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Coronavirus 19
From WikiSM
Other Names
- Covid 2019
- Covid-19
- Coronavirus 2019
- Coronavirus Disease 2019
Background
- This page refers to Coronavirus 19 (Covid-19), a novel coronavirus which causes viral pneumonia and started
History
- Confirmed to have originated in the city of Wuhan, Hubei province in China in December 2019[1]
- Declared a pandemic by the World Health Organization
Epidemiology
- As of 5/31/20, there are 6,165,181 confirmed cases with 371,995 deaths
- Note that this data is updated daily[2]
Pathophysiology
- Enters the body through respiratory droplets
- Person-to-person spread is primary vector
- Individuals cough, sneeze or come in contact with another person's mucous membranes
- Rate of transmission is estimated to be 1-5% (need citation)
- Similar to other coronaviruses (including SARS, MERS)
- Suspected etiology is animal market, specifically Bats
Risk Factors
- Older age confers greater risk of
- Illness
- Death
- Mostly surrounding chronic disease
- Diabetes Mellitus
- Hypertension
- Chronic Kidney Disease
- Cardiovascular Disease
- Obesity
- Chronic Lung Disease
Differential Diagnosis
- Influenza
- Upper Respiratory Infection
- Bacterial Pneumonia
- Bronchitis
- Asthma
- Exercise Induced Asthma
- Exercise Induced Bronchospasm
Clinical Features
- History
- Incubation period after exposure up to 14 days
- May patients are asymptomatic
- Patients who are symptomatic may endorse fever (99%), dry cough (59%), myalgias, fatigue, shortness of breath
- Fever and cough are initial symptoms
- Shortness of breath takes an average of 9 days to present
- Less commonly, patients may endorse headache, sore throat, nausea, vomiting, nasal congestion
- Some patients may endorse anosmia (lack of smell), dysgeusia or ageusia (loss of taste)
- Physical Exam
- Careful cardiopulmonary examination
- Close attention to vital signs, patients may be profoundly hypoxic but well appearing
Evaluation
Radiographs
- Chest Xray
- Portable is preferred to minimize exposure to staff
- Sensitivity 59% (need citation)
- Findings
- Normal early
- Patchy, multifocal infiltrates
- In ill patients, may see ground glass opacities
CT
- Not indicated for diagnostic imaging
- May be normal early in disease process
- Sensitivity 86% (need citation)
Ultrasound
- Role of pulmonary/ lung ultrasound in Covid19 unclear
Laboratory
- Test kits vary by region
- RT-PCR (reverse transcriptase polymerase chain reaction)
- Most commonly used for confirming tests
- Sensitivity 75%, specificity high (need citation)
- Turnaround hours-days
- Real Time PCR
- Aka "rapid test"
- Turn around in <1 hour typically
- Serology
- Testing for IgG, IgM not widely available yet
- Some test kits may not distinguish antibodies from other coronaviruses
- Need more research, better test kits to clarify roll
Classification
Prevention
- Prevention of transmission among athletes, staff, fans and community at large is critical
Impact on Sports
- All spring sports for college were cancelled or postponed to help reduce or prevent transmission
- Professional leagues are currently evaluating their options to safely return to sport
Goals of Prevention
- Reduce risk of spread to community
- Minimize interruptions in training, competition
- Minimize transmission or spread to opposing teams
- Minimize risk on individual athletes ability to perform at highest level
Prevention Recommendations
- Hand Hygiene
- Hand sanitizer with at least 60% alcohol
- Soap and water (superior to hand sanitizer)
- Disinfecting common areas
- Areas that are frequently visited or touched should be cleaned regularly
- Social Distancing
- Athletes should avoid high risk exposures by social distancing
- CDC recommendation is areas where you can maintain 6 feet of distance[5]
- Avoid mass gatherings, congregations
- Travel
- Travel restrictions have been implemented in various degrees around the world
- Athletes should follow their regional guidelines
- When traveling from high risk areas, they will need to quarantine for 14 days
- Face Mask
- At this time, recommendations for or against wearing a face mask in public are limited
- If athletes choose to wear a face mask, they should not use medical equipment designated for healthcare workers.
- N95 masks should be reserved for high risk workers only
Training Modification
- Excessive training can stress the immune system
- Some experts are suggesting modification of training to reduce risk of this phenomenon
- One approach is to limit training session to less than 60 minutes at less than 80% of maximal exertion
- No evidence to really support this approach[6]
Immunization
- As of 6/1/20 there are no vaccines available
- Estimated end of 2020 or into 2021
Management
Testing
- Testing options reviewed in detail above
- Athletes should be tested if symptomatic, immunocompromised or in close contact with someone with Covid-19
Prognosis
- In general, athletes are younger age with fewer comorbidities
- Thus lower risk for severe disease and death
- Roughly 10% of individuals age 18-45 required hospitalization
- Mostly due to hypoxia
- This is likely an overestimated percentage due to limited testing availability and many asymptomatic patients who are not tested
Management
- If the patient is very symptomatic or ill appearing, they should be evaluated clinically
- Patient should have puleox >93% on RA, RR under 20, HR under 110 when afebrile
- If patient is determined to be sick, they should be directed to the nearest emergency department
- Isolation
- Recommended for athletes with confirmed, suspected Covid-19
- Other members of household should be isolated away from athlete
- Antipyretics
- Acetaminophen, NSAIDS
- Concern about NSAID use is theoretical, best evidence currently supports their safety
- Corticosteroids
- Not indicated unless other comorbidities such as Asthma
- Other Medications
- Symptomatic management with anti-tussive, decongestants, etc is recommended at clinician discretion
Drugs Under Investigation
- Remdesivir
- May shorten duration of illness
- Currently only recommended in critically ill
- Not recommended or available for outpatient use at this time
- Lopinavir / Ritonavir (Kaletra)
- Used in MERS, SARS
- At this time, no known benefit for Covid-19[7]
- Hydroxychloroquine
- Not recommended for treatment or prophylaxis based upon best available evidence
- Azithromycin
- Recommended if suspected bacterial co-infection[8]
- Other drugs not indicated
- Oseltamivir
- Baloxavir marboxil
- Ribavirin
Team Management
- If an athlete develops symptoms consistent with Covid-19 or confirmed case
- Exposed teammates, coaches and other staff in the previous 14 days should begin home isolation
- If the athlete who is symptomatic undergoes testing and it is negative
- Exposed teammates and staff can discontinue isolation
- Teams should be prepared to expand testing to exposed, asymptomatic athletes and staff
- Important to have a plan in place with a testing facility
- Consider implementing daily temperature checks (prior to exercise)
Discontinuing Isolation
- Home isolation can be discontinued if the following conditions are met[9]
- Absence of fever
- Resolution of respiratory symptoms
- Two consecutive negative Covid-19 tests collected 24 hours apart (controversial)
- Non-testing strategy
- 7 days since apperance of symptoms
- 72 hours since last symptoms were present (without use of antipyretics)
Mental Health
- Suspended and cancelled seasons can be distressing for athletes
- Can lead to grief, stress, anxiety, frustration, and sadness for an athlete[10]
- Sports medicine physicians and staff should anticipate this need
- Ensure regular check in with athletes
- Arrange for telehealth consultation with a psychiatrist or sports psychologist
- Encourage maintaining social circle in the context of social distancing
Rehabilitation
Return to Play
- Goal: mitigage and minimize risk to athletes, team staff, facility staff, community at large
Sick Athletes
- Athletes must be asymptomatic prior to return to standard training or play
- Energy levels should have returned to normal
- Vital signs at rest should be normal
- During the the tail end of isolation, athletes can consider light, low-intensity training at home
- Coach, physical therapist, strength and conditioning coachs, etc will have to individualize plans with athletes
New Normal
- We are going to see a 'new normal' in the Covid-19 era in sports
- Using the best information we have available, what is normal for a team will have to be different from what it was prior to Covid-19
- Many practices might change
- Recognize that we can not reduce risk to zero
- Screening of athletes prior to participation/ RTP
- Increased education to coaches, staff, families
- Health screenings
- Temperature check
- Encourage self reporting of symptoms
- Disinfect everything
- Consider the following during games and practices
- Avoid locker rooms when possible
- Use proper social distancing when practical
- Do not share water bottles
- Elimination of team huddles
- Elimination of handshakes, fist bumps
- Coaches, officials should wear masks
- Sanitize gear when possible
Facility Changes
- Increased signage
- Consider traffic patterns
- Bathrooms
- Increased cleaning of high frequency points
Changes for Players and Families
- Increased distance for spectators
- Fewer or no fans
- Must wear mask
Communication
- Critical for all stakeholders
- Utilize
- Phone
- Text
- Increased Signage
- Social Media
Staged Return for Teams
- Recognition that some sports are higher risk than others
- High risk: team sports, contact sports, collision sports
- Lower risk: individual sports such as golf, tennis, track
- Most teams and leagues are recommended some form of staged return
- Each stage should last 2 weeks (or some other predetermined time) to ensure there are no outbreaks
- USA Lacrosse has a well outlined, 5 stage RTP[11]
- Outlines risk, goals, hygiene and social distancing, facility or venue, training and injury prevention
- Stage 1: At home individual training
- Stage 2: Small Group (less than 10) Modified Lacrosse Activity/Practice
- Stage 3: Medium group (less than 50) Modified intra-squad scrimmages/practices
- Stage 4: Medium group (less than 50) local competition/practices from teams within same locale
- Stage 5: Larger group gatherings (more than 50) and full competition resumption
Complications
- Death
- Pneumonia
- Acute respiratory distress syndrome (ARDS)
- Myocarditis
See Also
- Infectious Disease (Main)
- External
References
- ↑ https://www.who.int/westernpacific/emergencies/covid-19
- ↑ https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6
- ↑ National Basketball Association . NBA to suspend season following Wednesday’s games. https://www.nba.com/article/2020/03/11/nba-suspend-season-following-wednesdays-games.
- ↑ nternational Olympic Committee . Joint statement from the International Olympic Committee and the Tokyo 2020 Organising Committee. https://www.olympic.org/news/joint-statement-from-the-international-olympic-committee-and-the-tokyo-2020-organising-committee.
- ↑ Centers for Disease Control and Prevention . Coronavirus disease 2019 (COVID-19) risk assessment and management. https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html.
- ↑ Campbell, JP, Turner, JE. Debunking the myth of exercise-induced immune suppression: redefining the impact of exercise on immunological health across the lifespan. Front Immunol. 2018;9:648.
- ↑ Cao, B., Wang, Y., Wen, D., Liu, W., Wang, J., Fan, G., ... & Li, X. (2020). A trial of lopinavir–ritonavir in adults hospitalized with severe Covid-19. New England Journal of Medicine.
- ↑ https://www.massgeneral.org/assets/MGH/pdf/news/coronavirus/mass-general-COVID-19-treatment-guidance.pdf
- ↑ Centers for Disease Control and Prevention . Discontinuation of home isolation for persons with COVID-19 (interim guidance). https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html.
- ↑ Toresdahl, B. G., & Asif, I. M. (2020). Coronavirus Disease 2019 (COVID-19): Considerations for the Competitive Athlete. Sports Health, 12(3), 221–224.
- ↑ https://www.uslacrosse.org/return-to-play
