Frontline Experiences on Managing COVID


FEATURE STORY


COVID ravages all nations worldwide, respecting no super powers. In the United States, several states including Washington State, New York, Oregon and California have declared states of emergency, as more than 760 cases have been confirmed, with 27 deaths across the country, as of this writing.

Of the 27 deaths, 23 were in Washington State, two in Florida and two in California. It is to be recalled that Bill Gates, who is based in Washington State, made the chilling warning two years ago that a pandemic, which the world is not prepared to handle, might kill tens of millions. He proposed that the Trump administration should allocate a bigger funding for the Centers for Disease Control and Prevention (CDC). He also urged the government to prioritize the drafting of a national response plan to determine and control allocation of resources during a pandemic or biological weapons attack.

Dr. Martha Blum, medical director of infection prevention at Community Hospital in California and Montage Health’s head of infection prevention and antimicrobial stewardship, was cited as source of some important insights and experiences gathered from a conference of the Infectious Disease Association of California (IDAC) Northern California last March 7. Attending the conference were physicians from various parts of California like Santa Clara, San Francisco and Orange Counties who had all seen and cared for COVID-19 patients, both returning travelers and community-acquired cases.

These are some of the key takeaways the doctors shared from their experiences:

1. The most common presentation was one-week prodrome of myalgias, malaise, cough, low grade fevers gradually leading to more severe trouble breathing in the second week of illness. It is an average of 8 days to development of dyspnea and average of 9 days to onset of pneumonia/pneumonitis.

2. It is not like influenza, which has a classically sudden onset. Fever was not very prominent in several cases. The most consistently present lab finding was lymphopenia (with either leukocytosis or leukopenia). The most consistent radiographic finding was bilateral interstitial/ground glass infiltrates. Aside from that, the other markers (CRP, PCT) were not as consistent.

3. Co-infection rate with other respiratory viruses like influenza or RSV (respiratory syncytial virus) is <=2 percent. That means, if you have a positive test for another respiratory virus, then you do not test for COVID-19. This is based on large dataset from China.

4. So far, there have been very few concurrent or subsequent bacterial infections, unlike influenza where secondary bacterial infections are common and a large source of additional morbidity and mortality.

5. Patients with underlying cardiopulmonary disease seem to progress with variable rates to acute respiratory distress syndrome (ARDS) and acute respiratory failure requiring BiPAP (bilateral positive airway pressure) then intubation. There may be a component of cardiomyopathy from direct viral infection as well.

6. Intubation is considered “source control” equal to patient wearing a mask, greatly diminishing transmission risk. BiPAP is the opposite, and is an aerosol generating procedure and would require all going into the room to wear (powered air purifying respirators) PAPRs.

7. At facilities that had significant numbers of exposed healthcare workers (HCW), they did allow those with low and moderate risk exposures to return to work well before 14 days. Only HCW with highest risk exposures were excluded for almost the full 14 days (I think 9 days). After return to work, all wore surgical masks while at work until the 14 days period expired. All had temperature check and interview with employee health prior to start of work, also only until the end of the 14 days. Obviously, only asymptomatic individuals were allowed back.

8. Symptom onset is between 2-9 days post-exposure with median of 5 days. This is from a very large Chinese cohort.

9. Patients can shed RNA from 1-4 weeks after symptom resolution, but it is unknown if the presence of RNA equals presence of infectious virus. For now, COVID-19 patients are “cleared” of isolation once they have 2 consecutive negative RNA tests collected >24 hours apart.

10. All suggested ramping up alternatives to face-to-face visits—like telemedicine, “car visits”, telephone consultation hotlines.

11. Sutter and other larger hospital systems are using a variety of alternative respiratory triage at the Emergency Departments.

12. Health Departments state the Airborne Infection Isolation Room (AIIR) is the least important of all the suggested measures to reduce exposure. Contact and droplet isolation in a regular room is likely to be just as effective. One heavily affected hospital in San Jose area is placing all “undifferentiated pneumonia” patients not meeting criteria for COVID testing in contact+droplet isolation for 2-3 days while seeing how they respond to empiric treatment and awaiting additional results.

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