Author: Will Humble

I’ve noticed that many people including journalists are often using the words “isolation” and “quarantine” interchangeably.  They are words that are referring to different things and they refer to different kinds of recommended actions.

Isolation refers to separating sick people with a contagious disease from people who aren’t sick.  So, for example, if you have been diagnosed with COVID-19 disease, then you should isolate yourself from other people until you’re no longer infectious. When a person is in Isolation they separate themselves from people who aren’t infected to prevent spread of the communicable disease. Isolation for public health purposes may be voluntary or compelled by federal, state, or local public health order.

Quarantine refers to separating and restricting the movement of people who were exposed to a contagious disease to see if they become sick.  So, this is the word that you would use if you have been exposed to someone with COVID-19 disease but you yourself aren’t sick. When a person is in quarantine they separate themselves from people who haven’t been exposed to prevent the possible spread of the communicable disease.

For example, my daughter and niece came back to Arizona after having been living in NYC. They have been exposed to people in the last couple of weeks that have tested positive for the virus but my daughter and niece aren’t sick. They are quarantining together, but neither of them are in isolation, because they aren’t sick. If one of them comes down with symptoms, that person will go into isolation. If neither get sick in the next 14 days then they can come home with our family.

The governor signed a new series of Executive Orders late last week to mitigate the spread of COVID-19.  One says that “all licensed healthcare facilities and providers halt all non-essential or elective surgeries, including elective dental surgeries, that utilize personal protective equipment or ventilators.”

This order is consistent with best-practices for preparing for a surge in demand for hospital care which we may see in the coming weeks. Hospitals all have preparedness plans to implement procedures like this – but it does take a lot of execution to make it happen. One of the judgment calls is determining what’s elective and what’s not. The Order started last Saturday.

Additional Executive Orders signed late last week require the closure of all bars, movie theaters and gyms in counties with confirmed COVID-19 cases. Restaurants can still provide take out.  The National Guard has been activated to help grocery stores and food banks. 

Yesterday CMS approved AHCCCS’ waiver request asking for flexibility in responding to the COVID-19 outbreak. The approved waiver does these things:

1. Waive cost-sharing and premiums for ALL participants during the state of emergency, including KidsCare premiums and premium balances

2. Extend KidsCare renewal deadlines so kids can stay enrolled beyond their certification period

3. Delay renewal processing and delay action on circumstance changes to eligibility (though we do not have specifics at this time, this will include KidsCare renewals)

4. Provide 6 months of temporary housing support for participants who test positive for COVID-19 and who are homeless or at risk of homelessness.

5. Allow for payment for home and community-based services provided by family members or other legally responsible parties.

Testing finally became more available early this week with testing now available through LabCorp  and Quest Diagnostics, but a new problem has arisen and testing continues to be a big barrier to an effective response.

Many doctors and hospitals are unable to get their hands on the actual COVID-19 testing kits (swabs and transport medium). So even though commercial testing is available, if clinicians don’t have the swabs and transport media to get the specimens to the lab then they can’t get the testing done. Some hospitals, clinics and clinicians do still have swabs and transport media- but many don’t.

Last week the ADHS offered the following advice and resources:

1. “Fisher Scientific has E-Swab by Copan (Catalogue # 481C and 482C) and Opti-Swab by Puritan (Catalogue # LA-117), available but they are on a 2-week backorder. These are Aimes-based kits instead of VTM, but the FDA medical device website indicates that these can be used for COVID testing.  https://www.fda.gov/medical-devices/emergency-situations-medical-devices/faqs-diagnostic-testing-sars-cov-2”

2. “You can also reach out directly to the FDA hotline (1-888-INFO-FDA) 24 hours a day for labs to call regarding difficulties obtaining supplies for collecting patient specimens for COVID-19 testing, including swabs and transport medium.”

Because of the swab supply chain issues, testing is basically not available in the outpatient setting right now. Often, testing isn’t necessary for individual treatment- but it certainly helps public health monitor the disease, give folks definitive info about their need to isolate, determine how effective our social distancing interventions are working and help guide future interventions.

Not all is lost, because of the lack of testing because public health has other tools like ILI surveillance, mathematical modeling and hospital admissions and capacity data that helps.

Having a negative test can relieve anxiety but the best thing to relieve anxiety will be to reduce the spread of disease. Public health asks everyone to do the following to reduce the spread of disease and to reduce anxiety:

• Stay home and away from others when you have even the slightest cold symptom.  Don’t expose anyone else until 72 hours after your symptoms are gone.

• Most people recover at home with rest and fluids. If you are over 60 or have chronic medical conditions, call your healthcare provider and get guidance. Only go to the emergency room if you are experiencing severe symptoms of COVID-19 like trouble breathing, trouble staying awake, or fever that won’t go away. 

• Avoid groups > 10 people and reach out to older family, friends and neighbors to make sure they have what they need and they are healthy.

• Please, please wash your hands and don’t touch your face.

Hopefully I can report something more encouraging next week on the testing front.

Younger Adults at Higher Risk for Hospitalization than Previously Thought, but with a Caveat

Now that we have community spread of the new Coronavirus, we’re beginning to get some U.S. specific surveillance data. Up until now, we’ve needed to rely on data from China, S. Korea and Italy.  The new US results are summarized in a CDC MMWR this week (MMWR stands for a Morbidity and Mortality Weekly Report).

Previous mortality data from S. Korea were primarily mortality data, so this is our first real view into what percentage of cases are serious enough to require hospitalization or intensive care.  The previous mortality data found that younger adults are at much lower risk for dying from the illness- but these new hospitalization data suggest that younger adults are at risk of serious enough symptoms to be hospitalized.

Among the 508 patients known to have been hospitalized in the US (12% of the cases), 20% were between 20–44 years old, 18% were 45–54, 17% were aged 55–64 years, 26% were aged 65–84 years, and 9% were over 85.  Overall, 31% of cases, 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths were among adults aged ≥65 years.

So, in that young adult cohort you can see that 29% of the cases are among folks 20-44 years old and 20% of the hospitalizations were among that group. Slightly under-represented in terms of hospitalization percentage but not by much.

The CDC doesn’t have information about chronic medical conditions and or how many of these younger adults have medical conditions, which we know puts people at higher risk for severe disease, so this is a big limitation in the report.

Among the 121 patients admitted to an ICU so far, 7% of cases were ≥85 years, 46% were 65–84 years, 36% were 45–64 years, and 12% were 20–44 y/o.  Percentages of ICU admissions were lowest among adults aged 20–44 years (2%–4%) and highest among adults aged 75–84 years (11%–31%).

There have been 44 known deaths so far.  80% (35) of them were older than 65 and 20% (9) have been younger adults.

The CDC identifies several limitations in the data used for the report, and it’s also very early in the US epidemic- so as you think about these results take into consideration that these are preliminary data- but still useful in planning for the healthcare system response.

Here’s a link to the Full MMWR Article.

An allotment from the Strategic National Stockpile arrived Saturday (yesterday). State government will be shipping the supplies to the local health departments and the counties will deliver the resources to healthcare facilities and 1st responders (just like we did during H1N1). Last week’s shipment includes:

• 60,900 N95 masks;

• 244,000 surgical face masks;

• 26,208 face shields;

• 22,200 surgical gowns;

• 102 coveralls; and 

• 90,000 sets of gloves.

Don’t celebrate too much though. This shipment isn’t enough to meet the needs out there right now. Counties will likely be prioritizing acute care facilities to protect those who are providing care to patients who are the most sick.

Outpatient providers have the option to use telehealth or refuse patients, which is not ideal but offers some relief. Maricopa County is planning to provide some PPE to long term care facilities who care for the most vulnerable patients and would be impacted the most by an outbreak.

Yesterday’s shipment is 25% of the stockpile that’s earmarked for AZ.

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