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From an ID conference in California #COVID19

3/8/2020

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 <=2%, interpret that to mean 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.

  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 โ€œsource controlโ€ 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 didnโ€™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 Gileadโ€™s RCT (5 vs 10 days of Remdesivir) or the NIHโ€™s โ€œAdaptiveโ€ RCT (Remdesivir vs. Placebo). Others have tried Kaletra, but didnโ€™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.

  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 โ€œclearedโ€ 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, โ€œcar visitsโ€, 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 โ€œundifferentiated pneumoniaโ€ 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.

an American reconnaissance satellite?


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