One little 2 little 3 little Pathogens Clay

One little, 2 little, 3 little Pathogens Clay Watson, M. D. Optum Medical Director for CO and UT

Cold, Flu and COVID season • Virus Comparison • Syndrome Comparison • Post-Acute COVID/Long COVID • Flu and Covid co-infection • COVID Vaccine update Flu

D I V O C For

Management of post-acute covid-19 in primary care BMJ 2020; 370 doi: https: //doi. org/10. 1 136/bmj. m 3026 (Published 11 August 2020)Cite this as: BMJ 2020; 370: m 3026

Post-Acute Covid • Approximately 10% of people experience prolonged illness after covid-19 • Many patients recover spontaneously with holistic support, rest, symptomatic treatment, and gradual increase in activity • Defined as syndrome extending beyond 3 -weeks as long as 12 -weeks • Even mild covid-19 may be associated with long term symptoms, most commonly cough, low grade fever, and fatigue, all of which may relapse and remit. • Other reported symptoms include shortness of breath, chest pain, headaches, neurocognitive difficulties, muscle pains and weakness, gastrointestinal upset, rashes, metabolic disruption (such as poor control of diabetes), thromboembolic conditions, and depression and other mental health conditions. • Skin rashes can take many forms including vesicular, maculopapular, urticarial, or chilblain-like lesions on the extremities (so called covid toe).

Post Acute COVID • Cardiopulmonary Complications ~20%-myocarditis, pericarditis, MI, PE, dysrhythmia • “Chest Pain” and breathlessness-CP described as burning or musculoskeletal pain as well as breathlessness which improves with deep breathing exercise • Thromboembolic complications-DVT-PE, anticoag for 10 -30 days postdischarge among high risk • Neurologic-headache, dizzy, brain fog…rare stroke, Sz, encephalitis, cranial neuropathy

The sportsperson returning to exercise (summarised from Stanford-Hall statement 43) • After recovery from mild illness: 1 week of low level stretching and strengthening before targeted cardiovascular sessions • Very mild symptoms: limit activity to slow walking or equivalent. Increase rest periods if symptoms worsen. Avoid high-intensity training • Persistent symptoms (such as fatigue, cough, breathlessness, fever): limit activity to 60% maximum heart rate until 2 -3 weeks after symptoms resolve • Patients who had lymphopenia or required oxygen need respiratory assessment before resuming exercise Barker-Davies RM, O’Sullivan O, Senaratne KPP, et al. The Stanford Hall consensus statement for post-COVID-19 rehabilitation. Br J Sports Med 2020; bjsports-2020 -102596. doi: 10. 1136/bjsports-2020 -102596 pmid: 32475821 • Patients who had cardiac involvement need cardiac

COVID-er Influnza-er

Title: Interactions between SARS-Co. V-2 and Influenza and the impact of coinfection on disease severity: A test negative design 19, 256 people who were tested for both flu and SARS-Co. V-2 from 20 January to 25 April 2020. Analysis by Public Health England

Cold Viruses Respiratory Epithelium COVID Influenza

Candidate Mechanism Sponsor Trial Phase Institution Ad 5 -n. Co. V Recombinant vaccine (adenovirus type 5 vector) Can. Sino Biologics Phase 3 Tongji Hospital; Wuhan, China AZD 1222 Replication-deficient viral vector vaccine (adenovirus from chimpanzees) The University of Oxford; Astra. Zeneca; IQVIA; Serum Institute of India Phase 3 The University of Oxford, the Jenner Institute Corona. Vac Inactivated vaccine (formalin with alum adjuvant) Sinovac Phase 3 Sinovac Research and Development Co. , Ltd. Covaxin Inactivated vaccine Bharat Biotech; National Institute of Virology Phase 3 JNJ-78436735 (formerly Ad 26. COV 2 -S) Non-replicating viral vector Johnson & Johnson Phase 3 Johnson & Johnson No name announced Inactivated vaccine Wuhan Institute of Biological Products; China National Pharmaceutical Group (Sinopharm) Kaiser Permanente Phase 3 Washington Health Research Institute Henan Provincial Center for Phase 3 Disease Control and Prevention NVX-Co. V 2373 Novavax Phase 3 Novavax m. RNA-1273 m. RNA-based vaccine Nanoparticle vaccine Moderna

Summary of Paper • The risk of testing positive for SARS-Co. V-2 was 58% lower among flu positive cases • 58 people with coinfection, among whom the mortality rate was 43. 1% (25) and 80% (20) were aged over 70. • combining ventilator use or death into a composite variable, the odds of death were 6. 43 times greater in people with coinfection than in those with neither virus • The odds of death were 2. 27 times as high (95% confidence interval 1. 23 to 4. 19) as in people with SARS-Co. V-2 alone

What can we do? ? ? • Consistent application of Infection Control • Make sure our patients, providers and staff all have the flu shotdecreases illness and spread • Rapid clinical evaluation and isolation • Please don’t close to providers-CMS guidelines clearly state this is a no no! • Isolate symptomatic patients and test • Influenza treatment and prophylaxis—have the protocol ready • COVID Vaccine when available