Community Representatives Met to Discuss Approaches if Coronavirus hits closer to home

On Monday March 9, 2020 at the South Library Conference Room at Scotland County Hospital, community representatives from different agencies were present to participate in a meeting on Scotland County to discuss the outbreak of the Coronavirus which at the time had not been considered a pandemic. The meeting was called by Thelma Norton, the hospital’s employee health nurse and Infection Control Nurse, to discuss proactive approaches Scotland County could take if the Coronavirus hit closer to home.

 

Those present included the following:

Mason Alley, Scotland County Health Department Representative, Epidemiology specialist

Lisa Steele and Tammy Teter, Scotland County Care Center

Tim Graham, Scotland County Fire Chief

Kirk Stott, Scotland County R-1 High School Principal

Duane Ebeling and David Wiggins, Scotland County Commissioners

Allen Creek, City of Memphis

Jeremy Head, Scotland County Chief of Police

Ashley Hoak (KTVO)

Elizabeth Guffrey, Robert Miller, Richard Jackson, Olivia Steele, Alisa Kigar, Lezah Cline and Thelma Norton, Scotland County Hospital

Lori Fulk, Scotland County Hospital Board of Directors

Lori Nelson and Lacie Snyder, Memphis Medical Service

Jeffrey Davis, DO; Randall Tobler, MD; Shane Wilson, DO, Kelsey Davis-Humes, DO; Aurora Bell, DO; Celeste Miller-Parish, DO; Jessica Christen, DNP

Lois Quenneville, PA; Marissa Burgess, PA;

Erick Byrn, Scotland County EMS Director

 

Dr. Davis opened the meeting with discussion of how Scotland County Hospital was preparing for COVID-19. First, he stated a triage line will be staffed by RN’s to handle callers and assign priority. The phone number for the triage line is (660) 956-6820 and will be manned at all times by administrative employees, nursing directors or the clinic director, or a supervisor. Dr. Davis said someone would man the phone 24/7 for questions and specifically to help identify those in need of being tested for the coronavirus which is the reason for the Triage line being sent up. “We want people to be able to get information rather than feeling like they just have to come to the emergency room or having to walk into the walk-in clinic or urgent care,” said Davis.

Davis told the story of a woman who traveled from Italy back to Chicago, got on the train to St. Louis and two days later began feeling the symptoms and knew she had been exposed. She didn’t go to a doctor’s office or the E.R. instead calling public health officials on Thursday and arranged to go into Mercy St. Louis on Friday to be tested with a testing kit from the state health lab. The test was performed, and she was sent home. She wasn’t admitted to the hospital; instead she was put into isolation for the collection of a sample.

“That’s the way we want to handle it in our community when we have someone who has been traveling or if we have someone who’s been exposed to someone with a known positive Coronavirus,” said Davis, “we want communication with the person prior to them arriving at the hospital or the clinic and subsequently exposing multiple people. We want to make sure we have uniformed information to give to our public.

Dr. Davis stated, starting on March 9th, there would be a limit on the number of vendors and pharmaceutical representatives at Scotland County Hospital and Memphis Medical Services/LMS.  Pharmaceutical representatives and representatives have been told not to come back to the facility until after the spread of virus has been contained. Dr. Davis indicated this a procedure underway in all Veteran’s Affairs facilities statewide, with several VA facilities being in St. Louis, having closed their facilities to visitors and vendors by order of the governor and Dr. Randall Williams of the Department of Health and Senior Services.

Dr. Davis said there was not a case of Coronavirus in Scotland County yet the potential existed for something like what happened in Washington state, when the residents in a nursing home were exposed in addition to being highly susceptible because of their ages and comorbid conditions, which made the fatality rate higher.  He said officials in Missouri would be remiss if they were not thinking about it ahead of time and planning to begin limiting access to the facility.

A few days after the meeting, an issuance went out discouraging non-essential visits in light of following precautionary guidelines and that no visitors were not allowed in the hospital as well as the reduction of entrances to the hospital. The current entrances are through the E.R., the North door, and Memphis Medical Services. Entrances through the ambulance bay, the loading dock, the clinic entrance, the library entrance, the OB entrance, service entrance, and doors that come over from the nursing home, will remain closed until further notice.

At the meeting, Dr. Davis stated “We’re not prepared and planning to close those yet. but if we get cases closer to Scotland County, if a spread starts to occur from community members, not here, but we see a community spread in Missouri, we’re likely to limit it to two or three entrances and begin screening visitors and patients that are coming with their travel history, their exposure to the Coronavirus, symptoms of fever, cough, runny nose, sore throat, things like that.” He continued saying that communications from the hospital to all their primary care providers, primary care providers in the health departments for the areas that surround Scotland County were being conducted due to servicing several patients from Knox County, Clark County, and Schuyler County.

There are FDA approved commercial tests available on the West Coast that were developed at Stanford University. The test was created around January of this year, and despite not being the CDC’s test, or handled by the state of Missouri’s own state health lab, Stanford’s testing was FDA approved and is beginning to be commercially available. Richard Johnson was asked to call to see if 100 tests for availability from Quest. Currently only California, Oregon, Nevada, and Washington state can do commercial testing and send test samples to Quest for them to run.

“They hope that testing will be available in Missouri soon and Rich {Jackson} is hooked up to get information from that to contact them so we can find out as soon as that’s available. We would be able to offer that,” Davis said. He briefly talked about meeting with the governor on Saturday, who then attended a press conference in St. Louis. The governor said there are 900 places in Missouri where test kits can be available. The Scotland County Health Department secured two testing kits.  More tests can be gotten though what happens when someone identifies a person under investigation, such as someone who thinks, they may have been exposed or may have traveled to someplace where they could have been exposed, if they do the appropriate thing such as contacting the health department, the triage line, the hospital’s office, Memphis Medical Service, and the emergency department, those concerned will be informed they have other criteria to meet due to the CDC tests that Missouri public health has have restricted usage, meaning only to those who meet criteria. To use the test, an Emergency Use Authorization must be issued.

Duane Ebeling and David Wiggins, Scotland County representatives, brought up a potential concern with the August elections. Davis said if there were high cases at that point. The preference primary election was held the next day and municipal elections in April were yet to come. A recommendation was made for the primary elections: to have sanitizer or sanitizer wipes before and after every use of pens. Single use ball-point pens will also have been used. Voters can either use the pen and throw it away or leave it sit out in the sun for a day to kill the virus and then use the pen, which are common sense things people don’t think about is unknowingly spreading a virus by just sharing things that has been used such as a keyboard, pen, telephone, or anything.

According to Kirk Stott the school is using preventative measures as they do with the flu, which Stott mentioned was rampant at the time. Kids are given wipes to help sanitize items, such as iPads. Stott also mentioned that “in the office they are disinfecting things almost hourly. I can’t chew or taste anything but Lysol now. We’re basically treating it like we do with the flu right now, just trying to prevent, follow the policies about fevers, they got to home.

Dr. Davis commented about the closing of John Burroughs and Villa Duchesne as a father and daughter in St. Louis broke their quarantine and attended a pre-party and a father-daughter dinner dance, consequently, the schools were closed down as there was significant exposure that occurred. He further explained possible quarantine issues if there was a case in Scotland County, “if there was some problem with quarantine and isolation, then whether or not people would be exposed, and we wouldn’t want them coming into places with large gatherings of people are together like the school.” The father who broke quarantine was put under house arrest.

Another health official commented that if someone called the triage line, there is a form that is filled out, and if it is a parent of a school child, they know which school the child attends and the school nurse will be contacted the next day to let them know that a parent called the triage line about somebody having symptoms. She continued, saying that with regards to daycares, “we can’t possibly keep all the phone numbers for all the daycares around so we will instruct the parent to notify the daycare. Same thing with employers, if you’re an adult and you call and you have an employer, willing to ask the individual that calls to let their employer know, if throughout the Triage process they are notified they need to stay at home.” She followed with stating the health department would get all of that information as well.

            EMS Director Erick Byrn stated that EMS was following state guidelines and asks if anyone has traveled anywhere recently and then, if they have been exposed to Coronavirus. “We have a checklist that the state has put out and we follow that. Once we get there, we’ll either notify the E.R. and talk to them and see what the recommendations are, because we have to talk to a physician before we can go anywhere because we can’t just leave them there. The health department will be notified. I can tell you we’re not going to know when we walk in what we’re walking into so we’re not going to be gowned up and stuff like that. So, if we do get exposed it’s going to limit our resources for EMS because we’re going to a 14-day quarantine no matter what. It will probably be at the base is where we’ll be quarantined, they won’t get to go home or anything like that. They’ll be stuck there for 14 days. But that’s where we’re at right now.” He went onto say that no one should try to get filtering masks or anything related as there are none, as vendors are running out, which is shortens the limit for EMS, as they are now having to go through the state (EMS) to get them.

Dr. Davis interjected that others are probably getting them from the national stockpile. Byrn continued saying he received daily emails about this and how things have changed at the state level, which will be adopted by the Scotland County Ambulance.

Dr. Tobler mentioned he had received a private message from a fellow physician in St. Louis that said people are stealing sanitizers and gels from bathrooms in their offices. Dr. Tobler said to remember that while sanitizer and gels are popular, “there’s always good old-fashioned soap and water. It doesn’t need to be antibacterial soap.” He also commented that doing a simple song, such as sing the ABC’s or Twinkle, Twinkle Little Star, for example would be a good way to make sure someone has been washing their hands for twenty seconds.

The conversation then switched to the potential of having a patient who tested positive and was being taken care of at home after their positive and they’re in their quarantine, if they develop more severe signs and symptoms, such as shortness of breath, respiratory stress, would EMS have the capabilities in that kind of situation to go in, to which Byrn responded that EMS did have the capabilities as they had gowns, masks, and gloves.

With Dr. Davis stating that one of his concerns, after having listened to the epidemiologist from the University of Nebraska’s region conference call, was the possibility of 30-40% of the community at some point could have the Coronavirus if the current situation turns into a pandemic, asking how quickly short EMS resources could be drained if all people were exposed. Byrn commented that there were precautions on each truck that can be taken if they know, as though someone may have any other infectious disease. Byrn said, “I can tell you if we get it our resources our going to run out in Scotland County.”

Alley asked about EMS guidelines and had questions regarding coming up with a coded dispatch to prevent the possibility adding to potential hysteria. In his question directed at Byrn he asked if the dispatch unit had any special code to identify just so the public didn’t hear it and then mass hysteria spreads via Facebook on what they hear on their scanners.

Byrn responded, saying the dispatch was a work in progress so that is something when they start asking questions. Alley responded by saying he asked other counties if they had a specified e-lines that monitors the county and that information is relayed onto the proper agency and that they were doing that in ways, with the dispatches have created a specific code for responding to that presence anyway. Byrn followed with mentioning the state had sent out a questionnaire that was about fifteen questions long.

Dr. Davis was asked if he agreed with federal spokespeople on the response team and personal advice towards people who are at risk, so over 60 and/or have chronic medical conditions, respiratory or otherwise to not go out into public places unnecessarily for non-essentials and if he agreed with the statement, to which he, Dr. Davis, did agree while jokingly mentioning canceling cruises for anyone 60 and older, which caused a brief moment of laughter in the room.

The Scotland County Care Center representatives mentioned that they were treating everybody, and they already have standards in place due to the influenza at this time of year and that all staff at the care center had been briefed in an Inservice meeting with. Also, they mentioned that notes are being posted on doors, saying STOP, if someone is ill, or showing any of the symptoms, to not come and that they would need to speak to a medical director about when to actually say no visitors, with Dr. Davis remarking that was also a discussion point in Clark County and Knox County, both of which Davis referred to as being semi-open and asking people to self-select and not come. The care center has been vaccinating double the last two years, starting in October and February with the hope that those who are vaccinated will be helped during this time until the virus has passed.  He then referred to Elizabeth Guffey who would need to speak to staff about reporting signs and symptoms of illness.

Tim Graham, Scotland County Fire Department representative, said the Fire Department was still gathering information right behind EMS and mentioned they wouldn’t be too far behind if they had to go on call. A small part of the conversation centered around the usefulness of face masks, if there was any use for them at all as well as what might happen if the hospital had to go down to two entrances.

Next, hospitalist Dr. Shane Wilson spoke, responding to Davis’ questions about his thoughts on if resources become scarce, reverse isolation would not be required or necessary and the consideration that the hospital could take care of three pressure, ventilated patients. Beyond that the hospital is limited to what they can take care of, although, they could, potentially, be unable to transfer a patient to another facility due to another facility being filled to or above capacity. Wilson observed, “I think what everyone is doing here is excellent, to have a plan in place, an idea. The first and foremost encourage you to ponder as well as the people you are talking to, is influenza and strep pneumonia that we are vaccinated for would fall into that category by and large, by every statistical analysis up to this point, even in China killed way more people than this virus has even attempted to. Granted not all the information is in yet. By and large the people who suffer high mortality from this specific virus are the elderly people who have significant medical conditions that end up exacerbated by the respiratory component of this virus. So please don’t expand on the paranoia of this virus. We don’t know what it entails yet first and foremost I would encourage that and would encourage that paranoia should be second. You know what, we should all be cleaning our hands, wiping our pens off at the voters’ booth every time we use them because we spread MRSA and influenza, and adenovirus, Human met pneumonia virus all which have been documented to kill more people than the Coronavirus. Let that be known first.”

Dr. Wilson continued, “Second, I wish we had rapid tests for the Coronavirus and other viruses that we don’t know and we’re going to be limited. We’re going to do everything we can in the in-patient setting to do as much isolation as we can for the patients that we have high suspicion of any respiratory. Our community has been getting hammered with influenza for the past two weeks. I’m way more concerned with influenza right now than Coronavirus; we’re going to be taking those precautionary measures and keep those in place. Really, there’s honestly not enough information out about this pandemic event that’s not a pandemic yet that needs to be gleaned and teased through. We have everything in place. Most of these people, in reality, won’t overwhelm us because it looks like, at this point, the symptoms and severity of this illness usually are not overwhelming unless we have immunocompromised patients and or the elderly who have comorbid conditions who would be isolated anyway. So, just do our due diligence, wash your hands. It’s a wakeup call, not just for the Coronavirus but for all the viruses we spread for our community.”

Dr. Tobler joined the conversation asking how Dr. Wilson weighed in on getting an influenza or pneumococcal vaccine. Dr. Wilson responded that with the recent local outbreak in influenza. It is still recommended that if anyone hasn’t gotten the vaccine, they should get it and in two weeks you’ll be covered. For the most protection that can be provided prophylactically, and to keep people from getting Type A or Type B Influenza, a vaccine is the best option. Dr. Wilson also mentioned that if someone is at high-risk and knows they have been exposed, high-risk, meaning someone is immunocompromised and is taking chronic steroids or on a medication that decreases someone’s immune response or a person is very frail, or have morbid conditions. He noted that some children who have preexisting conditions would be considered high risk by and large. If someone lives with a person who is diagnosed with influenza that doesn’t mean anyone needs to rush and buy Tamiflu and take it for ten days, as doing such has not been scientifically validated, with the best thing being getting vaccinated. “I hope this coronavirus thing, if nothing else, makes people realize what we can vaccinate, get them. It is our best defense at this point. That’s what I hope happens.”

Dr. Davis added that it is one of the reasons why epidemiologists and the World Health Organization and CDC because this is a non-human form hence why it is referred to as Novel Coronavirus and no has been vaccinated for it. He continued saying that millions had been vaccinated for influenza, though not as many as should be, because there is a fifty-percent effectiveness of getting people in the community vaccinated, noting that three influenza cases had been diagnosed on earlier on March 9th.

A hospital official added that  Scotland County Hospital, on average, was seeing six influenza cases a day, with Dr. Davis responding that there had been as many as 10-12 in one day, or as low as four to five cases a day, which had been happening for the past two weeks. Conversely, the discussion of patients who showed flu-like symptoms but were not in distress and were testing negative for influenza was brought up. One representative said she had been treating them with Tamiflu and telling them to self-quarantine. She questioned if health workers should be dealing with the issue more forcefully, stating she was writing for people to go back to work after two days after starting the Tamiflu, if they were feeling up to it.

Dr. Davis’ response: “I think the recommendations that are out there are for sure with the people who have comorbid conditions just like Dr. Wilson talked about who are early in their illness and are testing them to know for sure if they have it or don’t have it is appropriate. But in a community outbreak where there’s a lot of influenza-like illness, I think the IDSA guidelines that say people that are at the highest risk who have influenza-like illness can be treated as well.” He continued saying that as far as returning to work, Dr. Davis said that isolation with sick patients in the hospital until they have been afebrile for a time and then for a specific timeframe afterwards, ranging for 24-48 hours, after having no fever.

He said that we all know we should cough into our elbow and not our hands, then shake somebody’s hand. All those things need to be stressed along with the fact that there are a multitude of viral infections that causes sneezing, running nose, congestion and fever, malaise, that are not influenza and with Tamiflu doing nothing.

A concern for when to screen for the Coronavirus, such as at the walk-in clinic or the E.R., where there is a possibility the first cases will be seen, is when someone has shakes and body aches, when does a test for Coronavirus become necessary. One note is that if someone has taken care of someone with known exposure or has traveled. The Coronavirus has been identified in Des Moines, Iowa, those who returned from a cruise ship that was in Egypt, who were Persons Under Investigation (PUI) and Chicago, along with confirmed cases in Missouri. A young girl in Missouri, who was quarantined with her family had been in a Level-3 country. The tests that are available through the health department and the CDC require a waiver to be used along with meeting additional criteria.

Dr. Tobler commented that the cardinal symptoms of the Coronavirus he didn’t think really include the myalgias, the aching, that was more related to the flu. Several others began chiming in including Byrn, who said health workers would see the respiratory distress more than anything.

Dr. Davis commented that he believed Johns Hopkins was conducting follow-ups with those who have recovered from confirmed cases of Coronavirus. The number of confirmed recoveries, on March 8th, was at 60,000 people.

There are also people who have symptoms who don’t get tested they are not sick enough as to where they believe they should go to the doctor. For example, having a common cold-like symptom, some people do home remedies and the symptoms go away. The reality of the positive Coronavirus exposure and transmission is likely, possibly double what anyone knows about. Talking of death-rates, currently, less than 2%, the majority of which are in countries that do not have the full access to healthcare such as that in the US. One speaker cited the number of people who died in China, around 2,000, had several medical comorbidity issues and were over the age of 60. Multiple factors attributing to this specific respiratory illness not unlike influenza. Dr. Tobler contributed, “the denominator of infected people expands more rapidly than the numerator of fatalities the rate will drift down.” Someone else commented that there is speculation that the mortality rate will drop once everything is said and done will drop to the severe or moderate-severe seasonal influenza. Epidemiologists expect around 0.5%, the equivalent to what influenza has and dramatically lower than SARS, which was about 10%.

            During the last fifteen minutes with the Q&A, one of the city reps asked about the regular flu vaccines the question posed was this: “Is the flu shot that we got in October still good? How long does that last? I know it’s not a forever kind of flu.”

The answer: “The CDC is estimating that has been received this year has been 45-50% effective at keeping from people from getting the influenza or making their illness much less severe. It has been studied before the high dose flu vaccine came out that, which we have offered this year and the past couple of years, for those who qualify for it, age 65 and over. Prior to that there were studies done that estimated your immune antibodies in your system lasted four to five months from when you get the vaccination. It’s the problem when we have these late-breaking flu seasons like we’re having right now, is the CDC is asking us to begin vaccinating as soon as the vaccine is available. Well, last year the vaccine was available in August and early September and if we would have vaccinated then we would be looking at January before people start losing their immunity. Here we are in March with an outbreak, so a lot of people didn’t get vaccinated until October when did our flu clinic and other people came in later, we have been vaccinating people as of last week. It is a good question.”