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Wednesday, June 3, 2020

Be Hopeful but Cautious about COVID-19 Vaccine

BY MARK MOSLEY, MD, MPH

I’m sure you’re getting the same questions I am: “Are you seeing much of the virus?” “Do you think there will be a second wave?” “Do you really think we should be wearing a mask everywhere?” “I’ve heard they might have a vaccine available pretty soon. What do you think?”

You are not only a front-liner, but everyone in your community sees you as a leader, probably for the first time in your career. This is in your wheelhouse. A couple of times every shift, a nurse or someone in your department, regardless of his training, says to you, “Sorry, I don’t feel comfortable about what is happening in room X (e.g., mental status, breathing, blood pressure, patient behavior). Can you come there?” Without fail, you stop what you are doing, often immediately, and assess the information you’ve been given. You doubt this will amount to much, so why do you respond so promptly and seriously? There are at least three reasons:

Humility: Your assumption might be wrong, and this might be something life-threatening that needs your immediate action. We can all think of countless times that someone saved us by picking up on something we didn’t know about or that we just missed.

Respect: You honor the staff by taking them seriously with a prompt evaluation. You value them by thanking them for communicating with you, even if their fears were unjustified. And when things go bad, you sure don’t throw them under the bus by proclaiming that they didn’t make it seem important when they told you.

Responsibility: You do it for the patient and the culture of the department. A good leader does not demand leadership, he earns it. You model the behavior of service to others by doing the hardest work and not leaving it to nurses or students. With the most difficult patients and situations, you want the ball at the end of the game, no matter how tired you are. You do this without hyperbole, without threat, without blaming, without malice. You lay out enormous complexity and emotional challenges like a cool glass of water.

Humility, respect for others with less experience or education, honor and value of others’ efforts without blaming, courage to take full responsibility, strength to finish a conflict with class, all for the purpose of serving others. This is the leadership that is necessary during the COVID-19 pandemic. You already have this.

We may be needed even more for these leadership skills by our family, friends, and larger community as we approach a vaccine. Like a patient with an unusual disease you’ve never seen, vaccination may not be an area as comfortable for you as chest pain or trauma, but this may be our time. Good leadership begins with an accurate assessment of terms and barriers. If I may offer a quick and incomplete briefing:

When everyone begins yelling, “We have a pulse!!” (in this case, they’ll yell, “There’s an available vaccine!”), you will need to be the one, like you always are, who calmly steps forward, becomes even more watchful, and says, “Good. Now, we need a blood pressure” because you know that a pulse is not an outcome. Even a blood pressure is not an outcome. The ultimate goal is meaningful life. A good leader needs to be thinking of the problems that will occur and keep his eyes on the outcome.

A few problems to think about with an available vaccine:

Availability as discovery: There are eight vaccines currently in phase I trials with predictions that one will be available by late 2020 or early 2021. Vaccine development usually takes years, not months. Even the unlikely gift of an available vaccine in 2021 means only that we have discovered it. I would remind us that COVID-19 tests were available to “anyone who wants a test” in mid-March, and as I write this in June, we are still struggling to get sufficient testing, to say nothing about reliability.

Availability as large-scale manufacturing: There is a chasm between discovery and large-scale manufacturing. After years of developing and testing the Salk vaccine for polio, five pharmaceutical companies were left to produce the vaccine without significant oversight. As speed took precedence over caution, serious mistakes went unreported. Cutter Laboratories distributed a vaccine so contaminated with live virus that it left 164 children paralyzed and 10 dead. (Paul A Offit. The Cutter Incident: How America’s First Polio Vaccine Led to the Growing Vaccine Crisis. 2007. New Haven/London: Yale University Press.) It is difficult to fathom the resources, materials, planning, infrastructure, labor, and execution to manufacture billions of COVID-19 vaccines on a scale to make it available to the entire world while maintaining quality controls.

Availability as global distribution: To think of distributing vaccines securely throughout a country as geographically challenging as the United States is unimaginable. To distribute it throughout the globe is insurmountable. And an America-first approach is a completely ineffective strategy unless we literally close all our borders to everyone (which we can’t do). In an America-first scenario with international commerce and travel continued, competition kills. (“Even finding a COVID-19 vaccine won’t be enough to end the pandemic.” Washington Post. May 11, 2020; https://wapo.st/2A0RT26.)

Availability as a most effective prioritized distribution: As we know, triage is not first come, first served, and you don’t move to the front of the line if you have better insurance. The most effective distribution is often not equitable. The triage of a COVID-19 vaccine in the United States should not be prioritized to the wealthy and famous who have the power to get them but strictly from a scientific evidenced-based perspective to the poor, African Americans, Latinos, and indigenous people. (JAMA. 2020;323[19]:1891; https://bit.ly/2U4BaC7.) The politics of this rational scientific-based decision would be a racial cauldron, not to mention the reluctance of communities that have endured U.S. government experimentation, like African Americans with syphilis. (Susan M. Reverby. Examining Tuskegee: The Infamous Syphilis Study and Its Legacy. 2013. Chapel Hill: University of North Carolina Press.) A vaccine provided to poor people of color will more likely be a vaccine reasonably refused.

Availability as an effective and safe vaccine: Discovery of a vaccine that is sufficiently immunogenic with minimal adverse effects in vaccine trials is not the same as a vaccine in the community that is effective and safe. Efficacy and safety require large numbers over a fair period of time, even under the best of conditions. Concerns of a new swine flu in 1976 led to a government-backed mass vaccine program that was rushed. Some who received the vaccine had no immune response at all, and a few individuals came down with Guillian-Barré syndrome. (Emerg Infect Dis. 2006;12[1]:29.)

Availability as a vaccine actually used (not refused): A miracle will be needed to produce a vaccine at warp speed that has better efficacy than the influenza vaccine with fewer side effects than any other vaccine we have produced. More than ever, it’s all about trust. (JAMA. May 26, 2020; https://bit.ly/3gPvg1u.) The COVID-19 vaccine will have one shot to be nothing less than perfect in our current cultural climate. Any failure will be fuel to anti-vaxxers.

But many others are also hesitant. Mistrust of the government as a rule and of this administration in particular runs high, making the adoption of an effective and safe vaccine challenging. Currently, only three of four people would be willing to take the vaccine, and only 30 percent would take it soon after it is available. And this is in the heat of the pandemic when people are more accepting of trying anything. (JAMA. May 18, 2020; https://bit.ly/3gSqiRg.) If the vaccine arrives next year without an alarming second wave, the desire to take a vaccine will diminish further. This does not account for internet conspiracy stories and fake, inaccurate claims (e.g., autism).

Availability as meeting the outcome of herd immunity: The outcome is herd immunity, not discovery, manufacturing, distribution, prioritized distribution, efficacy and safety, or even public health salesmanship. Many people cannot or will not take the vaccine—children on chemotherapy, pregnant women, the immunocompromised, the underprivileged, the mentally disabled, or even the vaccine-hesitant whose socioeconomic conditions mean they cannot get a vaccine. These are the American citizens who must have herd immunity to survive.

It is true that getting a good vaccine to one person will protect him, and one goal is to prevent infection in the individual. But a larger goal is to prevent transmission of the virus to others, and the ultimate outcome is herd immunity. Experts say this will require 55 to 82 percent of a population being immunized with an adequate vaccine. (The New York Times. May 28, 2020; https://nyti.ms/370Stt4.) If herd immunity requires that kind of response, we might want to consider putting ourselves on the endangered species list.

In a world that says, “I am the only science I need,” “I am the only government I need,” and even “I am the only race I need,” many people have migrated into a mental habitat that has quit thinking about a “we” world. It is immunologically lethal to live in an open society with that kind of closed mind. Opinion no longer even cares to look at the complexity of truth. We like or dislike something in a hot minute. Unfortunately, it is not enough to say, “You must do it for the village even if it impedes your personal choice.” It is still sadly uncertain if this current cultural climate can change.

This challenge will not be easy and probably will not be over for a while. When the media and everyone around you begin yelling, “We have an available vaccine,” we need to be the ones who step calmly closer, watch even more carefully, encourage hope but be exquisitely cautious, and say, “Good. Now we need a blood pressure.”

Dr. Mosley is an emergency physician in Wichita, KS.

Read all of EMN's breaking COVID-19 coverage at http://bit.ly/COVID-19-EMN.

Stay updated on our new COVID-19 articles by following us on Twitter @EMNews.


Monday, June 1, 2020

A COVID-19 Loss Too Close to Home

BY MARIA PAONE, MD

I lost my mother and aunt to COVID-19. They were infected by a well-meaning cousin who did not realize she was infected. She also died. They were elderly (88 and 94), and they had medical problems (hypertension, obesity), but they were still vibrant and central figures in our big, loving family. Mom played poker (and won most hands), and my aunt was blind but lived independently in New York City.

Even before these latest tragedies, I was haunted by the deaths of so many people I had met in the ED. You know them: Those happily hypoxic patients who talk and laugh through a sat of 74%. They tease you by doing well on the nonrebreather for a day or two, and then the inevitable crash comes, and you see notes on the chart about vent settings.

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Dr. Paone’s mother, Frances Paone, left, and her aunt, Domenica (Dee) Diodati, right, who both passed away from COVID-19, with her aunt, Mary Gluck, center. Courtesy of Maria Paone.

No matter how much you hope, their creatinine starts to rise and their blood pressure starts to fall. And those lovely, smiling faces fade away. You are left with the memory of the loving words of the mothers who said goodbye to them in the waiting room. Especially the mother who said a blessing over you, the person who is her last hope. You try to reassure her, but maybe you falter on a word or your eyes slide away for a moment, and her face falls as she realizes her son is in danger.

Everything you have heard about loss in the time of COVID-19 is true: You cannot grieve with your family. You cannot mourn or celebrate your loved ones. You cannot observe the rituals that ease the transition from a life with a person in it to one without her. Once I thought these rituals a bit macabre. Now, being unable to observe them, I understand their importance in acknowledging a person's life and its loss.

But this has a previously unknown grimness. Bodies cannot be retrieved because the funeral homes are full. Cremations are delayed because there is a backlog and something that involves permits. "Good news" is finding out that my aunt can be moved from the rental truck in the garage to the morgue. In an interesting turn of events, my grandparents' grave has acquired some uninvited guests over the past 30 years, and so I must find someone to "test the grave" to determine if my aunt can be interred where she wanted. No, I'm not kidding, although this actually is kind of funny, considering we are Italian.

My boss asked me if I needed time off. My first thought was, "Why?" The greatest difficulty is not being able to be with my wonderful extended family to laugh, eat, tell stories, and comfort one another. No offices are open to help me sift through the aftermath of the loss of two long lives. My husband is working from home, and has advised me that my ceaseless background chatter is not conducive to Zoom meetings. There is only so much bad and good TV I can watch, photos I can edit, books I can pretend to focus on. I have made an enemy of the dog after applying what I learned from watching instructional grooming videos on YouTube. Sometimes I try to cook. Essentially, I am a menace to myself and others when at home, and it is better if I just go to work.

So I go to work, and I keep going back. No one understands why amid such staggering loss and sadness and grim responsibility I would resist taking any time. To me, it is simple: It is easier to be at work among people who understand me better than most. Just being around people is a rare privilege. Granted, they are overworked and scared and cranky and tired. But they know why I don't cry. They know why I make bad jokes about Mom almost beating COVID-19 by eating pepperoni (and sheer stubbornness). Why it is easier to stumble around in other people's desperate fear, grief, and misfortune than to sit at home with my own. It's just who we are and how we cope. Maybe our ED family is dysfunctional, but it is ours. And, in that, I find tremendous comfort.

Dr. Paone is an emergency physician in Westchester, NY, where she has practiced in a community ED for 18 years.

Read all of EMN's breaking COVID-19 coverage at http://bit.ly/COVID-19-EMN.

Stay updated on our new COVID-19 articles by following us on Twitter @EMNews.

Friday, May 29, 2020

'I Survived COVID-19'

BY LOUIS PHILIP ROTKOWITZ, MD, MPH

A few months ago, I never thought I would contract a virus that could take my life, but recently I had to deal with COVID-19 that I caught from a patient.

I had been assigned by the emergency department director to the March 28 overnight tour of our newly assembled hot zone. It was my job to direct and provide care for the sickest patients who came through the door. The powered air-purifying respirator (PAPR) that I strapped around my waist felt so foreign to me, and it made me feel distant from my patients. I said goodbye to a colleague who had covered the day shift, and found myself alone in a micro-epicenter of COVID-19.

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This photo was taken the day Dr. Rotkowitz was exposed to COVID-19 despite the PAPR he wore. He had intubated multiple patients that evening.

I was worried that I might be infected, but all my experience and training had not prepared me for this. The virus unleashed its fury right before my eyes, and it completely crippled the operations of the emergency department. Exhausted, I struggled to maintain my role as team leader. Days later, I began experiencing symptoms after another exhausting overnight shift. By April 1, I was officially offline: SARS-CoV-2 was dismantling my physiology.

Slow Recovery
My quarantine at home began immediately. I had debilitating symptoms the first week that worsened as days passed. My body aches increased every day, and I lost my sense of taste and smell. Sleep offered no relief; even my dreams were filled with feverish nightmares. By the morning of April 8, my oxygen saturation levels were becoming concerning. My breathing was starting to become labored, and my body was experiencing an unprecedented level of stress. Later that morning, a concerned friend came to check on me and found my oxygen saturation level at 78%. I was admitted to NYU Langone Medical Center that afternoon in critical condition, requiring specialized high-velocity nasal insufflation.

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Dr. Rotkowitz’s chest x-ray on the day he was admitted for COVID-19.

Throughout my 10-day hospital stay, I struggled to comprehend the course of events. I had sacrificed countless hours of studying, training, and dedication for my career, but now my personal safety hung in the balance. I was worried that might need mechanical intubation. I had witnessed many serious COVID-19 emergencies, and I knew what to expect—I feared for my life. Knowing that intubation often leads to death, a new frightful reality stood before me, but I had every confidence in the members of the care team at NYU Langone. Everyone was concerned, compassionate, and caring. That made this terrifying experience much easier.

I was released from NYU Langone two weeks later requiring supplemental portable oxygen. I expect to be restored to a decent level, but I find myself exhausted and unable to concentrate on any tasks as I write this a month after first experiencing symptoms. As fragile as things seem, I strive to make small recuperative steps each day. The hospitalization left my body weak, and my mental acuity is far from as sharp as it was before my infection.

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New York City Fire Department EMT Gregory Hodge, who died from COVID-19 on April 12. Courtesy of FDNY.

While I recover physically, my spirit remains crushed as I mourn for my patients and lost colleagues, like Lorna Breen, MD, the medical director of the emergency department at New York-Presbyterian Allen Hospital, who died by suicide on April 26 after treating many COVID-19 patients. I will fondly remember New York City Fire Department EMT Gregory Hodge, 59, who died from complications of COVID-19 on April 12. He was a 24-year veteran of the FDNY, a commercial pilot, and a survivor of 9/11.

New Way to Live

I have no idea what the ultimate effects of the coronavirus will be upon my body. Obviously, I am hoping for the best, but long-term health consequences are possible. My emergency medicine colleagues are already transitioning to other specialties. Some of them have begun moving away from New York. Returning to a full-time emergency department schedule is questionable. This experience has truly made me aware of how important my master's in public is in this new world. The accidental combination of my illness, the circumstances surrounding it, and the educational path I have taken have certainly brought me to a defining juncture in my life.

The COVID-19 pandemic will likely bring about fundamental changes in all workplaces. Hospitals and all health care facilities are going to be financially pressured while enduring the loss of experienced staff due to fear, illness, and exhaustion. As this health care crisis moves past the first wave, survivors in pandemic hotspots will reevaluate their definition of work. I never envisioned that things would turn out like this. Healing includes processing the devastation and sadness that I witnessed and the role I played in all of this.

This pandemic will be the ultimate influencer in how we interpret our daily existence and future goals. Dealing with it has made me reexamine my career and look toward a new definition of each day. My new five-year career goal will be about finding happiness and stepping into a healthier lifestyle. These defining moments of my career now lie before me.

Dr. Rotkowitz is an emergency physician in Queens, New York.

Read all of EMN's breaking COVID-19 coverage at http://bit.ly/COVID-19-EMN.

Stay updated on our new COVID-19 articles by following us on Twitter @EMNews.

 


Wednesday, May 27, 2020

Did Diseases Freeze during the COVID-19 Surge?

BY MARK MOSLEY, MD, MPH

I was watching TV when a commercial aired with a well-respected emergency physician asking for people to come to the emergency department! This was not a glossy appeal for a new for-profit health center. We have all seen that commercial. No, she was speaking on behalf of all emergency care providers in the United States, pleading for Americans to bring their medical problems to our emergency departments.

What? I’ve been in emergency medicine for almost 30 years, and we rant daily about the patients who should be staying home: the 17-year-old brought in by ambulance for menstrual period pain, the man on the way to work who stops for a work excuse with no physical ailment, the patient who has an appointment with his specialist in 45 minutes but didn’t want to wait. Many shifts I know the face, name, allergies, and medications of 10 percent of the patients I see because I care for them a couple of times every month. As emergency professionals, we have loudly bemoaned that Americans overuse emergency services. Americans without grandmothers to call drive to the medical McDonald’s for a McTest of reassurance, some fried patient satisfaction, and a happy meal.

Now, because of a global pandemic, we are placing nurses and critical hospital staff on furlough. Patient volume is down everywhere 30, 40, or 50 percent or more. We are not just shortening the hours of emergency physicians and midlevel providers, we are cutting out whole shifts and trimming our pay to the proverbial osteopenic bone during the worst medical emergency in the history of America. Even those emergency departments that were hammered by COVID-19 saw almost only COVID-19. How does that make sense?

What happened during those six weeks from the middle of March to early May? Where did all the disease go during the COVID-19 surge? This is not simply an anecdotal perception across the country. We have real data, most of them economic and underlined in red. Calls to the cath lab for acute myocardial infarction were down almost 40 percent. Strokes, appendicitis, and cholecystitis also decreased dramatically. Americans who easily jump on board conspiracy theories will see this as proof that we are in cahoots with somebody to overdiagnose and make a buck. Those who work in EDs know better. These same numbers were recorded in other countries with national health systems like Spain. Every article from major media outlets that addressed this bizarre phenomenon suggested that those diseases did not go away but still happened, and people stayed at home because they were too afraid to go the ED where they might catch the coronavirus.

I just don’t think that potato is fully baked. Yes, our volume is down dramatically because most of what we see in a shift are the worried well who need reassurance or the mentally impaired who come because of alcohol, drugs, or mental health dysfunction. One would think we would see more of those patients during a global pandemic. I am certain there may have been a small percentage of patients who had a heart attack, stroke, or appendicitis and stayed home. Why didn’t we see them three days later in florid congestive heart failure from their heart attack or aspiration pneumonia from their stroke or a ruptured appendix from their appendicitis? Why didn’t we see an EMS procession of death from people with COPD, CHF, and septic shock who decided to stay home? If stress plays a factor in heart disease and stroke, wouldn’t you see more disease while you are not getting paid, worried you might die, and all your kids are locked up in your home? Everyone is giving a round answer that does not fit in the square of the logic.

What made other diseases appear to stop during the COVID-19 surge? I am not in the camp of people who believe in Bigfoot. I don’t smoke marijuana, and I have never watched an episode of Dr. Oz. But something mind-altering happened, and no one reasonable seems to be continuing the conversation.

Of course, we all believe that the mind (whatever that is) can affect the material of the brain and its control of bodily functioning. In emergency medicine, we live that every patient, every shift but in a way that teases the mind from the brain. We listen to the history and perform the physical to decipher patterns of physiology and decode it from the patient’s emotional and mental experience. We dissect the seizure from the pseudoseizure, the stroke from the confabulation, the early Parkinson’s from depression. This is not just neurology titrated out of the beaker of psychology—this holds true for all diseases seen in the ED: Angina or anxiety? Atrial fibrillation or palpitations? The tachypnea of DKA and pulmonary embolus or hyperventilation? Compartment syndrome or pain drama? Emergency medicine, almost by definition, is sorting out the real needle from the mental haystack. If you miss the needle, eventually you will get stuck by it.

But with all diseases frozen in time for six weeks, I am suggesting an entirely different paradigm of brain and mind. I am not saying there is something about SARS-CoV-2 that arrests other diseases; I am asking questions perhaps more outlandish, “Can real heart attacks, real strokes, and real appendicitis be somehow affected by mental input? Or social behavior? Can a fight, flight, or freeze response in an emergent situation be maintained for weeks as a means of neurochemical protection? Can you metaphorically freeze pathology? Can a feeling create a state of real survival?

I don’t want to speculate beyond that question because, frankly, I don’t even know what I am talking about. But I can, along with the rest of the emergency providers in the world, say that something made diseases freeze. It wasn’t that patients experienced diseases and just stayed home.

Dr. Mosley is an emergency physician in Wichita, KS.

Read all of EMN's breaking COVID-19 coverage at http://bit.ly/COVID-19-EMN.

Stay updated on our new COVID-19 articles by following us on Twitter @EMNews.

Friday, May 22, 2020

The Danger of Don’t-Look-Don’t-Test for COVID-19

BY MARK MOSLEY, MD, MPH

It is the middle of May. Half of the country is walking back into their jobs (and lives) with psychological masks covering their eyes but no mask over their nose and mouth hoping a don’t-look-won’t-see approach will make this all go away.

The other half doesn’t want to take the mask off, but say they can’t keep breathing this way. They are begging for a test to reassure them. A don’t-test-don’t-tell approach is imposed on these people—they don’t meet the criteria to be tested or no one at work wants them to be tested for fear of what it will do to staffing. No one, it seems, is taking the lead in talking about who needs to be tested and what we do with the test results. This is just as true among ED staff.

If a person is tested privately, is positive but asymptomatic, and goes back into the workplace because he cannot afford to lose the income, what are the infectious and legal ramifications of such a decision? What about HIPAA? What if he remains asymptomatic? Most ED staff go to work when they are sick. Do we think they are going to stay home when they feel well just because a private test was positive?

If the testing is offered by an employer, as I have suggested under the banner of employee wellness (“Batch-Testing Can Protect Everyone and Put the Country Back to Work,” EMN Breaking News Blog. May 12, 2020; https://bit.ly/2TlF7Sr), would the uncertainties of employees taken out of the workplace due to positive tests and the “police powers” surrounding a positive person in the workplace serve as a disincentive to test employees without clearer guidance by the Centers for Disease Control and Prevention?

Consequences of Testing
The CDC always states that its recommendations evolve and vary according to geographic regions and temporal conditions. The question of when to test depends in large degree on the prevalence of disease and how the result will be used.

A surveillance and containment strategy for COVID-19 has public health officials finding symptomatic COVID-19 and looking for presymptomatic COVID-19 to contain asymptomatic and presymptomatic close contacts and limit the spread of communicable disease. This public health surveillance approach is aware of the inherent false-positives that can be generated. (Why is the current terminology COVID-19-indicated instead of COVID-19-positive?)

From a practical standpoint, you cannot test everyone who wants a test. From a statistical viewpoint, you don’t want to test everyone who wants a test because some people need a test who don’t want one. The fallout from false-positives from unvetted tests with the isolation of COVID-19-indicated people and the quarantine of their close contacts would be enormous.

It is not unreasonable in some parts of the country, under current conditions, to live in a no-testing, symptom-based environment outside health care facilities, nursing homes, homeless shelters, and prisons. A don’t-look-don’t-see approach may be acceptable in some pockets of the country, but this is a dangerous approach for others.

One can imagine a family-owned business or a small ED where a COVID-19-positive test in one employee bankrupts the family or business by placing everyone in isolation or quarantine. One can understand why a don’t-test-don’t-tell approach for fear of government intervention could be entertained. Or a don’t-test-don’t-tell approach is taken for fear that a positive result will prevent other employees from being willing to come to work.

Equally possible, one can imagine the same family-owned business or ED that chooses to ignore testing or physical distancing recommendations, and the business closes when one person gets COVID-19 and infects several members of the family, causing the death of the matriarch or a coworker. Both of these unlikely events could occur and will be used as social media flags by those who want to fight a cultural war to confirm their bias.

Isolation or Quarantine?
The 10-day data come from China in a retrospective analysis with large numbers, in which viral shedding was the outcome (as opposed to infectivity, which is different). They found that 98 percent of symptomatic COVID-positive individuals no longer shed the virus by day 10. Our current CDC 10-day isolation recommendations for symptomatic COVID-19 patients match these data. (CDC. May 3, 2020; https://bit.ly/2z4HPoC.)

It is not clear if an asymptomatic COVID-19-indicated patient who remains asymptomatic should be placed in isolation for 10 days. The CDC recommends two consecutive negative PCR tests 24 hours apart to allow a symptomatic COVID-19-positive person not to be in isolation. This is a reasonable laboratory approach but not a practical one given an ongoing lack of tests with slow turnaround times depending on the day of the week and location where you are tested. We need data that tell us the median and range of time between exposure and acquisition of symptoms—the period a symptomatic COVID-19 patient is presymptomatic. We should be cautious about getting these data retrospectively because recall bias is so prevalent.

Some of our best current data come from patient clusters in Singapore (MMWR. 2020;69[14]:411; https://bit.ly/2Zq2vBU), family gatherings in Chicago (MMWR. 2020;69(15):446; https://bit.ly/2zcfGfg), and a choir practice in Washington state. (MMWR. 2020;69(19):606; https://bit.ly/2zcfGfg.) The average time from exposure to symptoms was one to three days in Singapore (n=243), a median of four days in Chicago (range: one to seven days; n=16), and three days in Washington (n=122). Given the weak scientific nature of these data, it is still some of our best current data.

Based on these case studies (and it is likely subject to change), I don’t think it is unreasonable in a low-prevalence geographic area when an asymptomatic employee tests positive for COVID-19 to isolate him to and quarantine close contacts for four days. If symptoms occur, extend the isolation and quarantine for close contacts to 10 days. If no symptoms occur in the lead case, I think you can bring everyone back into the workplace with close monitoring and restricted travel on day five until further data suggest otherwise.

A 14-day quarantine arose from international travel as an extra precaution to prevent global spread in which 98 percent certainty may not be sufficient. One needs to approach 100 percent certainty. The 14-day quarantine may be prudent for travelers who came into contact with COVID-positive patients, but may be excessive for the domestic close contact of a positive-COVID-19 patient, particularly if the positive patient remains asymptomatic.

I believe we should discourage asymptomatic individuals from seeking testing on their own. What local and state public health officials decide to do for surveillance testing will vary, and it is presumed that all sanctioned labs are reporting positives to proper public health officials. A first step is employer-directed batch-testing for employee wellness in low-prevalence areas. When there is a positive COVID-19 test, clear definitions need to be given about who is not a close contact (e.g., most employees are not close contacts). For asymptomatic people and their close contacts, based on current information, a shorter period of time needs to be given for isolation and quarantine if the positive employee remains asymptomatic.

Dr. Mosley is an emergency physician in Wichita, KS.

Definition of Terms
Close Contact:
This is a family member who lives with you, someone you carpool with almost every day, or someone who shares a cubicle with you at work. This would not necessarily include someone in your office or a customer who comes into your workplace. Public health officials can help determine who is a close contact.

Honor System v. Criminal Action: It is true in theory that a person who breaks quarantine could in some circumstances in some states be subject to criminal action (a misdemeanor). One could imagine such an action could be warranted in some circumstances, such as a mentally unstable person who was a close contact who spits on the grocery store floor. The last time legal action like this was taken as a country was during the 1918 influenza pandemic. Recognizing the immense value Americans place on civil and individual rights (and the political fallout of threatening those), issues of isolation and quarantine for most people in most places under most circumstances will be based on the honor system.

Isolation for COVID-19-Positive Employees: Figure out the first day of influenza-like symptoms. Count 10 days (used to be seven) and allow return on day 11 if symptoms are improving and no fever has been recently documented. Whether a health care worker or not, it is reasonable that anyone returning to a workplace after recently being ill would wear a mask, preferably a surgical mask.

Quarantine for Close Contacts of COVID-19-Positive Patients: For a known close contact exposure to a COVID-19-positive individual, the current recommendations are a 14-day separation and restriction of movement. The CDC is aware that this 14-day quarantine for close contact exposure is not consistent with its 10-day isolation of a symptomatic individual with proven COVID-19 Read all of EMN's breaking COVID-19 coverage at or influenza-like illness.

Isolation of Asymptomatic COVID-19-Indicated Patients and Quarantine of their Close Contacts: This area is unknown because we have limited tests and therefore limited good data to guide us. Some will point to current CDC guidelines for a 10-day isolation from the time of the positive test and a 14-day quarantine for their close contacts, but this makes no rational sense for the United States-based employee who remains asymptomatic and even less sense for his close contacts. As surveillance testing increases, this scenario must be more specifically and clearly addressed.

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