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Posted on: May 19, 2020

COVID-19 Update for Clinicians: May 19, 2020

SUMMARY: See this health alert for

  • Augmented Case & Contact Investigations for COVID-19
  • COVID-19 Clinical Trials
  • Multi-System Inflammatory Syndrome in Children Associated with COVID-19
  • COVID-19 Data

Augmented Case & Contact Investigations for COVID-19 

Actions Requested:

  • Test for COVID-19 in all patients with compatible clinical syndromes. For additional guidance, please re-visit the Washington State Department of Health’s COVID-19 testing guidance.
  • Advise tested patients to stay home and away from others until test results are known and provide them with the following information sheet: What to do if you have confirmed or suspected COVID-19
  • If you have a patient with suspected or confirmed COVID-19 who is unsheltered, homeless, or who cannot safely isolate at home (e.g., due to inability to remain out-of-contact with vulnerable household members), please contact the Snohomish County Isolation & Quarantine facility at 425-238-3439.
  • Advise patients that if they test positive for SARS-CoV-2, they will be contacted by the Health District to complete a confidential case investigation and launch contact notification efforts. Please encourage them to be responsive to and cooperate with the Health District’s efforts in this respect.

Background:

Using augmented resources, the Health District will now resume direct involvement in COVID-19 contact notification-and-home-quarantine, no longer delegating such to cases to execute.  When the initial surge of cases occurred in late February through early March, the Health District was forced by circumstance to triage contact notification efforts, delegating most cases to notify contacts on their own. Case isolation and contact notification-and-quarantine has become a central strategy for suppression of transmission necessary to support a safe, incremental return to activity. 

Resources:

COVID-19 Clinical Trials

Action Requested:

Consider referring patients to University of Washington studies addressing (1) treatment of cases and (2) post-exposure chemoprophylaxis for contacts of COVID-19.

Background

The University of Washington is recruiting subjects for multi-site investigations of chemotherapy and chemoprophylaxis of COVID-19. 

The treatment study for confirmed cases is a phase IIb, double-blinded, placebo-controlled, randomized trial designed to compare the efficacy of low dose hydroxychloroquine plus azithromycin versus placebo to prevent hospitalization and death in symptomatic adult outpatients with COVID-19. Inclusion criteria are:

  • ≥18 years of age
  • Positive test from the nose or throat for COVID-19 RNA from any respiratory specimen collected within the last 72 hours.
  • Experiencing at least one of the following symptoms: fever, cough, or shortness of breath
  • Agree not to participate in another COVID-19 study during the study. Participants may participate in another COVID-19 study if they get hospitalized.

The post-exposure prophylaxis (PEP) study for contacts will randomly assign participants to take hydroxychloroquine or a placebo over two weeks, and nasal swab samples will be collected and tested daily to confirm new COVID-19 infections across the two groups.

Both studies will use telemedicine as an interface, reducing time, transportation, and health care visit demands on participants.

To refer a patient, simply direct them to the appropriate web-site for self-enrollment:

Multi-System Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19

Actions Requested:

Be aware of an uncommon, new syndrome of severe inflammation with Kawasaki disease-like features associated with COVID-19 that is being reported in children.

  • Consider this syndrome in children who present with persistent fever, inflammation (e.g., neutrophilia, lymphopenia, elevated inflammatory markers [e.g., CRP, ESR, D-dimer, ferritin]) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder). See below for additional information.
  • Perform both PCR and serological test to detect the presence of SARS-COV-2, the virus that causes COVID-19, and/or corresponding antibodies in the patient.
  • Use COVID-19 PPE and infection control precautions while patients are under evaluation for and if diagnosed with COVID-19.
  • Healthcare providers who have cared or are caring for patients younger than 21 years of age meeting MIS-C criteria should report suspected cases to the Health District (425-339-5278) within 24 hours.

Background:

  • In the United Kingdom and Europe, a possible link has been reported between COVID-19 and a serious inflammatory disease initially termed “Pediatric Multi-System Inflammatory Syndrome Temporally Associated with COVID-19.”
  • This syndrome has features which overlap with Kawasaki Disease and toxic shock syndrome. Inflammatory markers may be elevated, and fever and abdominal symptoms may be prominent. Rash also may be present. Myocarditis and other cardiovascular changes may be seen. Additionally, some patients have developed cardiogenic or vasogenic shock and required intensive care. This inflammatory syndrome may occur days to weeks after acute COVID-19 illness.
  • As of May 5, 2020, 64 cases had been reported in children in New York State.
  • As of May 11, 2020, one pediatric clinical case compatible with multi-system inflammatory syndrome associated with COVID-19 has been reported in a Snohomish County resident. This adolescent patient presented with several days of fatigue, headache, dizziness, confusion, fever, rash, nausea, vomiting, and loose stools. Clinical findings included hypotension, tachypnea, myocarditis with reduced ejection fraction, elevated BNP, lactic acidosis, leukocytosis, acute renal insufficiency, mild elevations in transaminases, elevated inflammatory markers, and normal plain chest radiography. A nasal mid-turbinate swab was negative for SARS-CoV-2 RNA by PCR and serum was positive for anti-SARS-CoV-2 IgG.
  • It is advisable to explore other microbial causes, including bacterial sepsis, staphylococcal or streptococcal shock syndromes, and infections associated with myocarditis such as enterovirus. Clinicians should not delay seeking expert advice while waiting for results of these investigations.
  • Early recognition by pediatricians and prompt referral to an in-patient specialist, including to critical care, is essential.
  • Pediatricians and specialists should elicit any recent history of illness with COVID-19 or close contact with individuals who are known to have COVID-19 in children presenting with symptoms that are compatible with pediatric multi-system inflammatory syndrome potentially associated with COVID-19.
  • The majority of patients who have presented with this syndrome have tested positive for SARS-CoV- 2 or corresponding antibodies. Some tested positive on diagnostic, molecular testing for SARS-CoV-2, others were positive on serological testing for corresponding antibodies.
  • Surveillance case definition (not necessarily applicable to individual medical decision making):
    • Compatible clinical syndrome, AND
    • Absence of a probable cause other than COVID-19, AND
    • Positive testing for or known exposure to COVID-19.


Resources & Additional Reading

Source: adapted from Washington State Department of Health, May 15, 2020.

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Note: data is incomplete for the most recent 7-10 day period.

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