Special considerations in children

Who’s at increased risk?

You’re at high risk for contracting SARS-CoV-2 if you come into contact with someone who’s carrying it, especially if you’ve been exposed to their saliva or been near them when they’ve coughed, sneezed, or talked.

Without taking proper preventive measures, you’re also at high risk if you:

• live with someone who has contracted the virus
• are providing home care for someone who has contracted the virus
• have an intimate partner who has contracted the virus

Older adults and people with certain health conditions have a higher risk for severe complications if they contract the virus. These health conditions include:

• serious heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
• kidney disease
• chronic obstructive pulmonary disease (COPD)
• obesity, which occurs in people with a body mass index (BMI) of 30 or higher
• sickle cell disease
• a weakened immune system from a solid organ transplant
• type 2 diabetes

Pregnant women have a higher risk of complications from other viral infections, but it’s not yet known if this is the case with COVID-19.

The CDC states that pregnant people seem to have the same risk of contracting the virus as adults who aren’t pregnant. However, the CDC also notes that those who are pregnant are at greater risk of getting sick from respiratory viruses compared to those who aren’t pregnant.

Transmitting the virus from mother to child during pregnancy isn’t likely, but the newborn is able to contract the virus after birth.

Bruton’s Tyrosine Kinase Inhibitors

Acalabrutinib

Acalabrutinib is a second-generation, oral BTK inhibitor that is FDA approved to treat B-cell malignancies (i.e., chronic lymphocytic leukemia/small lymphocytic lymphoma, mantle cell lymphoma). It has a better toxicity profile than first-generation BTK inhibitors (e.g., ibrutinib) due to less off-target activity for other kinases.13 Acalabrutinib is proposed for use in patients with COVID-19 because it can modulate signaling that promotes inflammation.

Data regarding acalabrutinib are limited to a retrospective case series of 19 patients with severe COVID-19.14 However, data interpretation to discern any clinical benefit is limited by the study’s small sample size and lack of a control group.

Please check ClinicalTrials.gov for the latest information on studies of acalabrutinib and COVID-19.

Ibrutinib

Ibrutinib is a first-generation BTK inhibitor that is FDA approved to treat various B-cell malignancies9 and prevent chronic graft-versus-host disease in stem cell transplant recipients.15 Based on results from a small case series, ibrutinib has been theorized to improve inflammation and protect against ensuing lung injury in patients with COVID-19.16

Data regarding ibrutinib are limited to an uncontrolled, retrospective case series of six patients with COVID-19 who were receiving ibrutinib for a condition other than COVID-19.16 However, evaluation of the data for any clinical benefit is limited by the series’s small sample size and lack of a control group.

Please check ClinicalTrials.gov for the latest information on studies of ibrutinib and COVID-19.

Zanubrutinib

Zanubrutinib is a second-generation, oral BTK inhibitor that is FDA approved to treat mantle cell lymphoma.17 It has been shown to have fewer toxicities than first-generation BTK inhibitors (e.g., ibrutinib) due to less off-target activity for other kinases.18 Zanubrutinib is proposed to be of use in patients with COVID-19 by modulating signaling that promotes inflammation.

What are the symptoms?

Doctors are learning new things about this virus every day. So far, we know that COVID-19 may not initially cause any symptoms for some people.

You may carry the virus for 2 days or up to 2 weeks before you notice symptoms.

Some common symptoms that have been specifically linked to COVID-19 include:

• shortness of breath
• a cough that gets more severe over time
• a low-grade fever that gradually increases in temperature
• fatigue

Less common symptoms include:

• chills
• repeated shaking with chills
• sore throat
• headache
• muscle aches and pains
• loss of taste
• loss of smell

These symptoms may become more severe in some people. Call emergency medical services if you or someone you care for have any of the following symptoms:

• trouble breathing
• blue lips or face
• persistent pain or pressure in the chest
• confusion
• excessive drowsiness

The Centers for Disease Control and Prevention (CDC) is still investigating the full list of symptoms.

COVID-19 versus the flu

We’re still learning about whether the 2019 coronavirus is more or less deadly than the seasonal flu.

This is difficult to determine because the number of total cases, including mild cases in people who don’t seek treatment or get tested, is unknown.

However, early evidence suggests that this coronavirus causes more deaths than the seasonal flu.

An estimated 0.04 to 0.2 percent of people who developed the flu during the 2019–2020 flu season in the United States died as of April 4, 2020.

This is compared to about 6 percent of those with a confirmed case of COVID-19 in the United States, according to the CDC.

Here are some common symptoms of the flu:

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  Pang QL, He WC, Li JX, Huang L.
  Pang QL, et al.
  World J Clin Cases. 2020 Dec 6;8(23):6181-6189. doi: 10.12998/wjcc.v8.i23.6181.
  World J Clin Cases. 2020.

  PMID: 33344621
  Free PMC article.

• Full recovery of a stage IV cancer patient facing COVID-19 pandemic.

  Parmanande A, Simão D, Sardinha M, Dos Reis AFP, Spencer AS, Barreira JV, da Luz R.
  Parmanande A, et al.
  Autops Case Rep. 2020 Jun 5;10(3):e2020179. doi: 10.4322/acr.2020.179.
  Autops Case Rep. 2020.

  PMID: 33344300
  Free PMC article.

• A critical analysis and review of Lancet COVID-19 hydroxychloroquine study.

  Toumi M, Biernikiewicz M, Liang S, Wang Y, Qiu T, Han R.
  Toumi M, et al.
  J Mark Access Health Policy. 2020 Sep 10;8(1):1809236. doi: 10.1080/20016689.2020.1809236.
  J Mark Access Health Policy. 2020.

  PMID: 33343837
  Free PMC article.

  Review.

• .

  Fogha JVF, Noubiap JJ.
  Fogha JVF, et al.
  Pan Afr Med J. 2020 Sep 18;37(Suppl 1):14. doi: 10.11604/pamj.supp.2020.37.14.23535. eCollection 2020.
  Pan Afr Med J. 2020.

  PMID: 33343793
  Free PMC article.

  French.

• Potential Therapeutic Effect of Traditional Chinese Medicine on Coronavirus Disease 2019: A Review.

  Qiu Q, Huang Y, Liu X, Huang F, Li X, Cui L, Luo H, Luo L.
  Qiu Q, et al.
  Front Pharmacol. 2020 Nov 9;11:570893. doi: 10.3389/fphar.2020.570893. eCollection 2020.
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Executive Summary

Two main processes are thought to drive the pathogenesis of COVID-19. Early in the course of the infection, the disease is primarily driven by replication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Later in the course of infection, the disease is driven by an exaggerated immune/inflammatory response to the virus that leads to tissue damage. Based on this understanding, it is anticipated that antiviral therapies would have the greatest effect early in the course of disease, while immunosuppressive/anti-inflammatory therapies are likely to be more beneficial in the later stages of COVID-19.

In the earliest stages of infection, before the host has mounted an effective immune response, anti-SARS-CoV-2 antibody-based therapies may have their greatest likelihood of having an effect. In this regard, although there are insufficient data from clinical trials to recommend either for or against the use of any specific therapy in this setting, preliminary data suggests that outpatients may benefit from receiving anti-SARS-CoV-2 monoclonal antibodies early in the course of infection. The anti-SARS-CoV-2 monoclonal antibodies bamlanivimab and casirivimab plus imdevimab are available through Emergency Use Authorizations for outpatients who are at high risk for disease progression.

Remdesivir, an antiviral agent, is currently the only drug that is approved by the Food and Drug Administration for the treatment of COVID-19. It is recommended for use in hospitalized patients who require supplemental oxygen. However, it is not routinely recommended for patients who require mechanical ventilation due to the lack of data showing benefit at this advanced stage of the disease.1-4

Dexamethasone, a corticosteroid, has been found to improve survival in hospitalized patients who require supplemental oxygen, with the greatest effect observed in patients who require mechanical ventilation. Therefore, the use of dexamethasone is strongly recommended in this setting.5-8

The COVID-19 Treatment Guidelines Panel (the Panel) continues to review the most recent clinical data to provide up-to-date treatment recommendations for clinicians who are caring for patients with COVID-19. Figure 1 summarizes the Panel’s recommendations for managing patients with varying severities of disease. A comprehensive summary of the clinical data for the drugs that are being investigated for the treatment of COVID-19 can be found in the Antiviral Therapy, Immune-Based Therapy, and Adjunctive Therapy sections of these Guidelines.

Thromboembolic Events and COVID-19

Critically ill patients with COVID-19 have been observed to have a prothrombotic state, which is characterized by the elevation of certain biomarkers, and there is an apparent increase in the incidence of venous thromboembolic disease in this population. In some studies, thromboemboli have been diagnosed in patients who received chemical prophylaxis with heparinoids.14-16 Autopsy studies provide additional evidence of both thromboembolic disease and microvascular thrombosis in patients with COVID-19.17 Some authors have called for routine surveillance of ICU patients for venous thromboembolism.18 See the Antithrombotic Therapy in Patients with COVID-19 section for a more detailed discussion.

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  Brown SA, et al.
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• Recent Progress in the Drug Development Targeting SARS-CoV-2 Main Protease as Treatment for COVID-19.

  Cui W, Yang K, Yang H.
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  Front Mol Biosci. 2020.

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  Free PMC article.

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• Impact of repurposed drugs on the symptomatic COVID-19 patients.

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  Hussain I, et al.
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• Coronavirus vaccine development: from SARS and MERS to COVID-19.

  Li YD, Chi WY, Su JH, Ferrall L, Hung CF, Wu TC.
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  Review.

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  Zheng X, Zhao Y, Yang L.
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References

1. Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the treatment of COVID-19 — final report. N Engl J Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32445440.
2. Wang Y, Zhang D, Du G, et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet. 2020;395(10236):1569-1578. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32423584.
3. Spinner CD, Gottlieb RL, Criner GJ, et al. Effect of remdesivir vs standard care on clinical status at 11 days in patients with moderate COVID-19: a randomized clinical trial. JAMA. 2020;324(11):1048-1057. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32821939.
4. Goldman JD, Lye DCB, Hui DS, et al. Remdesivir for 5 or 10 days in patients with severe COVID-19. N Engl J Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32459919.
5. Recovery Collaborative Group, Horby P, Lim WS, et al. Dexamethasone in hospitalized patients with COVID-19 — preliminary report. N Engl J Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32678530.
6. Jeronimo CMP, Farias MEL, Val FFA, et al. Methylprednisolone as adjunctive therapy for patients hospitalized with COVID-19 (Metcovid): a randomised, double-blind, Phase IIb, placebo-controlled trial. Clin Infect Dis. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32785710.
7. Tomazini BM, Maia IS, Cavalcanti AB, et al. Effect of dexamethasone on days alive and ventilator-free in patients with moderate or severe acute respiratory distress syndrome and COVID-19: the CoDEX randomized clinical trial. JAMA. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32876695.
8. Writing Committee for the R-CAPI, Angus DC, Derde L, et al. Effect of hydrocortisone on mortality and organ support in patients with severe COVID-19: the REMAP-CAP COVID-19 corticosteroid domain randomized clinical trial. JAMA. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32876697.

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References

1. Zhong J, Tang J, Ye C, Dong L. The immunology of COVID-19: is immune modulation an option for treatment? Lancet Rheumatology. 2020;2(7):e438-e436. Available at: .
2. Wang X, Guo X, Xin Q, et al. Neutralizing antibodies responses to SARS-CoV-2 in COVID-19 inpatients and convalescent patients. medRxiv. 2020;Preprint. Available at: https://www.medrxiv.org/content/10.1101/2020.04.15.20065623v3.
3. Mair-Jenkins J, Saavedra-Campos M, Baillie JK, et al. The effectiveness of convalescent plasma and hyperimmune immunoglobulin for the treatment of severe acute respiratory infections of viral etiology: a systematic review and exploratory meta-analysis. J Infect Dis. 2015;211(1):80-90. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25030060.
4. Shetty AK. Mesenchymal Stem Cell Infusion Shows Promise for Combating Coronavirus (COVID-19)- Induced Pneumonia. Aging Dis. 2020;11(2):462-464. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32257554.
5. Marovich M, Mascola JR, Cohen MS. Monoclonal antibodies for prevention and treatment of COVID-19. JAMA. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32539093.
6. Horby P, Shen Lim W, Emberson J, et al. Effect of dexamethasone in hospitalized patients with COVID-19: preliminary report. medRxiv. 2020;Preprint. Available at: https://www.medrxiv.org/content/10.1101/2020.06.22.20137273v1.
7. Shakoory B, Carcillo JA, Chatham WW, et al. Interleukin-1 receptor blockade is associated with reduced mortality in sepsis patients with features of macrophage activation syndrome: reanalysis of a prior Phase III trial. Crit Care Med. 2016;44(2):275-281. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26584195.
8. Xu X, Han M, Li T, et al. Effective treatment of severe COVID-19 patients with tocilizumab. Proc Natl Acad Sci USA. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32350134.
9. Zhou Q, Wei X, Xiang X, et al. Interferon-a2b treatment for COVID-19. medRxiv. 2020;Preprint. Available at: https://www.medrxiv.org/content/10.1101/2020.04.06.20042580v1.
10. Cao Y, Wei J, Zou L, et al. Ruxolitinib in treatment of severe coronavirus disease 2019 (COVID-19): a multicenter, single-blind, randomized controlled trial. J Allergy Clin Immunol. 2020;146(1):137-146. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32470486.

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Clinical Data

Retrospective Study of Hydroxychloroquine and Azithromycin With or Without Zinc

This study has not been peer-reviewed.

A retrospective observational study compared zinc supplementation to no zinc supplementation in hospitalized patients with COVID-19 who received hydroxychloroquine and azithromycin from March 2 to April 5, 2020. On March 25, the institution’s standard of care was updated to include supplementation with zinc sulfate 220 mg orally twice daily. Patients who received any other investigational therapies were excluded. Only patients who were discharged from the hospital, transferred to hospice, or died were included in the analysis. Outcome measures included duration of hospital stay, duration of mechanical ventilation, maximum oxygen flow rate, average oxygen flow rate, average FiO₂, maximum FiO₂, admission to the intensive care unit (ICU), duration of ICU stay, death or transfer to hospice, need for intubation, and discharge destination.9

Results

• A total of 932 patients were included in this analysis; 411 patients received zinc, and 521 did not.
• The two groups had similar demographic characteristics.
• Patients who received zinc had higher absolute lymphocyte count and lower troponin and procalcitonin levels at baseline than those who did not receive zinc.
• In univariate analysis, no differences were observed between the two groups in duration of hospital stay, duration of mechanical ventilation, maximum oxygen flow rate, average oxygen flow rate, or average FiO₂.
• In bivariate logistic regression analysis, zinc supplementation was associated with a decreased mortality rate or rate of transfer to hospice; however, the association with a decreased mortality rate was no longer significant when analysis was limited to patients who were treated in the ICU.

Limitations

• This is a retrospective review; patients were not randomized to receive zinc therapy or to receive no zinc. The statistical methods used do not account for confounding variables or patient differences between those who were treated with zinc sulfate and those who were not, with one exception: the authors attempted to account for the change in the institution’s treatment standards by using a logistic regression analysis for patients admitted after March 25.
• The preprint did not include specific details on the timing of zinc initiation, and the patients’ clinical statuses at the start of therapy were not reported.
• The preprint also did not specify how many patients did or did not receive zinc before and after the institution’s treatment standards changed to include zinc sulfate on March 25. The authors used a logistic regression analysis to account for this, as discussed above.
• Only patients who died or who were transferred to hospice or discharged are included in the analyses. The exclusion of those who were still hospitalized as of April 5 makes it difficult to compare the clinical outcomes for those who received or did not receive zinc sulfate.

Given the nature of the study design and its limitations, the authors do not recommend using this study to guide clinical practice.

What to do if you’re sick

, follow the steps below to care for yourself and to help protect other people in your home and community.

• Stay home. Most people with COVID-19 will have only mild illness and can recover at home without medical care. Do not leave your home, except to get medical care. Do not visit public areas.
• Take care of yourself. Get rest and stay hydrated. Take over-the-counter medicines, such as acetaminophen, to help you feel better.
• Stay in touch with your doctor. Call before you seek medical care. Be sure to get care if you have trouble breathing, have any other , or if you think it is an .

If you have these emergency warning signs, call 911.

References

1. Omura S, Crump A. Ivermectin: panacea for resource-poor communities? Trends Parasitol. 2014;30(9):445-455. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25130507.
2. Fritz ML, Siegert PY, Walker ED, Bayoh MN, Vulule JR, Miller JR. Toxicity of bloodmeals from ivermectin-treated cattle to Anopheles gambiae s.l. Ann Trop Med Parasitol. 2009;103(6):539-547. Available at: https://www.ncbi.nlm.nih.gov/pubmed/19695159.
3. Yang SNY, Atkinson SC, Wang C, et al. The broad spectrum antiviral ivermectin targets the host nuclear transport importin alpha/beta1 heterodimer. Antiviral Res. 2020;177:104760. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32135219.
4. Tay MY, Fraser JE, Chan WK, et al. Nuclear localization of dengue virus (DENV) 1-4 non-structural protein 5; protection against all 4 DENV serotypes by the inhibitor ivermectin. Antiviral Res. 2013;99(3):301-306. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23769930.
5. Wagstaff KM, Sivakumaran H, Heaton SM, Harrich D, Jans DA. Ivermectin is a specific inhibitor of importin alpha/beta-mediated nuclear import able to inhibit replication of HIV-1 and dengue virus. Biochem J. 2012;443(3):851-856. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22417684.
6. Barrows NJ, Campos RK, Powell ST, et al. A screen of FDA-approved drugs for inhibitors of Zika virus infection. Cell Host Microbe. 2016;20(2):259-270. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27476412.
7. Caly L, Druce JD, Catton MG, Jans DA, Wagstaff KM. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antiviral Res. 2020;178:104787. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32251768.
8. Chaccour C, Hammann F, Ramon-Garcia S, Rabinovich NR. Ivermectin and COVID-19: keeping rigor in times of urgency. Am J Trop Med Hyg. 2020;102(6):1156-1157. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32314704.
9. Guzzo CA, Furtek CI, Porras AG, et al. Safety, tolerability, and pharmacokinetics of escalating high doses of ivermectin in healthy adult subjects. J Clin Pharmacol. 2002;42(10):1122-1133. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12362927.
10. Arshad U, Pertinez H, Box H, et al. Prioritization of anti-SARS-CoV-2 drug repurposing opportunities based on plasma and target site concentrations derived from their established human pharmacokinetics. Clin Pharmacol Ther. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32438446.
11. Bray M, Rayner C, Noel F, Jans D, Wagstaff K. Ivermectin and COVID-19: a report in Antiviral Research, widespread interest, an FDA warning, two letters to the editor and the authors’ responses. Antiviral Res. 2020;178:104805. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32330482.
12. Cepelowicz Rajter J, Sherman M, Fatteh N, Vogel F, Sacks J, Rajter J. ICON (ivermectin in COVID nineteen) study: use of ivermectin is associated with lower mortality in hospitalized patients with COVID19. medRxiv. 2020. Available at: https://www.medrxiv.org/content/10.1101/2020.06.06.20124461v2.

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Drugs used to treat COVID-19

The following list of medications are in some way related to, or
used in the treatment of this condition.

Learn more about COVID-19

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