2020 Symposia Series 1 COVID-19: Update for NPs and PAs Learning - - PowerPoint PPT Presentation

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2020 Symposia Series 1 COVID-19: Update for NPs and PAs Learning - - PowerPoint PPT Presentation

Mar 04, 2024 37 likes •309 views

2020 Symposia Series 1 COVID-19: Update for NPs and PAs Learning Objectives Describe what is currently known about COVID-19 transmission and how to prevent it Assess current COVID-19 diagnostic strategies Discuss evolving therapeutic

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2020 Symposia Series 1

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COVID-19: Update for NPs and PAs

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Learning Objectives

  • Describe what is currently known about COVID-19 transmission and how

to prevent it

  • Assess current COVID-19 diagnostic strategies
  • Discuss evolving therapeutic strategies for patients with COVID-19

infection

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  • Transmission
  • Diagnostics
  • Therapeutics
  • Prevention

COVID-19

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US Incidence Rates (5/11/2020)

Johns Hopkins University & Medicine. coronavirus.jhu.edu/us-map. Accessed May 11, 2020

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Transmission

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COVID-19 Is Spread Chiefly by Droplets

  • Droplet

‒ 3 to 6 feet ‒ Contaminates surfaces/fomites ‒ Hand to face

  • Airborne

‒ Especially with intubation, suctioning, close exposure ‒ ? Aerosolization of tissue containing virus

  • Other routes

‒ Fecal, nosocomial, ?perinatal

Centers for Disease Control and Prevention. www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#adhere. Accessed April 26, 2020.

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  • Why rapid and global spread?

‒ Asymptomatic shedding

  • Estimates 25% to 50% of infected (CDC/NIAID)?
  • Role of asymptomatic cases affecting models/forecasts
  • USC-LA County study 4/20/20: COVID-19 infections far exceed confirmed cases

‒ 4.1% of county’s adult population has antibodies to the virus ‒ Adjusting to statistical margin of error: between 2.8% and 5.6% have antibody

  • Thus, between 221,000 and 442,000 adults in the county have had the infection
  • 28 to 55 times higher than the 7994 confirmed cases reported to the county by the

time of the study in early April

Transmission and Contagiousness

CDC = Centers for Disease Control and Prevention. Redfield R. CDC; Fauci A. NIAID/NIH. County of Los Angeles Public Health news release. April 20, 2020. Available at publichealth.lacounty.gov/phcommon/public/media/mediapubhpdetail.cfm?prid=2328.

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COVID-19: PPE for Healthcare Personnel—CDC Guidelines

Centers for Disease Control and Prevention. www.cdc.gov/coronavirus/2019-ncov/downloads/COVID-19_PPE_illustrations-p.pdf. Accessed April 15, 2020.

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Diagnosis

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Range of COVID-19 Disease States and Potential Therapeutic Targets

Siddiqi HK, Mehra MR. J Heart Lung Transplant. 2020. doi: https://doi.org/10.1016/j.healun.2020.03.012. ARDS = acute respiratory distress syndrome; CRP = C-reactive protein; IL = interleukin; JAK = Janus kinase; LDH = lactate dehydrogenase; SIRS = systemic inflammatory response syndrome.

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  • Descriptions mostly limited to

hospitalized patients

  • Signs, symptoms

‒ Fever (46%-98%) ‒ Cough (46%-82%, usually dry) ‒ Myalgia or fatigue (11%-44%) ‒ Shortness of breath at onset (31%) ‒ Chills

Clinical Presentations

  • Less common symptoms

‒ Pharyngitis ‒ Loss of taste/smell ‒ Headache ‒ Productive cough ‒ GI symptoms

  • May be heralding

‒ Hemoptysis – Leukopenia in ~70% hospitalized patients – LDH often elevated

Chan JF, et al. Lancet. 2020;395:514-523; Huang C, et al. Lancet. 2020;395:497-506; Wang D, et al. JAMA. 2020; [Epub ahead of print]; Zhu N, et al. N Engl J Med. 2020;382:727-733.

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Hospitalization Rates and Characteristics of Patients Hospitalized With Laboratory-Confirmed COVID-19

  • COVID-NET
  • 14 states
  • Mar 1-30, 2020
  • By age group

Kim GS, et al. MMWR Morb Mortal Wkly Rep. 2020;69:458-464.

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  • 1482 patients

‒ ≥50 years (74.5%) ‒ Male (54.4%) ‒ Underlying health conditions (89.3%)

  • Hypertension (49.7%)
  • Obesity (48.3%)
  • Chronic lung disease (34.8%)
  • Diabetes (28.3%)
  • Cardiovascular disease (27.8%)

COVID-19: US Hospitalizations

  • Higher hospitalization rates in

certain patients ⎻ Black

Kim GS, et al. MMWR Morb Mortal Wkly Rep. 2020;69:458-464.

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  • High priority: nucleic acid or antigen testing

⎻ Hospitalized patients ⎻ Healthcare facility workers, others in congregate living settings, first responders with symptoms ⎻ High priority patients

  • With COVID-19 symptoms
  • Asymptomatic people if from a racial or ethnic minority group

disproportionately affected by adverse COVID-19 outcomes ⎻ African Americans, Hispanics and Latinos, some American Indian tribes (eg, Navajo)

CDC: Priorities for Testing Patients With Suspected COVID-19 Infection

Centers for Disease Control and Prevention. www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html. Accessed May 5, 2020.

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  • Asymptomatic people who are prioritized by clinicians or public health

departments ‒ Public health monitoring ‒ Sentinel surveillance ‒ Comorbidities or disability ‒ Residence in congregate housing, homeless shelter, or long-term care facility

  • Recommendations for antibody testing

‒ CDC has no recommendations for diagnostic purposes

CDC: Priorities for Testing Patients With Suspected COVID-19 Infection (cont’d)

Centers for Disease Control and Prevention. www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-criteria.html. Accessed May 5, 2020.

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  • Increasing testing capacity, but still

limited in many places

  • Issues with sensitivity of NP swabs

‒ 70 to 85%?

  • Need for additional
  • High clinical suspicion

?need for test

  • Is (+) later in course reflective of

infectiousness?

  • Lower vs upper samples

Diagnostics

  • Rapid molecular diagnostic tests

‒ Cepheid COVID GeneXpert, <45 minutes ‒ Abbott ID Now COVID, <5 min (+), <15 min (–)

NP = nasopharyngeal.

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  • FDA eased approvals, allowing laboratory-developed tests (LDTs)
  • Serology: “No IMMUNITY PASSPORT” likely valid at this time

‒ Many tests now available—unclear how well validated; FDA warnings ‒ Tests have not been reviewed by the FDA ‒ Negative results do not rule out COVID-19 infection (molecular needed) ‒ Results from antibody testing should not be used as the sole basis to diagnose or exclude COVID-19 infection ‒ Results from antibody testing should not be used to inform infection status or protective immunity ‒ Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E

Diagnostics (cont’d)

Food and Drug Administration. www.fda.gov. Accessed April 29, 2020; Auwaerter P. Expert Opinion. 2020.

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Therapeutics

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Many Investigational Therapeutic and Preventive Approaches

Kupferschmidt K, Cohen J. Science. 2020;367:1412-1413.

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Source: microbenotes.com/remdesivir/. Accessed May 5,2020. Image created with biorender.com.

Remdesivir: Potential Repurposed Drug Candidate for COVID-19

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Wang Y, et al. Lancet. Published online April 29, 2020. doi.org/10.1016/S0140-6736(20)31022-9. Accessed May 5, 2020

Remdesivir in Adults With Severe COVID-19: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial

  • N = 237 patients, halted
  • Confirmed infection, 12 days or fewer of symptoms, lung involvement
  • Remdesivir 200 mg day 1, then 100 mg IV daily vs placebo

Findings:

  • No clinical improvement (subgroup <10 days with trend)
  • No difference in mortality (subgroup <10 days with trend)
  • No effect on viral load in upper or lower respiratory tracts
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  • Sponsor: National Institute of Allergy and Infectious Diseases
  • Randomized, controlled trial studying remdesivir vs placebo (began 2/21/20)
  • 1063 patients from 68 sites (47 in US; 21 from Europe and Asia)

Preliminary results

  • Patients who received remdesivir had 31% faster time to recovery than those who received

placebo (P <0.001)

  • Median time to recovery: 11 days for patients treated with remdesivir vs 15 days for those who

received placebo

  • Survival benefit?

‒ Mortality rate of 8.0% for the group receiving remdesivir vs 11.6% for the placebo group (P = 0.059)

Adaptive COVID-19 Treatment Trial (ACTT): Remdesivir

www.nih.gov/news-events/news-releases/nih-clinical-trial-shows-remdesivir-accelerates-recovery-advanced-covid-19. Accessed April 29, 2020.

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Prevention

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Rationale for Social Distancing

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Several Vaccines in Development

  • 115 candidates
  • >90 currently at exploratory or preclinical stages
  • Most advanced candidates now in clinical

development ‒ mRNA-1273 (Moderna) ‒ Ad5-nCoV (CanSino Biologicals) ‒ INO-4800 (Inovio) ‒ LV-SMENP-DC and pathogen-specific aAPC (Shenzhen Geno-Immune Medical Institute)

  • Many others have indicated plans to initiate

human testing in 2020 (eg, J&J, phase 1 testing anticipated Oct. 2020)

COVID-19: Vaccines in Development

Thanh LT, et al. Nat Rev Drug Discov. 2020 [epub ahead of print].

9 22 2 4 4 8 4 2 5 2 9 7 6 8 2 5 2 2 2 2

10 20 30 40 50 60 Exploratory (confirmed) Exploratory (unconfirmed) Preclinical Phase I

Number of Projects Current Stage of Development

Live attenuated virus Inactivated Non-replicating viral vector Replicating viral vector Recombinant protein Peptide-based Virus-like particle DNA RNA Unknown

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2020 Symposia Series 1