COVID-19 Primary Care Forum: Family Practice Teleconference- Hosted by the EasT-FPN
This is an opportunity for family practices in East Toronto to participate in an open forum on COVID-19 with Dr. Jeff Powis, Medical Director, Infection Prevention and Control at MGH.
We have added the capability for you to ask questions in advance of the session. We have launched our Open Forum Q&A content compilation to find the information you need.
Click here to join via video-conference. To receive a calendar invite that will be updated with materials in advance of the session please contact us at contact@eastfpn.org.
Take a look at the EasT-FPN Events Calendar for the exact dates of the Primary Care Open Forum and other EasT-FPN forums.
**The Primary Care Open Forum is on hiatus and will resume near the end of summer/early fall**
Within the forum participants receive:
COVID-19 epidemiology and clinical updates
East Toronto Family Practice Network (EasT-FPN) initiatives
Knowledge sharing from family practices in the East
Q&A with Dr. Jeff Powis - for the current compilation of past conferences.
Thanks to Dr. Jeff Powis for his expertise and time during these teleconferences.
Summary Documents
Missed a forum or would like to refer to a specific session? Take a look at our summary documents for more information below:
Content Discussed
The notes and compilation of Q+A are from weekly webinar meetings with Dr. J. Powis. This is not clinical advice but rather a guide based on discussions at the Open Forum. For additional clarity, please call in to our Open Forum or contact Public Health.
I. PPE V. CLINICAL SYMPTOMS
II. TESTING VI. MEDICATIONS TAKEN FOR CHRONIC ILLNESS
III. TREATMENT VII. RETURN TO WORK/RECOVERY
IV. POST DISCHARGE VIII. TRANSMISSION
PPE Questions
Prevention is key – COVID 19 has communicability prior to symptom onset, so someone can seem well and still potentially be contagious, no different from influenza and similar viral infections
Universal masking and eye protection during patient facing time
Self-inoculation is how this transmits - do not put contaminated hands near nose, eyes or mouth - if you wear gloves and touch your face this will not help
Focus more on donning and doffing technique rather than the type of mask
Careful not to self-contaminate when removing mask
Don’t eat or drink while seeing patients
Shoe covers only needed if you touch your shoes then your mouth/eyes/nose; if small children at home that like to play with your shoes then be careful
Clean common spaces commonly; gowns should never leave clinical area.
Q: In preparation to do CPR in office, after speaking to an ER doc, it was suggested we stick with chest compressions and defibrillation. Another option would be to get the filter for our ambulance bag (which is used for respirations). Any idea where we could get this filter?
A: CPR is an aerosol generating procedure
Full PPE, N95, googles, gloves, gowns, hair cover
No Bag/Valve Mask
Can use 100% O2 non-rebreather mask to put on patient - no ventilation
AED/ call EMS
Q: Is it reasonable to use cloth masks for asymptomatic pts coming to clinics and laundering between pts?
A: Value of masking everyone is to keep their germs to themselves, not protecting the person wearing the mask, so when the recommendation comes out that we all need to wear a mask out of the home, it is not to say that is safe to take more trips out of the home. It is just that not everyone can stay fully home.
Do not use cloth mask for HCW provided patient care
Cloth masks are for people to keep their viruses to themselves
Used for regular essential visitors to the hospital - e.g. dialysis pts, etc
Not meant for protecting HCWs
But yes, can give cloth masks to asymptomatic patients
Q: Are KN95 masks manufactured in China, which are FDA approved but not NIOSH approved, the same as NIOSH approved N95 masks?
A: These do not replace the N95
Q: The OCFP sent an email suggesting that when seeing an ASYMPTOMATIC patient that providers wear a surgical mask as well as eye protection and gloves. Is that really necessary? Do we need to be wearing PPE during our well baby visits?
A: Yes, droplet precautions for all patient facing care.
SEE VIDEO here for donning/doffing and preserving PPE as well as CHART for PPE requirements. Enveloped virus - any household cleaner will kill it. SEE VIDEO here showing self-contamination while wearing masks.
Q: What are your thoughts on using cloth gowns as PPE?
A: Essentially what you need is some level of water resistance on gown - Recommend level 2 gowns (fluid resistant for 30 sec). Can look at PIDAC guidelines for PPE as resource.
Q: Visors - what is the current recommendation for the duration of wear before discarding? Are there acceptable re-use strategies for visors in primary care that can be shared?
A: Visors are cleaned and disinfected regularly.
Clinical Symptoms
In hospital experience- fever, cough, malaise, sore throat- not as common symptoms: diarrhea, rhinorrhea. On CBC- some leukopenia, low O2sats, CXR lower lungs bilateral diffuse interstitial infiltrate rounder in appearance. Worsens day 5-12; can get precipitous drop in O2 sat and patients may not feel dyspnea. For those in hospital monitoring O2 sats to see re: need to augment treatment. Symptoms lasting longer in those that are older (more than 50) and even longer (more than 70). Risk factors are: older, male, obese, hypertension, co-morbidities the prognosis is lower.
Treat the patient not the test. Community spread - If typical symptoms, presume COVID-19.
Q: I haven't seen the classic triad of fever/cough/SOB but have seen a lot of sinusitis. If someone presents with sinusitis and headache, with maybe later some PND and cough, is that COVID?
A: Yes.
Q: I have a patient with fever for 23d now COVID+ at our hospital, neg cxr, cbc ok - what now, just watch it? Acetaminophen?
A: Longer course for those that are older, symptom control.
Q: Hi Jeff- I believe in your presentation, you said, we should assume patients with URI symptoms as COVID positive, even if they had a negative swab done recently? I saw a woman with cough in hospital (outpatient department) but staff were reassured by the negative swab she had done a week prior when she was admitted. Is there any point in swabbing admitted patients with URI symptoms as we should just assume COVID+ to avoid false re-assurance?
A: Treat the patient not the test, assume COVID +; the test is only as good as the person doing the swab.
Q: How should we manage patients with typical seasonal allergy symptoms - itchy eyes, runny nose, sneezing, inpatients with a known history of allergies and no other Sx. Should they self-isolate?
A: Allergy season is also at this time of year - if nasal stuffiness, typical symptoms of patient’s allergies, itchiness and no fever, cough, malaise, likely allergies.
Q: I have several patients with predominantly neurological symptoms: flushing, foggy thinking, intermittent sensory changes (tingling, as well as hot/cold), headache, tinnitus. These seem to be cyclical - coming together, and leaving completely together for a time. Is this likely also COVID-19? There has also been a bit of a sore throat initially, but no fever or respiratory symptoms.
A: Not the symptoms that have been typically seeing in the hospital setting.
Q: Child with tonsillar swelling with no fever or other URTI symptoms. Aside from ruling out acute pharyngitis diagnoses, are there other management/monitoring you recommend? Child lives with at risk mother who is >34wks GA with frequent contact with health care facilities.
A: Rule out other causes, but would not qualify for testing, for pregnancy see PHO guidelines – attached HERE.
Q: As the pandemic moves on from months to maybe years, there will be many cases of sniffles, fever, rashes and diarrhea in young children. What advice would you give the families re: isolation:
1) Take 2 weeks off for every minor illness, even if the illness was short-lived (ex 24 hours?) (this is a tough sell for many reasons) OR
2) Get every child tested every time this happens? (This does not seem practical at all)
A: Children don’t shed this virus for long as compared to other infections. Advice would be to synthesize all the information you have (i.e incident rate in community, secondary transmission in family, risk profile of child etc.) to make the best clinical impression/decide what the clinical probability of COVID is for a patient. Hoping for more testing availability for these contexts but may be delayed getting results - management might not be able to be dependent on results.
Q: Are you aware if there are any cases in the city of pediatric multi-system inflammatory syndrome? If yes, any risk profile?
A: About two cases in the city. Risk profile seems to include older children i.e adolescents and more black vs non-black individuals. Might be tied to social determinants of health rather than anything else (based on US trends) Presents predominantly as conjunctivitis and then fever.
Q: I have a COVID+ patient that started with headache, fever, chills and cough. Patient now has persistent headache for two months but no other symptoms. Their headache is exertional with some photophobia. Any cases with viral meningitis with COVID? Any recommendations for management/treatment of this?
A: Seen COVID cause encephalitis and these persistent symptoms presented in the case; make seek a different opinion. Seen weird vascular and thrombophilia.
Q: British Columbia has eliminated some of the symptoms from their screening list - any comments?
A: Rhinorrhea is a common COVID symptom in children. Until we learn more about transmission in school, have to be cautious.
Testing
The test is just a test, treat the patient, not the test; If typical symptoms, presume COVID-19 even if test negative.
Nasopharyngeal swab is the better test, no role for throat swab. Click HERE to see the video.
If you are going to take a swab, you should know before you go in, label ahead of time, bring that in with specimen bag; if able to find a buddy to come to the door when you are done to drop the bagged specimen into clean plastic sealable bag is ideal. If no buddy, then set on top of a wipe and when done with patient, place in additional bag and wipe the new bag down.
Remember this is an enveloped virus- easy to kill with anything- H2O2/ bleach any standard wipes.
Current testing guidelines are HERE.
Q: I realize there are certain guidelines on who the assessment clinic will test- However with the current push to do more testing-If a patient actually is seen there-why not just test them. We are looking after patients and have sent pts to center after watching them for some time- only to have them sent home with no test?
A: PHO looking at sustainability of supply chain for testing and reagents. Agree that to really get a handle need to test more people, however, just getting rid of backlog testing now, and if we open will again be back to the situation where we are treating those in hospital without their rest results.
Q: Can you please comment on the validity and accuracy of testing asymptomatic patients (specifically those who will be admitted/discharged from hospital). Considering when will be opening up health care to more patients, should we be testing more asymptomatic patients (and staff)?
A: Currently testing 1 week prior to procedure will not be helpful, need POC testing day of surgery, will depend on labs ability to turn around test. PHO working on this. Hard to know sustainability of supply chain.
Q: Nova Scotia is doing both nasopharyngeal and oropharyngeal swabs. Should we also do this? Any use for paediatric population rather than NPS?
A: We abandoned oral for two reasons: 1) Nasopharyngeal have increased specificity and sensitivity. 2) We are very familiar with nasopharyngeal swabs. Oral swabs are definitely easier to obtain, so in terms of comfort especially for paediatric population (who shed virus in large numbers) we can think about saliva or oral. Not advised to do both at once because there is not an infinite supply of swabs.
See here on how to perform a mid turbinate nasal self-swab
Q: In helping non-clinicians with screening questions, which ones would you recommend?
A: MOH list is too laborious. No research to tell us what are the useful questions. Look for the highest prevalent symptoms and then focus on those – as list keeps increasing and we need to be pragmatic.
These are the current questions being asked when entering the hospital at Michael Garron.
Q: Any updates on antibody testing?
A: Antibody testing is being validated, struggling to get a clinical trial open for health care providers testing. It is the specificity of the test that is hard.
Q: Where can we get 24 hr turn around for results? When can we expect home COVID testing kits? Is there an effective anti-fogging agent for glasses and shields? How soon after infection do COVID tests reliably become positive? Will vaccines have to be kept frozen until just before administration and if so is there planning for vaccine administration ouside of physician offices?
A: Cannot expect 24 hr turnaround anywhere at the moment in the province. Unlikely to get a home test. Future goal is to send samples from home to lab – nearly ready to go live with the saline gargle at MGH site. Most infectious for 2 days prior to getting symptoms and 5 days after symptom onset. Highest load then.
A: Work with community providers to maximize testing.
Q: Staff are wondering how to address the following question from clients: If they have downloaded the COVID alert app and it shows they may have been in proximity with someone who tested positive - do they need to go get tested? Can they monitor for symptoms and only go if developing symptoms? Do they need to self isolate for 14 days? Sometimes they are not notified until many days after potential exposure.
A: Fewer people then hoped had app. Advice is to monitor for symptoms - if informed by Public Health, then get tested.
Q: On one of the AAFP podcast they recently compared patients self swabbing for COVID (NP, mid and throat) versus clinician swabbing - no difference in test results (pos, neg) - have you heard about this becoming an option in Ontario for asymptomatic people to expedite testing? Could we offer this in primary care with a YouTube video showing how to?
A: Have done this at some of the shelter sites and had people do mid-turbinate swabs on direction of HCP. Self NP swab is physically hard to do due to dexterity issues and despite education.
Q: Swabbing kids - Mid turbinate versus Oral? I did not think oral was considered efficacious but I know it is being done at some places.
A: Next best is a throat swab if NP is not feasible. Saline gargle is hope for paediatric.
Q: If you do a throat swab at the Assessment Centre, can it be run for both COVID and strep?
A: No - viral transfer media is different.
Medications Taken for Chronic Illness
Q: Has there been any further research on the impact of NSAIDs on severity of respiratory symptoms in COVID? I have patients asking if they should stop the NSAIDs they are taking for arthritis in case they get COVID. I am unsure whether they need to be this proactive or could simply stop their NSAIDs if they do get sick with COVID-like symptoms.
A: Currently no recommendations to stop NSAIDs or ACEI/ARBs at this time. Patients should continue to take their routine medications.
Treatment
Q: Any recommendations for treating COVID+ patients (anti-tussive, cough suppressants, Vitamin C)? What are best practices for managing each symptom (cough, fatigue)? Rest vs stay active?
Q: Ventolin and Bricanyl supplies are low in the community. Is there any benefit in its use in moderate symptoms in the community or are we making ourselves feel better as something to offer?
A: Symptomatic treatment, rest, fluids, codeine qhs prn, no role for Ventolin/bricanyl, unless they have history of underlying issues- keep on regular meds.
Q: Should we be recommending Acetaminophen over NSAIDS?
A: Acetaminophen is a good medication with limited side effects, can err on side of caution to recommend this over NSAIDs.
Q: In light of recent reports of hypoxemia in some cases preceding other clinical symptoms with Covid-19 infection: Do we need to change our advice to patients to stay home, to not proceed to Emerg unless for example significant shortness of breath and cough? Should we be thinking about O2 sat monitoring in the community? Increased role for CXR in primary care? Any way to use the COPD tele-heath infrastructure to monitor O2 sats at home?
Is the pneumonia in Covid-19 patients strictly viral? Are you using supportive measures only for this? Are there any other bacterial pathogens involved? Is there a role at all for our usual strategies for CAP here?
A: Monitor especially from day 5-14 for decompensation/shortness of breath. CT scan better at imaging than CXR; those with risk factors should be monitored closely. Home O2 monitoring can be used if available.
www.antimicrobialstewardship.com as possible resource.
Return to Work/Recovery
Q: How long BEFORE emergence of symptoms do we consider someone contagious? Is it hours or days...
A: No definitive answer to this yet, those that are symptomatic early on are likely most contagious then.
A: (from MD working in shelter) had 9 swabbed contacts of known case: on day of swab no symptoms for any of the patients, on day 3 when tests came back 4 positive tests- those that came back positive were now all symptomatic.
Q: I have patients who returned from the UK, and have symptoms consistent with COVID-19: initial fever, air hunger, loss of taste and smell, deep fatigue, headache; also some vertigo and light-headedness, red faces (no fever), difficulty swallowing at times, and intermittent loose stools. Their symptoms started about 5 weeks ago, and are very gradually improving, waxing and waning as they go. They haven't been tested because of the restrictions on testing, but wonder if they might still be contagious, and if there's any information on time to resolution of symptoms in milder cases.
A: Viral shedding in stool noted, but hard to know if still transmitting disease. Patients should remain in self-isolation until 14 days post onset of symptoms and72 hours after being asymptomatic. Has had long courses of disease, especially in those over 70.
Q: Regarding symptoms in recovered positive pts: Have you seen an increase in patients complaining of nasal congestion (allergy like symptoms) after recovery? I have patients who have recovered well but have on/off congestion and stuffiness. ? Allergies now or post-COVID symptoms?
A: Post viral symptoms seems to happen more with this virus than others (including loss of smell), but protracted fatigue and persistent cough is more common from what he’s seen, not so much nasal congestion).
Q: I'm wondering for doctors/nurses who have URI symptoms/fever I assume it isn't feasible to continue to get screened over time. Is there direction around return to work for health care?
A: Currently no one should be going to work sick; stay home, also not feasible to get the 2 negative tests done at this time; most everyone still testing positive at day 7. RTW at 14 days post symptoms and 72 hours post resolution whichever is longer. There may be a point if we are very short staffed that staff will need to come even if symptomatic and mask/ glove- not there yet.
Q: Staff are worried. For staff at risk of transmitting to family who are elderly or immunosuppressed, should they be going to work given the increased risk of being a health worker?
A: No, transmission is via droplet. Ensure good hand hygiene, no self- inoculation by avoiding touching face/ eyes/ mouth/ nose; launder clothes in hot water. Keep cell phone separate.
Q: For a patient that tests positive in the hospital but was seen two weeks earlier in clinic, what is the protocol for testing clinic staff?
A: Two weeks in the past is not a significant exposure – suggests to go back 48 hrs for contact tracing. Need to clarify symptom onset - anyone with exposure to the individual should then be tested and/or self-isolate.
Q: Do you recommend all asymptomatic HCP including doctors and staff- be tested-and if we do- how often going forward? Or only if situation of known contact?
A: Doesn’t think this is the best way for testing, need to use testing as a resource and testing with a purpose – only if a situation dictates then need testing.
Q: We are struggling with a policy for our clinic with regard to care providers whose kids may have a sore throat or sniffles (for physicians, nurses, front staff). Do you recommend isolation until test results are back of symptomatic child? Are sniffles/sore throat a “probable” COVID case in terms of screening?
A: At present time, household contacts of someone with symptoms can continue with regular activities while they are waiting for COVID test to come back AND they are asymptomatic. Likely lots of rhinoviruses this season. PPE does protect clients and colleagues – so asymptomatic staff can come in unless they have come into contact with a probable case.
Q: I have had two daycares ask parents of children in my practice whose kids have had cold symptoms to get a Doctors note to clear them to return to the daycare when they are free of symptoms, but without doing a COVID test. The children have had no fever or cough, but have had runny noses for a number of days. What are we supposed to do with this?
A: Very difficult position to be in - very difficult to rule out COVID without symptom resolution and a negative test. Rhinorrhea is a common COVID symptom in children.
Q: I was wondering about any recommendations for staff return to work after domestic travel. There are the standard quarantine guidelines for international travel but none for domestic, and in looking at the federal resources, there is definitely risk of exposure with domestic travel as well. Appreciate your thoughts.
A: Not imposted any restrictions as of now for domestic travel. Risk is more about the destination.
Post Discharge
Q: What communication is going out from hospital/doctors office to the community to when we take patients/clients back home to self-isolate with covid/suspected covid? If after hours many community agencies have on call supervisors 24/7. What do you need from us to ensure we have timely communication to support these folks?
A: Currently team at MGH- is a virtual team looking monitoring those being discharged from MGH- someone from team will call patient and ensure recovering.
Q: How do we counsel COVID+ patients on home CPAP after discharge from hospital?
A: In general: CPAP is safe to use if >14 days from symptoms onset AND >72 hours symptoms free, whichever is longer (same criteria for healthcare workers returning to work).
The patient should be counselled on usual positional strategies and avoid use until meeting this criteria.
If CPAP is considered absolutely necessary and the patient is still symptomatic:
Their bed partner should sleep in another room
The patient should put a towel to dam the base of the bedroom door
The patient must wait one hour after turning off device before they can remove the towel and open the door
The patient should open up doors and window in the house to increase air circulation
Q: Is there any guidance on helpful information I can provide to patients who have persisting COVID symptoms or patients who "recovered" but then had a return of symptoms to better support my care (as of now it’s just symptom management/reassurance).
A: There is evidence of post infection inflammation. Need to be vigilant for hyper-coagulation since some people have had recent MI events and PE.
Q: Are hospitals taking dementia or possible dementia into consideration prior to discharging COVID+ patients? This poses problems for social isolation.
A: Unsure if they proactively looking into dementia but they do look at a patient’s capacity/ability to self-isolate during discharge.
Transmission
Q: Given the current heat wave, is there any concern for seniors living in condo buildings that have central air conditioning rather than their own units, in terms of risk of virus transmission from one unit to another if someone was infected with covid? Is it ok to use central A/C in this context?
A: Virus is not airborne, but air currents can change trajectory of droplets. Can have a greater droplet dispersion due to air current. There is some concerns about fans blowing directly at face as that can lead to droplet spread.
A: Misting station - Droplets fall more quickly in higher humidity, but misting station might decrease physical distancing which is not good - Take mask off in misting station, then put back on - Not good for them to be wet.
Q: Chiropody/foot care opening up services: Are there any specific PPE considerations that are unique to foot care, where the position of the provider is lower to the ground for prolonged periods of time, where droplets are likely to fall?
A: The safest way is to have client at the same level as you. Elevate patient’s foot where possible to higher location. If not possible, then look into better eye protection from above (eg. pull hair bouffant over front of visor). Address the gap between the forehead and goggles. The foam on the face shield visors are sufficient for this barrier.
Q: Is there a concern where aerosolized feces can be propelled into the air through what is called a “toilet plume”? The spread of aerosols, sometimes containing infectious fecal matter” caused by a flush? Toilets at home have a lid, but public toilets do not.
A: Viable virus in feces found in a very small # of people - extremely low risk event
Q: Is there any other surveillance type activities that are occurring that may identify particular hotspots in our city? How will these be flagged from the Community?
A: Current system is not perfect as data is only from MGH community assessment centre - Need a robust centralized Public Health database for analysis of cases/geography/tracing to help control this and this system does not exist. TPH will be releasing. more localized data, but not sure how detailed it will be.
Q: Thoughts on contact tracers in the city, training for contact tracers and whether they are employed by Public Health?
A: Unsure of Public Health’s plan in respect to contact tracing – again, need to draw from other countries for success in terms of contact tracing – There is an online training course through John Hopkins for free that is six hours, can be done faster. Training is not the barrier, database/synthesizing information is the barrier.
Q: Any information around choir/singing transmission? Does singing general aerosols? For church congregations who can safely distance at 6 feet and wearing an ear loop mask, would singing still pose a hazard? What about singing in a choir for choir practice? PPE?
A: Droplets are still small enough to be thrown around with air currents and where they are propelled. With respect to fans and air conditions, if now air currents, would be 6 feet. If there is a fan, it will move in the air current. 6 feet movement is with no air current. If there is someone singing, outside of 6 feet and direction with which they are singing, if someone is in back row will throw it forward. Not be staggered row or row, horizontally and apart from each other. Either ear loop +/- face shields.
Q: Given the concerns around airborne transmission, what should primary care providers be doing to optimize air quality in what are often small, enclosed exam rooms? Are there recommendations available regarding HVAC settings (e.g. air change rate in rooms)? Should we be using portable HEPA filters?
A: COVID is transmitted through droplets (shared aired). Air exchanges/ventilation is important though given some case examples – so look at your own setting, ideally larger rooms should be used. Do not need to be negative pressure but some ventilation. Can look into portable HVA unit.
Q: What is the incubation period for COVID 19?
A: The incubation period is 14 days. Median for symptom development is 5-6 days, 97% by day 11.5. Isolation for full 14 days post exposure, if negative on day 5 of exposure still have approximately 30-40% chance of COVID-19.
Q: What is the transmission period for COVID 19?
Communicability period- to 5 days prior to symptom onset and 10 days after symptom onset. This means, that for contact tracing it should start from 5 days before symptom onset or 5 days before the positive test date if asymptomatic.. People with COVID 19, need to remain at home until at least 10 days after their symptom onset. Current guidance is looking at exposure when neither person is wearing a face mask or PPE. Exposure is considered a higher risk if you have spent a total of 15 minutes time in total in 24 hour period within 6 feet with neither person wearing PPE.