COVID-19: Variants, Vaccines, and Treatments

This course will be taken down on 8/19/2022 due to outdated information.  You can find CEUFast's latest course on COVID-19 at the following link:ceufast.com/course/covid-19-current-practice-guidelines

In January 2020 the novel coronavirus, SARS-CoV-2, COVID-19, officially entered the United States. Since then, COVID-19 has affected people in every state, causing over 45 million infections and over 700,000 deaths (CDC, 2021a). COVID-19 has been detected on every continent and almost every country in the world. As the COVID-19 pandemic continues to impact the world, healthcare providers must learn how to adapt to the ever-evolving virus and healthcare issues associated with it.

Between researching the viral variants, preventing transmission of the disease, and finding treatments to cure COVID-19, the world is aggressively trying to find a way to resolve COVID-19. Since its first detection in Wuhan, China, in December 2019 and rapid spread through the world, there have been numerous theories, therapies, and prevention strategies to reduce the impact of COVID-19.

Ongoing strategies to prevent the spread of COVID-19 include (CDC, 2021j):

• COVID-19 vaccines have been authorized to help protect against all current variants of COVID-19. Vaccination is the key to begin returning to pre-pandemic activities.
• Wear a mask in indoor public places. Masks are recommended for those older than two years of age. While previously, those who were fully vaccinated were able to remove their masks in indoor spaces, masks have been re-recommended for indoor events with the emergence of the Delta COVID-19 variant. Masks should always be worn in areas of public transport. Masks are generally not required for outdoor events unless there is a large crowd and in areas with high numbers of COVID-19 cases.
• Continue social distancing, staying at least 6 feet away from others.
• Avoid crowds and poorly ventilated places.
• Wash hands often and thoroughly. Hand washing should be performed with soap and water for at least 20 seconds each time. Hand sanitizers with at least 60% alcohol are acceptable alternatives to handwashing if soap and water are not readily available.
• Always cover coughs and sneezes and throw away any tissues in the trash. Immediately wash hands after coughing or sneezing.
• Clean and disinfect high-touch surfaces every day. Disinfection is especially important in areas where people diagnosed with COVID-19 have resided. A list of approved disinfectants for coronavirus (COVID-19) can be found on the EPA website.
• Perform daily health monitoring. Know the symptoms of COVID-19, especially fever, cough, and shortness of breath. If symptoms develop, obtain appropriate testing to determine COVID-19 status and initiate quarantine measures.

Testing for COVID-19 is still the preferred way to identify whether one has been infected with COVID-19. Ongoing testing recommendations include (CDC, 2021l):

• Those with symptoms of COVID-19 should be tested for the virus.
• For unvaccinated people, COVID-19 testing should be performed for those who are exposed to others with suspected or confirmed infection upon finding out about the exposure and again 5-7 days after the last exposure with that person.
• For vaccinated people, COVID-19 testing should be performed for those who are exposed to others with suspected or confirmed infection 3-5 days after the exposure.
• Community, workplace, school, and/or healthcare providers can mandate COVID-19 screening and testing for those not fully vaccinated.

The CDC continues to recommend specific quarantine measures for those exposed to and infected with COVID-19. For unvaccinated people exposed to COVID-19, quarantine should be implemented for 14 days following the last exposure. Quarantine is not indicated for fully vaccinated people only exposed to COVID-19; however, they should wear a mask in all indoor and public spaces for 14 days following the last known exposure with a person with confirmed COVID-19 (CDC, 2021e).

For people infected with COVID-19, vaccinated or unvaccinated, quarantine should be implemented for at least ten days following the onset of symptoms. Positive persons should also be 24 hours without fever and with other COVID-19 symptoms improving before breaking quarantine (CDC, 2021e).

Since the identification of the SARS-CoV-2 (COVID-19) virus, the CDC and worldwide laboratories have been closely tracking mutations and variants of the virus. Variants are not to be unexpected in viruses. Viruses are known to mutate as they spread. As more infections occur, new opportunities for viral mutation also occur. As the virus mutates, it potentially becomes more difficult to stop (CDC, 2021k). As of September 2021, eleven COVID-19 variants have been identified and are being followed closely. The variants identified include (CDC, 2021c):

• Alpha (B.1.1.7, Q.1-Q.8)
• Beta (B.1.351, B.1.351.2, B.1.351.3)
• Gamma (P.1, P.1.1, P.1.2)
• Delta (B.1.616.2 and AY.1 sublineages)
• Epsilon (B.1.427 and B.1.429)
• Eta (B.1.525)
• Iota (B.1.526)
• Kappa (B.1.617.1)
• B.1.617.3
• Mu (B.1.621, B.1.621.1)
• Zeta (P.2)

Of these variants, the one of most concern is the Delta (B.1.616.2 and AY.1 sublineages) variant which was first identified in India (CDC, 2021d). In July 2021, healthcare systems suddenly noticed an uptick in new COVID-19 cases. Prior to July, the cases had been steadily declining due to the introduction of the COVID-19 vaccination since January 2021 (CDC, 2021i). The CDC reported the difference in rolling 7-day average went from 12,000 cases in June to greater than 60,000 cases in July (CDC, 2021i).

On July 27, 2021, the CDC acknowledged the increased number of COVID-19 cases by increasing previously reduced isolation recommendations and pushing harder for people to seek vaccination against COVID-19. Delta became and continues to be the predominant variant of COVID-19 in the United States (CDC, 2021i; CDC, 2021k).

As more data has emerged, the Delta variant has been identified to be more infectious than the other COVID-19 variants. The CDC (2021i) reports that the Delta variant is more than twice as contagious as the other COVID-19 variants. With increasing numbers of people infected with the Delta variant of COVID-19, the healthcare systems are, once again, becoming saturated with people sick with COVID-19 (CDC, 2021i).

Unvaccinated people are the most likely to be infected with COVID-19, especially the Delta variant. Unvaccinated people also make up the majority of patients hospitalized with effects from COVID-19 (CDC, 2021d). Not only did the Delta variant cause infection in non-vaccinated people, but vaccinated people more commonly have become infected with the variant as well. However, it is important to note that those fully vaccinated and infected with the Delta COVID-19 variant were less sick and less likely to be hospitalized than those infected and not vaccinated.

As with all the variants of COVID-19, prevention of contracting the Delta variant begins with masking, handwashing, and social distancing. Vaccinations are the next, and equally important, step in helping to prevent the spread of COVID-19.

Vaccinations play an important role in helping to prevent the spread of disease. Researchers across the world worked to find a vaccine to help prevent transmission and illness with COVID-19. The first mRNA vaccination, Pfizer-BioNTech (COMIRNATY) COVID-19 vaccination, was released under an emergency use authorization in December 2020. A few weeks later, the second mRNA vaccination, Moderna COVID-19 vaccination, was approved. In February 2021, the Johnson & Johnson/Janssen COVID-19 single-dose vaccination also joined the Pfizer-BioNTech (COMIRNATY) and Moderna COVID-19 vaccinations in approval. (CDC, 2021h)

The FDA fully approved the Pfizer-BioNTech (COMIRNATY) COVID-19 vaccination on August 23, 2021, for adolescents and adults 15 years of age and older. For adolescents 12-15 years of age, the Pfizer-BioNTech COVID-19 vaccination can be administered under the continued emergency use authorization. The other two vaccines currently available are expected to gain full FDA approval in later 2021. Vaccines are recommended for all people eligible to receive the vaccination.

Treatments for COVID-19 are managed by the COVID-19 Treatment Guidelines Panel (the Panel). The Panel works to ensure that the most updated information is disseminated to healthcare providers to support the needs of patients with COVID-19. As of September 15, 2021, the COVID-19 treatment guidelines are outlined below (NIH, 2021b).

The COVID-19 Treatment Guidelines Panel’s Statement on Bamlanivimab Plus Etesevimab for the Treatment of Mild to Moderate COVID-19 in Nonhospitalized Patients:

From June 25, 2021, to September 2, 2021, the distribution of bamlanivimap plus etesevimab was paused due to the spread of the Gamma (P.1) and Beta (B.1.351) SARS-CoV-2 variants. Bamlanivimab plus etesevimab retains activity against the Delta variant (B.1617.2, non-AY.1/AY.2). This treatment distribution and use have been resumed.

The Panel recommends the use of an anti-SARS-CoV-2 mAb regimen in clients with mild to moderate symptoms and who are at high risk of clinical progression. Monoclonal antibodies should be administered as soon as possible and within ten days of symptom onset and after a positive SARS-CoV-2 antigen or nucleic acid amplification test (NAAT) result (NIH, 2021a). Only one of the therapies should be used. The following Anti-SARS-CoV-2 Monoclonal Antibodies have received emergency use authorizations from the Food and Drug Administration (NIH, 2021a):

• Bamlanivimab plus etesevimab
  • Dose: Bamlanivimab 700mg plus etesevimab 1,400mg
  • Administration: Intravenous infusion
• Casirivimab plus imdevimab
  • Dose: Casirivimab 600mg plus imdevimab 600mg
  • Administration: Intravenous infusion or subcutaneous injection
• Sotrovimab
  • Dose: Sotrovimab 500mg
  • Administration: Intravenous infusion

The COVID-19 Treatment Guidelines Panel’s Statement on the Prioritization of Anti-SARS-CoV-2 Monoclonal Antibodies for the Treatment or Prevention of SARS-CoV-2 Infection When There Are Logistical Constraints:

The Panel recommends the use of anti-SARS-CoV-2 mAbs for mild to moderate symptoms of COVID-19 as mentioned above and for post-exposure prophylaxis (PEP) in patients with concern for the development of severe COVID-19. Logistical constraints to mAb administration technicalities and staffing availability can impact the ability to administer mAbs to all eligible patients. Recommendations are limited to ensure that those with the highest chance of benefit from the mAbs receive those first.

Therapeutic Management of Hospitalized Adults With COVID-19:

The Panel recommends that dexamethasone or other corticosteroids be used only in patients with COVID-19 who are hospitalized and require supplemental oxygen. Dexamethasone may be given alone if the combination medication Dexamethasone plus remdesivir is not available or if remdesivir cannot be used. Clients who require high-flow oxygen therapy or noninvasive ventilation may receive either baricitinib or IV tocilizumab along with dexamethasone or dexamethasone plus remdesivir. For clients pending admission to the ICU, dexamethasone plus IV tocilizumab or IV sarilumab (if IV tocilizumab is not available or feasible) should be administered.

Additional Panel recommendations under this update include recommending:

• IV sarilumab can be offered as an alternative to IV tocilizumab
• Tofacitinib can be used as an alternative to baricitinib if baricitinib is not available or feasible to use

The COVID-19 Treatment Guidelines Panel’s Statement on the Emergency Use Authorization of Casirivimab Plus Imdevimab as Post-Exposure Prophylaxis for SARS-CoV-2 Infection:

As of July 30, 2021, the Food and Drug Administration expanded the emergency use authorization for the anti-SARS-CoV-2 monoclonal antibodies casirivimab plus imdevimab to be used for post-exposure prophylaxis (PEP). Casirivimab plus imdevimab is recommended as PEP for people at high risk for progression to severe COVID-19 if infected with SARS-CoV-2 and who have either been incompletely vaccinated or who are fully vaccinated but may not have amounted an appropriate immune response and who have exposure history to COVID-19. Doses of casirivimab plus imdevimab should be administered as soon as possible within seven days of high-risk exposure.

Dosing of casirivimab plus imdevimab includes 600mg of each medication (casirivimab 600mg plus imdevimab 600mg) as four subcutaneous injections, each 2.5ml, at four different sites or as a single IV infusion. Observation of the patient for one hour after the injections or infusion is required in the case of adverse effects.

At this time, there is insufficient evidence to repeat dosing of casirivimab plus imdevimab every four weeks or for those who have repetitive high-risk exposures.

Prior and additional guidance regarding the treatment of SARS-CoV-2 (COVID-19) can be found within the full NIH COVID-19 Treatment Guidelines.

In some patients with COVID-19, symptoms continue to affect their lives long after their initial infection. Most people with COVID-19 recover completely from the illness within a few weeks. However, those with post-COVID conditions may experience a range of new or ongoing health issues that occur for four or more weeks after the initial COVID-19 infection (CDC, 2021f). It is important to note that even people who initially had no or mild COVID-19 symptoms are at risk for developing post-COVID conditions.

Types of post-COVID conditions can include individual or combinations of the following symptoms (CDC, 2021f):

• Difficulty breathing, shortness of breath
• Fatigue
• Post-exertional malaise (worsening symptoms after physical or mental activities)
• Difficulty focusing (“brain fog”)
• Cough
• Chest or stomach pain
• Headache
• Heart palpitations
• Joint or muscle pain
• Pins-and-needles sensation
• Diarrhea
• Sleep problems
• Fever
• Dizziness with standing or position changes
• Rash
• Mood changes
• Change in smell or taste
• Change in menstrual periods

Patients with severe COVID-19 illness may be at increased risk of multiorgan effects or autoimmune conditions. While rare, children are at increased risk for multisystem inflammatory syndrome (MIS) during or immediately following a COVID-19 infection (CDC, 2021f).

Patients hospitalized with COVID-19 may have difficulty discerning long-term symptoms of COVID-19 versus complications from hospitalization. Symptoms from hospitalization can occur, especially if hospitalization was prolonged and/or illness was severe. Patients may experience severe weakness and exhaustion. Patients with severe illness and requiring intensive care may develop post-intensive care syndrome (PICS) and/or post-traumatic stress disorder (PTSD) (CDC, 2021f).

The incidence of post-COVID conditions is not yet known. The best way to prevent post-COVID conditions is to prevent COVID-19 illness. People eligible for vaccination should be vaccinated as soon as possible. People should continue to practice mask-wearing and social distancing. Frequent hand washing and avoiding crowds and poorly ventilated indoor spaces are also helpful in preventing COVID-19 infection.

The healthcare system continues to be stressed by COVID-19. Healthcare providers are experiencing burnout, short staffing, limited hospital space, and concerns for their own health. COVID-19 has challenged not only the physical well-being of healthcare providers but also everyone’s mental health. Continuing to have resiliency in fighting against COVID-19 is essential to caring for communities and the healthcare systems that support them.

A 48-year-old patient with shortness of breath with suspected SARS-CoV-2 infection is admitted to a designated COVID-19 unit at a local hospital. A SARS-CoV-2 test was obtained, but the results have not yet returned. The charge nurse on the unit must combine client rooms as there are no more open single rooms to admit the patient. The charge nurse prepares to transfer a different patient with positive SARS-CoV-2 into a room with another patient with positive SARS-CoV-2 infection. The clients have no other respiratory pathogens as determined by PCR testing. After housekeeping appropriately disinfects and cleans the transitioned patient’s room, the charge nurse accepts the admission of the 48-year-old into the cleaned room.

The charge nurse takes the appropriate action in consolidating patient rooms when needed. Patients with the same respiratory pathogen can be roomed together if needed. The client with suspected COVID-19 infection should not be roomed with a client with a positive COVID-19 test result unless the suspected client receives positive SARS-CoV-2 test results.

As more information regarding COVID-19 emerges, recommendations are destined to change. The recommendations for the management and prevention of COVID-19 are updated regularly with the CDC. Healthcare providers must continue to be resilient and treat COVID-19 to the best of their abilities.

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