In this video, two of UCSF’s pediatric infectious disease specialists provide an important update. Find out when to suspect MIS-C, a serious syndrome that can affect a child’s heart, and which treatments help. Then learn how to guide families with a positive test on isolation practices and community resources.
so we'll focus on is really the M. I. S. C. Or the multi system inflammatory syndrome that's associated with starts Kobe to and briefly if there's time allows, we have time for discussion and talk about some of the other political manifestations. But since this is the one that has been um focused on and mostly identified in Children as one of the more severe or manifestations of um stars Kobe two or covid 19 and pediatric population. I thought we'd spend some time on this. So going backwards a little bit in terms of timeline, it all started around april where the Royal College of Pediatrics and Children Health um from U. K. Described eight patients presenting with this hyper inflammatory syndrome which is out of characteristic unusual for their uh normal Kawasaki like patients that they do see. Um in terms I think they described their usual was maybe four or 5 and then they saw eight in a row. And that prompted this uh news um to be distributed among the physicians in the UK. And and really for them they had their normal or median age was about 6 to 14 years of age, 60% of them are male. And then 75 of them were afro caribbean descent and all were initially pcR positive. Similar reports that started coming up from italy Spain and France. Um Subsequently in May um NyC Health Department put out an advisory of similar uh inflammatory syndrome that was noted in kids. Um Initially had 15 cases, four of them were PcR positive and uh Uh and six of them were antibody positive and negative. PCR. by May 13 there were about 100 cases reported in the entire New York state. Subsequently on may 15th the W. H. O. Came up with a case definition for this and subsequent to that C. D. C. Also came up with their case definition. And since then there have been numerous case reports that have been published describing this phenomenon. And um really places where they have seen a higher number of kids with covid 19. They've also seen this uh M. I. S. C. Syndrome. So looking closely at the case definitions as defined by the W. H. O. And the CDC. So left hand uh column is the W. H. O. Case definition. Children and adolescents 0 to 19 years of age with fever greater than three days and two of the following rash or bilateral non Purell in consecutive itis or mucous cutaneous information, signs of oral hands or feet, hypertension or shock features of myocardial dysfunction including pericarditis, vasculitis or coronary abnormalities, evidence of cardiomyopathy and acute gastrointestinal problems such as diarrhea, vomiting or vomiting. Okay associated with that they have to have an elevated inflammatory markers with the S. R. C. R. P. Pro calcitonin and no other obvious microbial cause of information such as substance or toxic shock syndrome because a lot of those other defining features are over laughing and then you have to have evidence of covid 19 either by pcr or antigen test or you have to have astrology positive or be in contact with the person that close contact with the person who had Covid 19 C. D. C. definition is similar although they have I think less stringent criteria, some would say. But they are defining it as less than 21 years of age presenting with fever. Lab evidence of information, evidence of clinically severe illness requiring hospitalization with two multi system involvement, cardiac kidney, respiratory human logic. G. I. Germany logic or neurologic. They have to have fever for greater than 24 hours or report of subjective fever lasting than 24 hours. A lot of evidence including but not limited to cr pes are Fred religion propelled the timer 14 um not the gas acidosis I. 06 and increased beautiful or decreased lymphocytes and low albumin. They have to have no alternative diagnosis and they have to have a current or recent diagnosis of SARS COV two exposure within four weeks prior to onset of symptoms. So you can see the C. D. C. Definition is a little bit lax and note that they don't give you specific numbers or threshold. So you don't have to have crp greater than three or s are greater than 40. Um there are differences in case definitions from Kawasaki disease, although I'm sure you can note that there are some similarities. So looking closely at what we have or what we know and how the data started to come out. Initially there was a UK report that was put up by land set around in May, which describe the eight patients with the hyper inflammatory syndrome, as I mentioned before, their ages were around 6 to 14, predominantly male had africa being descent 75% of them and about almost 90% of them were weight greater than 75th percentile. All were initially pcr negative, although two did later test positive post discharge. All of them are. Most of them actually had no respiratory symptoms. And even those who never integrated were because they had cardiac dysfunction, not primarily respiratory dysfunction and all of them received. I B I G, the italian report came out and this was the paper that was much talked about. So I think we kind of like um as a medical or a scientific community have gone from one report to the other. And there was a cluster um emails that were sent around, do you see this UK report? And then I think a couple weeks later, did you see this italian report? So there was a big uh chatting chat about the Bergamo province and they noted a 30 fold increase in their incidents of Katie like disease, which they described um um as uh and they compare the kids between pre um like March april and then uh and during March and april and they noted that there was a 34 increase in the March to april cohort generally those kids when you compared to the pre covid versus during the post covid, the March to april generally, they were older. They had elevated crp elevated white count with new flick shift and then lower platelets and elevated for certain. And as I go through these reports, you'll start to see sort of a threat in a pattern to the laboratory reports and also the clinical manifestations subsequent to that. There was a France and Switzerland report. 35 patients were 14 centers admitted to the ICU for cardiogenic shock. They had left particular dysfunction and severe inflammatory stage, median age was about 10 years and 28% of them had comorbidities, including as many over right about all of them received I. B. I. G. And one third of them received steroids in terms of their systemic signs and symptoms. Um Majority of them had the ballpark on gingivitis. They definitely half of them had red, cracked lips. They had an apathy storm esoteric and apathy is in about 60% of them. Skin rash was noted about greater than half of them. And then there was definitely a product predilection towards left ventricular dysfunction. Come on. So this is the most recent case report or case series that we have seen. Now, it's been published in Jama and june, this is a cohort of 58 kids from eight hospitals in UK that described this pimps which is similar to M. I. S. C. There are a couple of different terminologies that were uh initially talked about, but I think we have mostly settled on M. I. S. C. Now. So, um as you can see, and I just want to point out point your direction or attention to, it's the first column here. Um and they did stratify them by multiple different categories. So, for example, stratification by Kawasaki, they had coronary artery aneurysms, stratification by evidence of stars Kobe too. So median age, again closer to 10 years of age, a lot of them are, majority of them had abdominal pain, diarrhea associated with their presenting symptoms and um the injectable injection because membrane changes and so on so forth. So in terms of laboratory findings, this was very similar to what the previous reports had noted. They had elevated crp their profiles. Children was also elevated. Fair 10 was pretty elevated as well, although if you uh know from H. L. H. Usually the hyper fertile anemia can be really, really significant in those patients who have H. L. H. Um upwards of tens of thousands. The timer was elevated and then I'll six um was elevated as well. And the proponents were elevated in most of this cohort. And then looking at what kind of farm agro therapy these patients got. So you can see 71% of them are universities. All of them got I. V. I. G. A fair majority of them got corticosteroids and then there are various other immuno modulators such as a camera or inflicts a map which is often what we also use Ward Kawasaki. Um Some degree got these what they don't mention here. And I would be interested to find out like how many of them got anti coagulation. What and and looking at particularly patients with shock. So how did these patients compare with in terms of their laboratory findings between Shaq and those didnt have shock. And I think that's kind of relevant in a pediatric outpatient setting because a lot of these patients that you will see in an outpatient setting might have fever for greater than 24 hours. But you can kind of see from this chart in terms of the comparative scale, those that had shock had much higher mutual account. Their crp was definitely higher than the non shock group. There. Lymphocytes were lower in the shock group as versus the non shock group. The D. Diamond was also elevated and the proponent was was also elevated in the shop group as opposed to the non shot group. They didn't really find any significant findings when they looked at the similar comparative group, but those who have coronary aneurysms and those that didn't in terms particularly looking at black findings. So um temporally we know these cases were seen usually after a peak number of cases. So about 2 to 4 weeks post the peak of your covid 19 cases came this this uh cohort of kids who had the multi system inflammatory syndrome. Um the testing results was very variable. Some were pcr positive somewhere antibody positive. Some had only known contact with a covid 19 and both pcr and serology negative. Although I would say at least just from very anecdotally speaking I think most were astrology positive. Um So but there definitely appears to be a spectrum or a pattern of presentation of syndrome. Not everybody who will fit the case definition of M. I. S. C. Necessarily has to be in the ICU or necessarily have to have all the complications that have been known or associated with it so far. So we know that some patients will just have persistent elevated inflammatory markers with no features of Katie shock or organ failure. What they'll just have as persistent fever and elevated markers. Then there'll be that cohort that will fulfill the Katie criteria but there won't be in shock. And then the third category would be the patients who have shock and have clinical and choreograph and laboratory findings of myocardial injury. And of course this is the group that we all worry about and we all don't want to mess when we are evaluating a child with the possible M. I. S. C. So um and and and notably so there can be evidence of coronary involvement in all of these three groups. Even if we don't have shock or in failure. So um in terms of epidemiological clinical and laboratory features how the M. I. C. Differs and similar to Kawasaki. We know that increased incidents of M. I. C. In patients with african or afro caribbean and possibly even hispanic defense descent, but lower incidents in those of east asian descent. And this is so different than what we see classically Katie, there's also a broad range of symptoms but more prominent gi and neurologic symptoms present present in more frequently in uh in shock and those that have cardiac dysfunction. Um There was the case series that was reported that even some I think a couple of patients got lab happy because they had such significant or severe abdominal symptoms on presentation. Before this was sort of like a known defined phenomena looking in particular. So really how different is it from Katie? Um So Children with this particular study also looked at Children who met the criteria for um my sc and then compared it to comparative cohort of patients who have Katie pre covid. Um and they generally found that these kids who had M. I. S. C. Were older, they had a higher nutritional account. So if you look at the first one here, this is the Pimm's or M. I. S. C. Group, this is the KD group and this is the Katie shot group. These two are pre covid and generally they found that the crp was higher, definitely the fair 10 was much higher. The age was higher in in the M. I. S. C. Group. The proponents tend to be higher as compared to the Katy versus the non Katie. And really the lymphocytes are lower in the M. I. S. C. Group versus the Katy versus non Katie. Um Katie shock patients. So um this this sort of initially when people were talking about the Katie phenomena they really I think there's more divergence in talking about as this as two separate or different entities. What why what are the mechanisms? I think a lot of people are still have ongoing theories but there are no clear answers the timing of the disorder in relation to the pandemic. Most patients are pcr negative and serology positive. So um we tend to think that there is an average development of acquired immunity. So your immune system sort of as it's developing your serology or or antibodies you go into this hyper inflammatory syndrome. There's also theories where people think that the antibodies accentuate your disease either through everybody enhancement of viral entry your replication. So similar to Dengue. So Deng is one viral syndrome where the first time you get it you don't you don't get sick. But the second time you get it because you have antibodies, those antibodies enhance your viral entry into the cells and you get much sicker or you can get much sicker the second time around you get Dengue or if it's triggering of our host inflammatory response either through formation of immune complexes or direct anti tissue cellular activation. We we just don't know and I thought this chart was um nice to kind of think about what happens in terms of your time course to illness and severity of illness. And and for most part we think that the kids are sort of um sparing the space to or the pulmonary phase where we're not seeing a whole whole lot of kids who have acute pulmonary illness or their ICU intubated and getting a lot of pulmonary disease. But we are seeing kids who enter this third stage of a hyper inflammatory stage where there's a host response phase and you just get this very elevated inflammatory markers. Your crp I'll 60 dime er fair tin troponin et cetera. So in terms of treatment I think there's continued an ongoing discussion about treatment. I think first things first I think hopefully I have um alluded to you guys about the degree of cardiac involvement and um to to what extent these kids can have cardiac involvement even if they look okay. So most of them are recommending an echocardiogram at diagnosis and also close follow up with cardiology. Some recommendations include getting a cardiac MRI about 2 to 6 months after the diagnosis of M. I. S. C. With those particularly which have significant transient lb dysfunction in the acute phase of illness. I think most people have settled on immuno modulators with I. B. I. G. As your first line there is still debate about corticosteroids um and role of steroids. Some institutions have adopted into their clinical algorithm. Others have not others to kind of choose it on case by case basis. Um I think it is important to note that because there is such a spectrum of clinical presentation. I don't think that one therapy can fit all. I do think that there have to be a case by case consideration in terms of even patients who might even need remdesivir or an antiviral therapy that is recommended for or has been known to have benefit for patients with covid 19 for example a patient who is pcr positive and and presenting with similar features to M. I. S. C. And a Kendra. Um The benefits of Anakin dra are that it's a short acting with about 46 hours of half life and then acting era is the aisle six inhibitor. But there are really ongoing trials about that and I'm not sure if there's even published literature in pediatrics about the efficacy of that. This is another area of hot debate about the anti platelet or anti coagulation therapy in terms of doing low dose versus high dose. Uh Yes aspirin therapy and as you can see a lot of these patients can even have low platelets. So generally it's avoided in patients who present the severe samba city side of pina but most of the patients are getting low dose aspirin at least. So I wanted to touch base on implications in the outpatient setting, as most of us in the audience are practicing in the outpatient setting. So in terms of outpatient evaluation may be appropriate if a child has normal vital signs, reassuring physical exam and close follow up is um uh generally insured. So they should be referred to the E. D. If they have abnormal vital science, toxic cardiac takinmia, respiratory distress of any severity neurological deficits or change in mental status evidence even with mild or hypoxic injury and if they have elevated inflammatory markers abnormal PNG or BMP or troponin. Um This is just a general very general guideline and I've sort of incorporated it from other institutions and I think this particular one comes from N. Y. U. I don't think that the CDC or to hire you know sort of um institutional guidelines that every institution has sort of come up with their own guidelines in terms of guiding the general pediatricians about um what would be the appropriate way to manage these kids And they felt that this was fairly reasonable. And and this is another when when would you consider that diagnosis? So you would assess for severe symptoms and they develop hearing. You could be reassured if they describe a fever for about 24 to 72 hours. You look for signs and symptoms. What we talked about. G. I. Rash can be very variable. Um Congestive itis or only coastal changes, extremity changes, neurologic or psychiatric symptoms or lengthen itis. And I think if they have any of those signs of symptoms, I think it would be quite reasonable to get labs and based on your labs. If you have any sort of concerning signs and symptoms, it would be um I would advise to refer these patients to E. D. Because there's still a lot of it is unknown in these patient populations. I just wanted to touch base very briefly about COVID-19 and childcare settings and return to school. I think a lot of it's an audience probably have kids of our own and trying to deal with child care situations among ourselves. And then of course our patient population is probably asking me by similar questions. Again, this comes with the caveats of like we don't know everything about this entity and pandemic. And we have farming are educated information as we have data coming in. So the key questions that come in and what I think about is that risk for Children who developed covid 19. What are the risks? So if a child does get covid 19, are they're short term or long term implications. We just talked about one of the most severe manifestations that a child could have. But I would say there is still a very small small number of kids who present with M. I. S. T. In terms of what are the risks for Children to acquire it and then to transmit the stars Kobe to infection? Um, we know that there is a small portion of COVID-19 cases and the pediatric burden has been fairly low. Um the among as of June 15, there were only 4% of kids who were affected with COVID 19. And globally the burden has been low as well. In terms of other severity of symptoms. We know 90% of the kids will have mild to moderate disease and they can receive care at home and less than 1% will be critical. We have all heard about this in terms of droplet in contact transmission is the most common one. We actually don't know the viability of the virus truly in a environmental settings on for mites, but we tend to recommend that it's um, you know, wise for us to um clean the high touch surfaces and other factors. But really we don't see aerosolization of this virus. And we think the primary mode of transmission is respiratory droplet. Um this looks too, I'll go through these slides fairly quickly because I think we all kind of know about this uh by this point, um larger than network, the more chances you have of transmission, the smaller your cohort, the last chance you have for transmission. So, um, I think that's why the reasoning for sheltering in place, but also at the time. But if you're thinking about return to school, return to childcare settings, like what really is going to be the cohort of the child that he's going to go back into that setting. So what do we know about Children as household contacts? Their transmission to Children may be lower than two adults. So in China they looked at 105 index cases out of those, 4% of their child contacts were tested positive and 17% a larger proportion of them were adult contacts. And they similarly looked at NY State 229 index cases out of which 30% more Children and 66% of all we're adults. So certainly the burden was more on adults than kids In terms of particularly looking at transmission by by schools. So in Australia they looked at 18 infections, nine where students, nine were teachers and they did contact tracing of about 735 and only two student infections were identified french alps. There was a nine year old gold with symptomatic infection. They identified 100 and 12 school contacts and no transmission was identified in that case. And in Malaysia there was a 13 year old without any symptoms who attended school and there was 29 contact tracing stated in one teacher tested positive for that and our land. Similarly, they had six infected patient people, three students, two teachers and they did over 1000 contact tracing and no secondary cases were identified as as a consequence of that and this has been in talks I think the most recent paper that has been talked about the most is the modeling study that recently came out by the center for mathematical modeling of infectious diseases in the U. K. These are this is the center that the initial modeling for talking about if we don't do shelter in place, what would be the consequence? And I think finally um convinced the higher ups including the federal government to do recommendations for sheltering in place. Um So they looked at particularly in Children and and the possible reasons for lower case numbers and Children. So lower luck if if the Children fulfilled with the first two criteria lower likelihood of becoming infected and lower likelihood of showing symptoms if infected only, then you could match what happened in Wuhan when it came to childhood cases. Um they did for their stratification, um age stratification and they estimated the susceptibility to infection in less than 20 years of age was half for those over 20. And then um but at the end of the day, it's still a modeling study there. It's only so good as your data and our data is still coming out and it's still pretty raw and fresh. So there are still unknowns about disease transmission in Children. And at this point, I probably handed over to Dr Petra to talk about when you do have a positive case and when you do have a child with Covid 19. What do you do? And what your steps right? Hi. I'm ann Petry and one of the pediatric infectious disease docks in Oakland, anybody who's been around the last 40 years probably has heard my name once. Now you'll hear it a second time. I've become I used to be the HIV guru and now it became the covid center in the sense that I am the one who gets all the phone calls from the lab when we have a positive covid test. And initially I started by calling the individual providers who ordered the test and started one on one, educating them about what we need to do and think about when we get a patient who's covid positive. Yeah. And this process has now expanded because we're getting more and more positives to give you a rough idea. We've done about 3300 tests and we have about 90 for positives in Children. So I'm gonna tell you what to do if I can figure out how to advance those lines. There we go. Um what to do when you get a patient or a family that has a positive covid test. And I want briefly to review the differences between sheltering in place isolation and quarantine. So we all know what sheltering is, stay at home as much as possible. Go to the grocery store with a mask if you have to go the grocery store, go to work with a mask. If you have to be working if you're an essential worker. And as the restrictions are now gradually loosening, we find more and more people going out. But we also find more and more people not wearing masks in places where they should be wearing them. When I put this talk together. Initially I was focused on the patients in Alameda and Contra Costa County and then was asked to expand the talk to include san Francisco and now to include a lot of providers from Solano County, all of the counties issued to their local hospitals and clinics specific orders that say basically we, the county health departments are so overwhelmed that we need help from you, the medical providers to disseminate information to the patients where you suspect covid either because somebody in the household has covid or because they present with symptoms that make you suspicious. And so our responsibility is and we do distribute to every family. When we test them copies of the orders from the county that are legal orders, you must isolate if you're found to have covid and until your test comes back, you also must isolate if you're covid test is negative and you have an exposure to someone with covid, you need to be quarantined quarantine means you're not infected that we know but you need to be isolated in a way that will decrease the chance of you transmitting to someone else in case you are in the middle of an incubation period and will um, shed virus soon. So for the Solano County listeners, I was able to find this um, link to the information in Solano County. It's uh, the orders from the county health public health officer. I know that these orders carry a potential risk of either incarceration or isolation, forest isolation if someone is intentionally out there exposing other people to coronavirus and putting others at risk. So people need to understand that these are serious orders. They are part of the health and safety code and public health has the responsibility to write such orders in order to protect people. Um, so Solano, I couldn't find the same details for Solano County as I did for Alameda and Contra Costa. But I know the information is in this document. This document is unfortunately like 15 pages long. So there's a lot more info than most people will wade through. But the gist of it is that we need to help families understand this is another. Solano County website has a lot of good information. Um, there's one phone number and one website. So hopefully it'll be easier to find in some of the counties that have many different resources. It's also available in Spanish and some of the other counties have information available in 45, 6, 7 languages. The gist of what these messages deliver is the distinction between isolation for those who are infected proven or suspected and those who are exposed but not necessarily infected at this time. And I'll walk you through this briefly, it's important to understand because the family is going to come back to you with questions and say, so how many days am I supposed to be isolated? And when does that start? And so I want to help you kind of think this through. So isolation applies to all suspected or proven with COVID-19, including those with the pending test. The violation is potentially a $10,000 fine or a year in jail and there can be civil detention at some health care facility that will prevent you from going out and spreading it to others. The orders basically say that you have to stay at home. You can only leave for medical care and you need to carefully you the family, you the providers who are walking your families through this. You need to walk through these guidelines that say very clearly do not go to work. You cannot go to school and you cannot go to any public areas. And finally, how long does that last? Generally it's 10 days from the onset of symptoms if they're symptomatic Included in that 10 days is at least three days where they've recovered substantially from their clinical presentation, where they no longer have fever if they had fever to begin with and they cannot be using aspirin or ibuprofen or Tylenol to suppress fever. It has to be no fever without fever reducing meds and whatever symptoms they started with must have substantially improved. So 10 days is the minimum period of isolation from onset of symptoms. Or if somebody is not symptomatic from the day that they first test positive, that's for infected people. Those who were test positive In the right side or those are the quarantine instructions and this applies to anyone who is a close contact of someone and the quarantine period starts 48 hours after the onset of symptoms. In the index case, especially if you live in the same household, but it can go longer. The definition of close contact is move. The definition of close contact is great is within six ft and this 10 minutes has been changed to 15, which I neglected to change on the slide. Sorry about that. Um, so close contacts, household contacts, but also close work contacts. If people share an office together, that would apply the same crime applies. And the instructions for quarantine are to stay home and monitor your health. If you're sick, you monitor your symptoms and you see care. If you meet the criteria that suggest you're more sick than can stay at home safely. Um, testing is not required for people who are in quarantine, even if the test is negative, the patients need, to people need to stay in quarantine for a minimum of 14 days and that 14 days starts When there's an interruption of transmission. So if you're living in a house together and someone has 10 days of illness and you're living with them, your quarantine period does not start until day 10 of the index patient's illness and goes another 14 days beyond that. So it's it can be much longer than people would like to believe. Right? Um All right. So while in isolation, as I mentioned, no work, no school and no public areas, ideally you need to try to separate people from others in the home, sick people in one room with access to a bathroom if they have a separate space and the healthier people at the other end of the house wearing masks in the home. When there's contact between the infected and quarantined people not allowing new visitors into the home, not taking public transportation, sharing rides or going by taxi and to prevent the spread covering the nose and the mouth with coughing and sneezing. Always washing hands, often sharing utensils, plates, cups and cleaning and disinfecting those high touch surfaces often and thoroughly when a patient is at home because of covid, the medical management of them is sort of standard for almost all respiratory illnesses at home fluids, rest Tylenol for fevers or pain and seeking medical care for the conditions that are listed here. If they need to go to a see a physician or health care provider or go to a hospital. They must always wear a face mask when they go And notify the hospital before or immediately upon arrival or notify 911 if they call for help that they have confirmed COVID infection, they cannot take public transportation. I mention this because we just had a case of a family whose sister, the aunt of the Children came from Los Angeles already sick on an airline having left six people in Los Angeles and came up here to visit her family here and the mother, the father and two Children are all covid infected, one of whom is an employee here. So we really need to emphasize that people cannot take public transportation because that puts others at risk. The public health Department will not notify workers or employees unless it's necessary to protect health and the health of others. They're not. But we need to tell families that these are not people from ice, they're not immigration restriction. People, they aren't going to put you in jail because you have covid. Um, and people need to understand that they will get a call from public health and public health responsibility is to establish safe zones in pandemics. There are a few exceptions to the rules I just reviewed about quarantine. One of them is for healthcare workers and first responders. If their contact is an intimate partner or household contact or if you're taking care of somebody with COVID-19 the employers need to be notified, but they may be allowed to continue at work. If they remain asymptomatic and they must be able to return to work when when needed. So if I'm you know I know I'm talking mostly to primary care providers in the community and at this point when I wrote the slide three weeks ago there were 3000 were now at 3300. Half of these have been done in the last four weeks. The turnaround time for our tests varies if their imminent admissions to the icu or the nursery or if it's a patient who's about to have surgery, we can do the test in house but we have a very limited supply of those test kits. When we do that we can get a turnaround time of 2-3 hours. But most of our tests are done And sent to San Francisco UCSF Mission Bay Lab where the turnaround time is an average of 16 or 18 hours and could be as long as 24 if their traffic problems. When we get negative test results are hospitals approaches that we've assigned one of the nurses who works with me and infectious disease to contact the families of patients who come through our drive through for testing. If they are referred by community physicians and they'll call well our nurse will call those families and tell them good news your test is negative but you will then work with the family to help them understand if they have a household contact what it means to still be in quarantine. We have patients who are tested because they're scheduled to have surgery, Bone marrow, spinal tap intestinal endoscopy and they get pre op testing. The pre op clinics are the ones who notify families of those negatives. And our communication with the family is documented as a telephone encounter and we use an interpreter. If needed Advice about quarantine is still important to know because you can't just say good news, your kid is negative. You can run around and play with all the neighbors. Not true, right. If there's a contact they need to remain in quarantine until 15 days after that last contact with an index case, The ones that are positive get called to me and I had the biggest day yet. Today I got 10, 10 calls about positive um tests. There were two families, one had three Children, one had two and many of these families are families where a parent was diagnosed and the family wants to know about all the Children in the house. Is it going to make a difference? I think we need to ask ourselves those questions because if both parents are sick with covid but not sick enough to be in the hospital, who's going to take care of the five Children, Are they going to send them somewhere? Well now they're sending kids who've been exposed. So you're potentially exposing another household or do you bring a grandparent in to take care of potentially sick kids. Not necessarily. So every phone call about a positive has significant implications. And it typically takes about half an hour to have that communication for a fairly sophisticated family and as much as an hour for families that are really struggling because they'll say you know you're telling me I can't go out, I can't go to the store, I can't go to the bank. How am I supposed to buy groceries? I don't have a credit card. I don't have a relationship with the delivery service because I can't afford it. So the phone calls to families who must remain isolated and quarantined are very complicated. In our computer system. We have this infection flag the big yellow box that's here that says covid confirmed. As soon as the lab test is reported positive, this flag pops up on our electronic health record and it will immediately identify if the patient is admitted if there's an isolation infection mismatch. If the patient is not in the proper isolation for confirmed covid case. So the lab calls me eye contact the primary care docks. We send the confidential morbidity reports the CMR more reports to the individual counties and we then determine how best to communicate to the family. If the patient is an impatient the medical team will tell the family, we contact the nursing unit and we send out notification forms internally to make sure that anybody who might have had contact with the patient who wasn't wearing appropriate protective equipment is notified of a possible exposure for outpatients, We contact the primary medical doctor if they were referred by the P. M. D. S. Or we contact the clinics when when patients were had tests ordered in slightly different ways. We also document that communication and I send the reports to the primary doc so they'll get a brief note for me that basically says the patient is positive. You ordered the test is your responsibility to communicate to the family about the implications of a positive test result. And that's why one of the reasons why I'm doing this talk is that I want everyone to be brought up to speed on the issues that will come up in those phone conversations. Um and public health will eventually follow up with these families but they're often delayed because they're so overwhelmed. Yeah So the huge challenges for families, I sort of implied that we have a huge number when I first was counting the number of patients who spoke other languages. 24 of the 26 spoke Spanish mom or Arabic. Now we're closer to 100 and I think I have five who speak English and the rest are non English speaking families. Many of them even though they have been given public health department documents when they get tested. Many of them haven't read those documents or they can't read they are not able to or it's not in a written language. Mom is a verbal language but not written language. Um Usually the families that we've come across live in crowded living situations and often multigenerational. Often somebody is working outside of the home because these families need a source of income to pay the rent and to pay for food. They often lack sufficient supplies to keep them going for 10 or 15 days. I had one mom with eight people that she feeds every day. Tell me I only have enough food for tomorrow. How am I going to get food? As I mentioned, credit cards and home delivery of food are not options for many and many don't have family or friends who can drop food off for them. So the conversations take a long time and you need to be prepared in your community to know what resources are available, but all is not lost. There are several mom speaking resources. This is a video on Youtube so that if it's possible to find a way to give them the info and they can access Youtube. There's one way of giving a lot of information. A second one is in both mom and spanish. There are services available in various counties in Alameda County. It's broken up. Unlike Solano that has a single phone number in Alameda County, you have to go to many different places to get the info you need. There's public health guidance listed here. There are food distribution centers for people with covid, some of them are associated with testing sites, but many not. Um, there also is financial support statewide for undocumented people. So even if people have no documented immigration status, this particular resources available to them. It's distributed. It's called uh, abbreviation is C. D. A. I C D. A. R. California, disaster assistance relief. I think it stands for in Alameda County. It's managed through catholic charities. And what happens is that a family living with Covid who's undocumented can get $500 for up to each of two adults living in the home. So it could be $1,000 of immediate financial support for a family that's undocumented. There also are new housing services. Alameda County has something called project room key which is using hotel rooms and converting them into safe spaces for people living with Covid so that they can get the covid infected people out of the home or they can address needs of homeless people um, san Francisco similarly and in Solano County. Again, the One Resource Network, a resource one site Resource. So what do I need you to do? Think ahead of time about what's going to happen when you get the phone call for me or anyone else saying that you have a family in your practice that has covid. You need to figure out what your local support services are. This is the information about the disaster real relief assistance for immigrants, D. R. A. I. Uh, document your encounters when you communicate with public health. It really helps to know how many people are living in the house and what you know about them. You need accurate phone numbers and usually need more than one. Whenever I have information that I share with the county I give them every phone number that I have from a family because very often one of the numbers is wrong or is not answered or the mailbox is full and you can imagine other reasons why you can't reach people. So whatever info you have about close contacts is really important to hold on to. Um, you don't need to test everyone who lives in the household if they have similar symptoms, they all have covid. It's fair for me to say that right now because when we look at respiratory viral panels that test for all the other viruses we know about were hardly seeing anything We do roughly 30 or 40 in a week. We might see one adenovirus or one enterovirus or one um rhinovirus, but we don't see a large number of any other viruses circulating right now. So a household full of respiratory disease. If one person has covid you can bet they all do and you're not gonna do anything different because we don't have treatment and we don't have a vaccine. So the answer is isolating those with disease and quarantining those who are exposed, the other is to be prepared and have equipment available in your office so that you protect yourselves because if our workforce of providers get sick, we're going to have a harder and harder time. I'm really hoping that today's list of 10 names of positives are not, uh, foreboding future for us, but we've gone from one or two patients a day to now, having five yesterday and 10 today. And if this continues, we're all in big trouble.