Waco COVID-19 Update 3/18/20

Fellow McLennan County Physicians,

The time has arrived where we have our first confirmed cases of COVID-19 in Waco.  The confirmed local presence of this will create additional public concern, thus it remains pivotal that we all remain united, with good communication, in order to best relay data, treat, limit and help prevent further cases locally.  Dr. Farley Verner, local Health Authority and Infectious Disease specialist, has joined with me to start sending out these additional updates, Q&A and local information.  As always, we want to keep this relevant.  Let us know if you have any additional issues, suggestions or questions that you think would be helpful for the entire McLennan County Medical Society.  Please continue to follow CDC recommendations and any hospital issued recommendations for those employees of the hospitals.

Situation Update as of 3/18/20
·  Worldwide Cases – 217,977 confirmed cases.  8,800 deaths. China, Italy, Iran and Spain have the highest confirmed cases. US now ranks 6th worldwide in total cases.
·  US Cases – 9,371 confirmed cases. 153 deaths. New York, Washington, California, and New Jersey have the highest confirmed cases. Texas ranks 10th nationally in total cases.
·  Texas Cases – 83 confirmed cases. 2 deaths. Harris County, Fort Bend County and Dallas County have the highest confirmed cases.
·  McLennan  – 6 confirmed cases. 0 deaths. All with travel history.
*Note for case counts – We are reporting case counts from the CDC website. Due to increasing testing capacity at State and local labs around the country, the count may be lower than the numbers reported by media.

Local Update
·  The City of Waco issued a Disaster Declaration on Tuesday, March 17th. That Declaration included the closure of restaurants and other public facilities, as well as prohibiting gatherings of 50 people or more. Questions about those closures can be found here: https://www.waco-texas.com/information-release-2.asp
·  Both hospital systems and the Family Health Center have implemented some form of drive thru testing. Patients need to be screened on the phone or online prior to going to these locations for testing
·  Weekly meetings are occurring with members from both hospitals, the Family Health Center, city leadership, the health department, the medical society and Dr. Verner.
·  An iPhone app option through BSWH and Providence are both available for patients to receive local tele-consultation and guidance for further testing.
·  Both hospitals are prepared to provide care for any patients who ultimately test positive and need hospitalization.
·  Activation of the EOC/MOC will occur this week, Thursday afternoon at the earliest. It will be a mostly virtual activation with daily IAPs and Sitreps distributed.
·  Up until a week ago all local tests were performed at the CDC or at the Texas DSHS state lab. These specimens are submitted with the coordination of the Health District. Baylor Scott and White system laboratory has begun performing its in-house test for its Waco affiliates. During the week of March 9 local commercial laboratories began accepting specimens for testing. The ascension Providence system, The BS&W system and the Family Health Center are each developing specific sites for use in obtaining specimens within their systems.  They give all details to their providers.
·  Laws/TMB regulations have been relaxed for tele-health visits and many local physicians have transitioned to offering some of these visits when applicable.

Q: At what point do we consider “possible” domestic exposures as a potential exposure to pursue testing?  Which locations nationally are considered?

A: Sustained community spread has occurred in California, in two places, Oregon and Washington.  The criteria for testing has been expanded to include more symptomatic persons, even in the absence of travel to affected areas as the ability to access testing is improving.

Q: Should post-exposure prophylaxis be used for people who may have been exposed to COVID-19?

A: There is currently no FDA-approved post-exposure prophylaxis for people who may have been exposed to COVID-19.

Q: What do I do if I have concerns about a patient being infected?

If patient calls your clinic with a concerning history for infection and meets screening criteria:
Advise patients to contact their PCP’s office for further direction in the evaluation and testing.

If patient is in your office:
If you work at a BS&W Hillcrest or Ascension Providence facility, follow the protocols designated by your hospital.  Several clinics have been trained to test at point of care after proper screening if needed.
If independent, follow “Screening Questions” in previous email or on CDC website, contact the health department at 750-5411 (physician line only) and/or contact local EMS.

Q. Are there any guidelines regarding cancellation of surgeries or non-emergent chronic follow up appointments?

A: Many factors are involved with these considerations.  See American College of Surgeons recommendations.
https://www.facs.org/about-acs/covid-19/information-for-surgeons/triage

Q: If someone from our office staff is potentially exposed either by a positive case or family member/friend, what are the recommendations?

A: This will become a more relevant question as the confirmed cases become more prevalent.  More information to come. https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/hcp-return-work.html

Q: What if we do not have any N-95 masks or have a shortage of PPE?

A: The TMA has a resource where physicians can contact their Regional Advisory Committee. There is anticipation of a greater shortage in the coming days. We advise early recognition and planning. Contact the health department for further questions and plans to obtain additional PPE.

Q: Are there any new treatment guidelines?

A: Corticosteroids are not routinely recommended for viral pneumonia or ARDS and should be avoided unless they are indicated for another reason (e.g., COPD exacerbation, refractory septic shock following Surviving Sepsis Campaign Guidelines).  There are no antiviral drugs licensed to treat COVID-19 at this time. Vaccinations are also in the works but will not be available in the near future.

The Lancet published an article on 3/17/20 showing no clinical evidence of a connection between ACE inhibitors and ARBs with worsened symptoms of COVID-19.

Mixed information has been disseminated from France about avoiding ibuprofen usage in the presence of COVID-19. There has not been an official American recommendation given at this time due to limited evidence.

See the CDC website for more information:
https://www.cdc.gov/coronavirus/2019-nCoV/summary.html
https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html
https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html

Again, this is a consolidation of physician specific information from the Waco-McLennan County Public Health District, CDC, BS&W Hillcrest, Ascension Providence and DSHS communications.  We advise following the guidelines distributed from your hospital system if applicable. More information and updates will follow as the situation continues to evolve.

*Please reply to this email with any COVID-19 management criticisms and/or suggestions that we can bring to city and healthcare officials.*

William McCunniff, MD, MBA                Farley Verner, MD
McLennan County Medical Society       McLennan County Health Authority
President                                               Infectious Disease Specialist

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