After a snapshot of pandemic-related challenges in health care delivery, this hourlong update features UCSF pediatric infectious disease specialist Ann Petru, MD, who presents guidelines on managing COVID cases and households. Bonus: graphics that clarify recommendations at various stages of exposure or illness, treatment strategies and prevention tactics.
welcome to everybody to this. Uh, and and um, I have a great deal of appreciation for the team for putting this together. Um, and hopefully kind of stating the obvious to that, that this is a current topic that everybody has a lot of questions, a lot of anxiety, A lot of concerns about also not new. This has been going on for several months as dealing with coronavirus and and it's not over. And so we will be focusing really on pediatric aspects of uh, of covid response and in really perspectives both at the hospital within the Bay Area regionally nationally and cover the waterfront. I know everybody has been talking about a lot of these topics a great deal. Um, let me start by saying, it may seem odd to you that that a surgeon is talking to you about this stuff and in some ways, I guess that's odd to me too. But um, I am the P I of a federally funded program uh, that uh, that I'll talk about and this is this is part of the introduction of explaining exactly what this is. Um, uh, so we have no other disclosures other than that when I get through just describing what this program and disaster management for kids is. Um, uh, I'm going to get dr Petru into um, give you the details and data for um, I think where everybody has questions and uh, get us all up to date. Um, if we have time at the end, uh, I will try to end and this will be an opportunity for Q and A as well. I hope uh with multiple topics where we don't necessarily have the answer, but these are issues that everyone is talking about and are controversial and we're trying to figure out what the right thing is. So um hopefully we'll get to doing that because I think that's that's really a um that's part of this that everyone looks forward to. So introductions and just kind of perspectives of what this regional management infrastructure is and what it means for kids in particular. So kids getting response and resources and resiliency in the face of pandemics and disasters has for many, many years been a problem, not just on the west coast around the country. Um I everybody has appreciated this um in all regions of the country, been high priority on the on the A. P. S. Uh to do list to try to fix all of this and it's been hard to fix. So our group got formed just this year as a new federally funded program to try to impact specifically the kid piece of this. Uh I'm not gonna get into details of what's on this slide, but I do want to kind of point out the complexities of the entire system and um and understanding how all of these acronyms and pieces fit together is so complex and it's so difficult and if anybody ever wants to spend a day getting a primer on it. I'm happy to do that because it took me forever to learn all of this as a brief overview that those top two lines that have health and human services and asper and fema and MDMS and the National Response Framework and S. F. A. Those things is the national big infrastructure. This is the stuff and the team that you see at at the press conferences and they set the tone and they and they managed the national stockpile and uh and they control a lot of the purse strings of of how the help comes out to throughout the whole country. Then there is separately regional level infrastructure and that's those are the HRC and the Net IQ programs than their state level programs. So in California we have the C D ph California Department of Public Health and the Office of Emergency Management. Then we have Bay Area programs that is things like the health care preparedness program and coalitions and in a regional disaster Medical Director. Okay. And I point this out because this has significant impact to us practically day today, if you are a private pediatrician or in a community hospital or pediatric hospital and you need help with certain things how to access that national infrastructure is almost impossible. And the pathway is knowing these acronyms and knowing how to access the local public health departments and um uh and those regional managers. So partly this is what we have done. Um and I put this this slide up just for reference to show how this whole system conceptually is put together, there is at the at the most basic level um local infrastructure, this is your local county health department and um uh and your state, you know infrastructure, these are the entities you will you will interact directly with to get things and they do have things like PPE equipment through uh you know the cow department of public health that is being offered to small practitioner offices and community health departments now um uh you can access these things, you just need to know how to get there. So the regional organization that we put together um I'm not gonna get into grand detail of how this is organized but I do want to point out one important thing, you will see the list of participants on here and yes it may be shocking that Davis and UCS have in stanford are together talking in a collaborative yeah, so is Loma linda and USC and UCLA Yes this is you know this is a collection of hospital groups um that have not always worked well together but for this project they are all involved. So when we began talking about what is a community standard, what is everybody doing? How do we help each other out? This was established as a platform to try to get there. Mhm. Um so that's the organization, this all began in september, we were about 56 months into trying to organize this stuff and then corona virus began. Um so all of these partners began trying to figure out what was needed for kids. It quickly became apparent what I think most people recognize most of the breathtaking and heartbreaking clinical impact is with adults and the elderly. Um and while that is a parent, what is less obvious maybe to the general public but clear to us is the pediatric population is really impacted quite significantly by ripples from all of this. Even if the kids are not filling up our ICUs. The impact of um supplies and needs on the adult hospitals impacts every pedes hospital, the impact on our health care workforce and nurses and techs and the anxiety of just coming into a hospital is not minor. This is a big deal. Um, uh, the impact on families. So all the kids that are sheltering in, not just the ones that we take care of through our clinics but our own kids who are now not in school and we have to figure out how to balance being in a hospital and being in a clinic and and dealing with, you know, our our own Children who are home alone trying to learn online. Um so lots of ripples, lots of anxiety, lots of problems even if it's not the primary clinical issues. So this organization began to tackle all of these, There was many, many small niches of problems that came up locally in the Bay Area throughout the West Coast and ultimately nationally? So this is just a list of a few of the projects that we that we got very involved with? And uh, so there's examples here. So uh increasing the telemedicine infrastructure across multiple states that could cross state lines, not a minor problem. And um uh, and as an example, um it's great when you're a big academic center like University of Washington. And I pull and I use that as an example because this is one of the problems we got involved with. University Washington had great infrastructure, but the pediatrician offices weren't necessarily plugged into that, nor could they be um, that had to get fixed. And um, and in the middle of February two, middle of March that time frame fixing that problem, there was short time to do it. We had a few days to a week to try to find a solution. So all of these problems happen very rapidly. Lots of good fixes, lots of examples of what it means to collaborate and what it means to pull together partnerships that didn't exist before. Um, and I'll give you one other just as an example because I could sit and talk about these things all day. But this was a really interesting, you know, illustration of some of the difficulty of what it means to tackle these problems. So there was a point where every pediatric hospital across the country was confused and uncertain about how do we continue to function how do we cancel elective cases how do we protect the anesthesiologist? What about cases that are high risk for R. E. N. T. And pulmonologist. And um what about education and residents and how do we deal with all these problems? And the truth is there was no data. There's no Delphi there's no time to do a randomized controlled trial. Um But there's tons of questions um and no standard and no guidance. Um And most of these questions were coming up in a one week period. We've got to figure out the answer right now. So we did this we pulled together a platform so that every pediatric hospital in the country could put down their responses of this is what we are doing with X. This is what we did with resident education with PPS in the O. R. With cancelling cases. And it goes on and on. What developed was um Nonscientific. This is not randomized controlled p. Value anything. It's just what everyone is doing and it was sharing common experience and the end result was a pretty unified community standard of this is how we're all doing it. Um This developed in one week we did this for surgery. We did this for Obi labor and delivery in Nicu to some extent. E. N. T. Surgeons across the country. Kind of did this on their own. Um uh It was an amazing development of something that really has never happened before. So, um I said I'm not gonna get into all the details, but I want to illustrate where when we talk about standards and what everyone is doing and what the recommendations are. Um it's good to know where this is coming from. All right, let me say a couple quick words about where we are now in recovery stages and and uh and then I'll let dr Petrie get in here. So um beginning, you know, several weeks ago, most communities across the country began to reopen began to relax restrictions. This included every pediatric hospital in terms of doing more surgical cases. And so a lot of talk about, we are now in recovery. So first let me state recovery when you talk about disasters, adults or kids goes through several well accepted, well defined stages and so I listen if you haven't there. Um and that includes things like making changes and some of the changes are permanent and that's things like figuring out lessons that you've learned and catching up on lost productivity. Um So for several weeks, many of the hospitals us included have been engaged in many of these little levels. Um of course, um opening up and recovery is making a couple of very big assumptions and for the operating rooms as an example, we have maintained, you know, to open up elective cases, you must have adequate protection for your staff and adequate PPE and you must have testing capabilities and you must have beds available and um uh the case metrics, you know, the need to be relatively stable so that we're not going to get into trouble with ventilator availability. Um if those assumptions are not true, then our health care system has to adjust right now um locally in in the Bay Area. The Children's hospitals are okay. We are managing in these metrics. Um but it's concerning because the numbers obviously have been rising and there is of course several communities around the country who are not doing okay and uh and I can get into, you know, which ones those are. I talked to him all the time. So, um you know, the communities in Houston and Arizona and southern California um are struggling and having to do creative things. Uh and yes, this impacts the kids right now for, you know, for Oakland, for the East Bay for U C. S. F. Uh We are managing, but we watch this every day and um uh and it's something that we have to be aware of may change at any time. Um Now let me, and we can get into a lot of the controversial stuff like I said later, but let me get dr Petra in to talk about detailed stuff because I like I said, I think this is what everybody wants really wants to hear. Thank you chris I think you're going to have to control the slides because I don't think I can do that. So I'm sorry, it's okay. Um, you know, I wasn't quite sure whether this audience would overlap with the one that I spoke to a few, two weeks ago and four weeks ago. So there may, you know, I was hesitant to do duplication of some of the things I did before, but I was really asked to say, kind of bring us up to date on each of the aspects of management of Children who have Covid and I kind of throwing in some other stuff for you. So, some of the information, because I'm mostly involved with the nitty gritty of how do I deal with the six positives for this morning and making sure that the pediatricians all know so that the families can be notified and haven't been um, because we haven't been hit hard by clinical illness in patients. We've had very few kids hospitalized and certainly very few hospitalized because of Covid. We don't have a lot of direct hands on experience taking care of them. But I did get some great resources. And so, you know, I, to be brief, I looked broadly and I borrowed some spectacular slides. I'm going to share those with you. And then we'll move on from some of the borrowed slides. So let's go chris next one dr Gandhi at massachusetts general and dr Gallagher at Temple University put together this slide set, which I unashamedly borrowed from them and I'll show you what they've put together, which I think is terrific. So here we go. Next one after this. Next one. So I love this array because it shows us the spectrum of disease from before you get exposed. Where the only thing that will help you is a vaccine two after exposure. What can you do to mitigate the severity of disease to those who get sick and have mild, moderate or severe disease? And a few people who develop critical illness and hopefully most afterwards will recover. And if you look then at the goal line, our first goal is to prevent infection, masks, masks, masks and social distancing. That's what we can do. And we need to really emphasize that in our communities once people have acquired, then the question is, is there any benefit to post exposure prophylaxis before you develop symptoms or if you do already have symptoms, is there any role for treatment? And at what stage of illness does treatment become important? And then is there anything that you can do to hasten recovery at the end? And the next section about disease pathogenesis emphasizes in the blue box or blue diamond viral replication happens in a few days before onset of symptoms, peaks at 5 to 7 days into the course of illness and then gradually subsides while the inflammatory processes that includes the MSC. The multi inflammatory syndrome associated with Covid occurs as you get into the moderate to severe disease. And this inflammatory component drags on and can be responsible for a lot of late symptoms that are associated with bad covid disease. Yeah, correspondingly we look at antiviral therapy and is there a role for it early or is it only beneficial when we start developing more severe disease? And I'll get into some of that. And then some comments about immune boosters and drugs to decrease inflammation, which is where steroids come in. So I thought this was a nice slide that put the whole picture together of how we need to be thinking about management. Next slide. So here you see a summary about the one drug that everybody has been talking about Remdesivir, an antiviral drug that interferes with with them are RNA synthesis and this is used in hospitalized patients. And you see to the middle and the right columns for recommendations that come from the National National Institute of Health or from the infectious Disease Society of America. So if you look at hospitalized patients with severe disease, both big organizations recommend using Remdesivir and for from the I. D. S as perspective it's a conditional recommendation with a moderate evidence of certain certainty of evidence for its use when patients are not so severe. No law not intubated five days, maybe adequate and for those who are mechanically ventilated. The recommendations are generally a 10 day course of remdesivir. For people with mild or moderate disease, there is not sufficient data to recommend for or against it. And I'd say doesn't address it. And it's that group of patients where research studies need to give us guidance about whether we should be starting it earlier or only with those who are severely affected next side. The data about Remdesivir was updated also in the new England Journal article recently. Um This one is from very recent. It shows you that there's not a significant difference, a huge difference but there is some difference between remdesivir and placebo. And the Summary info comes in the middle of the slide here. The mortality at 14 days is 7% with remdesivir And almost 12% with placebo which shows shows that there is a protection from using remdesivir in these patients who had more severe disease. Um In uh you're good. No you're good. Next slide is good. So the next group of drugs that will look at is corticosteroids. You've heard about dex a method zone I suspect for mechanically ventilated patients. The NIH does recommend it at a dose of six mg daily for up to 10 days. The I. D. S. A. Has the same recommendation but in patients who are not mechanically ventilated um We're still using methadone as a recommendation but when you don't need oxygen you don't need decks and methadone and if anything may be detrimental. So we're not trying to jump the gun and hit everyone who has suspicious symptoms with steroids if they're not so sick as to require serious significant hospitalization and intensive care. Next one this is looking at dexamethasone again. Um This is addressing the controversy and viral pneumonia because you obviously don't want to use it for some forms of viral pneumonia. Um And there's such a hyper inflammatory state that steroids are often the drugs that we lean towards because they are the ones that interfere with the inflammatory response. So this was looking at a randomized open label study and hospitalized patients in the United Kingdom, half a third of them received exa methadone and two thirds of them got usual care. And you see that broken down in the table here Where the relative risk of mortality was only .83 for those who got decks and methadone versus usual care Which is a significant with a P value of .0007. So very significant. But if you look at the bottom line, the group that did not require oxygen. There was actually a higher risk of mortality if you treat with decks and methadone. So the caution is to use it for the sickest patients but not those if they don't need oxygen. Next slide. Yeah to get to those two controversial drugs, hydroxychloroquine which is more often used for rheumatic disease and chloroquine used for malaria. These are the studies that look at them. Bottom line is that we we don't think that these are beneficial. Um The NIH recommends against it except in a clinical trial. The I. D. S. A. Only suggests its use in the setting of a clinical trial and the combination of hydroxychloroquine with azithromycin. The NIH recommends against it except in research studies. Similarly the IDSA recommendation. So despite the fact that our president thinks it saved his life I think that we ought to stay away from it. Here's some of the data shows you overlapping graphs for those patients who got hydroxychloroquine versus those who got nothing. And this is looking at the probability of um I can't even read it myself. Event living event free. So it's not going to benefit you if you take hydroxychloroquine or the combo of the two with zero next one. This is looking at randomized, this is randomized control trials. The previous ones were not randomized and not controlled. So here you're looking at post exposure prophylaxis. I got exposed to covid I want to know if hydroxychloroquine will help me. This is the percent of patients with new covid diagnoses And you see that at five days they're exactly the same at 10 days. They're exactly the same at 14 days. They overlapped tremendously. There is no benefit and if you look here hydroxychloroquine the proportion or hazard ratio of dying is 25% with hydroxychloroquine and only 23% with usual care without. So again stay away from hydroxychloroquine. Most of the patients. Sorry the limitation in this study is that most of these patients were not enrolled or enrolled 3-4 days after exposure and only two or 3% had confirmed diagnoses. So it's really a mixed bag of patients they're looking at and not useful. We need to wait for more detailed and carefully controlled studies next side convalescent plasma. This is what you collect from a patient who has recovered from covid. And the big questions that we still have unanswered have to do with whether or not the antibodies that people produce in response to a disease are protective or what we call neutralizing antibodies unless we know that an antibody is neutralizing. It doesn't really help to use an antibody to measure something. If you're going to say that you're looking at a large population and they all have antibody. If the antibody doesn't protect them from disease, again, you'd be giving people false hope that they're safe and that they can go expose themselves to someone with Covid and that they might be protected. Convalescent plasma is not measuring the neutralizing antibody body. But just saying if somebody is acutely ill, can we get to help them get over that hump by giving them antibody that's been produced by people who have recovered. So these are this is available through a large nationwide study that's controlled by organized, I think through the mayo clinic and so far there's not sufficient data to recommend either for or against it. But we need to enroll people in this clinical trial Next line. What about passive antibody therapy? This is the same idea. But instead of using you can use convalescent plasma as one source of passive antibody. But there also are monoclonal antibodies being produced. These are antibodies that respond to the spike protein that is the outside pokey thing on the coronavirus that gives it its name. And we have antibodies that might interfere by preventing the spike protein from attaching to the ace two receptor on the mucosal surface that allows the virus to get into the cell. I realize I'm using my arrow two point but you're probably not seeing my arrow. So either way, I'm sure you can follow the there you go chris is gonna follow us into the cell. And then there's another form of antibody that might prevent the virus from penetrating through the membrane to get into the intracellular space where the viral genetic material can replicate. And so this passive antibody is another approach to intervention. And we're looking at that still, there was an open label randomized trial of convalescent plasma in china that showed no benefit to the overall population. But it could be helpful in those with more severe disease. They've given it to more than 20,000 people with COVID in the United States. There's been a very low level of transfusion reactions or other complications and their ongoing trials that will help us understand whether convalescent plasma and monoclonal antibodies are beneficial. And if so at what stage of illness. Next slide? This is also a slide I really like from this set. Looking at this like colors in a row. I have my clothes in my closet lined up by color, but this shows us where in this timeline we can intervene. And so, as I mentioned earlier, if you're at risk meaning your may be exposed to somebody or you have been exposed to somebody, the biggest bang for the buck is trying to stop the disease at that point. And that's where acute interventions maybe with antiviral drugs or with vaccines might prevent disease development. Um, for those who have been exposed, you also have that opportunity to intervene. And there's a study coming out of Minnesota of post exposure prophylaxis. Can we use hydrochloric Win in that setting? Um, don't get me started. I'm not very hopeful. But there are people who believe that that's a way to use it. So the study is ongoing. Once you're infected. If you become symptomatic, what can we do right now? You see there are no arrows pointing to the line after symptomatic before hospitalization, there is nothing that we have currently available to intervene in the course of illness if people are not so sick to be hospitalized. So it raises the question that I ask you to think about and that is you have a family where mom and dad have covid and therefore kids in the house, they're either minimally symptomatic or not symptomatic, do you need to test them to prove that they are or aren't infected? There is no intervention available at this point. So do you really need to test them? You probably just should keep them home and quarantine for 14 days after the infected parents have finished their course of isolation. But there is nothing else you would do. And so I'm somewhat discouraging people from sending the minimally symptomatic patients for testing if you already know the household is full of covid. On the other hand, if you're hospitalized this big orange boxes, the collection of things that are being tried or evaluated that might prevent the progression of disease from mild or moderate respiratory symptoms bad enough to require admission to those who are going to develop respiratory failure and for those who are already in respiratory failure to prevent the progression to death. So I think this is a cool slide because it sort of gives us this opportunity to talk about that. This is not just one disease, but it's a spectrum from nothing to everything next side. So the data that we just talked about kind of is broken down here according to what treatments are recommended in what phase of disease or what do we know about the treatments and you can see the recommended column is empty. There is nothing that we are recommending to do for people who have mild disease and who are known positive or asymptomatic and known positive. But if you have severe disease Remdesivir is one source and that's the one that's most highly proven. And we have available drug distributed through the state of California, through the counties to the hospitals and most hospitals have a small supply proportionate to what they might need. And that supply is limited. It was available for free to begin with. But as you've probably heard through the media, it's going to be available for purchase by hospitals in the very close future. Five days of treatment is suggested for patients who are requiring oxygen but not on a ventilator And 10 days often for patients who are more ill decks of methadone for people who require oxygen or are ventilated clinical trials, I've gone through some of these Lopez never return here, which I'm awfully familiar with because it's been available in my patient population for the last 20 years for treating HIV infection. Lopez Rivera tonight, there has not been proven to be beneficial. So clinical trials are the only way to get more information before people jump on the bandwagon uh tokenism to kill is a mob. I can never pronounce these monoclonal antibodies but this one is also through clinical trials only in clinical and convalescent plasma through the mayo study against data suggesting against the use of hydroxychloroquine and chloroquine especially with a Z throw and promoted in was also looked at and does not have a benefit steroids for people who have no oxygen requirement are not recommended. So there you have the spectrum of disease management kind of what is available and what is in the pipeline next slide. So now you get to the boring, not so colorful and Petra slides, but I threw these together fairly quickly because when chris asked me to give this talk, I wasn't sure what subjects I was going to try to cover. So I tried a little bit of everything and I'll give you some of that flavor. At this point, As of yesterday, July 15, we had done over 4500 tests. Our monthly rate is gradually rising. We went from 1.1 into the threes in May and June and now in July were at 5.3% positive. One could ask whether this is because we're testing more or whether we are testing a different population. We are definitely testing more but a higher percent of those we are testing are positive. We're also being a little bit more restrictive in who we test because we really don't want to be testing the asymptomatic patients who live in a house with someone with Covid. What you need to do is quarantine them. You don't need to test them. It's not going to change your management. Very few patients have been admitted to the hospital. We really only had one teen who was admitted because of respiratory symptoms due to Covid and she had underlying cancer. We have a few kids in the hospital now one has had two or three months of anemia being followed in Stockton drop the hemoglobin down to four, which seemed low enough to warrant admission. So he got admitted with a hemoglobin, a foreign cred of 12. And admission His covid test was positive is covid related to his anemia. Probably not. He had no other symptoms to the last three days and now he has fever and cough. So yes, he probably has a viral syndrome that pushed his underlying lying anemia to the limit. But it was already very concerning. We also have a few babies in the hospital. We have one who was admitted this morning. Born yesterday whose parents are both infected. I was told that the baby's test was also positive, but I can't find it in care everywhere. We're going to isolate the baby needless to say and the parents won't be allowed to visit till they've gotten past their isolation period. Most of the patients were admitted to the hospital with covid were incidental findings. There was a surgical patient admitted for a ruptured appendicitis. Incidentally had Covid. We put off the surgery until the covid symptoms went away. Tried to bring the kid back tested repeatedly. She's still positive. Still positive but positive. Just means you have RNA in your respiratory secretions. It doesn't mean That you have significant amounts of virus and good studies that have been done that I'm not presenting as data showed that if you test a large number of people more than two weeks after onset of symptoms and you look at all their household and other contacts, that the disease is not transmitted beyond 14 days. So we are not concerned about the patients. If they are more than two weeks out from their onset of symptoms, as long as those symptoms have improved or they never had symptoms. And that's important because if somebody really needs a procedure, they need the procedure. And if it's been three weeks since the kids acute presentation, the kid has recovered, you still need to do the procedure. So there's no real point in doing testing at that point, because you knew the kid had. It does it mean that the disease is recurring? It doesn't seem to be a pattern. Once you've had Covid, you get over the vast, vast majority of people don't have ongoing symptoms or re crude essence of the disease. What we don't know is whether six months from now, if that patient gets exposed to covid, will they get it again? We don't know that We don't have the data yet. The flip side is not the patient side, but the employee's side. And we've had tested about 250 employees here, but we also have a number of employees who were tested elsewhere because they didn't have hospital exposures. They had community exposures. They have partners who were at risk, they were partying and not wearing their masks, you can imagine. So we've had 13 infected employees, but only two of them acquired the infection here and they were not hands on healthcare workers. They were office people who sat in a back room and had lunch together without wearing masks. So we don't have any evidence of patient to employee transmission in the hospital setting. And we also don't have evidence of patient to patient transmission in the hospital setting. And in our best efforts after that appendicitis patient, we've decided that we're not going to allow patients to share rooms here as much as we can. And I know that a number of you on the call our former Children's hospital residents. So you know that we mostly had double rooms here. We've stopped doing that as much as we can, but as our senses has risen, we're sort of reconsidering which patients might be safe to put together and we certainly will not put people together until we have two things, no history of exposure and a confirmed negative test at the time of admission. If those two match, then it's reasonable to put them in a room together for a short period of time. And that's the only way that we may be able to take care of the number of patients who need our services at Children's Oakland. We also have a lot of beds at the Summit campus and the summit beds are almost all single patient rooms. So we are preferentially putting patients there if they don't need frequent procedures and services that are only available at the main hospital. There's also a good data from UCSF about their employee health showing very clearly to that transmission from patients to employees is very low likelihood 0.6%. Um and I think that that's uh you know, says a lot about the PPE. We need to be using it. We had an advanced warning because we saw what happened in new york and New Jersey before it hit California, but we need to be using the PPE sometimes, you know, this is a uh anecdotal comment, we go board and that we're using it for all sorts of circumstances where the risk of transmission is low, but it's become too complicated to say you wear this equipment under this circumstance, but not under that circumstance. And the test may or may not have come back and the family may or may not have exposure. Sometimes it's just safer to wear the PPE. The concern we have is we want to protect our workers and we want to make sure that they stay safe and that they can continue to provide the services in the hospital because if we wipe our employees out and have to send them all home for two weeks of furlough because they've been exposed. We won't have people here to take care of the patients. That's what I had to say about the PPE and employees. What are we doing for testing? We test patients now at admission to the hospital always. We test them in the emergency room if they have symptoms that are suggestive or compatible with Covid, which is almost anything that involves fever or respiratory symptoms or gi symptoms. A pure trauma patient who doesn't need hospitalization I would argue, probably doesn't need to be tested. But if they're sick enough to be admitted, they definitely will get tested. We do testing in our clinics, We do testing in the pre op clinic as well in anticipation of surgery and anesthesia in the next 3-5 days. And we do testing at our drive through site by referral only. Why? By referral only because we'd be inundated with everyone driving through something I want to test and we need to be able to focus on the patients who need it. The most. About half the patients coming through the drive thru now are pre op patients and the others are symptomatic patients referred by our community providers. We're still getting a lot of asymptomatic patients referred because mother is infected and the kid is three months old and it is breast fed. You're not going to take the kid away from the mother. The exposure is already happened. So I would argue that we don't really need to know if the kids not sick. Um My plug for selectively referring the patients who are symptomatic. Um and testing results, we've had a huge evolution in this process from the time we were excited because we have the first patient and had to figure out what to do with it to getting 5-7 a day, which is overwhelming my life and that of my, my colleagues. Um we are now faxing results to the office of the provider who ordered the test if we know who that provider is and we've negotiated with various clinics to identify the best possible person to contact when you're clinic has a patient who was seen here and the patients test turns out positive. We've provided information and guidance to our community colleagues and I'm totally available to sending that to you again. So an dot petru UCSF dot e d u If you haven't gotten it, send me an email and I'll send you the guidance that we provide. It will include the slide set about how to walk people through. Your child has Covid. Now what or your child has a negative test. Now, what? Because negative in this case is not the same as your kids, same as saying your kid doesn't have gone a rubio syphilis. I mean that's a, you know, moment in time, but if you don't have Covid, but you live in a household with a vulnerable grandparents and your parents both have it. You need to understand what it means to be quarantined. You can't send the kid outside to play with the neighborhood Children. And so we really have very specific advice about how to handle those two scenarios. Next slide, chris earth to chris Thank you. So this is what I ended up compiling when I found myself explaining this verbally so many times that I was getting tired of explaining it and I figured that a picture is worth 1000 words. So if I walk you through this briefly, it will help you with your explanations to your patients. In the scenario, one is a patient who is infected. That person needs to be isolated for a minimum of 10 days. That's the big yellow box at the top. And during that 10 day period, the patient should be staying at home, ideally in their own room, in their own corner of the house with their own bathroom. If that person is symptomatic, they need to be wearing a mask all the time when anyone is in close contact with them And they need to be a federal for three days and have significant improvement in their symptoms before they come out of isolation at 10 days. Alameda County as an example, has this explained in a pictograph and they're allowed to self release from isolation after those 10 days At that period. Uh, they can come out of isolation. But if they continue to have symptoms, you have to continue where the gray box goes a few more days. If the fever continues beyond 10 days or beyond seven or eight days, you just stay in isolation till the fever is gone. The second section is the scenario of a person who is not infected but lives with someone who is during the entire time that the isolated person, the yellow bar is in isolation. Everyone living in that household is in quarantine And the timing of quarantine really only starts when you get to day 10 for the infected person, that is a period of time during which the exposed person might develop symptoms and be contagious to others. So the green bar is the time the time when you count quarantine days, you're in quarantine when you live with someone, but you're quarantine period starts On day 10 for someone who is no longer, you know, the household is no longer contagious and goes 14 days more. Scenario three is the scenario where somebody says, all right, my dad is infected. My dad was moved out of the house and since the fifth day of his illness, none of us have been around anyone with covid. Then your quarantine period starts on day five and from day six today, 15 or day six, sorry, For 14 more days you stay quarantine. And the final scenario on the bottom is you're not separating people in the household and the first person was infected and got better. But the second person got sick on day three or four. So now you're adding another 10 day period of isolation for the second person in the house and everyone starts their quarantine period after that person's isolation is over. So you can see on the right that this could go as long as 28 days. You live with a series of people who have covid you stay in quarantine for a long period of time. People don't get that when you tell them you're isolated for 10 days. If you've got it your isolated for 14 days if you're in quarantine. But they don't explain that quarantine doesn't start till later. So this is also available for anyone who needs it so that you can walk any family through the scenario to understand who stays isolated for how long and who gets quarantined for how long next slide. So what do we do with test results? I just said all of this stuff infected people 10 days minimum and quarantined exposed people 14 days minimum. But again you start only after the contagious period is interrupted. We've been relying for decades on public health to help us with these kind of scenarios. But public health is completely overwhelmed. So I spent two hours this morning on a phone call with Alameda County Public health with a whole bunch of community health care service providers basically begging for some help. There are grants available. So you can submit a request for proposal to hire two teams, five people each who will help do all of this contact investigation. Our case investigation and contact tracing, which means finding all those people. They've been around to help stop the pandemic. So that's the next big thing that public health will do. But right now we send our documents to them every day. 456 patients or staff and patients and I don't know that public health is getting to them because they just so grossly understaffed. Next slide talked already about PPE just sort of a reminder that surgical masks are worn to prevent people from spreading it. Asymptomatic and unbeknownst to the person who's wearing the mask, they may be putting somebody else at risk. So they should be wearing a mask right in the hospital setting. We're moving towards n 95 masks. Not because I believe this is an air assault airborne transmitted disease, but because cal OSHA is wishy washy and when cal OSHA's wishy washy, a lot of people, including unions, jump on it and say you're not protecting us well enough. So we're probably going to give in to the cal OSHA verb e ege and say if you're in a hospital setting and 95 masks when you're in direct contact with patients. The other thing that we've added is the use of face shields or goggles. Two different options. There are many different forms of this. This is a pair of goggles. They're transparent. You wear them over your glasses over your ears. They provided added protection to prevent you from getting exposed as an inoculation going into your eyes from somebody who's coughing in your face. The alternative which will protect both a mask and your eyes is a face shield to look something like this. You've seen them they're being rapidly produced now By three D. Printers and many other ways. U. C. L. A. Hospital got the um apple to produce them for them in a three D. Printer. So they're calling them I shields with a little eye and a capital S. Um And they've made tons of them to supply U. C. L. A. So it doesn't matter who makes them basically. It's added protection to decrease your risk of exposure and to keep your hands off your face. If you're touching something or somebody you may have contaminated them you don't want to be touching your face. Well this is a reminder when you're in direct patient contact in the clinical setting. We recommend always using surgical masks for everyone and Children over when you're with Children over to who can't tolerate him. And now adding the face shield especially if the patient and parents are not masked and it's just easier to do it for everyone. You don't know when someone's gonna take their mask off. Um and the absolute is that we want to be using an N- 95 mask for any aerosol generating procedures which should be done in rooms that have negative pressure or at least in a single patient room. Um ideally in the outpatient world, you want to separate healthy kids from sick ones. Many clinics are saying healthy kids come in the morning, sick kids come in the afternoon, then you spend time cleaning the office in the space. Many people will also encourage families to stay in the car and just make phone contact and say I'm in the parking lot and when it's their turn to come, then they come and go straight into a room rather than sitting in a waiting room and exposing other Children, needless to say parents will be grateful that their Children and their families aren't being exposed to many others. So try really hard to keep Sick kids out of the waiting room areas and uh telehealth is the other that's mentioned on here and Chris already mentioned that we've made a huge transition to telehealth. We went down to something like 10% of our normal outpatient volume and now we're getting up towards 90% of where we were because we're expanding telehealth next slide. So, you know, the big picture is kind of grim. Where are we going in the United States with this disease? We have to prepare for the long haul despite the guidance to shelter in place and to limit social interactions, people aren't doing that. You see it all the time. You see, you know, a block away from the hospital, there's a liquor store at the corner of 55th and Martin Luther King. When I drive by there often three or four teenage boys hanging out together and nobody is wearing a mask. No, you know, I mean that's what they're doing right. We went, I went for a walk along Alameda Beach, huge crowds of people with volleyball with a net with certain skateboards, none of them wearing masks. So it's going to continue until people get this message and we're working on trying other ways to deliver it. An interesting thought that came up today was doing it like an amber alert, have an amber alert go off in communities where the infection rate is climbing, climbing, climbing. Somehow. We've got to get through to people that this is real. Um, and I think it's going to last easily six or 12 months if not longer. It will get much more complicated when we have all the other winter respiratory pathogens coming. Um, and we've got to be patient and we have to be persistent in our messaging to our families. We absolutely need to continue standard immunizations. We're going to get winter respiratory illnesses, some of which are definitely preventable with immunizations and we can't get kids far behind when it comes to the time when they eventually do go back to school and shared spaces whenever that will be. There's also a strong um, push for flu vaccine this year and I think that, you know, in the winter when people get flu, we're going to have a huge problem with both flu and covid concurrently and they are overlapping disasters that are going to set our hospital systems off. So everybody we need to push away from the idea of opening up our society soon because we have to get this under control first and we aren't there yet. Next slide. Um yesterday. Sorry, I can't stop my phone from talking to me. Yesterday there was news about this new article that's a preliminary info that became available from the new England Journal the day before. So from Tuesday, this article came out about the first vaccine that's been studied in the United States. It's an Mrna vaccine called 1273 and it encodes for a little pre fusion spike protein. So it looks like the virus. And what they've done is the phase one study that involves 45 adults all 18 to 55. I wouldn't qualify. Um they record, they get two doses of vaccine a month apart. They have three groups, a low dose 25 micrograms, a middle dose, 100 and a high dose to 50. The incredible news from this study is after two dough. After one. Does everybody developed some antibody. After two doses, the antibody went sky high. The level of antibody measured after the second dose was comparable to the neutralizing antibodies that are measured in people who have covid disease acquired naturally. So yes, it does trigger an immune response. Does it protect them from exposure in the future? We don't know that yet. There were very few adverse events in this vaccine. They were worse in the higher dose group. Um it did induce a good response in these participants and there was no trial limiting safety concerns. So they're going to move from this to a 30,000 person vaccine study and that's going to give us the information about whether this vaccine will protect people from disease. So stay tuned. It's the first of many and I think Dr Fauci said that he thinks this vaccine will be available before the end of the year, possibly as early as september next slide. So we have to be cautious. As I said, we haven't had any patients acquire covid here we see many more by telehealth. Our surgery schedule is filling up dramatically, as evidenced by our crowded drive through testing site and the pre op testing sites that are done testing that's done elsewhere. Our families seem to be very pleased with the process. Anyone who's gone through the drive thru site, almost everyone gives us 2-4 thumbs up. It takes about three minutes. They get registered in advance. They get given a time for their appointment and when they get there it's a pretty smooth process. The providers in the hospital who do telehealth visits have now been able to build for those which we weren't able to do in the past. Um So patients get screened by phone before they come to the clinic and they get screened again when they arrive in the lobby and it's safe to send your patients to the hospital here. That's the message I'm delivering and I think it's what chris wanted me to say, mm.