Infectious Disease

CDC

Among hospitalized patients, research frequently reports that the signs and symptoms of COVID-19 include:

• Fever.
• Cough.
• Myalgia or fatigue.
• Shortness of breath at illness onset.

Other less commonly reported respiratory symptoms include:

• Sore throat.
• Headache.
• Cough with sputum production or hemoptysis.

Some patients have experienced gastrointestinal symptoms, such as diarrhea and nausea, prior to developing fever and lower respiratory tract signs and symptoms.

Review Clinical Presentation From the CDC

American College of Gastroenterology

The American College of Gastroenterology, in partnership with other gastroenterology (GI) organizations, has released a message sharing additional GI-related COVID-19 symptoms:

• The incidence of GI symptoms including nausea and/or diarrhea are uncertain with some reports below 5% and others at 50%. There have been some reports of isolated diarrhea preceding cough and fever.
• The virus may be present in GI secretions and viral RNA is detectable in stool. Gastrointestinal infection and potential fecal-oral transmission must be considered.
• Asymptomatic spread can occur during the prodromal phase (the mean incubation period is around five days, with a range of zero to 14 days), with viral shedding greatest when symptoms begin.
• Abnormal liver enzymes are observed in 20-30% of patients confirmed to have COVID-19.
• Leukocyte counts drop in patients confirmed to have COVID-19, and elevated white blood cell count is a poor prognostic sign.

Review GI Symptoms

CDC

Reported cases have ranged from very mild (including some with no reported symptoms) to severe cases resulting in death. Those who are at a higher risk of developing serious COVID-19 symptoms include:

• Adults aged 65 years or older.
• People who have serious underlying medical conditions, such as heart disease, diabetes, asthma and lung disease.

In addition to clinical symptoms, nurse practitioners (NPs) may want to consider whether:

• The patient has recently traveled from an affected area.
• The patient has been in close contact with someone diagnosed with COVID-19 or someone diagnosed with pneumonia of an unknown cause.
• The patient resides in an area where there has been community spread of COVID-19.

Review CDC Clinical Guidance

CDC

Currently, 95 public health laboratories have completed verification and are offering testing, including one or more in all 50 states plus Washington D.C., Guam, the U.S. Virgin Islands and Puerto Rico. The CDC recommends health care providers should use their best judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. This includes:

• Hospitalized patients who have signs and symptoms compatible with COVID-19.
• Other symptomatic individuals, such as older adults and individuals with chronic medical conditions and/or an immunocompromised state.
• Anyone who, within 14 days of symptom onset, had close contact with a suspect or laboratory-confirmed COVID-19 patient or who have a history of travel from affected geographic areas within 14 days of their symptom onset.

Review CDC Interim Guidance on Evaluating and Testing

In addition, as of March 14, public health laboratories using the CDC assay are no longer required by the Federal Drug Administration (FDA) to submit samples to the CDC for confirmation. The CDC is maintaining surge capacity while delivering other support to state public health laboratories and improving options for diagnostics for use in the public health sector.

FDA

As of April 1, 23 emergency use authorizations have been issued for diagnostic tests. Additionally, the FDA has been notified that more than 110 laboratories have begun testing.

CDC

All health care providers, including NPs, should take steps to prepare for COVID-19 in their practice as well as follow recommended infection control procedures to protect themselves and others:

• Limit how germs can enter health care facilities. This may include:
  • Canceling elective procedures.
  • Using telehealth when possible.
  • Limiting points of entry and managing visitors.
  • Screening patients for respiratory symptoms.
  • Encouraging patient respiratory hygiene using alternatives to face masks.
• Isolate symptomatic patients as soon as possible. This may include:
  • Setting up separate, well-ventilated triage areas.
  • Placing patients with suspected or confirmed COVID-19 in private rooms with the door closed and with a private bathroom.
  • Prioritizing airborne infection isolation rooms (AIIRs) for patients undergoing aerosol-generating procedures.
• Protect health care personnel. This may include:
  • Emphasizing hand hygiene.
  • Installing barriers to limit contact with patients at points of triage.
  • Limiting the number of staff members providing care.
  • Prioritizing respirators and AIIRs for aerosol-generating procedures.
  • Implementing personal protection equipment (PPE) optimization strategies to extend supplies.

• Thoroughly clean and disinfect surfaces in all high-traffic, frequently touched areas and at home, including:
  • Stair rails, escalator handrails, office computers and phones.
  • Steering wheels and car door handles.
  • Home door handles and faucet handles, refrigerator and drawer handles, remote controls, and computer keyboards and mice.

Review CDC Interim Guidance on Infection Prevention and Control

American College of Gastroenterology

The American College of Gastroenterology, in partnership with other gastroenterology (GI) organizations, has released a message sharing additional guidelines for infection control in for clinicians and GI practices, which includes:

• Patients on immunosuppressive drugs for irritible bowel disease (IBD) and autoimmune hepatitis should continue taking their medications. The risk of disease flare outweighs the chance of contracting COVID-19. These patients should also follow CDC guidelines for at-risk groups by avoiding crowds and limiting travel.
• Strongly consider rescheduling elective non-urgent endoscopic procedures. Some non-urgent procedures are higher priority and may need to be performed, such as cancer evaluations, prosthetic removals and the evaluation of significant symptoms. Classifying procedures into non-urgent/postpone and non-urgent/perform may be useful. Of note, on March 14, the Surgeon General advised hospitals to postpone all elective surgeries.

Review Guidelines for GI Practices

CDC

Currently, COVID-19 transmission is thought to occur mostly from person to person via respiratory droplets among close contacts. If health care providers are in close contact with a patient confirmed to have COVID-19 while not wearing all recommended PPE, they may be at an increased risk of infection.

To limit this risk, health care providers should follow the CDC's recommendations for infection prevention and control:

• Assess and triage patients with acute respiratory symptoms and risk factors for COVID-19 to minimize chances of exposure. This includes placing a face mask on the patient and placing them in an examination room with the door closed.
• Use standard and transmission-based precautions when caring for patients with confirmed or possible COVID-19.
• Perform hand hygiene with alcohol-based hand rub before and after all patient contact, before and after contact with potentially infectious material and before putting on and upon removal of PPE. Use soap and water if hands are visibly soiled.
• Practice how to properly don, use and doff PPE in a manner to prevent self-contamination.
• Perform aerosol-generating procedures, in an AIIR, while following appropriate infection prevention and control practices, including in the use of appropriate PPE.

As a public health reminder, the CDC encourages health care facilities and clinicians to prioritize urgent and emergency visits and procedures in order to preserve staff, personal protective equipment and patient care supplies; ensure staff and patient safety; and expand available hospital capacity during the COVID-19 pandemic.

Recommendations include:

• Delay all elective ambulatory visits.
• Reschedule elective and non-urgent admissions.
• Delay inpatient and outpatient elective surgical and procedural cases
• Postpone routine dental and eye care visits.

Review CDC Recommendations for Health Care Providers

FDA

The FDA has issued an emergency use authorization to allow for certain ventilators, anesthesia gas machines modified for use as ventilators, positive pressure breathing devices modified for use as ventilators, ventilator tubing connectors and ventilator accessories that the FDA determines meet specified criteria for safety, performance and labeling to be used in health care settings.

On March 30, 2020, the FDA issued guidance to help expand the availability of surgical apparel for health care professionals, including gowns (togas), hoods and surgeon’s and patient examination gloves. In addition, the FDA outlined an enforcement policy to help expand the availability and capability of sterilizers, disinfectant devices and air purifiers.

WHO

WHO has expanded its Operational Planning Guidelines to Support Country Preparedness and Response to include new Operational Guidance for Maintaining Essential Health Services During an Outbreak.

CDC

Telehealth is suggested by the CDC as an alternative for in-office appointments, as triaging and assessing ill patients by telephone, text monitoring system, video conference or other telehealth methods can reduce the chance of exposure for staff members and minimize a surge on health care facilities.

AANP

AANP's COVID-19 Telehealth Updates include several Centers for Medicare and Medicaid (CMS) documents related to telehealth, as well as information on policies and legislation affecting telehealth-delivered care.

View COVID-19 Telehealth Updates

FDA

On March 31, the FDA began the Coronavirus Treatment Acceleration Program (CTAP) to bring new therapies to sick patients as quickly as possible while supporting research to further evaluate whether these therapies are safe and effective.

On March 28, 2020, the FDA issued an emergency use authorization to allow hydroxychloroquine sulfate and chloroquine phosphate products donated to the Strategic National Stockpile (SNS) to be distributed and used for certain hospitalized patients with COVID-19.

As of March 24, the FDA has stated that there is no scientific evidence connecting the use of non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, with worsening COVID-19 symptoms.

U.S. National Library of Medicine

A number of drugs are under investigation in clinical trials or are being considered for clinical trials to treat COVID-19.

View Clinical Studies Related to COVID-19

On March 16, President Trump announced COVID-19 guidelines for the U.S., which have since been extended through April 30. The guidelines include, among other recommendations:

• Avoid social gatherings in groups of more than 10 people.
• Avoid eating or drinking at bars, restaurants and food courts — use drive thru, pick up or delivery. In states with evidence of community transmission, bars, restaurants, food courts, gyms and other indoor and outdoor venues where groups of people congregate should be closed.
• Avoid discretionary travel, shopping trips and social visits.
• Governors of states with evidence of community transmission should close schools in affected and surrounding areas. Governors should close schools in communities that are near areas of community transmission, even if those areas are in neighboring states. In addition, state and local officials should close schools where COVID-19 has been identified in the population associated with the school.

See the Administration's Coronavirus Guidelines for America

This presentation provides the NP with a guide that encompasses how and when to screen for hepatitis C, current treatment modalities, when to refer to transplant, treatment of complicated populations with HCV and how to educate the patient for long-term management of chronic liver disease.

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Mumps is a viral infectious disease that historically was a common childhood illness. The mumps vaccine, first licensed in 1967, has successfully decreased the number of cases to the point that mumps is no longer a frequently encountered disease. Prior to the mumps vaccine program, approximately 186,000 cases of mumps were reported each year in the United States (U.S.). Even with the sporadic clusters of re-emergence, there has been a 99% decrease in the number of reported cases since the inception of the vaccination program. As of July 15, 2017, there have been 3,886 cases of mumps reported this year in 45 states, making it a clinically relevant, though not prevalent, illness. Although not a new illness, many health care providers may not have diagnosed or treated patients diagnosed with mumps. Here, we provide vital information to NPs, so they may adequately diagnose and treat mumps as well as remain vigilant in their surveillance of such an old virus that continues to infect individuals today.

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The CDC estimates that there were 37,600 new HIV infections in 2014. Pre-exposure prophylaxis (PrEP) is a highly effective tool for the prevention of new HIV infections that was approved by the FDA in 2012. PrEP is largely under utilized by primary care providers. This clinical feature addresses provider barriers that impede prescribing PrEP to high-risk patients and provides a straightforward approach for NPs to offer PrEP in the primary care setting.

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