Evidence and experience based resources for managing Covid-19 in primary care
Table of Contents
(1) Coronavirus disease 2019 (COVID-19) – BMJ Best Practice
Management predominantly depends on disease severity, and focuses on the following principles: isolation at a suitable location; infection prevention and control measures; symptom management; optimised supportive care; and organ support in severe or critical illness.
Consider whether the patient can be managed at home. Generally, patients with asymptomatic or mild disease can be managed at home or in a community facility.
Admit patients with moderate or severe disease to an appropriate healthcare facility. Assess adults for frailty on admission. Patients with critical disease require intensive care; involve the critical care team in discussions about admission to critical care when necessary. Monitor patients closely for signs of disease progression.
Start supportive care according to the clinical presentation. This might include oxygen therapy, intravenous fluids, venous thromboembolism prophylaxis, high-flow nasal oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation. Sepsis and septic shock should be managed according to local protocols.
Consider empirical antibiotics if there is clinical suspicion of bacterial infection. Antibiotics may be required in patients with moderate, severe, or critical disease. Give within 1 hour of initial assessment for patients with suspected sepsis or if the patient meets high-risk criteria. Base the regimen on the clinical diagnosis, local epidemiology and susceptibility data, and local treatment guidelines.
Consider systemic corticosteroid therapy for 7 to 10 days in adults with severe or critical disease. Moderate-quality evidence suggests that systemic corticosteroids probably reduce 28-day mortality in patients with severe and critical disease, and probably reduce the need for invasive ventilation.
Assess whether the patient requires any rehabilitation or follow-up after discharge. Discontinue transmission-based precautions (including isolation) and release patients from the care pathway 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms.
Location of care
The decision about location of care depends on various factors including clinical presentation, disease severity, need for supportive care, presence of risk factors for severe disease, and conditions at home (including the presence of vulnerable people). Make the decision on a case-by-case basis using the following general principles.
Mild disease: manage in a healthcare facility, in a community facility, or at home. Home isolation can be considered in most patients, including asymptomatic patients.
Moderate disease: manage in a healthcare facility, in a community facility, or at home. Home isolation can be considered in low-risk patients (i.e., patients who are not at high risk of deterioration).
Severe disease: manage in an appropriate healthcare facility.
Critical disease: manage in an intensive/critical care unit.
The location of care will also depend on guidance from local health authorities and available resources. Forced quarantine orders are being used in some countries.
The strongest risk factors for hospital admission are older age (odds ratio of >2 for all age groups older than 44 years, and odds ratio of 37.9 for people aged 75 years and over), heart failure, male sex, chronic kidney disease, and increased body mass index (BMI). The median time from onset of symptoms to hospital admission is around 7 days.
Approximately 8.6% of patients with COVID-19 who were discharged from an accident and emergency department returned within 72 hours. Nearly 5% of patients were admitted to hospital within 72 hours of the initial visit, and 8.2% were admitted within 7 days. Risk factors associated with an increased rate of return admission included older age, abnormal chest x-ray, fever, and hypoxia on presentation.
Children are less likely to require hospitalisation, but if admitted, generally only require supportive care. Risk factors for intensive care admission in children include age <1 month, male sex, pre-existing medical conditions, and presence of lower respiratory tract infection signs or symptoms at presentation. The majority of children who require ventilation have underlying comorbidities, most commonly cardiac disease. Children with COVID-19 are reported to have similar hospitalisation rates, intensive care admission rates, and mechanical ventilator use compared with those with seasonal influenza.
Overall, 19% of hospitalised patients require non-invasive ventilation, 17% require intensive care, 9% require invasive ventilation, and 2% require extracorporeal membrane oxygenation. The rate of intensive care admission varies between studies; however, a meta-analysis of nearly 25,000 patients found that the admission rate was 32%, and the pooled prevalence of mortality in patients in the intensive care unit was 39%. The most common reasons for intensive care unit admission are hypoxaemic respiratory failure leading to mechanical ventilation and hypotension. Patients admitted to intensive care units were older, were predominantly male, and had a median length of stay of 23 days (range 12 to 32 days). The strongest risk factors for critical illness are oxygen saturation <88%; elevated serum troponin, C-reactive protein, and D-dimer; and, to a lesser extent, older age, BMI >40, heart failure, and male sex.
Management of Mild cases
Patients with suspected or confirmed mild disease (i.e., symptomatic patients meeting the case definition for COVID-19 without evidence of hypoxia or pneumonia) and asymptomatic patients should be isolated to contain virus transmission.
Location of care
Manage patients in a healthcare facility, in a community facility, or at home. Home isolation can be considered in most patients, with telemedicine or remote visits as appropriate. This decision requires careful clinical judgement and should be informed by an assessment of the patient’s home environment to ensure that: infection prevention and control measures and other requirements can be met (e.g., basic hygiene, adequate ventilation); the carer is able to provide care and recognise when the patient may be deteriorating; the carer has adequate support (e.g., food, supplies, psychological support); the support of a trained health worker is available in the community.
Discontinue transmission-based precautions (including isolation) and release patients from the care pathway: 10 days after positive test (asymptomatic patients); 10 days after symptom onset plus at least 3 days without fever and respiratory symptoms (symptomatic patients).
The US Centers for Disease Control and Prevention (CDC) recommends discontinuing home isolation once at least 10 days have passed since symptoms first appeared, and at least 24 hours have passed since last fever without the use of antipyretics, and symptoms have improved, if a symptom-based strategy is used. In asymptomatic people, the CDC recommends discontinuing home isolation once at least 10 days have passed since the date of a positive test. Alternatively, it recommends at least two negative reverse-transcription polymerase chain reaction (RT-PCR) tests on respiratory specimens collected 24 hours apart before ending isolation if a test-based strategy is used. If the patient is hospitalised, the CDC guidance for discontinuing isolation is the same as for moderate disease (see below).
Guidance on when to stop isolation depends on local recommendations and may differ between countries. For example, in the UK the self-isolation period is 10 days in patients with milder disease who are managed in the community.
Infection prevention and control
For patients in home isolation, advise patients and household members to follow appropriate infection prevention and control measures:
Fever and pain: paracetamol or ibuprofen are recommended. There is no evidence at present of severe adverse events in COVID-19 patients taking non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, or of effects as a result of the use of NSAIDs on acute healthcare utilisation, long-term survival, or quality of life in patients with COVID-19. Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms.
Cough: advise patients to avoid lying on their back as this makes coughing ineffective. Use simple measures (e.g., a teaspoon of honey in patients aged 1 year and older) to help cough. A meta-analysis found that honey is superior to usual care (e.g., antitussives) for the improvement of upper respiratory tract infection symptoms, particularly cough frequency and severity.
Olfactory dysfunction: consider treatment (e.g., olfactory training) if olfactory dysfunction persists beyond 2 weeks. Often it improves spontaneously and does not require specific treatment. There is no evidence to support the use of treatments in patients with COVID-19.
Advise patients about adequate nutrition and appropriate rehydration. Too much fluid can worsen oxygenation.
Provide basic mental health and psychosocial support for all patients, and manage any symptoms of insomnia, depression, or anxiety as appropriate.
Closely monitor patients with risk factors for severe illness, and counsel patients about signs and symptoms of deterioration or complications that require prompt urgent care (e.g., difficulty breathing, chest pain).
(2) Managing COVID-19 symptoms (including at the end of life) in the community: summary of NICE guidelines
(3) CDC-Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) REF
The largest cohort reported to date, including more than 44,000 people with COVID-19 from China, showed that illness severity can range from mild to critical:(35)
- Mild to moderate (mild symptoms up to mild pneumonia): 81%
- Severe (dyspnea, hypoxia, or more than 50% lung involvement on imaging): 14%
- Critical (respiratory failure, shock, or multiorgan system dysfunction): 5%
In this study, all deaths occurred among patients with critical illness, and the overall case fatality ratio (CFR) was 2.3%.(35) The CFR among patients with critical disease was 49%.(35) Among children in China, illness severity was lower than in adults, with 94% of affected children having asymptomatic, mild, or moderate disease; 5% having severe disease; and less than 1% having critical disease.(13) Among U.S. COVID-19 cases reported January 22–May 30, 2020, overall the proportion of people who were hospitalized was 14%, including 2% admitted to the intensive care unit (ICU). Overall 5% of patients died.(36)
Among patients in multiple early studies from Wuhan, China who had severe COVID-19 illness, the median time from their onset of illness to the time they experienced dyspnea was 5–8 days; the median time from onset of illness to acute respiratory distress syndrome (ARDS) was 8–12 days; and the median time from onset of illness to ICU admission was 9.5–12 days.(5,6,37,38)
Clinicians should be aware of the potential for some patients with COVID-19 to rapidly deteriorate about one week after illness onset.
Among all hospitalized patients, 26%–32% of patients were admitted to the ICU.(6,8,38) Among all patients, 3%–17% had ARDS compared with 20%–42% for hospitalized patients and 67%–85% for patients admitted to the ICU.(1,4-6,8,38) Mortality among patients admitted to the ICU ranged from 39% to 72% depending on the study and characteristics of patient population.(5,8,37,38) The median length of hospitalization among survivors was 10–13 days.(1,6,8)
Risk Factors for Severe Illness
Age is a strong risk factor for severe illness, complications, and death.(1,6,8,13,34,35,39-42) Among the cohort of more than 44,000 confirmed cases of COVID-19 in China, the CFR increased with advancing age, and was highest among the oldest cohort. Mortality among people 80 years and older was 14.8%; 70–79 years, 8.0%; 60–69 years, 3.6%; 50–59 years, 1.3%; 40–49 years, 0.4%; and for those younger than 40 years, 0.2%.(35) Based on U.S. epidemiologic data through March 16, 2020, CFR was highest in people aged 85 years or older (range 10%–27%), followed by people aged 65–84 years (3%–11%), aged 55–64 years (1%–3%), and was lower in people younger than 55 years (<1%).(39)
CFR in the large cohort in China was elevated for patients with comorbidities, with 10.5% of those with underlying cardiovascular disease, 7.3% of those with diabetes, 6.3% of those with chronic respiratory disease, and 5.6% of those with cancer dying of COVID-related illness.(35) Prior stroke, diabetes, chronic lung disease, and chronic kidney disease have all been associated with increased illness severity and adverse outcomes due to COVID-19. Heart conditions, including heart failure, coronary artery disease, cardiomyopathies, and pulmonary hypertension, put people at higher risk for severe illness from COVID-19. People with hypertension may be at an increased risk for severe illness from COVID-19 and should continue to take their medications as prescribed. (43)
Accounting for differences in age and prevalence of underlying conditions, the mortality associated with COVID-19 that has been reported in the United States appears similar to reports from China.(36, 39) See People Who Are at Increased Risk for Severe Illness to learn more about who is at increased risk.
Clinical Management and Treatment
The National Institutes of Health (NIH) published guidelines on prophylaxis use, testing, and management of patients with COVID-19. For more information, please visit the NIH Coronavirus Disease 2019 (COVID-19) Treatment Guidelinesexternal icon. The recommendationsexternal icon are based on scientific evidence and expert opinion and are regularly updated as more data become available. The U.S. Food and Drug Administration (FDA) has approved one drug remdesivir (Veklury) for the treatment of COVID-19 in certain situations. Clinical management of COVID-19 includes infection prevention and control measures and supportive care, including supplemental oxygen and mechanical ventilatory support when indicated.
Mild to Moderate Disease
- Patients with a mild clinical presentation (absence of viral pneumonia and hypoxia) may not initially require hospitalization, and most patients will be able to manage their illness at home.
- The decision to monitor a patient in the inpatient or outpatient setting should be made on a case-by-case basis. This decision will depend on the clinical presentation, requirement for supportive care, potential risk factors for severe disease, and the ability of the patient to self-isolate at home.
- Patients with risk factors for severe illness (see People Who Are at an Increased Risk for Severe Illness) should be monitored closely given the possible risk of progression to severe illness, especially in the second week after symptom onset.(5,6,35)
Common presenting symptoms of coronavirus disease 2019 include fever, dry cough, shortness of breath, and fatigue. However, patients may have a wide range of symptoms representing a spectrum of mild to severe illness. Symptoms in children tend to be milder and may include fever, cough, and feeding difficulty. The incubation period is two to 14 days, although symptoms typically appear within five days of exposure. Multiple testing modalities exist, but infection should be confirmed by polymerase chain reaction testing using a nasopharyngeal swab. There are no evidence-based treatments appropriate for use in the outpatient setting; management is supportive and should include education about isolation. In hospitalized patients, remdesivir should be considered to reduce time to recovery, and low-dose dexamethasone should be considered in patients who require supplemental oxygen. Overall, 85% of patients have mild illness, whereas 14% have severe disease requiring hospitalization, including 5% who require admission to an intensive care unit. Predictors of severe disease include increasing age, comorbidities, lymphopenia, neutrophilia, leukocytosis, low oxygen saturation, and increased levels of C-reactive protein, d-dimer, transaminases, and lactate dehydrogenase.Cheng et al. – 2020 – Outpatient Management of COVID-19 Rapid Evidence
(5) Primary care management of the coronavirus (COVID-19) in South Africa
South Africa is in the grip of a novel coronavirus pandemic (COVID-19). Primary care providers are in the frontline. COVID-19 is spread primarily by respiratory droplets contaminating surfaces and hands that then transmit the virus to another person’s respiratory system. The incubation period is 2–9 days and the majority of cases are mild. The most common symptoms are fever, cough and shortness of breath. Older people and those with cardiopulmonary co- morbidities or immunological deficiency will be more at risk of severe disease. If people meet the case definition, the primary care provider should immediately adopt infection prevention and control measures. Diagnosis is made by a RT-PCR test using respiratory secretions, usually nasopharyngeal and oropharyngeal swabs. Mild cases can be managed at home with self-isolation, symptomatic treatment and follow-up if the disease worsens. Contact tracing is very important. Observed case fatality is between 0.5% and 4%, but may be overestimated as mild cases are not always counted. Primary care providers must give clear, accurate and consistent messages on infection prevention and control in communities and homes.
If someone meets the case definition given above then infection prevention and control measures should be immediately adopted and specimens taken for a diagnosis. Mild disease can be managed at home (Box 3) with symptomatic treatment and self-isolation (Box 4).
Self-isolation can be ended when the patient’s symptoms have improved or resolved and they have two consecutive negative RT-PCR tests at least 24–48 hours apart.
If severe or critically ill, take or send them to an emergency or resuscitation area, keep waste in a designated area and do not share equipment with other patients. Consult a more senior doctor.
There is no specific treatment for COVID-19 and treatment is supportive.8 Treat fever and myalgia with paracetamol and offer oxygen if there is difficulty breathing.
(6) Covid-19: breaking the chain of household transmission – BMJ REF
We urgently need new measures to protect household contacts
The UK is one of the countries most severely affected by covid-19. Recent outbreaks in English towns such as Oldham, probably involving transmission within large multigenerational households, show the importance of getting the right public health measures in place now to prevent more widespread surges in infections.
Current UK guidance advises household contacts to isolate within the same home as the index case for 14 days.5 They make up the majority of contacts for infected individuals and are likely to remain exposed to the infected household member during this period of isolation.6 Despite guidance advising household members to socially distance, contacts are likely to interact repeatedly—during mealtimes, for example—and to share facilities such as bathrooms.
We know that transmission is more likely to occur indoors than outdoors.7 The cumulative risk to household contacts from an infected person is likely to be substantial during peak viral shedding. In one study in New York State, 38% of household contacts tested positive for SARS-Cov-2, and similar secondary infection rates have been reported in China.89 Transmission may be even higher among household contacts of essential workers, who are at greater risk of being infected than the general population.10
Household members who are older, have underlying medical conditions, or share a bed or vehicle with the index case are the most susceptible.91112 Children seem to be at lower risk of being infected.13 However, their stool samples and nasopharyngeal swabs can remain positive for SARS-CoV-2 for more than two weeks after symptom resolution,14 although their role in transmission remains to be established.
Governments should consider new public health measures to prevent household transmission as we prepare for a potential second wave. Household quarantine is likely to remain an important pandemic control measure, and government support for people quarantined at home is conspicuously absent in the UK: this position has been challenged by independent experts.15bmj.m3181.full
(9) Management of post-acute covid-19 in primary care – BMJ
Management of covid-19 after the first three weeks is currently based on limited evidence
Approximately 10% of people experience prolonged illness after covid-19
Many such patients recover spontaneously (if slowly) with holistic support, rest, symptomatic treatment, and gradual increase in activity
Home pulse oximetry can be helpful in monitoring breathlessness
Indications for specialist assessment include clinical concern along with respiratory, cardiac, or neurological symptoms that are new, persistent, or progressive
(7) Mild to Moderate Covid-19 Clinical Practice – NEJM
A 73-year-old man with hypertension and chronic obstructive pulmonary disease reports that he has had fever, cough, and shortness of breath for 2 days. His medications include losartan and inhaled glucocorticoids. He lives alone. How should he be evaluated? If he has coronavirus disease 2019
Mild or Moderate Covid-19
Covid-19 has a range of clinical manifestations, including cough, fever, myalgias, gastrointestinal symptoms, and anosmia.
Diagnosis of Covid-19 is commonly made through detection of SARS-CoV-2 RNA by PCR testing of a nasopharyngeal swab or other specimens, including saliva. Antigen tests are generally less sensitive than PCR tests but are less expensive and can be used at the point of care with rapid results.
Evaluation and management of Covid-19 depend on the severity of the disease. Patients with mild disease usually recover at home, whereas patients with moderate disease should be monitored closely and sometimes hospitalized.
Remdesivir and dexamethasone have demonstrated benefits in hospitalized patients with severe Covid-19, but in patients with moderate disease, dexamethasone is not efficacious (and may be harmful) and data are insufficient to recommend for or against routine use of remdesivir.
Infection control efforts center on personal protective equipment for health care workers, social distancing, and testing.
(CovidGandhi et al. – 2020 – Mild or Moderate Covid-19
-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), then how should he be treated?
(8) Fangcang shelter hospitals: a novel concept for responding to public health emergencies – Lancet
This may be not economically feasible for Sri Lanka. However the concept and some of the structural arrangements can be used for even Intermediate management centres.
Fangcang shelter hospitals are a novel public health concept. They were implemented for the first time in China in February, 2020, to tackle the coronavirus disease 2019 (COVID-19) outbreak. The Fangcang shelter hospitals in China were large-scale, temporary hospitals, rapidly built by converting existing public venues, such as stadiums and exhibition centres, into health-care facilities. They served to isolate patients with mild to moderate COVID-19 from their families and communities, while providing medical care, disease monitoring, food, shelter, and social activities. We document the development of Fangcang shelter hospitals during the COVID-19 outbreak in China and explain their three key characteristics (rapid construction, massive scale, and low cost) and five essential functions (isolation, triage, basic medical care, frequent monitoring and rapid referral, and essential living and social engagement). Fangcang shelter hospitals could be powerful components of national responses to the COVID-19 pandemic, as well as future epidemics and public health emergencies.PIIS0140673620307443