On July 12 Florida set a national record for the highest number of COVID-19 cases in one day in any state. A week later, Florida set a statewide record for numbers of weekly deaths from the virus (740) on July 19. Meanwhile, medication shortages recently caused Gov. Ron DeSantis to order 30,000 vials of remdesivir for rapidly filling hospital beds. In Hillsborough County, the teacher’s union sued Gov. Ron DeSantis in opposition to a full school reopening in August.
With coronavirus surging and no end in sight, the Hillsborough County Medical Association held its second Town Hall in two months to address the local response to the virus, featuring the County’s Medical Director Dr. Douglas Holt, two infectious disease specialists from USF, and Dr. Charles Lockwood, Dean of the USF College of Medicine in Tampa.
Below are six takeaways from that July 21 discussion.
1. COVID-19 cases peaked rapidly in the past 6 weeks
Florida now has three of the nation’s 10 fastest-growing hot spots, with Miami at No. 1 and the Tampa-St Petersburg-Clearwater area No. 8 with more than 21,000 infections or nearly 1,200 cases per day since early July. In the past week, Florida, as a whole, has had more COVID-19 cases than any other state in the country.
As Dr. Holt explained “we are still in the first wave of this virus which, in Hillsborough County reported about 50 cases per day as of May 1. Two weeks later we were seeing 200 cases per day and peaked at around 700 cases per day or about 45 cases per 100,000 in the general population. It’s phenomenal where we went in such a short period of time and with the rush to get back to normal the virus just exploded.”
Currently, he adds, “Hillsborough County has started to crawl our way back down to below 40/100,000, much below Miami, which has been seeing rates close to 80/100,000, the highest rate in the country.”
2. Cautious optimism on response to the virus
Dr. Holt indicated area hospitals were in “pretty good shape” regarding ICU bed capacity, which he pointed out is an expandable one by using beds from other areas when needed. He noted that “Pinellas County was a bit more stressed than Hillsborough” due to an older population with COVID-19 patients having an average age of 48 versus 35 years of age in Hillsborough.
Infectious Disease Specialist Dr. Kami Kim pointed out that local ICUs are now filled with ventilated patients like never before and with increased ventilator time required by most COVID patients, specialized respiratory and nursing staff have felt considerable stress.
On the positive side, Hillsborough County’s case fatality rate has remained quite low at 1% and recently dropped to less than 0.9% in the past week, according to Dr. Lockwood. Florida’s case fatality rate has remained low as well, now at 1.4%, a three-fold drop since early June.
Dr. Lockwood cautioned, however, ”these rates are subject to many variables that can lower the rate, like the recently ramped up testing in Hillsborough County, which has detected more young people and those with very mild infections or who were asymptomatic.”
One thing that has contributed to a lower mortality, he noted, has been our improved understanding of possible treatments since March and April, such as the use of remdesivir (a broad-spectrum antiviral medication), dexamethasone (an anti-inflammatory medication), and convalescent plasma therapy (an experimental treatment using blood collected from patients who have recovered from the novel coronavirus disease), as well as better ventilation management.
The panel commented on the importance of using aspirin or in some cases, potent anti-clotting drugs like Xarelto or Eliquis that reduce the risk of blood clots that COVID-19 patients are at risk for developing, usually in their second week of symptoms. Dr. Lockwood, a widely published obstetrician-gynecologist, noted that because pregnancy is actually a hyper-coagulable state, experts are now recommending anticoagulation for all pregnant patients who are admitted with COVID-19.
3. New CDC guidelines for testing
Dr. Kim, Chief of the Infectious Disease Division and a prominent researcher at USF Health, noted the PCR test -- which detects the virus’ RNA -- remains the most accurate test for diagnosis because of its sensitivity and specificity in detecting the COVID-19 virus.
The downside is that the test, usually performed from a nasopharyngeal swab sample, is more expensive and more complex, requiring a specialty lab to perform it. And while patients remain infectious usually only for up to 10 days from the onset of symptoms, the PCR can remain positive for much longer -- up to several months.
Dr. Kim notes this has created much confusion previously in patients who have recovered, waited out the 10 days when they are supposed to be non-infectious, but still have a positive PCR test.
The other main test for COVID-19 is the serology or blood test that is an indirect test to measure the body’s immune system by measuring antibody levels. This test indicates that a patient has responded to the virus but the test does not establish of presence or absence of active infection or reinfection.
There are several other tests, explained Dr. Kim, that are often used at the bedside (so-called point-of-care tests) or used for screening large groups. These are quicker, more convenient tests, but they also tend to be less accurate and require a higher volume of the virus to test positive.
Dr. Holt noted that a recent change from the CDC is that retesting is no longer advisable before three months after a positive PCR test in patients who remain asymptomatic. A positive test during this time more likely represents persistent shedding of viral RNA than reinfection.
Also, it is no longer necessary to have a test performed when returning to work. For most persons, with mild to moderate illness, isolation can generally be discontinued 10 days after symptom onset and resolution of fever for at least 24 hours along with improvement of other symptoms, according to the new CDC Guidelines.
Patients who never develop symptoms but test positive for COVID-19 can discontinue isolation and return to work 10 days after the test was done. This “symptom-based” approach as opposed to one that was “test-based” has now become the new return-to-work standard.
The new guidelines, released by the CDC on July 17, are also used now by Florida’s Agency for Health Care Administration (AHCA).
4. What about "herd immunity''?
Dr. Lockwood noted that this bold Swedish experiment to protect older folks and let younger folks get infected turned out not to be such a good idea when their mortality rates became substantially higher than in neighboring Nordic countries. Achieving herd immunity in such a fashion is not a useful approach unless the vast majority of cases are very mild or asymptomatic, which has not been the case in the United States with Covid-19.
With the current coronavirus pandemic, Dr. Lockwood pointed out, “We don’t really know the number of asymptomatic patients with estimates being wildly discordant.”
CDC estimates now report the true number of COVID-19 patients may be anywhere from 2-fold to 10-fold higher than laboratory-confirmed cases.
“If this is true, we are a long way from herd immunity in Florida,” says Lockwood.
The best way to attain “herd immunity” is with an effective vaccine. Until then, we must focus on “flattening the curve,” that is, to reduce the number of cases through mitigation – primarily use of social distancing, face coverings, and limiting gatherings to fewer than 10 people. The virus will still be around, just more manageable, and in a way that allows the country to open up more safely.
5. Where are we with obtaining a vaccine?
Dr. Kim reminded the audience that typically vaccine development takes two to 10 years. But she also remarked that she was much more hopeful about a timely vaccine than she was three months earlier, due to aggressive partnering by government, industry, and the scientific community.
“I find that pretty impressive,” she remarked. “Our knowledge of this virus really began only this year and already there are three vaccine candidates that appear safe, produce antibodies, and appear promising” potentially for distribution as soon as next year.
The panelists cautioned that when a vaccine does become available, the first wave of distribution likely will go to first responders and health care workers, followed by the elderly and those at risk for disease. Not everyone will be able to get it immediately upon its availability.
Important issues will be assuring access to the vaccine for marginalized communities, including minority groups, and educating and engaging the general public, which has been more skeptical of vaccines in recent years. How long a vaccine would be effective remains unknown. Yet several pharmaceutical manufacturers are now ramping up the production of promising candidates even before vaccine approval in order to be ready once that happens.
Dr. Sinnott cautiously pointed out that the Chinese have been working unsuccessfully on a vaccine for SARS, the original coronavirus, for 25 years.
“I worry a little bit about our vaccine chances,” he said.
On the other hand, Dr. Lockwood suggested that the use of a new vaccine along with using existing influenza vaccines might suppress the virus. “I’m inclined to think we’ll be OK,” he added.
6. What about going back to school?
This question appeared to challenge the doctors the most, with general agreement on hybrid approaches that utilize some online learning, smaller classes, frequent outside breaks, and the use of masks.
Dr. Holt indicated the need for quarantine and contact tracing protocols as well as concerns for the safety of teachers as issues that need to be addressed.
In a call for creative solutions, Dr. Sinnott pointed out that outside classes were successfully held in tents during the Great Influenza of 1918. He said he would be reluctant to expose children to indoor classes in Florida at present without knowing the virus’s long-term effects in the pediatric population.
Dr. Lockwood mentioned a novel approach being discussed between USF and the FDA, “pool testing” where large groups are screened by using samples from several people and testing them all at once and with results obtainable within 24 hours.
The panelists' final recommendations
“Today, our only real tool remains wearing a mask,” noted Dr. Lockwood, who reminded physicians of their duty as role models to wear masks routinely.
Dr. Michael Cromer, President of the Hillsborough County Medical Association who served as moderator of the panel, reminded everyone to be diligent about the “4 Cs”: Clean your hands. Cover your face. Avoid close Contact. And avoid Crowds.
- Dr. John Sinnott, Chairman of the Department of Internal Medicine at USF Morsani College of Medicine as well as an epidemiologist for Tampa General Hospital.
- Dr. Douglas Holt, Director of the Hillsborough County Health Department and Professor of Medicine at USF Morsani College of Medicine.
- Dr. Kami Kim, Professor of Medicine and Director of the Division of Infectious Disease and International Medicine at USF Morsani College of Medicine.
- Dr. Charles Lockwood, Senior Vice President USF Health and Dean of the Morsani College of Medicine.
- Dr. Michael Cromer, President of the Hillsborough County Medical Association, served as the moderator.