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Assess signs/sx (% reflects sx over dz course) and exposure hx. Non-resp sx may precede fever/resp sx.1 Asymptomatic: ~35%, per CDC; ~½ of SNF pts asymptomatic/presymptomatic;1 81% of cruise ship cohort had no sx2 - Fever may be prolonged or intermittent (83%–99%)3
- Respiratory: cough (59%–82%), 86% of in-pts; SOB (31%-40%),3 80% of inpts;3 sputum, sore throat, congestion, rhinorrhea, hemoptysis1
- Fatigue (44%–70%), anorexia (40%-84%), myalgia (11%-35%)3
- GI: vomiting, diarrhea, nausea1,3
- Neuro: new anosmia, dysgeusia, confusion, HA,1 less often as 1st/only sx;4 dizziness, ↓consciousness, sz, stroke;5 delirium, encephalopathy, encephalitis, agitation/anxiety, affect disorders (eg, in inpts), Guillain-Barre, etc;3
- Atypical presentations may be seen in pts who are older or have underlying conditions,6 (eg, fatigue, ↓alertness/mobility, appetite loss, delirium, diarrhea, absent fever).3 Multisystem Inflammatory Syndrome w/ multi-organ involvement reported in pts <21 yo;1 sx include new confusion, unable to arouse/stay awake, abdo pain, cyanosis, SOB, persistent chest pain/pressure, neck pain, conjunctival injection, rash, etc
- Pregnant pts’ sx not different, but sx like SOB, GI sx, fatigue may overlap w/ pregnancy sx3,6
- Course may deteriorate wk 2; half of pts w/ severe dz had dyspnea @ 5-8 days after sx onset.1 Some pts develop hypercoagulability w/ ↑risk for venous/arterial thrombosis
Assess exposure (eg, unprotected contact w/in 6 ft for 15+ total min): incubation period 2 to 14 days (median, 4-5 days 6); of pts developing sx, 98% do so w/in 11.5 days, 1 consider local case countsAssess comorbidities assoc w/ severe illness1 - Age ≥65 yo (>60 yo, per WHO3)
- Long-term care facility/nursing home residence
- Chronic conditions. T2DM, smoking, heart dz (eg, HF, CAD, cardiomyopathy, pulm HTN), COPD, CKD, Down Syndrome
- Obesity: BMI ≥30
- Pregnancy
- Heme/Onc. cancer, sickle cell dz
- Immunocompromise d/t solid organ txp
- Might ↑risk (limited evidence): overweight (BMI >25 but <30), HTN, mod/severe asthma, T1DM, liver dz, cystic fibrosis, pulmonary fibrosis, cerebrovascular dz, neuro dz (eg, dementia), inherited metabolic dz, thalassemia; or immunocompromise d/t steroids or other drugs, bone marrow txp, HIV, immune deficiency dz
- Health/Societal inequities that ↑risk of COVID-19 infxn and/or severe COVID-19 dz: rural residence, non-Hispanic Black, Hispanic/Latino, American Indians/Alaskan Natives
Post-COVID persistent sx (incl in pts w/ mild dz) may last months:6 - Cardiopulm & general: fatigue, palpitations, SOB
- Localized pain: joints, chest, myalgia
- Psych (less frequent in pts >60 yo): anxiety, depression, mood changes
- Neuro: HA, vision changes, ↓hearing, ↓taste/smell, impaired mobility, numb extremities, tremor, memory loss, cognitive impairment
Footnotes 1 CDC 2021. Healthcare Workers: Information on COVID-19. Updated 12/27/21. Accessed 4/1/22
• Clinical Care Information for COVID-19. Updated 4/17/21. Accessed 4/1/22
• Interim Clinical Guidance for Management of Patients With Confirmed Coronavirus Disease (COVID-19). Updated 2/16/21. Accessed 4/1/22
• People With Certain Medical Conditions. Updated 2/25/22. Accessed 4/1/22
Kimball A, et al. Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility — King County, Washington, March 2020. Morb Mortal Wkly Rep. 2020. Apr 3;69(13):377–381. PubMed abstract | Free full-text PDF
Burke RM et al, Symptom Profiles of a Convenience Sample of Patients with COVID-19 - United States, January-April 2020. Morb Mortal Wkly Rep. 2020. Jul 17;69(28):904-908. PubMed abstract
Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With Coronavirus Disease 2019 (COVID-19). CDC Health Alert Network 00432. May 14, 2020. Free full-text article online
Multisystem Inflammatory Syndrome in Children (MIS-C) Case Definition requires all of these 3:
1) Clinical manifestations
• <21 yo
• fever lasting ≥24h (subjective or T>38.0°C)
• lab evidence of inflammation (eg, any of ↑CRP, ESR, fibrinogen, procalcitonin, d-dimer, ferritin, LDH, IL-6, neutrophils; ↓lymphocytes, albumin)
• severe illness requiring hospital care, w/ >2 organs (cardiac, renal, resp, hematologic, GI, derm, neuro) involved
2) No alternative plausible diagnosis
3) COVID-19 status:
• positive by RT-PCR, serology, or antigen test; OR
• COVID-19 exposure w/in 4wk prior to sx onset
Notes: Report to local/state health dept cases that meet definition, even if Kawasaki dz full/partial criteria fulfilled. Consider MIS-C in pedi deaths w/ SARS-CoV-2 infxn.
2 Ing AJ, et al. COVID-19: In the Footsteps of Ernest Shackleton. Thorax. 2020. May 27;thoraxjnl-2020-215091. Online ahead of print. PubMed abstract
3 WHO 2021. Living Guidance for Clinical Management of COVID-19. World Health Organization. Updated 11/23/21. Accessed 4/1/22
4 Spinato G, et al. Alterations in Smell or Taste in Mildly Symptomatic Outpatients With SARS-CoV-2 Infection. JAMA. April 22, 2020. Research Letter
Phone survey (N=374 mildly sx COVID+ adults), 64% self-reported smell/taste alteration; of these, 35% also reported blocked nose. Noticed prior to other sx (in 12%), simultaneous w/ other sx (23%), after other sx (27%), or as only sx (3%).
5 Mao L, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. April 10, 2020. Accessed 4/14/20
• Wuhan, China case series (N=214 mod/severe inpts; mean age, 52.7 yo)
• Neuro sx seen in 36%, more so w/ severe dz, but may be presenting sx in pts w/o typical cough/fever
• Sx: dizziness (17%), HA (13%), skeletal muscular pain (11%), ↓consciousness (8%), ↓taste (6%), ↓smell (5%). Stroke, sz also reported.
6 NIH 2021. COVID-19 Treatment Guidelines. COVID-19 Treatment Guidelines Panel. Clinical Spectrum of SARS-CoV-2 Infection. Updated 10/19/21. Accessed 4/1/22
Sign/sx/hx eval complete, awaiting testing Virus test symptomatic pts & those w/ close contact (w/in 6 ft for 15+ total min) w/ known case. Coinfections may occur1 Determine disposition based on sx; isolate/implement prevention control measures; report cases, persons under investigation to health dept;1 - Mildly ill stable pt (incl no signs of pneumonia/hypoxia).2 If isolating at home: Educate about when to seek care (eg, trouble breathing, persistent chest pain/pressure, new confusion, unable to awaken, blue lips/face).1 Pts who are older, have underlying conditions, or immunocompromise are @ higher risk, so should contact physician early, even for mild sx,1 and warrant closer monitoring2
- Mod dz. Non-severe pneumonia signs (fever, cough, SOB, ↑RR, SpO2 ≥90% on room air)2
- Severe sx. Pneumonia signs (fever, cough, dyspnea, rapid breathing plus 1+ of these: RR >30, severe resp distress, SpO2 <90% on room air)2,3 warrant immediate care1,2
- Critical illness/Multisystem Inflammatory Syndrome signs/sx2 warrant emergency care1
Footnotes 1 CDC 2021. Healthcare Workers: Information on COVID-19. Updated 12/27/21. Accessed 4/1/22
• Clinical Care Information for COVID-19. Updated 4/17/2. Accessed 4/1/22
• Interim Clinical Guidance for Management of Patients With Confirmed Coronavirus Disease (COVID-19). Updated 2/16/21. Accessed 4/1/22
• People With Certain Medical Conditions. Updated 2/25/22. Accessed 4/1/22
Kimball A, et al. Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility — King County, Washington, March 2020. Morb Mortal Wkly Rep. 2020. Apr 3;69(13):377–381. PubMed abstract | Free full-text PDF
Burke RM et al, Symptom Profiles of a Convenience Sample of Patients with COVID-19 - United States, January-April 2020. Morb Mortal Wkly Rep. 2020. Jul 17;69(28):904-908. PubMed abstract
Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With Coronavirus Disease 2019 (COVID-19). CDC Health Alert Network 00432. May 14, 2020. Free full-text article online
Multisystem Inflammatory Syndrome in Children (MIS-C) Case Definition requires all of these 3:
1) Clinical manifestations
• <21 yo
• fever lasting ≥24h (subjective or T>38.0°C)
• lab evidence of inflammation (eg, any of ↑CRP, ESR, fibrinogen, procalcitonin, d-dimer, ferritin, LDH, IL-6, neutrophils; ↓lymphocytes, albumin)
• severe illness requiring hospital care, w/ >2 organs (cardiac, renal, resp, hematologic, GI, derm, neuro) involved
2) No alternative plausible diagnosis
3) COVID-19 status:
• positive by RT-PCR, serology, or antigen test; OR
• COVID-19 exposure w/in 4wk prior to sx onset
Notes: Report to local/state health dept cases that meet definition, even if Kawasaki dz full/partial criteria fulfilled. Consider MIS-C in pedi deaths w/ SARS-CoV-2 infxn.
2 WHO 2021. Living Guidance for Clinical Management of COVID-19. World Health Organization. Updated 11/23/21. Accessed 4/1/22
3 NIH 2021. COVID-19 Treatment Guidelines. COVID-19 Treatment Guidelines Panel. Clinical Spectrum of SARS-CoV-2 Infection. Updated 10/19/21. Accessed 4/1/22
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Assess signs/sx, exposure (eg, unprotected contact w/in 6 ft for 15+ total min). Non-resp sx may precede fever/resp sx1 - Pedi sx may be milder than adults; 16%-45% may be w/o sx.1 Cough, fever most common; signs/sx may mimic other pedi illnesses (eg, flu, strep throat, allergic rhinitis)
- Sx: fever/chills, cough1 (w/ or w/o sputum2), URI sx (nasal congestion, sore throat, rhinorrhea); SOB, GI sx (abd pain, N/V, diarrhea), may occur,1 as well as fatigue, anorexia or poor feeding, lethargy, malaise, myalgia, HA,1,2 agitation, confusion, encephalitis, Guillain-Barre, etc.2 Cough, fever are main sx, per WHO; co-infection w/ other resp pathogens possible.1,2 New anosmia, dysgeusia reported.1 Neonate sx: fever, lethargy, rhinorrhea, cough, tachypnea/↑work of breathing, emesis, diarrhea, feeding intolerance, ↓intake, etc1
- Atypical presentations. May be seen in pts w/ underlying conditions.1 Multisystem Inflammatory Syndrome reported in pts <21 yo w/ fever ≥24h, 2+ organs involved (eg, derm, resp, GI, cardiac, neuro), etc;1 sx include new confusion, unable to awaken, abdo pain, cyanosis, SOB, persistent chest pain/pressure, neck pain, conjunctival injection, rash, etc1
- Course may deteriorate wk 2; fever may be prolonged or intermittent1
Assess exposure (eg, unprotected contact w/in 6 ft ≥15min): incubation period 2 to 14 days (median, 4-5 days 3); of pts developing sx, 98% do so w/in 11.5 days, 1 consider local case counts; in China, most child cases had household exposure 1Assess comorbidities associated w/ severe illness;1 most children w/ severe illness have underlying condition(s), (though); evidence limited:1 - Conditions that might ↑risk of severe illness: obesity, asthma/other chronic lung dz (eg, CF), medically complex children, severe genetic/neuro dz, inherited metabolic dz, smoking, diabetes, CKD, congenital heart dz, sickle cell dz, immunosuppression d/t malignancy or immunosuppressive drugs
- Infants <12 mo old may be @ ↑risk of severe illness
- Pregnancy is assoc w/ ↑risk of severe illness
- Health/Societal inequities. Hospitalization rate higher in Hispanic/Latino & Black non-Hispanic children; may be related to ↑rates of obesity & other underlying conditions; rural residence
Post-COVID persistent sx (incl in pts w/ mild dz) may last months:3 - Cardiopulm & general: fatigue, palpitations, SOB
- Localized pain: joints, chest, myalgia
- Psych: anxiety, depression, mood changes
- Neuro: HA, vision changes, ↓hearing, ↓taste/smell, impaired mobility, numb extremities, tremor, memory loss, cognitive impairment
Footnotes 1 CDC 2021. Healthcare Workers: Information on COVID-19. Updated 12/27/21. Accessed 4/1/22
• Clinical Care Information for COVID-19. Updated 4/17/21. Accessed 4/1/22
• Interim Clinical Guidance for Management of Patients With Confirmed Coronavirus Disease (COVID-19). Updated 2/16/21. Accessed 4/1/22
• People With Certain Medical Conditions. Updated 2/25/22. Accessed 4/1/22
• Information for Pediatric Healthcare Providers. Updated 12/30/20. Accessed 4/1/22
Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With Coronavirus Disease 2019 (COVID-19). CDC Health Alert Network 00432. May 14, 2020. Free full-text article online
Multisystem Inflammatory Syndrome in Children (MIS-C) Case Definition requires all of these 3:
1) Clinical manifestations
• <21 yo
• fever lasting ≥24h (subjective or T>38.0°C)
• lab evidence of inflammation (eg, any of ↑CRP, ESR, fibrinogen, procalcitonin, d-dimer, ferritin, LDH, IL-6, neutrophils; ↓lymphocytes, albumin)
• severe illness requiring hospital care, w/ >2 organs (cardiac, renal, resp, hematologic, GI, derm, neuro) involved
2) No alternative plausible diagnosis
3) COVID-19 status:
• positive by RT-PCR, serology, or antigen test; OR
• COVID-19 exposure w/in 4wk prior to sx onset
Notes: Report to local/state health dept cases that meet definition, even if Kawasaki dz full/partial criteria fulfilled. Consider MIS-C in pedi deaths w/ SARS-CoV-2 infxn.
2 WHO 2021. Living Guidance for Clinical Management of COVID-19. World Health Organization. Updated 11/23/21. Accessed 4/1/22
3 NIH 2021. COVID-19 Treatment Guidelines. COVID-19 Treatment Guidelines Panel. Clinical Spectrum of SARS-CoV-2 Infection. Updated 10/19/21. Accessed 4/1/22
Sign/sx/hx eval complete, awaiting testing Virus test symptomatic pts & those w/ close contact (w/in 6 ft for 15+ total min) w/ known case. Coinfections may occur 1
- COVID-19 signs/sx
- Recent exposure to known/suspected case; testing recommended for all neonates born to mother w/ suspected/ confirmed COVID-19 regardless of absence of signs/sx in mother & neonate
- Periodic testing (incl asymptomatic pts) for early detection in close-quarter, vulnerable settings (eg, long-term care facilities)
- Public health surveillance
Determine disposition based on sx; isolate/implement prevention control measures; report cases, persons under investigation to health dept1 - Mildly ill stable pt (incl no signs of pneumonia/hypoxia).2 If isolating at home: Educate family about when to seek care (eg, trouble breathing, persistent chest pain/pressure, new confusion, unable to awaken, blue lips/face;1 infant grunting, unable to feed/drink/interact, etc2). Pts w/ underlying conditions or immunocompromise are @ higher risk, so should contact physician early, even for mild sx,1 and warrant closer monitoring2
- Mod dz. Non-severe pneumonia signs: adolescent w/ fever, cough, SOB, ↑RR, SpO2 ≥90% on room air; child w/ cough/ breathing difficulty plus chest indrawing +/or ↑RR (<2 mo old ≥60; 2-11 mo ≥50; 1-5 yo ≥40)2
- Severe sx. Adolescent w/ pneumonia signs (fever, cough, dyspnea, rapid breathing plus 1+ of these: RR >30, severe resp distress, SpO2 <90% on room air).2,3 Child w/ pneumonia signs (cough/SOB) plus 1+ of these: central cyanosis, SpO2 <90%, severe resp distress (fast RR, grunting, very severe chest indrawing), general danger sign (unable to breastfeed/drink, lethargy/unconsciousness, convulsions), ↑RR by age (<2 mo ≥60; 2–11 mo ≥50; 1–5 yo ≥40)2,3 warrant immediate care1,2
- Critical illness/Multisystem Inflammatory Syndrome signs/sx2 warrant emergency care1
Footnotes 1 CDC 2021. Healthcare Workers: Information on COVID-19. Updated 12/27/21. Accessed 4/1/22
• Clinical Care Information for COVID-19. Updated 4/17/21. Accessed 4/1/22
• Interim Clinical Guidance for Management of Patients With Confirmed Coronavirus Disease (COVID-19) Updated 2/16/21. Accessed 4/1/22
• People with Certain Medical Conditions Updated 2/25/22. Accessed 4/1/22
• Information for Pediatric Healthcare Providers. Updated 12/30/20. Accessed 4/1/22
Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With Coronavirus Disease 2019 (COVID-19). CDC Health Alert Network 00432. May 14, 2020. Free full-text article online
Multisystem Inflammatory Syndrome in Children (MIS-C) Case Definition requires all of these 3:
1) Clinical manifestations
• <21 yo
• fever lasting ≥24h (subjective or T>38.0°C)
• lab evidence of inflammation (eg, any of ↑CRP, ESR, fibrinogen, procalcitonin, d-dimer, ferritin, LDH, IL-6, neutrophils; ↓lymphocytes, albumin)
• severe illness requiring hospital care, w/ >2 organs (cardiac, renal, resp, hematologic, GI, derm, neuro) involved
2) No alternative plausible diagnosis
3) COVID-19 status:
• positive by RT-PCR, serology, or antigen test; OR
• COVID-19 exposure w/in 4wk prior to sx onset
Notes: Report to local/state health dept cases that meet definition, even if Kawasaki dz full/partial criteria fulfilled. Consider MIS-C in pedi deaths w/ SARS-CoV-2 infxn.
2 WHO 2021. Living Guidance for Clinical Management of COVID-19. World Health Organization. Updated 11/23/21. Accessed 4/1/22
3 NIH 2021. COVID-19 Treatment Guidelines. COVID-19 Treatment Guidelines Panel. Clinical Spectrum of SARS-CoV-2 Infection. Updated 10/19/21. Accessed 4/1/22
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