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COVID-19 in the Primary Care Setting (6/15/20)

Transmission

 

  • Respiratory Droplets
    • Cover mouth: cough/sneeze
    • 6 feet away
    • Wear mask in public
  • Surfaces: wash hands/don’t touch face
  • Protection with standard mask usually ok
  • N95 mask especially important with ill patients and aerosol-generating procedures
  • No Vertical transmission seen in small study

 

Onset

 

  • Incubation 2-14 days (average is 5 days)
  • First Sx’s → SOB, viral pneumonia ~ 5 days
  • First Sx’s → respiratory failure ~ 10 days (ARDS, cytokine storm)
  • Multi-organ failure/cytokine storm can happen in a matter of hours
  • Extubation: after ~ 10 days on vent if able

 

Testing
 

  • ~70% sensitivity (~30% false negatives)
  • ↓ Sensitivity early in dz/with poor technique

 

Prognosis

 

  • 80% self-limiting
  • 15% hospitalized
  • 5% ICU/vent → ~80% die

Clinical Manifestations

 

  • 90% fever but only about half at onset
  • 70% fatigue
  • 60% dry cough (some produce sputum)
  • 40% ↓ appetite +/- loss of smell/taste
  • 35% muscle aches
  • 30% shortness of breath
  • Silent hypoxemia common/pulse ox ↓ 
  • GI sx’s (more common in kids) can indicate more severe disease in adults
    • Nausea without vomiting
    • Belly discomfort with loose BMs

 

Influenza compared with COVID-19  

 

  • Influenza: more rapid onset
  • Influenza: ↑ fever, ­ ↑ body aches
  • Influenza:­ ↑ congestion, ↑ ­GI sx’s (N/V/D)
  • Influenza: less cough, less SOB
  • Influenza: 2° Bacterial Pneumonia is complication (not w/ COVID-19)
  • Influenza: only 1-4 days incubation
  • Influenza: affects children more
  • Influenza: Mortality ~0.1%

 

RFs for Severe Dz/Mortality

 

  • Smoker                          Mortality
  • Cancer                           Overall: ~1%
  • Diabetes                        Rare in Kids
  • Hypertension                 50s: ~0.1%
  • Kidney Dz                      60s: ~0.5%
  • Heart/Lung dz                70s: ~2%
  • Immunosuppression       80s: ~6%

 

Treatment

 

  • Avoid steroids
  • Ibuprofen may ↑ severity/duration of COVID-19 (insufficient evidence)
  • ACEi’s/ARBs may help or worsen dz:
  • COVID-19 binds to ACE receptor (and gains access to cells) → up-regulation of these receptors. On the other hand,  ACEi/ARBs may protect against lung dz.
  • Remdesivir: may hold promise, worked with MERS
  • Convalescent plasma may be helpful
  • Statins: fewer severe viral pneumonias, decrease cardiac complications, may ↑ immune response in viral infections
  • Hydroxychloroquine: Limited data, may be more harmful than helpful
     

Labs

 

  • ­↑ CRP, Ferritin, AST/ALT
  • ↓ WBC, platelets

 

Primary Care Role

 

  • Triage and guide Pts with respiratory symptoms including asthma and COPD
  • Promote overall wellness to maximize immune system health
  • Manage chronic dz and keep patients healthy and away from the ED/hospital
  • Beware of racial inequalities and bias, disproportionately affecting brown and black communities

Wayne Altman, MD, FM Chair, Tufts University SOM