Provider Update for Sunday March 22, 2020

Sunday, March 22, 2020

JoAnn Wood MD, MHA, CMO- Baptist DeSoto
Lillian Ogari, Ph.D., MPH., Associate Professor of Microbiology BCHS
Amanda Comer DNP, RN
Jillian Foster, PharmD, MBA, System Pharmacy/Radiology Administrator
Stephen Threlkeld MD. Medical Director Infectious Disease Baptist Memorial Health Care

Coronaviruses are a large family of lipid-enveloped RNA viruses. These viruses are commonly occurring in Humans and many different species of animals, including camels, cattle, cats, and bats. Rarely, animal coronaviruses can mutate to infect humans and then spread between people such as with MERS-CoV, SARS-CoV, and now with this new virus (named SARS-CoV-2) COVID -19 . The evidence on MERS-CoV and SARS-CoV demonstrated that those pathogens were more difficult to transmit than common influenza but were much more clinically dangerous than the flu. COVID -19 is a novel virus; hence, there is precious little scientific data available about the infections it has now caused in humans. There is also precious little herd immunity among humans to COVID -19. These infections were first discovered in China in late November –early December 2019 in and around Wuhan City in Hubei Province, China. The COVID -19 virus was able to efficiently infect thousands of Wuhan City residents in a matter of weeks leading to an epidemic. The CDC has substantiated that COVID -19 causes SARS-CoV-2, and that an individual infection can quickly lead to community spread. This epidemiologic pattern has been particularly observed in China, Italy, Iran, Spain and now in the U.S. The virus has now spread around the world and meets the WHO classification as a pandemic.

The SARS-CoV-2 virus is a betacoronavirus, like MERS-CoV and SARS-CoV. All three of these viruses have their origins in bats. The RNA sequences from COVID -19 infections in U.S. patients demonstrate a similar RNA sequence when compared to the sequence that researchers from China initially posted. This information strongly suggests a likely single, recent emergence of the novel virus arising from an animal reservoir. Early on, many of the patients at the epicenter of the outbreak in Wuhan City had some link to a large seafood and live animal market, suggesting animal-to-person spread. Later, a growing number of patients reportedly did not have exposure to animal markets, indicating community transmission via person-to-person spread. Within a matter of weeks from the first reported cluster of cases arising from the market-exposed patients, massive community transmission was reported.

Testing for the COVID -19 Virus

Current tests for COVID -19 consist largely of RT-PCR (Reverse Transcription Polymerase Chain Reaction) techniques. RT-PCR requires minute amounts of the RNA from a COVID -19 sample (i.e. nasal swab from a patient) to be amplified to allow adequate detection of the viral type and sequence. This, in essence, allows identification of the viral type even if there are relatively small amounts of RNA within the collected sample. The sensitivity and specificity of RT-PCR is extremely high with low risk of false positives or false negatives. Other test are available or are under development, but RT-PCR is the gold standard as of 3-21-20.

Early Virology Understanding of COVID -19

Like other coronaviruses, COVID -19 can be spread by contact with droplets by direct inhalation or by contact with a contaminated surface. Aerosol transmission is also possible. In a recent paper in the NEJM (3), researchers from Princeton found that the COVID -19 virus remained active at 3 hours in aerosol suspension and remained active for days on multiple types of contact surfaces including metals, plastics, cardboard and paper (reference). The virus can be inactivated with alcohol based and chlorine based cleansing agents and most cleaning agents approved for the healthcare setting are sufficient for use in decontaminating surfaces.

Preventing COVID -19 infections

Currently there are no approved vaccines to prevent a COVID -19 infection. A worldwide effort is underway to develop a vaccine. However, it is realistic to assume that widespread immunization could not begin until the earliest late 2020 or early-mid 2021. The COVID -19 virus has been shown to use Angiotensin converting enzyme 2 (ACE 2) receptors as a point of entry into the human cell facilitated by type transmembrane serine proteases (TMPRSS2). There are several drugs currently being tested which would target this pathway to prevent viral entry and possibly prevent overt infection.

The best preventive steps for avoiding COVID -19 infection is to limit one’s exposure to the pathogen. The most dangerous exposure is via direct transmission from an infected person via aerosol, droplet or surface contact. Avoiding large groups of people in close contact is imperative in preventing community spread of COVID -19. Avoiding close physical contact with others in the form of hugging, shaking hands, and kissing is also protective. In the healthcare environment every effort should be made to mask potentially infected patients, and for health care providers (HCP’s) to use proper application of the proper personal protective equipment (PPE). Careful hand hygiene using approved products and with soap and water can prevent transmission. Please see below.

Current Condition: 3-22-20

Prevalence in the World

World as of 3-22-20: Total cases: 307,341

PREVALENCE IN USA AND OUR REGION

USA as of 3-22-2020: 26,747 cases

COVID -19: U.S. at a Glance (CD and Johns Hopkins Coronavirus Resource)

  • Total cases: 26,747
  • Total deaths: 318
  • States reporting cases: 50
  • US Territories reporting cases: 4

Cases of COVID -19 Reported in US, by Source of Exposure (CDC)

TENNESSEE

  • Total cases: 371
  • Total deaths: 1

MISSISSIPPI

  • Total cases: 140
  • Total deaths: 1

ARKANSAS

  • Total cases: 122
  • Total deaths: 0

LOUISIANA

  • Total cases: 763
  • Total deaths: 20

Preparing for the Surge

The USA, like countries across the world, has been quickly impacted largely due to mass transit of people around the globe who harbored the virus in an asymptomatic state or in an early symptomatic state. From what is understood at this time, there is little to no natural immunity to COVID -19 as it is a new variant of other coronaviruses. The population currently: reported to be positive with the disease is likely to be a gross underestimation.

So why all the hype?

The main reason for immediate concern is that the virus has been able to spread very quickly leading to a sharp increase in the numbers of individuals requiring admission and acute care. The case counts rose so quickly in China and Italy that hospital capacity and ICU capacity were overwhelmed. Roughly 3.5-5% of patients required ICU care with many requiring ventilator support. In Italy, Spain and Iran many patients in need of care for a variety of non-COVID -19 medical or surgical conditions could not access appropriate support.

How can Healthcare Providers be Protected?

The most important thing we can do to protect healthcare providers is to use proper PPE in then proper way. Further below you will find the CDC recommendations on Personal Protective Equipment.

Healthcare workers seem to have an increased risk of acquiring this virus and requiring hospitalization. One reason for this has been inadequate use of PPE. Studies have shown that when monitored, healthcare workers properly don and doff PPE only about 40% of the time. A second reason is that in this epidemic many hospitals have run out of PPE. Baptist is constantly working to ensure adequate supplies and will be updating you regularly with modified plans when/if they are needed. The last reason may be that healthcare workers are exposed to a higher load of viral particles because of the interventions performed on or near the airway. Therefore, all of our hospitals and medical staff have been working to reduce direct contact and exposure time with COVID -19 patients using telemedicine while also balancing the importance of providing excellent and compassionate care.

The virus can be spread by individuals who are having few if any symptoms. As stated earlier, COVID -19 virus is extremely transmissible. Ying and colleagues reported that a COVID -19 positive patient can infect on average 2.2 people compared to influenza which on average is transmitted to 1.3 people. The virus is more contagious than the flu and leads to significantly higher rates of severe respiratory compromise and death compared to influenza.

What should I do if I am caring for a patient with COVID -19?

Healthcare personnel caring for patients with confirmed or possible COVID -19 should adhere to CDC recommendation for infection prevention and control (IPC):

  • Assess and triage patients with acute respiratory symptoms and risk factors for COVID -19 to minimize chances of exposure, including placing a face mask on the patient and placing them in an examination room with the door closed in an Airborne infection Isolation Room (AIIR) if available.
  • Use standard precautions, contact precautions, and airborne precaution when caring for patients with confirmed or possible COVID -19.
  • Perform hand hygiene with alcohol-based hand rub before and after all patient contact, contact with potential infectious material, and before putting on and upon removal of PPE, including gloves.
  • Use soap and water if hand are visibly soiled.
  • Practice how to properly don, use and doff PPE in a manner to prevent self-contamination.
  • Perform aerosol-generating procedures, in AIIR, while following appropriate IPC practices, including use of appropriate PPE.

What are the most frequent signs/symptoms of patients with COVID -19?

As this is a new infection it will benefit HCP’s to read a recent case study that was published in the NEJM (4). Listed here are the most frequently occurring symptoms in patients with active COVID -19 infections:

  • Fever
  • Dyspnea
  • Cough
  • Upper respiratory symptoms (congestion, runny nose, etc.)
  • Gi Distress
  • Diarrhea
  • Hematemesis
  • Abdominal pain

Lab Findings

  • Leukopenia
  • Lymphopenia
  • AKI
  • Mildly elevated AST, ALT, LDH and TBili
  • Low procalcitonin (May be elevated if a bacterial superinfection present)
  • Elevated Ferritin
  • Elevated IL-6
  • Elevated CRP

CXR: Hazy, bilateral peripheral opacities.
POCUS: Numerous B Lines; pleural lining thickening; consolidations with air bronchograms.
CT: Ground Glass Opacities (Crazy paving) bilaterally, most commonly

Treatment options

There are no proven effective treatment regimens. However, there are a growing number of reports citing efficacy of medications including, remdesevir, camostat mesylate, hydroxychloroquine and interventions such as ECMO . The therapeutic options will develop and change rapidly. Our infectious disease efforts led by Dr. Stephen Threlkeld and our pharmacists at Baptist led by Dr. Jillian Foster are vigorously working to stay abreast of the developing literature to help determine which medications and what support equipment is needed at any given time. Dr. Maggie DeBon the Executive Director of the Baptist Clinical Research Institute (BCRI) is supporting the applications for compassionate use of investigational drugs such as remdesevir from Gilead Labs. Dr. DeBon also is leading oversight of clinical research trial applications and IRB approval processes.

Corticosteroids are not recommended for use in these patients. Ibuprofen should be avoided according to the CDC.

OK, what should physicians and advanced practice providers do?

  1. Ask that any patient with concerning symptoms be given a mask if available.
  2. Properly don and doff PPE.
  3. Protect your families by wearing your own scrubs and white coat to the hospital and taking them off and carrying them back home in a plastic bag which is immediately thrown into your washing machine and utilizing aggressive detergents and when possible bleach. Use careful hand hygiene before leaving the hospital and as you arrive home.
  4. Ask your direct family members to follow social distancing when in any public forum to avoid high risk social interactions during the next 2-4 months. This could help block community spread to your family and then to you. In the next 2-4 months your ability to continue service within the clinical setting is crucial for the patients who will need care.
  5. Personally practice immaculate hand sanitation in the hospital and clinic settings. Avoid touching your face, eyes, nose and mouth as much as possible. Encourage others to do the same.
  6. Wipe down your work surfaces with appropriate cleaning materials regularly.
  7. If you identify a concern, please quickly escalate it to the appropriate leadership immediately. Your CMO, CEO or Clinic Director will be able to address the issue most effectively with your assistance. As a physician, you are a leader within the clinical arena. The frontline staff look you for guidance, support and calm actions in critical situations.
  8. If you interact with a patient who eventually tests positive for the virus, and if you were using PPE appropriately, it is reasonable for you to monitor your symptoms and check your temperature twice daily. If you develop concerning symptoms or if your temperature rises above 100.4 please contact employee health. Otherwise, you should continue to work. If you were not wearing proper PPE, please contact employee health immediately for instructions.
  9. If sick, or symptomatic in any way please stay at home.
  10. Finally, knowledge is power. Check this website regularly for updates and changes in recommendations. “Up-to-Date” has a terrific page which is regularly being refreshed.

References

  1. Liu Y, Gayle AA, Wilder-Smith A, Rocklöv J. The reproductive number of COVID -19 is higher compared to SARS coronavirus. J Travel Med. 2020;27(2):taaa021. oi:10.1093/jtm/taaa021
  2. Cynthia Liu, Qiongqiong Zhou, Yingzhu Li, Linda V. Garner, Steve P. Watkins, Linda J. Carter, Jeffrey Smoot, Anne C. Gregg, Angela D. Daniels, Susan Jervey, Dana Albaiu. Research and Development on Therapeutic Agents and Vaccines for COVID -19 and Related Human Coronavirus Diseases. ACS Central Science, 2020; DOI: 10.1021/acscentsci.0c00272
  3. https://www.nejm.org/doi/full/10.1056/NEJMc2004973?query=featured_home
  4. https://www.nejm.org/doi/full/10.1056/NEJMoa2001191?query=featured_home