Archives

Yes.

There are a few medications that are under investigation as potential treatments for COVID-19. A couple of them look promising, especially an old anti-malarial drug called chloroquine and its cousin hydroxychloroquine, which is used on-label for Lupus. It’s starting to look like hydroxychloroquine and maybe chloroquine could be safe and scaleable treatments. 

In cell cultures, they reduce the ability of SARS to get into cells,  interfering with reproduction of the virus if it does get in.  They are cheap, have a proven safety record, and manufacturing could be ramped up quickly because they are simple drugs.  Here’s a study with the cell-culture In Vitro Results. The results are statistically significant and promising.

There’s also an In Vivo (human) case series study with promising results. Despite the study’s small sample size, the survey shows that hydroxychloroquine treatment is significantly associated with viral load reduction/disappearance in COVID-19 patients. Results were even better when combined with azithromycin (Zithromax). There are open trials going on for healthcare workers and contacts. Because these meds have been around for decades and have a good safety record- they could be scaled up and used fast off-label (plus they’re generic and cheap).

Another drug is a “nucleotide-analog” drug called remdesivir.  It’s a med developed to treat Ebola and there’s some evidence that it works against other RNA viruses (the SARS CoV virus is an RNA virus and so is Ebola). Testing for Ebola showed that it was safe and it’s under trial now for SARS CoV.  Results are expected in mid to late April.

Another drug called favipiravir which can be helpful with Influenza (also an RNA virus).  That one works by interfering with making new RNA. That drug is also being tested for efficacy for SARS CoV too.

Interferons might also be a useful treatment. Those drugs promote a widespread antiviral reaction in infected cells including shutting down protein production and switching on RNA destroying enzymes. Again, this is under testing.

Finally, the SARS CoV virus tends to overstimulate some parts of the immune system- especially the inflammatory response. A drug called Actemra (tocilizumab) is an antibody that targets receptors on cell surfaces and clogs up the interleukin-6 receptors, slowing down a targeted immune response.  This med is normally used to help with autoimmune diseases like Rheumatoid arthritis.  In China, it was observed to improve outcomes among infected folks and China has approved the med for COVID-19 treatment.

Editorial Note: If researchers and scientists can find an existing medication that has been proven safe that can be used off-label to limit the progression of the illness it could be a game changer.  I honestly believe one or more medications are out there that will work- we just need to fund the kind of research and researchers to find them, chloroquine and hydroxychloroquine and others might very well work.

If so, it could give policy makers an alternative to the dramatic and economically damaging social distancing measures currently underway.These interventions are having a profoundly negative impacts on the social determinants of health.

Dear Maricopa County Healthcare Providers,

First, thank you for continuing to see patients during this critical time. You are the boots on the ground and the core of public health.  I wanted to provide some situational awareness about COVID-19 testing availability as of March 18 in Maricopa County and share some new information about COVID-19 in pediatric patients.

Testing Update

There is a lot of confusing information about the availability of COVID-19 testing in Maricopa County. I would like to clear up some misconceptions and tell you where we are.  First, I have heard your concerns about lack of public access to testing in the outpatient setting.  There simply isn’t a way to get people with mild to moderate illness tested right now. There are plenty of commercial laboratories that have the capability to test for COVID-19.  These include, but are not limited, to Quest and LabCorp.  The bottleneck is a lack of availability of specimen collection supplies (NP swabs and viral transport medium).  Unfortunately, the supply chain is interrupted.   We have raised this need to the very highest levels of government (FDA) and elected officials. But we don’t have a solution yet.

The other issue is that primary care providers are telling us they don’t have the personal protective equipment (PPE) or supplies to collect specimens.  I assure you that we are working closely with ADHS and healthcare facilities to stand up drive-through testing for COVID-19 so we can support primary care providers and the public. As soon as we are able to get testing supplies, so we can get drive-through testing sites up and running, we will notify providers. 

During this time with limited testing, it is critical that you tell your patients with any respiratory illness to self-isolate at home, drink fluids and rest.  The vast majority of people do very well recovering at home. Getting a COVID-19 test does not change the treatment or the outcome. Patients with respiratory symptoms will be told to self isolate until 72 hours after their fever and symptoms resolve, regardless of a test result.  Availability of testing is not what will ultimately impact the spread of this outbreak.  But staying home when sick, washing our hands, not touching our faces, and avoiding unnecessary physical contact and group gatherings of more than 10 people will. Please help your patients stay calm and let them know what they can do to protect themselves during these uncertain times.

Pediatric Disease

President Trump just referenced the following paper accepted for publication in Pediatrics, “Epidemiological Characteristics of 2143 Pediatric Patients with 2019 Coronavirus Disease in China.” I read the paper in detail and here are the take-home points. They did a retrospective review of 2,143 children less than 18 years old with suspect (1,412) and confirmed (731) COVID-19 in China. The main conclusion is that children have less severe disease than adults. Overall, 5.9% of children had severe or critical disease compared with 18.5% of adults in China.  It also highlights that infants have a higher risk of severe disease (10.6% vs. 5.9%).  There was only one pediatric death (14 y.o.). That means 94.1% have mild to moderate disease, which can be managed at home.

But there is a MAJOR LIMITATION. Suspect cases are classified based on high-risk of contact with a person with COVID-19 PLUS 2 of 3 sets of criteria, and could include ANY viral respiratory or GI illness. (For example, a suspect case could be a child with high-risk contact who presents with fatigue and a NORMAL white blood cell count.) Further, suspect cases have a higher proportion of severe and critical disease than laboratory-confirmed cases, which suggests that many of the suspect cases do not have COVID-19. This likely overestimates the percentage of severe and critical cases, including severe disease in infants.  The manuscript does not include the breakdown of severe and critical disease among laboratory-confirmed cases, which would be a much better estimate of severe COVID-19 disease. Lastly, only 4.4% of “cases” are considered asymptomatic, which is very unlikely to be a true estimation of asymptomatic disease.  This is another reason I think these proportions are overestimates of severe disease.  So, take these numbers with a grain of salt.  Overall, I am reassured that children have milder illness with COVID-19, and pediatric mortality is far less for COVID-19 than it is for influenza.  We’ve had two pediatric flu deaths in Maricopa County this season alone.  Attached are our MCDPH Primary Care Pediatric Guidelines for COVID-19, in case you have more questions.

So, please tell parents that their kids will be OK.  Keep them home when they are sick, give them lots of rest, fluids and love.  And please, please teach them to wash their hands, avoid touching their face and to cover their coughs and sneezes.

Stay healthy,

Rebecca

A big problem in the COVID-19 response the last couple of weeks has been the lack of testing capacity.  The lack of testing capacity has been impairing the ability of doctors to diagnose and treat their patients and  public health’s ability to accurately characterize the spread of the illness.

Late last week I think we finally turned the corner. That’s because private sector COVID-19 testing became available from LabCorp and Quest Diagnostics. Healthcare providers can now order private sector tests and it’s not necessary to contact public health for testing to order the tests.

Details on ordering the tests are on the LabCorp & Quest Diagnostics websites.  The FDA issued Emergency Use Authorizations for the Roche and Thermo Fisher SARS-CoV-2 Tests late last week too but I don’t have any info about the commercial availability of those tests.

Here’s Maricopa County Public Health’s Commercial Laboratory Testing Guidance for Healthcare Providers and Healthcare Provider Testing Guidance for the particulars.

Our county health departments will continue to work with healthcare providers and the state public health laboratory to test patients who meet the stringent statewide testing criteria. 

Here are the most recent guidance documents from MCDPH:

• Commercial Laboratory Testing Guidance for Healthcare Providers

• Long-Term Care Facility Guidance

• Healthcare Provider Testing Guidance

• Persons Under Investigation and Household Contacts At-Home Guidance

• COVID-19 Post-exposure Guidance for Healthcare Personnel

• Healthcare Facility Guidance

Editorial Note: With the testing capacity ramping up significantly and with the restrictions being lifted on who can get tested with the private sector tests, I expect the number of cases to increase a lot in the coming days.  That won’t necessarily mean that infections suddenly- it will mean that clinicians are finally better able to test their patients and we will be detecting cases and transmission that has been happening without our awareness because of the lack of testing up to now

As of this morning, S. Korea (the country with the best surveillance data) has 8,162 confirmed cases and 75 deaths (an average case fatality rate of 0.9%). 

But the case fatality rate varies a lot with age. Of the deaths in S. Korea, 25 have been over 80 years old, and 28 between 70-79 y/o. Fourteen were between 60-69 and 6 deaths have been among people 50-59 y/o.

Seventy-one percent (71%) of the deaths in S Korea are among people 70 years old and above and 89% are among those over 60. The case fatality rate for those over 80 is about 9%, and for all those over 70 it’s about 6.7%.

However, for people under 40 years it’s just 0.04% or 4 in 10,000. You can see from those data that COVID-19 is far more serious among those over 70 years old, and that for those under 40 it’s really not all that lethal.

The South Korean CDC updates their surveillance daily in English, and you can explore their data by going to this website.

Last Wednesday the governor declared a public health emergency to get enhanced authority to respond to the COVID-19 pandemic. This is the 2nd time that this governor has declared a public health emergency (the first one was to respond to the opioid epidemic).

So what does that mean?

It means that there are things that state government can do now that they couldn’t before last Wednesday.  That extra authority is in ARS 36-787. The governor’s press release about the Order provided some clues as to what extra authority he intends to use at least at the start. The Order specifically:

• Allows ADHS to waive licensing requirements during heightened demand;

• Gives the state to access $500,000 in emergency funds to buy stuff and provides the state with emergency procurement authority to buy it;

• Requires insurance companies to cover out of network providers;

• Waives co-pays and deductibles for consumers related to COVID-19 diagnostic testing;

• Implements consumer protections on COVID-19 of diagnosis and treatment-related services; and 

• Requires symptom checks of healthcare workers and visitors at skilled nursing facilities, nursing homes, and assisted living facilities.

Some of the additional authority in ARS 36-787 that wasn’t mentioned in the executive order provides authority for:

• Establishing a temporary waiver of the professional licensing requirements;

• Granting temporary waivers of health care institution licensing requirements; 

• Mandating medical examinations for exposed persons;

• Rationing medicine and vaccines; 

• Buying medicines and vaccines; and 

• Under more narrow circumstances, mandate treatment or vaccination of people and even order the isolation and quarantine of folks.

The US has had a Strategic National Stockpile of medical supplies that can be used when there’s a public health emergency. It’s released when state or local officials ask the fed’s to help support their response.

Back at the beginning of the H1N1 epidemic we asked for personal protective equipment for healthcare workers and antiviral medications from the stockpile. It was remarkable how fast the trucks arrived at our warehouse. The materials were released to hospitals and community health centers and others in anticipation of a surge in demand.

I haven’t heard whether the ADHS is considering asking for SNS materials or not.

Only hours after the governor signed the executive order, the legislature amended and passed SB 1050.  It had been a simple agency continuation bill for ADHS.  It quickly became a vehicle to transfer a whole bunch of money to the agency for the COVID-19 epidemic. 

It appropriates $5M from the rainy day fund to the ADHS Public Health Emergencies Fund right now and up to an additional $50M more from that fund. The ADHS is supposed to notify the Joint Legislative Budget Committee what they want to use it for.

This money is over and above the generous roughly $12M that it will soon be receiving from the CDC for the response.

The President signed an Executive Order declaring a National Emergency Friday. It basically gives the Secretary of HHS the ability to waive or modify regulations in Medicare, Medicaid, CHIP and HIPPA for the duration of the emergency. Presumably those would relate to the treatment of patients and the payments for those services.

He mentioned that there would be some kind of public-private partnership to expand testing capabilities (that would certainly be welcome)!

He also said that an additional $50B would become available to state and local governments for the response through the Stafford Act (although I don’t see that info in the actual declaration). That Stafford funding could be for “providing emergency medical care and temporary medical facilities; supplying food, water, medicine, and other supplies; and management control and reduction of immediate threats to public health and safety“.

Perhaps we will hear more about what these resources would be used for in the coming days from our state officials.

P.S. Last Friday the CDC released new guidance for folks to make decisions about whether or not to dismiss schools as a public health intervention.  it includes a visual decision tree.

Clinical Characteristics of Coronavirus Disease in China

INTRODUCTION

Since December 2019, when coronavirus disease 2019 (Covid-19) emerged in Wuhan city and rapidly spread throughout China, data have been needed on the clinical characteristics of the affected patients.

METHODS

We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death.

RESULTS

The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%).

Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission.

CONCLUSIONS

During the first 2 months of the current outbreak, Covid-19 spread rapidly throughout China and caused varying degrees of illness. Patients often presented without fever, and many did not have abnormal radiologic findings. (Funded by the National Health Commission of China and others.)