As the novel coronavirus or COVID-19 continues to spread throughout the U.S. and throughout the world, elderly and immunocompromised or immunodeficient patients can be at high risk to be hard hit from the effects, including severe respiratory syndrome and a cytokine storm involving the liver, kidneys and GI tract.
In a recent webinar hosted by Harvard Medical School, which was led by J. Kevin Tucker, MD, chief of nephrology at Brigham and Women's/Faulkner Hospital, faculty director of accreditation and maintenance of certification for Harvard Medical School Postgraduate Medical Education, and assistant professor of medicine at HMS, four leading clinical experts from institutions across the country shared insights gleaned from their experiences working with some of the highest-risk groups to help guide other health care professionals. The views and perspectives shared in this article are based on information from a webinar recorded on March 24, 2020. It has been edited and condensed for clarity and accuracy.
COVID-19 in the Dialysis Population
Dialysis patients are particularly vulnerable to the risk of COVID-19, according to Suzanne Watnick, MD, Chief Medical Officer at Northwest Kidney Centers in Seattle, Washington, where the first recorded person in the U.S. to die of complications related to COVID-19 had been receiving dialysis.
She points out that now every patient—both going on and also coming off dialysis—and every staff member coming into a Northwest Kidney Centers’ facility is screened for fever, new shortness of breath, new cough and sore throat. She stresses that the concept of new for these symptoms is a very important distinction in this population, since many of the patients typically have cough and shortness of breath related to fluid overload when they come for dialysis.
Responding to Positive Screens
“If patients screen positive for any of those symptoms, they're immediately masked and put into a private room [currently available in most of the facilities] or [are placed] at the end of a row,” Watnick says. “We are urging everyone [even with symptoms] to still come to dialysis rather than going to the emergency room,” she says.
Since personal protective equipment—including facemask, eye protection and gloves—is limited, she adds that it is currently only being used for symptomatic staff and patients.
Screening and Cleaning
If any staff member—including dialysis nurses, dialysis technicians, social workers and dieticians—has a new symptom, they must immediately cease working and be tested. If they test negative, they are able to come back to work after they are afebrile and have no symptoms for 24 hours. If they test positive, or if they are not tested due to lack of supplies, Watnick says they must wait 14 days and 72 hours after marked improvement, whichever comes last before returning to work.
For cleaning, the facility uses a hydrogen peroxide cleanser and is now paying particular attention to high-touch areas, including rails on the scale, doorknobs in the bathroom, the surfaces in the waiting room and armrests on the wheelchairs.
Addressing COVID-19 in the Elderly
Elderly patients are also at high risk for COVID-19. This is because this population often has multiple comorbidities, such as heart failure, chronic kidney disease, COPD, dementia, interrelated changes in organ physiology and relative immunosuppression due to aging and polypharmacy—taking multiple medications at once—explains Jeremy D. Whyman, MD, who works in Geriatric Medicine, Hospice and Palliative Medicine and Primary Care at Beth Israel Deaconess Medical Center. Yet, he points out it’s important to remember that not all older patients are the same, and frailty needs to be assessed as part of the equation.
“There's a clinical frailty scale that is easily accessible online and can help identify patients who are frail and [quantify] the degree of their frailty. It's a scientific and heavily objective measure that helps put together a patient's comorbidities, their functional status, their energy and strength, to help assess prognosis,” Whyman says.
This can help to understand how a person experiencing an acute illness may respond to a severe stressor. “Specifically thinking about COVID-19, we know that the elderly have age-related changes in many of their organs, and this is inclusive of lung tissue and physiology that makes people’s lungs more susceptible to damage by severe infection as they age,” he says.
Learning from the data
From the data we have so far, “we believe that in both the young and the elderly, the most frequent clinical symptoms seem to be cough, sputum production, significant fatigue and shortness of breath difference,” Whyman says. “We are seeing a lot of chest tightness, which is distinct from what we see in other viral syndromes. We have also seen loss of taste and loss of smell in COVID-19 patients,” he adds.
Whyman also points out that a lot of older patients who present in a clinic or at the hospital are initially afebrile. “The other thing I would say is that we're seeing patients becoming symptomatic, improve and then quickly decompensate.” This is important to watch closely.
COVID-19 Challenges in Skilled Nursing Facilities
The elderly who live in skilled nursing facilities can also be at increased risk for COVID-19. “We have a tremendous amount of frailty in our residential and outpatient congregate living situations,” says Helen Chen, MD, who specializes in Geriatric Medicine and Primary Care at Beth Israel Deaconess Medical.
“We have been closely monitoring what happened on the west coast in long-term care facilities and are learning from their experiences. In addition to the strict droplet precautions that we used for inpatients early on, we started screening all visitors coming into the facility, asking them questions about symptoms and about travel, and checking for temperatures,” Chen says.
With group activities ceased and visitors prohibited now, she says they continue to screen employees and other people that come into the facility—such as food delivery representatives.
Handling positive test results
When any patient tests positive for COVID-19, the way the situation is handled really depends on the resources available.
“I think a lot of facilities simply can't manage the patient within the confines of their building, where they have no ability to isolate that patient, and they're left with the choice of transferring that person to the acute care hospital,” Chen says.
“We have been able to test patients on site without sending them to the ER or to the hospital,” she says, thanks to the local acute care hospitals that have allowed them to be part of their testing program and thanks to the commercial testing labs that have ramped up capacity. This is particularly important for many of the patients in skilled nursing facilities. “Any time one of our frail patients is sent to acute care, we put them at enhanced risk,” she adds.
The Risk of COVID-19 for People with HIV/AIDS
Another vulnerable population is people who live with HIV/AIDS.
“We've seen a really striking uptick in cases, both in the general population and also in our hospital over the last week, which likely reflects the increase in testing as much as the presence of the disease,” says Turner Overton, MD, Professor of Medicine at the University of Alabama at Birmingham. He says that a lot is still unknown about the risks for people with HIV/AIDS.
Co-morbidities and increased risk
“The data that we have thus far highlights certain co-morbidities in HIV/AIDS patients, including hypertension, diabetes and COPD that seem to show risk for increased severity of disease,” he explains.
He points out that the Department of Health and Human Services (DHHS), the World Health Organization and the British HIV Medical Association agree that for patients who are on antiretroviral therapy with a suppressed viral load and a good CD4—T-cell—count, their risk is similar to that of the general population.
On the flip side, individuals with the highest level of immunosuppression are probably at the greatest risk for becoming more seriously ill with COVID-19. “They're not necessarily at higher risk for infection, but should they get infected, their risk for more severe disease is greater,” Overton says.
Exploring HIV/AIDS Medications for COVID-19
The potential of using HIV/AIDs medications and pre-exposure prophylaxis for COVID-19 has been of particular interest to the medical community, although so far these approaches don’t seem to be panning out. “However, there is interest in studying these further,” Overton says.
Risks among other immunocompromised groups
For other immunocompromised patients, such as transplant patients and cancer patients, not much is yet known about their risk since not a lot of data exist yet.
“What I can say is the risk may be similar to that of the geriatric population—the accumulation of comorbidities leaves someone with less reserve, and less resilience, to respond to the disease and so therefore, likely does subject them to a worse outcome,” Overton says. “However, certain immunomodulatory treatments may actually mitigate the severity of disease because it's blunting that inflammatory response,” he adds.
“A lot of people are looking at various molecules to see if these may have activity against different viruses and specifically, against COVID-19,” he says.
This article features four interviews adapted from the Managing Vulnerable Populations and COVID-19 webinar recorded on March 24, 2020.