Course Objectives: At the conclusion of this activity, the learner should be prepared to:
- Discuss the basic pathophysiology of COVID-19, as well as risk factors, signs, and symptoms.
- Describe the current diagnostic process for COVID-19.
- Review the acute management and isolation precautions currently being recommended for those with known or suspected COVID-19.
- Discuss the top ten ways in which nurses can help their communities cope with the COVID-19 pandemic.
- Recognize the daily strategies nurses can use to boost their own immunity in light of this most recent pandemic.
- Explore some of the investigational medications being researched to help manage COVID-19.
The Coronavirus Infectious Disease 2019 (or COVID-19) has dominated 2020. Since this is a novel, or new virus, what do we really know? The purpose of this activity is to provide nurses with the best and most up to date science currently available regarding the pathophysiology, symptomatology, and management of COVID-19 as of early April 2020.
Pathophysiology, Signs/Symptoms, and Risk Factors
COVID-19 is a respiratory virus that is related to the severe acute respiratory syndrome (SARS-CoV) and Middle East respiratory syndrome (MERS) coronaviruses. COVID-19 is also referred to as SARS-CoV-2. The current outbreak was believed to have started in an outdoor market in Wuhan, a city in Hubei Province, China. Imported, person-to-person, and community spread of the virus (people infected with the virus who are not sure how or where they were exposed) has been confirmed outside of China, including in the US (The Centers for Disesae Control and Prevention [CDC], 2020). Currently, the US has the most confirmed cases in the world, and more than twice as many cases as the second highest country (Italy) (Johns Hopkins University, 2020). Most of the spread is person-to-person, and people appear to be most contagious when they are most symptomatic. Currently, the virus appears to be more contagious and deadlier than influenza, but less contagious than the measles. Droplet transmission is the most common, although airborne transmission via small respirable particles (aerosols or droplet nuclei) over short distances may be possible; though this is still uncertain. The CDC recommends social distancing, remaining at least six feet away from all people other than immediate family members. The latest recommendation from the CDC for slowing the spread of COVID-19, in addition to social distancing, is the suggestion of using cotton facemasks/face coverings when people venture out for essentials, such as trips to the grocery store. They should not be used on those under the age of two or those with difficulty breathing. These facemasks should not be medical grade (these should be reserved only for healthcare providers [HCPs]). These face coverings are intended to prevent asymptomatic individuals from unknowingly spreading the virus, not as protection for the individual wearing the mask (CDC, 2020).
The incubation period can last up to 14 days, with a median of four to five days for most patients, and 97.5% of patients develop symptoms within 11.5 days. The primary symptoms include fever (83-99% of patients), cough (59-82% of patients), fatigue (44-70% of patients), anorexia (40-84% of patients), shortness of breath (31-40% of patients), sputum production (28-33% of patients), and myalgias (11-35% of patients). Approximately 2% of the reported cases in China were in patients under the age of 20, while the majority occurred in patients aged 30-69 (77.8%). The numbers within China indicate that roughly 81% of those infected develop mild or moderate disease, 14% develop severe disease, and 5% develop critical disease. A certain percentage of those infected may also be asymptomatic, but the definitive proportion is unknown. Severe and critical cases are resulting in respiratory distress and death, although the numbers regarding severity and death rates are difficult to assess accurately at this point. Of those patients infected in the US, approximately 19% have required hospitalization, and 6% have required intensive care. The official case fatality rate in China was 2.3%, but the worldwide fatality rate currently stands at over 5%, with the US death rate reported as roughly 2.5%. See Table 1 for a brief overview of the timeline of COVID-19 in the US (The Centers for Disease Control and Prevention [CDC], 2020).
COVID-19 Timeline in the US
Coronavirus Guidelines for America
Those at increased risk for contracting the virus include individuals residing in areas with a higher rate of community spread, HCPs, family members and close contacts of those infected, as well as those travelling from affected areas. Older adults, residents of skilled nursing facilities and long-term care facilities, and individuals with underlying health conditions (i.e., heart disease, pulmonary disease, diabetes) appear to be at increased risk for severe disease requiring hospitalization and respiratory support. There is insufficient data on whether or not someone can be reinfected after recovering, but it is thought to be unlikely (CDC, 2020). However, there have been isolated case reports of patients recovering and then testing positive for the virus again. These patients remain asymptomatic despite testing positive a second time, and experts are unsure if their testing was falsely negative or if they were re-exposed. They are also doubtful that they are infectious, but this remains uncertain (Feng & Cheng, 2020). Most patients present with the aforementioned common symptoms, although some report gastrointestinal symptoms prior to the onset of respiratory symptoms. If dyspnea is going to develop, it typically presents in 5-8 days, acute respiratory distress (ARDs, 3-17% of patients) presents in 8-12 days, and most ICU admissions occur on days 10-12. Most patient (83%) of hospitalized patients present with lymphopenia (or lymphocytopenia, a low level of lymphocytes). Those with more severe cases also present with laboratory abnormalities including neutrophilia (increased level of neutrophils), increased liver enzymes (ALT and AST), increased lactate dehydrogenase, increased c-reactive protein (CRP), and increased ferritin levels. A chest x-ray typically demonstrates bilateral air space consolidation, whereas CT scans often show bilateral peripheral ground glass opacities (CDC, 2020).
Testing and Risk Reduction
Unfortunately, this virus appears to be spreading in the community easily, with sustained community transmission in most states. As of March 10, 2020, the CDC distributed test kits (using real time reverse transcriptase polymerase chain reaction, rRT-PCR) to state and local health departments in all 50 states. While a revised protocol for the use of these kits has been granted discretionary authority by the US Food & Drug Administration (FDA), the existing Emergency Use Authorization (EUA) for the test is still being revised by the CDC. This change, reducing the protocol down to two instead of three components, corrects an initial performance issue related to the manufacturing of one of the reagents without affecting accuracy (CDC, 2020).
Commercial labs have developed their own tests to allow for local testing, and most of these tests are conducted using nasopharyngeal swabs. As of April 3, 2020, the CDC reports testing in 95 state and local public health labs across all 50 states. The CDC labs have tested over 4,800 specimens, while public health laboratories report over 176,700 tests have been completed as of April 3, 2020. Despite being told initially that all symptomatic patients could get tested, most local and state health departments are still being forced to be selective regarding testing patients. The CDC suggests that symptomatic hospitalized patients and symptomatic HCPs be given first priority in testing to ensure proper isolation precautions. The CDC recommends secondary priority for testing be granted to symptomatic older adults, symptomatic patients with underlying medical conditions that predispose them to worse outcomes, symptomatic long-term care facility residents, and symptomatic first responders. The third level of priority for testing includes all symptomatic individuals who do not fit into one of the previously mentioned categories, especially critical infrastructure employees. This third level also includes asymptomatic HCPs and first responders, and those with mild symptoms in high-risk communities. The CDC lists asymptomatic patients (screening) currently as a nonpriority for testing. Primary care, urgent care, and pediatric clinics should be aware of their local resources, including who to contact and how to facilitate testing for any patients that meet the above criteria. Infectious disease departments and state or local health departments should be notified of any persons under investigation (PUI). Sputum specimens should be tested if possible in those with productive cough, and lower respiratory samples should be tested for those on mechanical ventilation via aspirate or bronchoalveolar lavage (CDC, 2020). Most communities are currently utilizing a drive-thru testing set-up, whereby patients are screened by their primary care provider first; if deemed appropriate, patients are given an order and directed to the drive-thru screening area for a nasopharyngeal swab. This is often after first establishing a fever, cough, and negative flu and/or strep swabs.
On March 27, 2020, Abbott laboratories received EUA from the FDA for a molecular point-of-care test for COVID-19. Abbott purports that this test can deliver a positive result in as little as five minutes, and a negative in as little as 13 minutes. The obvious advantage to this system is the ability to test patients in urgent care and physician offices. Their press release on March 27th promised 50,000 tests per day beginning the first week in April. Their ID NOW platform is already in use for influenza, strep A and respiratory syncytial virus (RSV) testing in offices across the US. Combined with their lab-based rRT-PCR, Abbott predicts being able to complete 5 million tests in April (Abbott Laboratories, 2020). Unfortunately, reports from HHS and FEMA documents indicates that on March 30 indicate that only 5,500 test cartridges and 780 new ID NOW machines would be shipped to 55 state and local labs across the US. In addition, the sensitivity and specificity of this test is still unknown (Kaiser Health News, 2020).
At this time, there are no effective vaccines or medications to treat COVID-19. Acetaminophen (Tylenol) can be used for fever and body aches; however, ibuprofen (Motrin) should be avoided if possible. Preliminary information has emerged from a study of patients in Italy, which has seen more severe cases than in any other part of the world. According to a recent study published in the Lancet (Fang et al., 2020), it was determined that one of the common factors in many of the Italian cases was that the majority of patients took ibuprofen (Motrin) at home. Based on this and unclear laboratory evidence, researchers are not certain if ibuprofen (Motrin) and other nonsteroidal anti-inflammatory drugs may accelerate the multiplication of the virus, leading to a more severe course of the disease. In addition, the same study determined that those patients treated with anti-hypertensives, particularly angiotensin-converting enzymes (ACE-inhibitors) and angiotensin II type-I receptor blockers (ARBs) may also be at heightened risk for severe disease due to interactions between the viral uptake and these medications (Fang et al., 2020). This is due to the fact that the ACE2 receptor has been identified as the entry point into human cells for SARS-CoV-2. Despite this, the American College of Cardiology (ACC) and the American Heart Association (AHA) have publicly released guidance that patients with underlying cardiac conditions requiring these medications should NOT be taken off of their current regimen at this time due to lack of data. They report insufficient evidence to justify the risk of stopping these medications in patients with heart failure, hypertension, or ischemic heart disease (ACC/AHA/Heart Failure Society of America, 2020). Similarly, corticosteroids should also be avoided, as they may prolong viral replication (as seen previously with COVID-19’s cousin, MERS-CoV and influenza). The CDC recommends that corticosteroids only be used in those patients requiring them for concurrent COPD or septic shock as per the Surviving Sepsis Campaign guidelines (CDC, 2020).
Patients without breathing difficulty are encouraged to self-quarantine and recover at home if appropriate supportive caregivers are available. Most treatment is supportive, and patients at home should be encouraged to rest, hydrate, and maintain adequate and balanced nutrition. Patients should be placed in a separate bedroom/bathroom away from other family members, and appropriate personal protective equipment (PPE, at a minimum gloves and facemask) should be provided to the family. Patients recovering at home should not to leave their home except to attend medical appointments, if telemedicine is not an available or appropriate alternative. Hand hygiene and cough etiquette are compulsory, and if possible, the patient should maintain a facemask when around people. Dishes, towels, and other household items should not be shared and should be thoroughly washed with soap and hot water after being used by the patient. High-touch surfaces such as counters, doorknobs, light switches, toilets, and phones should be disinfected daily. Those with family members at high risk (over 65, young children, pregnant women, immunocompromised patients, chronically ill) should be isolated outside of the home when possible. Hospitalized patients may require intravenous hydration and varying levels of oxygenation and respiratory support (CDC, 2020).
To enhance the safety of HCPs, patients with respiratory symptoms should be instructed to call ahead and be processed through a nurse-directed triage protocol. Masks should be worn throughout their visit whenever possible. Patients being seen for well-child visits or unrelated complaints should be rescheduled when possible or physically separated from those with respiratory symptoms. EMS personnel should contact facilities prior to arrival when transporting patients with respiratory symptoms to obtain transport protocol instructions for arrival. Facilities should consider limiting entry points and encourage all patients to adhere strictly to hand hygiene and cough etiquette, ensuring alcohol-based hand sanitizer and tissues are available. Triage centers may be set up outside the facility or in ancillary buildings for screening purposes. PUIs should be quickly triaged, given a facemask, and immediately isolated in a closed examination room, personal vehicle, or otherwise separated from other patients by at least six feet. Those with known or suspected COVID-19 who are admitted to a facility should be placed in a private room, and providers should utilize standard precautions as well as donning a respirator, gown, gloves, and eye protection when entering the room (this is most similar to a combination of both contact and droplet transmission-based isolation precautions- see Figure 2). Transmission-based precautions can be discontinued once fever and other symptoms have resolved, and after two negative nasopharyngeal swabs at least 24 hours apart. Alternatively, patients may be released from transmission-based precautions after at least 72 hours of remaining asymptomatic (no fever, cough) and at least seven days after the initial onset of symptoms (CDC, 2020).
Many hospitals have reported shortages of PPE such as N95 respirators, face masks, and gowns. See Figure 3 for types of PPE clarification. The CDC has established optimization strategies for hospitals dealing with inadequate PPE supplies. Contingency plans should be utilized by all healthcare facilities at this time, which include maximizing engineering and administrative controls to prevent transmission, cancelling all elective procedures and appointments, and reserving all available PPE for HCPs (they suggest replacing public supplies of source control masks with tissues). This may include reducing the length of stay of hospitalized patients. Reusable PPE should be used and processed/disinfected for reuse in lieu of disposable options, such as other classes of filtering facemask respirators: elastomeric respirators or powered air-purifying respirators (PAPRs). Expired PPE can be used beyond its published shelf life for training and demonstration purposes. Finally, facilities should consider using respirators or facemasks/eye protection beyond a single patient. This may include extended use of N95s (without removing the mask) for a cohort of patients all infected with COVID-19. They also propose the limited re-use of N95 masks, which includes the donning/doffing of a single mask up to five times by the same HCP. This has been established as low risk when contact transmission is not a significant concern (such as in tuberculosis) but has not been well-established in COVID-19. Respirators should be hung up or stored in paper bags between uses (CDC, 2020). Additional safety considerations for the extended use/limited re-use of N95s include:
- Discard N95 respirators following use during aerosol generating procedures.
- Discard N95 respirators contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients.
- Discard N95 respirators following close contact with any patient co-infected with an infectious disease requiring contact precautions.
- Consider use of a cleanable face shield (preferred3) over an N95 respirator and/or other steps (e.g., masking patients, use of engineering controls), when feasible to reduce surface contamination of the respirator.
- Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross-contamination, store respirators so that they do not touch each other and the person using the respirator is clearly identified. Storage containers should be disposed of or cleaned regularly.
- Clean hands with soap and water or an alcohol-based hand sanitizer before and after touching or adjusting the respirator (if necessary for comfort or to maintain fit).
- Avoid touching the inside of the respirator. If inadvertent contact is made with the inside of the respirator, discard the respirator and perform hand hygiene as described above.
- Use a pair of clean (non-sterile) gloves when donning a used N95 respirator and performing a user seal check. Discard gloves after the N95 respirator is donned and any adjustments are made to ensure the respirator is sitting comfortably on your face with a good seal (CDC, 2020).
Face masks versus Respirators
The second tier of optimization strategies, crisis alternate strategies, apply to facilities with severe PPE shortages. In situations of short supply, N95 respirators could potentially be used for HCPs beyond their shelf life and should be reserved for situations where respiratory protection is most important (performance of aerosol-generating procedures and direct patient care of tuberculosis, measles, and varicella). Internationally certified respirators may be considered. If facemasks are the only PPE available, source control for the patient (a surgical mask) should also be considered. If the HCP is to be more than six feet away from the patient, no mask or respirator is required. If the HCP is to be within three to six feet of the patient, placing a mask on both the patient and the HCP should provide sufficient protection. If the HCP is directly caring for the patient (within three feet), both the patient and HCP should be wearing a facemask, or if the patient must be unmasked, the HCP should be wearing a respirator. If engaged in an aerosol- generating procedure, the HCP must have an N95 respirator in place. A decontamination process, the Battelle Decontamination System, recently obtained EUA from the FDA to sterilized N95s (CDC, 2020).
In the direst of scenarios, when no N95s remain in a facility, the CDC recommends restricting those HCPs at high risk from direct patient care and encourages convalescent HCPs to volunteer for the care of COVID-19 patients. Ventilated headboards may help reduce the risk to HCPs in the room, in addition to expedient patient isolation rooms using portable high-efficiency particle air (HEPA) fans. Surgical masks should be used when no respirators are available, and homemade cloth masks may be used if surgical masks are unavailable.
What Can we do now, as Nurses?
- Prepare, do not panic.
- As always, hand hygiene. Diligent. Thorough. Consistent.
- Know the signs and symptoms of COVID-19: fever, cough, myalgia, fatigue, and SOB, which typically present 4-5 days following exposure to the virus (but may be as much as 14 days).
- Avoid travel when possible:
Level 3 (avoid nonessential travel, with restrictions on entry into the US): China, Iran, and most of Europe, including the UK and Ireland
Level 3 (avoid nonessential travel, without restrictions on entry into the US): Global outbreak
- If you can, stay in- call elderly neighbors and family members to check on them and ensure they have any supplies that they need. Avoid restaurants, gyms, coffee shops, etc. If possible, order groceries, dry goods, and paper products to be delivered or brought out to the car to avoid wandering through grocery stores, and only leave the house for essentials or to report to essential employment.
- Boost your immune system naturally- get adequate sleep/rest, eat a balanced diet high in all essential vitamins and minerals, ensure sufficient hydration, and limit stress (more on this below).
- Educate yourself- go to cdc.gov and click on COVID-19 for the latest information.
Symptoms of COVID-19
Regarding our own immune system, aside from utilizing appropriate protective equipment when caring for our patients (gloves, respirators, face shield, and disposable gowns when appropriate) and washing our hands compulsively, the best way to protect ourselves and our families is to boost our body’s defense system. We currently do not have a medication to fight COVID-19, so our immune systems will be responsible for handling that for us. Harvard Health Publishing (2014) lays it out in plain language: choose a healthy lifestyle. This includes not smoking, eating fruits and vegetables, exercising regularly, maintaining a healthy weight, drinking alcohol in moderation only, getting adequate sleep, and minimizing stress. Healthy people continuously generate more lymphocytes than is needed, so there is no need to boost the level of any one cell type. Micronutrient deficiencies (i.e., zinc, selenium, iron, copper, folic acid, and vitamins A, B6, C and E) have been shown to alter immune responses in animals and may have the same effect on the human immune response. Mega doses of a single vitamin do not appear to enhance immunity. Exercise not only promotes overall health, supporting a healthy immune system, but it also enhances circulation, allowing immune cells and other necessary nutrients to move through the body more easily. Age naturally reduces our body’s immune response, likely due to reduced T-cells secondary to thymus atrophy and/or bone marrow inefficiency (Harvard Health Publishing, 2014).
While many supplements will advertise immune boosting effects, most have not been proven in large clinical trials. Black elderberry has shown some antiviral promise. A 2001 invitro study by Barak and colleagues found that elderberry extract increased production of inflammatory cytokines, especially tumor necrosis factor (TNF-alpha). A 2004 study in Norway including 60 people with influenza found that 15 ml of elderberry syrup taken four times daily shortens the average length of symptoms from seven/eight days to two/four days. Another study of 64 people indicates that 175 mg of elderberry (lozenge) for two days decreases flu symptoms such as fever, headache, muscle aches, and nasal congestion. Finally, an Australian study in 2016 including 312 subjects indicates that 300 mg of elderberry extract take three times daily resulted in illness of a short duration with less severe symptoms. Uncooked berries and leaves of the black elderberry plant should be avoided due to risk of cyanide and lectins, which may cause gastrointestinal symptoms (Mandl, 2018). Similarly, some small studies have indicated that zinc nasal gel or oral lozenges, when administered within 24 hours of the onset of cold symptoms, typically caused by the rhinovirus, can shorten the duration and reduce the severity of cold symptoms (Hulisz, 2004). Given their general antiviral effects, these two may help shorten the duration or reduce the severity of other viral infections, such as COVID-19, although this is purely speculative and has never been studied as this is a novel (new) virus.
Research and Development
The scientific community is working feverishly to develop a vaccine, and clinical trials are ongoing to establish if remdesivir, an investigational intravenous broad-spectrum antiviral produced by Gilead, may be an effective treatment option. Preclinical data suggests that it is effective against the other coronaviruses MERS and SARS-CoV, and it has in-vitro activity against SARS-CoV-2. The NIH is sponsoring a placebo-controlled double-blinded trial of adults requiring supplemental oxygen or mechanical ventilation. There are two open-label phase 3 clinical trials for adults with radiographic evidence of pneumonia and oxygen saturations above or below 95% on room air respectively. See clinicaltrials.gov for more info. There are also some patients being given remdesivir on an uncontrolled compassionate use basis, but currently this is on an individual basis only (CDC, 2020).
Hydroxychloroquine (Plaquenil) and chloroquine (Aralen) are oral medications used for the treatment of malaria and other inflammatory conditions including chemoprophylaxis, rheumatoid arthritis, and systemic lupus erythematous. Both drugs have in-vitro activity against SARS-CoV-2 and other coronaviruses. Hydroxychloroquine (Plaquenil) appears to have a higher potency against SARS-CoV-2. A study in China indicated benefit from chloroquine (Aralen) versus a comparison group. Both medications have known safety risks, such as prolonged QT syndrome in patients with hepatic or renal dysfunction and immunosuppression. They have been reportedly well-tolerated in COVID-19 patients and are currently recommended for treatment of hospitalized COVID-19 patients in several countries based on limited in-vitro and anecdotal evidence. Hydroxychloroquine (Plaquenil) has been administered on an uncontrolled basis to hospitalized patients in the US. Anecdotal evidence suggests dosing hydroxychloroquine (Plaquenil) 400 mg twice daily on day one, followed by 400 mg daily for five days or 200 mg twice daily for four days. Alternately, 600 mg twice daily could be given on day one followed by 400 mg daily on days two through five. A small study using hydroxychloroquine (Plaquenil) indicates reduced viral RNA in respiratory secretions but did not assess clinical benefit. Several clinical trials of hydroxychloroquine (Plaquenil) are ongoing in the US, both for treatment and prophylaxis of COVID-19, and providers should see clinicaltrials.gov for more info. Lopinavir-ritonavir (Kaletra) had disappointing results in a recent trial in China but is currently being investigated in a WHO study (CDC, 2020).
The current plan for containment of this virus in the US is largely self-quarantine and social distancing. Most areas have closed schools, restaurants, gyms, theatres, and bars to force the social distancing. Many states have issued stay-at-home orders for non-essential personnel. Parents are having to take a leave of absence from their jobs in order to stay home with children as schools close. Those in the service industry may have weeks or even months without pay. School districts are sprinting to not only provide some educational resources to their students remotely, but also to determine how best to feed the thousands of students who rely on free or reduced meals while in school for the bulk of their nutrition. The US Congress passed multiple relief bills in March and April to provide relief to families and economic stimulus to the country. As previously mentioned, the CDC has recommended that the public utilize homemade cloth masks when forced to leave their house to perform essential functions to prevent asymptomatic individuals from unintentionally spreading the virus to others (CDC, 2020). As of April 3rd, 2020, more than 275,000 cases have been reported in the US to a dashboard managed by the Johns Hopkins School of Engineering, and more than 7,000 people have died (Johns Hopkins University, 2020). The WHO Director-General is encouraging everyone to remember that while social distancing may help, the backbone of the COVID-19 response should be testing, isolation, and contact tracing. His message: Test, test, test. Test every suspected case.” Additional concerns regarding capacity are currently being discussed in hopes of troubleshooting how to increase the number of hospital beds and ventilators that are available for use if needed. Temporary field hospitals are being constructed, and two US military hospital ships are being used off the coast of New York and California (Chappell, 2020, para. 30).
*(Most of this information is up to date as of April 3, 2020)
Abbott Laboratories. (2020). Detect COVID-19 in as little as five minutes. https://www.abbott.com/corpnewsroom/product-and-innovation/detect-covid-19-in-as-little-as-5-minutes.html
American College of Cardiology, American Heart Association, & Heart Failure Society of America. (2020). HFSA/ACC/AHA Statement addresses concerns re: using RAAS antagonists in COVID-19. https://www.acc.org/latest-in-cardiology/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addresses-concerns-re-using-raas-antagonists-in-covid-19
Barak, V., Halperin, T., & Kalickman, I. (2001). The effect of Sambucol, a black elderberry-based natural product, on the production of human cytokines: I. Inflammatory cytokines. European Cytokine Network. 12(2), 290-6.
Cameron, B. (2020). I ran the White House pandemic Office. Trump closed it. https://www.washingtonpost.com/outlook/nsc-pandemic-office-trump-closed/2020/03/13/a70de09c-6491-11ea-acca-80c22bbee96f_story.html
The Centers for Disease Control and Prevention. (2020). Coronavirus (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov/index.html
Chappell, B. (2020). Coronavirus: US tells Americans to home-school; The WHO urges: ‘Test, test, test’. NPR. https://www.npr.org/sections/health-shots/2020/03/16/816428320/coronavirus-u-s-enters-quarantine-life-as-many-schools-and-businesses-close
Fang, L., Karakiulakis, G., & Roth, M. (2020). Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? The Lancet. https://doi.org/10.1016/S2213-2600(20)30116-8
Feng, E. & Cheng, A. (2020). Mystery in Wuhan: Recovered Coronavirus patients test negative ... then positive. https://www.npr.org/sections/goatsandsoda/2020/03/27/822407626/mystery-in-wuhan-recovered-coronavirus-patients-test-negative-then-positive
Harvard Health Publishing. (2014). How to boost your immune system. https://health.harvard.edu/staying-healthy/how-to-boost-your-immune-system
Hulisz, D. (2004). Efficacy of zinc against common cold viruses: An overview. Journal of the American Pharmacists Association 44(5), 594-603. https://doi.org/ 10.1331/1544-3126.96.36.1994.hulisz
Johns Hopkins University. (2020). Coronavirus Resource Center. https://coronavirus.jhu.edu/map.html
Kaiser Health News. (2020). Trump touted Abbott’s quick COVID-19 test. HHS document shows only 5,500are on way for entire US. https://khn.org/news/trump-touted-abbotts-quick-covid-19-test-hhs-document-shows-only-5500-are-on-way-for-entire-u-s/
Mandl, E. (2018). Elderberry: Benefits and dangers. Healthline. https://www.healthline.com/nutrition/elderberry#risks-and-side-effects
Whitehouse.gove (2020). The president’s coronavirus guidelines for America. https://www.whitehouse.gov/wp-content/uploads/2020/03/03.16.20_coronavirus-guidance_8.5x11_315PM.pdf