the majority of patients will have mild (nonsevere) disease,e while the more severe cases predominantly occur among the elderly and those with underlying health conditions.e While children and younger patients are more likely to have mild, uncomplicated illness, they are still able to transmit virus and should follow CDC recommendations to prevent spreading COVID-19 in their communities.f

Evaluating Patients Under Investigation

The CDC's clinical criteria for a COVID-19 patient under investigation (PUI) have been developed based on what is known about MERS-CoV and SARS-CoV and are subject to change as additional information becomes available. The criteria established by the CDC are intended to serve as guidance for evaluation. Patients should be evaluated, and the results of those evaluations discussed with public health department officials on a case-by-case basis if their clinical presentation or exposure history is unclear.

With rapid evolution of guidance, we are making syndicated content in this section provided and maintained by the CDC

Source: CDC – Evaluating and Reporting Persons Under Investigation (PUI)

Evaluating a PUI

For a face-to-face encounter with a patient who has met criteria to be considered a PUI:

  • The patient should be instructed to put on a facemask and should be isolated to a private room in your clinic before further medical evaluation can be performed. If possible, a negative pressure isolation room should be used, if available
  • The designated medical provider should wear appropriate PPE and follow infection-prevention guidelines presented in this workshop.

For a patient contacting your clinic from home who has met criteria to be considered a PUI:

  • The patient should be instructed to put on a facemask (if available) and isolate himself/herself to a private room away from close contacts.
  • Home care guidance can be given, depending on the severity of illness and a health department consultation.

Taking a good travel history

The healthcare provider performing the health assessment and interview is responsible for obtaining a detailed travel history for any PUI being evaluated. This information should be reported to the local health department by the same interviewing provider and should include the following:

  • Date of departure from the United States, destination country/city, date of arrival in country/city, dates of travel within the country, modes of travel within the country, specific regions (i.e., city, province, villages, and townships) visited within the country, country/city of departure, date of departure from country, and date of return to the United States.
  • Information about close contacts who were sick with fever and respiratory symptoms during travel, including date of interaction with sick contact, the number of hours spent with sick contact, and location of interaction (e.g., outdoors, office building, hotel room).
  • A record of the onset of symptoms (record specific dates if possible), a timeline of symptom development (e.g., developed fever on X date, followed by cough on Y date), and severity of symptoms.

Reporting a PUI

Healthcare providers should immediately notify both infection-control personnel at their healthcare facility and their local or state health department in the event of a PUI for COVID-19 and provide the case history gathered (see above).

Houston-area health department contact information

If the links below are not relevant to your locale, please consult the Directory of Local Health Departments.

Name Details
Harris County Public Health
  • Telephone: 713-439-6000
  • Fax: 713-439-6306
  • After Hours: 713-755-5050
Houston Health Department
  • Telephone: 832-393-5080 (24 hr #)
  • Fax: 832-393-5232
Brazoria County Health Department
  • Telephone: (979) 864-2168
  • Fax: (979) 864-3694
  • After Hours: 800-511-1632
Chambers County Health Department
  • Telephone: 409-267-2731
  • Fax: 409-267-4276
  • After Hours: 409-267-9862
Fort Bend County Health and Human Services
  • Telephone: 281-342-6414
  • Fax: 832-471-1817
  • After Hours: 832-407-7385
Galveston County Health District
  • Telephone: 409-938-2322
  • Fax: 409-938-2399
  • After Hours: 888-241-0442
Montgomery County Public Health Department
  • Telephone: (936) 523-5026
  • Fax: (936) 539-9272
  • After Hours: 888-825-9754
Texas Department of State Health Services: Health Service Region 6/5 South
  • Telephone: 713-767-3000
  • Fax: 713-767-3006
  • After Hours: 800-270-3128

State health department contact information

If the links below are not relevant to your locale, please consult the State Health Departments After Hours/Epi-on-Call Contact List.

Source: CSTE
Jurisdiction After Hours/Epi-on-Call Phone Number Infectious Disease Outbreak-Related Questions
Texas (512) 221-6852 (512) 221-6852
Texas, Dallas (877) 605-2660 (214) 819-2004 or (877) 605-2660
Texas, Harris County (713) 755-5000 (713) 755-5000
Texas, Houston (832) 393-5080 (832) 393-5080
Texas, San Antonio (210) 207-8876 (210) 207-8876

Making the Diagnosis

Healthcare providers should begin by contacting their local/state health department immediately to notify them of patients with signs and symptoms compatible with COVID-19.

As noted above, decisions on which patients receive testing should be based on the local epidemiology of COVID-19, as well as the clinical course of illness. Epidemiologic factors that may help guide decisions on whether to test include: any persons, including healthcare workers, who have had close contact with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset, or a history of travel from affected geographic areas (see list above International Areas with Sustained [Ongoing] Transmission) within 14 days of symptom onset.

Note

Although the CDC criteria has expanded testing to a wider group of symptomatic patients, local and state health departments while awaiting increased testing availability may have elected to continue to employ protocols prioritizing testing based upon close contacts and travel history. Regarding the availability and timing of testing in Texas:

  • The Texas Department of Public Health, Harris County, and the City of Houston will continue to prioritize testing based upon close contacts and travel history.
    • Priority given to close contacts and travel history
    • Turn around time 1-2 days
  • Commercial Testing Availability
    • Labcorp has testing available. Takes 3-4 days
    • Quest will have testing available on Monday, March 9th, 2020.

Once this is done, the following chain of operation will commence:

  • Local/state public health staff will help clinicians determine if the patient meets the criteria for a PUI for COVID-19.
  • Clinical specimens will be collected by healthcare personnel (e.g., Physician or nurse-hospital lab/personnel) from PUIs for routine testing of respiratory pathogens at either clinical or public health labs.
  • State or local health departments that have identified a PUI or a laboratory-confirmed case should complete a PUI and Case Report form through the processes identified on CDC’s Coronavirus Disease 2019 website.
  • State and local health departments can contact CDC’s Emergency Operations Center (EOC) at 770-488-7100 for assistance with obtaining, storing, and shipping appropriate specimens to CDC for testing, including after hours or on weekends or holidays
  • Currently, diagnostic testing for COVID-19 can be conducted at CDC or by local public health laboratories and some commercial laboratories.
  • Testing for other respiratory pathogens by the provider should be done as part of the initial evaluation and should not delay specimen shipping to CDC.
  • Specific guidelines for collecting, handling, and testing clinical specimens from PUIs for COVID-19 can be reviewed at https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html.

Differential Diagnoses

When encountering any patient who has fever, cough, and shortness of breath, remember to keep your differential diagnosis broad. Even for those patients who are returning travelers, symptoms of fever, cough, and shortness of breath can be caused by any number of circulating seasonal respiratory viruses. These include influenza A/B, respiratory syncytial virus, adenovirus, human metapneumovirus, classical coronaviruses (not SARS-CoV-2), and parainfluenza. Other respiratory diseases like exacerbation of chronic obstructive pulmonary disease and community-acquired pneumonia should also be considered.

Patient Disposition

The decision to hospitalize PUIs or confirmed COVID-19 cases should be at the discretion of the admitting provider and driven by the clinical presentation and severity of symptoms. Limited information is available to characterize the spectrum of clinical illness, transmission efficiency, and the duration of viral shedding for patients with COVID-19. Please refer to the infection prevention section for further information regarding isolation precautions for hospitalized patients with COVID-19.

The CDC has developed Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of Hospitalized Patients which has been developed based on available information about COVID-19 and what is known about similar diseases caused by related coronaviruses. Patients should be discharged from the healthcare facility whenever clinically indicated. Isolation should be maintained at home if the patient returns home before the decision is make to discontinue isolation precautions. The decision to discontinue in-home isolation for patients with COVID-19 should be made on a case-by-case basis in consultation with clinicians and public health officials. Interim Guidance for Discontinuation of In-Home Isolation for Patients with COVID-19 is available on the CDC website.

Infection prevention and control considerations for healthcare facilities providing obstetric care for pregnant patients with confirmed coronavirus disease (COVID-19) or pregnant persons under investigation (PUI) in inpatient obstetric healthcare settings including obstetrical triage, labor and delivery, recovery and inpatient postpartum settings are available on the CDC website (Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings). This webpage includes sections on mother/baby contact, breastfeeding, and hospital discharge of postpartum women.

Treatment

Currently, no vaccine or specific treatment for the COVID-19 infection is available; care is supportive only; however, “Interim guidance for the clinical management of severe acute respiratory infection when 2019-nCoV infection is suspected” is available from the World Health Organization.c

Misinformation

The COVID-19 outbreak has stoked anxieties across the globe. In this age of fast-spreading information and social media accessibility, it has become important to acquire accurate and up-to-date information from credible and reliable sources and public health authorities. To date, numerous rumors, hoaxes, and misinformation campaigns regarding the COVID-19 outbreak have spread across the Internet and into the homes of our patients and communities (Coronavirus: Here Are 10 Misconceptions Being Spread [Forbes]). As healthcare providers, we are obligated to ensure that we are sharing only accurate and up-to-date information during this global emergency response. It is important to remember that this is a rapidly developing situation that requires our attentiveness to new information as it becomes available.

Trustworthy press material for information on the COVID-19 can be found at the following links:

References

  1. Wang D, Bo H, Chang H et al. Clinical Characteristics of the 138 hospitalized patients with novel coronavirus-infected pneumonia in Wuhan, China. JAMA Published online Feb 7, 2020 doi:10.1001/jama.2020.1585.
  2. Guan W-j, Ni Z-y, Hu Y, Liang W-h, Ou C-q, He J-x, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine. 2020.
  3. Huang C, Wang Y, Li X, et al. “Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.” Published online January 24, 2020 https://doi.org/10.1016/S0140-6736(20)30183-5.
  4. World Health Organization. “Clinical management of severe acute respiratory infection when novel coronavirus (2019-CoV) infection is suspected: Interim guidance, 28, January 2020. https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf. Accessed February 14, 2020.
  5. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. Jama. 2020.
  6. Centers for Disease Control and Prevention. Preventing COVID-19 Spread in Communities. [CDC link] (https://www.cdc.gov/coronavirus/2019-ncov/community/index.html). Accessed March 7, 2020.
* On February 11, 2020, the World Health Organization named the novel coronavirus disease “COVID-19”. The agent responsible for COVID-19 is the novel coronavirus, SARS-CoV-2.