COVID Awareness
Katie A. O’Connell, MS 

What is COVID-19? How is it spread?
Coronavirus disease 2019, also known as COVID-19, is caused by the virus SARS-CoV-2. It is spread from person to person via droplets in the air. Droplets are released when a person talks, coughs, or sneezes.¹ Anyone is at risk of becoming infected with COVID-19, however, different people may be affected to varying degrees. 

COVID-19 Symptoms 
Most individuals who develop symptoms will do so within 4-5 days of becoming infected. However, in some cases, symptoms may take up to 2 weeks to develop.² Symptoms are non-specific and include fever, cough, difficulty breathing, fatigue, chills, muscle aches, loss of a sense of smell and/or taste, and headaches.^1,2 Many of these symptoms may appear similar to seasonal influenza. It is important to contact a healthcare professional if you experience any of these symptoms. Your healthcare professional will be able to direct you towards the next best steps. 

COVID-19 Testing 
Testing should be done if a person exhibits the above symptoms of COVID-19, has been in close contact with a person testing positive for COVID-19 (close contact is defined as being within 6 feet of an infected person for a period greater than 15 minutes), or if your healthcare professional recommends you to take a test.² There are several tests that can be done to confirm a diagnosis of COVID-19. The Centers for Disease Control and Prevention recommend any of the following:³ 

1. Nasopharyngeal swab
2. Nasal swab from both anterior nares or from nasal mid-turbinate
3. Nasal or nasopharyngeal wash/aspirate
4. Oropharyngeal swab 
5. Saliva specimen (1-5 mL)

COVID-19 Prevention Strategies
In order to prevent the spread of COVID-19 and protect yourself and your loved ones there are several important steps you can take.¹

1. Wear a mask.

The Centers for Disease Control and Prevention recommends all Americans wear a cloth face mask to limit the spread of COVID-19. Studies have shown that mask wearing reduces the spread of the virus.^2,4

2. Wash your hands.

Remember to wash your hands for a minimum of 20 seconds with lukewarm water. Following hand washing, dry your hands gently with a clean towel. Next, apply hand cream or ointment. This will help keep your skin hydrated and reduce pain and irritation from frequent hand washing. For more information on best handwashing practices, visit the American Academy of Dermatology website:  https://www.aad.org/public/everyday-care/skin-care-basics/dry/coronavirus-handwashing

3. Follow social distancing protocols. 

Often, people infected with COVID-19 may be asymptomatic, thus, it is important to practice social distancing to avoid spreading the virus. Social distancing means staying 6 feet apart from individuals who are not part of your household. Although you may not personally experience symptoms, those you come into contact with and their loved ones could suffer significant consequences from COVID-19 infection.¹ If you are not vaccinated, wear a mask and practice social distancing whenever you are around individuals who do not live with you.

4. Get the COVID-19 vaccine.

Currently, three vaccines against COVID-19 are available for individuals age 16 and above. These vaccines significantly reduce the chance of serious infection and death from COVID-19. Please reach out to your health care provider for more information about becoming vaccinated.

Health and Social Inequities 
Numerous studies have identified that racial and ethnic minority groups are being disproportionately affected by the current pandemic.^5-11 Researchers believe this is due to a variety of factors related to long-standing health and social inequities.¹² COVID-19 can have devastating outcomes in both the elderly and those with comorbid conditions including, but not limited to, cardiovascular disease, diabetes, chronic kidney disease, and chronic lung disease.⁵ 

Cutaneous Manifestations of COVID-19
Many different forms of cutaneous manifestations of COVID-19 have been documented in the literature.¹³ However, the majority of published literature on these cutaneous manifestations involves patients with lighter skin types.¹⁴  Recently, several authors have made an effort to provide clinical photos of COVID-19 skin symptoms in skin of color.^15,16 One series identified seven patients with subtle findings on their toes and associated symptoms of swelling, pain, and itching.¹⁵ For some, this may be the only sign of COVID-19 infection.¹⁷ Please consult your healthcare provider if you or your loved ones develop new skin symptoms. 

Other Resources:

CDC Website: https://www.cdc.gov/coronavirus/2019-ncov/index.html
CDC Vaccine Information: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html 
CDC Health Equity and Coronavirus: https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/index.html 
World Health Organization: https://www.who.int/health-topics/coronavirus#tab=tab_1
American Academy of Dermatology Coronavirus Resource Center: https://www.aad.org/public/diseases/coronavirus
National Institute of Health: https://www.nih.gov/coronavirus
Benefits.gov Coronavirus Resources: https://www.benefits.gov/help/faq/Coronavirus-resources
American Psychiatric Association Coronavirus Resources for families: https://www.psychiatry.org/psychiatrists/covid-19-coronavirus

Resources:

1. Patient education: Coronavirus disease 2019 (COVID-19) overview (The Basics). In: UpToDate, Crowley K (Ed), UpToDate, Waltham, MA. (Assessed on October 11, 2020). 
2. Coronavirus (COVID-19). (2020). In: Centers for Disease Control and Prevention. Available from: https://www.cdc.gov/coronavirus/2019-ncov/index.html
3. Centers for Disease Control and Prevention. Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons Under Investigation (PUIs) for Coronavirus Disease 2019 (COVID-19). https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html (Accessed on October 15, 2020).
4. Hendrix MJ, Walde C, Findley K, Trotman R. Absence of Apparent Transmission of SARS-CoV-2 from Two Stylists After Exposure at a Hair Salon with a Universal Face Covering Policy — Springfield, Missouri, May 2020. MMWR Morb Mortal Wkly Rep 2020;69:930-932. DOI: http://dx.doi.org/10.15585/mmwr.mm6928e2external icon.
5. Stokes EK, Zambrano LD, Anderson KN, Marder EP, Raz KM, El Burai Felix S, Tie Y, Fullerton KE. Coronavirus Disease 2019 Case Surveillance – United States, January 22-May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020 Jun 19;69(24):759-765. doi: 10.15585/mmwr.mm6924e2. PMID: 32555134; PMCID: PMC7302472.
6. Killerby ME, Link-Gelles R, Haight SC, Schrodt CA, England L, Gomes DJ, Shamout M, Pettrone K, O’Laughlin K, Kimball A, Blau EF, Burnett E, Ladva CN, Szablewski CM, Tobin-D’Angelo M, Oosmanally N, Drenzek C, Murphy DJ, Blum JM, Hollberg J, Lefkove B, Brown FW, Shimabukuro T, Midgley CM, Tate JE; CDC COVID-19 Response Clinical Team. Characteristics Associated with Hospitalization Among Patients with COVID-19 – Metropolitan Atlanta, Georgia, March-April 2020. MMWR Morb Mortal Wkly Rep. 2020 Jun 26;69(25):790-794. doi: 10.15585/mmwr.mm6925e1. PMID: 32584797; PMCID: PMC7316317.
7. Health Equity Considerations and Racial and Ethnic Minority Groups. (2020) In: Centers for Disease Control and Prevention. Available from: https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
8. Gold JAW, Wong KK, Szablewski CM, Patel PR, Rossow J, da Silva J, Natarajan P, Morris SB, Fanfair RN, Rogers-Brown J, Bruce BB, Browning SD, Hernandez-Romieu AC, Furukawa NW, Kang M, Evans ME, Oosmanally N, Tobin-D’Angelo M, Drenzek C, Murphy DJ, Hollberg J, Blum JM, Jansen R, Wright DW, Sewell WM 3rd, Owens JD, Lefkove B, Brown FW, Burton DC, Uyeki TM, Bialek SR, Jackson BR. Characteristics and Clinical Outcomes of Adult Patients Hospitalized with COVID-19 – Georgia, March 2020. MMWR Morb Mortal Wkly Rep. 2020 May 8;69(18):545-550. doi: 10.15585/mmwr.mm6918e1. PMID: 32379729.
9. Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and Mortality among Black Patients and White Patients with Covid-19. N Engl J Med. 2020 Jun 25;382(26):2534-2543. doi: 10.1056/NEJMsa2011686. Epub 2020 May 27. PMID: 32459916; PMCID: PMC7269015.
10. Millett GA, Jones AT, Benkeser D, Baral S, Mercer L, Beyrer C, Honermann B, Lankiewicz E, Mena L, Crowley JS, Sherwood J, Sullivan PS. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol. 2020 Jul;47:37-44. doi: 10.1016/j.annepidem.2020.05.003. Epub 2020 May 14. PMID: 32419766; PMCID: PMC7224670.
11. Martin CA, Jenkins DR, Minhas JS, Gray LJ, Tang J, Williams C, Sze S, Pan D, Jones W, Verma R, Knapp S, Major R, Davies M, Brunskill N, Wiselka M, Brightling C, Khunti K, Haldar P, Pareek M; Leicester COVID-19 consortium. Socio-demographic heterogeneity in the prevalence of COVID-19 during lockdown is associated with ethnicity and household size: Results from an observational cohort study. EClinicalMedicine. 2020 Aug;25:100466. doi: 10.1016/j.eclinm.2020.100466. Epub 2020 Jul 17. PMID: 32840492; PMCID: PMC7366113.
12. Temiz LA, McKinley-Grant L, Glass DA 2nd, Harvey VM. COVID-19 Compels Closer Scrutiny of Disparities in Dermatology. J Am Acad Dermatol. 2020 Sep 30:S0190-9622(20)32678-5. doi: 10.1016/j.jaad.2020.09.077. Epub ahead of print. PMID: 33010313; PMCID: PMC7527280.
13. Freeman EE, McMahon DE, Lipoff JB, Rosenbach M, Kovarik C, Desai SR, Harp J, Takeshita J, French LE, Lim HW, Thiers BH, Hruza GJ, Fox LP. The spectrum of COVID-19-associated dermatologic manifestations: An international registry of 716 patients from 31 countries. J Am Acad Dermatol. 2020 Oct;83(4):1118-1129. doi: 10.1016/j.jaad.2020.06.1016. Epub 2020 Jul 2. PMID: 32622888; PMCID: PMC7331510.
14. Lester JC, Jia JL, Zhang L, Okoye GA, Linos E. Absence of images of skin of colour in publications of COVID-19 skin manifestations. Br J Dermatol. 2020 Sep;183(3):593-595. doi: 10.1111/bjd.19258. Epub 2020 Jul 16. PMID: 32471009; PMCID: PMC7301030.
15. Daneshjou R, Rana J, Dickman M, Yost JM, Chiou A, Ko J. Pernio-like eruption associated with COVID-19 in skin of color. JAAD Case Rep. 2020 Sep;6(9):892-897. doi: 10.1016/j.jdcr.2020.07.009. Epub 2020 Jul 12. PMID: 32835046; PMCID: PMC7354762.
16. Pangti R, Gupta S, Nischal N, Trikha A. Recognizable vascular skin manifestations of SARS-CoV-2 (COVID-19) infection are uncommon in patients with darker skin phototypes. Clin Exp Dermatol. 2020 Aug 16:10.1111/ced.14421. doi: 10.1111/ced.14421. Epub ahead of print. PMID: 32803786; PMCID: PMC7461456.
17. Covid Toes, rashes: How the coronavirus can affect your skin. (2020). In: American Academy of Dermatology. Available from: https://www.aad.org/public/diseases/coronavirus/covid-toes