COVID-19 Insights for Providers

Transcription:

Bill Klaproth: This Children's Health Coronavirus Podcast recorded on April 6th, 2020. As COVID-19 becomes a rising concern around the globe. We'll discuss the evolving epidemiology and clinical aspects of the virus, as well as public health measures designed to approach the situation. This is Pediatric Insights, advances and innovations with Children's Health where we explore the latest in pediatric care and research. I'm Bill Klaproth. With us to discuss COVID-19 insights for providers is Dr. Carla Garcia Carreno, Medical Director for Infection Prevention and Control at Children's Medical Center, Plano. And Pediatric Infectious Disease Specialist at PID Associates. Dr. Carreno, thank you for your time. First off, COVID-19 is a rapidly evolving situation and new information is being shared by the hour. Where can we find the latest information?

Dr. Garcia Carreno: The best way that we keep ourselves updated is by checking the CDC center for disease control and prevention page, and also as far of the numbers the John Hopkins University has a great dashboard that updates the numbers pretty accurate on all fronts. So those are the two places that I usually go.

Host: Okay, good information. And can you discuss the epidemiological and clinical features of COVID-19 and how they are evolving?

Dr. Garcia Carreno: Certainly, as you said, that epidemiology is constantly evolving, when pandemic processes are described the growth curve includes an initiation phase, a growth phase, which is usually exponential, a plateau, and finally a deceleration phase. With COVID-19 right now, we're talking about a pandemic disease in the acceleration of exponential growth phase in many parts of the world, especially now in the US we're in that phase. In Texas, it's in that phase. The doubling time has been estimated to be around five to seven days and the reproduction factor, meaning how many people will get infected from an index patient is estimated to be two to three. So each individual that has infection may spread it to two to three additional people. But as part of the epidemiology now, clinically it has been described to cause a wide range of disease from asymptomatic, meaning no symptoms at all to mild, moderate, and severe disease. The symptoms describing fever, cough, shortness of breath, sore throat, myalgia or muscle pain, headache and nausea and diarrhea and vomiting. And uncommonly that in adults, but has been reported in children, upper respiratory congestion. This severe disease has been mostly seen in the elderly population and those with underlying conditions that predispose to severe disease, including diabetes, heart disease, immunosuppressive conditions, chronic lung disease, and chronic kidney disease. In severe cases, pneumonia, ARDS or acute respiratory distress syndrome and respiratory failure are linked with an elevated morbidity and mortality.

Host: Wow. So people present with a variety of symptoms and obviously those with underlying conditions certainly are more at risk. So you were talking about the different phases, growth, plateau, decline. We're kind of in growth right now. How does COVID-19 spread?

Dr. Garcia Carreno: Yeah, so it is a direct respiratory pathogen, right? So respiratory pathogens spread via the respiratory route, mostly by droplets and by contact with surfaces or fomites contaminated with these droplets. That's why we recommend the added precautions in the healthcare setting, of using droplet and contact precautions with eye protection. So what are the respiratory droplets? There are large medium size drops that will fall to the ground within a six feet distance, cause the rationale for the social distances more than you know, six feet apart. There are certain cases where we perform aerosol  generating procedures like intubating a patient or noninvasive ventilation or giving localized treatment or bronchoscopy, suctioning, among other procedures. In those cases, these bigger droplets can be broken down to a smaller particles called aerosols. These are aerosols are tiny particles that can remain suspended for a longer distance and a longer period of time. So this is how tuberculosis and measles spread. So it's only recommended that healthcare workers are performing these procedures that we need to take isolation with airborne precautions, meaning being put in the patient in a negative pressure room and use of respirator, or like an N95 and so those masks need to be reserved for these aerosol generating procedures. So that's why it shouldn't be using the community. That's not the way COVID-19 spreads. Now when you take the respiratory sample for diagnosis in the clinic or the hospital, then you may also in use cough and sneezing, which may produce some aerosol. So it's also recommended that you wear an N95 on those circumstances.

Host: Right. Those N95 masks are critical for healthcare workers. So let's talk about testing for COVID-19 what specific test is needed to detect COVID-19 and what is the criteria for testing?

Dr. Garcia Carreno: Sure. So the diagnosis of COVID-19 is by detecting the vitals. The vitals that causes COVID-19 is called SARS COVI 2, SARS Coronavirus 2. And the diagnosis of that is by detecting these vitals by real time PCR. So you collect the respiratory sample, you perform the PCR, and the recommended respiratory sample at this time by the CDC, The Center for Disease Control and Prevention is a nasal pharyngeal swab, which is the swab from deep in the nose. When you reach the nasal pharynx. Now if you can not get that sample there are other respiratory samples that can be sent, like an oral pharyngeal swab or a lower respiratory sample, in case you collect it for some other reason. But in general, the nasal pharyngeal swab is the one that's recommended and that PCR is available at the CDC, certain public state health departments, including Dallas Health Department, commercial laboratories and certain institutions. Bill now has an in house testing, meaning that they have the PCR in the hospital.

The criteria for testing has evolved depending on the epidelogic circumstances. Currently since the US is an area or widespread community transmission, the travel history that used to be irrelevant recently is not relevant or is less relevant at this time. So clinicians, judgment needs to be considered. If the symptomatic patient has had a contact with a patient diagnosed with COVID-19, then this patient should be considered as a potential patient on their investigation, what we call PUI. So what the CDC is doing right now is they're prioritizing which patients need to be tested first since we don't have only limited availability of testing. And so the CDC says that the priorities are those suspected patients that would be hospitalized, symptomatic healthcare workers, and those patients with high risks of complications as we were mentioning, the elderly and those with underlying conditions. So those are the main groups that we need to concentrate our testing efforts.

Host: Right. And testing is very, very important and will be as we continue on through this pandemic, certainly through decline and after as well. So let's talk about treatment right now. Can you talk about the different clinical treatment methods that are being researched for COVID-19 as these treatment methods are becoming very important as well?

Dr. Garcia Carreno: Right. So right now we don't have anything that has been proven completely to be helping. We have a lot of clinical trials, but at this point, supported treatment is what is recommended. So I'm going to walk you some options that we are starting in the US right now. Remdesivir is a nucleotide analog that has three clinical trials at the NIH, the national Institute of health at this moment, but it's a phase two double blind randomized placebo controlled trial, in that our two phase three open label trials, so this is the medication that has been shown more promising in certain reports from China. And they also had had China randomized clinical trials. There is another medication called hydroxy chloroquine, that's what you've heard in the news a lot. Is a anti-malarial and an anti autoimmune medication. It's also being studied in clinical trials for pre-exposure and post exposure prophylaxis as well as treatment of mild, moderate and severe disease. However, we need to be careful with this medication because there is some concern for cardiac arrhythmias for long QT syndrome, and the cardiac rhythm needs to be closely monitored.

More study in France that use this combination with Azithromycin showed also some biological advantage, but this study was not randomized and the groups including the control group was not well defined, so I will be careful to interpret these studies. There was also a fairly big study in adults with Kaletra or lopinavir which is used for HIV and that study did not show significant benefit in China. Nowadays there is something also the option of plasma, using plasma from convalescent patients. So those patients that have recovered fully from COVID-19,14 days after they recover you can take their serum and use it to treat patients with severe disease. This is being considered by the FDA and could be evaluated on a case by case basis through participation in clinical trials or potentially by using an emergency investigation. And last year, as you know, the vaccine is also coming along. It's been trial in certain volunteers, but that has several phases in the study and we wouldn't have a vaccine available for 12 to 18 months, unfortunately.

Host: And we are all pulling for those researchers who are tirelessly working on treatments and vaccines. Dr. Carreno, can you also talk about how healthcare professionals are approaching care for COVID-19 based on current clinical descriptions of the virus and the fact that at this time there is no official treatment?

Dr. Garcia Carreno: So as you mentioned there is no official treatment. There is nothing that has been shown in clinical trials to be beneficial yet the trials are ongoing. So right now what we have under our plate is to provide supportive treatments. This is what is indicated at this time providing oxygen when it's needed and more advanced respiratory support depending on the circumstances. It is also really important to point that for healthcare workers practicing all infection prevention and isolation procedures in the healthcare facilities is key also to protect other patients and to protect our healthcare workers themselves. So basically supported treatment, what we have available at this time.

Host: Supportive treatment. Got it. So then you just mentioned isolation procedures. Can you describe the current prevention measures that are being practiced for the COVID-19 pandemic and how they are constantly evolving?

Dr. Garcia Carreno: The most important preventive measures are the public health interventions that include mitigation processes. I'm going to talk first in the community and then I'm going to tell you the hospital, what we're doing. So at times when you have widespread community activity of the disease, like it's happening in many places in the US containment becomes more difficult. And what is containing is identifying sick individuals and the contact tracing of those sick individuals. So right now because of the many patients that are infected, that's not reasonable anymore. So what we're doing now, are mitigation strategies. These mitigation strategies include social distancing, the shelter in place as is being recommended. In this manner, we might not decrease the total number of cases, but we can certainly flatten that curve. So this number of cases will occur in a longer period of time. With these, we can assure that we will have the resources in the hospitals to take care of the COVID-19 cases included the so much needed bed, so much needed ventilators and of course available personnel, protective equipment or PPE.

So we usually tell the community and also pediatricians need to continue our job of educating parents or family members that we need their help for social distancing. It's also important that people know that they should stay at home, only leave the place for a special activities, not going out when sick only to seek medical care and those facilities we need to be called in advance for the medical care if possible. And then practice all infection prevention measures, which include the frequent hand washing for 20 seconds. I know it looks like a very rudimentary tool, but that's very important at this point. Cough and sneeze etiquette and cleaning high touch areas as well once a day at home. Now are they using masks in the community is now recommended by the CDC that we can consider using masks, including cloth masks. But we need to prioritize the medical masks available for healthcare workers and those frontline personnel taking care of sick people. The masks mostly protect, all of them from getting sick with what we call source control. And protecting the person wearing the mask. And that person wearing the mass should be overly conscious of not touching the face frequently while wearing the mask because that tends to happen a lot. Currently use of cloth masks is not recommended in the healthcare facilities. We still need to prioritize the medical masks for the healthcare facilities.

Host: And as you talk about flattening the curve, helping to conserve resources in hospitals, can you talk about the current strategies that are being put in place to optimize hospital supplies?

Dr. Garcia Carreno: So shortness of  supplies, especially protective equipment or what do we call PPE is definitely a challenging situation that many hospitals worldwide. I mean the US are currently facing. Many institutions in anticipation for the situation and knowing that we may not restock, whatever we use anytime soon, we have different strategies for conserving that PPE or personal protective equipment. So the first step of that is by decreasing the need of use of PPEs. So what the hospitals are doing are rescheduling or postponing non origin basis on non origin surgeries and procedures as that, those particular procedures, we'll use additional PPE that otherwise we need to save. We also have decreased the number of staff visiting a patient and again to salvage that PPE available. We're implementing use of telehealth instead of personnel basis so we can address people's concerns and many of the questions can be addressed by telehealth rather than having the patient visit the healthcare center.

So that's what we're doing for decreasing the need for PPE. On the other hand, what we're also using is maximizing the use of available PPE. This includes things like extended use of PPE, what I call the head PPE, so the head PPE, the mask and the eye protection that is recommended to take care of these patients. So if you, for example, put your COVID patients all in one word or one wing of the hospital, you could walk from room to room just wearing the same head PPE and not needing to change that. So that's what we call extended use of PPE. Also certain institutions are also evaluating about reuse of PPE and decontaminating the mask. So for example, the goal was can be wiped down after you're done and preferably if you use it for the whole shift, then you take it out and you clean it, being very careful. And then the masks, the N95 masks are in many situations are being re collected for decontamination. So we can use it several times. So several institutions are decontaminating this masks.

Host: So let's talk about children for a minute. I know many parents are worried about this. What do we currently know when it comes to the pediatric population and COVID-19?

Dr. Garcia Carreno: Well this is probably a silver lining in all of this situation, in general COVID-19 has been described both less frequently in the pediatric population and less severe than in adults. The cases serious have reported that from all the cases, one to 2% of cases affected children 19 year old and younger. These have been reproduced in reports from China, South Korea and Italy. So as I was saying, not only by numbers but also that this very, they have been less than in the older population and there is a big chance that many of these kids may even be asymptomatic. So the symptoms that have been described have been seen in in topology, but also they have more other respiratory involvement than adults and more congestion than the lower respiratory manifestations that adults have. A story from China, which is found in the pediatrics journal, showed that from 731 confirmed pediatric cases, critical DCs that they define of ARDSM or acute respiratory distress syndrome, respiratory failure and shock, record only in 0.4% of the cases. So way less than the adult population. A study of nine infants younger than 12 months of age hospitalized in China reported no need for intensive care unit admission or ICU admissions and no need for mechanical ventilation. So, so far this is what we have seen and in the United States that has also been seen in Texas, the number of cases in less than 19 years of age have compromised 0.6% of all the cases.

Host: Well that is good news to hear those numbers. So thank you for sharing that with us. That's for sure. So lastly Dr. Carreno and thank you so much for your time. Do you have one main takeaway for healthcare providers about COVID-19?

Dr. Garcia Carreno: Definitely I would say. I mean these are stressful time when we worry about our patients. We worried about ourselves and our families. So we need, one of the most important points is that we need to stay informed of both epidemiology and the recommendation for care of these patients. Knowing and having that information will make us more objective thinkers. We can do it as I said by regularly checking the CDC web page the Center for Disease Control and prevention as we were mentioning. Also other sources include the WHO, World Health Organization and our local state department pages because we will know what is happening in our community. It's also really important to read from trusted medical sources and we need to be careful as many publications right now are being put out before peer review is completed because they want to make all their medical community to have these information available as soon as possible, but we need to be careful with what we read. So being informed will help us think objectively, as I was saying for our patients. It is also equally important to take our time and practice good infection prevention precautions, including the appropriate use of PPE, it's really important that we don't rush in to see a patient but take all the proper steps for putting on our PPE and for taking off our PPE that is already contaminated and then hand washing as we were mentioning, the very old medical tool for infection prevention is critical in these challenging times.

Host: Well, that's the perfect way to wrap it up. Dr Carreno, thank you so much for your time. We really appreciate it.

Dr. Garcia Carreno: Have a good day.

Host: That's Dr. Carla Garcia Carreno, and thanks for listening to Pediatric Insights. For more information, please visit childrens.com/COVID-19 and if you found this podcast helpful, please rate and review or share this episode and please follow Children's Health on your social channels. This is Pediatric Insights, Advances and Innovations with Children's Health. Thanks for listening.