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July 2020 Symposium Questions and Answers

Have the numbers only been "stabilized" over the past few weeks because of lack of testing?

Is SCHD hiring contact tracers? How would one apply for a job as a contact tracer?

Is it not in the best interest of the county to go back to Phase 1?

If a person can pass the virus on before they get symptomatic, why are they allowed to go back towork without a negative test when they are only asymptomatic for 24 hours? What if they still have thevirus? I realize that is CDC guidelines, but the CDC has not been right the entire time.

Will UTHSC faculty, staff, and students have antibody testing available?

What do we believe is causing TN to have the greatest number of cases compared to otherstates?

Can you break down numbers in children 0-10yrs and 10-18yrs?

What is safer given assumption of 100 people, attempting social distancing but not well done inboth forums. Would it be safer to be inside with required masking or outside without masks?

Is the recently reported [pediatric] patient who died counted as one of deaths in TN even thoughyou are saying he/she died of an underlying condition?

Two questions: 1) could the fact that we closed schools earlier be contributing to lower rates ofinfection in children and 2) do you think there is any validity to the thought that the MMR might giveprotection (asking for a friend...)

Workers at Regional One Health and at St. Jude are being tested for CoVID-19, but not at Le Bonheur. Why the difference?

Are hospitalized patients with co-morbidities at increased risk for disease if care takers are nottested and potentially exposing them to the virus?

Do you have any data on how the pandemic is affecting children with developmental disabilities?

Chronic lung disease is not a major risk factor for severe COVID in adults - why do you think this is the opposite in children? Could it just be that children have higher rates of asthma in general?

Based on the data regarding children 0-9 (low transmission and lower health risks, but higher need for in-person instruction), would it make sense to recommend the school systems focus on getting just those younger (Prek-to 3rd grade) children back in the classrooms — using the the school facilities to spread children out into much smaller class sizes? I assume it would be difficult to staff additional classrooms with a limited supply of teachers.

Have you considered wastewater monitoring to assess levels of community spread and potential for early detection and scale-back implementation?

If students are social distancing, wearing masks and washing hands and a student in the class tests positive the next day, does everyone in that class and the instructor need to isolate for 10 days?

I am not sure which panelist to address this question to, but I’d love to hear more information or at least acknowledgement of the people infected with COVID who do not recover within 2-3 weeks, dubbed “long haulers” or experiencing “long tail symptoms”. Earlier this month a study in JAMA found 87% of COVID survivors in a small study out of Italy had at least one lingering symptom. The data collected by the COVID Symptom Study indicate at least 10% do not fully recover within 3 weeks. Some European countries are setting up “COVID rehab” clinics to treat these long-haul patients. What do we know about people in Shelby county who never fully recover, or take many weeks or months to fully recover? What local resources are there for these people? Most local doctor’s offices refuse to see patients with any active COVID symptoms, regardless of date of onset.

Which if any local hospitals have in house testing now or expect to in the near future?

Can you help explain the ED perspective that the likelihood to worsen after day 8 is low With the intensivist’s perspective about the third phase association with worsening?

What is the staffing plan for the Alternate Care Site?

Is there any data to support that COVID-19 may have been here in Nov, Dec 2019 and Jan. 2020?

What ideas does he and other pediatricians have for increasing vaccinations for the 0-5 children who are getting behind during the pandemic. Are mobile vaccinations possible? Could this also be a means of screening for and connecting families with supports to address ACEs and Social Determinents of Health? What resources would be needed to do this?

Most deaths in children with influenza are associated with secondary bacterial infections, particularly staph pneumonia. Is this true with COVID-SARS or is the lethality due to the systemic inflammatory process caused by the virus itself.

What seems to be the rate of reinfection?

Reported in today’s NYTs, the most used antibody tests don’t measure the most significant COVID antibodies and cell mediated immunity isn’t assessed by tests. Can you comment on what type of antibody testing is best for assessing short term immunity and what will likely be best for assessing immunity long term?

I got the Antibodies test for COVID-19 and there were no Antibodies detected, how often am I to get tested for COVID-19?

How can patients volunteer for the local biorepository study with Dr. Jonsson?

What about using hydrochloroquine, zinc, and zithromax to treat covid-19?

Is it true that patients with COVID-19 should not take NSAIDS?

I would like to see what percent of patients who come to ER are COVID-19 patients.

Answers


Have the numbers only been "stabilized" over the past few weeks because of lack of testing?

Response by Dr. McCullers: Testing has remained sufficient in recent weeks, albeit reporting is delayed. So the stabilization is due to lower transmission, likely due to mask use in the community

Is SCHD hiring contact tracers? How would one apply for a job as a contact tracer?

Response by Dr. McCullers: They continue to hire contact tracers. Job postings can be found at:
https://www.shelbycountytn.gov/3302/Employment-Opportunities

Is it not in the best interest of the county to go back to Phase 1?

Response by Dr. McCullers: It would likely be the quickest path to getting the disease under control across the country, but would cause further economic hardships, and without sustained changes in behavior, a recrudescence of disease after Phase 1 was lifted would certainly occur.

If a person can pass the virus on before they get symptomatic, why are they allowed to go back towork without a negative test when they are only asymptomatic for 24 hours? What if they still have thevirus? I realize that is CDC guidelines, but the CDC has not been right the entire time.

Response by Dr. McCullers: The guideline is 24 hours asymptomatic AND at least 10 days have passed since diagnosis – with rare exceptions, we do not find persons are contagious after 10 days unless they have ongoing, significant disease.

Will UTHSC faculty, staff, and students have antibody testing available?

Response by Dr. McCullers: We are likely to make antibody testing available in the coming months: first as
research, and then more broadly.

What do we believe is causing TN to have the greatest number of cases compared to otherstates?

Response by Dr. McCullers: Our lack of a coordinated Federal or State response (e.g., national or State
mandates for mask use) has prevented us from seeing the success other States have enjoyed.

Can you break down numbers in children 0-10yrs and 10-18yrs?

Response by Dr. Yuan: The American Academy of Pediatrics and Children’s Hospital Association data that I referenced in my talk does not break it down further by age. The Shelby County dashboard does not either. However, the TN Department of Health does:

  • 0-10 years: 5,218 cases; 5% of total cases; 3 deaths
  • 11-20 years: 12,507 cases; 11% of total cases; 1 death

What is safer given assumption of 100 people, attempting social distancing but not well done inboth forums. Would it be safer to be inside with required masking or outside without masks?

Response by Dr. McCullers: It is an interesting theoretical question to which I do not have a good answer, as we have no comparable data.

Is the recently reported [pediatric] patient who died counted as one of deaths in TN even thoughyou are saying he/she died of an underlying condition?

Response by Dr. Yuan: That is correct. This is per the rules set by the state health department.

Two questions: 1) could the fact that we closed schools earlier be contributing to lower rates ofinfection in children and 2) do you think there is any validity to the thought that the MMR might giveprotection (asking for a friend...)

Response by Dr. Yuan: First, this could certainly be true and could have contributed to the lower rates of infection that we saw at the beginning of the pandemic when schools were closed. This article published July 29th proposes this may have had a significant impact, but there were likely other factors as well:
https://jamanetwork.com/journals/jama/fullarticle/2769034.


Second, there is not any evidence to support this at this time. There is some thought that the sailors on the USS Roosevelt may have had milder symptoms from COVID due to their vaccination status and epidemiological data shows areas where vaccination rates are higher may also have patients with milder symptoms, but there are likely many more factors in play here.

Workers at Regional One Health and at St. Jude are being tested for CoVID-19, but not at Le Bonheur. Why the difference?

Response by Dr. McCullers: Workers at Le Bonheur, which is part of the Methodist system, are being tested for COVID-19 on a randomized schedule.

Are hospitalized patients with co-morbidities at increased risk for disease if care takers are nottested and potentially exposing them to the virus?

Response by Dr. McCullers: In local adult hospitals, visitors (care-takers) are not currently allowed for patients with COVID, and all patients are tested on admission for COVID. At all hospitals, extensive screening and restrictions on visitors are in place to prevent this sort of issue.

Do you have any data on how the pandemic is affecting children with developmental disabilities?

Response by Dr. Yuan: While there is an overall lack of literature on this topic as of now, I was able to find
this data which was obtained from an analysis of an EMR database comparing those with IDD [Intellectual or Developmental Disability] diagnosed with COVID to those without IDD who were diagnosed with COVID: For patients between 0 and 17 years of age, those with IDD had a fatality rate of 1.6%, while those without IDD
3 had a fatality rate of less than 0.1%, the study revealed. However, this was not able to account for other
underlying medical conditions.

Chronic lung disease is not a major risk factor for severe COVID in adults - why do you think this is the opposite in children? Could it just be that children have higher rates of asthma in general?

Response by Dr. Yuan: To clarify- the CDC does say that moderate to severe asthma may be a risk factor for children. There is not enough data yet. But, yes, I think.

Based on the data regarding children 0-9 (low transmission and lower health risks, but higher need for in-person instruction), would it make sense to recommend the school systems focus on getting just those younger (Prek-to 3rd grade) children back in the classrooms — using the the school facilities to spread children out into much smaller class sizes? I assume it would be difficult to staff additional classrooms with a limited supply of teachers.

Response by Dr. Yuan: I do believe that this should be the main focus at this time in our community- I would suggest PreK through elementary children to be the first group that is brought back for in person learning. The lower health risks combined with the need for closer academic instruction, parental supervision, inability of parents to work while caring for children this age, etc., all contribute to the need to make this a national priority. This is an excellent article on the subject that was unfortunately published after my presentation: https://www.nejm.org/doi/full/10.1056/NEJMms2024920.

Have you considered wastewater monitoring to assess levels of community spread and potential for early detection and scale-back implementation?

Response by Dr. McCullers: Yes, this is being done on the UT Knoxville campus and is being piloted in Memphis. 

If students are social distancing, wearing masks and washing hands and a student in the class tests positive the next day, does everyone in that class and the instructor need to isolate for 10 days?

Response by Dr. Yuan: You can find the UTHSC/Le Bonheur Back to School Task Force Guidelines here and
I’ve taken a few excerpts to address this question: https://mcusercontent.com/98e00013cd446bc8c2c44c8fa/files/d5b0f616-7993-4a0d-9a00-
e658cf85ea95/Back_to_School_Task_Force_Le_Bonheur_Children_s_UTHSC_Recommendations_FINAL.pdf.

Contact tracers should determine through interviews with students and teachers which individuals spent
more than 15 minutes within 6 feet of the infected individual, starting two days before onset of symptoms.
Enforcing physical distancing will make contact tracing much easier. Individuals wearing full PPE (i.e. school nurse with gown, gloves, N-95 mask and face shield) will not be considered contacts regardless of distance and duration of exposure.


Individuals who are identified as contacts of a possible case should be excluded from school until the suspected case is confirmed positive or negative. If the suspected case has a negative test, then contacts can return to school.

The classroom where the exposure took place will be shut down for at least 24 hours for a thorough cleaning. The Health Department may choose to shut the classroom or school for two to five days for cleaning and contact tracing. If the school remains open, the individuals (including entire class) should be rescreened for symptoms and fever. Children who are not considered contacts (were not within six feet for ≥
15 minutes) may be able to stay at school, but contacts will be immediately sent home. If possible, the remaining class members could be moved to a different room while the other classroom is cleaned and ventilated per CDC guidance.

If a cluster of cases (two or more cases sharing a common source) occurs in a school, or if widespread
exposures have occurred as a result of an infected teacher or counselor who spent time in multiple locations in the school, then the school will need to be closed to allow for contact tracing and cleaning. This will also be done in consultation with the Health Department.

I am not sure which panelist to address this question to, but I’d love to hear more information or at least acknowledgement of the people infected with COVID who do not recover within 2-3 weeks, dubbed “long haulers” or experiencing “long tail symptoms”. Earlier this month a study in JAMA found 87% of COVID survivors in a small study out of Italy had at least one lingering symptom. The data collected by the COVID Symptom Study indicate at least 10% do not fully recover within 3 weeks. Some European countries are setting up “COVID rehab” clinics to treat these long-haul patients. What do we know about people in Shelby county who never fully recover, or take many weeks or months to fully recover? What local resources are there for these people? Most local doctor’s offices refuse to see patients with any active COVID symptoms, regardless of date of onset.

Response by Dr. Sodhi: There is emerging data that patients who have “recovered” from COVID19 may have
lingering symptoms and health effects. We are in the nascency of understanding long term effects of this
virus. Current data suggests some patients may develop fibrosis of the lungs, continued shortness of breath
and constitutional symptoms like myalgias and fatigue. Patients who have needed hospitalization (especially
in the ICU) for COVID19 may take weeks or even months to improve, especially due to significant deconditioning that occurs as a result of severe illness. The percentage of patients who develop these lingering symptoms is unknown at this time.

MLH has a “COVID” clinic meant specifically for patients who currently have COVID19 and do not need
hospitalization. Patients who have recovered from COVID19 can be seen in the MLH primary care practices.

Which if any local hospitals have in house testing now or expect to in the near future?

Response by Dr. Sodhi: St Jude’s Hospital has in house testing. As far as I am aware, they are the only
hospital in town with in house testing.

Can you help explain the ED perspective that the likelihood to worsen after day 8 is low With the intensivist’s perspective about the third phase association with worsening?

Response by Dr. Walker: It is true that rapid worsening can occur at any time. The key is risk stratification of
patients being evaluated for discharge. There are documented cases of patients deteriorating beyond this
time period, but rapid deterioration that is unexpected usually occurs by day 8-10 after patient presents on
day 2-5. This is also the average time for admission to the ICU on admitted patients. Persons who are stable
or improving and able to tolerate room air or 1-2 L O2 BNC are candidates to go home after this time frame.
They will still require observation and follow up. There is no sure fire way to tell, but triaging home those  likely to do well frees bed space for the more acutely ill in the hospital. Those who are getting worse would obviously not be good candidates for early discharge. At home observation and PCP rechecks are essential to the patient’s safety with this process.

Clinical judgement and risk stratification is also important. In this paper:

Risk factors for disease progression in COVID-19 patients Min Cheol Chang1, et al. ORCID: orcid.org/0000- 0002-7724-4682, BMC Infectious Diseases.

Age, fever, dyspnea, initial chest Xray findings and (most importantly other than age) diabetes were predictors of poor outcomes. Neutropenia and elevated inflammatory markers were also predictors of a more difficult clinical course. Patients with severe or multiple risk factors would justify inpatient observation rather than aggressive discharge. An otherwise healthy 38 year old with someone to help at home might be better off at home with oxygen and a pulse oximeter. 

What is the staffing plan for the Alternate Care Site?

Response by Dr. Walker: The staffing for the ACS hospital is via a national staffing company. We also plan to
use appropriate candidates from the local medical reserve corps and even clinic physicians who are trained in internal medicine but who may currently only be working in an outpatient clinic (which would be closed during a surge). There were a number of local physicians that fell into that group during the Phase 1 shutdown in Memphis this spring. Rather than have them sitting at home looking for something to do, we can use them at the ACS. Many surgical nurses found themselves out of work around the country for the same reason (elective surgeries were mostly all cancelled) during the initial shutdown. Critical care at the site will be provided by Pulmonary/Critical Care physicians and/or Emergency Medicine physicians. Given that the nation has never faced such a need in virtually every state at once in our lifetime, this situation remains fluid.

Is there any data to support that COVID-19 may have been here in Nov, Dec 2019 and Jan. 2020?

Response by Dr. McCullers: There are no data suggesting this, and it seems very unlikely. 

What ideas does he and other pediatricians have for increasing vaccinations for the 0-5 children who are getting behind during the pandemic. Are mobile vaccinations possible? Could this also be a means of screening for and connecting families with supports to address ACEs and Social Determinents of Health? What resources would be needed to do this?

Response by Dr. Yuan: Pediatricians across our community, the state, and beyond have been working hard to address this! Some practices are conducting drive by vaccinations clinics or have been open for extended
hours on nights and weekends. The state is planning a vaccine blitz day I believe. In our practice we have
held additional clinics at a community center that is in a location that we identified as a hot spot for children
who needed vaccines, especially those who are entering kindergarten or 7th grade and must receive the required vaccines for school entry. I think screening for social determinants of health at these types of events are a great idea. The community center that our clinic has been held has services available for food and other needs. I do think that screening for ACEs should primarily be done in the primary care setting so that those patients and families can be connected to the proper resources and have proper follow up from trained professionals on those issues.

Most deaths in children with influenza are associated with secondary bacterial infections, particularly staph pneumonia. Is this true with COVID-SARS or is the lethality due to the systemic inflammatory process caused by the virus itself.

Response by Dr. Yuan: I do not think that we have enough data to reliably answer that question at this time.

What seems to be the rate of reinfection?

Response by Dr. Thomas: This is still really unknown. The data available would suggest that thus far it is fairly low. While some reports have emerged of individuals with prolonged virus shedding, or a second round of positive tests after previously testing positive and then negative, it's difficult to determine to what extent these reports represent differences in testing efficiency and/or false positives. There are not welldocumented, well-characterized cases that definitively show a second SARS-CoV-2 infection in an otherwise healthy individual following successful clearance of the first infection. Research is very intense in this area now though so the hope is that these questions will be answered soon.

Reported in today’s NYTs, the most used antibody tests don’t measure the most significant COVID antibodies and cell mediated immunity isn’t assessed by tests. Can you comment on what type of antibody testing is best for assessing short term immunity and what will likely be best for assessing immunity long term?

Response by Dr. Thomas: This is also still an open question. Particularly with respect to long term immunity,
the infection has not been in humans long enough for those assessments to be made. In general, for other respiratory viruses, the most valuable antibodies are those targeting the surface receptors viruses use to enter or exit a cell. In this case, that would be the Spike protein, and many assays do measure these antibodies and report good sensitivity and specificity for documented infections. Some of the commercial tests measure a structural protein, N, or nucelocapsid, which is likely not as relevant (though it remains to be proven one way or another) for protection, but is still probably correlated to some degree with other aspects of the immune response, including Spike antibodies and cell-mediated immunity. The question of how much antibody is necessary for conveying short and long term immunity--basically, what would be a good "correlate of protection" for either N or Spike antibodies--still remains to be determined.

I got the Antibodies test for COVID-19 and there were no Antibodies detected, how often am I to get tested for COVID-19?

Response by Dr. Thomas: There is no specific recommendation that I am aware of for antibody testing frequency. The antibody test, if it is sensitive and specific, can only tell you that you had COVID-19, it does not tell you whether you currently are infected. That is done with a PCR test for the viral nucleic acids (the viral genome). Since we do not know what a protective level of antibody is, knowing you had COVID-19 can help explain a previous illness or help contribute to understanding the epidemiology and spread of the virus, or just satisfy your curiosity, but there are not currently to my knowledge any specific medical reasons to be antibody tested.

How can patients volunteer for the local biorepository study with Dr. Jonsson?

Response by Dr. Finkel: To enroll, the volunteer may contact the UTHSC Biorepository team at biorep@uthsc.edu. The team will send the volunteer’s contact information to the study scheduler. The  scheduler will let the volunteer know what times are available to do the initial informed consent and sample collection. The volunteer will also be told where to go for the first in-person visit.

On behalf of Dr. Jonsson, the dedicated Biorepository team, and all of us at UTHSC, thank you very much for your support!

What about using hydrochloroquine, zinc, and zithromax to treat covid-19?

Response by Dr. Finkel: The National Institutes of Health (NIH) recommends against using hydroxychloroquine, with or without azithromycin, for the treatment of COVID-19, except in a clinical trial.

The National Institutes of Health recommends against using zinc supplementation above the recommended dietary allowance for prevention of COVID-19, except in a clinical trial.

Hydroxychloroquine, azithromycin, and zinc have been hyped, even politicized, in the lay press as preventive agents or treatments for COVID-19. There has unfortunately been no reliable data to back up these claims. In early June, a large randomized, controlled study conducted in the U.S. and Canada showed that hydroxychloroquine did not prevent viral infection or symptoms of COVID-19 when patients received the drug within 4 days after a moderate- to high-risk exposure.

Hydroxychloroquine has been evaluated for treatment of COVID-19 in many small clinical trials and case studies. Most of these studies showed that hydroxychloroquine with or without azithromycin has no clinical benefit and makes no difference in the body’s ability to clear the virus. Some of these studies, such as a small French study which suggested benefit, suffered from missing or uninterpretable data, preventing any conclusions from being drawn. Several large studies looking back at patients with COVID-19 who have taken hydroxychloroquine with or without azithromycin also showed no clinical benefit. In addition to their lack of benefit, these drugs can do severe harm in some patients, including increasing the risk of an abnormal heart rhythm and cardiac arrest.

Within the last week, one of the largest prospective controlled studies of COVID-19 patients treated with hydroxychloroquine and azithromycin was published in the New England Journal of Medicine. You can read the article at this web address: DOI: 10.1056/NEJMoa2019014. In this study, patients with confirmed or suspected Covid-19 were treated with hydroxychloroquine and azithromycin, hydroxychloroquine alone, or with usual care. The researchers evaluated these patients after 15 days of treatment. The researchers concluded there was no significant difference in disease outcome between these groups. Of concern, those patients taking hydroxychloroquine with or without azithromycin experienced significantly more side effects than those who did not.

Vitamin and mineral supplements (including vitamin C, vitamin D, and zinc), have been promoted for the treatment and prevention of respiratory viral infections; however, their roles in treating COVID19 are unproven. Doses of zinc above the recommended daily allowance can cause harm.

Is it true that patients with COVID-19 should not take NSAIDS?

Response by Dr Sodhi: Recent studies suggest that there is no clear increased risk in patients who were taking NSAIDs compared to patients who were not taking NSAIDs when they were diagnosed with COVID-19. Current recommendations are that there is not enough evidence to discontinue NSAIDs if someone is on them and is diagnosed with COVID-19. 

I would like to see what percent of patients who come to ER are COVID-19 patients.

Response by Dr. Walker: That number is fluid and a little inaccurate, but is usually about 7-10% right now. We do NOT test everyone who comes to the ED, but we do test every patient admitted to the hospital.
May 26, 2022