key: cord-289476-8wh3hn0n
authors: Leiker, Brenna; Wise, Katherine; Perlman, Jane R
title: COVID - 19 BRIEF INTRODUCTION IN MENTAL HEALTH CONSIDERATIONS FOR HEALTH CARE WORKERS AND PATIENTS
date: 2020-07-28
journal: Dis Mon
DOI: 10.1016/j.disamonth.2020.101059
sha: 
doc_id: 289476
cord_uid: 8wh3hn0n

I.. COVID-19: TESTING: A.. Laboratory Testing - CDC Guidelines;

***For further guidance the reader is also referred to their local, or state health department for region specific testing guidelines, and your health care facility laboratorian for information on best protocols.

CDC does not currently recommend using antibody testing as the sole basis for diagnosis of acute infection, and antibody tests are not authorized by FDA for such diagnostic purposes. In certain situations, serologic assays may be used to support clinical assessment of persons who present late in their illnesses when used in conjunction with viral detection tests. In addition, if a person is suspected to have post-infectious syndrome (e.g., Multisystem Inflammatory Syndrome in Children) caused by SARS-CoV-2 infection, serologic assays may be used.

Serologic assays for SARS-CoV-2, now broadly available, can play an important role in understanding the transmission dynamic of the virus in the general population and identifying groups at higher risk for infection. Unlike viral direct detection methods, such as nucleic acid amplification or antigen detection tests that can detect acutely infected persons, antibody tests help determine whether the individual being tested was previously infected-even if that person never showed symptoms.

It is currently not clear whether a positive serologic test indicates immunity against SARS-CoV-2; serologic tests should not be used at this time to determine if an individual is immune. As additional data are collected to understand the significance of the presence or level of antibodies and their correlation with immunity, serologic tests may have utility in infection control decisions, but for now this evidence is not available.

These tests can help determine the proportion of a population previously infected with SARS-CoV-2. Thus, demographic and geographic patterns of serologic test results can help determine which communities may have experienced a higher infection rate.

This document describes five categories of people for SARS-CoV-2 testing with viral tests (i.e., nucleic acid or antigen tests) [the following are hot links to CDC resources]:  Testing individuals with signs or symptoms consistent with COVID-19  Testing asymptomatic individuals with recent known or suspected exposure to SARS-CoV-2 to control transmission  Testing asymptomatic individuals without known or suspected exposure to SARS-CoV-2 for early identification in special settings  Testing to determine resolution of infection (i.e., test-based strategy for Discontinuation of Transmission-based Precautions, HCP Return to Work, and Discontinuation of Home Isolation)  Public health surveillance for SARS-CoV-2

Generally, viral testing for SARS-CoV-2 is considered to be diagnostic when conducted among individuals with symptoms consistent with COVID-19 or among asymptomatic individuals with known or suspected recent exposure to SARS-CoV-2 to control transmission, or to determine resolution of infection. Testing is considered to be surveillance when conducted among asymptomatic individuals without known or suspected exposure to SARS-CoV-2 for early identification, or to detect transmission hot spots or characterize disease trends.

CDC recommends using authorized nucleic acid or antigen detection assays that have received an FDA EUA to test persons with symptoms when there is a concern of potential COVID-19. Tests should be used in accordance with the authorized labeling; providers should be familiar with the tests' performance characteristics and limitations.

According to the CDC "Clinicians should use their judgment to determine if a patient has signs or symptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough) but some infected patients may present with other symptoms as well. Clinicians are encouraged to consider testing for other causes of respiratory illness, for example influenza, in addition to testing for SARS-CoV-2 depending on patient age, season, or clinical setting; detection of one respiratory pathogen (e.g., influenza) does not exclude the potential for co-infection with SARS-CoV-2. Because symptoms and presentations may be different in children, consider referencing the CDC guidelines for COVID in neonates and for multisystem inflammatory syndrome in children." ***CDC rightly notes that the severity of symptomatic illness due to infection with may vary. Among persons with extensive and close contact to vulnerable populations (e.g., healthcare personnel [HCP]), even mild signs and symptoms (e.g., sore throat) of possible COVID-19 should prompt consideration for testing. Additional information is available in CDC's. The reader is referred to the CDC Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19).

Testing is recommended for all close contacts of persons with SARS-CoV-2 infection, especially initial testing during an outbreak or pandemic due to the high likelihood of exposure. Because of the potential for asymptomatic and pre-symptomatic transmission, it is important that contacts of individuals with SARS-CoV-2 infection be quickly identified and tested.

 In areas where testing is limited, CDC has established a testing hierarchy; refer to the Interim Guidance on Developing a COVID-19 Case Investigation and Contact Tracing Planpdf icon for more information.  CDC specifically recommends testing for all neonates born to women with COVID-19, regardless of whether there are signs of infection in the neonate.

Their guidance towards COVID -19 includes:

In some settings, broader testing, beyond close contacts, is recommended as a part of a strategy to control transmission of SARS-CoV-2. This includes high-risk settings that have potential for rapid and widespread dissemination of SARS-CoV-2 (e.g., meat processing plant) or in which populations at risk for severe disease (e.g., long-term care facilities, including nursing homes, intermediate care facilities for individuals with intellectual disabilities, and psychiatric residential treatment facilities) could become exposed. Expanded testing might include testing of all contacts in proximity to someone with SARS-CoV-2 infection, or even testing all individuals within a shared setting (e.g., facility-wide testing). Currently CDC recommends expanded contact testing in the following guidance documents:

 Testing guidance for nursing homes.  Following identification of SARS-CoV-2 infection in a worker in a high-density critical infrastructure workplace

Certain settings can experience rapid spread of SARS-CoV-2, resulting in substantial adverse effects. This is particularly true for settings that house vulnerable populations in close quarters for extended periods of time (e.g., long-term care facilities, correctional and detention facilities) and/or settings where critical infrastructure workers (e.g., healthcare personnel, first responders) may be disproportionately affected.

A strategy aimed at reducing introduction of SARS-CoV-2 into the setting through early identification could reduce the risk of widespread transmission in these situations.

Facilities are encouraged to work with local, territorial, and state health departments to help inform decision-making about broad-based testing. Before testing large numbers of asymptomatic individuals without known or suspected exposure, the facility should have a plan in place for how it will modify operations based on test results.

Approaches for early identification of asymptomatic individuals include:

 Initial testing of everyone residing and/or working in the setting,  Regular (e.g., weekly) testing of everyone residing and/or working in the setting, and  Testing of new entrants into the setting and/or those re-entering after a prolonged absence (e.g., one or more days)

Settings for which these approaches could be considered include:

 Long-term care facilities  Correctional and detention facilities  Homeless shelters  Other congregate work or living settings including mass care, temporary shelters, assisted living facilities, and group homes for individuals with intellectual disabilities and developmental disabilities  High-density critical infrastructure workplaces where continuity of operations is a high priority

 Pre-admission or pre-procedure testing as part of the evaluation of patients could be considered to inform decisions about deferring elective care (e.g., certain dental procedures) or procedures and the use of personal protective equipment.  Testing guidance for nursing homes

A test-based strategy, which requires serial tests, can be used as an alternative to a symptom-based or time-based strategy, to determine when a person with SARS-CoV-2 infection no longer requires isolation or work exclusion. This strategy could be considered in three situations: Public health surveillance for SARS-CoV-2

Testing is a fundamental part of the United States SARS-CoV-2 Surveillance Plan, which uses multiple surveillance systems and epidemiology networks, in collaboration with state, local, and academic partners, to monitor the progression and impact of SARS-CoV-2 spread in the United States.

Viral tests are used in community, outpatient, and hospital-based surveillance systems to identify cases of SARS-CoV-2 infection. These data help identify areas of ongoing circulation (hot spots), determine trends in disease by location, provide insight into the impact of the disease over time and by location, and inform disease forecasts.

Antibody tests are increasingly used to monitor disease burden by location and over time.

Use of serologic assays in populations can help determine the proportion of a population previously infected with SARS-CoV-2. Thus, demographic and geographic patterns of serologic test results provide data that can be used in forecasts of disease spread that can support resource allocation decisions and planning by local, territorial and state officials. 

For initial diagnostic testing for SARS-CoV-2, CDC recommends collecting and testing an upper respiratory specimen. The following are acceptable specimens:  A nasopharyngeal (NP) specimen collected by a healthcare provider; or  An oropharyngeal (OP) specimen collected by a healthcare provider; or  A nasal mid-turbinate swab collected by a healthcare provider or by a supervised onsite self-collection (using a flocked tapered swab); or  An anterior nares (nasal swab) specimen collected by a healthcare provider or by onsite or home self-collection (using a flocked or spun polyester swab); or  Nasopharyngeal wash/aspirate or nasal wash/aspirate (NW) specimen collected by a healthcare provider.

Swabs should be placed immediately into a sterile transport tube containing 2-3mL of either viral transport medium (VTM), Amies transport medium, or sterile saline, unless using a test designed to analyze a specimen directly, (i.e., without placement in VTM), such as some point-of-care testsexternal icon. If VTM is not available, see the standard operating procedure for public health labs to create viral transport mediumpdf icon in accordance with CDC's protocol.

The NW specimen and the non-bacteriostatic saline used to collect the specimen should be placed immediately into a sterile transport tube.

Testing lower respiratory tract specimens is also an option. For patients who develop a productive cough, sputum should be collected and tested for SARS-CoV-2. The induction of sputum is not recommended. When under certain clinical circumstances (e.g., those receiving invasive mechanical ventilation), a lower respiratory tract aspirate or bronchoalveolar lavage sample should be collected and tested as a lower respiratory tract specimen.

For providers collecting specimens or within 6 feet of patients suspected to be infected with SARS-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens.

For providers who are handling specimens, but are not directly involved in collection (e.g. self-collection) and not working within 6 feet of the patient, follow Standard Precautions; gloves are recommended. Healthcare personnel are recommended to wear a form of source control (facemask or cloth face covering) at all times while in the healthcare facility.

PPE use can be minimized through patient self-collection while the healthcare provider maintains at least 6 feet of separation.

Sterile swabs for upper respiratory specimen collection may be packaged in one of two ways:

 Individually wrapped (preferred when possible)  Bulk packaged

Bulk-packaged swabs may be used for sample collection; however, care must be exercised to avoid SARS-CoV-2 contamination of any of the swabs in the bulk-packaged container.

 Before engaging with patients and while wearing a clean set of protective gloves, distribute individual swabs from the bulk container into individual disposable plastic bags.  If bulk-packaged swabs cannot be individually packaged: o Use only fresh, clean gloves to retrieve a single new swab from the bulk container. o Close the bulk swab container after each swab removal and leave it closed when not in use to avoid inadvertent contamination. o Store opened packages in a closed, airtight container to minimize contamination. o Keep all used swabs away from the bulk swab container to avoid contamination.

 As with all swabs, only grasp the swab by the distal end of the handle, using gloved hands only.  When patients are self-collecting their swabs under clinical supervision:

o Hand a swab to the patient only while wearing a clean set of protective gloves. o The patient can then self-swab and place the swab in transport media or sterile transport device and seal. o If the patient needs assistance, you can help the patient place the swab into transport media or a transport device and seal it.

Proper collection of specimens is the most important step in the laboratory diagnosis of infectious diseases. A specimen that is not collected correctly may lead to false negative test results. The following specimen collection guidelines follow standard recommended procedures.

For more information, including illustrations and step-by-step guidance, see the CDC Influenza Specimen Collection pdf icon instructions. Note that these instructions are applicable for respiratory viruses in general, and not specific for only influenza virus.

Use only synthetic fiber swabs with plastic or wire shafts. Do not use calcium alginate swabs or swabs with wooden shafts, as they may contain substances that inactivate some viruses and inhibit PCR testing. CDC is now recommending collecting only the NP swab, although OP swabs remain an acceptable specimen type. If both NP and OP swabs are collected, they should be combined in a single tube to maximize test sensitivity and limit use of testing resources.

NP swab: Insert mini tip swab with a flexible shaft (wire or plastic) through the nostril parallel to the palate (not upwards) until resistance is encountered or the distance is equivalent to that from the ear to the nostril of the patient, indicating contact with the nasopharynx. Swab should reach depth equal to distance from nostrils to outer opening of the ear. Gently rub and roll the swab. Leave swab in place for several seconds to absorb secretions. Slowly remove swab while rotating it. Specimens can be collected from both sides using the same swab, but it is not necessary to collect specimens from both sides if the minitip is saturated with fluid from the first collection. If a deviated septum or blockage create difficulty in obtaining the specimen from one nostril, use the same swab to obtain the specimen from the other nostril.

OP swab: Insert swab into the posterior pharynx and tonsillar areas. Rub swab over both tonsillar pillars and posterior oropharynx and avoid touching the tongue, teeth, and gums.

Use a flocked tapered swab. Tilt patient's head back 70 degrees. While gently rotating the swab, insert swab less than one inch (about 2 cm) into nostril (until resistance is met at turbinates). Rotate the swab several times against nasal wall and repeat in other nostril using the same swab.

Using a flocked or spun polyester swab, insert the swab at least 1 cm (0.5 inch) inside the nostril (naris) and firmly sample the nasal membrane by rotating the swab and leaving in place for 10 to 15 seconds. Sample both nostrils with same swab.

Attach catheter to suction apparatus. Have the patient sit with head tilted slightly backward. Instill 1 mL-1.5 mL of non-bacteriostatic saline (pH 7.0) into one nostril. Insert the tubing into the nostril parallel to the palate (not upwards). Catheter should reach depth equal to distance from nostrils to outer opening of ear. Begin gentle suction/aspiration and remove catheter while rotating it gently. Place specimen in a sterile viral transport media tube.

Bronchoalveolar lavage, tracheal aspirate, pleural fluid, lung biopsy Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container.

Due to the increased technical skill and equipment needs, collection of specimens other than sputum from the lower respiratory tract may be limited to patients presenting with more severe disease, including people admitted to the hospital and/or fatal cases.

Educate the patient about the difference between sputum and oral secretions (saliva). Have the patient rinse the mouth with water and then expectorate deep cough sputum directly into a sterile, leak-proof, screw-cap collection cup or sterile dry container.

Store specimens at 2-8°C for up to 72 hours after collection. If a delay in testing or shipping is expected, store specimens at -70°C or below.

If local laboratory capacity is unavailable, samples may be shipped to CDC if repeated testing results remain inconclusive or if other unusual results are obtained.

Please contact CDC at respvirus@cdc.gov prior to submitting samples and other information. As discussed in the SARS and MERS sections of this article, early radiographic studies with regular follow up evaluations, including CT scans is important in helping to characterize and quantify the magnitude of illness, as well as monitor progression, which can be rapid in the highly pathogenic coronaviruses, especially COVID-19, as experience worldwide will attest (1) (2) (3) (4) .

In the earlier stages of COVID -19, as with other highly pathogenic coronaviruses that cause a severe acute respiratory syndrome, chest XRays often reveal various stages of pneumonia (1) (2) (3) (4) (5) (6) (7) . In advancing disease clinical features consistent with acute respiratory distress syndrome (ARDS), and acute cardiac injury may be present (1, (3) (4) (5) . Such patients should rapidly receive a CT scan of the chest, which often reveals various forms of ground glass opacity (GGO). In some cases there are multiple GGO located located in sub-pleural regions of bilateral lungs. These likely influence the immune response, which may lead to significant pulmonary inflammation (1-7).

In early work of Hosseiny et al, the diagnosis of COVID-19 is suspected on the basis of symptoms of pneumonia (e.g., dry cough, fatigue, myalgia, fever, and dyspnea) as well as history of recent travel or exposure to a diagnosed positive COVID-19 patient (1) . [See Section on Case definition and diagnosis later in this article].

Chest imaging plays an important role in both assessment of disease extent and follow-up. Chest radiography typically shows patchy or diffuse asymmetric airspace opacities, similar to other causes of coronavirus pneumonias (8) . Consistent with various early reports, Hosseiny note the first report of patients with COVID-19 described having bilateral lung involvement on initial chest CT in 40 of 41 patients, with a consolidative pattern seen in patients in the ICU and a predominantly ground-glass pattern in patients who were not in the ICU (1,6).

The highly pathogenic coronaviruses SARS, MERS, and COVID-19 share several clinical and radiographic similarities (Table 1 ) (Figures 1 and 2) , with some notable exceptions (1-3,7) . The propensity for COVID-19 to involve both lungs more often and earlier in the illness is increasingly well documented (1). Of note, aggressive testing -radiographic and other modalities, should be utilized early with moderately to severely ill COVID-19 patients owing to significant extrapulmonary illness (1) (2) (3) (4) .

Consider in Figure 1 (9) a CT study obtain from a 27 yo MERS patient. Notice the Lower lung image reveals large right lower lobe and small focal left lower lobe subpleural consolidations. Figure  2 (1) is from a 79 yo COVID-19 patient. Notice bilateral multiple, patchy, and peripheral ground glass opacities (GGO) A study reviewing the initial chest CT findings in 21 individuals with confirmed COVID-19 revealed abnormal findings in 86% of patients, with a majority (16/18) showing bilateral lung involvement (7) . Multifocal ground-glass opacities (GGO) (57%) and consolidation (29%) were also reported. Of note there was a tendency towards peripheral lung involvement (Figs. 2 and 3) (1).

In another study, chest imaging was obtained from a family cluster of seven persons with testing confirmed COVID-19; their studies showed bilateral patchy ground-glass opacities.

There was greater involvement of the lungs reported among older family members (1, 10).

As noted earlier, although imaging features of COVID-19 resemble those of MERS and SARS (1) (2) (3) (4) , it is important to recognize involvement of both lungs on initial imaging is more likely to be seen with COVID-19 (Figures 3 and 4) (1). By comparison, initial chest imaging abnormalities in SARS and MERS more often are unilateral ( The next CT scans (Figures 5 and 6 ) were obtained from a 47 yo man with 2-day history of fever, chills, productive cough, sneezing, and fatigue who presented to the emergency department, and was ultimately diagnosed with COVID-19 (1). As noted in the above CT scans, COVID-19 can cause early and significant pulmonary findings on chest CT, which may progress rapidly. The severity of which may portend early or greater extrapulmonary involvement. The astute clinician will anticipate the potential for rapid clinical deterioration, especially in higher risk populations, as described earlier (including advancing age, frailty, immunosuppressed state -from disease or pharmacotherapy, cardiac and other comorbidities) and manage the patient accordingly. It is worth repeating that individuals considered lower risk have also experienced rapid deterioration, and death, such that the use of risk stratification while important in accelerating management, should be used with the caveat we cannot let our guard down for any patient, as COVID-19 demonstrates an ability to cause rapidly progressive illness even among younger and seemingly more robust adult patients.

Radiology perspective of Coronavirus Disease 2019 (COVID-19): Lessons from Severe Acute Respiratory Syndrome and Middle East Respiratory Syndrome AJR

Coronaviruses: severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus in travelers

Middle East respiratory syndrome coronavirus: what does a radiologist need to know?

Radiology of severe acute respiratory syndrome (SARS): the emerging pathologic-radiologic correlates of an emerging disease

Severe acute respiratory syndrome coronavirus as an agent of emerging and reemerging infection

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

CT imaging features of 2019 novel coronavirus (2019-nCoV)

Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study

Middle East Respiratory Syndrome Coronavirus

A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster