COVID-19 Q&A
With Dr. Erlaine Bello

April 24, 2020
Aloha PMAG Physicians,

Pasted below, we've compiled your COVID-19 questions and had them answered by Dr. Erlaine Bello, Infectious Disease expert (Chief, Division of Infectious Diseases; Associate Professor Department of Medicine at JABSOM).

We separated the categories as follows: Prevention, Treatment and Prognosis.

Starting next week, we'll be collecting your questions every Monday and Tuesday and then sharing Dr. Bello's answers on Friday. Click here to submit your questions .

Sincerely,

Pacific Medical Administrative Group (PMAG)
PREVENTION
Q:  How do we continue to see our office visits when LITERALLY each one could represent a COVID case? (Pediatrics)

A:  There are measures that I am sure you are already taking in your office to be able to see your pediatric patients. These include:
  1. Careful pre-visit symptom screening so that you know who is coming in with what and when.
  2. Taking advantage of Telehealth and phone visits which most insurers are supporting but to varying degree as you suggest with HMSA ; Medicare has specific guidance on components of its Annual Wellness exam which can be done by Telehealth.
  3. Using appropriate PPE for those with symptoms.
  4. Masking the patient if they can tolerate upon entry to your office as source control
 
Q.  Throat cultures as aerosol generating event?

A.  Doing a nasopharyngeal washing, aspirate and scoping are considered aerosol generating events. When obtaining a nasopharyngeal swab for suspected :
  1. Specimen collection should be performed in a normal examination room with the door closed.
  2. HCP in the room should wear an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a gown.
  3. If respirators are not readily available, they should be prioritized for other procedures at higher risk for producing infectious aerosols (e.g., intubation), instead of for collecting nasopharyngeal swabs.
  4. The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for specimen collection.
  5. Clean and disinfect procedure room surfaces promptly as described in the section on environmental infection control below. A simple throat culture is not considered an aerosol-generating event.
  • There is no published data on the transmission risks of COVID-19 from crying or singing of which I am aware.
  • If you are wearing a face shield or goggles and an N95 or surgical mask your risk is low. Face shields can be wiped down between visits with the usual disinfection wipes. Iolani School continues to make face shields for health care providers free of charge. Let me know if you need these. PMAG is assisting with its members with PPE.

Q.  How should we counsel patients regarding grocery shopping or eating take-out food?

A. There is no evidence that COVID-19 is transmitted by food. Store-bought food:
  • It's always a good idea — even when there's no pandemic — to rinse fresh fruit and vegetables with water to remove dirt, debris and pesticides, and reduce levels of foodborne germs.
  • There's no need to wash food with soap. "Soap is for hands, not for food,"
  • If you are concerned about food packaging, you can wash your hands after handling the packaging. If you are concerned about your food, you can cook it at 149 degrees Fahrenheit (65 degrees Celsius) for 3 minutes, which will significantly reduce levels of any virus particles. Takeout:
  • Should be low risk as the food industry has a heightened awareness about food safety. To further reduce the risk,wash your hands after handling food packaging or takeout bags This is a good opportunity for people staying at home to prepare their own healthy food that they have stood in line for for so long at Costco! Also could you comment on the role of transmission from symptomatic persons?
TREATMENT
Q.  What are your thoughts about hydroxychloroquine in COVID disease management?

A.  The data for efficacy is mixed as what has been reported so far is mostly anecdote with a variety of doses in patients at different stages of disease. A lot of people latched onto hydroxychloroquine (HCQ) because it was readily available and nothing else has shown efficacy. Randomized, controlled trials are going on now including at Queen’s Medical Center for hospitalized patients. Hydroxychloroquine is not without side effects including eye/vision and prolongation of the QTc interval. The Infectious Diseases Society of America recommends the drug be used only in the setting of a clinical trial.
 
Q.  What about using HCQ in a symptomatic patients who have a negative influenza test while waiting for COVID test results?

A.  Would not recommend that empiric treatment strategy for the following reasons:
  1. Early data out of China suggested a low rate of co-infection. However a study published in JAMA last week looked at a larger number of patients in Northern California that found a much higher rate of co-infection with rhinovirus /enterovirus in about 12% and influenza A about 3%.
  2. As above hydroxychloroquine is not necessarily a benign drug
  3. Treatment efficacy is not proven
  4. There is now a limited supply as there seem to have been hoarding going on just like toilet paper and rice. Physicians in particular were writing large prescriptions for themselves in the hundreds of tablets. Patients who take the drug for rheumatologic diseases on a chronic basis for which HCQ has proven efficacy should be the prioritized recipients of HCQ.
  5. Patients with mild symptoms who are not sick enough to warrant hospitalizations should be managed with symptomatic care.
PROGNOSIS
Q:  How do we ever return to running a busy office which mixes teenage physicals with acute sore throats, lingering coughs with full exam rooms and crowded waiting areas?

A:  Yes, our practice environment has changed dramatically in a short time. It may not go back or at least not for a long while. But there are ways to re-engineer our practices as above for starters. Change is difficult and rapid change is even more difficult. But I believe that as a profession we can respond with resilience and endurance if we support each other. PMAG has already provided a number of resources to support us and will continue to do so.
Email below previously distributed on April 13, 2020.
COVID-19 Q&A
SUBMIT YOUR QUESTIONS
DR. ERLAINE BELLO WILL ANSWER
Aloha PMAG Physicians,

PMAG is coordinating a COVID-19 Patient Care Q&A effort to answer our clinicians' specific questions regarding the novel coronavirus.

Our board member, Dr. Erlaine Bello, a well-known Infectious Disease expert (Chief, Division of Infectious Diseases; Associate Professor Department of Medicine at JABSOM) is willing to take time from her busy schedule to answer questions for our PMAG physicians.
If you would like to watch Dr. Bello’s webinar from March 25, 2020, "COVID-19: The Crown Evolves," click here for the first 45 minutes recording Click here for entire talk on Powerpoint .
Here is the process:
  1. PMAG Physicians submit questions regarding COVID-19 Patient Care using this link.
  2. PMAG will collect the questions and forward to Dr. Bello.
  3. Dr. Bello will answer your questions as soon as she is able.
  4. PMAG will share the COVID-19 Q&A collected via email and post the Q&A on our website www.pmaghawaii.org.

We hope this effort will provide needed answers to our members during this critical time. Please submit your questions here. Dr. Bello will answer them as soon as she is able.

If you have questions about our COVID-19 Q&A efforts or process, please contact Jeong Ku Hwang, PQH Project Manager at jhwang@pqhhawaii.com .

Together, we can create win-win-win even in difficult situations. Thank you for your trust and patience with PMAG.

Sincerely,

Gregg Shimomura, MD
PMAG Medical Director