COVID-19 AND DIABETES: CURRENT AND FUTURE IMPACTS PANELISTS: • Carlos del Rio, MD • Guillermo Umpierrez, MD • Mohammed K. Ali, MD, MSc, MBA • Shivani Agarwal, MD MODERATOR: • K.M. Venkat Narayan, MD, MSc, MBA GCDTR is funded by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institute of Health (P30DK111024)
FRAMING QUESTIONS 1) Are people with diabetes truly at higher risk for COVID-19? If so, why? 2) Are people with diabetes truly at higher risk for COVID-19 complications (hospitalization, ICU admission, ARDS, pneumonia, death)? If so, why? 3) Will COVID increase diabetes disparities? If so, why, and in whom? 4) What are the challenges and solutions for diabetes prevention and care in the COVID era? 5) What specific public health and clinical guidelines are needed for people at risk of or with diabetes to deal with the risk of COVID? 6) What can we learn about COVID and diabetes through global collaboration?
CO COron onaVirus Infec ectiou ous Disease e – 19 19 (COV OVID-19) 19) CARLOS DEL RIO, MD EMORY UNIVERSITY CarlosdelRio7
ACE2 receptors: Lungs Heart GI Kidneys https://www.eurekalert.org/multimedia/pub/226254. php?from=457812. German Primate Center
“Wuhan p pneu eumon onia” Wuhan, a city in central China, is the capital of Hubei province. 31 December 2019: WHO China Country Office was informed of cases of pneumonia of unknown etiology detected in Wuhan. 07 January 2020: Chinese authorities identified a novel coronavirus (2019-nCoV) as the probable causative agent. ◦ Disease now named COVID-19 by WHO ◦ Virus named SARS-CoV-2 (https://www.biorxiv.org/content/10.1101/2020.02.07.937862v1) As of April 3, 2020: > 1,000,000 confirmed cases and > 54,000 deaths ◦ Three cases > 100,000 cases: USA (245,380); Spain (117,710) & Italy (115,242) Human to Human transmission driving the epidemic Significant risk to Healthcare workers
Current Status of the COVID-19 (March 27, 2020) Global case numbers: > 1,000,000 cases & > 54,000 deaths ◦ https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda759 4740fd40299423467b48e9ecf6 ◦ https://www.worldometers.info/coronavirus/ US case numbers: > 245,000 cases and > 6,000 deaths ◦ https://www.cdc.gov/coronavirus/2019-ncov/cases-in-us.html
Expon onen ential g growth….> 6 600,000 cases es The r rapid gr growth th in t the n e number of case ses Took 67 days from the first reported case to reach the first 100,000 cases. Then… - 11 days for the second 100,000 cases - 4 days for the third 100,000 cases - 3 days for the fourth 100, 000 cases - 2 days for the fifth 100,000 cases - 1 day for the sixth 100,000 cases Source: WHO
COVID-19 C 19 CASES I IN N THE HE U U.S. . https://w /www.worldometer ers.info/coronavi virus/country/us/
COVID-19 Cases & deaths per capita by county (as of April 2, 2020) https://public.flourish.studio/visualisation/1759890/
COV OVID-19 C 19 CASES I IN T THE U U.S. https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html#states Per 100,000 Per 100,000 State Cases Deaths Mortality pop pop New York 92,770 472.9 2,653 13.5 2.8% New Jersey 25,590 288.1 539 6.1 2.1% California 10,925 27.9 243 0.6 2.2% Michigan 10,791 108.4 417 4.2 3.8% Louisiana 9,150 196.2 310 6.6 3.3% Florida 9,000 43.7 144 0.7 1.6% Massachusetts 8,966 131.3 154 2.3 1.7% Illinois 7,695 60.0 165 1.3 2.1% Pennsylvania 7,016 54.9 90 0.7 1.3% Washington 6,585 90.3 300 4.1 4.5% Georgia 5,444 52.9 176 1.7 3.2%
COV OVID-19 T Tran ansmission on Respiratory secretions - main mode of transmission ◦ Spread through respiratory droplets in the air and that land on surfaces ◦ Transmission from people ~ 24 – 48 hrs before onset of symptoms occurs Tang JW et al, J Hosp Infect 2006; 64:100-14 . Stool – unlikely to be a source Perinatal – no transmission observed
Clinical Characteristics of COVID-19 Incubation period is ~5 days (range = 2 – 14 days) ~80 % have mild illness (~80%) ◦ fever (83 – 98%) ◦ cough (76 – 82%) ◦ myalgia or fatigue (11 – 44%) ~ 30% of hospitalized patients required intensive care ◦ 5-10% require mechanical ventilation No approved medication ◦ NIH clinical trials have started Supportive care has been very successful for most patients
Risk factors for severe disease Age >55 Elevated D-dimer Underlying pulmonary disease CPK > 2x ULN Cardiovascular disease CRP >100 Hypertension LDH >245 Diabetes Elevated troponin Lymphopenia <0.8 x103cells/minute Immunocompromise (history of transplant, HIV regardless of CD4 count, use of biologics) Platelet count <100 Physical exam findings including RR>24, Ferritin >300 HR>125, oxygen saturation <90% on room air https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext
COVID-19 Mortality
What about ICU and mechanical ventilation? • A machine that helps a patient breathe (ventilate) when he/she cannot breathe on their own for any reason. • 2,704 US hospitals have ICU services (51.4% of all US hospitals) – 74% in metropolitan areas. • There are ~ 96,596 ICU beds in the US (16.7% of all hospital bed) • This is 34.7 per 100,000 population • 25,157 step-down beds & 1,183 burn beds • ICU occupancy rates are ~ 66.6% • US hospitals have ~ 100,000 ventilators and there are ~ 12,700 in the SNS
Testing for COVID-19 Testing by detecting RNA of virus: ◦ Nasopharyngeal swab and Throat swab ◦ Lower respiratory sample if possible Until recently only available at CDC ◦ Now available in all state laboratories Commercial labs (ej: Quest, LabCorp, ViraCor) also performing testing Time from sample acquisition to test result is still longer than desired Supplies and throughput still an issue Still needed: greater ability to obtain testing without coming to hospital or busy clinic
Personal Protective Equipment Gown Gloves N-95 Respirator Face Shield Personal Protective Equipment are Single Use Only Discard after leaving the patient room and perform hand hygiene
Challenges in Infection Prevention In the case of 2019-nCoV, the difficulty in controlling the virus includes: • presence of many mild infections: difficulty in identifying and isolating cases at an early stage • limited resources for isolation of cases and quarantine of their close contacts • Training needed to donning and duffing PPE • Great video from NETEC: https://www.youtube.com/watch?v=bG6zISnenPg
Protective efficiencies: • N95 mask = 89.6% • Surgical mask = 33.3% • Bandana = 11.3% • Dust mask = 6.1% Abaluck, J at al. The Case for Universal Cloth Mask Adoption and Policies to Increase Supply of Medical Masks for Health Workers (April 2, 2020). Available at SSRN: https://ssrn.com/abstract= : • universal mask use could reduce infections by around 10 percent
Non-pharmacologic measures Border screenings/closures Little value at this point Mass gatherings Important to prevent them – may have significant impact on conferences and sporting event In Atlanta the NCAA Basketball final 4 and the Decennial Conference in Infection Prevention Public transportation Potential place for spread School closures Have to be implemented early to have impact Isolation of infected Critically important, need testing to identify those infected!
Goals of Mitigation Strategies • Minimizing morbidity • “Flattening” the epidemic curve to avoid overwhelming healthcare services • Keeping impact on economy manageable • Slowing progression of epidemic to allow for vaccine and other treatment development
Social Distancing “TO LIMIT THE SPREAD IN THE COMMUNITY WE NEED TO SPREAD THE COMMUNITY”
Social Distancing
Impact of social distancing – Mobility Index
The Emory COVID-19 Checker: https://c19check.com Based on the answers to questions about signs and symptoms, age and other medical problems, a person is directed to guidance based on CDC guidelines and is placed into one of three categories: • high risk - needs immediate medical attention, • intermediate risk - can contact their doctor for guidance about how to best manage their illness, • low risk - can most likely administer self-care or recover at home.
Conclusions 1. It is going to get worse before it gets better 2. We need to “prepare for the worst and hope for the best” 3. This is going to be long (3 -4 months) and there will be significant pain. a. We need to protect our healthcare workers but also need to be prepared as some ofour friends, family and colleagues will get infected b. We need to provide psychological support/counseling 4. We can make a difference as persons, society and healthcare system a) Help promote social distancing b) Make sure those sick with fever or respiratory symptoms stay home 5. This too shall pass, how long it lasts is really up to us
The Future Rapid Diagnostic Test Antiviral Therapy? Identification of “Super” spreaders, most efficient transmission routes, period of infectivity, etc. Spectrum of Disease: ◦ asymptomatic transmission Vaccines Understanding why outbreak occurred and prevent from happening again
https://jamanetwork.com/journals/jama/fullarticle/2760782 https://jamanetwork.com/journals/jama/fullarticle/2762510
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