here include COVID-19, Zika virus, West Nile virus, Ebola virus disease,

Legionnaires disease, and pertussis. Bioterrorism agents such as anthrax and

plague are also considered emerging infectious diseases because a bioterrorist act
would introduce a new mode of transmission for these agents. Other examples,
covered earlier in this chapter, include novel influenza viruses, CRE, and C. auris.
Infectious diseases may begin anywhere in the world; therefore, epidemiologists
worldwide collaborate to share information about the detection of new diseases,
their clinical presentations, laboratory identification methods, and possible
treatments. In the United States, the CDC is the central agency for this
coordination. The CDC collaborates with numerous agencies, including other U.S.
government agencies (such as the National Institutes of Health [NIH] and Food
and Drug Administration [FDA]) as well as the WHO and other international
agencies, faith-based agencies, nongovernmental organizations, and businesses
throughout the world. Elaborate disease surveillance and reporting methods are
established with the goal of early detection and control of actual and potential
epidemics and pandemics (CDC, 2017).
Many factors contribute to newly emerging or re-emerging infectious diseases.
These include travel, globalization of food supply and central processing of food,
population growth, increased urban crowding, population movements (e.g., those
that result from war, famine, or human-made or natural disasters), ecologic
changes, human behavior (e.g., risky sexual behavior, IV/injection drug use),
antimicrobial resistance, and breakdown in public health measures.
Emerging infectious diseases are important from an epidemiologic standpoint
because their incidence is not stable. When the pattern of disease in a community
is not well understood in the medical-scientific community, patients, families, and
others in the community often become alarmed about these diseases. During times
of increased concern about bioterrorism, whether triggered by actual events or by
hoaxes, nurses have responsibility to rationally separate facts from fears. In
discussions with patients and other caregivers, it is important to keep the focus on
what is known and to clarify the plan for diagnosis, treatment, and containment.

COVID-19

The COVID-19 pandemic began in Wuhan, China, in late 2019. As research into
the novel pathogen responsible for the 2019–2021 global pandemic progresses,
new information about the pathogenesis, risks, clinical manifestations, and
management of patients infected with SARS-CoV-2 continues to emerge. Of those
individuals in the United States diagnosed with COVID-19, the case fatality rate is
estimated to be 5.6% (Johns Hopkins University & Medicine Coronavirus
Resource Center, 2020).

Pathophysiology
COVID-19 transmission occurs through virus-laden droplets and aerosols exhaled
by an infected host while breathing, speaking, coughing, and sneezing (Prather,

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Wang, & Schooley, 2020). SARS-CoV-2 gains entry into host cells through the
angiotensin-converting enzyme 2 (ACE2) cellular surface receptors (see Chapter
27, Fig. 27-2) (Vaduganathan, Vardeny, Michel, et al., 2020). In addition, the
aerosols of SARS-CoV-2 can accumulate, remain infectious in indoor air for hours,
and can be inhaled deep into the lungs (Prather et al., 2020). The virus multiplies
rapidly within an infected host and, unless checked by the immune system,
symptoms begin with a week of transmission (Prather et al., 2020).

Risk Factors
Individuals of any age, gender, and ethnicity can be at risk for infection; however,
adults 65 years of age and older, and those who reside in long-term care or skilled
nursing facilities are at higher risk of death from COVID-19 (NIH COVID-19
Treatment Guidelines Panel, 2020). Some studies suggest that men with COVID-
19 have a higher fatality rate compared to women (Chen, Zhou, Dong, et al., 2020;
Deng, Yin, Chen, et al., 2020). While information on risk continues to evolve,
Chart 66-9 lists the demonstrated and possible risk factors for COVID-19 in adults.
Having a history of several chronic diseases, particularly if the diseases are not
properly managed, appears to be associated with higher risk of severe disease and
death (CDC, 2020g; CDC, 2020h). Patients who are immunosuppressed for a
variety of reasons (e.g., active neoplasm, organ transplant recipient) are also
thought to be at higher risk of dying from COVID-19 (CDC, 2020g; CDC, 2020h;
NIH COVID-19 Treatment Guidelines Panel, 2020).

Clinical Manifestations
COVID-19 clinical manifestations occur on a wide spectrum, from mild symptoms
that can be managed at home to severe illness with manifestations that can cause
multisystem morbid complications requiring care in an ICU setting. While
primarily respiratory in nature, mild COVID-19 manifestations may include fever,
nonproductive cough, sore throat, fatigue, myalgias (muscle aches), nasal
congestion, nausea, vomiting, diarrhea, anosmia (loss of smell), and ageusia (loss
of taste) (Cascella, Rajnik, Cuomo, et al., 2020; Kim & Gandhi, 2020). See
Chapter 19 for further discussion of the spectrum of clinical manifestations in the
patient with COVID-19.

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Chart 66-9 RISK FACTORS

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Development of Severe Illness due to COVID-19 in Adults

Increased Risk Demonstrated

• Cancer
• Chronic kidney disease
• COPD
• Down Syndrome
• Heart failure, coronary artery disease, or cardiomyopathy
• Immunocompromised state from solid organ transplant
• Obesity (body mass index [BMI] of 30 kg/m2 or higher but ≤40
kg/m2)
• Severe obesity (BMI ≥40 kg/m2)
• Pregnancy
• Sickle cell disease
• Smoking
• Type 2 diabetes

Possible Increased Risk

• Asthma (moderate-to-severe)
• Cerebrovascular disease
• Cystic fibrosis
• Dementia
• Hypertension
• Immunocompromised state from blood or bone marrow transplant,
immune deficiencies, HIV, use of corticosteroids, or use of other
immune weakening medicines
• Liver disease
• Overweight (BMI ≥25 kg/m2, but ≤30 kg/m2)
• Pulmonary fibrosis
• Thalassemia
• Type 1 diabetes
COPD, chronic obstructive pulmonary disease.
Adapted from Centers for Disease Control and Prevention (CDC).
(2020g). Interim clinical guidance for management of patients with
confirmed coronavirus disease (COVID-19). Retrieved on 7/24/2020
at: www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-
management-patients.html; Centers for Disease Control and
Prevention (CDC). (2020h). COVID-19: People with certain medical
conditions. Retrieved on 7/24/2020 at: www.cdc.gov/coronavirus/2019-
ncov/need-extra-precautions/people-with-medical-conditions.html

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Medical Management
Patients with mild symptoms, about 80% of patients, can be managed at home
(Cascella et al., 2020; Kim & Gandhi, 2020). Those with severe illness are
hospitalized (Kim & Gandhi, 2020). See Chapter 19 for further discussion of
medical management of the patient with mild, moderate, and severe COVID-19
infection.
Nasopharyngeal samples are the recommended method of diagnosing SARS-
CoV-2 (NIH COVID-19 Treatment Guidelines Panel, 2020). Those testing people
for possible infection with SARS-CoV-2 either work with their state, tribal, local,
and territorial health departments to coordinate testing through public health
laboratories, or with commercial or clinical laboratories using molecular and
antigen tests. The type of specimen collected is based on the test being used and
the specific manufacturer instructions (CDC, 2020a).
Ideally, the diagnosis of COVID-19 is confirmed by patient self-administration
of bilateral nasal swabbing for viral antigen or nucleic acid. Self-swabbing
minimizes the risk of person-to-person transmission of respiratory droplets. The
act of patient self-swabbing should be observed by a health care provider whenever
possible to assure it is performed properly (CDC, 2020a).

COVID-19 Vaccines
Operation Warp Speed was an unprecedented response to the study of safety and
efficacy of new vaccine platforms never before used in humans (Castells &
Phillips, 2020). Two SARS-CoV-2 mRNA vaccines were authorized for
emergency use in the United States in December of 2020, less than a year after the
SARS-CoV-2 sequence was discovered (Castells & Phillips, 2020). Both vaccines
require 2 doses for efficacy, the second dose of the Pfizer-BioNTech 21 days after
the first dose, and the Moderna mRNA 28 days later. Early reports indicated the
Pfizer-BioNTech vaccine had an anaphylaxis rate of 1 in 100,000 compared with a
rate of 1 in 1,000,000 for other vaccines (Castells & Phillips, 2020). Ongoing
efforts are needed by nurses and all health care workers to maintain a proactive
response to support public confidence and reduce vaccine hesitancy. Anaphylaxis
is a treatable reaction that requires early recognition and an appropriate and timely
response (see Chapter 33). A VAERS form must be completed for any adverse
reaction and can be submitted online (see the Resources section). Nurses should be
vaccinated for COVID-19 and should advocate for all of their professional and
personal contacts receiving the vaccine at the first available opportunity.

Nursing Management
Nursing management of the patient with COVID-19 mirrors that of medical
management. The majority of patients with known or suspected mild COVID-19
may be managed on an outpatient basis within their homes, which conserves
hospital resources and diminishes the likelihood of exposure to others, including
health care workers (Kim & Gandhi, 2020). Few medications are used to either

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treat COVID-19 or to mitigate its effects in patients with mild disease who are
managed at home; thus, care is largely supportive. The nursing management of
patients with mild COVID-19 mirrors that of other viral respiratory illnesses.
Patients with moderate or severe COVID-19 are most often managed in the
hospital setting. Health care workers are at increased risk for acquiring COVID-19
and should wear complete PPE as discussed earlier in this chapter (CDC, 2020c).
See Chapter 19 for further discussion of nursing management of the patient with
mild, moderate, and severe COVID-19 infection. Supportive care for a patient,
whether at home or in the hospital setting, requires very careful use of infection
control measures and psychological support for the patient and family.
Early in the COVID-19 pandemic, important measures were recommended by
the CDC to help mitigate the spread of SARS-CoV-2. Nurses should provide
education to help patients and their families implement these measures to help
slow viral transmission. One measure is to wear a mask with 2 or more layers of
breathable fabric that snugly covers the nose and mouth; this type of mask should
be worn in public places to help patients and families protect themselves and
others (Prather et al., 2020). One study of mask usage reported that among 139
clients exposed to two symptomatic hair stylists with confirmed COVID-19, while
both the stylists and the clients wore face masks, no symptomatic secondary cases
were identified (Hendrix, Walde, Findley, et al., 2020). Another important practice
is to ‘socially distance’ by remaining at least 6 feet apart from others and avoiding
crowds. The nurse should also encourage frequent handwashing with at least 20
seconds of scrubbing, rinsing, and drying after washing (CDC, 2002). If
handwashing is not possible, then hand sanitizer with at least 60% alcohol should
be used.

Zika Virus
The Zika virus was first discovered as a pathogen in monkeys in the Zika Forest of
Uganda in the 1940s; it was found to cause human disease in the 1950s. The
epidemiologic pattern changed as the first large outbreak in humans did not occur
until 2007 in Micronesia. The disease was not seen in the Western Hemisphere
until July 2015, when a large outbreak began in Brazil. Within the next year,
infections were noted in countries throughout the Americas and Pacific Islands
(WHO, 2016).
The incubation period for Zika virus disease is estimated to be between 3 and
14 days (Krow-Lucal, Biggerstaff, & Staples, 2017). Among patients who are
symptomatic, most have self-limiting illness of 2 to 7 days duration with mild
fever, rash, headache, conjunctivitis, or joint and muscle pain. Zika has been
associated with microcephaly and other congenital abnormalities in infants of some
women infected with Zika during pregnancy. The virus can also cause Guillain–
Barré syndrome, a condition with nerve and muscle weakness that often quickly
progresses to a paralysis (WHO, 2016).
Zika is primarily transmitted through bites of infected mosquitos from the
Aedes genus. Sustained outbreaks have been more common in tropical areas where
these mosquitos thrive. The Aedes mosquito is also the carrier of other mosquito-

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