Q&A With Healio RheumatologyPerspective

Unmasking COVID-19: Masks 'not necessary,' hand hygiene crucial for patients, providers

Cassandra Calabrese

Disclaimer: This interview was conducted prior to the declaration of a state of emergency for coronavirus. It may contain outdated recommendations given the current state. According to Cassandra Calabrese, DO, “the situation is much more serious and is likely to get worse — social distancing is of the utmost importance. At the Cleveland Clinic, we are encouraging our rheumatology patients to cancel non-essential visits, and that we touch base over the phone instead. Patients who are scheduled for medication infusions at present are encouraged to keep these appointments, to avoid disease flares that would require high doses of prednisone or even hospitalization.”

The situation with COVID-19, or the currently circulating coronavirus, is developing so rapidly that new information may likely be available by the time you reach the end of this paragraph. But along with factual information, misinformation also abounds on social media, on cable news channels and in print publications. Healio Rheumatology will attempt to set the record straight for health care providers looking to sort out fact from fiction.

Cassandra Calabrese, DO, of the Cleveland Clinic, sat down to answer some questions about the realities of the epidemic. Her first order of business was to direct readers to the CDC website, which she said has been “fantastic” about keeping citizens informed.

According to the site, there have been 647 cases of COVID-19 in 36 states, including the District of Columbia, reported in the U.S. Twenty-five deaths have been reported.

Public health laboratories have been set up in 42 states to test potential patients. Increased testing will likely lead to more patient identification, at which point experts will understand more about the nature of the infection, severity and mortality rates.

 
According to the CDC, there have been 647 cases of COVID-19 in 36 states, including the District of Columbia, reported in the U.S.
Source: Adobe

In the meantime, beyond boilerplate recommendations about handwashing, restricting unnecessary travel and covering coughs, the CDC knows little about how the disease might be impacting immunocompromised patients. It is noted that elderly individuals and those with chronic conditions like heart and lung disease may be at risk, but no information is available for those with autoimmune diseases, or for patients being treated with TNF inhibitors or other biologic therapies.

In the absence of that information, Calabrese hoped to provide rheumatologists with a playbook for talking to patients.

Q. How should rheumatologists address the coronavirus with their patients?   

Calabrese: It is an ever-present topic. Patients are reading about it, seeing it on the news and social media, and I have been fielding a lot of questions. I think every patient I have seen in the past 2 weeks has brought it up. Some of the information they are seeing might be true but much of it is not. We are encouraging all patients to talk with their provider about the facts, specifically addressing what is safe for day-to-day activities and for travel. We are all trying to stay as up to date as possible as information emerges and have the discussion with our patients when they bring it up, particularly if they are planning to travel.

   

Q. Beyond patients who are hoping to travel, possibly the next most important question is how will this impact immunosuppressed patients?   

Calabrese: We do not know much yet. Or, rather, we do not know if immunosuppressed patients are at an increased risk for acquiring COVID-19, but we do believe that those patients might have a higher risk for complications if they acquire it. Those patients should be following CDC recommendations to consider avoiding unnecessary international travel or avoid traveling through major international airports. Beyond that, wash your hands. This cannot be stressed enough. Do not touch your face, eyes, nose or mouth. Stay away from someone who is visibly sick — try to keep it at 6 feet, but any distance is helpful.

Q. What about masks?    

Calabrese: The simple face masks that people have been using do not prevent them from acquiring COVID-19 infection. If it makes the patient feel better while traveling or helps to prevent touching their face, that would be fine, but it is not necessary. However, if a person is sick, they should wear a mask to prevent others from catching their infection. For patients who are sick and absolutely have to travel, a mask can help keep their germs to themselves.

Q. What are some helpful tips for talking panicked patients through their fears?

Calabrese: There are many patients who are concerned, and some who are definitely panicked. They believe they should not leave their house, and they are asking about filing Family Medical Leave Act papers so they do not have to go to work. I try to remind them to be calm. It is true that while we still have much to learn, the majority of cases are not severe in nature. There have been several reports about the mortality rate, but we are still learning about COVID-19.

One thing I can say is that any time there is a new epidemic or infection, early on, the mortality rate is often predicted to be higher than it ends up being, primarily because we do not yet have the true denominator of cases. In the case of COVID-19, we are currently not testing enough people, but it seems clear that many more people have it than we originally thought.

As for patient fears, I would encourage them to simply go about their business. However, if they are nervous about traveling or going into large crowds, then just don’t do that. If you are going to be nervous and anxious, maybe it is better to stay home. I try to break it down to informed decision-making based on data and based on how the patient feels. 

Q. What protective measures should rheumatologists reinforce among themselves?   

Calabrese: Rheumatologists should also be following all the strategies we have discussed: hand washing, not touching your face and adhering to all the same things we are telling our patients. A more poignant one for the health care community, however, is to avoid work if you are feeling sick. It can be difficult for health care workers to stay home, particularly in a situation like this, but it is absolutely necessary.

Of course, we should also pay attention to travel bans and what is happening in other parts of the world. As health care professionals, we travel a lot, but meetings are being canceled for a reason: The hope is to decrease the number of large masses of people and transmission of COVID-19. Fortunately, most meetings are going virtual. If you have to go to a meeting, do not shake hands. Do the elbow bump. I was at a meeting last weekend and I successfully did not shake anyone’s hand.

Q. Shifting gears, let’s talk about TNF inhibitors. What do clinicians and patients need to know about the potential impact of the virus in patients taking these drugs?   

Calabrese: We simply do not know. I will say that it is not recommend that anyone stop their medications preemptively. Patients should continue to come in for their infusions. If a patient wants to stop their immunosuppressive medication, we encourage them to first discuss it with their rheumatologist. However, the fact remains that there are zero data on biologics at the moment.

Q. With so little information available, how important is it for rheumatologists to coordinate with other providers who may be treating their patients?   

Calabrese: I encourage providers to stay up to date with the policies of the institutions and associations of their specialties, and encourage both patients and providers to ensure they are getting their information from reliable, factual resources. The CDC has been fantastic with almost daily information for health care providers.

Q. Any guesses at a time frame for the spread and/or ultimate containment of this virus?   

Calabrese: I don’t know but we hope for it to be not much longer. Early identification of those infected, contact tracing, and isolation of those infected and their contacts will be crucial. It is unclear what proportion of those infected do not develop symptoms, but is felt to be less than 1%. The virus can also be spread during the incubation period, before symptoms develop, and those people need to be isolated to prevent spreading the infection. For now, unfortunately, that means quarantine.

It seems that the incubation period is probably about 2 weeks. The concern is that people who have the virus but do not become symptomatic are spreading it that whole time. In my opinion, the most immediate need is a fast and reliable test. Additionally, the most effective way to stop it will be with a vaccine.

Q. Any time frame on a vaccine?   

Calabrese: I would say we are 8 to 12 months away.

Q. How about treatment?   

Calabrese: We can offer patients supportive care, but there is no current treatment for COVID-19.

Q. In closing, could you offer a further word on the large amount of information and misinformation available to doctors and patients?   

Calabrese: There is a lot of both out there so I would advise sticking to sources that provide facts. If you can, avoid social media. While there are, in fact, some good sources of facts on social media, there is also obviously considerable incorrect information. Turn off your television, and instead, turn to your doctor if you have any questions. – by Rob Volansky

For more information:
Cassandra Calabrese, DO, can be reached at 9500 Euclid Ave., Desk A50, Cleveland, OH 44195; email: calabrc@ccf.org.

Disclosures: Calabrese reports no relevant financial disclosures.

Cassandra Calabrese

Disclaimer: This interview was conducted prior to the declaration of a state of emergency for coronavirus. It may contain outdated recommendations given the current state. According to Cassandra Calabrese, DO, “the situation is much more serious and is likely to get worse — social distancing is of the utmost importance. At the Cleveland Clinic, we are encouraging our rheumatology patients to cancel non-essential visits, and that we touch base over the phone instead. Patients who are scheduled for medication infusions at present are encouraged to keep these appointments, to avoid disease flares that would require high doses of prednisone or even hospitalization.”

The situation with COVID-19, or the currently circulating coronavirus, is developing so rapidly that new information may likely be available by the time you reach the end of this paragraph. But along with factual information, misinformation also abounds on social media, on cable news channels and in print publications. Healio Rheumatology will attempt to set the record straight for health care providers looking to sort out fact from fiction.

Cassandra Calabrese, DO, of the Cleveland Clinic, sat down to answer some questions about the realities of the epidemic. Her first order of business was to direct readers to the CDC website, which she said has been “fantastic” about keeping citizens informed.

According to the site, there have been 647 cases of COVID-19 in 36 states, including the District of Columbia, reported in the U.S. Twenty-five deaths have been reported.

Public health laboratories have been set up in 42 states to test potential patients. Increased testing will likely lead to more patient identification, at which point experts will understand more about the nature of the infection, severity and mortality rates.

 
According to the CDC, there have been 647 cases of COVID-19 in 36 states, including the District of Columbia, reported in the U.S.
Source: Adobe

In the meantime, beyond boilerplate recommendations about handwashing, restricting unnecessary travel and covering coughs, the CDC knows little about how the disease might be impacting immunocompromised patients. It is noted that elderly individuals and those with chronic conditions like heart and lung disease may be at risk, but no information is available for those with autoimmune diseases, or for patients being treated with TNF inhibitors or other biologic therapies.

In the absence of that information, Calabrese hoped to provide rheumatologists with a playbook for talking to patients.

Q. How should rheumatologists address the coronavirus with their patients?   

Calabrese: It is an ever-present topic. Patients are reading about it, seeing it on the news and social media, and I have been fielding a lot of questions. I think every patient I have seen in the past 2 weeks has brought it up. Some of the information they are seeing might be true but much of it is not. We are encouraging all patients to talk with their provider about the facts, specifically addressing what is safe for day-to-day activities and for travel. We are all trying to stay as up to date as possible as information emerges and have the discussion with our patients when they bring it up, particularly if they are planning to travel.

PAGE BREAK
   

Q. Beyond patients who are hoping to travel, possibly the next most important question is how will this impact immunosuppressed patients?   

Calabrese: We do not know much yet. Or, rather, we do not know if immunosuppressed patients are at an increased risk for acquiring COVID-19, but we do believe that those patients might have a higher risk for complications if they acquire it. Those patients should be following CDC recommendations to consider avoiding unnecessary international travel or avoid traveling through major international airports. Beyond that, wash your hands. This cannot be stressed enough. Do not touch your face, eyes, nose or mouth. Stay away from someone who is visibly sick — try to keep it at 6 feet, but any distance is helpful.

Q. What about masks?    

Calabrese: The simple face masks that people have been using do not prevent them from acquiring COVID-19 infection. If it makes the patient feel better while traveling or helps to prevent touching their face, that would be fine, but it is not necessary. However, if a person is sick, they should wear a mask to prevent others from catching their infection. For patients who are sick and absolutely have to travel, a mask can help keep their germs to themselves.

Q. What are some helpful tips for talking panicked patients through their fears?

Calabrese: There are many patients who are concerned, and some who are definitely panicked. They believe they should not leave their house, and they are asking about filing Family Medical Leave Act papers so they do not have to go to work. I try to remind them to be calm. It is true that while we still have much to learn, the majority of cases are not severe in nature. There have been several reports about the mortality rate, but we are still learning about COVID-19.

One thing I can say is that any time there is a new epidemic or infection, early on, the mortality rate is often predicted to be higher than it ends up being, primarily because we do not yet have the true denominator of cases. In the case of COVID-19, we are currently not testing enough people, but it seems clear that many more people have it than we originally thought.

PAGE BREAK

As for patient fears, I would encourage them to simply go about their business. However, if they are nervous about traveling or going into large crowds, then just don’t do that. If you are going to be nervous and anxious, maybe it is better to stay home. I try to break it down to informed decision-making based on data and based on how the patient feels. 

Q. What protective measures should rheumatologists reinforce among themselves?   

Calabrese: Rheumatologists should also be following all the strategies we have discussed: hand washing, not touching your face and adhering to all the same things we are telling our patients. A more poignant one for the health care community, however, is to avoid work if you are feeling sick. It can be difficult for health care workers to stay home, particularly in a situation like this, but it is absolutely necessary.

Of course, we should also pay attention to travel bans and what is happening in other parts of the world. As health care professionals, we travel a lot, but meetings are being canceled for a reason: The hope is to decrease the number of large masses of people and transmission of COVID-19. Fortunately, most meetings are going virtual. If you have to go to a meeting, do not shake hands. Do the elbow bump. I was at a meeting last weekend and I successfully did not shake anyone’s hand.

Q. Shifting gears, let’s talk about TNF inhibitors. What do clinicians and patients need to know about the potential impact of the virus in patients taking these drugs?   

Calabrese: We simply do not know. I will say that it is not recommend that anyone stop their medications preemptively. Patients should continue to come in for their infusions. If a patient wants to stop their immunosuppressive medication, we encourage them to first discuss it with their rheumatologist. However, the fact remains that there are zero data on biologics at the moment.

Q. With so little information available, how important is it for rheumatologists to coordinate with other providers who may be treating their patients?   

Calabrese: I encourage providers to stay up to date with the policies of the institutions and associations of their specialties, and encourage both patients and providers to ensure they are getting their information from reliable, factual resources. The CDC has been fantastic with almost daily information for health care providers.

PAGE BREAK

Q. Any guesses at a time frame for the spread and/or ultimate containment of this virus?   

Calabrese: I don’t know but we hope for it to be not much longer. Early identification of those infected, contact tracing, and isolation of those infected and their contacts will be crucial. It is unclear what proportion of those infected do not develop symptoms, but is felt to be less than 1%. The virus can also be spread during the incubation period, before symptoms develop, and those people need to be isolated to prevent spreading the infection. For now, unfortunately, that means quarantine.

It seems that the incubation period is probably about 2 weeks. The concern is that people who have the virus but do not become symptomatic are spreading it that whole time. In my opinion, the most immediate need is a fast and reliable test. Additionally, the most effective way to stop it will be with a vaccine.

Q. Any time frame on a vaccine?   

Calabrese: I would say we are 8 to 12 months away.

Q. How about treatment?   

Calabrese: We can offer patients supportive care, but there is no current treatment for COVID-19.

Q. In closing, could you offer a further word on the large amount of information and misinformation available to doctors and patients?   

Calabrese: There is a lot of both out there so I would advise sticking to sources that provide facts. If you can, avoid social media. While there are, in fact, some good sources of facts on social media, there is also obviously considerable incorrect information. Turn off your television, and instead, turn to your doctor if you have any questions. – by Rob Volansky

For more information:
Cassandra Calabrese, DO, can be reached at 9500 Euclid Ave., Desk A50, Cleveland, OH 44195; email: calabrc@ccf.org.

Disclosures: Calabrese reports no relevant financial disclosures.

    Perspective
    Brian B. Baggott

    Brian B. Baggott

    Recommendations for the use of PPE are being evaluated and updated continually. Hand washing is crucial. The CDC website endorses (with several supporting references) that hand washing decreases respiratory infections, diarrheal infections, and gastrointestinal illness. Hand washing is critical in helping prevent the spread of an infectious disease and is a cornerstone of public health policy and CDC recommendations. Early in the COVID–19 pandemic evidence suggested standard surgical masks do not protect you from someone who is infected (N–95 masks do), but if you were infectious or if you had exposure to a person under investigation (PUI), masks would help decrease the spread from the infectious person. That’s still the CDC position on masks but is being refined by further data analysis. Institutionally, PPE recommendations have to be balanced by the realities of availability.

    A recent paper in Gastrointestinal Endoscopy described the use of PPE according to patient risk stratification before endoscopy. They recommend that if a patient is not considered high risk, the PPE should include a mask, eye protection, and single-use gown and gloves. For high risk patients undergoing endoscopy (COVID-19 positive or a PUI the above should be used but the mask should be a N-95.

    Reference:

    Repici A, et a. Gastrointest Endosc. 2020; doi: 10.1016/j.gie.2020.03.019.

     

    • Brian B. Baggott, MD, FACG
    • Vice Chair of Clinical Operations
      Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease & Surgery Institute
      Section Head Comprehensive Gastroenterology
      Cleveland Clinic

    Disclosures: Baggott reports no relevant financial disclosures.

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