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Could echocardiography changes be recognized earlier than the severity of symptoms clinically recognized?
- It is possible. Echocardiogram typically has been done after onset of severe symptoms but don’t know for sure.
- There was a study published about subtle changes, but not totally aware of pre-monitoring of echos.
Do you know what the oldest age this syndrome (MIS-C) has been seen in?
There were some cases of people in their 20s with a very similar syndrome. The case definition goes up to age 21 but time will tell about if it is in fact MIS-C.
Do you think that we have a better understanding of the prevalence of MIS-C in children globally?
Probably have a better understanding than we did several months ago. Some of the milder cases may be going unrecognized so it is suspected that there are more than reported.
Have there been fatalities from MIS-C?
- Yes rate of 1-1.5%, which is notably higher than the deaths from native COVID-19 infection.
- Profound disproportionate mortality rate in minority children who have died.
In young adults post COVID, is there more depression, fogginess, and feeling off?
There has been some literature about the long-term rehab that is needed. Again, depends on how severe your illness was. Elderly are more severely impacted and may not bounce back as quickly. Rehab physically and mentally may need to be done, but there is no percentage that can be confidently stated for now.
Can you explain why high doses of PPI may increase the risks of SARS-Cov2?
Not seen this association so cannot respond confidently on this question.
Is it clear that superspreaders are such because they have a high viral load or is it because they are in a superspreading setting, eg: indoor settings, prolonged time, multiple people?
From a public health standpoint, someone’s ability to be infectious, there will need to be more research on viral load. Higher viral load certainly leads to higher spread. It is multifactorial so being in close contact, or not following the public health recommendations of physical distancing or mask wearing.
Has there been any correlation with migraine headaches after COVID infection?
Not quite sure but there are certainly symptoms of fogginess or confusion. Anecdotally, particularly in children the symptom was a headache. However, we are still learning.
When is the right time to contact the physician?
Currently, we’re in a public health crisis and the plans right now – that are everchanging – are in place to care for those at high risk and try to mitigate the spread.
Not everyone needs to be tested for COVID-19. Here is some information that might help in making decisions about seeking care or testing:
- Most people have mild illness and are able to recover at home.
- There is no treatment specifically approved for this virus.
- People can utilize the drive-thru testing sites. We want people to avoid emergency departments and away from other people if possible.
- If you have symptoms of severe illness and are a high-risk individual, you should seek medical care in an emergency department.
Should people in rural areas without instant access to drive-thru testing sites be encouraged to drive farther to get that testing done or stay home?
Unfortunately, this is a hardship for those in rural areas. Testing sites are expanding, so hopefully there will be a closer site to those rural areas.
Is there information about protecting those with long-term respiratory illness?
Quarantining is key! Social distancing will help protect these high-risk patients with long-term illness.
Any suggestions on how we can we help children at heightened risk of abuse, neglect, exploitation and violence amidst intensifying containment measures?
Healthcare professionals are encouraged to screen for this more at this time over telehealth and phone. Foster families are being moved to TeleVisits. There are also resources on how to cope with stress during the COVID-19 outbreak.
What is the overall consensus for outpatient clinics that separate symptomatic and asymptomatic patients? What is the recommendation for mask/glove/eye coverage for outpatient clinics that are seeing only asymptomatic patients?
It is hard to gain consensus, but if possible, it is preferred to see all patients at this time in at least a basic layer of PPE – basic mask, gown, goggle. Those seeing patients with symptoms and COVID-19 screening should be in a more advanced PPE.
Triaging and separating patients to assure symptomatic and asymptomatic patients aren’t in the same environment is considered best practice at this point in time.
Do we have a titer test to see if a person has had the virus?
Under development – hopefully these will become available soon. We are working on an ELISA (enzyme-linked immunosorbent assay, also called ELISA or EIA) which is a test that detects and measures antibodies in your blood. This test can be used to determine if you have antibodies related to certain infectious conditions. This test would be rapid and helpful to the community and to healthcare professionals. There does appear to be an immunity but there is no certainty about this yet.
Is a homemade mask effective?
Homemade masks are not as effective as medical grade masks.
There are agencies trying to help with the shortage like the schools of Engineering faculty and students who have been working to fabricate reusable 3D-printed face masks for medical professionals in locations where personal protective equipment (PPE) supplies, such as N95 masks, have been depleted by the sharp increase in patient numbers due to COVID-19.
There are FPS and FNs associated with some of the recently EUA tests due to the sample types and sample size. What are the confirmatory tests for validating the discrepancies?
Molecular test and false positive and negative is relative to which test is being performed. Confirmatory assay has not been established, would be next generation sequencing. False positive and negatives can be repeated if concerned.
Can you speak to the risk specifically for persons with HIV and persons with autoimmune disease an on immunosuppresants?
People with HIV who are well controlled are most likely no greater risk for COVID-19. So far, their clinical outcomes have not looked much different than anybody else’s.
How do those of us in the community access testing at Ruby?
Ruby testing is designated for Ruby facilities. In the community if you are symptomatic and want to be tested, then it is suggested to contact Ruby command center COVID-19 hotline. If symptoms are severe enough then you can come to the Emergency Department to get tested. There are a number of communities around the state with drive through testing as well.
How soon do you anticipate having antibody testing?
Technically there is testing now but the validity of it has not been assessed yet. Timeline for an assay coming out of Ruby is a good month and a half. Currently in communication with manufacturers for a relevant serological assay.
Any comment on the effectiveness of homemade fabric facemasks for using over N95?
- Making homemade fabric facemasks are recommended that it is with 600 thread (hold piece of fabric up to bright light and if you can see holes in it is not optimal) – should have multiple layers (4-6)
- Cloth masks are overall very different than N95 masks and not for the frontline healthcare workers. CDC recommended that homemade fabric facemasks are for those who are asymptomatic.
The phenotypic characteristic of symptoms tend to vary from state to state and country to country. In WV, over 53% of those tested (+) are under 50 years, what are your assumptions for such variations?
The clinical data emerging from US has much more commonality than differences with other countries like China and Italy. Mortality rate has been very different in countries, however. We still do not understand all the reasons for that so it will be interesting to see as this evolves. Earlier data would suggest there are differences.
Thinking of the deaths, and funerals, is this still contagious after the person dies with it?
Human body that passes away still has the ability to act as a fomite. Virus is viable so there are strict policies on how to handle patients passing and testing them before passing just to verify and protect the community.
Could you clarify the discussion of ones on BP medications having a higher issue with COVID-19?
The American College of Cardiology recommends patients not to be taken off ACE inhibitors and ARBs because of the connection with the COVID-19 virus. Hypertension is found to be much more common than any of the other comorbid conditions. No definite recommendation on taking patients off any medications, it is still being under review.
SD Biosensor Point-of-Care antibody test -- what are the sensitivity and specificity? It says that the test may be positive for some other viruses, so what is the appropriate way to deploy these, either for asymptomatic or symptomatic or previously symptomatic people?
One of the bare minimum requirements for Ruby’s laboratory to pursue serological assay is attempts at pursuing the EUA validation process. SD biosensor chose not to do that and to manufacture an assay with a minimal verification/validation approach. The package insert indication that there may be cross-reactivity with other viruses is exactly that. The beta coronaviruses or potentially even the common alpha coronaviruses or flu that are circulating could potentially create a cross-reactivity.
I have a general COVID question: What criteria are other hospitals looking at as a benchmark of when it will be OK to restart outpatient services? Testing? Treatment improvement? Number of cases declining?
Currently (4/16/20) cases are still on the upswing
There isn’t any excellent information on treatment or widespread availability
What is the availability of diagnostic testing and the Turn around time on suspected or symptomatic patients?
We have a severe lack of widespread diagnostic testing. We are definitely missing a lot of cases, and we are having trouble getting the results back in an appropriate timeframe.
Do you foresee any role for the rapid IgG/IgM testing, like Cellex, in the Family Practice clinic setting?
Short answer – Yes. The FDA has approved three more tests similar to Cellex, and others are available through the emergency use authorization. Practice caution with the serological testing – but a combination of serological testing and PCR based testing is critical for moving into ‘phase 2’.
If a N95 mask is not compromised, how many times would you recommended reusing and we have been told to cover with a regular surgical mask to last longer.
It is better to use a face shield instead of a surgical mask over N95.
In this current non-standard clinical care state prolonged use is preffered over reuse (keeping it on and not touching face/N95 is better than donning/doffing). Stop use when the mask becomes compromised.
And also after doffing how would you recommend storing until next use?
Simple storage is fine as long as it’s closed. A clean paper bag would work even.
What about direct sunlight or UV light to sanitize the N95?
“Decontamination methods tested included vaporized hydrogen peroxide (VHP), 70-degree Celsius dry heat, ultraviolet light, and 70% ethanol spray.
All four methods eliminated detectable viable virus from the N95 fabric test samples. The investigators then treated fully intact, clean respirators with the same decontamination methods to test their reuse durability. Volunteer RML employees wore the masks for two hours to determine if they maintained a proper fit and seal over the face; decontamination was repeated three times with each mask using the same procedure.
The scientists found that ethanol spray damaged the integrity of the respirator’s fit and seal after two decontamination sessions and therefore do not recommend it for decontaminating N95 respirators. UV and heat-treated respirators began showing fit and seal problems after three decontaminations — suggesting these respirators potentially could be re-used twice. The VHP-treated masks experienced no failures, suggesting they potentially could be re-used three times.
The authors concluded that VHP was the most effective decontamination method, because no virus could be detected after only a 10-minute treatment. UV and dry heat were acceptable decontamination procedures as long as the methods are applied for at least 60 minutes. The authors urge anyone decontaminating an N95 respirator to check the fit and seal over the face before each re-use.”
Is there a protocol for testing after a positive result??I spoke to a member today and she tested positive and was in hospital, is now home, and was told at d/c she would need another test but the health department is telling her no.
It depends on the situation – there is a clear protocol for healthcare workers (2 negative tests greater than 24 hours apart). In a non-healthcare worker situation persons should only be retested if the result would change the behavior or management of the individual situation. Everyone should consider re-testing on an individual basis.
Can anyone speak about shedding COVID after recovery? Still able to spread it?
We do not yet know about the transmissibility of this virus even though there is presence of positive of PCR testing.
I have heard several people, including physicians and nurses, say they 'are sure' corona virus was in the US/WV before February. This morning there was a report in the NYT about two cases in Santa Clara Co, California that have been determined by autopsy to pre-date the first cases in Washington State. Could there be any truth to these rumors that the virus was here much earlier? I tell people it was more likely flu. It seems if it had been COV-2, things would have been much worse much sooner. How can we know?
Certainly is possible that there is truth behind these rumors. Especially when dealing with a new virus (one that can present as asymptomatic or similar symptoms as the flu) and global travel.
Knowing the earlier studies on COVID-19 showing a higher vulnerability of older populations, why didn’t we protect the nursing homes and SNFs through a stronger mitigation plan?
Nursing homes were the first step taken in the state. The industry was very proactive in this. Before any first cases in WV and before any social distancing measures, nursing homes were first to implement CMS guidelines and strict visitation.
What about recombinant antibodies? Are they the same theory as the convalescent plasma?
This is plasma obtained from patients who have already been successfully treated for COVID-19. So, hopefully there are specific antibodies generated against COVID-19 virus. We don’t know if just having generic antibodies are helpful.
I’ve had many patients ask me if they should take vitamins to boost their immune system but because of the cytokine storm, what should I tell them?
These are all anecdotal evidence. Nobody knows if these really work in this situation. It does not hurt to take vitamins but there is no evidence that it will prevent COVID-19.
Should older patients with chronic diseases consider low dose aspirin as prophylaxis?
There is no evidence that aspirin helps in anyway.
How are nursing homes currently planning to handle post-rehab patients with respect to COVID-19 testing? Do we have testing capacities to handle the volume of these patients to be transferred from the hospitals to the nursing homes?
There is a CMS recommendation that an individual be tested and have a test transferred back to a facility. Several policies in long-term care facilities are looking at that. What’s most important is that the facility has the ability to manage the patient if they have an unknown status. This is a tough issue/area and we want to avoid introduction of COVID-19 in these facilities while still keeping care going. Emphasizing the ability to isolate individuals for 14 days to assess to make sure they are not developing any symptoms.
I had some questions about pulmonary function and sleep lab testing/requirements/ suggestions… Could you touch on some options that may be available for operation moving forward – cautiously of course? There hasn’t been much guidance put out, and we’re anxious to get some information.
This is not a well described area surprisingly – however, in general it is seen as an aerosolizing procedure. Most of the equipment have filters and are disposable. Right now we are working how we want to reopen the current C-pap lab. Sleep lab is broken down in a lot of pieces but the part to be concerned is the C-pap titration. The rules have changed a little about that – can approach anything that aerosolizing in one of two ways, and that is either: 1. Lots of PPE or 2. Pre-procedure testing. Trying to test patients a day or two before their C-pap titration to manage that as an issue for the C-pap lab. There is no guidance.
Regarding Dr. Krupica’s didactic on 5/7/20: How do we know who the team is in our regions? Can you send out a list?
We do have that list and can work with the WV healthcare association to disseminate that. Trying to determine the best way for everyone to have access to that information. There is representation in several academic centers in the state and are paired up based on the epidemiological region.
Any thoughts on how + cases in child care centers should be handled. Should they perform retesting on these child care providers in a location where they did have a + worker? Currently, one of the Child care centers that had a + employee plans to reopen Next week and no retesting of employees has been recommended.
- Regarding the child care center - it will likely be a case by case basis and as Dr. Krupica indicated there needs to be lots and lots and lots of communication with many parties. Specifically, there needs to be discussion with the local health department and subsequently with the state. It would depend upon when the worker tested posted, the contacts to that person, and what type of PPE was being used as a list of few areas needing addressed.
- The Bureau for Public Health will be releasing guidance on Daycare facility outbreaks within the next couple of days that should also help.
Could someone comment, if we know, about plan to phase in dental clinics? Many are closed, and patients are seeking care through primary care offices rather than DDS, and I’ve not heard anything specific about plans for this sort of care.
- At least one of the private practice dental offices in Morgantown is now open, including for routine cleanings.
- Some locations are opening back up on May 11th, 2020
- Timelines for each practice are different
Mathematics question: Can you discus how the R0 changes for a given virus? Is this related to social distancing measures or are there innate viral factors that affect the R0?
The short answer is: both. The natural history of a virus without any intervention gives you a particular epidemic curve. However the last few weeks, there have been several human interventions that occurred (i.e. social distancing, stay at home, etc.) and that does change the R0. There is a group for the state of WV that is continuously looking at that and how to keep it below 1. There are human factors that alter the R0 of the disease pattern. There are also viral factors – viruses are amazingly poor at always replicating accurate. Viral replication produces errors. Some of these errors may produce a virus that is more infectious or less infectious. There has been a lot of data trying to track different viral strains in different geographic regions. So yes, human factors and viral factors can both play a role in changing the R0.
Do you think pediatric cases are under-reported as most children being seen in outpatient setting wouldn’t meet testing criteria?
Tough question but in the inpatient setting, there have been broad testing criteria. In the beginning, we were testing any child admitted with fever. But this is a more acute scenario since it is inpatient. As our testing capabilities expand in the state, I think we will see more pediatric patients being tested. This question would probably be the same for adults based on CDC strategies/recommendations.