Provider Update for Tuesday, March 24, 2020

Tuesday, March 24, 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

Update in Brief: 3-24-20

Coronavirus cases continue to rise across the mid-south. In our three state region, within the Baptist system, we have diagnosed 181 cases with over 90% of those individuals being cared for at their homes under quarantine conditions. We are working with the Health Departments in each state to identify positive individuals, support contact tracing, and impose quarantine recommendations for all non-hospitalized positive individuals. Today we will take steps to begin using masks for patients with COVID-19 positive tests and all patients with URI/ILI symptoms. We are also sequentially expanding the use of surgical masks for all frontline providers and employees. We continue to urge physicians and their patients to avoid elective procedures, tests and routine medical care during the next 2-3 months. However, we are taking aggressive steps to support a wide variety of telemedicine options in our clinics and in our facilities. We continue to assertively, but compassionately limit visitors in all our facilities. Please contact your local CEO/CMO/Clinic administrator with any specific questions.

—Paul DePriest, MD, MHCM, EVP-COO 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 general 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 scores of humans. There is also precious little herd immunity among humans to COVID-19. These infections were first discovered during 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 WHO and CDC have both 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 viral particles detected in U.S. patients demonstrate a similar RNA sequence compared to the sequence that researchers from China initially posted. 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. Collectively, this information strongly suggests the recent emergence of a novel coronavirus, arising from an animal reservoir, which upon mutation was capable of infecting humans.

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) which is then 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. Baptist, through a relationship with AEL, is currently able to process over 2000 COVID-19 tests per day. The actual RT-PCR test takes 2 hours to run, but results reporting is usually a 1-3 day process. Other tests are available or are under development, but RT-PCR is the gold standard as of 3-24-20.

On 3-21-20 the FDA approved the Cepheid point-of-service test platform for COVID-19 detection. This test is a form of RT-PCR which uses immunofluorescence technology to identify specific identifying RNA sequences of COVID-19. The test can be performed within the clinical setting and takes only 45 minutes to get results. Baptist has the Cepheid testing platform in many of our labs. However, it is still unclear when COVID-19 test kits for the Cepheid platform will be available at scale, or the cost of each kit.

Early Virology Understanding of COVID-19

Like other coronaviruses, COVID-19 can be spread by contact with droplets, by direct inhalation of aerosolized viral particles, or by contact with a contaminated surface. In a recent paper in the NEJM, 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 (3.). The virus can be inactivated with alcohol based and chlorine based cleansing agents. Alcohol-based hand sanitizers are an effective agent for hand hygiene in the healthcare setting. Most cleaning agents approved for the healthcare setting are sufficient for decontaminating solid 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 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 (2.). There are several drugs currently being tested which would target this pathway in an effort to prevent viral entry and possibly prevent overt infection.

The best way to prevent infection with COVID-19 is to limit one’s direct exposure to the pathogen. The most dangerous exposure is via direct droplet or aerosol transmission from an infected person. Contact with surfaces contaminated with secretions harboring COVID-19 particles also can lead to infection. 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: 3-23-20

Prevalence in the World

World as of 3-22-20: Total cases: 384,429

PREVALENCE IN USA AND OUR REGION

USA as of 3-22-2020: 46,455 cases

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

Total cases: 46,455
Total deaths: 593
States reporting cases: 50
US Territories reporting cases: 4

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

TENNESSEE

Total cases: 615
Total deaths: 2

MISSISSIPPI

Total cases: 249
Total deaths: 1

ARKANSAS

Total cases: 197
Total deaths: 0

LOUISIANA

Total cases: 1172
Total deaths: 35

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.

What can we do to immediately prepare for the surge

First and fore most we can work together to cancel elective care during the ensuing surge in cases. We have asked each patient and each physician to work with local hospital and clinic administration to cancel elective office visits, elective testing and elective surgery. We can move to the use of telemedicine for many types of elective care that keeps the patients safely in their homes and the health care providers in a position to decrease their own exposure. By down regulating health resource utilization in a critical time we will open capacity for the patients that need care the most while decreasing the risk of exposing non- COVID-19 patients to a dangerous viral illness.

We should work with our patients and administration to limit visitors and non-essential workers in the high risk hospital and clinic environments. We understand that compassionate care is usually rendered to a critically ill person and their loved ones. Limiting unnecessary visitation will be protective for other patients, for the families, for healthcare providers and for the community.

Be frugal with the use of PPE. Identifying safe ways to avoid PPE wastage will help protect supplies for the weeks ahead when we will need every mask and gown we can find.

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?

Caring for the COVID-19 patient should proceed as you would care for any other patient with a respiratory viral infection, but with greater caution regarding the highly infectious nature of this novel infection. A recent case study published in the NEJM can help you better understand the presenting signs and symptoms and early management.

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?

These 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?

Ask that any patient with concerning symptoms be given a mask if available.
Properly don and doff PPE.
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.
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.
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.
Wipe down your work surfaces with appropriate cleaning materials regularly.
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.
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.
If sick, or symptomatic in any way please stay at home.
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

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
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
https://www.nejm.org/doi/full/10.1056/NEJMc2004973?query=featured_home
https://www.nejm.org/doi/full/10.1056/NEJMoa2001191?query=featured_home