2 Diagnosing and managing COVID-19

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Contents

• Objectives
• Clinical features of COVID-19
• Management of people with COVID-19
• Confirming the diagnosis of COVID-19
• Case studies

Objectives

Once you have finished this chapter you should be able to:

1. List the symptoms of COVID-19.
2. Manage a person with mild COVID-19.
3. Recognise the signs of pneumonia.
4. Explain how to confirm the clinical diagnosis of COVID-19.
5. Understand how to identify people who have recovered from coronavirus infection.

Clinical features of COVID-19

2-1 Is it easy to diagnose coronavirus infection?

No, as many infected people remain well and have no symptoms of illness.

2-2 What are the common symptoms of COVID-19?

Sometimes people with coronavirus infection remain well. However, others become ill with COVID-19 and experience one or more of the following symptoms:

• Temperature of 38℃ or more or feeling feverish
• Cough
• Sore throat
• Marked tiredness (lethargy) and general weakness
• Muscle aches (flu-like symptoms)
• Shortness of breath or difficulty breathing
• Headache
• Abdominal pain, nausea, vomiting and especially diarrhoea
• Loss of smell and taste
• Red eyes (conjunctivitis).

Not all symptoms are always present and different symptoms may appear at different stages of the infection. Remember that many people with coronavirus infection may not have any clinical symptoms (asymptomatic infection).

2-3 What is the common presentation of mild COVID-19?

Most patients with mild COVID-19 will have a dry cough and a sore throat. They will also feel unwell with tiredness. Most have a fever (high temperature) at some point during their illness. Other symptoms are less common.

Many other viruses can also cause a cough, sore throat, and fever. These symptoms may be caused by another condition such as the common cold or influenza.

Management of people with COVID-19

2-4 What is the management of people with mild COVID-19?

Most people with mild COVID-19 can be managed at home. The important steps are:

• Isolate the person so they do not infect others. They must stay at home.
• Give paracetamol (Panado) to bring down a fever (high temperature) and make the person feel a bit better. The adult dose of paracetamol is 2 tablets or capsules every 6 hours.
• Make sure the person is getting enough to drink. They may not want to eat.
• The person should self-monitor by taking their temperature twice a day, if they have a thermometer, and record how they feel.
• If the person feels short of breath or has any breathing difficulty, or if they have a high fever that does not improve with paracetamol, they must immediately contact their healthcare provider. The 24-hour toll free number for the COVID-19 helpline is 0800 029 999 or 0800 111 32.
• Most people will want to stay in bed. They should feel better in 5 to 7 days.

2-5 How can you isolate a person at home?

If someone is infected with coronavirus, they should have as little contact as possible with others in the home. They must sleep alone in a separate room if possible. Do not allow visitors for 14 days after the start of the infection or symptoms. The person caring for them should preferably be young and healthy, to avoid exposing elderly individuals who are at risk for severe COVID-19.

No one else should enter the room. If they must enter the room, they must wear a cloth face mask. Food can be left outside the door to be collected. Dirty dishes can also be left outside the door for collection. Dirty clothes can be placed in a plastic packet and dropped directly into soapy hot water. Family members must wash their hands well after handling clothes, plates, cups, cutlery and any other items that have been used by the ill person. Wash hands well after using a shared toilet. Clean any shared living areas and bathroom surfaces frequently (at least twice a day) with soap and water.

2-6 Who should keep in contact with a person with mild COVID-19 at home?

Anyone being isolated at home with mild COVID-19 must self-monitor and have the contact number of a healthcare facility or health professional who can be contacted immediately if symptoms get worse, such as breathing difficulties or a fever (high temperature) that does not respond to treatment with paracetamol (Panado).

2-7 What happens when the person is moved to hospital?

People admitted to hospital with COVID-19 will not be allowed visitors as this will increase the risk of spread. It is important that the patient and the hospital staff have the phone number of the person’s family. A cellphone is especially useful to keep contact between the patient and their family.

2-8 What is the management of the other people in the house?

They must self-isolate in the house and self-monitor as they are at high risk of also developing coronavirus infection and COVID-19. They may not go to work or go to the shops. If they need to see a doctor, they need to phone the helpline first.

2-9 Is it safe for children to live with someone who has COVID-19?

Yes, as children usually do not get very sick if they are infected with coronavirus. However, children should follow the same isolation rules as anyone else. Moving children to another home will increase the spread of coronavirus.

2-10 What is the most important complication of mild COVID-19?

Pneumonia. This presents with shortness of breath, difficulty breathing or fast breathing. Patients with mild COVID-19 may suddenly deteriorate with pneumonia after being mildly ill for a few days. This is a serious complication. It is especially important for other household members to recognise the signs of pneumonia as soon as possible as these patients need to be transferred to hospital.

2-11 How can pneumonia be diagnosed at home?

Pneumonia due to the spread of coronavirus from the throat to the lungs is a serious condition. These patients are often unable to get enough oxygen from the air in their lungs into their blood. Patients who develop coronavirus pneumonia will have rapid breathing (more than 30 breaths per minute) and may have cyanosis (blue hands, lips and tongue). Breathlessness or difficulty breathing are important symptoms as these suggest that the person has developed pneumonia.

2-12 Why should people with pneumonia not be managed at home?

Because they need extra oxygen which can usually only be given in a hospital or in an ambulance on the way to the hospital. A reading on a saturation monitor of less than 92% indicates that the patient needs oxygen therapy.

2-13 Can COVID-19 pneumonia be treated with antibiotics?

No, as antibiotics are not effective against a virus. However, doctors often add antibiotic treatment to patients with severe COVID-19 because the possibility of a bacterial infection cannot be ruled out.

Confirming the diagnosis of COVID-19

2-14 How can the clinical diagnosis of COVID-19 be confirmed?

By identifying coronavirus in the upper respiratory tract (nose and throat). This is done by taking a nasopharyngeal (back of the nose) or oropharyngeal (back of the throat) swab and sending it to a laboratory to identify the presence of the coronavirus. This test is reliable in people who have symptoms of COVID-19 and may still be positive for a few days after the person recovers from the illness. However, this test may not detect coronavirus during the incubation period and in some well people with asymptomatic infection. Therefore, a negative test does not mean the person is not infected.

2-15 How can people who have recovered from COVID-19 be identified?

People who have recovered from COVID-19 will have antibodies to coronavirus in their blood. A blood test that detects these antibodies can be used to identify people who have already had coronavirus infection. Soon a bedside test on a drop of blood will be available for both health facility and home or community testing.

2-16 Can people who have recovered from coronavirus infection be infected again with the same virus?

Probably not, as they will be protected by coronavirus antibodies. However, it is not known for how long these antibodies provide protection against being infected with coronavirus again.

2-17 Why is it important to identify people who have recovered from coronavirus infection?

Because it is probably safe for them to return to work as they will not be infected with coronavirus again. This is especially important for people who work in a health service, as they no longer need to worry about getting infected. As more people recover from coronavirus infection, they will be able to help relieve the staff shortage caused by colleagues getting infected with coronavirus.

2-18 What will happen when most people have antibodies to coronavirus?

When most people have antibodies, due to infection or immunisation, the spread of coronavirus in the community will slow down and eventually stop. This is the way that all pandemics end.

2-19 How can community health workers help in diagnosing people with COVID-19?

Community health workers play an especially important role in helping to find people with COVID-19 and prevent the spread of coronavirus in the community. There are number of important tasks that need to be done:

• Screening members of the community for COVID-19
• Identifying those that need to be tested for coronavirus
• Collecting samples for testing
• Tracing people who have been in contact with someone who has, or is suspected of having, coronavirus infection
• Helping to educate the public while carrying out these tasks.

Screening, testing and tracing are discussed in chapter 3.

Case study 1

Sidwell is feeling unwell with a dry cough and a sore throat. His wife takes his temperature, which is 39℃. A few days before, he arrived home from a business trip to Europe. Their family doctor takes a swab for testing and the result is positive, confirming the diagnosis of COVID-19.

1. Do his symptoms suggest COVID-19?

Yes, cough, fever and a sore throat are common presenting symptoms of mild COVID-19.

2. When did he probably get infected with coronavirus?

During his trip to Europe.

3. Where should he be managed?

He can be isolated at home and will probably want to stay in bed.

4. How should he be managed?

He should take 2 paracetamol (Panado) tablets (1 gram) every 6 hours to bring his temperature down. It will also make him feel a bit better. He should self-monitor by recording his temperature and his symptoms.

5. How should the other family members in the home be managed?

They must self-isolate and have as little direct contact with Sidwell as possible.

Case study 2

After Sidwell has been cared for at home for 5 days, he starts to feel breathless. He is breathing fast and his lips look a little blue. He also has a high temperature. He and his wife were warned that this might happen, so she phones the helpline for advice.

1. What complication do you think he is developing?

He probably is getting coronavirus pneumonia. He feels breathless, he is breathing fast and his lips look a little blue.

2. Why is he looking slightly blue?

He has cyanosis (blue lips and tongue) because he is not getting enough oxygen into his blood due to coronavirus pneumonia. This is a serious complication.

3. Can he be treated at home with antibiotics?

No, as antibiotics do not cure pneumonia caused by a virus. He needs oxygen urgently and must be transferred to hospital.

4. What test will become positive once he has improved and is discharged home again?

A blood test for antibodies to coronavirus. These antibodies should protect him from getting coronavirus infection again in future.