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of SARS-coronavirus-2.
And by natural history, I mean, what
happens to someone when they get a SARS-coronavirus-2 infection.
So what does happen to someone after they're infected
with SARS-coronavirus-2?
Well, many people get an illness that we call COVID-19.
COVID-19 is short for coronavirus disease that
emerged in 2019, and for short we say, COVID-19.
So not everyone who gets infected
with SARS-coronavirus-2 gets sick.
So not everyone develop signs and symptoms.
However, if they do get sick, we're
going to talk about what their signs and symptoms are.
We would want to know how long they're sick.
We'll talk about that as well.
Importantly, we're going to talk about how long
they can infect people and spread the virus,
and where and how people shed the virus.
So these are all the different components
of what happens to someone when they're infected
with SARS-coronavirus-2.
Let's talk, next, about signs and symptoms of disease.
So you may have heard these words before,
but it's important to define them so the difference
between signs and symptoms.
Signs of disease are objective measurements
to characterize an illness or disease that can be observed
during a physical exam.
So, for example, temperature is a sign of disease,
because it can be measured by taking your temperature.
Breathing faster than usual is also a sign,
because someone can count the number of times
that you're breathing per minute and determine
whether it's faster than usual.
Symptoms are not something that can be objectively measured,
but how the patient says they're feeling.
So, for example, fatigue is a symptom,
because it's how someone is feeling.
They're feeling very tired.
Nausea is a symptom, because it can't be measured.
It's how someone is feeling.
A loss of taste or smell is also something that someone reports.
It's something that they're observing themselves,
not something that can be observed
during a physical exam.
Muscle ache is the same.
Fever can be both a sign and a symptom,
because it can be measured by someone else
and you can also feel when you have a fever.
So it's important to keep these general definitions in mind.
Now, let's talk about the signs and symptoms of COVID-19.
And this disease is unusual, because it
can cause such a wide variety of signs and symptoms.
It makes it difficult to classify.
So as we just mentioned, some people have no symptoms at all.
This is called being asymptomatic.
So this means that someone can be
infected with SARS-coronavirus-2,
and they will never know.
They feel just fine.
They're perfectly healthy.
Other people will have some disease, but it will be mild.
They may not need to seek care at all.
It may feel like just a head cold, or a very mild fever,
or respiratory illness.
Other people will have very serious disease.
They'll feel very sick, and it can lead to death
in some people who develop severe disease.
So, again, it's a wide range of signs and symptoms
with this infection.
Among people who do develop signs and symptoms,
there are some common signs and symptoms of COVID-19.
Many people will develop a fever.
Many people will feel very tired,
or have what we call fatigue.
People may have chills.
That often goes along with the fever.
Some people will experience muscle pain.
Some will develop a cough.
Many people think about COVID-19 as a respiratory disease,
and think about coughing, but not all people with COVID-19
will have a cough.
Many people who have COVID-19 say
that they recently lost their ability to taste or smell.
Some will have difficulty breathing
and feel like they're short of breath.
That's a more serious symptom of COVID-19.
Some people with COVID-19 could also
have a headache and a sore throat.
It's important to keep in mind that people who have COVID-19
may have only one of these signs or symptoms.
They may have just a few of these signs or symptoms.
Some people may have all of these signs or symptoms.
So there's not one right way to define COVID-19.
But you should be aware of all the possible signs and symptoms
that people may have.
And many signs and symptoms of COVID-19
are what we call non-specific.
It means they're common to other infections as well.
So fever, cough, myalgia or muscle pain,
are common to many different types of infections.
So people with these signs and symptoms may have COVID-19,
but it's hard to tell without a test.
Some signs and symptoms are more specific for COVID-19.
I mentioned one previously, and that's
the recent loss of the ability to taste or smell.
About 1/3 of patients report this loss of taste or smell,
and this is something that's a bit more specific for COVID-19,
because it's very rare in other types of infections.
There are some signs and symptoms
that mean the disease is becoming more severe
or progressing, and these are important to know,
because when people have these signs and symptoms,
they may need to seek immediate care.
The most common signs of progression of the infection
are increased or more severe fevers, an increased difficulty
breathing.
Anyone who is experiencing these signs and symptoms
should contact a doctor.
Patients should immediately seek emergency care
if they develop any of these warning signs or symptoms,
including, bluish lips or face.
That could mean that they're not getting enough oxygen. If they
have an increased rate of breathing,
which means they're breathing much faster than normal.
If they're feeling shortness of breath, which means
they feel like they're not getting enough air in,
even though they're breathing quickly.
If someone is experiencing chest pain when breathing,
this is a serious symptom and they
should seek immediate care.
If someone is waking up from sleep feeling
like they're short of breath, and they're not
able to get enough air in, they should seek care right of way.
Anyone who develops new confusion,
so they're confused about events, or people,
or what's happening, or they're difficult to wake up,
should also seek immediate emergency care.
All of these are signs that the patient is not
getting enough oxygen, and that's
a very serious condition.
And they should seek care right away.
Play video starting at 7 minutes 59 seconds and follow transcript7:59
One of the ways that COVID-19 causes severe disease
and death, is through congesting in the lungs.
So our lungs are how we get oxygen into our body.
And if the lungs don't function properly,
we can't get enough oxygen.
So on the left side here, you can see healthy lungs and what
healthy lung tissue looks like.
You can see here that the field is dark.
This shows you that the tissue is healthy.
Play video starting at 8 minutes 32 seconds and follow transcript8:32
On the right side, however, are the lungs of someone
who has severe COVID-19.
So in red here, you can see the same lung area
that's pictured on the left, except you can see that it's
white instead of dark.
That shows that the tissue is severely damaged by the virus,
and this shows that this person is having a very difficult time
breathing and getting enough oxygen into their body.
This shows you what the virus can do,
and how it causes severe disease and death.
Play video starting at 9 minutes 6 seconds and follow transcript9:06
Now, let's talk about the incubation
period for SARS-coronavirus-2.
It's important for you to learn the term incubation period,
because you're going to hear it throughout this course.
So the incubation period is the time
from when someone is infected until they develop symptoms.
So usually this takes a number of days.
So the incubation period for SARS-coronavirus
ranges from 2 to 14 days.
So most people infected with this virus
will develop signs and symptoms between 2 to 14 days
after they're infected.
You can see here on your screen the proportion
of people who develop symptoms by each day
after they are infected.
So 5% of all people infected with this virus
will develop signs or symptoms within two days.
So it can be very quick.
And 1/2 of people infected, will develop signs and symptoms
within five days.
So just five days after infection,
1/2 of everyone infected will develop signs and symptoms.
By 14 days, 95% of all people who are infected
will have developed signs or symptoms.
Play video starting at 10 minutes 30 seconds and follow transcript10:30
OK, now let's define the infectious period.
This is an important term that you'll
need to know for the rest of the course.
The infectious period is the time
at which someone infected with SARS-CoV-2
can transmit the virus to other people.
So for people who have COVID-19 disease,
their infectious period starts two days
before the start of their signs and symptoms.
And they could infect other people
throughout the end of their illness.
So we define the end of their infectious period
as being at least 10 days after the onset of their illness.
And as long as their symptoms are improving,
and they haven't had fever within the past three days,
we could assume that they're no longer infectious.
So it's a bit tricky to identify exactly when
the end of the infectious period is, but these
are some of the markers we use to identify when someone
may no longer be infectious.
As you know, some people who are infected with SARS-CoV-2
may never develop any kind of symptoms.
They are asymptomatic.
But they can still be infectious.
They could still infect someone else.
For these people, it's more difficult to define
their infectious period.
It's more difficult to define when
they could infect someone else.
But, typically, we assume this period
to be about 10 to 14 days, and we
should assume that it started before they had a test that
showed that they had the infection,
and to last for at least 10 days after the test.
So now, let's think about the timeline
of infection using these new terms that we've learned,
the incubation period and the period of infectiousness.
So here, first, we see that someone
is infected by someone else.
And then, they enter their incubation period.
So the person is infected, but they haven't developed
signs or symptoms yet.
They may not know that they're infected.
Remember, this incubation period can range from 2 to 14 days,
but on average is about five days.
The incubation period here is represented in the orange line.
At the end of their incubation period,
again, which will be an average of five days,
but can be up to 14 days, they will develop signs and symptoms
of disease.
So for people who have mild illness,
that illness is going to last about ten days.
For people who have more severe illness,
that can last two weeks or more.
Now, let's think about when that person is infectious,
or when could they possibly transmit the virus
to someone else.
So you can see here in yellow, that this person who developed
signs and symptoms here on day 14
was infectious starting from day 12,
and they are going to be most infectious on the first day
of onset of symptoms, which will be around day 14.
So on the day that they first notice
that they are sick, the day they first start feeling badly,
is the day that they are most infectious,
or probably most likely to infect someone else.
They can continue to be infectious
throughout their signs and symptoms.
This will be at least ten days, possibly longer.
Particularly for people who have severe disease,
they're going to be infectious for much
longer and through the duration of their illness.
So it's important to remember here a few key things.
People can infect others before they become sick,
before they know they're sick, and particularly on the day
that they're sick.
And they can continue to be infectious and transmit
to others through out their illness period,
as long as that illness period lasts.
So that's going to vary from person to person,
but we'll be at a very minimum ten days.
Hello.
My name is Emily Gurley, and I'm an infectious disease
epidemiologist at the Johns Hopkins Bloomberg School
of Public Health.
I want to talk to you now about the steps
to investigate cases and trace their contacts.
By the end of this lecture, you should
be able to identify all of the basic steps
to investigate cases and trace their contacts.
You should be able to provide examples
of the kinds of questions that you
might ask of cases and contacts during each step.
And you should be able to describe
the kinds of social support that cases and contacts
may need to carry out isolation and quarantine.
After all, asking people to isolate and quarantine
is difficult, and they may need some additional support.
And finally, we're going to present
an example of a simple case investigation
and contact tracing call so that you can hear what
this sounds like in practice.
Next, let's go through the basic steps--
naming them, understanding what they mean,
and how they come in the sequence.
On this slide, you can see the six steps of case investigation
and contact tracing.
Please know that this is a major simplification of what's
actually happening, but hopefully it can provide you
with a framework to think through the different
components of what you'll do while you're investigating
cases and tracing contacts.
So let's go through these briefly first.
First, when you call a case, you'll introduce yourself,
and you'll get their basic information.
We'll talk more about that in just a minute.
Next, you would inquire and find out
about their infectious period.
So you need to ask them questions
to be able to determine that.
Once you define their infectious period,
you would move on to step 3, which
is identifying the contacts they had
during their infectious period.
Then you would move on to step 4 of that call
with the case, where you're providing them
with instructions on isolation and helping
them to identify challenges to their ability to do that.
You would also provide them with any support
that you could to allow them to isolate.
So then we move on to number 5, which is about the contacts.
You'll initiate contact tracing, which
means calling or contacting the contacts in some way,
informing them about their exposure,
asking about symptoms, and giving them
instructions about quarantine.
Finally, in step 6, you're going to implement regular check-ins.
And this refers to the contacts as well as the cases,
and you're going to follow up with them
throughout their isolation or quarantine period.
On this slide, you can see how the steps fit together
in a sequence, one after the other.
So steps 1 through 4, again, are about calling the case
and having a number of conversations
with that case on introducing yourself,
inquiring about the infectious period,
identifying their contacts, and giving them
instructions on how to isolate.
After that first call, where you've done all four steps,
you move on to step 5 where you call their contacts.
And that step-- step 5, where you're calling the contacts--
could be repeated many times.
It would be repeated for all the different contacts
that they had.
And on those calls, you're asking about symptoms
and instructing them on quarantine.
Finally, step 6 is an ongoing step as well.
So you're going to be implementing regular check-ins,
being in constant contact with the case and their contacts
to follow up on symptoms and how things
are going with their isolation and quarantine.
So you can refer back to this to see how each of the steps
are going to link together.
Now that we've defined each of the steps,
let's talk about what happens in each step and talk about some
of the questions that you might use in each of the steps.
So on this slide, please note that the words in italics
are the questions that you may use during each of these steps,
or something similar, just to give you an idea of how
these conversations flow.
First, you might want to identify your organization.
To do this, you may say something like, "Hi.
This is Julie from the health department."
Next, you want to be able to confirm their identity
and their residence.
Because you're going to be talking
with them about personal information,
you want to make sure that you have the right person.
So when you say, "Is this Swetha,"
they confirm that it is them.
And you say, "Nice to meet you.
I need to discuss some sensitive information with you.
Before we keep talking, can you please tell me
your birthday and address?"
And then if they can confirm that,
then you can feel confident going on.
Next, in this step, you want to discuss the positive test
with them, because that's really the reason why you're calling.
So you might say, "I'm calling about your coronavirus test.
Have you talked with your provider yet?"
It's possible that they've already heard about their test
from their health care provider.
You also want to describe the importance and the benefits
of the call to the case.
You want to say something like, "I'm calling to see how you are
and to help keep you, your family,
and your community safe."
You want to provide them some assurances
and confirm that the call is confidential.
So you might say something like, "What we talk about
is between you and me."
You want to check in about the length
and the safety of the call before you continue.
So you may say something like, "This call
should take about 20 minutes.
Is now a good time to talk?
Are you in a safe place to talk?"
While you're on the call, it's important to pause and ask
and assess about the need for medical care.
If you notice that the person you're talking to
has trouble breathing, or is having chest pain that
doesn't go away, if they seem confused
or is having trouble talking, those
could be some indicators that the person is very severely
ill.
And if that's true, you would need
to help get them medical care right away.
You wouldn't finish the call.
You would just turn from the questions
you're asking to helping them get medical care.
As you remember, step 2 is also part of the call with the case.
In step 2, you want to inquire about their infectious period.
So there are a few questions you're
going to have to ask to determine
when their infectious period started.
If they had symptoms, you're going
to ask questions like, "What date did your symptoms start,"
or, "Did you feel like you had a fever?
How has your fever improved without medication?
How are you feeling now?"
And if they didn't have any symptoms--
maybe it's someone who's been diagnosed with an infection,
but they never had signs and symptoms-- remember,
we call this an asymptomatic case--
you may ask them, what date did they get tested?
So depending on the answers that they provide,
you can calculate the period of time
that the case may have spread SARS-CoV-2 to others
or when they were infectious.
You can also find out who was close to the case
during that period of time.
Please note that there may be differences
in how the infectious period is calculated, depending
on whether there were symptoms or fever.
While you're talking with the case,
you'll move on then to step 3.
Now that you've identified their infectious period,
you'll need to identify who they had contact
with during that period.
So anyone considered a contact of the case
during their infectious period will be quarantined,
which includes but isn't limited to people
who live with the case, were face-to-face
within six feet of the case for 15 minutes or more,
or had other types of direct contact with the case,
like kissing, or had contact with secretions of the case.
So someone taking care of them may
have cleaned up their used tissues, for example.
Some helpful questions you may want to use
are, "Do you have any caretakers or housemates?
Would you be willing to look at your calendar, or phone,
or social media to help jog your memory about what
you did this past week?
Where have you traveled?"
All of those questions will help you
to help the case remember the things that they
may have been doing during their infectious period.
So in step 4, you're still on the call with the case,
and you're going to issue isolation instructions
for them.
There are four components of issuing the isolation
instructions.
First, you'll explain isolation to them in simple terms.
So what does isolation mean?
What are you asking them to do?
Then in number 2, you'll ask questions
to check that they understood completely
about what isolation means and help them make a plan.
Isolating yourself isn't easy, so they'll need a plan.
Third, you should identify the challenges
that may stop them from following your isolation
instructions.
And then, finally, offer them resources
to improve the chances of following the isolation
instructions and being able to carry it out.
Let's break these four components of the isolation
instructions out a little bit more
and think about some things you may do.
So to explain isolation simply, you
could say something like this.
"Isolation means that you should try
to eliminate your contact with other people,
except if you need to see a doctor.
If you live with others, you might
try to find a different place to stay,
or you might use your own bedroom and bathroom.
If you need to be around other people,
you should wear a mask."
Next, you'll need to check their understanding
and help them make a plan.
To do that, you'll need to ask them some questions.
So you may ask questions like, "Do you
have a safe place to stay?
Will you need food soon?
If so, how could you get it?
Do you take any medications, and will you need a refill soon?
And do you have a mask?"
So they'll need plans.
Next, you'll want to help them identify challenges.
Again, this could be done through asking them
some more questions, like, "What concerns
do you have about your responsibilities
and mental health?"
Some examples of concerns they may have
are taking care of their parents or kids,
or they're the only employed person in their home.
It's also possible they're in a domestic violence situation
and may need help finding a safe place to stay.
Finally, based on the challenges that they've
identified with you, you would want
to be able to offer them some resources.
It's important to keep in mind that the resources
available to people are going to be different
depending on where you are.
Some examples of resources you may have to offer them
include the 211 number.
This is not available in all parts of the United States,
but it is in some.
And it's a place where people can access some immediate needs
they may have.
You could put them in touch with food banks,
other local services, organizations, or neighborhood
and community support groups that can support people
during this time.
At the end of the call with the case,
you're going to wrap up that call.
You're going to make sure that you answer their questions
and have a plan for follow-up.
So you'll say something like, "Thank you for your time.
We've talked a lot today, and I've
given you tons to think about.
You'll probably have more questions
over the next few days.
If you think of something, here's our phone number.
But either way, I'll be calling back soon to check on you.
Bye."
After you're done with the call with the case,
you're going to move on to step 5, which is contact tracing.
When you call a contact, first you're
going to inform them that they were in close contact
with someone who has coronavirus, or COVID-19.
Next, you're going to check to see if they have
any symptoms, such as a fever.
You're going to provide them instructions to quarantine.
You're going to help them identify challenges and offer
resources to overcome those challenges.
You're going to answer their questions
and then make a plan to follow up.
So you should recognize many of these,
because it's very similar to some of the things
you're going to do on the call with a case.
Checking if they have symptoms, identifying challenges
to quarantine, offering resources, answering questions,
and following up are very similar to what
you do with a case.
Some frequently asked questions from the contacts
include things like, "What happens if I get sick?
How do I get tested?
Do I need a mask?
Can you give me a letter for my job or landlord?"
And those are questions that you should anticipate
and have some answers for when you
are ready to talk to contacts.
Finally, we've come to step 6, which is implementing
regular check-ins.
So at this stage, you've established a relationship
with the case and with all their contacts,
and you're going to make sure that you keep following up
with them to check in on their isolation and quarantine
and, of course, their symptoms.
It's important to check in on symptoms,
because that can determine when they can end their isolation
or quarantine.
So on these regular check-in calls,
you're going to ask cases about their symptoms.
If they're getting worse, they may need medical care.
If they're getting better, then they
may be able to end their isolation soon.
You're going to ask them, importantly,
if they've had new contacts, because then you would need
to find those people as well.
You're going to offer continued support for isolation.
For follow-up calls with contacts,
you want to track and see if they've had any symptoms.
If so, they may need to get a test
and then may also need medical care.
And you'll also continue to offer support for quarantine.
As a contact tracer, you're going
to be providing important support
to members of your community to help
stop the spread of COVID-19.
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