By Gregory R. Wise, MD, FACEP, Editor in Chief

In a recent survey of 500 primary care physicians (PCPs), nearly half had no capacity to test patients for COVID-19, more than one-fifth reported a severe impact on their practice, and another 30% reported the strain as “close to severe.” Many practices had been affected by being overwhelmed by patients’ virtual questions, a lack of supplies, and clinicians out of work because of illness or self-quarantine.¹

Diagnosis

PCPs often are the first to communicate with potential COVID-19 patients. Without definitive testing, it is challenging to reliably be able to provide an accurate differential diagnosis, but there is a developing list of signs and symptoms associated with COVID-19. Unfortunately, this list is quite broad, nonspecific, and variable. The most common symptoms have been fever, cough, fatigue, sputum production, shortness of breath, sore throat, and headache.^2,3 Other presentations include anosmia and dysgeusia, as well as gastrointestinal symptoms, such abdominal pain and diarrhea.⁴

Typically, shortness of breath, chest pressure, and hypoxia come on later, but sometimes can develop quite rapidly, resulting in the need for urgent hospitalization and ventilator support. Early in the pandemic, PCPs did not have ready access to testing for their patients. Now, increasing access, with more rapid turnaround times, helps with the accurate identification of patients and the promotion of effective self-quarantining. The PCP should be familiar with the local testing sites for referral and needs to provide an order in harmony with currently evolving guidelines.

Prognosis

It is well recognized now that the risk of serious morbidity and mortality is linked to underlying conditions, such as advanced age, hypertension, diabetes, kidney disease, smoking, cardiovascular disease, lung disease, and cancer.⁵ Death rates are difficult to calculate accurately as a result of inadequate testing, but reports have ranged from 1% to 12%.⁶ It is also becoming clear that men and African-Americans are disproportionately showing higher mortality rates.⁷

Treatment

Although there currently is no approved treatment for COVID-19, four areas of research show promise: antivirals, convalescent sera, monoclonal antibodies, and vaccine. Antivirals now being studied include the RNA polymerase inhibitor remdesivir, lopinavir/ritonavir, favipiravir, hydroxychloroquine, and chloroquine.⁸

Unfortunately, a recent study employing lopinavir-ritonavir did not significantly advance clinical improvement, reduce mortality, or diminish throat viral RNA detectability in patients with serious COVID-19.⁹

An encouraging Australian study of the Food and Drug Administration-approved antiparasitic drug ivermectin has shown it to have broad-spectrum antiviral activity in vitro, resulting in a 5,000-fold reduction of SARS-CoV-2 viral RNA at 48 hours.¹⁰

N-acetylcysteine has been investigated in improving cell immunity and attenuation of influenza, and investigational trials are underway to aid in treating acute respiratory distress syndrome.¹¹ Patients in the United States already have been treated with convalescent sera with encouraging results. Vaccine development is well underway but is not expected to be available in 2020.

Telemedicine

Telemedicine for PCPs has exploded because of the pandemic’s need for social distancing whenever possible. The Centers for Medicare & Medicaid Services has provided a Medicare fact sheet for coverage and payment, as have many other third-party payers.¹² This technology comes with advantages and shortcomings. Like a virtual house call, often for the first time the PCP can see the patients and household members in their homes and can observe living conditions and environments that could not be easily assessed with an office visit. With videoconferencing, the physician can maintain eye contact, whereas in the office there often has been the distracting challenge of looking at the patient while entering data into the electronic medical record. Be alert to the increased risk of domestic violence for partners who are sheltering in place. Address control of modifiable comorbid conditions, such as diabetes and hypertension. Reinforce the benefit of social distancing and basic principles of hygiene. Look for developing or worsening anxiety and depression. General nutritional and immune-boosting recommendations that are inexpensive and reasonably safe when used judiciously might include the use of vitamin C, zinc, selenium, and multivitamins.¹³

Although not a substitute for the established public health initiatives, patients often want to do something. The PCP’s role also should help screen questions from patients regarding the proliferating scams and internet “cures.” Encourage those who have recovered to donate plasma.

Advance Directives

PCPs always have been encouraged to be proactive in addressing end-of-life issues with patients, but this might be a particularly appropriate time to be aware of patients’ wishes and be sure they have discussed advance directives and durable power of attorney for healthcare decisions with their families. This need has been highlighted by heartbreaking stories of spouses separated at the emergency department because of strict visitation limitations and not being able to see or communicate with their loved one as he or she progresses through respiratory collapse, ventilator support, and death. The risk of mortality increases with the duration of ventilator use.

Mitigation Measures

Telemedicine is a good opportunity to reinforce the adherence to public health measures, such as social distancing, disinfection of surfaces, frequent handwashing with soap and water for 20 seconds, and the use of cloth masks when outside the home with potential close contact with others. Social distancing is stressful, particularly for older patients who are unable to visit children and grandchildren. State and national guidelines will be reduced at some point, but that will not mean the risk of infection and its complications will plummet to zero, particularly for patients with underlying conditions, especially if the infection resurfaces in the fall.

Keeping Perspective

A widely circulating worst-case scenario by the Coronavirus Task Force projected up to 240,000 deaths in the United States by August, assuming perfect social distancing practices. There are 60 million Americans over the age of 65 years. Even if all the deaths occurred in this high-risk age group, that would be an overall fatality rate of “only” 0.4%. Alarming and tragic indeed, but not the bubonic plague. Fortunately, updated models are showing much lower death projections, presumably based on the effectiveness of mitigation measures.

Like every other pandemic, this one will end. America may look and behave very differently, but hopefully be better prepared for the next one. PCPs may be much more likely to be on the frontlines in that one.

REFERENCES

1. Primary Care Collaborative. Primary Care & COVID-19: Week 1 Survey. Published March 19, 2020. https://www.pcpcc.org/2020/03/19/primary-care-covid-19-week-1-survey
2. Wu D, Wu T, Liu Q, Yang Z. The SARS-CoV-2 outbreak: What we know. Int J Infect Dis 2020; March 11. [Online ahead of print]. doi:10.1016/j.ijid.2020.03.004
3. Guo YR, Cao QD, Hong ZS, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak – An update on the status. Mil Med Res 2020;7:11.
4. American Academy of Otolaryngology-Head and Neck Surgery. AAO-HNS: Anosmia, Hyposmia, and Dysgeusia Symptoms of Coronavirus Disease. Published March 22, 2020. https://www.entnet.org/content/aao-hns-anosmia-hyposmia-and-dysgeusia-symptoms-coronavirus-disease
5. Emami A, Javanmardi F, Pirbonyeh N, Akbari A. Prevalence of underlying diseases in hospitalized patients with COVID-19: A systematic review and meta-analysis. Arch Acad Emerg Med 2020;8:e35.
6. Mizumoto K, Chowell G. Estimating risk for death from 2019 novel coronavirus disease, China, January-February 2020. Emerg Infect Dis 2020: March 13. [Online ahead of print]. doi: 10.3201/eid2606.200233
7. Garg S, Kim L, Whitaker M, et al. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 – COVID-NET, 14 states, March 1-30, 2020. MMWR Morb Mortal Wkly Rep 2020; April 8. [Online ahead of print]. doi: http://dx.doi.org/10.15585/mmwr.mm6915e3
8. Fauci A, Lane HC, Redfield RR. Covid-19 — Navigating the uncharted. N Engl J Med 2020;382:1268-1269.
9. Cao B, Wang Y, Wen D, et al. A trial of lopinavir-ritonavir in adults hospitalized with severe Covid-19. N Engl J Med 2020; March 18. [Online ahead of print]. doi: 10.1056/NEJMoa2001282
10. Caly L, Druce JD, Catton MG, et al. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antiviral Res 2020; April 3. [Online ahead of print]. doi: 10.1016/j.antiviral.2020.104787
11. De Flora S, Grassi C, Carati L. Attenuation of influenza-like symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment. Eur Respir J 1997;10:1535-1541.
12. Centers for Medicare & Medicaid Services. Medicare Telemedicine Health Care Provider Fact Sheet. Published March 17, 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
13. National Institutes of Health. Office of Dietary Supplements. Vitamin C Fact Sheet for Health Professionals. https://ods.od.nih.gov/factsheets/VitaminC-HealthProfessional/