Rachael Zimlich, RN, BSN

Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

The primary care office has turned into the front line in the war against the novel coronavirus (COVID-19) racing across the globe.

As patients-some sick, others worried but well, and still others chronic patients with acute concerns-all turn to their primary care physicians, personal protective equipment (PPE) supplies dwindle and staffing gets tighter. Clinicians are being asked to provide telemedicine in lieu of office visits-in some cases without the proper infrastructure or reimbursement.

As the battle against this virus rages on and Americans are increasingly confined to their homes to 

, physicians and other healthcare workers may feel as though they are fighting alone. But help is available.

While state governments scramble to piece together a national strategy against 

national health leadership calls a failed response

, physician and healthcare organizations aren’t wasting time developing guidelines and best practices as best they can on this developing pandemic.

The American Academy of Family Physicians (AAFP) began making preparations weeks ago when the first case hit our shores. The result is 

 that is updated often with the latest guidance on testing, resources, advocacy, 

. AAFP has also offered advice on how to navigate new telehealth rules and procedure codes for testing. The 

Telehealth, developed and championed across healthcare over the last several years, is being leaned on to stem the rush of patients seeking help, but hadn’t really taken root in most health systems prior to this pandemic.

This could change all of that, says Gary L. LeRoy, MD, FAAFP, a practicing family physician in Dayton, Ohio, and president of the AAFP.

“We have had a patient portal for quite some time, but it hasn’t gotten much traction at all,” he says. “With COVID, patients are going to see the value of using these elements of telemedicine.”

LeRoy spoke to Medical Economics as he reviewed his own patient schedule, determining which appointments could be rescheduled and which patients would still need to be seen-either remotely or in the office.

“The real intention is to thin out the people who would be sitting in the waiting area,” LeRoy says. “Telemedicine is an evolved tool that has been under-utilized. Now I think we have good reason to dust it off and amplify what it has the capability of doing.”

An established relationship with a physician helps make telemedicine work, but in times like these, it can protect sick and well patients, in addition to clinicians and medical resources. Primary care is home to so many patients, and primary care physicians are who patients will turn to first for guidance and treatment.

“It’s going to get much more challenging,” LeRoy says. “We are on the leading edge of this whole thing in the United States. There is a concern from the medical community in primary care and family medicine that we are on the front line of care for these patients. There’s a trusted relationship, so we know they’re going to come to us first with those symptoms. It’s important to know the process works, and how to triage our patients and protect ourselves.”

This involves testing with prudence-many practices didn’t have tests until recently, have limited amounts, or are still waiting-setting up designated areas for suspected cases, and knowing the local resources that are available outside your immediate practice, LeRoy says. It also means protecting supplies of personal protective equipment. While some larger health systems worked to stock up in anticipation of this crisis, there likely won’t be adequate supplies in many areas for a long-term pandemic, and in some smaller practices these supplies are seldom used and not kept on-hand.

“It’s about getting the PPE out there in the hands of the people who are on the front line of healthcare that are in need, or who need the test kits or information about how well things are going, and realizing also that one size does not fit all as far as each community,” LeRoy says.

That’s especially true in the South Bronx, where Sarah C. Nosal, MD, FAAFP, works as a family physician and has seen roughly half of her patients-primarily low-income patients with chronic disease-with respiratory symptoms that are suspect for COVID.

“We already have some of the worst health outcomes that we’re really trying to fight and battle against. Two weeks ago, we knew something was coming. Monday, we were seeing what was happening around the world. By Thursday, we saw many patients sick with illness like we hadn’t seen before, and we have no tests,” Nosal says.

Only patients who met CDC screening criteria could be tested and were often directed to off-site testing centers. Nosal says this is a mistake. She says she worries about her disadvantaged and minority patients getting the appropriate care and testing. In her practice, she knows who recently had pneumonia or who is recently hospitalized. She knows who is high risk among her patients.

“I worry that my patients won’t have access or won’t be assessed properly,” she says. “It’s really hard to be a clinician. We sort of have a really realistic view of this situation. It’s already out of the bag-we’re just trying to slow the spread, and we don’t have proper equipment or testing.”

Nosal says her practice and the hospital partners in the area are all running low on masks and gowns already.

“People are reusing their masks, but there isn’t enough even then. It’s not going to sustain. And the cost for a private office is insurmountable from our normal cost of supplies,” she says. “We’re going through in a day what we went through during the whole flu season up until now.”

There are barriers to telehealth at smaller practices that haven’t had the infrastructure, reimbursement, and resources to develop these systems, she adds. Add to that the disadvantaged patient population that really requires a positive test result to change behaviors in most cases.

“If someone knows for sure they are positive, I think they make different decisions,” she says, adding that it’s difficult to choose between self-quarantine and food on the table without a positive result. “We need rampant testing. We want family doctors and community health to work together to liberate testing guidelines. Test everyone with symptoms and known exposures. That’s how we can stop this disease and really flatten the curve.”

It’s about doing what it takes to provide care in any way to patients right now, be it over the phone or video chat, and fighting for reimbursement later, she says. It’s also about considering the burden practices will face in the aftermath-in losing the volume of visits that keep practices afloat regularly while dealing with the crisis. And it’s about keeping clinicians safe in order to do no harm to patients-allowing immune-compromised and high-risk caregivers to stay home-and still having the staff to provide effective care.

When and where this will end is anyone’s guess, LeRoy says. It will certainly look worse before it looks better, with numbers increasing as testing ramps up. Whether increased numbers reflect an uptick in cases or better surveillance, or whether our efforts to flatten the curve our enough will remain a question for some time, he adds.

“We don’t know what we don’t know yet, as a nation,” LeRoy says.

All we can do, he says, is learn from the countries hit with this before us and try not to make the mistakes that have already been made.

“We have the technology to see around the world what’s happening,” he says. “We don’t have to make those mistakes that have been made in the past. We can be more proactive with it.”

Articles

As the battle against the COVID-19 virus rages on, physicians and other healthcare workers may feel as though they are fighting alone. But help is available.

Physician practices on front lines of coronavirus fight

The flu season is officially underway and, while an unexpected virus is taking center stage, treatments have been a good match so far for this year’s circulating viruses.

the Centers for Disease Control and Prevention (CDC)

, all regions of the country are now seeing flu activity-typical as the flu season typically peaks between December and March-with the highest level of activity occurring in the southern part of the country. What’s not typical, however, is the predominant circulating virus. CDC reports that most flu activity so far has been caused by Influenza B/Victoria viruses, which typically make an appearance later in the season. However, Influenza A (H1N1) is increasing in proportion in some regions, CDC notes.

“Nationally, flu activity has been elevated … and continues to increase; this represents somewhat of an early start to the U.S. flu season,” said Scott Pauley, a press officer for CDC. “Flu activity is currently being caused mostly by influenza B/Victoria viruses, followed by H1N1 viruses and H3N2 viruses. It is unusual for there to be this much influenza B activity at this time of year.”

According to CDC, 4.6 million flu cases have been diagnosed so far this year-up from 2.6 million in early December. This is a high number for so early in the season, but not yet at epidemic proportions. These flu cases have resulted in roughly 39,000 hospitalizations and 2,100 deaths from flu, according to CDC. Data indicates that roughly 70 percent of the current flu cases are Influenza B and about 30 percent have been caused by Influenza A.

Pauley stresses that it’s not too late to be vaccinated against the flu, and adds that antiviral medications have been working well against these circulating strains.

“It’s not too late to get vaccinated, but it’s also important to remember that flu antivirals drugs can treat flu illness and should be given as early as possible to people who are very sick and those with flu symptoms who are at high risk of severe flu illness like pregnant women, young children, older people and people with certain long-term health conditions,” Pauley said. “The vast majority of tested viruses this season remain susceptible to the CDC recommended influenza antiviral drugs.”

Paley also added that this has been a highly successful year for flu vaccination, with 170.3 million doses of the flu vaccine distributed across the U.S.

“This is the highest number of seasonal vaccine doses distributed in the U.S. in a single season,” Pauley said. “There’s not been any issues with the supply of the flu vaccine reported to us at this time.”

CDC will not be able to make any statements on the overall efficacy of the flu vaccine, however, until after the season has concluded.

Public health officials are hopeful a record number of flu vaccines can help stave off epidemic levels.

Influenza B leading the charge in 2020 flu season

A previously overlooked antibody may offer the key to more effective flu vaccines, according to a new report.

, detailed the almost accidental discovery of an antibody that could boost flu vaccine efficacy. According to the report, flu vaccines are currently developed to stimulate the body's creation of antibodies against hemagglutinin (HA). Hemagglutinin is a surface protein on the flu virus, but this protein often mutates with the evolution of flu viruses, requiring revaccination with seasonal flu vaccines each year.

In this study, however, researchers investigated a different surface protein, neuraminidase (NA), which doesn't mutate as often as hemagglutinin protein. Previous research has indicated that antibodies impacting neuraminidase proteins may offer broader protection against different flu strains, leading to better protection and less severe illness for patients who still become infected by the flu virus after vaccination. Researchers note that the mechanism behind this is similar to that of Tamiflu, which works by inactivating neuraminidase.

Florian Krammer, PhD, a professor of vaccinology at the Icahn School of Medicine at Mount Sinai, says neuraminidase has been overlooked in the past, but this study shows that it has significant potential.

"These antibodies guide us to a region of the virus that is conserved and a target for protective immune responses," Krammer says. "We can now try to develop vaccination strategies to specifically target this region."

The research team began testing how various monoclonal antibodies bound to neuraminidase after it was noticed as part of a separate study that a patient infected with the H3N2 influenza strain was developing antibodies to a protein other than hemagglutinin. Forty-five monoclonal antibodies were studied by the team, and three were found to bind to the neuraminidase protein on the H3N2 virus. As the team expanded their investigation, they found that these same three antibodies also bound themselves to the neuraminidase protein on other strains of the flu virus, as well.

One antibody in particular-1G01-bound to neuraminidase on all of the flu viruses tested, according to the report.

The next step for the researchers was to see whether these antibodies could protect against the flu, and if they could be used as a treatment. Mice were used to test the antibodies against both influenza A and B, and the study reveals that the antibodies were successful in protecting the mice against both strains. Even at lethal doses of the influenza virus, the mice were able to survive the infection and recover after treatment with the 1G01 antibodies, the study reveals. The mice were also infected with a lethal dose of the H3N2 virus, and treated with low doses of the antibody days later. All the mice recovered, according to the study.

Krammer says the results of this study offer hope that the antibodies could be used to improve the efficacy of flu vaccines overall.

"The monoclonal antibodies that we discovered could be developed into therapeutics," Krammer says. "We might be able to develop improved vaccines through antibody-guided vaccine design. Both will be valuable tools to protect patients from getting influenza virus infections or improve their outcomes if they are already infected."

While research has only been done in mouse models so far, Krammer says it may be possible to develop therapeutics based on these antibodies in the future. Research teams are actively working on making this happen, but it could take some time, he says.

"Most efforts that are currently underway to develop better influenza virus vaccines focus on the viral hemagglutinin or on internal proteins," Krammer says. "Our work shows that the neurominidase is a very valuable target as well, which might be used to develop broadly protective or universal influenza virus vaccines."

Antibodies that were previously overlooked may hold the key to a better flu vaccine.

Researchers look to antibodies to improve flu vaccines

The ketogenic diet has gained popularity for its weight loss results, and new research indicates that it may also be helpful in fighting the flu.

, researchers at Yale University found that specific diet changes may be effective in helping to fight influenza A infections.

“We found that mice on ketogenic diet were protected from flu because they were able to fortify the airway barrier better. This required a special type of lymphocytes known as gamma delta T cells,” said 

, principal investigator at the Iwasaki Lab at the Yale School of Medicine, Waldemar Von Zedwitz professor of Immunobiology and Molecular, Cellular and Developmental Biology, professor of Molecular Cellular and Developmental Biology, investigator at the Howard Hughes Medical Institute, and co-author of the study. “The keto diet expanded gamma delta T cells, and these cells modified the airway epithelial cells to secrete more mucus, which can trap the virus and protect the host from further spread.”

The discovery was accidental, according to the research team. The study was completed after researchers working on another project found that a ketogenic diet blocked the formation of immune system activators called inflammasomes, which can result in harmful immune responses. That discovery made researchers wonder what other immune responses might be impacted by the popular keto diet.

Immune responses are key to fighting infections, and for this project, mice in the study group were fed high-fat, low-carbohydrate ketogenic diets, while mice in the control group were fed high carbohydrate diets. The mice in the ketogenic group were found to have an expansion of gamma delta T cells in the lung, which improved barrier function against the flu.

In other words, the ketogenic diet was believed to activate certain immune cells that were previously not associated with the immune response to the flu, according to the research team. This response resulted in increased mucous production within the airway, which can help to trap the flu virus. Additionally, the research team found that when mice bred without coding for gamma delta T cells, a ketogenic diet offered no protection against influenza A.

Iwasaki said the studies have only been in mice so far, and additional research is needed to see if similar pathways would be activated in humans. There have also been criticisms of the 

, which historically has been used as a medical diet under the watch of a physician because of the risks it includes. Iwasaki said there are no plans yet to make any clinical recommendations in relation to the team’s discovery.

“We first need to know whether people on ketogenic diet have similar changes in the lung,” she said. “Without such data, it is not possible to recommend any changes in clinical practice.”

New research shows that a ketogenic diet may help activate new immune responses that can help fight influenza A.

Author | Rachael Zimlich, RN, BSN

Articles

Physician practices on front lines of coronavirus fight

Influenza B leading the charge in 2020 flu season

Researchers look to antibodies to improve flu vaccines

Can a keto diet help fight the flu?