The Official CORONAVIRUS oh *&^! thread. Time to start stocking up on food?

[pavlovacloud]

NOTES FROM THE FRONT LINES:

I attended the Infectious Disease Association of California (IDAC) Northern California Winter Symposium on Saturday 3/7. In attendance were physicians from Santa Clara, San Francisco and Orange Counties who had all seen and cared for COVID-19 patients, both returning travelers and community-acquired cases. Also present was the Chief of ID for Providence hospitals, who has 2 affected Seattle hospitals under his jurisdiction. Erin Epson, CDPH director of Hospital Acquired Infections, was also there to give updates on how CDPH and CDC are handling exposed health care workers, among other things. Below are some of the key take-aways from their experiences.

1. The most common presentation was one week prodrome of myaglias, 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 9 days to onset of pneumonia/pneumonitis. 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.

2. Co-infection rate with other respiratory viruses like Influenza or RSV is
3. 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.

4. Patients with underlying cardiopulmonary disease seem to progress with variable rates to ARDS and acute respiratory failure requiring BiPAP then intubation. There may be a component of cardiomyopathy from direct viral infection as well. 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 PAPRs.

5. To date, patients with severe disease are most all (excepting those whose families didn’t sign consent) getting Remdesivir from Gilead through compassionate use. However, the expectation is that avenue for getting the drug will likely close shortly. It will be expected that patients would have to enroll in either Gilead’s RCT (5 vs 10 days of Remdesivir) or the NIH’s “Adaptive” RCT (Remdesivir vs. Placebo). Others have tried Kaletra, but didn’t seem to be much benefit.

6. If our local MCHD lab ran out of test kits we could use Quest labs to test. Their test is 24-48 hour turn-around-time. Both Quest and ordering physician would be required to notify Public Health immediately with any positive results. Ordering physician would be responsible for coordinating with the Health Department regarding isolation. Presumably, this would only affect inpatients though since we (CHOMP) have decided not to collect specimens ordered by outpatient physicians.

7. At facilities that had significant numbers of exposed healthcare workers 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, tetemedicine, “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 (CDPH and OCHD) 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.

Feel free to share. All PUIs in Monterey Country so far have been negative.

Martha L. Blum, MD, PhD

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[PAinPenna]

21 minutes ago, pavlovacloud said:

2. Co-infection rate with other respiratory viruses like Influenza or RSV is

common or uncommon?? 

 

Thanks for the great information! 

[pavlovacloud]

Uncommon. less than 2 percent chance. If you have another positive test for a respiratory virus, no need to test for covid. Based on dataset from China.

 

 

 

 

 

[mgriffiths]

1 hour ago, pavlovacloud said:

7. At facilities that had significant numbers of exposed healthcare workers 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.

Out of curiosity, hospitals that have had exposed HCW with required quarantines...are they requiring the employee to take PTO time, or is this more considered a workman's comp situation?

[pavlovacloud]

Out of curiosity, hospitals that have had exposed HCW with required quarantines...are they requiring the employee to take PTO time, or is this more considered a workman's comp situation?

At my work, they require exposed HCW to take PTO. If we are out of PTO, then they will have us do unpaid time off.

" In the event you are asked to take PTO but you do not have any accrued PTO available, your time off will be unpaid. In the event you are asked to stay home for two weeks and you do not have PTO to cover time off from work, you may be eligible for unemployment benefits. More information about unemployment benefits for reductions in work during Covid-19 is available here: https://edd.ca.gov/about_edd/coronavirus-2019.htm"

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[pavlovacloud]

NOTES FROM THE FRONT LINES:

Notes from a UCSF meeting Wednesday on this COVID crisis (anyone from UCSF-please correct any inaccuracies):

Panelists:
-Joe DeRisi: UCSF’s top infectious disease researcher.
Co-president of ChanZuckerberg BioHub (a JV involving UCSF / Berkeley / Stanford). Co-inventor of the chip used in SARS epidemic.
-Emily Crawford: COVID task force director. Focused on diagnostics
-Cristina Tato: Rapid Response Director. Immunologist.
-Patrick Ayescue: Leading outbreak response and surveillance. Epidemiologist.
-Chaz Langelier: UCSF Infectious Disease doc

At this point, we are past containment. Containment is basically futile. Our containment efforts won’t reduce the number who get infected in the US.

Now we’re just trying to slow the spread, to help healthcare providers deal with the demand peak. In other words, the goal of containment is to "flatten the curve", to lower the peak of the surge of demand that will hit healthcare providers. And to buy time, in hopes a drug can be developed.

How many in the community already have the virus?

No one knows.
We are moving from containment to care.
We in the US are currently where at where Italy was a week ago. We see nothing to say we will be substantially different.

40-70% of the US population will be infected over the next 12-18 months. After that level you can start to get herd immunity. Unlike flu this is entirely novel to humans, so there is no latent immunity in the global population.

[We used their numbers to work out a guesstimate of deaths— indicating about 1.5 million Americans may die. The panelists did not disagree with our estimate. This compares to seasonal flu’s average of 50K Americans per year. Assume 50% of US population, that’s 160M people infected. With 1% mortality rate that's 1.6M Americans die over the next 12-18 months.]
The fatality rate is in the range of 10X flu.
This assumes no drug is found effective and made available.

The death rate varies hugely by age. Over age 80 the mortality rate could be 10-15%.

Don’t know whether COVID-19 is seasonal but if is and subsides over the summer, it is likely to roar back in fall as the 1918 flu did
I can only tell you two things definitively. Definitively it’s going to get worse before it gets better. And we'll be dealing with this for the next year at least. Our lives are going to look different for the next year.

What should we do now? What are you doing for your family?
Appears one can be infectious before being symptomatic. We don’t know how infectious before symptomatic, but know that highest level of virus prevalence coincides with symptoms. We currently think folks are infectious 2 days before through 14 days after onset of symptoms (T-2 to T+14 onset).

How long does the virus last?
On surfaces, best guess is 4-20 hours depending on surface type (maybe a few days) but still no consensus on this
The virus is very susceptible to common anti-bacterial cleaning agents: bleach, hydrogen peroxide, alcohol-based.
Avoid concerts, movies, crowded places.

We have cancelled business travel.
Do the basic hygiene, eg hand washing and avoiding touching face.
Stockpile your critical prescription medications. Many pharma supply chains run through China. Pharma companies usually hold 2-3 months of raw materials, so may run out given the disruption in China’s manufacturing.

Pneumonia shot might be helpful. Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.
-Get a flu shot next fall. Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.
-We would say “Anyone over 60 stay at home unless it’s critical”. CDC toyed with idea of saying anyone over 60 not travel on commercial airlines.
-We at UCSF are moving our “at-risk” parents back from nursing homes, etc. to their own homes. Then are not letting them out of the house. The other members of the family are washing hands the moment they come in.

Routes of infection
Hand to mouth / face
Aerosol transmission

What if someone is sick?
If someone gets sick, have them stay home and socially isolate. There is very little you can do at a hospital that you couldn’t do at home. Most cases are mild. But if they are old or have lung or cardio-vascular problems, read on.
If someone gets quite sick who is old (70+) or with lung or cardio-vascular problems, take them to the ER.
There is no accepted treatment for COVID-19. The hospital will give supportive care (eg IV fluids, oxygen) to help you stay alive while your body fights the disease. ie to prevent sepsis.

If someone gets sick who is high risk (eg is both old and has lung/cardio-vascular problems), you can try to get them enrolled for “compassionate use" of Remdesivir, a drug that is in clinical trial at San Francisco General and UCSF, and in China. Need to find a doc there in order to ask to enroll. Remdesivir is an anti-viral from Gilead that showed effectiveness against MERS in primates and is being tried against COVID-19. If the trials succeed it might be available for next winter as production scales up far faster for drugs than for vaccines. [More I found online.]

Why is the fatality rate much higher for older adults?
Your immune system declines past age 50
Fatality rate tracks closely with “co-morbidity”, ie the presence of other conditions that compromise the patient’s hearth, especially respiratory or cardio-vascular illness. These conditions are higher in older adults.
Risk of pneumonia is higher in older adults.

What about testing to know if someone has COVID-19?
Bottom line, there is not enough testing capacity to be broadly useful. Here’s why.
Currently, there is no way to determine what a person has other than a PCR test. No other test can yet distinguish "COVID-19 from flu or from the other dozen respiratory bugs that are circulating”.
A Polymerase Chain Reaction (PCR) test can detect COVID-19’s RNA. However they still don’t have confidence in the test’s specificity, ie they don’t know the rate of false negatives.
The PCR test requires kits with reagents and requires clinical labs to process the kits.
While the kits are becoming available, the lab capacity is not growing.
The leading clinical lab firms, Quest and Labcore have capacity to process 1000 kits per day. For the nation.
Expanding processing capacity takes “time, space, and equipment.” And certification. ie it won’t happen soon.
UCSF and UCBerkeley have donated their research labs to process kits. But each has capacity to process only 20-40 kits per day. And are not clinically certified.
Novel test methods are on the horizon, but not here now and won’t be at any scale to be useful for the present danger.

How well is society preparing for the impact?
Local hospitals are adding capacity as we speak. UCSF’s Parnassus campus has erected “triage tents” in a parking lot. They have converted a ward to “negative pressure” which is needed to contain the virus. They are considering re-opening the shuttered Mt Zion facility.
If COVID-19 affected children then we would be seeing mass departures of families from cities. But thankfully now we know that kids are not affected.
School closures are one the biggest societal impacts. We need to be thoughtful before we close schools, especially elementary schools because of the knock-on effects. If elementary kids are not in school then some hospital staff can’t come to work, which decreases hospital capacity at a time of surging demand for hospital services.
Public Health systems are prepared to deal with short-term outbreaks that last for weeks, like an outbreak of meningitis. They do not have the capacity to sustain for outbreaks that last for months. Other solutions will have to be found.

What will we do to handle behavior changes that can last for months?
Many employees will need to make accommodations for elderly parents and those with underlying conditions and immune-suppressed.
Kids home due to school closures
[Dr. DeRisi had to leave the meeting for a call with the governor’s office. When he returned we asked what the call covered.] The epidemiological models the state is using to track and trigger action. The state is planning at what point they will take certain actions. ie what will trigger an order to cease any gatherings of over 1000 people.

Where do you find reliable news?
The John Hopkins Center for Health Security site. Which posts daily updates. The site says you can sign up to receive a daily newsletter on COVID-19 by email. [i tried and the page times out due to high demand. After three more tries I was successful in registering for the newsletter.]
The New York Times is good on scientific accuracy.

Observations on China
Unlike during SARS, China’s scientists are publishing openly and accurately on COVID-19.
While China’s early reports on incidence were clearly low, that seems to trace to their data management systems being overwhelmed, not to any bad intent.
Wuhan has 4.3 beds per thousand while US has 2.8 beds per thousand. Wuhan built 2 additional hospitals in 2 weeks. Even so, most patients were sent to gymnasiums to sleep on cots.
Early on no one had info on COVID-19. So China reacted in a way unique modern history, except in wartime.

Every few years there seems another: SARS, Ebola, MERS, H1N1, COVID-19. Growing strains of antibiotic resistant bacteria.

Are we in the twilight of a century of medicine’s great triumph over infectious disease?
"We’ve been in a back and forth battle against viruses for a million years."
But it would sure help if every country would shut down their wet markets.
As with many things, the worst impact of COVID-19 will likely be in the countries with the least resources, eg Africa. See article on Wired magazine on sequencing of virus from Cambodia.

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[Marinejiujitsu]

Yeah, Santa Clara County



No testing of low risk people, 14+ day quarantine

High risk or admission-test repiratory panel, if positive, corona testing

If we are exposed we will work unless developing symptoms otherwise no quarantine. We are working with thermometers in our back pockets. Lol. Its a crazy time.


Apparently, we have less ventilators per capita than italy. Were we are in the bay it took 10 days for Italy to get to the collapsing of the healthcare system where they are letting anyone over 70 die and not ventilating them.

Hopefully, our less dense population in the US and social gathering bans causes it to not be as bad. I know I suited up for 17 people yesterday and belirve anothet 3 might have fell through the crack.


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[Arthropathy]

Hometown hospital just got first positive test. Not my employer so that's all I know. Grocery stores are insane.

[Reality Check 2]

Pavlovacloud - thank you for the great posts. Very helpful.

I was able to sign up for the Johns Hopkins updates in one try.

My county just got 3 positives today in Washington state. 

My employer is preparing but not really acting at this point. It is a bit worrisome. Our patient population is very high risk.

Local folks seem to struggle with the concept of social distancing. It baffles me. 

Has your facility starting canceling elective procedures or made stipulations on clinic visits other than promoting tele visits?  Were there recommendations regarding this at the conference?

Thanks again for the great info

[sas5814]

5 hours ago, mgriffiths said:

Out of curiosity, hospitals that have had exposed HCW with required quarantines...are they requiring the employee to take PTO time, or is this more considered a workman's comp situation?

If our exposure is work related it will be a full 2 weeks paid without charge to PTO. If it isn't work related we have to use PTO. Given that the people writing the checks also determine who was or wasn't infected at work I have an idea which way that will go.

 

[EMEDPA]

I am working with an older doc today who I really like. I am preferentially seeing all the cough, fever, etc folks because if I get this I will be fine and he might not be.

[Cideous]

6 minutes ago, EMEDPA said:

I am working with an older doc today who I really like. I am preferentially seeing all the cough, fever, etc folks because if I get this I will be fine and he might not be.

If he's in the same ED it won't matter.  This thing is airborne and we all know it.  If he's over 70 he should not be there.

[EMEDPA]

15 minutes ago, Cideous said:

If he's in the same ED it won't matter.  This thing is airborne and we all know it.  If he's over 70 he should not be there.

62 I think. Old school ER doc. Great guy. They are putting all the rule outs in 2 particular rooms on the edge of the ED. Me and 1 nurse are dealing with them.

[Cideous]

1 minute ago, EMEDPA said:

62 I think. Old school ER doc. Great guy. They are putting all the rule outs in 2 particular rooms on the edge of the ED. Me and 1 nurse are dealing with them.

Gotcha.  Not that you can rule out CV there.  Go home and self isolate?  About all you can tell them?

[EMEDPA]

1 minute ago, Cideous said:

Gotcha.  Not that you can rule out CV there.  Go home and self isolate?  About all you can tell them?

 

[Hope2PA]

1 hour ago, EMEDPA said:

I am working with an older doc today who I really like. I am preferentially seeing all the cough, fever, etc folks because if I get this I will be fine and he might not be.

Definitely must protect if your SP. May be a problem for some PA’s if their SP dies. But I image, in at least 30+ states they could find a cheap independent practitioner to take place of the assistant.

[EMEDPA]

39 minutes ago, Hope2PA said:

Definitely must protect if your SP. May be a problem for some PA’s if their SP dies. But I image, in at least 30+ states they could find a cheap independent practitioner to take place of the assistant.

In OR our law is no specific SP, but a supervising provider organization (SPO), so basically every doc in the group is a supervisor. So I have 9 at this job. some younger than me(young enough to be my kid).

[einstein2u]

from a source, curfews are coming this week.  we will know more in the next 48-72 hours

[EMSGuy1982]

“

Also, an emergency room doctor at a suburban Seattle hospital that has treated many people with coronavirus has contracted the disease.

EvergreenHealth Medical Center in Kirkland, Washington, said in a statement Sunday that the doctor was in "critical condition but stable.....told the newspaper the doctor had used personal protective equipment and that it was not known whether the physician contracted COVID-19 in the community or at work”

Be safe out there and no matter what, don that PPE every time..

 

https://amp.kitsapsun.com/amp/5056858002?__twitter_impression=true

Edited March 16, 2020 by EMSGuy1982
Added quotation

[mgriffiths]

9 hours ago, EMSGuy1982 said:

Be safe out there and no matter what, don that PPE every time..

If only we had PPE...other than gloves we have nothing in our outpatient clinics.  They don't even have any N95s at our official "coronavirus clinic."  One of my NP friends bought some N95s herself when she was volunteered to cover that clinic but she isn't allowed to wear them because "they weren't purchased by the hospital."

[Cideous]

22 minutes ago, mgriffiths said:

If only we had PPE...other than gloves we have nothing in our outpatient clinics.  They don't even have any N95s at our official "coronavirus clinic."  One of my NP friends bought some N95s herself when she was volunteered to cover that clinic but she isn't allowed to wear them because "they weren't purchased by the hospital."

Mercy...that boarders on criminal.

[mgriffiths]

22 minutes ago, Cideous said:

Mercy...that boarders on criminal.

I would agree...I told her to refuse to see patients until she's allowed to wear them.  She had even offered to share her N95s with coworkers before they told her that she couldn't wear them at all - so it's not push back because she wasn't sharing.  It's just ridiculous.

[Reality Check 2]

Wow, that is ridiculous to expect anyone to be around this and not have PPE.

I failed the PAPr here - too close to my face and too snug. I used to fear full suits in the OR without problem and wear an N95 at home during wildfire season due to asthma. The crappy N95s we have didn't seal on me either. I don't think they will let me bring mine with filters from home. 

We still don't seem to have a full plan at work - kind of full steam ahead, damn the torpedoes. No changes in our schedules to date and we have a very vulnerable population. 

This will indeed get worse before it gets better.

[BruceBanner]

I'm a bit late to this party but another update from the front lines:

At a Big 10 University health service, we have had multiple presumptive positives in the past week. Things hit the fan after students returned from spring break, as we predicted. We have a lot of resources at our disposal, but we are still woefully under-prepared. As of Friday, we were still seeing routine and walk-in visits! Many well students are still coming in "just to be checked". Tests are very limited. Nothing is in-house yet. It is nearly impossible for front end staff to appropriately risk-stratify patients. We have non-segregated waiting rooms, people with mild cold/flu sx being put into normal rooms and the obvious high-risk pts being put into "isolation", which are just normal rooms set aside for COVID suspects.

We have no functional PAPRs. I had to see a flu pt with an international travel hx in the walk-in clinic. I had full PPE including N95 but technically should have been wearing a PAPR being a male with stubble. He turned out to be positive.

Luckily I had scheduled vacation this week so I am off (obviously we didnt go), now awaiting word on whether or not I need to self-quarantine. Having serious doubts about returning to work with the situation there---I'm willing to do my job but not without proper PPE. Plus the absolute asinine policy of still accepting walk-ins off the steet. As usual, admins are nowhere to be seen in the clinics; they're safe in their ivory tower sending emails. Staff are going to start dropping like flies if they dont tighten things up.

Stay safe out there everyone.

[Cideous]

49 minutes ago, BruceBanner said:

As usual, admins are nowhere to be seen in the clinics; they're safe in their ivory tower sending emails. Staff are going to start dropping like flies if they dont tighten things up.

Stay safe out there everyone.

 

This is exactly what I was afraid of.  Money over safety for providers.  Corporate UC has the same mentality...see everyone, minimally protected and hope for the best.  By the time the corporate overlords realize we are screwed, it will be too late.  All providers will be infected and those of us older might not make it.

 

https://www.foxnews.com/health/emergency-room-doctors-critical-condition-coronavirus

Edited March 16, 2020 by Cideous