新冠日记 6 阶段小结
1月21号，在华盛顿州发现了第一例新冠肺炎病人。30多岁的年轻男性。
1月23号，武汉封城。
2月1号的时候，川普决定所有在中国停留或居住的旅游者不能进入美国。这个决定从2月2号星期天下午东部时间5:00实施。
2月4号，川普决定从武汉撤侨。
从1月21号的第一例开始，到2月5号，确诊的新冠肺炎的病人，基本上都是在武汉封城之前回到美国的中国人，或者是他们的家属。一共有12例。
2月10号到2月13号之间，从武汉撤侨回来的人群中，发现有三例阳性。
随后的一段时间，美国相对比较风平浪静。一直到2月25号，确诊病例一共有57个，而且其中的40例来自于钻石公主号游轮的返美游客。
二月份的最后一个周末注定是一个不平凡的周末。从某种意义上说也许闰年不吉利是有一定道理的。首先在星期五的时候在加州发现了的两例来历不明的肺炎，然后Oregon也发现了一名来历不明的肺炎。这个发现说明在了某些居住社区会有多人感染。
同时在这个周末还爆出了华盛顿州一个老人院多名老人和职工感染的情况。其中有一名50多岁的男性病人在2月29号去世。记录了在美国第一位因为新冠肺炎去世的案例。
截至2月29号的时候，美国确诊的感染人数是71位，其中有44来自于钻石公主号。正是由于这个闰年二月份的第五个星期六发现了不明来历的社区感染病人，CDC由此放松了检测的原则，开始以上呼吸道症状为主，并不苛刻要求相关的旅游史和接触史，我们这样才有可能检测更多的可疑患者，发现更多病例。
今天是三月九号，到目前为止美国的确诊的人数是753，是2月29号人数10倍还多，而只是十天而已。目前为止去世人数是26位。
加州，华盛顿州，纽约州都是重灾区。
在这里我放一份加州感染科医生开会做的一份会议讨论记录。感谢我的朋友转发给我，感谢加州同行慷慨的与医务人员分享。希望对大家有一定帮助，对疾病的症状，检查和治疗都有些了解。
这份总结很多数据都来自于一亩三分地。谢谢程序员们的努力。
3/8/2020
Notes from the front lines:
I attended the Infectious Disease Association of California (IDAC) Northern California Winter Symposium on Saturday 3/7. In attendance were physicians from Santa Clara, San Francisco and Orange Counties who had all seen and cared for COVID-19 patients, both returning travelers and community-acquired cases. Also present was the Chief of ID for Providence hospitals, who has 2 affected Seattle hospitals under his jurisdiction. Erin Epson, CDPH director of Hospital Acquired Infections, was also there to give updates on how CDPH and CDC are handling exposed health care workers, among other things. Below are some of the key take-aways from their experiences.
1. The most common presentation was one week prodrome of myaglias, malaise, cough, low grade fevers gradually leading to more severe trouble breathing in the second week of illness. It is an average of 8 days to development of dyspnea and average 9 days to onset of pneumonia/pneumonitis. It is not like Influenza, which has a classically sudden onset. Fever was not very prominent in several cases. The most consistently present lab finding was lymphopenia (with either leukocytosis or leukopenia). The most consistent radiographic finding was bilateral interstitial/ground glass infiltrates. Aside from that, the other markers (CRP, PCT) were not as consistent.
2. Co-infection rate with other respiratory viruses like Influenza or RSV is <=2%, interpret that to mean if you have a positive test for another respiratory virus, then you do not test for COVID-19. This is based on large dataset from China.
3. So far, there have been very few concurrent or subsequent bacterial infections, unlike Influenza where secondary bacterial infections are common and a large source of additional morbidity and mortality.
4. Patients with underlying cardiopulmonary disease seem to progress with variable rates to ARDS and acute respiratory failure requiring BiPAP then intubation. There may be a component of cardiomyopathy from direct viral infection as well. Intubation is considered “source control” equal to patient wearing a mask, greatly diminishing transmission risk. BiPAP is the opposite, and is an aerosol generating procedure and would require all going into the room to wear PAPRs.
5. To date, patients with severe disease are most all (excepting those whose families didn’t sign consent) getting Remdesivir from Gilead through compassionate use. However, the expectation is that avenue for getting the drug will likely close shortly. It will be expected that patients would have to enroll in either Gilead’s RCT (5 vs 10 days of Remdesivir) or the NIH’s “Adaptive” RCT (Remdesivir vs. Placebo). Others have tried Kaletra, but didn’t seem to be much benefit.
6. If our local MCHD lab ran out of test kits we could use Quest labs to test. Their test is 24-48 hour turn-around-time. Both Quest and ordering physician would be required to notify Public Health immediately with any positive results. Ordering physician would be responsible for coordinating with the Health Department regarding isolation. Presumably, this would only affect inpatients though since we (CHOMP) have decided not to collect specimens ordered by outpatient physicians.
7. At facilities that had significant numbers of exposed healthcare workers they did allow those with low and moderate risk exposures to return to work well before 14 days. Only HCW with highest risk exposures were excluded for almost the full 14 days (I think 9 days). After return to work, all wore surgical masks while at work until the 14 days period expired. All had temperature check and interview with employee health prior to start of work, also only until the end of the 14 days. Obviously, only asymptomatic individuals were allowed back.
8. Symptom onset is between 2-9 days post-exposure with median of 5 days. This is from a very large Chinese cohort.
9. Patients can shed RNA from 1-4 weeks after symptom resolution, but it is unknown if the presence of RNA equals presence of infectious virus. For now, COVID-19 patients are “cleared” of isolation once they have 2 consecutive negative RNA tests collected >24 hours apart.
10. All suggested ramping up alternatives to face-to-face visits, tetemedicine, “car visits”, telephone consultation hotlines.
11. Sutter and other larger hospital systems are using a variety of alternative respiratory triage at the Emergency Departments.
12. Health Departments (CDPH and OCHD) state the Airborne Infection Isolation Room (AIIR) is the least important of all the suggested measures to reduce exposure. Contact and droplet isolation in a regular room is likely to be just as effective. One heavily affected hospital in San Jose area is placing all “undifferentiated pneumonia” patients not meeting criteria for COVID testing in contact+droplet isolation for 2-3 days while seeing how they respond to empiric treatment and awaiting additional results.
Feel free to share. All PUIs in Monterey Country so far have been negative.
Martha.
Martha L. Blum, MD, PhD