Q&A: Interim protocols for COVID-19 in primary care

Elisa Choi

More than 118,380 cases of COVID-19 and 4,290 related deaths have been identified worldwide, including 938 cases and 29 deaths in the United States, according to WHO and the CDC.

As the COVID-19 outbreak is nearing the level of a pandemic, institutions are limiting employee travel and medical societies are canceling or postponing their annual medical conferences because of concerns about the disease. Vice President Mike Pence said during a press briefing on Saturday that more than 1 million COVID-19 test kits have been distributed across the country and more will become available in the coming weeks.

As test kits are being rolled out in the U.S., Healio spoke with Elisa Choi, MD, FACP, FIDSA, ACP Massachusetts Chapter Governor and member of the Infectious Diseases Society of America’s public health committee, about interim protocols for COVID-19 testing in primary care offices and how primary care physicians should manage suspected or confirmed cases of COVID-19.

What is the protocol for COVID-19 testing at primary care offices? How do these protocols vary by state?

There are protocols emerging at a number of clinical practices and primary care offices to determine if testing is appropriate. Symptoms of COVID-19 are very nonspecific; basically, they are upper respiratory infection symptoms. High-risk criteria for testing include recent travel to level 3 CDC travel-alert countries where there is documented widespread and community spread of COVID-19 infection, as well as direct or close contact with a known or confirmed COVID-19 case.

After determining an individual meets the criteria for testing, the specimen is obtained by nasopharyngeal and oropharyngeal swabs. Testing kit availability has been limited, and many primary care offices may not have the kits to perform COVID-19 testing. Typically, there is a local or state public health department hotline for COVID-19 concerns, and primary care offices can contact those public health officials to coordinate testing and for additional clinical guidance.

This situation is rapidly evolving, however, and protocols for COVID-19 testing may vary state to state, primarily because the labs that can process these tests for COVID-19 are not yet widespread. In virtually all states, though, the public health department is part of the testing protocol and will be involved in the testing for COVID-19.

What are the next steps after a patient tests positive?

After a positive COVID-19 test, the patient seen by a PCP would require additional follow-up testing from the public health department. Within the primary care office, infection control steps are needed to ensure the patient who tests positive would not be a source of additional spread of infection.

Infection prevention measures that are already carried out in primary care offices would definitely need to continue in that situation — wiping down frequently-touched surfaces and making sure that there is reduced exposure of the patient who tests positive to other clinical staff and other patients. These precautions will evolve as public health departments determine the extent of necessary infection control measures, but current protocols recommend clinicians wear personal protective equipment and that patients suspected of COVID-19 are isolated in a negative pressure room.

Once a patient is confirmed to be positive for COVID-19, they would need to be monitored and undergo a clinical assessment to determine how severe their symptoms are; if symptoms are mild they can be safely observed at home in isolation, but if their symptoms are more severe they may require hospitalization. Much of this, again, would need to go hand in hand with collaboration and partnership with public health departments so that there can be close observation of a COVID-19-positive patient to further mitigate spread.

As we are looking at data emerging from countries that are hardest hit by COVID-19, the level 3 CDC travel-alert countries like China, South Korea, Iran, Italy and — to a lesser degree — Japan, it has become pretty apparent that older individuals are much more at risk for severe COVID-19 symptoms and for progression of disease, as well as at higher risk for mortality from COVID-19. Amongst the deaths due to COVID-19 reported in the U.S., they have almost exclusively been in older patients. So, there is absolutely a need to keep a closer eye on older individuals in the community since they seem to be at greatest risk and most vulnerable to COVID-19.

Is insurance complicating testing and treatment? How can PCPs ensure their patients are receiving the appropriate care?

This is also an evolving area of discussion. CMS released a statement related to COVID-19 late last week stating that diagnostic and laboratory services are considered essential health benefits. So generally, payers and insurers are required by law to cover diagnostic testing for COVID-19. However, the specifics of coverage for such diagnostic services will vary, and patients may still have some cost sharing for COVID-19 testing. I have seen reports surfacing online that some individuals have found themselves stuck with rather large bills for assessment and evaluation of COVID-19. So, the short answer is that there are some potential complications in terms of insurance coverage for COVID-19 testing, though insurance coverage should be available.

Treatment for COVID-19, other than supportive management, currently is very investigational, and vaccine availability for clinical use is much further down the pipeline in the next 12 months. How insurance coverage would handle such investigational therapies, or future concerns, for COVID-19 will need further discussion.

Regardless of insurance coverage concerns, patients who have suspected COVID-19 should receive the care that they need and is clinically appropriate. While recognizing there may be some insurance coverage issues, it is imperative that patients receive the necessary clinical care and diagnostic testing for suspected COVID-19. The diagnostic tests themselves are not that unusual, as swabs from the oropharynx and nasopharynx are obtained for numerous other medical conditions, so hopefully insurance coverage can be clarified in the subsequent weeks. Telemedicine services may be considered to triage patients who may have suspected symptoms while mitigating potential spread of COVID-19. Telemedicine is covered by some insurance plans, but that coverage may also be variable.

How long should patients with COVID-19 be monitored? What follow-up care/testing is recommended?

The current guidelines recommend monitoring patients who have confirmed COVID-19 while they continue to have symptoms, and decisions about when to release them from isolation are made on a case-by-case basis to determine if they are still actively at risk for transmitting infection. Patients confirmed to have COVID-19 should be monitored for continued symptoms and get additional evaluation if symptoms persist or worsen. For follow-up testing, current guidance advises that PCR testing for COVID-19 after symptoms (including cough and fevers) have resolved can be obtained at the end of the observation. A patient needs to have negative testing for the virus on at least two consecutive respiratory samples obtained at least 24 hours apart before a patient with COVID-19 could be cleared to circulate back into the community.

What should PCPs be telling caregivers of patients with COVID-19?

Physicians with patients who have COVID-19 should let those patients’ caregivers know that the patient should be isolated from other household contacts in a different room, should not be sharing utensils, cups, plates, beverages or food with anyone else in the household, and should wear a mask when entering common areas in the household. Caregivers who enter the room of a patient with COVID-19 should wear a mask. As we better understand the epidemiology of COVID-19, these restrictive measures appear to be necessary to minimize the potential spread of COVID-19 to the caregiver, as well as to the remainder of the household. Reducing household spread of COVID-19 becomes particularly important if the caregiver of the COVID-19 patient is older or has other chronic medical conditions that present high risk for COVID-19 complications.

What other advice do you have for physicians?

My caveat with everything I have discussed with you is that the COVID-19 situation is incredibly fluid and what I have said today might be outdated in 48 to 72 hours. But the important thing to remember is for PCPs to keep themselves as up to date as possible with the rapidly changing information landscape about this novel coronavirus.

Also, as frontline physicians, it is important to dispel a lot of the fear that is going around and counsel patients with facts and not speculation.

One negative byproduct of this fear and “epidemic” hysteria is an ugly anti-Asian sentiment of discrimination and bigotry that has emerged. It is really unfortunate that the spread of this infection has led to racial profiling of individuals of Asian descent as “carriers” of COVID-19. As should be evident to everyone in the medical community, the virus doesn’t discriminate. Whether an individual is of East Asian descent has no bearing on whether they have COVID-19. So, in addition to spreading the facts and dispelling the rumors and misinformation, it is really incumbent upon our physicians to stop and quell any of the bigotry, discrimination and racist sentiments that have unfortunately arisen during this epidemic.

Disclosure: Choi reports no relevant financial disclosures.

Editor’s note: This interview reflects the views and opinions of Choi and not her affiliations or institutions.