Episode 15: Keeping Ahead of Coronavirus. Helpful Information During the COVID-19 Pandemic With Alaina Dekerlegand, PharmD, BCIDP

Stroll to the bottom for resources and protocols

What is COVID-19

COVID-19 is a new strain of coronavirus first identified in December 2019 in Wuhan, China

The disease was initially named Coronavirus disease 2019 (COVID-19). The virus has since been renamed Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) which is why you may see different names for it.

It is Related to the prior SARS-CoV which was first identified in 2003 and MERS-CoV (79% and 50% genetic similarity)

It is most closely related to 2 SARS-like coronaviruses in bats, with almost 90% genetic similarity

Initial cases and spread linked to a seafood market in Wuhan. There are Bats and bat droppings in the market and the surrounding region, which is consistent with viral genetics.

Mil Med Res. 2020 Mar 13;7(1):11.

What is the Method of Transmission?

The virus is spread through Human to Human transmission, via Droplets or direct contact

Limited data exists thus far on surface survival time of SARS-CoV-2

Prior coronaviruses do remain on inanimate surfaces for up to 9 days, and it’s likely that this viral strain will be very similar

One study of COVID-19 infected patients, researchers Isolated the virus on many surfaces (fan, toilet, floor, door handle, etc.) without any cleaning of the room

The good news is that the virus was not isolated outside of the patient’s room. Also, With proper cleaning of other rooms of COVID (+) patients, similar samples were negative in other patients

Is it possible for asymptomatic patients to spread the infection?

The transmission has been shown by asymptomatic carriers.

Mean incubation period of 6.4 days in humans (95% CI 2.1 – 11.1 days).

Early estimations from China propose almost 1/3 of infected individuals may be asymptomatic. This high estimation of asymptomatic carriers could explain the speed at which the virus has spread across the world

What are the current statistics on the number of people affected?

As of March 17th, the world health organization has reported over 167 thousand cases worldwide, with an overall mortality rate of 3.9% so far. They are updating their website daily with new information. The CDC has reported 4,226 cases in the US with 75 deaths, and a mortality rate of 1.8% thus far. The CDC is updating its website during weekdays, and most state departments are as well. Keep in mind that the mortality rates thus far will continue to increase, as a lot of the patients who have tested positive are still receiving care at this time. I also wanted to clear up some previous confusion thus far about the difference between CDC-reported numbers and those reported by state departments or local news stations. The CDC was previously performing confirmation tests on all (+) isolates identified by the state, which was causing a delay. They have since changed that requirement

Is COVID-19 expected to have any seasonality?



J Clin Virol.
2018 Apr;101:52-56.

Which patients are most at risk for contracting COVID-19?

Some of the Vulnerable Populations identified thus far are elderly patients, those with a prior immunocompromising condition, or any comorbidity such as hypertension. Some studies have shown up to 50% of patients with at least one chronic condition. This doesn’t mean that other populations are not at risk. These are the patient populations that have been diagnosed in the highest frequency thus far, but it is likely that other patients with non-severe symptoms are not presenting for testing.

What are the symptoms associated with COVID-19 infection?

Most symptoms are consistent with those of other respiratory viral illnesses. The most commonly reported symptom thus far is fever (83- 96% of patients depending on the pt cohort), followed by cough (68-82%). Other symptoms include shortness of breath, rhinorrhea, muscle aches, and confusion. Gastrointestinal symptoms are relatively uncommon, but were reported in 1-3% of patients.

What other laboratory tests and Diagnostics are used to diagnose COVID-19?

Official COVID-19 tests are being provided by the CDC to state laboratories. Every hospital should have in place or be developing a process for screening patients and obtaining tests from their state labs if patients qualify for testing.

What are Possible Treatment Options?

I want to stress up front that everything we have is experimental at this point. The mainstay of therapy for treating COVID-19 patients is still supportive care, but there are some agents with possible benefits based upon in vitro activity as well as very limited clinical data.

Guo YR, Cao QD, Hong ZS, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak – an update on the status. Mil Med Res. 2020;7(1):11

Supportive Care for COVID Patients

Are there any drugs to avoid in a COVID+ patient?

There is a lot of information that we just don’t know yet. However, there are a few things being discussed so far.

Corticosteroids: Prior studies have shown negative outcomes with corticosteroid use in respiratory viral infections. One study with the middle eastern coronavirus showed that corticosteroid therapy was associated with a significant delay in viral RNA clearance. We don’t have data yet for the effect of corticosteroids on this SARS-coronavirus 2 strain. Most experts are currently recommending AGAINST the use of corticosteroids in patients with COVID-19 infections. This is more tricky in patients with underlying COPD or those that develop ARDS. Use clinical judgment in those cases.

ACEi/ARBs: there are currently discussions going on surrounding ACE inhibitors and ARBs. In vitro, SARS-CoV-2 is thought to use ACE2 as a binding site. Patients on ACE inhibitors have increased the production of ACE2 on cells as a result of their ACE inhibitor therapy. The current recommendation is to discontinue ACE inhibitors or ARBs in patients diagnosed with COVID-19 infections since there is a possibility that therapy may increase the rate of infection of host cells by viral particles. This is probably easy to do, as these patients will often develop sepsis and hypotension at some point during their infection course.

NSAIDs: French authorities recently advised against the use of NSAIDs, as they may worsen the clinical course of coronavirus. Although there is no specific data yet, this is likely due to an immunosuppressive effect similar to corticosteroids, as well as an upregulation of ACE2 similarly to ACE inhibitors. At this point, it would be a good idea to avoid NSAIDs in these patients and use acetaminophen instead.

How should we handle situations like cardiac arrests for patients who are either suspected or confirmed COVID-19?

The answer to this question will differ based upon the design of each hospital and your standard workflow for code response. All healthcare personnel actively resuscitating the patient should be wearing appropriate N95 masks, especially if the patient is not intubated. Respiratory should be hopefully intubating them as quickly as possible if they weren’t intubated prior to the code. The number of personnel inside patient rooms should be limited in order to decrease exposure and also conserve our limited supply of PPE. One option is to have the medicine components of the code cart outside if the room for preparation, and then carefully pass compounded medications to personnel in the room. Be sure to discuss this process workflow at your institution.

What can we do to help decrease transmission?

We should follow all of the recommendations provided by the CDC thus far:

Avoid handshaking, Clean hands often, Avoid touching your face, Cover coughs and sneezes, Disinfect surfaces regularly especially if they are shared, Handle food carefully. Limit travel to necessary reasons

And try to avoid spending time in crowded restaurants and bars. I know that a lot of us are young and healthy and relatively unconcerned about COVID-19 because we would not have a high mortality risk if we contracted the virus. However, most of us are taking care of very high-risk patients and we don’t want to be the cause of anyone becoming sick.

There will be a lot of meetings in the coming months with updates on patient care: Videoconference when possible for meetings. (limit in-person meetings to those with <10-15 people if possible). Make sure any in-person meetings are held in open, well-ventilated spaces

If you or a family member is feeling sick, STAY HOME. Although our immune systems may limit the illness to mild symptoms, we may be carriers and spread the virus to our patients with weakened immune systems. In areas being hit hard thus far, there are reports of 10% of the workforce being out due to illness. We will already be stretched thin, and spreading the virus amongst each other could be catastrophic.

What can we do about the limited supplies worldwide?

The level of public panic has led to some crazy behaviors. Everything from toilet paper hoarding to buying up massive amounts of medical supplies, such as masks and cleaning supplies. Patients who use alcohol swabs on a daily basis for self-injection of medications are having difficulty finding them, and hospitals are having trouble obtaining masks. We can do our best to encourage everyone to be mindful of the needs of others and only buy what you and your family would reasonably need as a 1 month supply, which is the current recommendation. Try to keep members of our community informed that masks alone will not prevent spread– Encourage hand hygiene and social distancing instead. In the hospital, use of masks should be limited to essential personnel so we can conserve what we have

Related Posts and References

References

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