Infectious Q & A With Dr. Jade Le Save

Hi, I'm Jack Cush with roomnow.com. I'm here today with Doctor. Jade Lee, an infectious disease consultant here in Dallas, TX. Good afternoon, Jade. How are you?

Good, thank you. You for inviting me on.

Well, we're so delighted to have the real experts talk to our rheumatology audience about all things COVID right now. I mean, are a lot of things going around, and it seems like almost everybody's affected. How are you seeing what's going on in Dallas right now? We know about the real hot spots. What's the growth of this pandemic here locally?

So as we started to roll out more testing centers in Dallas, we have started to pick up more cases. So as we went beyond just the county health department testing patients who may have COVID-nineteen, and we have centers that are built in the community, as well as some community doctors have the capability and institutions to test for COVID-nineteen, we are seeing a rapid rise in the number of cases here, yes.

Yeah, you just fear it's gonna get a whole lot worse. So you've been dealing with this now for almost a month as we have, I really would like to know what are the two most common questions that you're getting?

Yes, so as an infectious disease physician, the most common questions that we get are regarding PPE or personal protective equipment. What types of masks should we be wearing? Where should we be wearing these masks? How often should we be changing the masks? Etc.

Again it's going to depend on the type of work you do as a physician. If you are ruling out someone with COVID-nineteen, you are supposed to wear certain protective gear to prevent yourself from getting the infection. Getting that nasopharyngeal swab is an aerosol generating procedure, So we recommend the N95 mask, the face shield or goggles if possible, a gown and gloves. If you are taking care of a patient who has COVID-nineteen, the CDC recommendations are for droplet precautions, which means a regular surgical mask, gowns, gloves. However, if you're a physician performing an aerosol generating procedure like intubation, bronchoscopy, etcetera, then that is airborne isolation, which means that N95 mask, face shield or goggles, gowns and gloves, or even the PAPR, the Powered Air Purifying Respirators.

So, you know, it wasn't but about three or four weeks ago, I put out the advice that I've been given from others is that routine patients on the street shouldn't be wearing masks because one, they're the wrong masks, they're not well fitted, they're not really designed to protect. It seems like there's been a flip on the use of masks. Can you talk about doctors using masks when seeing patients? And I'm not talking about patients suspected of having COVID or COVID symptoms, but just new patients coming in, should they be wearing masks? Patients out in the street, should they be wearing masks?

Yes, so those are fantastic questions. Realize the information is changing almost every few days we get new information. What we know right now is that if you are practicing in an area where there a lot where there's a high number of COVID-nineteen cases, you have to assume there is community transmission. And many medical institutions in those areas are recommending that doctors wear a regular surgical mask around all patients. And at our institution, all patients coming into the institution, as well as all physicians, health care workers, and any personnel in the hospital have to wear a surgical mask at all times, because we're assuming it's in the community.

And as we're learning from studies, there are patients who may be asymptomatic or pre symptomatic, and yet still can shed the virus and be infectious. And that's for that reason. Now, terms of people in the community, what we're learning from countries such as China, Taiwan, Singapore, and cities such as Singapore, Hong Kong, and South Korea is they do have a universal masking policy for the community. Those are the regular home sewn masks or masks you can buy in a store. They are not as protective as your surgical mask and definitely not as protective as an N95 mask, but the thought with those patients or those persons in the community is that maybe you can reduce the number of infectious droplets that are spewed from the asymptomatic or pre symptomatic persons.

So there may be some benefit to just wearing a face mask in public to reduce the amount of transmission.

Okay. I know you said that you would be getting questions, a lot of questions about deliveries and packages.

Yes.

What do you think we should tell patients?

Exactly. So there was a lab study that showed that the SARS coronavirus can last on cardboard, can be present on cardboard for up to twenty four hours, steel and plastic for two or three days. And because of this, there's a concern that delivered packages or delivered goods may transmit the virus. Remember, this study only looked for viral RNA. So yes, although they found the viral RNA, they did not prove that that RNA was infectious.

And so what we say is use your usual precautions. There is really no data to prove that we need to be wiping down cardboard boxes or grocery bags, etcetera. But if you're getting a delivery of vegetables and fruits, wash them as you normally would. If you're getting a delivery of meats, etcetera, make sure it's fully cooked as you normally would want it to be, etcetera. But there's no data to show that packages are transmitters of this coronavirus.

So it would be wonderful if you could give us some of your wisdom on how to handle patient flow. So what's we're now seeing in rheumatology, one of our patients, let's just say it's lupus and rheumatoid on our usual medicines with or without a biologic, they're doing okay, but they come down with symptoms. Going send them for a nasal swab. And the question is, and we're doing that because of, high likelihood, they don't have runny nose, they are having myalgias and low grade fever and respiratory symptoms and maybe loss of smell or taste or whatever, but the idea is we're sending them and what do we do with them from that moment on while we're waiting for the test and then thereafter? What's the sequence that you would use in managing that patient?

So for those patients, it depends on when they call you upon symptom onset. So if they call you early on and they have these mild symptoms and you send them for testing, which is usually the nasal pharyngeal swab. Turnaround time may be forty eight hours to up to five days. So what yeah depending on where you're they're tested, etc. So during that time period, what we say is number one, they should try to self isolate at home as much as possible.

Avoid contact with elderly persons in the home young kids pregnant women, etc. They should monitor their symptoms. So we usually recommend checking their temperatures at least a few days, watching for any worsening signs or symptoms. If they have more shortness of breath, the cough is getting worse, etcetera. Even if they're waiting for the test results to come back, they should go to an emergency department for evaluation.

Because what we've found with this coronavirus is that in high risk patients who tend to be older patients with comorbidities, when they have start having symptoms, that time period for when they look pretty good and then crash and become extremely ill and need to be in the ICU is a very short window period of time. Now, if they're self monitoring and they have no worsening of the fevers, or they notice their symptoms start to get better, again, self isolate, keep tabs of their symptoms, notify you of course, and go to an ER if their symptoms get worse.

Would you put someone on Zithromax if they are waiting for the lab test, they got symptoms, would you do that or is the data not good enough to say that?

So at this point in time, the data is not good enough. The studies looking at the use of azithromycin and Plaquenil for the treatment of patients with coronavirus disease, small study in France, very few patients got it. It was observational, not randomized, and there was no control arm. And based on that, all they could tell was the viral load dropped with the initiation of the two antibodies in a small group of those patients. There was not enough data to look at outcomes.

So there's not enough information for us to recommend this. Now the FDA has approved hydroxychloroquine for the treatment of coronavirus patients who are adults and hospitalized. That means that they must be severely ill in order to receive that, but there is not enough data yet. There are numerous studies looking at the use of plaque hydroxychloroquine for prevention, for post exposure prophylaxis, and for treatment of patients with coronavirus disease. But unless you're relying on anecdotal reports, small studies without a randomized, without randomization or control arms, it's hard to recommend that at this time, although there are doctors who are prescribing that combination.

Okay, now we're in this era of increased testing, which means we're gonna get more test results. I'm a little concerned about what the readout's gonna look like. So from one readout I saw, I think at our hospital, was a positive presumptive positive and negative, and then, you know, not well done and please repeat. What kind of results are you seeing and how should we react to these, especially if you're getting back, you know, one of these so so sort of answers?

So that's interesting that you're getting that presumptive positive. So what we do is if we think someone has coronavirus infection, we label them as a PUI, a person of interest, under investigation. That's a person in whom we will use the PPE, we'll treat them as a coronavirus patient until the test comes back negative. With these RT PCR tests, the nasopharyngeal swabs, you should be getting positive or negative. Either they detect the virus or they don't detect the virus.

That presumptive positive may be a combination of putting clinical symptoms, waiting for the test to read. I'm not clear about why you're getting that result unless your lab is looking at copy numbers and trying to figure out what amount of copies constitutes a true positive.

Okay. Let me end with, one, thanking you for answering these questions, and two, can you give my rheumatology colleagues advice on how and when they should contact their ID consultant? You guys are really busy right now, not able to sleep, not even able to take care of your own families, and we don't want to be calling you for every little thing. What should we do and when should we send you the patient or call you?

So for most of these patients with coronavirus disease, the ones who are sick enough to require treatment are usually the ones who end up in the hospital. So if patients have mild symptoms, again, the CDC, the Infectious Disease Society of America numerous medical organizations have great toolkits for advising patients to stay home monitor symptoms, etc. But if they are sick. You can call your local infectious disease doctors to see if they have algorithms that may be helpful for you to triage when to send them to the hospital, when not to. The most of the times in which we see the patients are when they are hospitalized, when we're trying to figure out which types of therapies to use.

And actually, in the hospital, what we're saying is that our rheumatologists and infectious disease doctors should be part of that team, including the critical care doctors, to decide what are the best treatments for these patients, because we are using many rheumatologic drugs that we traditionally don't use in infectious diseases. But in terms of calling your infectious disease doctors, I think it would be best to call them sooner than later to establish a relationship, to decide which types of protocols are most helpful for using in terms of triaging your patients to direct them to the hospital should they be very sick, stay at home, wait and watch, and decide with your infectious disease doctors whether or not they're considering hydroxychloroquine or hydroxychloroquine plus azithromycin as treatment of mild COVID infections.

So I want to just backtrack a little bit. Of the eighty percent of patients who have that mild to moderate disease are not gonna end up in the hospital, they don't necessarily need to be on treatment. Need to just convalesce isolate and weather the storm with symptomatic management. Is that right?

Exactly, exactly. Especially if most of those eighty percent have no risk factors for severe disease. If they're younger, if they do not have hypertension, heart disease, kidney disease, or immune compromising conditions, most of them get better without any form of treatment.

All right, Doctor. Lee, many thanks for your time. I'm sure we'll be asking more questions in the future. You have a good day.

Thank you so much. Bye bye.