Agenda for 09/02/2020

• Covid update

• Bradykinin hypothesis

• When to DC Isolation

• New state blueprint to reduce Covid cases

• Miscellaneous/Open Discussion

This activity has been designated for CME and

ABIM MOC credits and is being recorded

Today’s Activity Code: 13654

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Today’s Activity Code:

13654

Hope and fear cannot occupy the

same space. Invite one to stay.

-Maya Angelou

Teleconference Etiquette

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858-672-5202

Update not Covid related

• A CDC Health Advisory was issued Aug 27th, providing clinical guidance for Carbon

Monoxide poisoning in the wake of Hurricane Laura

• While San Diego is quite far from where that directly affected people, they do travel

• The advisory was intended to warm clinicians about CO poisoning, due to people

losing normal heat sources and turning to space heaters, and generators without

proper ventilation, in garages, homes, campers

• CO is colorless and lack of smell makes it insidious

• Symptoms are variable and nonspecific, and include tension-type headache,

dizziness, flu-like symptoms without fever, drowsiness and altered mental status

• The patients may exhibit tachycardia, tachypnea, hypotension, metabolic acidosis,

pulmonary edema, irritability, ataxia, and impaired consciousness

• Test for carboxyhemoglobin (COHgb); treat with high flow 100% O2

Update Sept 2

• Abbott released a $5 point of care test kit (BinaxNOW) that doesn’t require a machine

• It is a direct antigen test, whereas PCR tests for minute RNA pieces of the virus

• Intended to be used on symptomatic persons thought to have Covid

• Testing occurs in 3 settings: Diagnostic, Screening, and Surveillance

• PCR is still preferred for diagnosis, the antigen test might be useful for surveillance or

screening in congregate settings (college, SNF)

• Works similarly to a pregnancy test, but using a nasal swab

• While the company reports high (97%) sensitivity, a recent VA study here, showed it to

be closer to 58%

• The Hill, reported the Trump administration has ordered 150 million of these rapid tests,

which is nearly all of the tests produced by Abbott

• CA state contracted with a new lab that will increase covid PCR testing by 150,000

tests/day

Supercomputer help – The Bradykinin Hypothesis

• The Summit, the worlds 2nd fastest computer in the world at the Oak Ridge National Lab

in TN, started crunching data on more than 40,000 genes and 17,000 genetic samples,

and analyzed 2.5 billion genetic combinations

• They found a correlation with bradykinin that explains many of the unusual symptoms of

Covid, which unleashes a bradykinin storm, thru a tweak of the renin-angiotensin system

• ACE, which normally degrades bradykinin, is downregulated by Covid

• The dysregulations of bradykinin causes increase lung capillary permeability, and filling

the lungs with fluid while also increases hyaluronic acid (HLA) in the lungs, turning the

secretions into a hydrogel accounting for the difficulty oxygenating

• The RAS controls bradykinin, and aspects of cardiac contractions and blood pressure

• Covid may act like an ACE inhibitor, with cough, decrease in BP, increased K levels,

Covid toes, as well as loss of taste and smell

Update Sept 2 - Famotidine

• Famotidine (Pepcid) associated with benefits in hospitalized Covid patients, a finding

released from the American Journal of Gastroenterology Aug 25

• Observational study of 83 hospitalized Covid patients

• The mechanism of action, yet unproven, is that the drug inactivates certain

proteases, or through H-2 receptor blockade, decreasing histamine

• This study confirmed the findings of a previous study of 878 patients

• Currently being studied in a randomized controlled trial with either remdesivir or

hydroxychloroquine

Testing asymptomatic persons after Covid exposure

• Recent changes by the CDC and FDA, that asymptomatic people exposed to Covid did

not need testing, were walked back after considerable outcry from the medical

community, and now recommends testing

• Their initial recommendation came with a caveat that if the person exposed were in a

high risk group, then testing should be considered. (Prior studies show 95% of the

population has one of the high risk conditions)

• The change originated with the White House coronavirus task force, a division of HHS

• The World Health Organization issued guidance to encourage testing after exposure,

in response to the CDC change.

• The revision is based on asymptomatic viral shedding in as much as 50% of persons

that are pre-symptomatic or asymptomatic

Updates Sept 2 – Convalescent Plasma

• The FDA issued guidance Aug 23rd, to allow

emergency use of convalescent plasma from

recovered Covid patients. It is not an approved FDA

treatment outside clinical trials

• Sept 1 an NIH panel released a statement that there

is no evidence backing the use of convalescent

plasma to treat coronavirus patients

• They go on to say it is not standard of care, and more

prospective controlled trials are needed

• A June open label trial from China, 103 patients with

severe Covid were randomly assigned to standard

treat, with or without plasma

DC Isolation, and return to work

• CDC guidance changed, from a testing strategy to symptom-based

• For most persons, isolation can be discontinued 10 days after the onset of symptoms,

and afebrile without the use of fever-reducing meds

• A small subset of persons with severe illness may reproduce virus beyond 10 days,

so consultation with ID is recommended, and possibly DC isolation after 20 days

• For persons who never developed symptoms, isolation can be discontinued after 10

days from the date of the first Covid+ test

• For persons who are severely immunocompromised, a test strategy could be

considered in consultation with an ID specialist

• For persons who develop new symptoms within 3 months after initial Covid +

symptoms, no testing is recommended, and seek another diagnosis

New state blueprint for reducing Covid-19 – Sept 2

• Separates the state into 4 degrees of activity: Widespread, Substantial,

• San Diego is in the Substantial tier (2), and we need to maintain a case rate 4-

7/100k, and positivity rate 5-8%

• Many businesses allowed to open with modification of distancing, reduced clientele,

masks, and screening

• Still closed: Bars not serving food, breweries, concert venues, convention centers,

distilleries where no food is served, festivals, live theaters, saunas, steam rooms,

theme parks

• Many businesses can open with reduced seating, such as restaurants, movie

theaters, the zoo, gyms (10%),

• Moving between tiers requires a minimum of 3 weeks in that tier

• Tier 3 allows businesses at 25% of capacity can go to 50%, Tier 4 – full capacity

New cases

Reported 9/1, with 4% of tests reported positive

County Health Department testing sites

COVID-19 Resources

More than 100 community testing sites also offer free, confidential testing: Find a

COVID-19 Testing Site.

For more information about what Californians can do to prevent the spread of

COVID-19, visit Coronavirus (COVID-19) in California.

California continues to issue guidance on preparing and protecting California from

COVID-19. Consolidated guidance is available on the California Department of

Public Health's Guidance web page.

Resources

• Clinician On-call Center is a 24 hr hotline with trained CDC clinicians standing by

to answer healthcare personnel questions, at 800-CDC-INFO (800-232-4636)

• National Institutes of Health: Coronavirus Disease 2019 (COVID-19) Treatment

Guidelinesexternal icon

• California epidemiologist on call # 916-328-3605

• Guidelines for healthcare worker exposure at work

• https://www.sandiegocounty.gov/coronavirus.html

• California Health Alert Network (CAHAN)

• Sharp specific coronavirus site (sign in with your citrix (Cerner) password

• The reopening continues, with the following, while observing physical distancing:• https://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/commun

ity_epidemiology/dc/2019-nCoV/reopening.html

Open Forum and Questions

This will be no Monday webinars. We will continue to meet weekly, on Wednesdays,

same time and link.

Also anyone needing additional PPE, we do have some still available from the state,

being distributed by the CMA. Let your network representative know as soon as possible.

Reminder this activity

is being recorded

TEXT YOUR ATTENDANCEIts important that we know you are participating

Text Attendance Number:

(858) 247-3111

Today’s Activity Code:

13654