Last reviewed: 14 May 2021
Last updated: 10 Jun 2021
10 Jun 2021

What's new at this update

MHRA authorises use of Pfizer/BioNTech vaccine in 12 to 15 year olds

  • The UK’s Medicines and Healthcare products Regulatory Agency has extended the authorisation of the Pfizer/BioNTech vaccine to include 12 to 15 year olds. This follows on from recent authorisations to use the vaccine in this age group in the US and Europe.

  • The European Medicines Agency has also started evaluating an application to extend the use of the Moderna vaccine to include young people aged 12 to 17 years.

  • See the Primary prevention section for more information.

Delta variant now dominant in the UK

  • Public Health England experts now believe that the Delta variant has overtaken the Alpha variant as the dominant SARS-CoV-2 variant in the UK. Early evidence suggests there may be an increased risk of hospitalisation for the Delta variant compared with the Alpha variant, although more data is needed.

  • See the Aetiology section for more information.

IDSA publishes new guidelines for antigen testing

  • The Infectious Diseases Society of America has published new guidelines for the use of SARS-CoV-2 antigen tests. Based on current evidence, molecular testing remains the test of choice for diagnosis. However, antigen testing can be used when molecular testing is not readily available or is logistically unfeasible.

  • See the Investigations section for more information.

NICE does not recommend azithromycin

  • The National Institute for Health and Care Excellence has updated its COVID-19 rapid guideline to add a new recommendation on azithromycin. NICE does not recommend azithromycin to treat COVID-19 based on low-certainty evidence. The guideline panel considered that the results from studies of azithromycin for moderate to critical disease in the hospital setting and mild to moderate disease in the community setting showed no meaningful benefit in any of the critical outcomes.

  • See the Emerging section for more information.

Number of COVID-19 cases reported weekly by WHO Region, and global deaths, as of 6 June 2021[Figure caption and citation for the preceding image starts]: Number of COVID-19 cases reported weekly by WHO Region, and global deaths, as of 6 June 2021World Health Organization [Citation ends].

See Epidemiology

Original source of updateexternal link opens in a new window

Summary

Definition

History and exam

Key diagnostic factors

  • fever
  • cough
  • dyspnoea
  • altered sense of smell/taste

Other diagnostic factors

  • fatigue
  • myalgia or arthralgia
  • sputum production/expectoration
  • chest tightness
  • gastrointestinal symptoms
  • sore throat
  • headache
  • dizziness
  • neurological symptoms
  • ocular symptoms
  • rhinorrhoea/nasal congestion
  • audio-vestibular symptoms
  • chest pain
  • cutaneous symptoms
  • lower urinary tract symptoms
  • haemoptysis
  • bronchial breath sounds
  • tachypnoea
  • tachycardia
  • cyanosis
  • crackles/rales on auscultation

Risk factors

  • contact with probable or confirmed case
  • residence/work/travel in location with high risk of transmission
  • older age
  • male sex
  • ethnicity
  • residence in a long-term care facility
  • presence of comorbidities
  • obesity
  • cardiovascular disease
  • diabetes
  • chronic respiratory disease
  • chronic kidney disease
  • pregnancy
  • smoking
  • malignancy
  • cerebrovascular disease
  • solid organ or blood stem cell transplant
  • Down's syndrome
  • haemoglobin disorders
  • hypertension
  • dementia
  • immunosuppression
  • HIV infection
  • substance use disorders
  • children with certain underlying conditions
  • chronic liver disease
  • vitamin D deficiency
  • proton-pump inhibitor use
  • autoimmune disease
  • Parkinson's disease
  • physical inactivity
  • dyslipidaemia
  • surgery
  • blood groups A and B
  • gut dysbiosis
  • environmental factors

Diagnostic investigations

1st investigations to order

  • real-time reverse transcription polymerase chain reaction (RT-PCR)
  • pulse oximetry
  • ABG
  • FBC
  • comprehensive metabolic panel
  • blood glucose level
  • coagulation screen
  • cardiac biomarkers
  • serum C-reactive protein
  • serum erythrocyte sedimentation rate
  • serum lactate dehydrogenase
  • serum interleukin-6 level
  • serum procalcitonin
  • serum ferritin level
  • serum amyloid A level
  • serum creatine kinase and myoglobin
  • blood and sputum cultures
  • chest x-ray

Investigations to consider

  • computed tomography (CT) chest
  • serology
  • antigen test

Emerging tests

  • reverse transcription loop-mediated isothermal amplification (RT-LAMP)
  • lung ultrasound
  • calprotectin

Treatment algorithm

Contributors

Expert advisersVIEW ALL

Consultant and Emeritus Professor of Tropical and Infectious Diseases

Royal Liverpool University Hospital and Liverpool School of Tropical Medicine

Liverpool

UK

Disclosures

NJB is partially supported by the National Institute of Health Research Health Protection Unit (NIHR HPRU) in Emerging and Zoonotic Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine. He is affiliated with Liverpool School of Tropical Medicine. The views expressed are those of the author and not necessarily those of the NHS, the NIHR, the Department of Health, or PHE.

Senior Clinical Lecturer and Defence Consultant in Infectious Diseases

Royal Liverpool University Hospital and Liverpool School of Tropical Medicine

Liverpool

UK

Disclosures

TEF is a consultant/expert panel member to the World Health Organization, and is funded by the UK Surgeon General, the NHS, and Liverpool School of Tropical Medicine. TEF is partially supported by the National Institute of Health Research Health Protection Unit (NIHR HPRU) in Emerging and Zoonotic Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine. He is affiliated with Liverpool School of Tropical Medicine. He has received research grants from the Wellcome Trust, Medical Research Council, and the UK Public Health Rapid Support Team (UK-PHRST). The views expressed are those of the author and not necessarily those of the NHS, the NIHR, the Department of Health, or PHE.

H. Barrie Fairley Professor of Critical Care

University Health Network and Interdepartmental Division of Critical Care Medicine

Director

Clinical Epidemiology and Health Care Research

Institute of Health Policy, Management and Evaluation

Dalla Lana School of Public Health

University of Toronto

Chief

Tory Trauma Program

Sunnybrook Hospital

Toronto

Canada

Disclosures

RF declares that he has no competing interests.

Peer reviewersVIEW ALL

Professor

Division of Infectious Diseases and International Health

University of Virginia

Charlottesville

VA

Disclosures

WAP declares that he has no competing interests.

Attending Physician

The Fifth Medical Center of PLA General Hospital

Clinical Division and Research Center of Infectious Disease

Beijing

China

Disclosures

XZ declares that he has no competing interests.

Associate Professor in Medicine

Department of Clinical Microbiology and Infectious Diseases

Hadassah Hebrew University Medical Center

Jerusalem

Israel

Disclosures

RNP has received research grants from US-Israel Binational Science Foundation, Hebrew University, Rosetrees Trust, and SpeeDx. He is chair of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Mycoplasma and Chlamydia Infections (ESGMAC). RNP is a consultant for and has stocks in eDAS Healthcare. He is also chairperson of the Israeli Society for Infectious Diseases guidelines committee.

Section Editor (Infectious Diseases)/Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

Lead Section Editor, BMJ Best Practice

Disclosures

IC declares that she has no competing interests.

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Expert advisers: comorbiditiesVIEW ALL

Consultant, Older People's Medicine

Norfolk and Norwich University Hospitals

NHS Foundation Trust

Norwich

UK

Disclosures

MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare virtual conference in November 2020, for which he received no fee. MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018).

Consultant Renal Physician

Honorary Associate Professor

Nephrology Department

Leeds Teaching Hospitals NHS Trust

Leeds

UK

Disclosures

AL is Associate Clinical Director of NIHR Leeds In-Vitro Diagnostics Co-operative, Co-Chair of UK Kidney Research Consortium Renal Clinical Study Group, Member of Kidney Research UK Research Grant Committee, Committee Member of NICE Kidney Injury Clinical Guideline Update 2018-20, Committee Member of NICE Diagnostic Assessment for Point of Care Creatinine Testing 2018-19. AL attended the Acute Dialysis Quality Initiative Meeting in San Diego 2018 (accommodation expenses); AL was a speaker at the AKI & CRRT Conference in San Diego 2019 (travel and accommodation expenses), the AKI Conference in Coventry 2019 (travel expenses), and the NIHR AKI and Sepsis Meeting in Leeds 2019 (no expenses).

Professor of Cardiology

Imperial College London (Royal Brompton Hospital)

London

UK

Disclosures

MC is chair of the European Society of Cardiology Digital Health Committee and a trustee of the Atrial Fibrillation Society. He has previously been a non-executive director of the National Institute for Health and Care Excellence. MC provides consultancy advice to AstraZeneca, Servier, Abbott, Medtronic, Boston Scientific, and Genomics PLC. MC declares that none of these interests is directly related to topics advised on for this project.

Associate Professor (Clinical)

University of Leicester

Honorary Consultant Respiratory Physician

Glenfield Hospital

Leicester

UK

Disclosures

RAE has been reimbursed for a GSK Advisory Board meeting on Physical Activity and Asthma in November 2016, and three Chiesi Education meetings for GPs on COPD care in 2019. RAE received a travel award for ERS 2017 from Chiesi and participated in the GSK clinical experience programme - respiratory in August 2018. RAE participated in the BTS/SIGN guidelines for asthma update 2016 (no fee).

Consultant Physician and Head of Service

Diabetes and Endocrine Centre and the Diabetes Research Unit

Ipswich Hospitals NHS Trust

Ipswich

UK

Disclosures

GR has been paid for advisory board meetings with the following companies: Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Bayer. GR has received lecture fees from Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Novonordisk, Napp Pharmaceuticals Ltd.

Consultant Liaison Neuropsychiatrist

King’s College Hospital

South London and Maudsley NHS Foundation Trust

Honorary Senior Clinical Lecturer

Institute of Psychiatry, Psychology & Neuroscience

King’s College London

London

UK

Disclosures

SP declares that he has no competing interests.

BMJ Best Practice would like to gratefully acknowledge Dr Matthew Jones for his advice on a section of the stroke comorbidity content.

Matthew Jones, MD, FRCP

Consultant Neurologist

Greater Manchester Neurosciences Centre

Salford Royal Foundation Trust

Honorary Senior Lecturer

University of Manchester

Manchester

UK

Disclosures

AA and MJ declare that they have no competing interests.

Peer reviewers: comorbiditiesVIEW ALL

Consultant, Older People's Medicine

Norfolk and Norwich University Hospitals

NHS Foundation Trust

Norwich

UK

Disclosures

MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare virtual conference in November 2020, for which he received no fee. MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018).

Consultant Geriatrician

Liverpool University Hospitals NHS Foundation Trust

Visiting Professor

University of Cumbria

Carlisle

Honorary Clinical Associate Professor

University of Liverpool

Liverpool

UK

Disclosures

AA declares that he has no competing interests.

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