Americans returning to the US from Europe. March 15, 2020 at Chicago O’Hare
3/15/20 – Update on COVID-19
We wanted to send this update to share as much information as possible with our Cloud members as transparently as possible.
Last week our practice devoted a huge percentage of our administrative time and effort attempting to accurately answer the most fundamental questions that we believe are crucial to understand the evolving COVID-19 situation in order to make sense of where we are, and to help us make the best decisions in the days and weeks ahead.
I was taken aback by the amount of misleading and conflicting information that we were being given from various sources which we would have assumed to be reliable. However, after cross-checking each source with many others, we believe we have answered our main questions with reasonable accuracy. You can read some of our questions below, as well as the most updated answers based upon the best available information that we have to date.
1. How widespread is COVID-19 in our community currently?
As of noon Sunday, 3/15/20, according to the CDPHE website, there have been 711 tests run in Colorado thus far with 101 positives and 610 negatives. No positive cases in Boulder county were listed on this website, yet Cloud Medical has been notified of at least 2 verified cases in Boulder county. So there is clearly a delay in the website updates.
2. What percentage of local patients being tested (using current criteria) are positive?
According to these statistics, about 14% of Coloradans who have been tested turned out to be positive for COVID-19. We assume that only those who met the current stringent clinical testing criteria were tested. What is unknown is the actual number of individuals who have COVID-19 in our community population at large (including those currently sick with various cold and flu symptoms but who do not yet meet the testing criteria, as well as those who have no symptoms at all). This is a key question to answer ASAP if we hope to contain the spread of the virus. It is our hope that the CDC expands its criteria far more liberally in the coming days to include testing of such individuals.
(According to some studies, over 17% of patients infected with COVID-19 can be completely symptom-free, and it is yet unclear if such individuals are contagious.)
3. Are the testing criteria currently being used effective and efficient?
Based on the previous question, it is still unclear how rapidly the virus is spreading locally and nationally. Under more ideal circumstances as was seen in other countries (e.g. Taiwan) who were better prepared and more proactive than we have been in the US, testing would have been more available much sooner. This would have allowed the detection of a larger percentage of positive individuals with appropriate containment strategies of their contacts early in the course of the epidemic. The reason this is so important is that countries with slower responses have quickly overwhelmed the capacities of their local hospitals to care for the rapid influx of very ill COVID-19 patients who need advanced inpatient care. This is why “flattening the curve” is so important.
4. How accurate are the tests in terms of sensitivity (low false negatives) and specificity (low false positives)?
There is a significant uncertainty regarding the accuracy of the nasal swab test currently being used (even as the availability of this test is very limited at the moment). Most of the evidence suggests a sensitivity in the 70% range, which means that nearly a third of those who test negative, may in fact be positive for COVID-19.
5. What are the policies, protocols, strategies, and tactics most likely to help us with the two most important goals right now? 1.) decreasing mortality, and 2.) limiting the overwhelm of the healthcare system so that everyone sick enough to require hospital care is able to obtain it.
In order to accomplish these two goals, we will need to come together as a community and do our part to “flatten the curve” with simple, easy to implement, common-sense strategies. This can decrease unhelpful panic reactions which can lead to dangerous fear-based responses including violence, hoarding, and other forms of anti-social behavior.
I was struck when visiting two stores and a Boulder restaurant this weekend to witness no evidence of any of the simple steps (now well-publicized everywhere) that can and should be taken by local businesses to limit to person-to-person spread of the virus.
Unless we are currently sick or have had exposure to a known COVID-19 positive individual, we don’t need to be quarantined 24/7, but we do need take some basic precautions to protect ourselves and our neighbors. Store owners should help customers use credit card terminals without requiring them to touch the key pads and pens, provide alcohol based wipes for baskets and carts, maintain a safe “social distance” between customers and their employees, etc. These next few weeks will be crucial if we don’t want to end up like Italy. For a basic list of recommendations, here is the “Idiot’s guide” from an ER physician. We want to support our local business and help them avoid unnecessary economic fallout, but in turn we should expect them to take recommended precautions to decrease viral contagion.
6. Where in our area can testing be obtained?
This has been the biggest bottleneck so far. Over the past several days the “drive-up” testing facilities in Denver were quickly overwhelmed, local emergency rooms and hospitals were reserving COVID-19 testing only for those meeting the CDC criteria, and even some of our patients who did meet the criteria were turned away. Our practice was very grateful to receive a limited number of test kits which we do offer to our patient-members, and which are processed at a lab in Centennial, CO. Surprisingly however the lab is not processing specimens through the weekend, which is resulting in even further delays. If you meet the current criteria, and if we have an adequate supply of testing kits, we will continue to provide testing for our patient-members.
7. Are there any medications I should stop taking if I think I might have COVID-19?
There is some conflicting evidence regarding ACE-inhibitors (blood pressure meds like lisinopril and ramipril) and ARBs (includling losartan, valsartan, and olmesaltan). Initially there were reports that these medications might potentially be protective against COVID-19, however this has not been verified and we are awaiting further evidence prior to any recommendations of either starting or stopping these medications in context of the virus.
8. Are there any medications that are effective in treating COVID-19?
A number of drugs are being tested in rapidly organized clinical trials worldwide and show some preliminary promise against the virus. Tamiflu does not appear to be effective. An older anti-malarial drug, a newer anti-HIV drug, and an anti-Ebola drug area all being studied and used in select severe cases. None are currently being recommended preventatively or for milder cases. As we noted in prior newsletters, anyone with respiratory problems (such as asthma and COPD) should have a home pulse oximeter and be careful to not run out of important medications such as inhalers.
9. Should I still go to the gym?
In our previous newsletter we discussed the important strategies to maintain a strong immune system. Exercise is crucial, so it’s important to move our bodies. The best place to do that, especially now, is outdoors in nature. If you have to go to the gym, make sure there are wipes available, go during off-peak hours, avoid spending much time in the locker rooms, and maintain the other simple “social distancing” practices.
10. Should I still go to work?
Ideally, your workplace will have implemented strategies to limit unnecessary exposure by now. If it is practical and feasible to do your work from home, then we recommend you do so. If that is not possible, then use the general recommendations above.
We are here for you. We’re with you.
We hope these updates are helpful and feel free to reach out if you have more questions.
Your Cloud Medical Team