Mar 24, 2020
In this podcast, Dr. James Currie, an Infectious Disease Specialist and Internist with Lakeview Clinic, discusses the current COVID-19 pandemic, it's origins, where we are at of March 20, 2020 (the date of the podcast recording), and how we will continue to daily activities during the pandemic.
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Hello everyone, and thanks for turning into this special Ridgeview Podcast CME Series. COVID-19 continues to emerge onto the scene here in the state of Minnesota, and the U.S. in general. We have Dr. Jim Currie today, who is a blue grass musician, but his day job is an infectious disease specialist and internist with Lakeview Clinic, and here today to discuss the pandemic, it's origins, where we are at as of March 20, 2020 (the date of the podcast recording); and how we will weather the storm. Dr. Currie has special interests and experience in all manner of infectious illness, and a special interest in chronic viral conditions, HIV and more. As we will learn, it is a time to prepare, and not to panic. Let's keep the faith in our system and continue to advocate for more and better preventative strategies, and other needs that we on the frontlines will have, as well as what our patients will need to stay ahead of this pandemic.
Welcome, and enjoy the podcast with Dr. Currie.
Coronavirus includes many different viruses. They look "crown-like" under an electron microscope, which is where "corona" comes from. Most of them cause symptoms consistent with the common cold. In the last 10 years, some have caused serious illness, such as SARS-Cov-1. This current virus, SARS-CoV-2, or COVID-19, tends to cause more serious illness as well.
It is thought that this virus originated within a bat, but as Dr. Currie states, viruses are everywhere, including different species of animals, the water, and the soil among other places. There is evidence that viruses may have existed on earth when there were only single celled organisms present. In the traditional sense, viruses would probably not be considered life forms.
Present iteration of this virus started in Wuhan, China, and for reasons unclear, has spread easily to humans from an original host, and amongst humans with relative ease. The predecessor viruses, such as MERS, and H1N1 are also very aggressive, but did not spread as easily as this new coronavirus, known as COVID-19. Viruses are dependent on living cells; they insert their DNA (or RNA) into living cells and more viruses are made within these living cells. And in this virus's case, the spread happens via respiratory secretions.
We do not have enough data on this virus in terms of ease of transmission, but it's safe to say it is somewhere in the spectrum of influenza and chickenpox, for instance. We fortunately have a lot of information about this virus, but we still have much to learn.
Presently, there is an L and S type of COVID-19. And it is certainly possible that this virus has mutated already, and that there were always two subtypes. And further mutations can happen, but we do not yet know how quickly this virus mutates. Mutation can yield more virulent and less virulent virus types, which is important to remember. This is an RNA virus and it theorized that some of the reverse transcriptase inhibitors may be useful in treating this, but this hasn't played out yet. From a political and governmental standpoint, HIV research and treatment was a lesson we can learn from with this virus. In other words, funds and energy must be diverted to research, prevention and treatment for this and future similar viruses.
So what about PPE (personal protective equipment) and reuse of masks, in particular the N95. Well, whenever possible, the mask should be disposed of between patients. However, there are actual guidelines for N95s that stem back to the H1N1 outbreak, as there were shortages then as well. So recommendations for reuse were derived from that. If the mask is not soiled or damaged, and the mask has been handled well, in other words, gloves to apply the mask and not touching the inside of the mask. A surgical mask over the N95 when treating COVID-19 patients. After seeing the patient the N95, should be placed in a breathable receptacle, such as a paper bag. If gong (immediately) from one COVID patient to another, the mask doesn't need to be removed.
Why are the elderly so much more severely affected? Well, age may have a lot to do with it. This particular virus has a significant effect at the level of the ACE2 receptor. Is this upregulated by nonsteroidals? Possibly, but there is no firm data or recommendation right now to take or not take these medications. But the ace2 is found in large quantities in the pulmonary vasculature, so it is theorized that much of the severity in pulmonary symptoms is due to what's happening here.
Incubation of this virus is about 4 days, and initial symptoms include non to mild URI symptoms and fever. Progression to serious illness occurs 7 to 9 days after you initially become symptomatic. But there is of course a spectrum in severity that seems to align with the spectrum of age of the patients whoa re infected. And to date, we don't know fully what's so special about this virus that would explain such drastic differences in severity and outcome. But it's suffice to say that people who are multimorbid with chronic lung disease, diabetes, and/or advanced age seem to be more predisposed to severe illness.
Coinfection of influenza with COVID-19 is not well known right now, but in more severe illness with influenza, there is easier facilitation of co-infection because of the presence of influenza. Each patient scenario and clinical syndrome will be different and perhaps broader testing can be done as those test kits become available. Is the test for COVID-19 accurate? What is the sensitivity and specificity. The OP swabs are known to have a lower return rate than the NP swabs. We don't know the exact sensitivity and specificity of these tests yet, because we have not done enough of them, but they are assumed to have high specificity and moderately good sensitivity.
What are we supposed to do when we are tested therefore and our test is negative? 2 weeks of quarantining to go on even after a negative test. It's plausible that when symptoms are vastly improved or gone, that one could go out and continue to social distance. With a positive test, or symptoms and concern for exposure, the minimum of 2-weeks of self-quarantining is the current recommendation. What is not known exactly though yet, is how much longer we should be quarantining patients beyond that, and how will we know when we are officially no longer shedding virus. PCR testing availability is not yet ramped up in the U.S. on the date of this recording, but we also have not employed serology testing for this in order to tell who has been exposed and who is actively still likely contagious. Common sense prevails still, and adherence to social distancing in all cases, and of course home isolation and quarantine if you have symptoms, tests pending, and exposures to know COVID. And until we massively screen the population to know who has it and who had it, such as in the case of serologies, we won't have a firm handle on the scale of this particular outbreak.
Again, once symptoms have kicked in, we expect to see congestion, fever, cough, essentially URI symptoms. But the pneumonia and severe, even ARDS end of the spectrum is also seen. And the CXR findings may include patchy, interstitial, ground glass appearance, classically scattered in the periphery of the lungs. However, other findings can be seen as well, yet lobar consolidation is still most consistent with CAP bacterial pneumonia, CT has been noted to better detect the subtle pneumonia changes in the lungs, but it's use on a broader scale at this time is not recommended, at least here in the U.S. Remember, CT has a lot more rotation, and even if we pick up abnormalities, many of those patients test negative for COVID-19.
So, we have these hospitalized patients now, and what are we to do in our hospitals? We definitely will be isolating or cohorting our respiratory patients into one particular area of the ED and hospital in general. This will be a fluid process of course.
Identifying who potentially has the disease, for instance in Korea (South) and Singapore, in addition to isolation techniques, very aggressive case finding techniques including PCR testing but also merely checking temperatures, thus helping to enforce isolation and staying out of the public settings. IN Korea and Singapore, for instance, there was much better compliance with the above prescribed preventative measures. Indeed there are regional differences with this outbreak, and are likely due to adherence, resources and cultural differences throughout the world.
Pregnancy and COVID-19 at present has a lot of unknowns. We do not know of vertical transmission at this time, and we do worry about the potential for more severe illness given a mildly immunocompromised state, however thus far, based on the Wuhan experience, there is no data to suggest that pregnant patients will have amore severe course of the illness.
Most hospitalized patients in China, Italy, and elsewhere are inpatients for 7 to 10 days. Although it's not likely that treatment with oxygen at home or a SNF (skilled nursing facility) will not likely be implemented; because the progression of respiratory symptoms and shortness of breath to respiratory failure can apparently happen quickly, and these patients need to be in a medically supervised setting. PCR retesting to determine when someone is not infectious can not be done, as the test will remain positive. If ongoing fevers, of course one should not return to work, school, or otherwise. The jury is till out as to when one can go back onto society after symptoms resolve. In general, there's just not enough data yet to guide us in this. In general, at least a week after symptom and fever resolution may be appropriate, per Dr. Currie, but in Wuhan, for instance, these patients continue to be in quarantine, to the best knowledge for several weeks or more after resolution. Again, we just don't know yet.
Well, this is a pretty easy chapter to summarize. We basically have no specific treatment for this virus yet. COVID-19 trials are under way with chloroquine, and we will need to contact those trial centers to see if it is proving to be effective. Remdesivir could perhaps be used in a compassionate plea use of this and other drugs can be done, along with a lot of paperwork before, during and after treatment. Again, we will see if this is an option, but right now e have do data to go off of, especially in an off-label use. A recent trial was published with lopinavir-ritonavir, which is remarkable in such a .short period of time. It was from China and was unfortunately not shown to be helpful. Preventative measures, outside of maintaining good overall health, have not been shown to be helpful. Vitamin D may theoretically be helpful, but again, no data yet. Steroids have no use in the treatment of COVID-19. No data et either exists in terms of taking patients off of the ACE inhibitors or ARBs. Right now, we are left with conservative measures, fever control, hydration, oxygen and more advanced inpatient support for severe infection, up to and including ventilator and ECMO use. This is a moving target. Panic is not the order of the day, and staying the course with our PPEs, social distancing and other prevention measures such as exceptionally good personal hygiene will hopefully do much to keep ourselves, our loved ones and out patients safe.
Thanks again to Dr. Currie for his time and expertise. We wish all of you the best. Be sure to say updated through your particular health system's source of all that is current and changing with this disease as things progress. For Ridgeview listeners, that is on the RidgeNet site, which is always accessible. IN the meantime, to all of our Ridgeview family, and to all of you out there in the world dealing with this pandemic, take good care of yourselves, your loved ones, and indeed, your patients.
Be sure to listen after the end of the podcast to a little ditty by Rich Larson on how we can take the fight to COVID-19. It's "Wash Your Hands". Thanks for the levity and sharing of your talents, Rich!
Stay safe out there friends, and we'll see you next time on Ridgeview Podcast CME Series.