We knew it was coming…well, it is here and then some. Last week, the trickle started, like popcorn beginning to pop. Over the weekend, it became full on Redenbacher. My team had over 24 new consults; we average 7. Most are probable COVID cases. I just logged in; we already have 4 new consults this morning.
Yesterday, shopping for food, I saw a solider in fatigues. I asked him what he was deployed for. The soldier informed me that his group is setting up MASH units in NYC, starting with the Javits Center, City Colleges and then Westchester County. With social distancing in full effect, the epidemic should peak within 2 weeks.
This may seem like bad news, but it’s actually good news. Yes, this means the outbreak hasn’t peaked in this area yet. BUT, this move is the right move and the USA has a tremendous reserve of healthcare. Further, all hospitals have postponed elective surgeries and procedures. Certain physicians, like ID docs, intensivists, pulmonologists, radiologists and ER docs, are going to be VERY busy in the coming days. Less so for other doctors. Nurses too are going to be working very hard.
Testing in Jersey has been and is a big problem. The TAT or Turn Around Time is over 7 days. This week, Jersey hospitals are bringing the COVID assays in-house. Hopefully, the TAT will be very short, very soon. NYC hospitals already have in-house assays with TATs <24 hours. This is clarion call for Jersey Medicine, which is nowhere near where it should and could be.
There is no new news regarding treatment. We anxiously await the data from China, South Korea, Australia and France. I do think hydroxychloroquine (HCQ) has a positive effect, but my experience is anecdotal. Also, we need to reserve HCQ for COVID infected pts and NOT use it for prevention of well people. In other words, Don’t take HCQ for prophylaxis.
We don't know the sensitivity of the assay or test . To know that, we would have to have a gold standard, meaning another test which told us who was really infected or not. We don’t have anything close to a gold standard for this disease.
Studies have looked at virus carriage, which means the persistence of virus replicating in the respiratory tract, over time. On average, a COVID-19 pt has detectable viral RNA for 10-14 days. This suggests that the sensitivity is pretty high. Survivors clear virus quicker than those who don’t survive.
When the reports about Chest CT scans helping clinicians diagnose COVID-19, I didn’t believe them. I do now. The CT scans have unique features, I haven’t seen before. Since the tests’ Turn Around Time is several days, the CT scan is very useful in predicting who has COVID-19 and who doesn’t.
Back to viral carriage, the French Study was small, but did show improved viral clearance with hydroxychloroquine (HCQ) +/- azithromycin. The French researchers swabbed the nose of each pt, each day over time and showed that those who received HCQ stopped testing positive much sooner.
We still don’t have clinical data, but anecdotally HCQ, at least, appears to work. In Medicine, we question anecdotal data, but ironically, a given doctor’s wisdom is derived entirely form anecdotal experience. The best clinicians are those that process their anecdotal experience in an honest way.
I haven’t heard about the development of tests which specifically detect antibodies against this specific virus. Coronaviruses are similar. A specific antibody test would help a lot in the long term.
Thanks for your post Dr. Smith. I have a question on your thoughts of the sensitivity and specificity of that testing that is being used. The nasopharyngeal swab from my understanding is the RNA pcr which is highly dependent on the quality of the sample. Some are saying that CT chest for ruling out covid is better to check for ground glass opacities. do you think there will be a lot of false negatives from the nasal swab? and if high suspicion will you do chest ct?
also have you heard anything about antibody testing ig G or Ig M as there are a lot potential asymptomatic covid carriers? what are your thoughts and will you be ordering that also in addition to nasal swab?