#200 COVID-19 Update with Paul Sax MD

March 22, 2020 | By Sarah Phoebe Roberts

Thoughts on transmission, quarantine, PPE, diagnosis and management

Practical tips and discussion of what we do and don’t know about COVID-19 transmission, testing, NSAIDs, ACE inhibitors, quarantine, treatment, personal protective equipment (PPE) and more with Paul Sax MD, @paulsaxMD (Brigham and Women’s Hospital/Harvard Medical School). This episode is sure to go viral!

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Credits

Written and Produced by: Sarah Phoebe Roberts MPH; Chris Chiu MD; Beth Garbitelli; Hannah Abrams; Rahul Ganatra MD, MPH; Matthew Watto MD, FACP

Cover Art and Infographic by: Beth Garbitelli

Hosts: Rahul Ganatra MD, MPH; Matthew Watto MD, FACP; Paul Williams MD, FACP   

Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

Guest: Paul Sax MD

Time Stamps

• 00:00 Sponsor- Primary Care Internal Medicine of Ithaca https://www.primarycareinternalmedicineofithaca.com/
• 00:20 Intro, guest bio, guest one-liner
• 04:12 SARS-CoV-2/COVID-19 vs. SARS, MERS, and influenza 
• 07:00 Rahul highlights areas of caution interpreting COVID cases studies 
• 12:35 Sponsor- Primary Care Internal Medicine of Ithaca https://www.primarycareinternalmedicineofithaca.com/
• 13:20 Case of cold symptoms; Wearing masks in public; Advice on self quarantine with mild symptoms
• 18:05 Patient with mild symptoms and COVID exposure; Duration of quarantine and PCR positivity
• 21:15 Who merits testing for COVID-19
• 23:19 Case of confirmed COVID with mild symptoms; Instructions to patient and family about quarantine
• 25:50 COVID-19 testing characteristics (sensitivity, false negatives); Does co-infection occur?; Advice on when to send patient to a hospital 
• 30:10 ACEIs, ARBs, NSAIDS; Is reinfection possible?
• 32:20 Pharmacotherapy: Hydroxychloroquine, Remdesivir, Tocilizumab; Definition of the “high risk” patient; COVID-19 vaccine
• 36:50 Case of healthcare worker (HCW) with COVID exposure; How long can COVID live on surfaces? 
• 40:20 Do exposed HCWs without symptoms require quarantine?
• 41:30 Personal Protective equipment (PPE)
• 45:00 COVID-19 in pregnancy
• 47:30 COVID-19 and vulnerable patient populations (patients who are immigrants, homeless, incarcerated, etc.) 
• 50:45 Where should you get your COVID-19 information?
• 52:30 Closing remarks and outro

COVID-19 Pearls

Check out this great tweetorial by Dr. Travis Smith summarizing the key pearls!

A #Tweetorial #pearls recap of @thecurbsiders episode 200 on #COVID19 Update with @PaulSaxMD @BrighamSK @PaulNWilliamz @DoctorWatto Practical tips and discussion on transmission, testing, NSAIDs, ACE inhibitors, quarantine, treatment, and PPE https://t.co/z5B5y5QnCF

— Travis Smith, D.O. (@RosenelliEM) March 25, 2020

Coinfection is possible. We don’t yet know about reinfection, but Dr. Sax is optimistic that there will be some immunity. 

Patients with confirmed COVID-19 should remain in quarantine until afebrile for at least 72 hours and until at least one week after the start of symptoms .

SARS-CoV-2 can live on surfaces (fomites) for hours (cardboard) or days (on metals and plastics). It’s heavily dependent on the viral inoculum.

Hydroxychloroquine 400 mg bid for 1 day then 200 mg bid for 5-10 days is a reasonable option for patients admitted with COVID-19 and at high risk for severe disease.

Remdesivir and Tocilizumab are other early therapies that show some promise.

Pregnant women do not seem to experience severe disease and there doesn’t appear to be negative effects on the fetus, but we don’t yet have enough data (e.g. 1st trimester exposure).

COVID-19 Show Notes*

*NOTE: These show notes are not as comprehensive as our normal offering, but we wanted to rush this episode out ASAP.

SARS-CoV-2 / COVID-19 vs. SARS, MERS, and influenza 

• Note: SARS-CoV-2 is the name of the virus that causes COVID-19, the associated disease. 
• Is this like a bad seasonal flu? Short answer: No. COVID-19 is much more transmissible, and because its symptoms can be very mild it is harder to identify and therefore very prone to community spread. 
• It is a novel virus meaning the population is entirely susceptible as there is no existing immunity.
• Dr. Sax notes that the most striking difference is that the data so far indicates COVID-19 may be 5-10 times more lethal than influenza.

Review of epidemiology and limitations of current data

• There is a deluge of information in popular media and in the scientific literature. With a constantly-evolving pandemic, data is released frequently and conclusions frequently change or are updated based on new findings. 
• Drs. Ganatra and Sax point out that one must interpret early case studies and conclusions regarding mortality (Case Fatality Rate, “CFR”) with some caution, especially as studies tend to collect data on the most severe cases that may not be generalizable to the majority of patients. 
• South Korea’s data is a helpful point of comparison; it shows a high attack rate in young people and a lower case fatality rate (0.6-1%). 

Where transmissions take place

• We don’t know where most transmissions take place. Close contacts are at high risk, and data from China have shown that household transmission is very common. However, we do not have a complete picture of community spread given the lack of comprehensive testing. 
• Dr. Sax notes that in an ideal world we’d test everyone to gain insight into transmission, symptoms, etc. 

COVID-19 prevention and quarantining 

• Wearing masks in public–helpful or not? More effective for a sick patient to wear in order to reduce droplet spread. 
• Severity of symptoms/disease varies greatly. 
• Who should quarantine and for how long? Current CDC guidelines recommend waiting for symptoms to improve, including for 72 hours after fever has subsided, and until at least one week after symptoms began. 
• Incubation period for the virus can be up to 14 days, with most patients experiencing symptoms within 5 days. 
• When should a patient go to the hospital? If they start to recover, but suddenly get worse and/or if they report shortness of breath
• Recovering patients can continue to shed virus for a long time; unknown if this has clinical significance for virus transmission.
• We still face challenges from a lack of widespread testing, but the availability of inpatient testing is improving. 

COVID-19 Testing 

• Sensitivity/specificity: Depends on adequacy of specimen (nasopharyngeal swabs: for correct technique see Dr. Francisco Marty’s NEJM video here). 
• Dr. Sax is not too concerned about false positives at this time. 
• Coinfection with other viruses is possible (see this blogpost by Nigam Shah on Medium.com). 

COVID-19 Treatment

• NSAIDs–safe to use? In theory they could make the disease worse but there is not clear data indicating harm. WHO is not discouraging ibuprofen use at this time. 
• If Major Coryza recovers–is he immune or can he be reinfected? Uncertain, but cautiously optimistic that there can be immunity.
• To assess treatment efficacy, it’s best if patients enrolled in clinical studies.
• Hydroxychloroquine is being used. Some experimental data shows effectiveness. Dosing: Load with 400 mg BID for one day, then 200 mg BID up to 10 days (if better after 4 days, stop). 
• Lopinavir–ritonavir not effective. 
• Remdesivir may help and a Phase 3 clinical trial is ongoing https://www.clinicaltrials.gov/ct2/show/NCT04292899.
• Tocilizumab, used in some cases to reduce inflammation, works as an immunomodulator and is in clinical trials https://clinicaltrials.gov/ct2/show/NCT04317092. 
• Vaccine: A COVID-19 vaccine will not be available for at least a year.

Managing disease exposure

• COVID-19 is spread primarily by coughing/droplet transmission but can be spread by breathing and via surfaces (fomites). 
• Fomites: how long can it live on the surface? Shortest on cardboard (24 hours), longest on plastic (72 hours). However, the virus decays rapidly. 
• Quarantine procedures for healthcare workers who were exposed: depends on institutional policy. Dr. Sax notes that those with symptoms should not work. 
• The recommended PPE for standard encounters is droplet precautions: gown, mask, face shield, and gloves if a patient has confirmed or suspected COVID-19. 
• If doing any procedure that aerosolizes the virus (e.g. intubation, bronchoscopy, even specimen sampling), an N95 mask should be worn too and PPE gear switched to  airborne precautions.
• Surgical masks are effective barriers!
• Worst-case scenario: Something is better than nothing (e.g. scarf). Distance helps. Now is a good time to take advantage of telemedicine/virtual tools to avoid exposure. Don’t enter patient rooms unnecessarily. 

Other miscellaneous questions:

• What do we know about COVID-19 and its effects on pregnancy/lactation? So far, pregnancy does not appear to be a risk factor for severe COVID-19, but data is not robust. There does not appear to be any aggravated symptoms among pregnant patients, and no mother-to-child-transmission has been documented thus far. 
• Who are we not seeing in clinics/hospitals and what are their risk factors? Vulnerable populations include immigrants detained in ICE facilities, people who are incarcerated, people who rely on homeless shelters or are housing insecure. 
• The epidemic requires healthcare providers to assess patients’ social and safety net needs e.g. food security, utilities, housing–allows for identification of patients at elevated risk and can better target assistance and aid.
• How to stay current without being overwhelmed with info? Dr. Sax recommends science journalists Helen Branswell of STAT and Jon Cohen of Science. Many medical journals took down paywalls to increase accessibility of COVID-19 information. CDC, ACP, NEJM, BMJ, and hospitals at the center of the U.S. epidemic (e.g. University of Washington) have been sharing great information. 
• Look to South Korea and remain hopeful. Their model has provided hope for controlling this pandemic. The US is a country with resources. If we pull together we can do this!

Goals

Listeners will review the current research on COVID-19 including transmission, protection strategies, testing, symptoms, and basics of management.

Learning objectives

After listening to this episode listeners will know…

1. The basics of COVID-19 including epidemiology, prevention, transmission, and treatment
2. Where to find reliable data sources and how to interpret new studies with caution 
3. The importance of PPE and limiting disease exposure 
4. What drug regimens are recommended and what experimental treatments are available
5. The role of virtual visits, telemedicine and other non-traditional methods to reduce patient contact
6. Impact of COVID-19 on at-risk populations 

Disclosures

Paul E. Sax, MD, has disclosed the following relevant financial relationships:

Served as a director, officer, partner, employee, advisor, consultant, or trustee for: Bristol-Myers Squibb Company; Gilead Sciences, Inc.; GlaxoSmithKline; Janssen; Merck. Received research grant from: Bristol-Myers Squibb Company; Gilead Sciences, Inc.; GlaxoSmithKline; Merck.

The Curbsiders report no relevant financial disclosures. 

Citation

Sax P, Roberts SP, Chiu CJ, Garbitelli B, Abrams H, Williams PN, Watto MF. “#200 COVID-19 with Paul Sax MD”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. March 22, 2020.