How a doctor screened and helped Sacramento coronavirus patient get treatment
After undergoing a second round of testing, the first Sacramento County resident to test positive for the coronavirus now shows no signs of the disease and is ‘recovering well,’ said Dr. Xin-Nong Li, a Sacramento doctor consulting with the patient.
He fielded a call from the Sacramento County resident on Feb. 10, he said, and it didn’t surprise him. It was a conversation he said he had been preparing to have for several weeks. In fact, Li and hundreds of other Chinese American physicians around California have been connecting via the social media platform WeChat to discuss their role in helping to protect their communities, the state and the nation from the spread of new coronavirus, COVID-19.
Via WeChat, Li and other physicians distributed a newsletter to the Chinese American community informing them that if they didn’t have medical insurance or a primary care physician, the doctors would help them contact the U.S. Centers for Disease Control and Prevention to arrange a test for the new coronavirus. Thousands of people shared it.
On Feb. 10, when Li got the call, he learned that the person on the line had returned to the Sacramento area eight days earlier from a visit to China, he said. The caller had developed a low-grade fever and was worried, he said: Could this be the novel coronavirus?
Li said he leaned upon his training to evaluate the case: “As a physician, the first thing we do is get a patient’s medical history. That’s just a general physician’s work. Whether it’s a phone consultation, an office visit or a trip to the emergency room, every physician will do the same. Get the history.”
He said the patient had purchased a very good face mask, an N95 respirator, and had used it throughout the trip except when eating. The N95 face mask is 95 percent effective in stopping airborne particles, experts say, but it is only as effective as the training a person receives in using it.
Traveler followed CDC guidance
On the planes, though, there wasn’t a way to sanitize the bathrooms, and the seating was crowded, the patient told him. When the individual arrived at the airport in California, Li said, CDC screeners provided instructions to those who had traveled to China to wear the N95 masks, to avoid public transportation and to isolate themselves for 14 days in their homes away from other family members and pets.
A close contact had picked up the individual from the airport in a personal car, Li said, and on the way home, the traveler sat in the backseat and continued to wear the mask. Back at home, Li said, the individual remained isolated in a bedroom that had its own bathroom.
The CDC had provided a lengthy lists of do’s and don’ts, Li said, and both the traveler and close contact had studied it and complied with the directions. Among the instructions:
▪ Close contacts should stay away from the person with symptoms as much as possible. Make sure shared spaces have good air flow, near an air conditioner or opened window.
▪ Wear face masks if you’re together in the same room.
▪ Wash hands frequently or use hand sanitizer, Avoid sharing household items such as cups or dishes, towels and bedding.
▪ Clean all “high touch” surfaces: countertops and door handles, phone and computer keyboards; toilets and bathroom fixtures.
▪ People in close contact with those with the virus should monitor their health and should call a health care provider right away if they develop symptoms such as a fever, cough or shortness of breath.
The Bee could find no instructions requiring close contacts to isolate themselves before the individual has been diagnosed with COVID-19. Rather, the CDC recommends that close contacts “help the patient with basic needs in the home and provide support for getting groceries, prescriptions, and other personal needs.”
In this case, prior to the traveler’s diagnosis, a close contact of the individual continued to go to work at the Broadway office of the California Department of Justice, a department memo stated, and that news prompted calls and emails to The Bee from people questioning whether this defeated the purpose of isolating the individual.
Evaluating ‘close contact’ risk
CDC guidelines state that local public health officials will evaluate the close contacts to determine whether they are a risk — low, medium, high or no risk — of getting COVID-19. Dr. Olivia Kasirye, Sacramento County’s public health director, noted her team of nurses and communicable disease investigators do evaluations just like these regularly to contain the spread of diseases such as tuberculosis, bacterial meningitis, measles and syphilis.
“The staff that we have are very well-trained in interviewing or getting the information that is needed,” Kasirye said, “and most people are usually very compliant with that, and actually all of the people that we’ve been dealing with have been very compliant in giving us the information that we need.”
Even if a close contact is living with a person diagnosed with COVID-19 , CDC guidelines state the close contact is at only medium risk if both individuals follow agency instructions on face masks and hygiene.
Once the diagnosis was made, Li said, the close contact left work and started a 14-day quarantine in the home. The traveler diagnosed with the illness had two lab samples taken last week for a second round of tests and those came back negative. In the initial testing, he said, one test came back negative and the other positive.
‘I felt a test is needed’
It can be difficult, though, to get a test done, as Li found out. He called county public health officials to request a test the day he screened the patient, but county public health officials told him that the individual did not meet CDC guidelines for the test.
Li checked in with the patient daily, and he continued to push for the test with the county health department as the individual’s temperature rose to 100 degrees the next day.
“In the beginning, they still insisted that the patient only had one symptom, no cough, only low-grade fever,” Li said, “and they sent me the CDC guidelines showing it’s not the typical symptom they need to test. But ... this patient had really, really self-quarantined at home, so (the patient) had no chance to be infected with the flu or the common cold or something else. Even though this was not typical, I felt a test is needed to confirm whether (the individual) had it.”
A few days later, county officials agreed to do the test, Li said.
“They had their guidelines,” Li said. “The CDC has guidelines, and no one knows the natural characteristics of this virus. In the (health) department, they really, really follow the guidelines. They did their job. I did my job because as a clinician, we have to judge individual clinical information and symptoms. That’s what we call the art of medicine.”
This negotiation might trouble some outside the medical community, but what most people around the region don’t know is that Kasirye’s team has quietly been monitoring hundreds of individuals who may have been exposed to coronavirus in their travels abroad. Statewide, county public health departments have been monitoring thousands of returned travelers, checking in on their health and their compliance. And, if these individuals get ill, health officers are using CDC guidelines to determine who will get tested.
Tracking travelers takes time, resources
Sometimes, Kasirye said, travelers will check in with the public health department, but if they don’t, then her team reaches out to them and sets up a schedule of twice-daily calls. It’s unknown whether the agency had done so with the coronavirus patient in Sacramento County because the department will not discuss individual cases.
The additional workload from coronavirus translates into added costs for public health agencies.
“We definitely have had additional people reassigned to working on infectious disease issues,” Kasirye said. “Usually, we have a core team that deals with the regular diseases that we have reported to us, but in preparation for this, we have had weekly coordination calls. We also provide information to our partners that work with us such as law enforcement, EMS, the hospitals ... and the schools.”
Kasirye said her team has been able to track down travelers because of a long-established system where airlines provide passenger information to the CDC, which in turn shares that with state public health departments. The state then pushes the information out to counties. County public health officials get names, contact information and itineraries.
Professor Catherine Troisi, an epidemiologist with the University of Texas Health Science Center at Houston, said this type of ‘contact tracing’ is delicate, time-intensive work. On the up side, she said, public health workers are trained to handle these conversations, to explain both the import and seriousness of getting tested and following instructions, to ask questions that allow them to trace down contacts. On the down side, she added, not all public health departments have the same financial resources.
“Health departments aren’t sitting around twiddling their thumbs, waiting for something to happen,” Troisi said. “This is taking away from their routine duties and costing a lot of money.”
If need be, Troisi said, public health officers have the legal right to quarantine someone, ‘basically...lock them up,” to keep them from spreading a disease, said Troisi, but it’s a power they have been loathe to use because of public perceptions about such interventions.
The CDC warned Tuesday that U.S. citizens should prepare for a global pandemic that will eventually lead to person-to-person transmission in the U.S. CDC officials said their preparation effort will be widespread, from gauging response readiness of local and state governments, to reaching out to hospitals and health care networks, to marshaling technical assistance and funding for states.
To date, public health officials worldwide have reported 2,798 deaths resulting from the coronavirus, 94 percent of them in mainland China. More than 82,100 cases of the illness have confirmed globally. All but 3,332 of those cases have been in China.
The CDC has reported 60 cases in the United States, 45 of whom were U.S. citizens evacuated from the Diamond Princess cruise ship and Wuhan, China.
To help guard against an outbreak in the United States, Li said, he and other physicians used WeChat to quickly bring together 15 Chinese American associations in a group called Medical Urgency Alliance. Through this group, he said, they are disseminating CDC guidelines and other information in a form that their community can understand. They are stressing the importance of recognizing and reporting symptoms as well as teaching how to prevent the disease.
Li said that, above all else, the Sacramento County patient and close contact wanted to convey that they have done everything they were told would protect the Sacramento community.
How can you protect yourself from new coronavirus?
Keep in mind that public health agencies say the risk of human-to-human transmission in the United States is extremely low. To prevent the spread of COVID-19, they recommend using everyday precautions that people take to prevent cold and flu:
- Wash your hands often with soap and water for at least 20 seconds. If you really can’t get to soap and water, then use a hand sanitizer that has at least 60 percent alcohol.
- Can’t wash your hands right away? Avoid touching your mouth, nose and eyes as these are areas where the pathogens can grow.
- Do not stand close to people who are sick. That may mean taking the stairs rather than an elevator.
- If you take an elevator, try not to touch buttons with your fingers. That’s also true for other objects or surfaces that other people may touch. Clean and disinfect those areas if you can. Otherwise, avoid touching them.
- Cover your mouth when you cough or sneeze, either using a tissue or your elbow. Throw used tissues in the trash right away.
- If you are sick, stay at home. If you have traveled to China or have been on an international flight with others from Wuhan in the last two weeks, you may wish to seek medical treatment for any symptoms. Call ahead to let them know why you’re coming. They may wish to admit you into an isolated unit.
- Although many people have purchased face masks as a way of fending off infectious diseases, no public health agency has recommended that the general public use them. While masks prevent a spray of droplets from landing in your nose or mouth, airborne germs can still penetrate around the edges of the mask. N95 respirators can ward off germs, but they are most effective when employed by people who are trained to use them correctly. If you have facial hair, microscopic pathogens will be able to sneak through the tiny passages made by hairs.
This story was originally published February 26, 2020 at 2:23 PM with the headline "How a doctor screened and helped Sacramento coronavirus patient get treatment."
