November 13, 2020

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The Three Cs: Close Contact, Close Faces and Crowded Places

“Guidance for today is guidance for today.”—Dr. Stephen Sears

The information below is a summary and highlights of the Thursday, November 12, call for clinicians led by COVID-19 Response Team Clinical Advisor, Stephen Sears, M.D. For information on scheduled days and times for upcoming calls please reach out to MMA Director of Communications and Government Affairs Dan Morin by email or call/text at (207) 838-8613. Note: There will be no call on Thanksgiving, November 26. Calls will resume Thursday, December 10.

Maine’s positivity rate over the last few weeks has risen from 1.49 to 2.47.

Why is there a surge? The three Cs: Close Contact, Close Faces and Crowded Places.

  • Our rates have become higher as we move indoors
  • Respiratory viruses seem to do better in cooler temperatures and lower humidity

Good news is it may have less virulence overall and a lower fatality rate per hospitalization than what was seen early in the summer. It is believed that is due to better treatments and more effective management of oxygen early on and improved ICU treatment(s). Death rates are down and some consider it partly a result of improving therapeutics and a better understanding of symptoms and diagnosis.

Pfizer Vaccine

The preliminary data looks promising but Dr. Sears emphasized that the data is preliminary. Vaccine planning in Maine is ongoing and logistics are being developed. There is expected to be different levels of prioritization for dissemination toward priority groups such as first responders and hospital personnel first, and then high risk groups. There have been questions and concerns expressed about the necessity for ultra-cold storage of the Pfizer vaccine which requires -80 centigrade. However, it can remain outside cold storage for for delivery and use over several days. A vaccine from Moderna also seems to be close to release behind Pfizer

Studies & Observations

It’s important to note a common cautionary statement by Dr. Sears to be cognizant of studies and reports resulting from case reports versus those from controlled data. Some determination and observations may seem reasonable but they oftentimes do not yet tell us the answers.


Monoclonal antibody treatment was highlighted: First trials show it is not effective on hospitalized patients but did show efficacy for people prior to hospitalization according to a New England Journal of Medicine study. The federal government is making it available to all states in small quantities and for specific populations. The supply may grow but right now Maine plans to receive only 90 doses so will be used for those most likely to benefit according to the data.

He also referenced an MBio reference looking at the mutation rate in SARS-CoV-2 virus. We’ve now moved  to period showing a homogenous transmission rate countrywide.

None of the drugs are magic bullets but just another tool in the box.

Journal of Infectious Disease: Virucidal Efficacy of Different Oral Rinses Against Severe Acute Respiratory Syndrome Coronavirus 2

Dr. Sears—It does appear that mouthwash will not back viral load for a period of time after use. Listerine, for example, has shown to help. It may not protect from infection but it could theoretically decrease the viral load for infected persons.

US CDC Morbidity and Mortality Weekly Report: SARS-CoV-2 Exposure and Infection Among Health Care Personnel SARS-CoV-2 Exposure and Infection Among Health Care Personnel

Dr. Sears—Health care workers continue to be at risk due to exposures at work and publicly along with everyone else. The study shows hospitalized health care workers tend to be similar to general population in that those had underlying conditions such as obesity. Forty-three percent were in nursing.

Reminder to be aware of increasing mental health challenges associated with the pandemic, whether through COVID-19 or the environmental and personal effects of the pandemic. Continuing concerns about very strong data showing an increase in depressive disorders, anxiety disorders and suicide.

Dr. Sears referenced a current study for a new diagnostic test involving the placement of small nasal strips in the nostrils that absorb nasal fluid. They are not yet available . If effective they could be very helpful for pediatric patients. The study conclusion is in preprint phase and currently shows they are a reliable non-invasive sampling method.

Travel Medicine and Infectious Disease: Self-reported symptoms from exposure to Covid-19 provide support to clinical diagnosis, triage and prognosis:

Dr. Sears—An exploratory analysis survey 20,000 people had COVID and categorized symptoms and concluded the triad of anosmia, ageusia and fever best distinguished those who tested positive from those who tested negative and differentiates COVID-19 from other viral diseases. Loss of smell/taste with fever is highly associated with COVID and not much else. It’s not astounding but shows the effectiveness of those symptom screens when looking at a large population

Antigen testing

There are three major antigen tests

  • Quidel
  • BD
  • BinaxNOW
    • The test Maine has received from the federal government (different than Abbot ID NOW test) and the test outlined in this edition of Maine Medicine Weekly Update. The test will be more widespread due to the number available
    • Best used within symptomatic people within 7 days of symptoms. Not approved for anything other than symptomatic people but is increasingly being used for asymptomatic.
    • Currently being distributed to Walgreens, prisons, EMTs, and FQHCs. Other health care facilities and practice groups can apply for them. It may also potentially be used for serial testing of critical infrastructure workers.

They are not  as sensitive as PCR testing. First, the background prevalence will determine the predictive positive value and the predictive negative value.  Practically, if someone has symptoms consistent with COVID and have tested negative they should have the test repeated with PCR (be concerned with false negatives). If a-symptomatic and it’s positive you should be very concerned with false positives. Because of our relative low prevalence in Maine the positive predictive value of the BinaxNOW test is not as high as we would like (40% to 50% range). The thought is if someone has clinically compatible symptoms and gets a positive result it can be a very useful test.

Maine CDC urges to keep using POCR tests for outbreak settings

Oxford University has developed a rapid test not yet available in the that allegedly can identify the virus in 5 minutes or less. The company said it may apply for authorization from the U.S. Food and Drug Administration.

American Journal of preventative Medicine: Predictive Factors for a New Positive Nasopharyngeal Swab Among Patients Recovered From COVID-19

Dr. Sears—Close to 17 percent of patients recovered from COVID-19 could still carry virus. If retested within two weeks they still show positive which is why retesting is not recommended. It is not viable virus. It is viral particles (RNA) which are amplified within the genetic test.

JAMA: Cytokine Levels in Critically Ill Patients With COVID-19 and Other Conditions

Dr. Sears—JAMA study shows that much of what we thought about cytokine storm may not be all that different from sepsis and a number of the SERS syndromes.

There are some diagnostic studies that combine rapid PCR with antibody testing. According to Dr. Sears, it may be useful for people farther out in illness. It’s not widespread but coming along.

A key point emphasized was that there are a lot of different diagnostic studies appearing. Unfortunately, we’re getting them a lot earlier in their development. It doesn’t mean they aren’t useful but there are caveats which we wall need to be aware. Dr. Sears pointed one study example of a study conclusion being different this week than a few weeks ago. Three weeks ago a study suggested that ocular disease is a problem with COVID-19. Another was just released saying it isn’t a problem. We spent the first 4 or 5 months running to catch up clinically and now we have the opportunity to do appropriaste clinical trials to see what eventually turns out to be the most effective overall

Clinical Observations/Miscellaneous Information/Call Q&A:

Post COVID fatigue: By the second week most people remain ill but by six weeks most are better but some have chronic long term fatigue, mental fogginess and for people with serious pulmonary problems. Some have chronic symptoms for months although those are mostly people who were in the ICU. Long haulers-don’t have positive virus but positive symptoms

There’s a lot of reassessment on anticoagulation for the acute individual. The risk of clots is about 16 percent with severe COVID but the risk of complications of anticoagulation is really unknown but appears to be in the 10 percent range,

Antiphospholipid antibodies studies that seem to be associated with increased risk of anticoagulation disorders.

Autoimmunity is looking like one of the hallmarks of the disease and we are getting to better defining the conditions. Some of the neurologic effects seems to be related to immune responses. Questions remain as to why steroids and some other interventions seem to work? Unsure. There’s a lot of clinical data but it’s not controlled data so we need to be careful on how the information is interpreted. Things that we thought were useful sometimes turn out not to be.

Oral health issues remain something to be aware of. There’s a significant decline in treatment and routine care.

Remdesivir indications have been increased to include anyone hospitalized with COVID. Initially it was for those with sever COVID with a certain oxygen saturation  level or headed toward repository decline. Now indications have increased. There is a caveat. Those are US guidelines but WHO is looking at multi-national data that doesn’t show much benefit from Remdesivir.

Study about convalescent plasma showed it doesn’t have significant benefit although monoclonal antibodies do appear to have benefit. Prior to hospitalization, those with chronic conditions, over 65, obese, and other risk factors showed a clearly decreased viral load and decreased hospitalization.

Updates on antibody testing: There are a couple of companies (Seamans and Roche) seems to have higher sensitivity and specificity but the immune correlative for protection and/or immunity. Clearly it has something to do with anti-spike antibodies. It’s useful for some but difficulty to interpret.

PCR remains the best test overall but we are moving back into the area of reagents shortage and PCR availability. Some areas of Maine of moving back to prioritization for PCR. One pitfall is when large population screening is done with PCR it potentially prevents the flexibility of investigating outbreaks.

CMS is covering monoclonal antibody treatments for Medicare recipients without cost, however, there is concern because there are very few available and they will be needed for very specific populations. How well does it work? Just another tool but not a major breakthrough and is useful in certain situations

England study on infection fatality rate: 1.15 percent looking at compilation of approximately 175 various studies but we nee more studies of subpopulations

Neuropilin-1 (NRP1) is another molecular target now identified along with Ace2

No confirmed case yet for influenza in Maine. It’s still early. It’s typically seen later in November.

Vitamin D studies have been for and against. In most studies it doesn’t make much difference in most studies, however it’s not from controlled data.

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