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+Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19)Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19)
+Updated June 30, 2020
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+Summary of Recent ChangesRevisions were made on June 20, 2020, to reflect the following:
+Updated content to Clinical Presentation
+Refer to People Who Are at Increased Risk for Severe Illness
+New information about Reinfection
+New information about Therapeutics
+Minor revisions for clarity and updates to footnotes throughout
+Revisions were made on May 29, 2020, to reflect the following:
+Refer to updated symptoms of Coronavirus
+Revisions were made on May 25, 2020, to reflect the following:
+Refer to new multisystem inflammatory syndrome in children (MIS-C) guidance for healthcare providers
+Revisions were made on May 20, 2020, to reflect the following:
+Refer to new guidance for Evaluation and Management Considerations for Neonates At Risk for COVID-19
+Revisions were made on May 12, 2020, to reflect the following:
+New information about COVID-19-Associated Hypercoagulability
+Updated content and resources to include new NIH Treatment Guidelines
+Minor revisions for clarity
+On This Page
+Clinical PresentationClinical CourseViral TestingLaboratory and Radiographic FindingsClinical Management and TreatmentDiscontinuation of Transmission-Based Precautions or Home Isolation
+This interim guidance is for clinicians caring for patients with confirmed infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19). CDC will update this interim guidance as more information becomes available.
+Clinical Presentation
+Incubation period
+The incubation period for COVID-19 is thought to extend to 14 days, with a median time of 4-5 days from exposure to symptoms onset.1-3 One study reported that 97.5% of persons with COVID-19 who develop symptoms will do so within 11.5 days of SARS-CoV-2 infection.3
+Presentation
+The signs and symptoms of COVID-19 present at illness onset vary, but over the course of the disease, most persons with COVID-19 will experience the following1,4-9:
+Fever or chills
+Cough
+Shortness of breath or difficulty breathing
+Fatigue
+Muscle or body aches
+Headache
+New loss of taste or smell
+Sore throat
+Congestion or runny nose
+Nausea or vomiting
+Diarrhea
+Symptoms differ with severity of disease.  For example, fever, cough, and shortness of breath are more commonly reported among people who are hospitalized with COVID-19 than among those with milder disease (non-hospitalized patients). Atypical presentations occur often, and older adults and persons with medical comorbidities may have delayed presentation of fever and respiratory symptoms.10,14 In one study of 1,099 hospitalized patients, fever was present in only 44% at hospital admission but eventually developed in 89% during hospitalization.1 Fatigue, headache, and muscle aches (myalgia) are among the most commonly reported symptoms in people who are not hospitalized, and sore throat and nasal congestion or runny nose (rhinorrhea) also may be prominent symptoms.  Many people with COVID-19  experience gastrointestinal symptoms such as nausea, vomiting or diarrhea, sometimes prior to developing fever and lower respiratory tract signs and symptoms.9 Loss of smell (anosmia) or taste (ageusia) preceding the onset of respiratory symptoms has been commonly reported in COVID-19 especially among women and young or middle-aged patients who do not require hospitalization.11,12 While many of the symptoms of COVID-19 are common to other respiratory or viral illnesses, anosmia appears to be more specific to COVID-19.12
+Several studies have reported that the signs Signs and symptoms of COVID-19 in children are similar to adults vary by age of the child,  and are usually milder compared to adults.15-19 For more information on the clinical presentation and course among children, see Information for Pediatric Healthcare Providers.
+Asymptomatic and Pre-Symptomatic Infection
+Several studies have documented SARS-CoV-2 infection in patients who never develop symptoms (asymptomatic) and in patients not yet symptomatic (pre-symptomatic).16,18,20-30 Since asymptomatic persons are not routinely tested, the prevalence of asymptomatic infection and detection of pre-symptomatic infection is not yet well understood. One study found that as many as 13% of reverse transcription-polymerase chain reaction (RT-PCR)-confirmed cases of SARS-CoV-2 infection in children were asymptomatic.16 Another study of skilled nursing facility residents who were infected with SARS-CoV-2 after contact with a healthcare worker with COVID-19 demonstrated that half of the residents were asymptomatic or pre-symptomatic at the time of contact tracing, evaluation, and testing.27 Patients may have abnormalities on chest imaging before the onset of symptoms.21,22.
+Asymptomatic and Pre-Symptomatic Transmission
+Increasing numbers of epidemiologic studies have documented SARS-CoV-2 transmission during the pre-symptomatic incubation period,21,31-33. Virologic studies using RT-PCR detection have reported tests with  low cycle thresholds, indicating larger quantities of viral RNA and viable virus has been cultured from persons with asymptomatic and pre-symptomatic SARS-CoV-2 infection.25,27,30,34 The relationship between SARS-CoV-2 viral RNA shedding and  transmission risk is not yet clear. The proportion of SARS-CoV-2 transmission due to asymptomatic or pre-symptomatic infection compared to symptomatic infection is unclear.35
+Clinical Course
+Illness Severity
+The largest cohort reported of >44,000 persons with COVID-19 from China showed that illness severity can range from mild to critical:36
+Mild to moderate (mild symptoms up to mild pneumonia): 81%
+Severe (dyspnea, hypoxia, or >50% lung involvement on imaging): 14%
+Critical (respiratory failure, shock, or multiorgan system dysfunction): 5%
+In this study, all deaths occurred among patients with critical illness, and the overall case fatality rate was 2.3%.36 The case fatality rate among patients with critical disease was 49%.36 Among children in China, illness severity was lower with 94% having asymptomatic, mild, or moderate disease; 5% having severe disease; and <1% having critical disease.16 Among U.S. COVID-19 cases with known disposition, the proportion of persons who were hospitalized was 19%.37 The proportion of persons with COVID-19 admitted to the intensive care unit (ICU) was 6%.37
+Clinical Progression
+Among patients who developed severe disease, the median time to dyspnea from the onset of illness or symptoms ranged from 5 to 8 days, the median time to acute respiratory distress syndrome (ARDS) from the onset of illness or symptoms ranged from 8 to 12 days, and the median time to ICU admission from the onset of illness or symptoms ranged from 10 to 12 days.5,6,10,11 Clinicians should be aware of the potential for some patients to rapidly deteriorate one week after illness onset. Among all hospitalized patients, a range of 26% to 32% of patients were admitted to the ICU.6,8,11 Among all patients, a range of 3% to 17% developed ARDS compared to a range of 20% to 42% for hospitalized patients and 67% to 85% for patients admitted to the ICU.1,4-6,8,11 Mortality among patients admitted to the ICU ranges from 39% to 72% depending on the study and characteristics of patient population.5,8,10,11 The median length of hospitalization among survivors was 10 to 13 days.1,6,8
+Risk Factors for Severe Illness
+Age is a strong risk factor for severe illness, complications, and death.1,6,8,14,36-40 Among >44,000 confirmed cases of COVID-19 in China, the case fatality rate was highest among older persons: ≥80 years, 14.8%; 70–79 years, 8.0%; 60–69 years, 3.6%; 50–59 years, 1.3%; 40–49 years, 0.4%; <40 years, 0.2%.36,41 In early U.S. epidemiologic data, case fatality was highest in persons aged ≥85 years (range 10%–27%), followed by those aged 65-84 years (3%–11%), aged 55-64 years (1%–3%), and aged <55 years (<1%).37
+Patients in China with no reported underlying medical conditions had an overall case fatality of 0.9%. Case fatality was higher for patients with comorbidities: 10.5% for those with cardiovascular disease, 7.3% for those with diabetes, and approximately 6% for those with chronic respiratory disease, or cancer.1,6,14,36,38,41,42    Prior stroke, diabetes, chronic lung disease, and chronic kidney disease have all been associated with increased illness severity and adverse outcomes. Serious heart conditions, including heart failure, coronary artery disease, congenital heart disease, cardiomyopathies, and pulmonary hypertension, may put people at higher risk for severe illness from COVID-19. People with hypertension may be at an increased risk for severe illness from COVID-19 and should continue to take their medications as prescribed. At this time, people whose only underlying medical condition is hypertension are not considered to be at higher risk for severe illness from COVID-19.43,44
+Accounting for differences in age and prevalence of underlying condition, mortality associated with COVID-19 reported in the United States has been similar to reports from China.26,37,39
+Reinfection
+There are no data concerning the possibility of re-infection with SARS-CoV-2 after recovery from COVID-19. While viral RNA shedding declines with resolution of symptoms, it may continue for days to weeks.34,38,45 However, the detection of RNA during convalescence does not necessarily indicate the presence of viable infectious virus. Clinical infection has been correlated with the detection of IgM and IgG antibodies.46-49 However, definitive data are lacking, and it remains uncertain whether individuals with antibodies are protected against reinfection with SARS-CoV-2, and if so, what concentration of antibodies is needed to confer protection.
+Viral Testing
+Diagnosis of COVID-19 requires detection of SARS-CoV-2 RNA by reverse transcription polymerase chain reaction (RT-PCR). Detection of SARS-CoV-2 viral RNA is better in nasopharynx samples compared to throat samples.34,50 Lower respiratory samples may have better yield than upper respiratory samples.34,50 SARS-CoV-2 RNA has also been detected in stool and blood.15,45,47,51 Detection of SARS-CoV-2 RNA in blood may be a marker of severe illness.52 Viral RNA shedding may persist over longer periods among older persons and those who had severe illness requiring hospitalization (median range of viral shedding among hospitalized patients 12–20 days).34,38,45,46,53
+Infection with both SARS-CoV-2 and with other respiratory viruses has been reported, and detection of another respiratory pathogen does not rule out COVID-19.54
+For more information about testing and specimen collection, handling and storage, visit Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19) and Frequently Asked Questions on COVID-19 Testing at Laboratories.
+Laboratory and Radiographic Findings
+Laboratory Findings
+Lymphopenia is the most common laboratory finding in COVID-19, and is found in as many as 83% of hospitalized patients.1,5 Lymphopenia, neutrophilia, elevated serum alanine aminotransferase and aspartate aminotransferase levels, elevated lactate dehydrogenase, high CRP, and high ferritin levels may be associated with greater illness severity.1,5,6,8,38,55 Elevated D-dimer and lymphopenia have been associated with mortality.8,38 Procalcitonin is typically normal on admission, but may increase among those admitted to an ICU.4-6 Patients with critical illness had high plasma levels of inflammatory makers, suggesting potential immune dysregulation.5,56
+Radiographic Findings
+Chest radiographs of patients with COVID-19 typically demonstrate bilateral air-space consolidation, though patients may have unremarkable chest radiographs early in the disease.1,5,57 Chest CT images from patients with COVID-19 typically demonstrate bilateral, peripheral ground glass opacities.4,8,36,58-67 Because this chest CT imaging pattern is non-specific and overlaps with other infections, the diagnostic value of chest CT imaging for COVID-19 may be low and dependent upon radiographic interpretation.59,68 One study found that 56% of patients who presented within two days of diagnosis had a normal CT.60 Conversely, other studies have identified chest CT abnormalities in patients prior to the detection of SARS-CoV-2 RNA.58,69 Given the variability in chest imaging findings, chest radiograph or CT alone is not recommended for the diagnosis of COVID-19. The American College of Radiology also does not recommend CT for screening, or as a first-line test for diagnosis of COVID-19. (See American College of Radiology Recommendationsexternal icon).
+Clinical Management and Treatment
+The National Institutes of Health published guidelines on prophylaxis use, testing, and management of patients with COVID-19. For more information, please visit National Institutes of Health: Coronavirus Disease 2019 (COVID-19) Treatment Guidelinesexternal icon. The recommendations were based on scientific evidence and expert opinion and will be updated as more data become available.
+Mild to Moderate Disease
+Patients with a mild clinical presentation (absence of viral pneumonia and hypoxia) may not initially require hospitalization, and many patients will be able to manage their illness at home. The decision to monitor a patient in the inpatient or outpatient setting should be made on a case-by-case basis. This decision will depend on the clinical presentation, requirement for supportive care, potential risk factors for severe disease, and the ability of the patient to self-isolate at home. Patients with risk factors for severe illness (see People Who Are at Higher Risk for Severe Illness) should be monitored closely given the possible risk of progression to severe illness, especially in the second week after symptom onset.5,6,14,38
+For information regarding infection prevention and control recommendations, please see Interim Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease 2019 (COVID-19) or Persons Under Investigation for COVID-19 in Healthcare Settings.
+Severe Disease
+Some patients with COVID-19 will have severe disease requiring hospitalization for management. Inpatient management revolves around the supportive management of the most common complications of severe COVID-19: pneumonia, hypoxemic respiratory failure/ARDS, sepsis and septic shock, cardiomyopathy and arrhythmia, acute kidney injury, and complications from prolonged hospitalization, including secondary bacterial infections, thromboembolism, gastrointestinal bleeding, and critical illness polyneuropathy/myopathy.1,4-6,14,36,38,70-73
+More information can be found at National Institutes of Health: Coronavirus Disease 2019 (COVID-19) Treatment Guidelinesexternal icon and Healthcare Professionals: Frequently Asked Questions and Answers. Additional resources and guidance documents on the treatment and management of COVID-19, including inpatient management of critically ill patients, are provided below.
+Hypercoagulability and COVID-19
+Some patients with COVID-19 may develop signs of a hypercoagulable state and be at increased risk for venous and arterial thrombosis of large and small vessels.74,75  Laboratory abnormalities commonly observed among hospitalized patients with COVID-19-associated coagulopathy include:
+Mild thrombocytopenia
+Increased D-dimer levels
+Increased fibrin degradation products
+Prolonged prothrombin time
+Elevated D-dimer levels have been strongly associated with greater risk of death.74,76-79
+There are several reports of hospitalized patients with thrombotic complications, most frequently deep venous thrombosis and pulmonary embolism.80-82 Other reported manifestations include:
+Microvascular thrombosis of the toes
+Clotting of catheters
+Myocardial injury with ST-segment elevation
+Large vessel strokes83-86
+The pathogenesis for COVID-19-associated hypercoagulability remains unknown. However, hypoxia and systemic inflammation secondary to COVID-19 may lead to high levels of inflammatory cytokines and activation of the coagulation pathway.
+There are limited data available to inform clinical management around prophylaxis or treatment of venous thromboembolism in COVID-19 patients.
+Several national professional associations provide resources for up-to-date information concerning COVID-19-associated hypercoagulability, including management of anticoagulation. This is a rapidly evolving topic, with new information released often.
+More information on hypercoagulability and COVID-19 is available from the American Society of Hematology external iconand National Institutes of Health: Coronavirus Disease 2019 (COVID-19) Treatment Guidelines – Antithrombotic Therapy in Patients with COVID-19external icon.
+Pediatric Management
+Illness among pediatric patients with COVID-19 is typically milder than among adults. Most children present with symptoms of upper respiratory infection. However, severe outcomes have been reported in children, including deaths. Data suggest that infants (<12 months of age) may be at higher risk for severe illness from COVID-19 compared with older children.16 CDC and partners are also investigating reports of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19.
+For expanded guidance on the management of children with COVID-19 and associated complications, see Evaluation and Management Considerations for Neonates At Risk for COVID-19, Information for Pediatric Healthcare Providers, and the Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Childrenexternal icon.
+Investigational Therapeutics
+The National Institutes of Health have published interim guidelines for the medical management of COVID-19external icon which include information on therapeutic options for COVID-19 currently under investigation. No U.S. Food and Drug Administration (FDA)-approved drugs have demonstrated safety and efficacy in randomized controlled trials when used to treat patients with COVID-19, although FDA has granted an Emergency Use Authorization for the use of remdesivirexternal icon to treat severe cases. Use of investigational therapies for treatment of COVID-19 should ideally be done in the context of enrollment in randomized controlled trials, so that beneficial drugs can be identified. For the latest information, see Information for Clinicians on Therapeutic Options for COVID-19 Patients. For information on registered trials in the United States, see ClinicalTrials.govexternal icon.
+Discontinuation of Transmission-Based Precautions or Home Isolation
+Patients who have clinically recovered and are able to discharge from the hospital, but who have not been cleared from their Transmission-Based Precautions, may continue isolation at their place of residence until cleared. For recommendations on discontinuation of Transmission-Based Precautions or home isolation for patients who have recovered from COVID-19, please see:
+Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of Hospitalized Patients with COVID-19
+Interim Guidance for Discontinuation of In-Home Isolation for Patients with COVID-19
+Discontinuation of In-Home Isolation for Immunocompromised Persons with COVID-19.
+CDC Resources
+Healthcare Professionals: Frequently Asked Questions and Answers
+Information for Pediatric Healthcare Providers
+Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19)
+Frequently Asked Questions on COVID-19 Testing at Laboratories
+Infection Control Guidance for Healthcare Professionals about COVID-19
+Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) or in Healthcare Settings
+Evaluation and Management Considerations for Neonates At Risk for COVID-19
+COVIDView: A Weekly Surveillance Summary of U.S. COVID-19 Activity
+Additional resources
+World Health Organization. Interim Guidance on Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspectedexternal icon
+Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)pdf iconexternal icon
+Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016external icon
+Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Childrenexternal icon
+Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of Americaexternal icon
+ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infectionexternal icon
+National Institutes of Health: Coronavirus Disease 2019 (COVID-19) Treatment Guidelinesexternal icon
+Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19 Infectionexternal icon
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+Shi S, Qin M, Shen B, et al. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiol 2020.
+Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost 2020.
+Bikdeli, B; Madhavan, M; Jimenez,D et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up. Journal of American College of Cardiology. April 2020 , S0735-1097(20)35008-7 https://doi.org/10.1016/j.jacc.2020.04.031external icon
+Cannegieter, S; Klok, FA. COVID-19 associated coagulopathy and thromboembolic disease: Commentary on an interim expert guidance. Research and Practice in Thrombosis and Haemostasis, April 2020.  https://doi.org/10.1002/rth2.12350external icon
+Lippi G, Plebani M, Michael Henry B. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A meta-analysis. Clinica Chimica Acta.2020 Mar 13;506:145-148. DOI:10.1016/j.cca.2020.03.022
+Lippi G, Favaloro EJ. D-dimer is associated with severity of coronavirus disease 2019 (COVID-19): a pooled analysis. Thrombosis and Haemostasis In press. DOI 10.1055/s-0040-1709650
+Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost Feb 2020. https://doi.org/10.1111/jth.14768
+American Venous Forum. Considerations in prophylaxis and treatment of VTE in COVID-19 Patients. 2020. Accessed April 2020 at https://www.veinforum.org/covid-19/external icon
+Klok, FA; Kruip, MJHA; van der Meer NJM et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thrombosis Research, April 2020. In Press https://doi.org/10.1016/j.thromres.2020.04.013external icon
+Helms, J; Tacquard, C; Severac, F et al.  High risk of thrombosis in patients in severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Medicine, April 2020. In Press. DOI: 10.1007/s00134-020-06062-x
+Grillet, F; Behr, J; Calame, H et al.  Acute Pulmonary Embolism Associated with COVID-19 Pneumonia Detected by Pulmonary CT Angiography. Radiology. Published Online: Apr 23 2020 https://doi.org/10.1148/radiol.2020201544external icon
+Oxley, T; Mocco, J; Majidi,S et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. New England Journal of Medicine. April 2020. DOI: 10.1056/NEJMc2009787
+Li, Y; Wang, M; Zhou, Y et al.  Acute Cerebrovascular Disease Following COVID-19: A Single Center, Retrospective, Observational Study (3/3/2020). Available at SSRN: https://ssrn.com/abstract=3550025external icon
+Margo,C; Mulvey, J; Berlin, D et al. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: A report of five cases. Translational Research. April 2020 S1931-5244(20)30070-0. https://doi.org/10.1016/j.trsl.2020.04.007external icon
+Bangalore, S; Sharma, A; Slotwiner, A et al. ST-Segment Elevation in Patients with COVID-19-A Case Series. New England Journal of Medicine. April 17, 2020 DOI: 10.1056/NEJMc2009020
+National Institutes of Health. Covid-19 Treatment Guidelines. Accessed April 28, 2020 at: https://www.covid19treatmentguidelines.nih.gov/introduction/external icon
+Top of Page
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+Overview of Testing for SARS-CoV-2Overview of Testing for SARS-CoV-2
+Updated July 17, 2020
+Print
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+Minus
+Related Pages
+Note:  This document is intended to provide guidance on the appropriate use of testing and does not dictate the determination of payment decisions or insurance coverage of such testing for people residing in the United States, except as may be otherwise referenced (or prescribed) by another entity or federal or state agency.
+Summary of ChangesRevisions made on July 17, 2020
+Except for rare situations, a test-based strategy is no longer recommended to determine when an individual with SARS-CoV-2 infection is no longer infectious (e.g., to discontinue Transmission-Based Precautions or home isolation)
+Revisions were made on July 2, 2020, to:
+Added screening to possible testing types
+Removed examples – please refer to setting specific guidance
+This document provides a summary of considerations and current Centers for Disease Control and Prevention (CDC) recommendations regarding SARS-CoV-2 testing strategy. The CDC recommendations for SARS-CoV-2 testing have been developed based on what is currently known about COVID-19 and are subject to change as additional information becomes available.
+Recommendations for Viral Testing, Specimen Collection, and Reporting
+Authorized assays for viral testing include those that detect SARS-CoV-2 nucleic acid or antigen. Viral (nucleic acid or antigen) tests check samples from the respiratory system (such as nasal swabs) and determine whether an infection with SARS-CoV-2, the virus that causes COVID-19, is present. Viral tests are recommended to diagnose acute infection. Some tests are point-of-care tests, meaning results may be available at the testing site in less than an hour. Other tests must be sent to a laboratory to analyze, a process that may take 1-2 days once received by the lab. Testing the same individual more than once in a 24-hour period is not recommended.
+For more information on testing for COVID-19 see the Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens and Biosafety FAQs for handling and processing specimens from possible cases.
+Recommendations for Antibody Testing
+CDC does not currently recommend using antibody testing as the sole basis for diagnosis of acute infection, and antibody tests are not authorized by FDA for such diagnostic purposes. In certain situations, serologic assays may be used to support clinical assessment of persons who present late in their illnesses when used in conjunction with viral detection tests.  In addition, if a person is suspected to have post-infectious syndrome (e.g., Multisystem Inflammatory Syndrome in Children) caused by SARS-CoV-2 infection, serologic assays may be used.
+Serologic assays for SARS-CoV-2, now broadly available, can play an important role in understanding the transmission dynamic of the virus in the general population and identifying groups at higher risk for infection. Unlike viral direct detection methods, such as nucleic acid amplification or antigen detection tests that can detect acutely infected persons, antibody tests help determine whether the individual being tested was previously infected—even if that person never showed symptoms.
+Categories for SARS-CoV-2 Testing
+This document describes five populations for which SARS-CoV-2 testing with viral tests (i.e., nucleic acid or antigen tests) is appropriate:
+Individuals with signs or symptoms consistent with COVID-19
+Asymptomatic individuals with recent known or suspected exposure to SARS-CoV-2 to control transmission
+Asymptomatic individuals without known or suspected exposure to SARS-CoV-2 for early identification in special settings
+Individuals being tested to determine resolution of infection (i.e., test-based strategy for Discontinuation of Transmission-based Precautions, HCP Return to Work, and Discontinuation of Home Isolation)
+Individuals being tested for purposes of public health surveillance for SARS-CoV-2
+Generally, viral testing for SARS-CoV-2 is considered to be diagnostic when conducted among individuals with symptoms consistent with COVID-19 or among asymptomatic individuals with known or suspected recent exposure to SARS-CoV-2 to control transmission, or to determine resolution of infection. Viral testing is screening when conducted among asymptomatic individuals without known or suspected exposure to SARS-CoV-2 for early identification, and surveillance when conducted among asymptomatic individuals to detect transmission hot spots or characterize disease trends.
+Recommended testing for individuals with signs or symptoms consistent with COVID-19
+CDC recommends using authorized nucleic acid or antigen detection assaysexternal icon that have received an FDA EUA to test persons with symptoms when there is a concern of potential COVID-19. Tests should be used in accordance with the authorized labeling; providers should be familiar with the tests’ performance characteristics and limitations.
+Clinicians should use their judgment to determine if a patient has signs or symptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough) but some infected patients may present with other symptoms (e.g., altered smell or taste) as well. Clinicians are encouraged to consider testing for other causes of respiratory illness, for example influenza, in addition to testing for SARS-CoV-2 depending on patient age, season, or clinical setting; detection of one respiratory pathogen (e.g., influenza) does not exclude the potential for co-infection with SARS-CoV-2. Because symptoms and presentations may be different in children, consider referencing the CDC guidelines for COVID-19 in neonates and for Multisystem Inflammatory Syndrome in Children (MIS-C).
+The severity of symptomatic illness due to infection with SARS-CoV-2 may vary from person to person. Among persons with extensive and close contact to vulnerable populations (e.g., healthcare personnel [HCP]), even mild signs and symptoms (e.g., sore throat) of a possible SARS-CoV-2 infection should prompt consideration for testing. Additional information is available in CDC’s Interim Guidance on Testing Healthcare Personnel for SARS-CoV-2.
+Recommended testing for asymptomatic individuals with known or suspected exposure to SARS-CoV-2 to control transmission
+Testing is recommended for all close contactspdf icon of persons with SARS-CoV-2 infection.  Because of the potential for asymptomatic and pre-symptomatic transmission, it is important that contacts of individuals with SARS-CoV-2 infection be quickly identified and tested.
+In areas where testing is limited, CDC has established a testing hierarchy; refer to the Interim Guidance on Developing a COVID-19 Case Investigation and Contact Tracing Planpdf icon for more information.
+In some settings, broader testing, beyond close contacts, is recommended as a part of a strategy to control transmission of SARS-CoV-2.  This includes high-risk settings that have potential for rapid and widespread dissemination of SARS-CoV-2 or in which populations at risk for severe disease could become exposed.  Expanded testing might include testing of individuals on the same unit or shift as someone with SARS-CoV-2 infection, or even testing all individuals within a shared setting (e.g., facility-wide testing).
+Recommended testing for asymptomatic individuals without known or suspected SARS-CoV-2 exposure for early identification in special settings
+Certain settings can experience rapid spread of SARS-CoV-2. This is particularly true for settings with vulnerable populations in close quarters for extended periods of time.
+Local, territorial, tribal, and state health departments can help with informed decision-making about testing at these or other settings. Before testing large numbers of asymptomatic individuals without known or suspected exposure, facility leadership should have a plan in place for how they will modify operations based on test results.
+Approaches for early identification of asymptomatic individuals include, initial testing of everyone in the setting, periodic (e.g., weekly) testing of everyone in the setting, and testing of new or returning entrants into the setting.
+Recommended testing to determine resolution of infection with SARS-CoV-2
+A test-based strategy, which requires serial tests and improvement of symptoms, could be considered for discontinuing Transmission-based Precautions or allowing HCP to return to work earlier than the symptom-based strategy.  However, in most cases, the test-based strategy results in prolonged isolation of patients or work exclusion of HCP who continue to shed detectable SARS-CoV-2 RNA but are no longer infectious.  A test-based strategy could also be considered for some individuals (e.g., those who are severely immunocompromised) in consultation with local infectious diseases experts if concerns exist for the individual being infectious for more than 20 days. In all other circumstances, the symptom-based strategy should be used to determine when to discontinue Transmission-Based Precautions or when HCP can return to work.
+This strategy is described in the following documents:
+Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings
+Discontinuation of Isolation for Persons with COVID -19 Not in Healthcare Settings
+Assessing Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19
+Public health surveillance for SARS-CoV-2
+Testing is a fundamental part of the United States SARS-CoV-2 Surveillance Plan, which uses multiple surveillance systems and epidemiology networks to monitor the progression and impact of SARS-CoV-2 spread in the United States.
+Tests are used in community, outpatient, and hospital-based surveillance systems to identify cases of SARS-CoV-2 infection. These data help identify areas of ongoing circulation, determine trends in disease by location, provide insight into the impact of the disease over time and by location, and inform disease forecasts.
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+COVIDView: A Weekly Surveillance Summary of U.S. COVID-19 Activity
+Updated July 24, 2020
+Print
+Facebook
+Twitter
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+Email
+Syndicate
+Minus
+Related Pages
+Download Weekly Summary pdf icon[14 Pages, 1 MB]
+Key Updates for Week 29, ending July 18, 2020Nationally, levels of influenza-like illness (ILI) are below baseline, but higher than typically seen at this time of year. Indicators that track COVID-19-like illness (CLI) and laboratory confirmed SARS-CoV-2 showed decreases from week 28 to week 29 nationally; however there were regional differences. Areas of the country with high levels of CLI and laboratory confirmed SARS-CoV-2 in recent weeks (Regions 4 [South East], 6 [South Central] and 9 [South West/ Coast]) are starting to show signs of decreasing activity whereas other parts of the country (Regions 7 [Midwest], 5 [Central] and 8 [Mountain]) are increasing. Hospitalization rates show an increasing trend. Mortality attributed to COVID-19 remains above the epidemic threshold and increased slightly during the first two weeks of July after declining for 11 weeks since mid-April.
+VirusPublic Health, Commercial and Clinical LaboratoriesNationally, the overall percentage of respiratory specimens testing positive for SARS-CoV-2 decreased from week 28 (9.3%) to week 29 (8.6%) but increased in four regions. National percentages of specimens testing positive for SARS-CoV-2 by type of laboratory:
+Public health laboratories – increased from 7.5% during week 28 to 8.0% during week 29;
+Clinical laboratories – decreased from 7.2% during week 28 to 5.7% during week 29;
+Commercial laboratories – decreased from 9.9% during week 28 to 9.1% during week 29.
+Outpatient and Emergency Department VisitsOutpatient Influenza-Like Illness Network (ILINet) and National Syndromic Surveillance Program (NSSP)Two surveillance networks are being used to track outpatient or emergency department (ED) visits for illness with symptoms compatible with COVID-19.
+Nationally, ILI activity remains below baseline for the fourteenth week but is higher than typically seen at this time of year.
+During week 29, most regions had only slight changes in the percentage of visits for ILI or CLI; however, Regions 4 (South East), 6 (South Central) and 9 (South West/ Coast) reported a decrease in the percentage of visits for CLI.
+Recent changes in health care seeking behavior, including increasing use of telemedicine, recommendations to limit emergency department (ED) visits to severe illnesses, and increased practice of social distancing, are likely affecting data reported from both networks, making it difficult to draw conclusions at this time. Tracking these systems moving forward will give additional insight into illness related to COVID-19.
+Severe DiseaseHospitalizationsCumulative COVID-19-associated hospitalization rates since March 1, 2020, are updated weekly. The overall cumulative COVID-19 hospitalization rate is 120.9 per 100,000, with the highest rates in people aged 65 years and older (338.2 per 100,000) and 50-64 years (182.3 per 100,000). From June 20 – July 11, overall weekly hospitalization rates increased for three consecutive weeks.
+MortalityBased on death certificate data, the percentage of deaths attributed to pneumonia, influenza or COVID-19 (PIC) increased from week 26 – week 28 (June 27 – July 11) for the first time since mid-April. The percentage for week 29 is 9.1% and currently lower than the percentage during week 28 (11.5%); however,the percentage remains above the epidemic threshold. These percentages will likely change as more death certificates are processed.
+All data are preliminary and may change as more reports are received.
+A description of the surveillance systems summarized in COVIDView, including methodology and detailed descriptions of each data component, is available on the surveillance methods page.
+Key Points
+There are increases in the percentage of specimens testing positive for SARS-CoV-2 and the percentage of visits for ILI and/or CLI in multiple parts of the country. Three HHS regions (Regions 4 [South East], 6 [South Central] and 9 [South West/Coast]) are reporting percentage of visits for CLI and/or percentage of specimens testing positive for SARS-CoV-2 at higher levels than were seen in March/April, but these regions are starting to show evidence of declines in activity following the early July peak.
+Using combined data from the three laboratory types, the national percentage of respiratory specimens testing positive for SARS-CoV-2 with a molecular assay decreased from week 28 (9.3%) to week 29 (8.6%).
+The highest percentages of specimens testing positive for SARS-CoV-2 were seen in Regions 4 (South East, 13.9%), 6 (South Central, 15.7%) and 9 (South West/Coast, 9.7%).
+Increasing trends in the percentage of specimens testing positive for SARS-CoV-2 were reported in four of ten HHS surveillance regions: Regions 2 (NY/NJ/Puerto Rico), 5 (Midwest), 7 (Central) and 8 (Mountain).
+The percentage of outpatient and ED visits for ILI are below baseline nationally and in all regions of the country; however, ILI activity is above what is typical for this time of year. The percentage of visits to EDs for CLI decreased nationally and in the 3 regions (Region 4 [South East], 6 [South Central] and 9 [South West/ Coast] that were previously reporting the highest levels of CLI activity. CLI remained stable in the remaining areas of the country.
+Systems monitoring ILI and CLI may be influenced by recent changes in health care seeking behavior, including increasing use of telemedicine, recommendations to limit emergency department (ED) visits to severe illnesses, and increased practice of social distancing.
+The overall cumulative COVID-19-associated hospitalization rate is 120.9 per 100,000; rates were highest in people 65 years of age and older (338.2 per 100,000) followed by people 50-64 years (182.3 per 100,000). Hospitalization rates are cumulative and will increase as the pandemic continues.
+From week 25 – week 28 (weeks ending June 20 – July 11), overall weekly hospitalization rates increased for three consecutive weeks.
+Non-Hispanic American Indian or Alaska Native persons have an age-adjusted hospitalization rate approximately 5.3 times that of non-Hispanic White persons. Rates for non-Hispanic Black persons and Hispanic or Latino persons are approximately 4.7 and 4.6 times the rate among non-Hispanic White persons, respectively.
+Over a period of time similar to the length of an influenza season, overall cumulative hospitalization rates for COVID-19 are higher than cumulative end-of-season hospitalization rates for influenza for each of the past 5 influenza seasons. However, for children (0-17 years), cumulative COVID-19 hospitalization rates are lower than cumulative influenza hospitalization rates during recent influenza seasons.
+Based on death certificate data, the percentage of deaths attributed to pneumonia, influenza or COVID-19 (PIC) increased from week 26 – week 28 (weeks ending June 27 – July 11) after declining for 11 weeks since mid-April. The percentage of deaths due to PIC for week 29 is 9.1%, lower than the percentage during week 28 (11.5%), but above the epidemic threshold. These percentages will likely change as more death certificates are processed.
+U.S. Virologic SurveillanceThe number of specimens tested for SARS-CoV-2 using a molecular assay and reported to CDC by public health laboratories and a subset of clinical and commercial laboratories in the United States are summarized below. All laboratories are performing primary diagnostic functions; therefore, the percentage of specimens testing positive across laboratory types can be used to monitor overall trends in COVID-19 activity. As the outbreak progresses, it is possible that different types of laboratories will take on different roles, and the data interpretation may need to change.
+Summary of Laboratory Testing Results Reported to CDC
+Summary of Laboratory Testing Results Reported to CDC*
+Week 29
+(July 12 – July 18, 2020)
+Cumulative since March 1, 2020
+No. of specimens tested
+1,796,223
+28,745,587
+Public Health Laboratories
+246,839
+3,342,648
+Clinical Laboratories
+168,389
+2,834,547
+Commercial Laboratories
+1,380,995
+22,568,392
+No. of positive specimens (%)
+155,204 (8.6%)
+2,762,464 (9.6%)
+Public Health Laboratories
+19,771 (8.0%)
+285,259 (8.5%)
+Clinical Laboratories
+9,615 (5.7%)
+177,956 (6.3%)
+Commercial Laboratories
+125,818 (9.1%)
+2,299,249 (10.2%)
+* Commercial and clinical laboratory data represent select laboratories and do not capture all tests performed in the United States.
+Public Health Laboratories
+resize iconView LargerClosedownload iconDownload Imageimage icon[GIF, NAN ]
+View Data Table
+Clinical Laboratories
+resize iconView LargerClosedownload iconDownload Imageimage icon[GIF, NAN ]
+View Data Table
+Commercial Laboratories
+resize iconView LargerClosedownload iconDownload Imageimage icon[GIF, NAN ]
+* Commercial laboratories began testing for SARS-CoV-2 in early March, but the number and geographic distribution of reporting commercial laboratories became stable enough to calculate a weekly percentage of specimens testing positive as of March 29, 2020.
+View Data Table
+Additional virologic surveillance information: Surveillance Methods
+Outpatient/Emergency Department IllnessTwo syndromic surveillance systems are being used to monitor trends in outpatient and emergency department visits that may be associated with COVID-19 illness. Each system monitors a slightly different syndrome, and together, these systems provide a more comprehensive picture of mild-to-moderate COVID-19 illness than either would individually. Both systems are currently being affected by changes in health care seeking behavior, including increased use of telemedicine, compliance with recommendations to limit emergency department (ED) visits to severe illnesses, and increased social distancing. These changes affect the numbers of people seeking care in the outpatient and ED settings and their reasons for doing so.
+ILINet
+The U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet) provides data on visits for influenza-like illness (ILI) (fever [≥ 100○F] and cough and/or sore throat) to approximately 2,600 primary care providers, emergency departments and urgent care centers in all 50 states, Puerto Rico, the District of Columbia and the U.S. Virgin Islands. Mild COVID-19 illness presents with symptoms similar to ILI, so ILINet is being used to track trends of mild to moderate COVID-19 illness and allows for comparison with prior influenza seasons.
+Nationwide during week 29, 1.4% of patient visits reported through ILINet were due to ILI. This percentage is well below the national baseline of 2.4% and, while low overall, is higher than what is typical for this time of year compared to previous influenza seasons. Compared to week 28, the percentage of visits for ILI during week 29 was slightly higher for 0-4 year olds but slightly lower for all other age groups.
+resize iconView LargerClosedownload iconDownload Imageimage icon[GIF, NAN ]
+* Age-group specific percentages should not be compared to the national baseline.
+On a regional levelexternal icon, the percentage of outpatient visits for ILI ranged from 0.5% to 2.2% during week 29. All ten regions are below their region-specific baselines and reported only slight fluctuations in the percentrage of visits for ILI during week 29 compared to week 28.
+Note: In response to the COVID-19 pandemic, new data sources will be incorporated into ILINet as we move into summer weeks when lower levels of influenza and other respiratory virus circulation are typical. Starting in week 21, increases in the number of patient visits will be seen as new sites are enrolled and the percentage of visits for ILI may change in comparison to previous weeks. While all regions remain below baseline levels for ILI, these system changes should be considered when drawing conclusions from these data. Any changes in ILI due to changes in respiratory virus circulation will be highlighted here.
+Overall Percentage of Visits for ILI | Age Group ILI Data
+ILI Activity Levels
+Data collected in ILINet are used to produce a measure of ILI activity for all 50 states, Puerto Rico, the District of Columbia and New York City. The mean reported percentage of visits due to ILI for the current week is compared to the mean reported during non-influenza weeks, and the activity levels correspond to the number of standard deviations below, at or above the mean.
+The number of jurisdictions at each activity level during week 29 and the change compared to the previous week are summarized in the table below and shown in the following maps.
+ILI Activity Levels
+Activity Level
+Number of Jurisdictions
+Week 29
+(Week ending
+July 18, 2020)
+Compared to Previous Week
+Very High
+0
+No change
+High
+0
+No change
+Moderate
+2
+No change
+Low
+3
++1
+Minimal
+48
+-1
+Insufficient Data
+1
+No change
+*Data collected in ILINet may disproportionally represent certain populations within a state and may not accurately depict the full picture of influenza activity for the whole state. Differences in the data presented here by CDC and independently by some state health departments likely represent differing levels of data completeness with data presented by the state likely being the more complete.
+National Syndromic Surveillance Program (NSSP): Emergency Department (ED) Visits
+NSSP is a collaboration among CDC, federal partners, local and state health departments and academic and private sector partners to collect, analyze and share electronic patient encounter data received from multiple healthcare settings. To track trends of potential COVID-19 visits, visits for COVID-19-like illness (CLI) (fever and cough or shortness of breath or difficulty breathing or presence of a coronavirus diagnosis code) and ILI to a subset of emergency departments in 47 states are being monitored.
+Nationwide during week 29, 3.5% of emergency department visits captured in NSSP were due to CLI and 1.0% were due to ILI. In comparison to week 28, this week there was a decrease in the percentage of visits for both CLI and ILI. However, the percentage of visits for CLI increased from week 23 through week 28, and trends presented this week may change as more ED visit data are received.
+During week 29, seven of ten HHS regionsexternal icon (Regions 1 [New England], 2 [NY/NJ/Puerto Rico], 3 [Mid-Atlantic], 5 [Midwest], 7 [Central], 9 [Mountain] and 10 [Pacific Northwest]) reported only slight fluctuations in percentage of visits for CLI compared to week 28. Three regions (Regions 4 [South East], 6 [South Central] and 9 [South West/Coast]) that have been reporting elevated levels of CLI for several weeks, reported declines in week 29 compared to week 28.
+Additional information about medically attended outpatient and emergency department visits for ILI and CLI: Surveillance Methods
+HospitalizationsThe COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) conducts population-based surveillance for laboratory-confirmed COVID-19-associated hospitalizations in select counties participating in the Emerging Infections Program (EIP) and the Influenza Hospitalization Surveillance Project (IHSP).
+A total of 39,432 laboratory-confirmed COVID-19-associated hospitalizations were reported by sites between March 1, 2020 and July 18, 2020. The overall cumulative hospitalization rate is 120.9 per 100,000 population. Among the 0-4 years, 5-17 years, 18-49 years, 50-64 years, and ≥ 65 years age groups, the highest rate of hospitalization is among adults aged ≥ 65, followed by adults aged 50-64 years and adults aged 18-49 years.
+resize iconView LargerClosedownload iconDownload Imageimage icon[GIF, NAN ]
+Hospitalization Rates
+Age Group
+Cumulative Rate per 100,000 Population
+Overall
+120.9
+0-4 years
+11.2
+5-17 years
+5.8
+18-49 years
+78.6
+18-29 years
+47.1
+30-39 years
+77.2
+40-49 years
+121.0
+50-64 years
+182.3
+65+ years
+338.2
+65-74 years
+249.6
+75-84 years
+400.1
+85+ years
+635.1
+From June 20 (MMWR week 25) – July 11 (MMWR week 28), overall weekly hospitalization rates increased for three consecutive weeks. . Data for the week ending July 18 (MMWR week 29) currently show a decline; however, those data are likely to change as more data for admissions occurring during that week are received.
+resize iconView LargerClosedownload iconDownload Imageimage icon[GIF, NAN ]
+Among the 39,432 laboratory-confirmed COVID-19-associated hospitalized cases, 37,108 (94.1%) have information on race and ethnicity, while collection of race and ethnicity is still pending for 2,324 (5.9%) cases. When examining overall age-adjusted rates by race/ethnicity, non-Hispanic American Indian or Alaska Native persons have an age-adjusted hospitalization rate approximately 5.3 times that of non-Hispanic White persons. Rates for non-Hispanic Black persons and Hispanic or Latino persons are approximately 4.7 and 4.6 times the rate among non-Hispanic White persons, respectively.
+When examining age-stratified crude hospitalization rates by race and ethnicity, compared with non-Hispanic white persons in the same age group, crude hospitalization rates are 7.5 times higher among Hispanic or Latino persons aged 0-17 years; 9.8 times higher among non-Hispanic American Indian or Alaska Native persons aged 18-49 years; 7.4 times higher among non-Hispanic American Indian or Alaska Native persons aged 50-64 years; and 3.8 times higher among non-Hispanic Black persons aged ≥ 65 years.
+Hospitalization rates per 100,000 population
+by age and race and ethnicity — COVID-NET,
+March 1, 2020–July 18, 2020
+Age Category
+Non-Hispanic
+American Indian or Alaska Native
+Non-Hispanic Black
+Hispanic or Latino
+Non-Hispanic Asian or Pacific Islander
+Non-Hispanic White
+Rate1
+Rate Ratio2
+Rate1
+Rate Ratio2
+Rate1
+Rate Ratio2
+Rate1
+Rate Ratio2
+Rate1
+Rate Ratio2
+0-17y
+7.8
+3.9
+9.2
+4.6
+14.9
+7.5
+3.6
+1.8
+2.0
+1.0
+18-49y
+205.8
+9.8
+120.0
+5.7
+190.8
+9.1
+34.8
+1.7
+20.9
+1.0
+50-64y
+510.4
+7.4
+381.0
+5.5
+414.3
+6.0
+107.0
+1.5
+69.3
+1.0
+65+y
+597.2
+2.9
+784.5
+3.8
+513.4
+2.5
+204.5
+1.0
+206.9
+1.0
+Overall rate3 (age-adjusted)
+281.0
+5.3
+246.8
+4.7
+242.5
+4.6
+66.7
+1.3
+53.0
+1.0
+1 COVID-19-associated hospitalization rates by race/ethnicity are calculated using hospitalized COVID-NET cases with known race and ethnicity for the numerator and NCHS bridged-race population estimates for the denominator.
+2 For each age category, rate ratios are the ratios between crude hospitalization rates within each racial/ethnic group and the crude hospitalization rate among non-Hispanic white persons in the same age category.
+3 Overall rates are adjusted to account for differences in age distributions within race/ethnicity strata in the COVID-NET catchment area; the age strata used for the adjustment include 0-17, 18-49, 50-64, and 65+ years.
+Non-Hispanic Black persons and non-Hispanic White persons represent the highest proportions of hospitalized cases reported to COVID-NET, followed by Hispanic or Latino, non-Hispanic Asian or Pacific Islander, and non-Hispanic American Indian or Alaska Native persons. However, some racial and ethnic groups are disproportionately represented among hospitalized cases as compared with the overall population of the catchment area. Prevalence ratios show a similar pattern to that of the age-adjusted hospitalization rates: non-Hispanic American Indian or Alaska Native persons have the highest prevalence ratio, followed by non-Hispanic Black, and Hispanic or Latino persons.
+Comparison of proportions of COVID-19-Associated Hospitalizations, by race and ethnicity — COVID-NET, March 1–July 18, 2020
+Non-Hispanic American Indian or Alaska Native
+Non-Hispanic Black
+Hispanic or Latino
+Non-Hispanic Asian or Pacific Islander
+Non-Hispanic White
+Proportion of hospitalized COVID-NET cases1
+1.5%
+32.9%
+22.8%
+4.7%
+31.8%
+Proportion of population in COVID-NET catchment
+0.7%
+17.7%
+14.0%
+8.8%
+58.8%
+Prevalence ratios2
+2.1
+1.9
+1.6
+0.5
+0.5
+1 Persons of multiple races (0.2%) or unknown race and ethnicity (6.1%) are not represented in the table but are included as part of the denominator.
+2 Prevalence ratio is calculated as the ratio of the proportion of hospitalized COVID-NET cases over the proportion of population in COVID-NET catchment area.
+Among 10,227 hospitalized adults with information on underlying medical conditions, 90.9% have at least one reported underlying medical condition. The most commonly reported were hypertension, obesity, chronic metabolic disease, and cardiovascular disease. Among 217 hospitalized children with information on underlying conditions, 52.1% had at least one reported underlying medical condition. The most commonly reported were obesity, asthma, and neurologic conditions.
+resize iconView LargerClosedownload iconDownload Imageimage icon[GIF, NAN ]
+Additional data on demographics, signs and symptoms at admission, underlying conditions, interventions, outcomes, and discharge diagnoses, stratified by age, sex, and race and ethnicity, are available.
+Additional hospitalization surveillance information: Surveillance Methods  | Additional rate data  |  Additional demographic and clinical data
+Mortality SurveillanceThe National Center for Health Statistics (NCHS) collects death certificate data from vital statistics offices for all deaths occurring in the United States. Based on death certificate data available on July 23, 2020, the percentage of deaths attributed to pneumonia, influenza or COVID-19 (PIC) increased from week 26 – week 28 (June 27 – July 11) after declining for 11 weeks since mid-April. The percentage of deaths due to PIC for week 29 is 9.1% and, while lower than the percentage during week 28 (11.5%), remains above the epidemic threshold. These percentages will likely change as more death certificates are processed.
+Weekly mortality surveillance data include a combination of machine coded and manually coded causes of death collected from death certificates. Percentages of deaths due to PIC are higher among manually coded records than more rapidly available machine coded records. Due to the additional time needed for manual coding, the initially reported PIC percentages may be lower than percentages calculated from final data.
+resize iconView LargerClosedownload iconDownload Imageimage icon[GIF, NAN ]
+*Data during recent weeks are incomplete because of the lag in time between when the death occurred and when the death certificate is completed, submitted to NCHS and processed for reporting purposes.
+View Data Table
+Additional NCHS mortality surveillance information: Surveillance Methods  | Provisional Death Counts for COVID-19
+More Information
+Purpose and Methods
+Past Weekly Reports
\ No newline at end of file
diff --git a/src/cdcUpdatesMappingManagement.js b/src/cdcUpdatesMappingManagement.js
index 796e98fa..83d8f5e9 100644
--- a/src/cdcUpdatesMappingManagement.js
+++ b/src/cdcUpdatesMappingManagement.js
@@ -156,4 +156,5 @@ export default {
   '20-07-25': raw('../cdcupdates/management/20-07-25.txt'),
   '20-07-26': raw('../cdcupdates/management/20-07-26.txt'),
   '20-07-27': raw('../cdcupdates/management/20-07-27.txt'),
+  '20-07-28': raw('../cdcupdates/management/20-07-28.txt'),
 };
diff --git a/src/cdcUpdatesMappingScreening.js b/src/cdcUpdatesMappingScreening.js
index 627d0045..83a84a9d 100644
--- a/src/cdcUpdatesMappingScreening.js
+++ b/src/cdcUpdatesMappingScreening.js
@@ -157,4 +157,5 @@ export default {
   '20-07-25': raw('../cdcupdates/screening/20-07-25.txt'),
   '20-07-26': raw('../cdcupdates/screening/20-07-26.txt'),
   '20-07-27': raw('../cdcupdates/screening/20-07-27.txt'),
+  '20-07-28': raw('../cdcupdates/screening/20-07-28.txt'),
 };
diff --git a/src/cdcUpdatesMappingSummary.js b/src/cdcUpdatesMappingSummary.js
index a837f484..bba4470c 100644
--- a/src/cdcUpdatesMappingSummary.js
+++ b/src/cdcUpdatesMappingSummary.js
@@ -193,4 +193,5 @@ export default {
   '20-07-25': raw('../cdcupdates/summary/20-07-25.txt'),
   '20-07-26': raw('../cdcupdates/summary/20-07-26.txt'),
   '20-07-27': raw('../cdcupdates/summary/20-07-27.txt'),
+  '20-07-28': raw('../cdcupdates/summary/20-07-28.txt'),
 };