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

Last Thursday, California released the details of its previously announced “resilience roadmap,” giving requirements and recommendations for safely allowing resumption of activities based on public health risk.  This roadmap starts to give us some longer-term understanding of how the future will unfold in the months ahead. Stages 2 is fairly detailed now; stages 3 and 4 will have additional detail added later.  County health departments have been given important responsibilities in this process, ensuring sufficient community testing to allow opening up to occur, overseeing local implementation of the planning, workplace changes, and citizen communication.  We appreciate the difficult tradeoffs they are balancing in their decision-making; thank you!

The governor’s office is now shifting focus to developing strategies to address the massive budget shortfall being faced next year; their “May Revise” of the budget is due soon.  All programs that rely on state funding (education, health, public safety, transportation) are concerned about what cuts the state will use to prepare a balanced budget.

As of last week, six counties in the PHC service area (Marin, Sonoma, Napa, Yolo, Mendocino and Humboldt) now have mandates for facial coverings/masks when indoors or in crowded outdoor areas where physical distancing cannot be maintained.  Local community groups have stepped up to provide masks/facial coverings to vulnerable populations, including the homeless.  This demonstrates that a community need, combined with community spirit can ensure community-wide adherence to such requirements.

Here are a selection of updates gathered in the last 12 days, which we thought you would find helpful.  Thanks to everyone for sending suggestions and feedback!

1. Policy updates
   1. Verizon offers FCC grants to promote telehealth deployment.  Since it is a federal grant program, the paperwork and steps are rather complicated.  See the online application to get started.
   2. Congregate living environments have been particularly susceptible to COVID outbreaks across the U.S.  The CDC has posted guidance for owners/managers of these facilities to prevent spread of COVID-19.  Please pass this on to the managers of facilities where your patients live.

2. Public Health Update:  This pre-print article recalculates the estimated Ro (R-naught) of COVID-19 taking transmission of asymptomatically infected individuals into account.  Their revision increases the Ro to at least 5, with a mean likely Ro of 15.  This higher Ro helps explain the rapid spread in New York City, and the stubborn persistence of new cases and deaths in the California in spite of Public Health mitigation efforts.  The implication:  a higher level of herd immunity will ultimately be needed to eliminate outbreaks.

3. Efficient use and access to PPE.  In previous communication, we presented some PHC-generated guidelines on re-opening outpatient medical practices.  The AMA released similar guidelines.  In our discussions with local PCPs, insufficient access to sufficient masks and other PPE is a major barrier to re-opening.  Here are some new resources:
   1. CDC guidelines on optimizing efficient use of PPE.  The Centers for Disease Control and Prevention have released optimization strategies for PPE offer options for use when PPE supplies are stressed, running low, or absent.
   2. Free PPE Decontamination for Reuse.  The State of California, in cooperation with federal partners, is offering Battelle Critical Care Decontamination Systems as a solution to the N95 shortages impacting California, which will be available to all practices, free of charge.  There was some early miscommunication indicating that it was only available for hospitals, but we have confirmed that this is not true; outpatient health care offices may also use this service.

4. COVID Testing Updates
   1. Population Testing: Why is Open Testing a Goal?  The availability to test for SARS-CoV2 RNA is expanding steadily in our region, leading to rapid changes in local recommendations for testing.  While most PCPs are testing based on presence of symptoms or contacts with either cases or vulnerable populations, some external testing sites are encouraging anyone who wishes to be tested to get tested.  While on first blush this looks like an inefficient use of COVID tests, an interesting finding shows that there is some psychology to this policy.  When “asymptomatic” individuals who test positive are questioned, over half actually did have mild symptoms that they discounted at the time, suggesting that subconsciously these individuals were worried enough about these mild symptoms to seek out testing.
   2. Limits of “Rapid” RNA tests.  The first rapid COVID RNA test (Abbott) to come on the market has several important limitations.
      1. Once the specimen is collected, it must be run within 2 hours.
      2. Unlike the standard tests, no viral transport medium can be used; it can lead to false negative results.
      3. The company has not validated this test on asymptomatic individuals, and so recommends only using it for those with symptoms.  This recommendation may change in the future.
   3. Limitations of serology test interpretation.  The California COVID-19 Testing Task Force put together a succinct, easy to understand explanation of what serology tests help with and what they should NOT be used for.  The FDA has updated its policy on SARS-CoV2 antibody testing after a flood of serology tests came to market, some with poor performance and fraudulent labeling.
   4. New method of RNA testing.  Researchers are working to adapt the CRISPR gene editing methodology to identify SARS-CoV2.  Instead of amplifying, the viral sequence to the point of detection (done in PCR tests), the CRISPR method finds the viral sequence and then sends a signal, which is then detected.  The charming name for this testing methodology is SHERLOCK. If this technology is perfected, it will allow large scale rapid testing for RNA.

5. COVID disparities.  The COVID-19 outbreak initially involved cruise ship customers, international travelers and their direct contacts, and evolved to a pattern of community spread, disproportionately affecting individuals who live in crowded conditions and who continue to work as essential workers.  A steady stream of epidemiological data has showed that community spread in cities has disproportionately affected socioeconomically disadvantaged individuals.  This is reflected in analysis of hospitalizations and deaths in New York City, which showed Manhattan (with a higher median income) with less burden of disease than The Bronx and Queens, which have a much lower median income.  Evaluating race/ethnicity disparities in context is important, as there are many subconscious biases and tropes which humans are prone to attribute as causes of these disparities (thoughtfully summarized in this excellent NEJM article).

6. COVID Treatment Updates.
   1. Remdesivir:  Gilead asks Federal Government to Distribute for Compassionate Use:  Most Hospitals left out. Remdesivir is less available than previously as Gilead turned over responsibility for distribution of the drug to the Federal Government.  Remdesivir was approved under Emergency Use Authorization on 5/1/2020 for IV administration to hospitalized COVID-19 patients, based on preliminary data from the ACTT-1 study. Per the EUA factsheet, recommended adult dosing is 10 days for critically ill patients (intubated/ECMO) and 5 days for all others, with the ability to extend to 10 days if no clinical improvement. Per the distribution website, hospitals identified by the U.S. government as a recipient for donated remdesivir will be proactively contacted; to find out if your hospital has been designated to receive donated remdesivir, you can email remdesivir@amerisourcebergen.com Certain hospitals were given a supply, others were granted none.  The basis of this allocation has not been clear.
   2. Elevated PTT in serious COVID—Anticoagulate anyway!  This article found that the elevated Partial Thromboplastin Time (PTT) found in critically ill COVID patients is due to the presence of Lupus Anticoagulant, as part of an antiphospholipid syndrome.  As a result, it is an indication of a hypercoagulable state, needing anticoagulation.  Another study (added to several done before with similar findings) showed that critically ill patients with COVID had better outcomes if administered low molecular weight heparin.
   3. Pediatric Multisystem Inflammatory Syndrome (PMIS). A number have reports have been issued in the past two weeks on this topic, affecting 64 pediatric patients in New York and more in other countries with a serious condition that looks somewhat similar to Kawasaki disease:
      1. A child presenting with persistent fever, inflammation (e.g. neutrophilia, elevated C-reactive protein and lymphopenia) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder). This may include children meeting full or partial criteria for Kawasaki disease.
      2. Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal or streptococcal shock syndromes, and infections associated with myocarditis such as enterovirus.
      3. This literature is evolving quickly; any potential cases would warrant consultation with a pediatric infectious disease specialist for therapeutic advice.
   4. List of all clinical trials for treatment of COVID.  The Medical Letter has shared a comprehensive list of all drug trials being used to test    treatments of COVID.  It is worth a quick look to get a sense of the many strategies being considered.

That’s it for this week!  We at PHC continue to be proud to support and serve you as you support your community in your daily work.

Robert Moore, MD MPH MBA

Chief Medical Officer