Update of COVID Infection, Exposure, and Testing

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

You have probably read news stories of a problem with the state system for reporting and tracking COVID testing, and the slow turnaround time for COVID test results from many lab vendors.  When this is combined with the substantial increase in cases and deaths we were seeing before the state database issue, this means the local health departments are hobbled in any attempts to try to control the pandemic with contact tracing, isolation and quarantine.  This impacts essential businesses and will impact  counties in the PHC region that will have the option of opening schools.

This affects us in three ways:

  1. A change in advice on the role of testing when we, or those in our family “bubble,” have symptoms or are exposed to someone with symptoms.
  2. Instead of relying on county contact tracers, we all need to become knowledgeable in the essential advice contact tracers give, and work collectively to spread this information in our families and the communities we interact with.
  3. We all need to redouble our efforts to slow the spread of infection: diligently practice physical distancing (especially by limiting travel, large gatherings, and crowded settings), appropriate use of masks/facial coverings (covering nose and mouth when in a public setting, especially indoors or when continuous physical distancing is not possible), as well as hand hygiene.

Potential COVID-19 Symptoms and Potential COVID-19 Exposure: Updated recommendations

General Principles

The two reasons you may be at higher risk of COVID-19 transmission:

  1. You are infected with COVID-19 and have symptoms.
  2. You are infected with COVID-19 and have no symptoms (and probably don’t know you’re infected).

Isolation and quarantine are different:

  • Isolation is for either laboratory confirmed COVID-19 infections or for individuals with symptoms suspicious for COVID-19.  The time period for isolation is 10 days after the symptoms began or after the date of the test (if the person was asymptomatic), provided the patient has no fever for 24 hours while not taking a medication that would suppress fever AND any symptoms are substantially improved.  If a person is severely immunocompromised, the isolation period is extended to 24 days.  COVID test results do not change the isolation period.
  • Quarantine is for asymptomatic close contacts of confirmed or suspected COVID-19 infection or situations with high risk of transmission, such as gatherings of un-masked individuals or returning from travel to a high prevalence area.  The time period for quarantine is 14 days after the last day of exposure to the person or situation that put the person at risk.  If a person under quarantine develops symptoms, they become a suspected case and must begin a 10 day isolation period.  Due to the shortage of COVID testing, testing for all those in quarantine may or may not be possible.

If one person in a household bubble is isolated due to confirmed or suspected COVID-19 infection, the entire household would be subject to quarantine.  The isolated person must be separated from everyone in their household bubble who are now in quarantine, to reduce ongoing spread of infection from the isolated person and the quarantined people.  Exceptions may be made for parents with small children.

If some members of the house are quarantined, say because of a workplace exposure or recent attendance at gathering without masks, they must be separated from those in their household “bubble” that are not under quaratine, for the entire period of the quarantine, to prevent infecting them in the pre-symptomatic or asymptomatic phases of infection.

What does separation mean?  Briefly, sleeping in a room by themselves, staying in that room as much as possible throughout the day, wearing a mask when leaving the room, and avoiding shared bathrooms if possible.  For more details, see this summary from the Mendocino County Health Department.

Symptoms of COVID-19

If you develop any of these symptoms, you should stay at home for 10 days, and call your primary care provider.

CDC list of symptoms:
  1. Fever (temperature over 100 degrees F)
  2. New or different cough
  3. Shortness of breath
  4. Sore throat
  5. Loss of taste or smell
  6. Chills
  7. Muscle aches
  8. New headache that persists for more than a few hours or is different from your usual headache

Other common symptoms seen in COVID-19 infections:

  1. Fatigue
  2. New nasal congestion that persists for more than a day after treatment for allergies
  3. New rash
  4. Chest pain
  5. Nausea, vomiting, and diarrhea
  6. Stroke-like symptoms, such as confusion, slurred speech, weakness on one side of your body

Common Scenarios:

I had a stuffy nose all day and some allergy symptoms; must I isolate at home? 

Other illnesses can cause any of the symptoms listed above, but with the prevalence of COVID-19 being so high, it is best to assume that any of these symptoms could be COVID-19, even if you have other medical conditions that could explain them.  Doctors are sometimes giving inappropriate reassurances over the phone, without testing for COVID-19.

If you have one of these symptoms that persists, and you have been evaluated by your PCP and tested negative for COVID-19, and you normally would work within the office, you should reach out to your supervisor or the Human Resources Department in your organization to make sure it is OK to come into the office.

If I have one of these symptoms and it resolves, can I get a COVID test to see if I can come out of isolation?

You should stay home for at least 10 days after the symptom is resolved.  Given the shortage of tests some providers are not ordering tests on everyone with symptoms.  Given the high rate of false negative COVID test results, even a negative test should not be considered a pass to come out of isolation early if you had symptoms suspicious for COVID.  A positive test is helpful for reinforcing the importance of isolation and quarantine.

What Constitutes a Close Contact?

If you know you had recent close contact and possible exposure with someone you know has or recently tested positive for COVID-19, you could be infected.

A close contact to a confirmed or suspected case is defined as an individual who:

    1. Lives in or has stayed at the case’s residence, OR
    2. Is an intimate sexual partner of the case, OR
    3. Provides or provided care to the case without wearing a mask, gown, and gloves, OR
    4. Was within 6 feet of a case for a prolonged period of time (10 minutes or more).

AND

    E. This contact occurred while the case was determined to be infectious. A                 case is infectious within 48 hours before that person’s symptoms began                 and until that person is no longer required to be isolated.

Close contacts should follow the same precautions as those listed for someone who had to travel or attended a social gathering and is returning to work: a 14-day quarantine at home.

If you travel out of the area or if you break from universal precautions (by attending a party or wedding, for example, or even a smaller gathering outside your usual “bubble” or “pod” without wearing a mask), you should stay out of the office (ideally at home) for 14 days of quarantine after your transgression.

Preventing COVID-19 transmission when you don’t have symptoms

Universal Precautions: Take actions that assume you may be infected with COVID-19 and don’t know it, to prevent accidental spread in your community.

The best way to prevent COVID-19 transmission is to:

  1. Stay at home, away from face-to face social gatherings with people outside your bubble/pod,
  2. Wear a mask as directed by the state order
  3. Maintain physical distancing, and
  4. Wash or sanitize your hands.

If you do this well in your everyday life, this certainly minimizes (but does not eliminate) the risk of asymptomatic transmission.

As testing becomes more available, some of these recommendations will change; stay tuned.

Good Medical Decision-Making: Much More than Applying Evidence

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Medicine is best described not as a science, but as a form of flexible practical reasoning that often uses science.”

Adam Rodman, MD

How do the best clinicians apply their knowledge?

Last year, this monthly newsletter reviewed the propensity for mental shortcuts, biases and prior experiences that lead to poor medical decision-making, and discussed options for minimizing the degree that these cognitive traps affect our clinical decisions. Think of this as the cognitive psychology of medical decision-making.

When mental shortcuts are minimized, and reasoning is applied, we might, at first blush, think that the best reasoning limits itself to “Evidence Based Medicine” where high quality, prospective, placebo-controlled, double blind, allocation concealed studies are consistently applied in making medical decisions. In reality, several sources of knowledge (sometimes conflicting with each other) are brought to bear. The study of the nature of knowledge is also known as epistemology, a branch of philosophy. Within the medical realm, this is known as medical epistemology, a branch of the study of the philosophy of medicine.

In a grand rounds at Beth Israel Hospital in October, 2019, clinical professor Adam Rodman, MD defines a historical framework of medical epistemologies that clinicians use to decide on what treatments to offer patients:

  1. Observation – This involves obtaining a careful and complete history and physical examination, with review of lab work to categorize the disease or diseases that a patient has, and recalling how similar patients/disease categories that the clinician has directly observed or heard/read about have responded to treatments given. The earliest example of this is the 4,000-year-old Edwin Smith papyrus, in which an ancient Egyptian healer carefully described a series of 48 surgical cases and their treatments.
  2. Theory – Pre-scientific theories, such as ancient Greek humoral theory of disease dominated medical practice until the mid-nineteenth century, when they were replaced by scientific theoretical frameworks, such as physiology, immunology, biochemistry. These frameworks are then used to interpret observations (such as a rising creatinine in a patient receiving a diuretic), and make judgements based on this understanding.
  3. Experimentation/Clinical Trials – While there are scattered examples of medical experimentation before 1900, it was not very commonly used. It is primarily a twentieth-century framework, and led to the Evidence-Based Medicine movement, starting in the late 1980s. It includes applying a hierarchy of different types of medical trials and studies, with expert opinion at the bottom of the pyramid and meta-analysis reviews at the top. This pillar of understanding has crumbled to be replaced with the current standard: grading of available evidence, which takes many other factors into account.
  4. “Population Medicine”/Epidemiology/Biostatistics – This began in the early 1800s, in Paris and was first called the “Numerical Method.” This involves collecting data on numbers of patients and analyzing this data statistically for insights that can then be used to improve clinical decision making for the individual patient being cared for. The most modern applications of this are decision rules (for example for osteoporosis screening or genetic testing), “big data” analyses, and augmented intelligence medical applications.

Rodman contends that whenever clinicians make treatment decisions on individual patients, we use some or all of these frameworks, even on the same patient, in the same day. The frameworks often might lead to conflicting treatment options which need to be sorted out rationally. Importantly, the third framework is the preferred framework for Evidence-Based-Medicine purists, but real-life excellent clinicians seamlessly integrate EBM with the other 3 frameworks. We need not feel guilty or inferior when we use these other frameworks; they have a vital role in the decision making of all excellent clinicians.

In the end, to the extent medicine uses science, it is in the application of science to deciding on individualized treatment of patients that matters.

The medical ethicist Jose Alberto Mainetti stated it best in his research, Embodiment, Pathology, and Diagnosis: “Diagnosis is not knowledge for knowledge’s sake. It is knowledge for the sake of action. Medicine exists to cure, to care, to intervene, or in limiting cases to know when not to intervene. Medicine is not a contemplative science.”

Knowing the noble history of these four epistemologies can help us balance their use thoughtfully, both in our continuing educational activities to better master them and in applying them to make therapeutic decisions that best serve our patients.

Brief COVID-19 Updates

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“When we have nations, institutions and advocates working on this collective response, we do see remarkable impact.”
     -Bill Gates at the 2020 COVID-19 Conference

There are several timely updates that we know would be of interest to primary care clinicians. Please forward on to your staff.

Surge of Cases Nation-wide Leads to Testing Delays
Public testing sites sponsored by the State in several counties have found long delays in results for the lowest risk groups, as the state announced criteria for prioritizing testing. OptumServe and Verily sites sponsored by the counties are affected. County health lab and local hospital lab turnaround (including Kaiser) is faster, but capacity is limited. Home testing is being rolled out by Lab Corps and soon Quest will join them. We will include more information on this in the next update.

Although point of care RNA testing (Abbott and others) is less sensitive than PCR-based testing, but some public health experts feel that a less sensitive point of care test that turns around results quickly, is better on a population level for screening than a more accurate PCR test with results available in 10-14 days.

All COVID tests are covered by PHC when done by any lab provider with a Medi-Cal provider number, up to 2 tests per day, for both diagnosis and screening.

Remdesivir Shortage Leads to Narrower Treatment Criteria
On a call with one of our local health officers, we understand that Remdesivir treatment is now being delivered to those who are inpatient requiring low-flow supplemental oxygen, as these patients have the most likely benefit for the treatment. Patients not requiring oxygen and those on high flow oxygen or intubated are less likely to benefit and are not being prioritized. A five-day treatment regimen has become standard for most patients.

Eye Protection Recommended in Health Care Settings with Moderate Community Transmission
The CDC recommends that eye protection be worn in health care settings where patients with unknown or positive COVID status are being cared for. The eye protection should not have gaps between the skin and should not rest on the protective covering around the face, meaning eyeglasses are not sufficient (see CDC recommendation for details). We understand that CDPH is considering making this recommendation into a requirement in California.

Familial Autosomal Recessive Mutations Associated with Higher Risk of Severe Disease in Younger Patients
In a study that gives insight into the pathogenesis of COVID-19, a case series of 4 young male patients with severe COVID-19, were found to have a previously undiagnosed immune deficiency: a relatively rare putative loss-of-function variants of X-chromosomal TLR7 were identified that were associated with impaired type I and II interferon responses.

Obesity an Independent Risk factor for Severe COVID-19
A report from the American College of Physicians noted that Obesity is associated with an increased risk for intubation and death in COVID-19 patients under age 65, but not for those over age 65.

“Broken Heart Syndrome” Increased During COVID-19
An observational analysis of patients without COVID-19, receiving echocardiograms at the Cleveland Clinic, found an increased percentage with stress cardiomyopathy (also known as takotsubo syndrome or broken heart syndrome). The rate ratio before COVID-19 was 1.5 to 1.8%, while the rate ratio during the lockdown rose to 4.6%.

Stress cardiomyopathy is a physical manifestation of sustained psychological stress. This study shows the degree of population stress that the response to the pandemic is having on the community.

Childhood Immunization Rate Rebounding (Somewhat)
The graphic below, from the California Immunization Registry, shows that the rate of immunization for MMR (a proxy for overall childhood immunization activity in young children) has mostly rebounded in California in the past month. Overall, though, there is a remaining backlog. Without in-person school in many parts of the state, the usual August bump in immunization rates may not occur this year. Next week, PHC will be starting a state-mandated phone outreach campaign to children under age 2 to remind them of the importance of vaccination and well-child visits.