TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.
This week’s topics include a look at the Italian experience with COVID-19, a recalculation of age-specific mortality rates relative to the infection, and preparations at Texas Tech.
Program notes:
1:26 European Society of Anaesthesia
2:27 Designating hospitals for COVID patients
3:27 One of the most well developed systems globally
4:15 Estimates of severity and mortality
5:14 1.4% case fatality rate
6:02 Preparations at Texas Tech
7:02 In ED, who is going to be admitted
8:02 Masks worn continuously in hospital
9:02 Indicate to others the seriousness of the infection
10:02 Staff concerns?
11:02 Shortages?
12:02 More than one patient on a vent
13:02 Studies underway
13:40 End
Transcript:
Elizabeth Tracey: What does a look back at the Italian experience so far tell us about COVID-19 patients?
Rick Lange: An estimate of the severity of the COVID disease.
Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, we’ll just advise our listeners we’re going to do something a little different today. We’re talking about, of course, the updated research that’s out there relative to COVID-19, but then we’re also going to take a look at your preparatory efforts at Texas Tech as this pandemic moves across the country.
Rick: This is the first time we’ve ever done this. For the last 15 years, we’ve just reported on the newest studies that have come out that week. This is the first time we’re talking about personal experience — and I don’t plan to do it again — but we’re in a very unique situation. With that, take it off. Let’s talk about the studies, Elizabeth.
Elizabeth: I would just add one thing. One reason that I’d like you to talk about your preparations is because I think many clinicians I’ve talked to and had exposure to in the chaplain role have really been struggling with a lot of issues. I’m hoping that you’ll reflect, and I know you’re going to do that thoughtfully, about many of these issues that I will bring up shortly.
Let’s turn first to the journal Anaesthesia. This is from the European Society of Anaesthesia and Critical Care Medicine. They took a look at the experience in Italy up until fairly recently, just a couple weeks ago because, of course, it takes a little while to crunch all these numbers.
They characterized patients who were COVID-19 positive as 82% having fever, 81% having cough. They calculated the R0 as 2.68 and reflect that the reason that it’s that high is because there’s so much asymptomatic transmission. I would say that that number has been ratified in a lot of other data I’ve seen outside of this particular data, where this big concern about this asymptomatic viral shedding period is enormous and appears to be responsible for a lot of the transmission. Among healthcare workers one concern, of course, is the number who are becoming infected. This study so far seems to suggest that it’s less than 10%.
One thing they’re considering in Italy is designating actual hospitals as either COVID-positive or COVID-negative. Other things that they’re looking at and are reflecting on retrospectively include oxygenation with invasive or non-invasive methods, making the suggestion that perhaps early use of BiPAP or CPAP could help people avoid the need for mechanical ventilation and intubation if it’s initiated sometime early.
They also talk about the necessity for having an observer for the donning and doffing of PPE as people go in and out of units where they’re treating these patients, and this needs to be an experienced person who’s paying really close attention. We’ve seen that ratified in other outbreaks, specifically Ebola.
Rick: This was an interesting article in that it wasn’t a study necessarily, but it was a composite of their experience. They’ve talked about factors that contributed to the collapse of the healthcare system there despite the fact that the Italian healthcare system is really one of the most well-developed systems globally. They talked about the importance of public health. Several measures that were implemented there included the use of telemedicine consultations, domestic isolation of COVID patients, educational videos, and obviously firm restrictions against public gatherings. This is a very important study that talks about their experience, hoping that it could be shared worldwide to mitigate some of the consequences of COVID infection.
Elizabeth: Yeah, and unfortunately many prognosticators, of course, putting forward the idea that domestically we’re going to resemble Italy a lot more than we do China.
Rick: Right, and they report a case mortality rate in those over the age of 80 of 52.5%.
Elizabeth: Let us move to the next one, of course, in The Lancet Infectious Disease.
Rick: This was an attempt to get a better handle of the estimates of the severity of the coronavirus disease, specifically to talk about mortality. As we’re reporting it in real time or online, especially when there’s an exponential rise in the number of people becoming infected, those that die do so 2 or 3 or 4 weeks after they report symptoms, so there’s always a little bit of a lag. Early on, especially, the cases that get reported are really the most severe cases, and some individual with moderate disease or even mild disease that might not be first identified may have the disease and have a lower mortality rate. What these authors did is they did identify their crude case fatality ratio simply by dividing the number of deaths by the number of cases. They determined that it was about 3.7%.
Then they used individual case data — both from mainland China and also from cases detected outside of mainland China, people being repatriated — and they assumed a constant attack rate, and they adjusted for age, and demography, and location, and they actually determined that the case fatality ratio was actually 1.4%. The mean duration from symptom onset to death was about 18 days, and from the onset of symptoms to hospital discharge was about 25 days. The case fatality ratio increased dramatically based upon age. In those under 50 years of age, it was less than 1%, those 70 to 80 about 8.5%, and those over the age of 80 it was about 13%.
Elizabeth: I think that this changing denominator of course points to the need — and so many people have echoed this sentiment — for widespread testing and quick testing because we really don’t know what that denominator is still.
Rick: Right. The latest estimate, Elizabeth, is that 20% to 25% of individuals infected are actually asymptomatic.
Elizabeth: Well, so then let us turn now to our discussion of how you all are preparing. I guess I would say that for today, how many patients, if any, do you have?
Rick: If you’d look across the city of El Paso, we have 50 confirmed cases. We’re on the very early part of the curve.
Elizabeth: Tell me about your preparation efforts and what sources are you consulting to help you to prepare?
Rick: We face the same issues as other communities around the country such as a lack of testing — real-time, quick, available testing. We are very concerned also about facilities, the ability to handle surge, the ability to have all the equipment that’s necessary — particularly, people are focused on ventilators — and also trying to preserve PPE.
With regard to the testing, we have to be strategic and we have to prioritize. We prioritize those patients in whom identifying COVID infection early is most critical. That’d be those that are being hospitalized — because we want to geographically isolate those patients from the rest of the individuals in the hospital — people in the emergency department that are going to be admitted, and we have to decide which floor to put them on, and then finally healthcare providers who are on isolation. If we want to bring them back to work earlier, we have them tested at 7 days. If they’re negative, we allow them to be back in the workforce. We’d like to be able to expand it to all exposures, even those without symptoms, but there’s just not adequate testing to do that.
Elizabeth: So you would say that one of the major barriers right now to getting your arms around this is a rapid and reliable test.
Rick: I think so, Elizabeth. The way to prevent this is to isolate individuals that have the infection from the rest of the population. Because we didn’t take this seriously early on, I think we’re seeing the repercussions of it now. All of my healthcare workers that were outside the city traveling for either work purposes, or usually for personal purposes, before they can enter the workforce, I ask them to be on 14-day isolation to prevent infecting other healthcare workers and patients. So we’ve been pretty stringent. All of our healthcare workers wear a mask continuously while in the hospital regardless of whether they’re dealing with COVID-infected patients or not, just because we don’t know who could be infected. Furthermore, a case in a healthcare worker may have minimal or no symptoms and be a source of infection.
Elizabeth: You’re well aware, of course, that yesterday they reported that the CDC was considering widespread use of masks in public places after discouraging that. What made you decide to go to a full masks all the time in your health center?
Rick: Couple things. As you’re aware, I was recently in Vietnam. We were doing some work with some medical schools there. Probably 90% of the individuals that I saw were wearing masks around the city, 100% of the hospital. We were hosted by the Minister of Health there and they’ve done a very good job of minimizing the spread of the disease. I’m convinced that proper hand hygiene, social distancing, and not touching your mouth or nose are incredibly important for preventing the disease. If you have a mask on, you’re less likely to touch your mouth or your nose. When you have your mask on, you indicate to other individuals that this is a pretty serious infection. You also encourage social distancing here in the U.S. I understand that people say, “Well, it doesn’t filter out all the particles.” That’s only one of the benefits of wearing the mask.
Elizabeth: Well, I would just note that I’ve actually been wearing one in all public situations for about the last 5 days or so. There is a shortage, of course, but many, many pieces of data that seem to suggest that even using a modest face and nose covering — like a bandana — that’s washable is also helpful.
Rick: I don’t want to mislead our listeners to think that it filters out a lot of the virus particles. It can help decrease droplets. I think the secondary benefits are incredibly important too.
Elizabeth: I’d like to turn to something that has been really front and center for me in just the last several days. That is concerns of staff — both physicians, nurses, especially respiratory therapists and other folks in the hospital, even environmental services people — relative to this whole pandemic. What is your experience with your staff so far and what are you doing to help?
Rick: First of all, I’ve tried to remove the most vulnerable individuals, so I’ve asked all my healthcare providers over the age of 65 not to be involved in clinical situations. I’ve encouraged everybody to approach every patient and every colleague as though they could possibly be COVID-infected.
I’m a firm believer that if you use that approach and you’re vigilant about it, that your risk of infection — and if we remove the high-risk individuals from the workforce, your risk of mortality — is fairly low. We’re in an occupation where there will always be risk, but by approaching it very vigilantly and very seriously, I think we can minimize that.
We have single points of entry. We have screening. We allow no visitors at all in the hospital, even in labor and delivery. We are making sure they are employee assistance programs, that we’re encouraging each other, supporting one another through this difficult time.
Elizabeth: One of the concerns that I’ve heard among many clinicians is this issue of shortages, shortages of PPE, as well as shortages of ventilators, and even the medicines that are used to keep people comfortable when they’re on ventilators. How are you addressing those?
Rick: Right now we have a policy where there’s no wastage of PPE. For most situations around the hospital — not all — we have people wear a mask continuously, and that avoids individuals using three or four or five masks. The N95 mask, the ones that are the most protective, because they’re in short supply, we’re trying to be very targeted about where we use those.
Ventilators have become a significant issue around the country. We’re doing a number of things, Elizabeth. We’re monitoring their use daily and where they are around the city. Every morning, I have a call with all the chairs, deans, and CEOs of the hospitals so we could find out where the resources are and share those. We’re fortunate to have William Beaumont Army Medical Center in our community as well that will help us step up to the plate.
There are several centers around the country that are putting more than one patient on a ventilator when access is severely restricted, so we’re preparing for that as well. Finally, we’re assembling an ethics committee that will help us make the difficult choices when there aren’t enough ventilators to meet the needs of our patients.
Every day that we can delay this gives us opportunities to get more ventilators available, and then because the peaks in the country will occur at different times — I suspect that the peak in New York over the next couple weeks and then will begin to die down and the other cities will peak — that allow us to share resources around the country.
Elizabeth: Tell me both what your fantasy is or what your hope is relative to this pandemic. If you had one thing that you could pull out of the hat right now, what would it be?
Rick: We’re hoping there is some seasonal variation. Obviously all of us would like vaccines. They’re not going to be available in time. We’d like to have treatment options, and there are several under investigation right now that show promise. The studies are going so quickly I hope within 2 to 3 weeks we’ll have the answer and they’ll be available to our patients.
If I had one wish, it would be that we could socially isolate or distance everybody. To the healthcare workers on the frontlines, I want to express my appreciation. We’ve never seen anything like this before. We’re in very challenging times and we’re on the front lines, trying to take care of our ourselves and our patients in these difficult times. My hat’s off to you. I salute you, and want to thank you for what you’re doing across the country and across the globe.
Elizabeth: On that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.
Source: MedicalNewsToday.com
