EHPVA continues to practice medicine in service of all our patient’s medical needs. We appreciate the enthusiasm of our patient’s desire to fight the COVID19 pandemic and Stop the Spread. However, our small office cannot answer all questions and concerns about COVID19 and continue administering to our patients’ needs at the same time.
Patients, please review the bounty of resources available online from our official Federal, State, and Local health departments. After, please know EHPVA sees your calls and emails and works as hard as we can to address your concerns. However, EHPVA will continue to put first the immediate medical needs of our scheduled patients.
If you feel sick, take caution, and STAY HOME!
If you are experiencing a medical emergency, please do not call our office. Instead, call 911 or go directly to your nearest emergency room.
If you are experiencing COVID19 or flu-like symptoms or have been around someone with COVID19 or flu-like symptoms, DO NOT come to our office location.
Even a negative result of the COVID19 rapid test comes with self-quarantine guidance for a minimum of seven days, with re-testing occurring on day five or later or after ten days without testing.
The only current contraindication for the COVID19 vaccine is anaphylaxis to a prior vaccine.
Please Be Advised
Rapid testing is not always as accurate, and persistent symptoms of a high index of suspicion for COVID19 should be assessed with a PCR Test.
Routine testing requires prior planning. Please allow at least one week as tests can take up to ten days to come back, in the case of PCR.
EHPVA has zero ability to expedite the return of results. We cannot pull strings or ask for special treatment from the labs to return our patient’s results faster than others. We appreciate your humility and understanding in this regard.
It is flu and cold season. Please seek a proper and thorough evaluation of your symptoms, as not everything is COVID19.
Please Be Reminded
Asymptomatic transmission of COVID19 does occur.
Wash your hands, practice social distancing, and wear a mask.
Do not delay other medical needs while “waiting out” the pandemic. It is essential to seek medical care for all medical needs.
Patients follow-ups are required to receive medication. EHPVA provides telemedicine visits to limit exposure. Telemedicine visits are still billed and covered by insurance as a regular office visit.
EHPVA uses doxy.me, a web browser-based option (no application installment required) that can be done from any computer or phone with a microphone and camera access. Not all insurances will pay for telephone-only visits. If your insurance does not cover, you will be charged the cashed price. Patients may reach out to EHPVA’s biller with questions if they are unsure.
The labs and imaging centers continue to implement proper, safe, and effective health protocols. Patients, please do not skip your labs. Most locations now allow you to wait in your car.
EHPVA DOES NOT have the COVID19 vaccine, nor will we carry it.
To check for vaccine registration, please visit the Virginia Department of Health website. Distribution is based on place of residence, except for front line workers who should have already received information from their employers.
There is no recommendation for antibody testing after vaccination or to determine the need for vaccination.
Individuals who have been infected with COVID19 are advised to be vaccinated after a post-infection 90-day waiting period.
Final Note
If patients require specific guidance after reviewing available resources, patients are required to arrange a phone visit or discuss via the Patient Portal.
EHPVA thanks our patients for their time and understanding.
Curbside testing for Coronavirus is available through Piedmont Urgent care, but does require physicians’ orders I do believe that is for symptomatic patients.
In summary, we are deferring universal antibody testing for the moment until we have better data on which assays are most reliable. This is being done to prevent the adverse outcome of a potential false positive or false negative test. Serologic testing for IgG will not change your current treatment course. For those who believe they have an active infection, we would like you to have a swab for active disease using the PCR method. Piedmont Urgent Care is offering drive-up testing for active disease for patients meeting criteria for testing. Please understand: We are not refusing to test you for antibodies, simply requesting that you wait until we have better information to provide you with the most accurate assessment. I am happy to discuss with you further on an individual basis via our patient portal. Unfortunately, due to the large volume of calls, we have regarding other active health issues, I will not be able to discuss this by phone at this time.
Please continue to check our site periodically as we will be updating you when we have more information.
Since testing for SARS-CoV-2 (the name of the virus)/COVID-19 (the name of the disease) is all over the news and has the potential to generate controversy, I would like to take a few moments to discuss the different tests, their relative merits, and their usefulness.
The most commonly used test is known as a “PCR” test. This test looks for the virus’s genetic material that is typically found in the patient’s respiratory system. It is performed by obtaining a swab from the patient’s nose and/or throat. According to the FDA, these tests are believed to be highly accurate. This means a positive or negative PCR test is very likely to be true. One word of caution, particularly when someone is being tested to find out if they can come out of isolation after infection, is that these tests test only for the genetic material of the virus. It doesn’t mean that the material is actually part of a viable virus particle and capable of further transmission- only that the genetic material is still around. Currently there are no home-based PCR test kits for people to test themselves, but the FDA is actively working with developers in this space.
Another type of test, called a serology or antibody test, measures the amount of antibodies present in the blood when the body is responding to a specific infection, like COVID-19. This means the test detects the body’s immune response to the infection caused by the virus rather than detecting the virus itself. In the early days of an infection when the body’s immune response is still building, antibodies may not be detected. This limits the test’s effectiveness for diagnosing COVID-19 and why it should not be used as the sole basis to diagnose COVID-19.
In response to an infection, such as COVID-19, the body develops an overall immune response to fight the infection. One part of the immune system’s response is development of antibodies that attach to the virus and help eliminate it. The body’s initial immune reaction produces general antibodies that attack many infections, called “IgM” antibodies. IgM antibodies indicate an active or recent infection. Because it takes time for the body to make IgM antibodies in response to SARS-CoV-2, their absence does not mean that someone is not infected. A test for IgM antibodies may give a false negative result in a patient with SARS-CoV-2, particularly early in infection. A patient may have a negative result early in infection even when they are symptomatic or asymptomatic but actively shedding the virus. Since IgM antibodies may not develop early or at all in infected patients, this type of antibody test is not used to rule out SARS-CoV-2 in an individual.
Over time, the body develops a second type of antibody in response to the infection that is more specific to the virus, called “IgG” antibodies. Most antibody tests detect IgG antibodies. On average, IgG antibodies take about 4 weeks to develop, but the time to development may vary substantially, and there is still a lot we do not know about SARS-COV-2. Since IgG antibodies generally do not develop until several weeks after infection, this type of antibody test, even though it is more specific to SARS-CoV-2, is not used to rule-out SARS-CoV-2 infection in an individual.
Serology tests are of limited value in the immediate diagnosis or screening of a patient where COVID-19 infection is suspected because they cannot rule out the presence of the virus. But positive results from appropriately validated serology tests that are designed to be very specific to the SARS-CoV-2 virus can confirm either that a patient has (for IgM antibodies), or more likely has recovered from (for IgG antibodies) a COVID-19 infection. In addition, although not everyone who is infected will develop an antibody response, appropriately validated serology tests, when used broadly, can be useful in understanding how many people have been infected or exposed and how far the pandemic has progressed.
Then what is the purpose of these antibody tests, if they aren’t used for diagnosis or exclusion of COVID-19 infection? Using this type of test on many patients may help the medical community better understand how the immune response against the SARS-CoV-2 virus develops in patients over time and how many people may have been infected. While there is a lot of uncertainty with this new virus, it is also possible that, over time, broad use of antibody tests and clinical follow-up will provide the medical community with more information on whether or not and how long a person who has recovered from the virus is at lower risk of infection if they are exposed to the virus again. Serology tests can play a critical role in the fight against COVID-19 by helping healthcare professionals identify individuals who have been exposed to SARS-CoV-2 virus and have developed an immune response. In the future, this may potentially be used to help determine, together with other clinical data, whether these individuals may be less susceptible to infection. In addition, these test results can aid in determining who may donate a part of their blood called convalescent plasma, which may serve as a possible treatment for those who are seriously ill from COVID-19.
What’s important to know for now: we need to continue to test using PCR methodology in order to identify acute cases and conduct contact tracing. In the future, serology/antibody testing may be useful to determine population immunity.
Thanks again for everything you are doing in these uncertain and frightening times. One team. One mission.
Wade Kartchner, MD, MPH
Health Director: Rappahannock/Rapidan Health District
It’s time for another installment of our coronavirus updates! I wish what I am about to write was a belated April Fools’ joke, but alas, we are in a strange new reality.
As expected, many things have changed since my last posting. DC, MD, and VA have all imposed formal “stay at home” orders with actual penalties. I know that isn’t much fun for anyone, especially some of our parents who are now learning to home school while either working or trying to find ways to make ends meet. We here at EHP extend virtual hugs to all of you.
For starters: some disease-related updates and housekeeping.
If you are feeling sick, STAY AT HOME!
We are again maintaining our plan for telemedicine until further notice. I will be coming into the office one or two days a week for things that cannot be managed remotely. For questions about how that process works, please refer back to our original posting with FAQs.
Please continue to follow the guidance from the CDC on what to do if you think you are sick. For instances where you are only mildly ill, the guidance is still to stay home and limit your exposure unless you are worsening or have specific risk factors. Please continue to check the official site as guidance continues to change. The CDC site has been updated with a symptom checker that will give you a quick self-test to see if you need to call the office. We encourage you to start with that checker due to our high call volume.
For ROUTINE lab draws, I have checked and confirmed that Labcorp and Sunrise draw stations are open. They do close for lunch, as always. We will happily provide you with individualized guidance on what testing can be postponed. Where possible, the use of the patient portal will allow us to respond more readily.
Specifics on routine lab testing: In general, we are encouraging things that are not time-sensitive to please wait until the pandemic is under better control. The hospital has ongoing changes, so please check prior to going for routine blood work. When possible, we strongly encourage you to schedule your draw using the laboratory website, as that will also provide the most up to date service information. To date, Sunrise has not posted specific protocols during this time. Please click here to review current testing policies at Labcorp for non-COVID19 purposes. Remember to limit touching your face and other objects and to frequently clean your hands while in the community.
There has been updated guidance on the routine use of masks while out in public. While the original thought was that masks only protect those who are sick, the change is reflective of the fact we know the novel coronavirus can be transmitted by asymptomatic patients. Still, the recommendations were to use a homemade mask, if possible, so that hospitals and physicians’ offices already in short supply will not have to compete with the public for supplies necessary to protect front-line health workers. Special thanks go out to those who have been making masks to help protect their community. It’s important for our mental and emotional well being to be able to embrace the positives during a trying period as a county.
Speaking of, I hope all of you are working on finding ways to stay active at hometo avoid “the quarantine 15.” Take advantage of opportunities on the few sunny days we are getting to work in the garden or take a walk (while remaining socially distant!).
Have some suggestions? Send them over, and we may feature them in our next update!
That’s all for the housekeeping end of things.
Stay tuned for an update to discuss the public health side of the numbers we see daily. 🙂
The following letter is a reprint State Health Commissioner’s Treatment of COVID-19 Letter sent to Clinicians on March 25th:
Treatment of COVID-19
March 25, 2020
Dear Colleague:
In the most recent days, there has been a surge in demand of potential treatments for COVID-19 for drugs commonly used to treat malaria, lupus, rheumatoid arthritis, HIV, bacterial infections and other conditions. This is leading to an inadequate medication supply for patients already taking these medications for chronic conditions and hospitalized COVID-19 patients being treated with these medications under facility-specific treatment protocols while studies are ongoing.
There are currently no antiviral drugs approved by the U.S. Food and Drug Administration (FDA) to treat COVID-19. Some in-vitro or in-vivo studies suggest potential therapeutic activity of some agents against related coronaviruses, but there are no available data from observational studies or randomized controlled trials in humans for the CDC to support recommending any investigational therapeutics for patients with confirmed or suspected COVID-19 at this time.
The Virginia Department of Health in consultation with the Virginia Department of Health Professions recommends the following:
Prescriptions for chloroquine, hydroxychloroquine, mefloquine and azithromycin should be restricted in the outpatient setting and should require a diagnosis “consistent with the evidence for its use.”
Community pharmacists should use professional judgement to determine whether a prescription is valid and that there is a bona fide practitioner-patient relationship prior to dispensing.
Prioritize treatment for continuation of existing medication therapy, inpatient settings, and other indications where there is not an alternative therapy.
Advise against hoarding these medications or stockpiling.
CDC recently released the Coronavirus Self-Checker to help people make decisions about seeking appropriate medical care. This system is not intended for the diagnosis or treatment of COVID-19 or other diseases.
Despite expanding testing to more private laboratories and increasing capacity at participating laboratories, the demand for testing far
CDC is aggressively responding to the global outbreak of COVID-19 and community spread in the U.S.
exceeds the supply. Public health testing at Virginia’s state laboratory, the Division of Consolidated Laboratory Services (DCLS), is reserved for symptomatic people who meet the recently updated VDH priority investigation criteria.
To expedite approval for public health testing at DCLS, VDH developed an online COVID-19 Testing Request Form for healthcare personnel (HCP). After submitting the request, HCP will receive an email confirming receipt. VDH staff will monitor this system Monday through Sunday from 9 am to 5 pm and will provide a testing approval decision within three hours for requests received during this period. If the patient is being discharged in the meantime, you may proceed with specimen collection. VDH approval is not required to collect a specimen.
For COVID-19 testing at DCLS, collect one nasopharyngeal swab in viral transport media. Updated instructions are available on the DCLS website. Do not ship specimens without prior VDH approval.
For patients being tested at a laboratory other than DCLS, contact the laboratory for details about testing availability and instructions. VDH approval is not required for testing at these labs.
Regardless of testing status, please provide this VDH patient handout for people with confirmed or suspected COVID-19 who are being discharged. It is critical to instruct all those with suspected or confirmed COVID-19 to stay home, even if symptoms are mild, unless in-person medical evaluation and care are required.
Virginia’s local health departments do not provide primary care and thus are not equipped to clinically evaluate patients with respiratory symptoms. Please do not refer your patients to a local health department for testing.
A positive COVID-19 test result from DCLS or another laboratory is considered confirmed for case counting purposes. Confirmatory testing at CDC or another lab will not be performed.
The following post is a reprint of an article from Duke Antimicrobial Stewardship Outreach Network a (Duke Antimicrobial Stewardship Outreach Network, 2020)
Should non-steroidal anti-inflammatory drugs (NSAIDS) be administered to patients who have COVID-19?
On March 11, a correspondence published in Lancet Respiratory Medicine suggested theoretical harm related to the use of angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), thiazolidinediones, and nonsteroidal anti-inflammatory drugs (NSAIDs) for patients with COVID-2 infections. This theory was based on the ability of these agents to increase angiotensin-converting enzyme 2 (ACE2) expression. Coronaviruses, such as COVID-19, bind to their target cells through ACE2, which is expressed in lung, kidney, intestine, and blood vessel epithelial cells. The authors suggested that increasing ACE2 may lead to more severe disease, citing that patients who had presented in previous studies with severe disease were likely on ACEi or ARB therapy for their noted co-morbidities.1
After this article was published, the health minister of France tweeted on this topic and several media outlets picked up the story. Physicians in the United Kingdom began to weigh in and favor the use of paracetamol (acetaminophen) over ibuprofen for COVID-19 patients in a news article published in the British Medical Journal.2 On March 17, the National Health Service England (NHS) released a statement that there “appears to be no evidence that NSAIDs increase the chance of acquiring COVID-19” and that providers may use “paracetamol in preference of NSAIDS” in patients who have confirmed or suspected COVID-19 until additional information is available on this topic. The NHS further clarified that patients who are receiving NSAIDs for other medical reasons should continue therapy.3
At this time, there are no publicly presented or published data or clinical trials that support the hypothesis that NSAIDs increase the risk of serious complications from COVID-19 or place patients at increased risk of contracting the virus. In addition, the European Society of Cardiology, in conjunction with the American Heart Association (AHA), American College of Cardiology (ACC), and Heart Failure Society of America (HFSA) have issues statements urging providers to continue ACEi and ARBs, despite similar theoretical concerns related to the ability of these drugs to increase ACE2 expression.4-5
Reviewed on 3/18/20.
References:
a. Duke Antimicrobial Stewardship Outreach Network. (2020). Should non-steroidal anti-inflammatory drugs (NSAIDS) be administered to patients who have COVID-19?
1. Lei F, et al. Lancet Respir Med 2020; published online Mar 11. DOI:10.1016/PII
2. BMJ 2020;368:m1086. (Published online 17 Mar 2020).
3. Powis S. (NHS England Medical Director). Message for all clinical staff: Anti-inflammatory medications. 17 March 2020. Alert Reference: CEM/CMO/2020/010
4. The European Society of Cardiology Council on Hypertension. Position Statement of the ESC Council on Hypertension on ACE-Inhibitors and Angiotensin Receptor Blockers. 13 Mar 2020.
https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang Accessed 16 March 2020.
5. American Heart Association. HFSA/ACC/AHA statement addresses concerns re: using RAAS antagonists in COVID-19. 17 March 2020.
https://professional.heart.org/professional/ScienceNews/UCM_505836_HFSAACCAHA-statement-addresses-concerns-re-using-RAAS-antagonists-in-COVID-19.jsp
What you need to know about coronavirus disease 2019 (COVID-19)
A few of you have submitted questions about the recent statements in azithromycin and Plaquenil (hydroxychloroquine).
Please note that some of what is stated below is my personal opinion and not formal guidance. I have included source links where applicable and, as always, encourage you to continue to use the CDC and VDH guidance to help in your planning.
To begin, the CDC has posted an update on treatment options for COVID19, the disease caused by the 2019 novel Coronavirus, also known as SARS-CoV-2. Terminology can be confusing!
I acknowledge that even some of the medical community may have
Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission
underestimated the potential for this virus to wreak havoc as it has. In an attempt to find a balance between appropriate precautions and offering reassurance, new statements like, “it’s just like the flu,” were made by many. That statement concerned me because it showed how quickly history was forgotten. The flu of 1918 devastated the world, if you may recall. ***
There was an interesting editorial from 2018 regarding lessons learned. We have certainly made a great deal of progress. Still, these words were kind of chilling because many in the industry already knew this to be true: “Despite improvements since 1918, governments and health care systems remain inadequately prepared for the impact of a 1918-like severe influenza pandemic.”
That said, I strongly encourage people, whether you’re “at risk” or not, to embrace the recommendations for social distancing and aggressive handwashing. We are now starting to see what most HCW have said all along: we are ALL at risk! Even if you are young, you might still become very ill. An ER colleague of mine told me of a 36-year-old being placed on life support despite social smoking being his only risk factor. This is not meant to frighten you, but rather to remember that anyone can be the exception to the rule.
The District of Columbia reported cases in children over the weekend and several new cases under the age of 60. The DMV region is seeing increasing case numbers, which we partially expect because there are more testing sites. However, we also see more deaths.
Going back to the original question:
The results of the French study on azithromycin and hydroxychloroquine are publicly accessible here.
It’s certainly encouraging. My concerns lie in the fact that:
1. Much of the general population may not realize this is for treatment only. From the original French study, which was, to me, well designed, “we, therefore, recommend that COVID-19 patients be treated with hydroxychloroquine and azithromycin to cure their infection and to limit the transmission of the virus to other people to curb the spread of COVID-19 in the world. Further works are also warranted to determine if these compounds could be useful as chemoprophylaxis to prevent the transmission of the virus.”
There are chemoprophylaxis trials submitted for review – see clinicaltrials.gov (tables are listed below) or the shortlist at the end of this document. Still, some of these are not even recruiting participants yet and would not start till May, probably. The studies done to date in other countries are relatively small.
2. I don’t expect the general population to know the difference between chloroquine and hydroxychloroquine. They are not the same. Both possess a lot of side effects. The first part of the Hippocratic oath is to first, do no harm—these drugs, especially when mixed w azithromycin, put some people at risk for fatal arrhythmias. Caution is advised, and thus these drugs shouldn’t be used indiscriminately. But yes, they can be used safely for long term use, so I was glad to see the drugs being studied are ones with which we are already familiar. The danger in that is what I heard happening in other nations. People were trying to self-administer to the point the Nigerian govt had to issue public service announcements about it.
Plaquenil has a better safety profile than chloroquine, but we have already been seeing shortages. That becomes a bigger issue when understanding that this is a maintenance drug for patients with lupus. We don’t write Plaquenil for “just bad arthritis.” Lupus is an autoimmune disorder that already puts those patients at risk for infection. If they do not have access to their maintenance drug, they will be more likely to flare.
If you think getting a mask is difficult, imagine what providers are going through with these drugs, and this is just the beginning!
Speaking of masks… don’t forget that hospitals are already low or even out of masks, and while there has been encouragement by many to simply reuse the masks, most of my hospital colleagues have said their systems are not permitting reuse of masks because it increases the risk for self-contamination, and also surgical masks can lose their efficacy if they are wet or soiled with debris.***
I saw several studies from the past few years investigating self-contamination when the public wears a mask and also when masks are reused. That said, PLEASE be careful and follow the CDC guidance if you are using/reusing a mask. And please consider donating your supplies to a hospital if you have a surplus. Ideally, people should be socially distancing and not requiring masks as much.
An excerpt on the appropriate use of masks:
• Replace the face mask between each patient/situation/procedure or after 2–6 h if you are with the same patient or when it is wet on the inside. Avoid changing the mask if this can cause more contamination and risk, for instance, during surgery. Surgical masks are usually not changed during surgery.
• Never go with a face mask under the chin or around your neck! It is usually heavily contaminated by mouth and nose secretion after use and by splatter from the patient.
Finally, please understand that, as of now, I would not be treating COVID19 outside a hospital setting as we simply do not have the resources to do this safely, specifically testing materials and isolation materials. We also don’t have negative pressure to isolate a COVID19 patient from the rest of the patients. Like the rest of the population, I await further guidance on the next steps in the outbreak.
This is certainly an exciting time in medicine! We are cautiously optimistic about evolving treatment options. Please note that, as is the case with many things, prevention is the best approach. While we may debate about whether action should have been taken sooner or whether it’s already too restrictive, I want to encourage you all to work together as a community to help limit the spread of this illness by using common sense guidance that we have already heard: Wash your hands, don’t touch your face, and socially distance. We are finding a new mantra; it seems!
Please continue to stay safe and healthy!
With warm wishes from all of us here at EHPVA,
Dr. Kanal
*** These are the deeper cuts – the articles for those exceptionally curious folks out there who are interested in the policy side.
There was an interesting editorial from 2018 regarding lessons learned. We have certainly made a great deal of progress. Still, these words were kind of chilling because many in the industry already knew this to be true: “Despite improvements since 1918, governments and health care systems remain inadequately prepared for the impact of a 1918-like severe influenza pandemic. ”
The supply shortage isn’t a new issue, as journals have previously commented on the inappropriate use of masks and public perception potential leading to shortages. This Article is from 2016.
As of 3/17/2020, EHP has moved primarily to telemedicine visits for anything routine. Please refer
to the FAQ from our 3/17/2020 update to get more information on how this process works.
To limit exposure of patients and staff, EHPVA will be operating under limited office hours.
Dr. Kanal will be in-office, with those reduced office hours dedicated to patients who require a physical evaluation (this does
Share these facts about COVID-19
not include routine physical examinations or follow-ups.)
Dr. Kanal will be triaging patients, and the office will personally advise if you need to be seen in the office.
Kindly refer to the CDC guidance on “What to do if you are sick”before coming to the clinic. This source has been updated with a convenient self-assessment survey that may also help your answer your questions quickly.
Remember, you will protect both yourself and those around you by avoiding unnecessary community exposure.
We are answering messages as quickly as possible to help you be evaluated most safely and expeditiously. To facilitate this, we request that you avoid contacting the office multiple times for the same issue if it is something that is not time-sensitive
Again, the first and best advice is to avoid unnecessary social gatherings, to wash your hands frequently, and to avoid touching your face, eyes, or mouth.
For more State and Federal information on the Coronavirus, visit the links below:
I have been in contact with the local health department. They are not referring patients to their PCP for COVID-19 testing. Though commercial tests are being generated, these are only in limited supply. We do not have these tests available for mass testing. Please contact us to be evaluated by phone if you have flu-like symptoms so we can guide you for appropriate flu testing and any additional testing as indicated. Per the 3/9/20 update from CDC,”
Stop the spread of germs!
Mildly ill patients should be encouraged to stay home and contact their healthcare provider by phone for guidance about clinical management. Patients who have severe symptoms, such as difficulty breathing, should seek care immediately. Older patients and individuals who have underlying medical conditions or are immunocompromised should contact their physician early in the course of even mild illness.”
If asked to come in for evaluation, please wait outside to be given a mask before entering to protect the other patients. Face masks are now considered acceptable due to supply shortages. Please refer to the CDC and VDH pages as they will be updating recommendations frequently due to the dynamic nature of COVID-19.
We wish you all safety and health during this time!