From the COVID-19 front line: Experts discuss case control, testing, vaccine and more

The American Thoracic Society recently convened an expert panel to discuss the latest in COVID-19 news from the front line, including case control, testing and the need for communities to adhere to prevention strategies.

Controlling the spread

COVID-19 infections have continued to rise worldwide, with 7.1 million total cases and more than 204,000 deaths in the United States as of Tuesday. Outbreaks in different regions of the U.S. are anticipated in the fall and winter months, as well as after schools and universities have reopened with in-person or hybrid classes.

“Obviously, we would love to see fewer cases. There’s no doubt about that. And, if we can flatten the curve even further, that’s certainly ideal,” William Janssen, MD, section head of critical care medicine and professor of medicine in the division of pulmonary, critical care and sleep medicine at National Jewish Health in Denver, said during the virtual discussion Aug. 27. “But we’ll certainly continue to see outbreaks in different regions. And those outbreaks — those hotspots — are going to be the ones that could put the health care system to the breaking point.”

Testing continues to be an important focus of discussion.

On Sept. 18, the CDC again revised its COVID-19 testing guidance for asymptomatic people, saying definitively that people without symptoms who have been in close contact with an infected person for more than 15 minutes should be tested. “You need a test,” the guidance now states. The new language reversed a controversial revision of the guidance published in August that said asymptomatic people “do not necessarily need a test” if they have been in close contact with an infected person. Originally, the CDC recommended testing for “all close contacts of persons with SARS-CoV-2 infection.” (Read the full Healio article about the latest CDC recommendation here.)

“There needs to be ... an overhaul of the testing in this country as compared to what other countries are doing in that increasing the per capita availability of tests, having the ability to have quick turnaround for testing and an increase in contact tracing,” Gabriel C. Lockhart, MD, pulmonologist and assistant professor in the division of pulmonary, critical care and sleep medicine at National Jewish Health Institute, said during the discussion. “These are all methods to curtail the numbers of cases spread in the community and allow for people to have the knowledge base that they’re infected, you need to be quarantining yourself and you need to be contacting people who you could have potentially infected.”

Kenneth Lyn-Kew, MD, pulmonologist and associate professor in the division of pulmonary, critical care and sleep medicine in the department of medicine at Mount Sinai-National Jewish Health Institute, said there are “the three tenets” of importance to prevent the spread of SARS-CoV-2: masking, hand-washing and social distancing.

“We know that wearing a mask, washing your hands and maintaining distance are the three hallmarks of how we prevent the spread of this disease. This has been proven in our country, it’s been proven in other countries,” Lyn-Kew said.

Impact on the health care system

Early in the pandemic, health care systems had shortages of doctors, respiratory therapists, nurses and other staff, a lack of ICU resources, ventilators and personal protective equipment (PPE), and numerous other challenges.

Lockhart and Lyn-Kew traveled to New York City early in the pandemic.

“That was an invaluable experience ... being able to see first-hand the devastation to disease at this huge hotspot, being able to see what practices work from a logistics standpoint of how to expand the ICU resources and ... some places were at the brink of running out of certain things like PPE and ventilators,” Lockhart said.

“What we saw early on was that people in New York were using steroids earlier than was nationally accepted. They were doing trials along the way utilizing blood thinners earlier than what was accepted. And, there was a transition from early intubation to later intubation as we realized that we may wait a little longer to pull the trigger intubating patients and they had a very high mortality rate once patients were put on the ventilator,” he said.

Lockhart continued, “We utilized that experience that they had in New York to help guide our practices going forward. ... And we had better outcomes as a result.”

“I think what this highlights is that when a health care system is stressed, outcomes for patients can suffer,” Janssen said. “The whole goal for us going forward is going to be to reduce the rates of COVID-19 in the community to prevent spread of infection. And then, critically, when someone does come into the hospital they are now armed with some additional knowledge that we can use to treat those patients, whereas earlier in the pandemic everything was just brand new to us.”

Research continues

Research into a vaccine and treatment strategies continues. Some of those that have shown promise include convalescent plasma, steroids and remdesivir.

“We desperately need therapies that can prevent the spread of disease or that can treat it in patients [who are sick],” Janssen said.

“We have data for remdesivir that shows improvement in hospital length of stay,” Lyn-Kew said during the discussion. “Steroids, there’s some promise there. We had a trial ... on steroids for acute respiratory distress syndrome that showed some promise that came out in the end of February, just before COVID-19 ramped up, and that plus the current data on steroids and COVID are encouraging that this therapy may be beneficial.”

In late August, the FDA authorized emergency use of convalescent plasma as a therapy for patients hospitalized with severe COVID-19, saying the “known and potential benefits” of the technique outweigh any risks.

“Right now, we don’t have a good-quality randomized controlled trial comparing placebo to the convalescent plasma,” Lockhart said. “There’s a recent study ... that suggests that there’s an improvement with data, with patients that were given convalescent plasma early in the first 3 days of diagnosis compared to those who were given convalescent plasma in later stages.”

Another area of active research has focused on the presence of blood clots in patients with severe COVID-19.

Lyn-Kew said a multicenter trial is underway of the clot-busting drug tissue plasminogen activator.

“The trial is looking at whether busting these tiny clots that form in the lung can actually help our sickest patients who are on mechanical ventilation improve how much oxygen they require and ultimately help them get off the ventilator,” he said.

“When you look at what we have, everything is early data,” Lyn-Kew said. “What we do know is that providing good standard of care, critical care, which is timely — not too early, not too late in initiation — mechanical ventilation for those that need it, providing protection from the harms that can come with all the technologies in the ICU, providing the right nursing ratios, the right respiratory therapist ratios, these are all the things that are going to take care of patients with COVID-19 while we sort out the data. ... I believe every therapy we do in COVID-19, outside of standard of care, should be done in the context of a registry or a clinical trial.”

According to Janssen, “Without question, there’s tremendous pressure to find new therapies and, in large measure, that’s driven by the fact that 1,000 Americans are dying every day. And even more are getting sick. ... But that has to be balanced with safety. Hydroxychloroquine is a great example there. It was initially touted as a promising therapy based on a very small study. ... And so, what we’ve seen from a number of large randomized controlled trials is that hydroxychloroquine doesn’t benefit our patients with COVID-19.”

Focus on a vaccine

Researchers and regulatory agencies are racing against the clock to develop a safe and effective vaccine against COVID-19.

“There are legitimate concerns about releasing a vaccine — that it’s a different type of vaccine we’ve had in the past, with expedited trials,” Lockhart said. “All we can ask for is transparency from the CDC and these trials that are going on. ... And then when it’s deemed to be safe from FDA perspective, it’s going to require good acceptance among our population for it to be beneficial.”

“We need to make sure that the studies of the vaccines are following all the same levels of scrutiny and rigor that we use for any other drug ... so when a vaccine comes out and it’s ready for the population, we have to be very confident that it’s safe,” Janssen said.

Another concern addressed is possible coinfection with COVID-19 and influenza in the coming months.

“We know that people have forgone care and are afraid to go into hospitals for other care with this pandemic. My fear would be that people do not get vaccinated and then we have a flu pandemic or a flu season. A flu epidemic on top of a coronavirus pandemic would probably overrun our health care system,” Lyn-Kew said.

In addition to encouraging influenza vaccination, experts are urging communities to continue the precautions put in place at the start of the pandemic.

“There are four things that are efficacious for the flu and they happen to be the four things that are going to help us get through COVID-19 as well. ... No. 1, keep your distance; No. 2, wash your hands; No. 3, wear a mask; No. 4, get a flu shot,” Janssen said.