1月21號，在華盛頓州發現了第一例新冠肺炎病人。30多歲的年輕男性。
1月23號，武漢封城。
2月1號的時候，川普決定所有在中國停留或居住的旅遊者不能進入美國。這個決定從2月2號星期天下午東部時間5:00實施。
2月4號，川普決定從武漢撤僑。
從1月21號的第一例開始，到2月5號，確診的新冠肺炎的病人，基本上都是在武漢封城之前回到美國的中國人，或者是他們的家屬。一共有12例。
2月10號到2月13號之間，從武漢撤僑回來的人群中，發現有三例陽性。
隨後的一段時間，美國相對比較風平浪靜。一直到2月25號，確診病例一共有57個，而且其中的40例來自於鑽石公主號遊輪的返美遊客。
二月份的最後一個周末注定是一個不平凡的周末。從某種意義上說也許閏年不吉利是有一定道理的。首先在星期五的時候在加州發現了的兩例來曆不明的肺炎，然後Oregon也發現了一名來曆不明的肺炎。這個發現說明在了某些居住社區會有多人感染。
同時在這個周末還爆出了華盛頓州一個老人院多名老人和職工感染的情況。其中有一名50多歲的男性病人在2月29號去世。記錄了在美國第一位因為新冠肺炎去世的案例。
截至2月29號的時候，美國確診的感染人數是71位，其中有44來自於鑽石公主號。正是由於這個閏年二月份的第五個星期六發現了不明來曆的社區感染病人，CDC由此放鬆了檢測的原則，開始以上呼吸道症狀為主，並不苛刻要求相關的旅遊史和接觸史，我們這樣才有可能檢測更多的可疑患者，發現更多病例。
今天是三月九號，到目前為止美國的確診的人數是753，是2月29號人數10倍還多，而隻是十天而已。目前為止去世人數是26位。
加州，華盛頓州，紐約州都是重災區。
在這裏我放一份加州感染科醫生開會做的一份會議討論記錄。感謝我的朋友轉發給我，感謝加州同行慷慨的與醫務人員分享。希望對大家有一定幫助，對疾病的症狀，檢查和治療都有些了解。
這份總結很多數據都來自於一畝三分地。謝謝程序員們的努力。
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
