Physicians struggle against omicron surge, confusing guidelines and limited resources

The new year rung in record highs of COVID-19 cases as omicron quickly surpassed delta as the dominant variant in the U.S., according to the CDC.

National COVID-19 data for the first week of the year showed an 85.7% increase in daily new cases compared with the last week of 2021, with a current 7-day average of 586,391 reported cases. The CDC projected that omicron accounts for 99.5% of all cases, as of Jan. 19.

After the spike in cases, health care workers struggled to meet the demand for testing due to a limited supply of available SARS-CoV-2 tests.

For example, at the Mary’s Center in Washington, D.C., an influx of patients seeking testing at the center’s clinics and dedicated testing and vaccination sites overwhelmed their supply, according to Seiji Hayashi, MD, MPH, FAAFP, the chief transformation officer and administrative medical director of the Mary’s Center.

“People were lining up at 7 a.m. for services that open at 9 a.m., and we were out of testing supplies by noon on some days after doing 200 to 300 tests,” he told Healio.

Although cases were at an all-time high, several reports have suggested that the highly transmissible omicron variant may have a less severe disease profile compared with previous variants, Healio previously reported. Still, hospitalizations for COVID-19 have recently hit record levels in several states. Meanwhile, primary care physicians have experienced “an incredible increase in the number of patients with COVID-19,” Hayashi said.

“Before Thanksgiving, we only had a couple of cases each week, and we began planning to increase our in-person services,” he said. “Now, we are seeing more than half of our patients who come in with respiratory symptoms test positive.”

Adults as well as children have been impacted by the transmissibility of omicron. Pediatric hospitalizations have peaked in recent weeks. The rate of COVID-19-associated hospitalizations for children aged 4 years or younger was 4.3 per 100,000 during the week ending Jan. 1, up from 2.5 per 100,000 for the week ending Dec. 18, according to CDC data.

“Our triage nursing team is working all day and night fielding calls for illness, testing and vaccinations,” Hayashi said.

Healio spoke with Hayashi and other PCPs in the U.S. to learn more about how practices are handling the surge in omicron cases amidst changes in COVID-19 treatment and isolation guidelines.

‘A busy and hectic time’

Physicians are dealing with several different challenges, according to Elisa Choi, MD, FACP, FIDSA, an infectious disease and internal medicine specialist in clinical practice in Massachusetts.

“The current omicron COVID-19 surge has been very busy for physicians, as many of us are seeing more COVID-19 cases than since the start of the pandemic,” Choi, who is also the chair-elect of the ACP national board of governors, told Healio. “There have also been staffing issues in both hospitals and ambulatory settings, as many physicians need to stay out of work themselves due to COVID-19 infections or symptoms, so those who are working are doing additional ‘extra’ work with cross coverage for colleagues who are out sick.”

Sterling N. Ransone Jr., MD, FAAFP, a family physician and president of the American Academy of Family Physicians, is also facing staffing shortages at his practice in Virginia. Isolation and quarantine protocols reduced his practice’s staff while patient need increased.

“It has been a busy and hectic time. Coming off of the holiday season, it has been stressful for staff, physicians and for patients,” Alexander Kowalski, DO, a Healio Primary Care Peer Perspective board member and the medical director of Rowan Family Medicine in New Jersey, said in an interview. “We have seen a large increase in cases in the outpatient and inpatient setting, but the majority [of patients] are able to be treated outside the hospital.”

Overall, PCPs are facing an issue of capacity, according to Ransone.

“Just because we are in a pandemic doesn’t mean we are seeing fewer people with chest pains, asthma attacks or blood clots. We are still seeing all of that, plus we have COVID-19 patients,” he said. “Trying to adjust our capacity so we can get the folks in who need to be seen has been a challenge.”

Handling testing requests

Multiple factors have contributed to the influx in testing, including the surge of omicron cases, an increase in holiday travel and the post-holiday return to work and school environments.

Subsequent to the surge in cases, the Biden administration announced it will send 10 million COVID-19 tests to K-12 schools each month so that schools can meet the demand for testing.

Meanwhile, Kowalski and his colleagues have been referring patients to local testing sites.

“There have been such delays in receiving results that we have moved away from sending PCR testing as the quarantine period is typically completed before the result is available,” he said.

Since COVID-19 tests were in short supply, Ransone prioritized patients with immediate testing requirements.

 

“We will see some folks in for testing who have an employer that requires them to be tested prior to their return to work,” he said. “It all depends on the reason that the person needs to be tested, and that is something we like to hear from patients.”

For certain patients who contacted Ransone’s office about requiring a negative test to return to work, his office staff was able to communicate with their employer about why testing may not be necessary.

To avoid long wait times at clinics and COVID-19 test sites, many patients are turning to at-home tests. Recently, federal health officials announced that at-home rapid tests will qualify for insurance reimbursement. Up to eight over-the-counter SARS-CoV-2 tests will be covered per month. All antigen diagnostic tests with emergency use authorization (EUA) qualify for the reimbursement scheme, according to the FDA.

At-home tests are more accurate for symptomatic patients, Choi said. They are generally less accurate and more likely to yield a false-negative result for asymptomatic patients.

“Most at-home tests have a relatively low sensitivity, meaning that many people will test negative even if they have the disease,” Hayashi said. “This is especially true if the patient does not have symptoms or has mild symptoms. That's why a PCR test is necessary to confirm a negative rapid test.”

In contrast, a positive at-home test result is usually a good indication of a SARS-CoV-2 infection, according to Ransone.

‘The incidence of false-positive testing with home tests is relatively low,” Ransome said.

For patients who test positive with an at-home test and require COVID-19 treatment, Kowalski “generally” recommends securing confirmatory testing of a positive case when considering treatment. However, he added that “for those who can be treated symptomatically and who can isolate, we typically are not ordering further testing given the limited availability at this time.”

Antiviral treatment

Prior to the omicron surge, the FDA issued EUAs for two COVID-19 antiviral treatments. The EUA for Pfizer’s Paxlovid extends to individuals aged 12 years or older who test positive for SARS-CoV-2 infection and are at high risk for severe disease. In comparison, Merck’s molnupiravir is authorized for the treatment of mild-to-moderate COVID-19 in individuals aged 18 years or older who test positive for SARS-CoV-2, and who are at high risk for severe disease.

Hayashi said that he and his colleagues at the Mary’s Center are “excited” by the recent EUAs, as their center has been one of 200 in the U.S. selected to rollout the medications. They recently received the first shipment of the treatments and have started prescribing them, according to Hayashi.

“The logistics of testing and treatment will be complicated. Both medications must be taken within 5 days of symptom onset,” he said.

According to Hayashi, Paxlovid interacts with commonly prescribed medications, and molnupiravir is complicated to prescribe because it may result in serious adverse events among pregnant women. Based on findings from animal reproduction trials, the FDA does not currently recommend the use of molnupiravir during pregnancy. 

“Molnupiravir is only authorized to be prescribed to a pregnant individual after the prescribing health care provider has determined that the benefits of being treated with molnupiravir would outweigh the risks for that individual patient and after the prescribing health care provider has communicated the known and potential benefits and the potential risks of using molnupiravir during pregnancy to the pregnant individual,” the FDA said in a news release.

At his center, Hayashi said that any test, including at-home rapid tests, can be used to confirm a diagnosis before prescribing antiviral treatment.

“We can potentially do telehealth visits where patients test themselves and we set up a medication pick-up system at our clinics,” he said. “We are still trying to figure everything out.”

The antiviral medications are expected to become more widely available later in February, according to Choi.

“These medications are authorized only for treatment of COVID-19 infection and not for prevention or post-exposure prophylaxis,” she said.

Confusion over recommendations

Despite the authorization of new antiviral treatments, prevention is the first recommended line of defense against COVID-19. However, state and federal guidelines have baffled both patients and health care professionals.

“I think the current guidance that is out there is quite confusing for a lot of people,” Ransone said.

In December, the CDC updated its guidance to state that asymptomatic people with COVID-19 can isolate for 5 days instead of 10, followed by 5 days of wearing a mask around other people.

“Many people ... lose sight of the component requiring strict masking and distancing for the subsequent 5 days, and that 5-day period is also contingent on significant improvement of symptoms prior to return to work,” Kowalski said.

He has been recommending isolation until testing for asymptomatic contacts, but isolation within a household “can be extremely challenging and taxing on families, so each situation varies.”

Hayashi reiterated the confusion felt by health care workers.

“When does day 1 start? What constitutes improving symptoms? What if you have a mild cough after 10 days?” he said. “Testing requirements to return to school or work has been challenging. Sometimes a rapid test can be positive even when the person is no longer infectious.”

When reviewing new guidance from Virginia’s health department, Ransone said he needed to read it twice and then make his own flowchart “in order to figure out exactly where they were trying to go with this.”

Ransone described the recommendations as “not straightforward enough” and called on recommending bodies to do a better job of communicating.

“If a physician who has been doing this for 25 years has had to read [the guidelines] twice to understand what they’re saying, I hate to see what the general public thinks about it,” he said.

In response to widespread confusion, the AAFP, ACP, American College of Obstetricians and Gynecologists, American Psychiatric Association and the American Osteopathic Association jointly issued a letter to the Biden administration calling for more consistent and ongoing investment in resources and public messaging campaigns. The letter represented more than 500,000 physicians.

Scenarios explained

According to Choi, there are different isolation and quarantine recommendations depending on a patient's status, symptoms and severity of illness.

Patients should “isolate” from all people if they have a SARS-CoV-2 infection. Individuals should “quarantine” away from people if they have been exposed to someone with an infection.

Patients who feel ill but are unable to get tested “should seek medical attention as soon as possible, as their illness needs to be evaluated, even if they are not able to get COVID-19 testing,” Choi said.

“Their physician can determine whether this patient’s illness may need to be presumptively managed as a possible COVID-19 infection,” she added.

In a situation where an individual feels ill and tests positive for SARS-CoV-2 with an at-home test, the family members or other close contacts would not need to quarantine or stay home if they are up to date on their COVID-19 vaccinations, unless they develop symptoms, she explained. The family members would also need a COVID-19 test 5 days after the exposure, even if they do not develop symptoms.

“If those family members are not up to date on their COVID-19 vaccinations, then they should stay home and quarantine for at least 5 full days, and they would need a COVID-19 test 5 days after the exposure to someone who has COVID-19, even if they themselves don’t develop symptoms,” Choi said.

However, if the family members were exposed to COVID-19, and the family members themselves had prior confirmed SARS-CoV-2 infections within the past 90 days (via a viral test), the family members would not need to quarantine and do not need to stay home unless they develop symptoms, Choi said.

Patients who feel ill but test negative with an at-home test or PCR test should seek medical attention. Their physician can determine if alternate diagnoses should be considered, or if additional COVID-19 testing is required, according to Choi.

She stressed that COVID-19 can be prevented by staying up to date with COVID-19 vaccinations.

As for masking, Kowalski and colleagues in New Jersey recommend double masking, “ideally with an N95 or similar, and maintaining social distancing whenever possible.”

Moving forward

Considering the many other diseases and health issues that prompt patients to seek care, “COVID-19 has really put a strain on the primary care system, and preventive care and chronic disease care have been challenging to provide consistently,” Hayashi said.

However, the changes brought on by the pandemic may have a positive impact on the health care industry long term.

“The pandemic has highlighted how much work we need to do in order to provide equitable administration of health care to our population,” Ransone said.

He added that the past 2 years have “shown us we need to be prepared for the next potential pandemic or illness that might hit our nation.”

Throughout the pandemic, health care workers have carried an enormous burden, having to risk their safety and struggle against burnout and resource limitations while caring for patients.

“This variant of the virus has really taken a toll on the energy and souls of health care workers,” Ransone said. “I just hope that we can figure out ways to support health care workers to help them be able to take care of those who are ill.”

References:

Coronavirus (COVID-19) update: FDA authorizes additional oral antiviral for treatment of COVID-19 in certain adults. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-additional-oral-antiviral-treatment-covid-19-certain. Published Dec. 23, 2021. Accessed Jan. 24, 2022.

COVID data tracker weekly review. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html. Accessed Jan. 24, 2022.

Physician organizations urge Biden for greater pandemic response amid omicron. https://www.medscape.com/viewarticle/966401. Published Jan. 11, 2022. Accessed Jan. 24, 2022.

The COVID-19 treatment guidelines panel's statement on potential drug-drug interactions between ritonavir-boosted nirmatrelvir (Paxlovid) and concomitant medications. https://www.covid19treatmentguidelines.nih.gov/therapies/statement-on-paxlovid-drug-drug-interactions/. Published Dec. 30, 2022. Accessed Feb. 4, 2022.

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

Editor's note: A source’s comments were clarified in the story regarding drug interactions with molnupiravir. According to Merck, “no drug interactions have been identified based on the limited available data on the emergency use of molnupiravir.”