COVID-19 Update Jean Siebenaler MD, MPH July 22, 2020 Jean - - PowerPoint PPT Presentation
COVID-19 Update Jean Siebenaler MD, MPH July 22, 2020 Jean Siebenaler MD, MPH u Navy veteran (USNR Medical Corps); u Retired board-certified family physician with over 20 years experience; u Over 15 years experience in the design and management
Jean Siebenaler MD, MPH July 22, 2020
u Navy veteran (USNR Medical Corps); u Retired board-certified family physician with over 20 years experience; u Over 15 years experience in the design and management of epidemiology
research studies;
u Lives with husband and dog in Milton on Blackwater Bay since 2008. u Member of UUCP since 2019
u We are now 5 months into experiencing
the most significant medical crisis since the Spanish Flu Pandemic of 1918;
u There is a daily deluge of overwhelming
amounts of media reports and misinformation about this virus;
u Consequently, it is hard to know who or
what to believe.
We went from disbelief in March to ………………………………
Coronaviruses: viruses that cause illnesses such as: the common cold, severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS) In December 2019, a novel new Coronovirus was discovered in a disease outbreak in China. The virus was named the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) The disease it causes was named coronavirus disease 2019 (COVID-19)
*July 21, 2020 case fatality rate in US = 3.7 % and is decreasing with increased testing and finding more cases that survive.
u Median time = 4-5 days from
exposure to symptom onset
u Extends to 14 days u One study reported 97.5% of
persons with COVID-19 develop symptoms within 11.5 days of exposure
u Length of the incubation period
is a major factor in COVID’s high rate of infectiousness
u For comparison – influenza
incubation period is only 1-4 days
Illness severity can range from mild to critical:
u Mild to moderate (mild symptoms up to
mild pneumonia): 81%
u Usually managed at home
u Severe (dyspnea, hypoxia, or >50% lung
involvement on imaging): 14%
u Usually managed in the hospital non-ICU
ward
u Median time from exposure to hospitalization
= 7-10 days
u Critical (respiratory failure, shock, or
multiorgan system dysfunction): 5%
u Median time from exposure to ICU admission
= 10-12 days
u Mortality rate in the ICU = 39-72%
Most common risk factor < 55 years old
Sickle Cell Obesity (BMI > 30) Chronic Kidney Failure Diabetes II Solid Organ Transplant COPD CHF , CAD Conditions assoc. with the highest COVID severity at any age (CDC 6/25/2020)
uAccording to the 2010
census, racial distributions in Florida are as follows:
u 77.3% White (53.5%
Non-Hispanic White),
u 16.9% African
American (includes Afro-Caribbeans),
u 25.6% Hispanic or
Latino (of any race).
u High prevalence of pre-existing medical conditions
u Diabetes, hypertension, kidney disease, asthma, obesity, others
u Live in more multi-generational households u Unjustly over-represented in jails, prisons, and detention center hotspots u Represent a high percentage of service industry workers (e.g., NH/ALF staff, grocery
clerks, postal carriers, agriculture industry, bus drivers, etc.)
u Jobs more likely to lack paid sick leave or health insurance u Jobs more likely to be low wage with greater inability to afford health insurance copays that
impede access to health care
u Workers more likely to use public transportation to access jobs
u Long histories of medical bias in health care prior to pandemic
u Anecdotal reports of COVID symptom dismissal, refusals to test, ER discharges instead of
hospitalizations
u Systemic racism contributes to lifetime ravages of chronic stress and immune
suppression, with subsequent negative health effects of susceptibility to diseases.
Fever (83-99%) Cough (59-82%) Shortness of breath
breathing (31-40%) Fatigue (44-70%) Anorexia (40-84%) Sputum production (28-33%) Myalgias (11-35%) HA, sore throat, N/V/D (<10%)
u Vascular (i.e., arterial and venous blood clots); u Neurological (i.e., strokes, confusion, impaired
consciousness, poor motor control, numbness/tingling
u Abdominal pain and bowel infarctions; u Cardiovascular (i.e., angina, myocardial infarctions,
heart failure, dysrhythmias)
u Liver and kidney dysfunction; u Skin rashes u Conjunctivitis u Every organ can be affected because every organ is
vascularized
u
Leads to activation of the blood clot pathway and arterial inflammation
u
Cytokine storm
u Cytokines are inflammatory immunologic
proteins that are supposed to fight off infections, but they sometimes go out of control
u Symptoms include high fever, enlarged
spleen, excessive bleeding, low counts of all types of blood cells (red, white and platelets) and, potentially, multiple
u Cause is unknown
14 cases in Florida – July 22, 2020 (ages 2-17)
u COVID-19 virus is related to the Severe Acute
Respiratory Syndrome (SARS) virus, which was epidemic in 2003 primarily in Asia.
u SARS survivors have been studied and many show
long-term suffering and poor QOL >10 years.
u Impaired lung function u Poor immunity with susceptibility to common
infections
u Chronic fatigue u Higher incidence of cardiometabolic and
neurologic disorders
u Given COVID-19 prevalence, we may see chronic
health problems for many years in hospitalized survivors, with a heavy impact on our health care systems
u We will be studying and learning about COVID-19
survivors for a long time.
u USS Roosevelt -- >60% of the crew who tested positive
were asymptomatic.
u Iceland tested 6% of its population (the highest per
capita globally) and found that 43% of those who tested positive were asymptomatic.
u A 2-week study of almost all pregnant women in two
NYC hospital Labor and Delivery wards found that 88% of test-positive patients had no symptoms.
u As mass testing expanded in prisons, large numbers of
inmates showed no symptoms. In four state prison systems — Arkansas, North Carolina, Ohio and Virginia — 96% of 3,277 inmates who tested positive for the coronavirus were asymptomatic.
u Asymptomatic
u Never develop any symptoms u Degree of infectiousness
under debate
u Pre-symptomatic
u More common u Peak infectiousness time u Symptoms that develop may
be very mild (e.g., body aches, fatigue, sniffles)
u Lumped under the label of
“asymptomatic”
u Superspreader events typically involve
indoor gatherings with many people (e.g., weddings, funerals, church services, restaurants, work environments, exercise classes, etc.)
u New research finding that ~10-20% of
infected people are responsible for ~80% of cases.
u Associated with the 3 Cs:
u Close contact u Crowded u Closed space u 4th C -- Continuous exposure
u
March 10, 2020; state of Washington
u
2.5-hour choir practice with 61 members, one of whom was sick for a few days with cold symptoms
u Choir median age = 69 u Only 1/3 with pre-existing conditions
u
Members avoided physical contact but were <6 ft apart, singing, snacked on cookies and oranges, put away stacked chairs together when done
u
32 confirmed cases and 20 probable COVID-19 cases
u
Developed symptoms 1-12 days after exposure
u
3 patients hospitalized; 2 deaths
uSketch showing arrangement of
restaurant tables and air conditioning airflow at site of COVID outbreak, Guangzhou, China, 2020.
uYellow-filled red circle indicates index
case-patient who was asymptomatic and spent 1-1.5 hr dinner with 9 friends.
uRed circles indicate seating of future
case-patients.
Lu J, Gu J, Li K, Xu C, Su W, Lai Z, et al. COVID-19 outbreak associated with air conditioning in restaurant, Guangzhou, China, 2020. Emerg Infect Dis. 2020 Jul [date cited]. https://doi.org/10.3201/eid2607.200764
u Over a week, 94 of 216 employees on
11th floor in S. Korean call center became infected (blue chairs); mostly
u Estimates were that 94% of infections
were from respiratory droplets/respiratory exposure, and 6% from fomite transfer (door handles, shared water coolers, elevator buttons, etc.)
u Example of being in enclosed space,
sharing same air for prolonged period increases chances of exposure and infection.
Park SY, Kim YM, Yi S, Lee S, Na BJ, Kim CB, et al. Coronavirus disease outbreak in call center, South Korea. Emerg Infect Dis. 2020 Aug [date cited]. https://doi.org/10.3201/eid2608.201274
u Primarily from respiratory droplets in
nasopharyngeal secretions
u Larger droplets can land in mouths or
noses of nearby people
u Larger droplets can pass to infected
person’s hands that directly transfer to susceptible individual (direct contact)
u Larger droplets can land on surfaces
which susceptible individuals touch and bring to their face (indirect exposure)
u Small airborne droplet nuclei
(aerosols) may linger in the air or circulated for a short period of time (e.g. 3 hours) in enclosed space, where susceptible people can breathe in.
*Yao M, et al. Exhaled breath is a significant source of SARS-CoV-2 emission. medRxiv 2020. doi: https://doi.org/10.1101/2020.05.31.20115154
Now picture multiple people in a room speaking and breathing all day where the concentration of aerosol released by speaking and breathing for more than 4 minutes is equal to the concentration expelled for 30 seconds of singing or coughing
Surface particles at risk for re-suspension
If time is constant, being 6 ft from an infected person sneezing/coughing is a greater risk than being 6 ft from someone talking/breathing;
If time is held constant, being in public indoor spaces is a greater risk than being in public outdoor spaces; If time is held constant, being in unventilated public indoor spaces is a greater risk than being in public indoor spaces with circulating fresh air or filtered air; If time is held constant, being in small public indoor spaces with 20 people is a greater risk than being in large public indoor spaces with 20 people; Spending hours in a public indoor space is a greater risk than spending minutes in the same public indoor space.
Tallahasseereports.com Tallahasseereports.com
Tallahasseereports.com
A peak?
Coming down?
Tallahasseereports.com
July 22, 2020 Escambia County COVID Dashboard
“Just Keep Swimming”--Dory
u Don’t go out if you have upper
respiratory symptoms or a fever
u If you are an asymptomatic
spreader and are sneezing/coughing from allergies, you are spewing virus
u Practice frequent hand hygiene
u Wash hands with soap and water
for at least 20 seconds especially after coughing/sneezing/blowing nose and touching public surfaces;
u Use hand sanitizer with at least
60% alcohol content and let air dry before touching anything;
u Avoid touching nose, eyes, mouth
with unclean hands.
u Cover nose/mouth with elbow
sneezing
u Throw tissue away in trash; u Immediately wash hands or use
sanitizer.
u Disinfect frequently touched
surfaces
u Tables, doorknobs, light
switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks.
u Most common EPA-registered
household disinfectants will work.
Remember that super-spreader events are associated with the following:
u Closed indoor spaces u Crowded places u Close-contact u 4th C -- Continuous exposure
High risk groups should continue most restrictive distancing guidelines.
screened for illness, employees wearing masks, frequent disinfection
been touched by others;
In general, don’t go out if you don’t have to, but if you must, follow basic safety rules and:
uWear a face mask covering your nose AND
mouth (!) when in close public spaces
u Prevents 99% of large droplets from
escaping
u Protects other people from your
droplets in case you are an asymptomatic spreader
u CDC states that if 80% of population
wore masks in public, the rate of COVID spread would be reduced in half
u
Only well-fitting respirators like N95 masks protect us from 95% of other peoples’ droplets
u
Avoid people wearing masks with vents
Exercise Eat a healthy diet and maintain a healthy weight Stop smoking Avoid excess alcohol
u A flu shot will not protect you
from getting COVID;
u A flu shot will not prevent you
from spreading COVID if you have it;
u However, without a flu shot,
you are more susceptible to getting influenza which will increase your risk of:
u Being immune-suppressed, u Developing pneumonia, and u Being susceptible to COVID
infection and complications.
uPCR tests for active infection at that moment uIt doesn’t tell you if you were infected >2 weeks ago uIt doesn’t tell you if you are immune to COVID uThere is a very high false negative rate within the
first 5 days of exposure (up to 2/3), but 20% of infected people will still test negative 3 days after symptoms.
uNeed better viral test uIf you have COVID symptoms or have had exposure to
COVID, get PCR tested:
uSelf-quarantine while awaiting test results; uSeek medical advice from your physician about when
to seek emergency care if you are symptomatic;
uIf no symptoms, wait to get tested about 5 days after
exposure
uCan get tested at many community sites even without
history of exposure or symptoms
This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY-SA
uBlood test uMay be helpful if you believe you had COVID
and were never tested.
uAsk your doctor or call Health
Department to inquire about the availability
uLooks for antibodies that develop after COVID
infection
uIgM antibody – lasts for about 2 weeks
after infection
uIgG antibody – made more slowly over
about 4 weeks and lasts longer, but how long? Does it cause lasting immunity?
uDon’t worry -- Our immune systems are
complex and have memories to fight the infection
uRed Cross now testing all blood donors
0.05% of deaths = ages 5-14 = 8 deaths (currently 3 deaths) 0.24% of deaths = ages 15-24 = 38 deaths (currently 13 deaths) 3% of deaths = ages 25-44 = 480 deaths (currently 154 deaths) 13% of deaths = ages 45-64 = 2,080 deaths (currently 751 deaths) 83% of deaths = ages >65 = 13,280 deaths (currently 4,424 deaths) ~19,000 deaths ~12,000 deaths ~5200 deaths as of July 22 Assume ~16,000 deaths by Nov. 1
u Stay strong mentally and physically; u This will be in our rearview mirror some
day but not soon;
u Be prepared to live your lives in response
to credible new scientific evidence (e.g., wearing masks, attending outdoor events);
u Finally, work to prevent a similar disaster
Restore a government that believes again in science and pandemic preparedness;
Strive for societal justice and equality;
Elect principled government leadership with moral values;
Fix our broken health care system.