A National Institutes of Health panel has released new guidelines on treating patients with COVID-19. Here are some of the highlights:
The panel does not recommend any drug for pre- or post-exposure prophylaxis outside of clinical trials.
It does not make a recommendation for specific antiviral or immunomodulatory treatments, as no drug has been proven to be safe and effective. The panel does provide rationale for use of certain therapies under investigation, as well as a summary of studies on these treatments.
It comes out against use of hydroxychloroquine plus azithromycin outside of clinical trials because of the toxicity risk, as well as against lopinavir/ritonavir or other HIV protease inhibitors because of negative clinical trial results and unfavorable pharmacodynamics. The panel also recommends against interferons and Janus kinase inhibitors.
The group recommends against use of systemic corticosteroids for mechanically ventilated adults with COVID-19 who don’t have acute respiratory distress syndrome (ARDS).
It prefers low-dose corticosteroids over no corticosteroids in patients with refractory shock.
This page explains Pennsylvania’s CARES Act Pandemic Unemployment Assistance Plan (PUA). The PUA expands who is eligible for unemployment during the COVID epidemic.
It includes gig workers, independent contractors, people who have exhausted regular benefits, and people who have not worked long enough to get regular unemployment. This is a separate state unemployment program and you may be eligible.
for health care providers working directly with sick people
This specialized mask should be reserved for people in direct contact with people confirmed to have COVID-19 and are in the hospital. N95 respirators are fit to have a tight seal, and should be reserved for health professionals
for people working in a health care or emergency responder setting
Though not a tight-fitting as an N95 respirator, surgical masks can help filter particles out of the air. Meant to be one-use only, these masks should be reserved for health care professionals who are more exposed to the COVID-19 virus at work
The CDC now recommends wearing a face covering when outside the home. Cloth face coverings are not substitutes for surgical masks, which are in short supply, but may help prevent community spread.
Wash with soap and water after use
Wash hands before and after putting mask on and off
A direction from a more general professional, like a primary care physician, to a specialist for further action
The COVID-19 testing sites in Philadelphia want a referral from your doctor, which is why people who have symptoms are directed to call their primary care physician first. Some have a process for people without a referral, but it takes more time.
The graphic illustration below shows the importance of social distancing. It shows us that we all have the power to prevent the spread of COVID-19 in our communities by limiting our contacts with others.
At this moment, if we do nothing, one person who is infected will infect 2-3 people in 5 days and over 400 in thirty days. This is if we do nothing.
But if we were to just cut our contacts by 50% only 15 people would be infected by that same one person in thirty days. And if we cut our contacts by 75% ( three quarters) only 2-3 people will be infected in thirty days.
Remember: A contact is anybody you get near. You have to limit your contact with your family, your extended family, your friends, and strangers. Everybody.
If we all do this, we can stop the spread of COVID-19 and save lives.
Interim Guidance for COVID-19 and Persons with HIV
Last Updated: March 20, 2020; Last Reviewed: March 20, 2020
This interim guidance reviews special considerations for persons with HIV and their health care providers in the United States regarding COVID-19. Information and data on COVID-19 are rapidly evolving. This guidance includes general information to consider. Clinicians should refer to updated sources for more specific recommendations regarding COVID-19.
Guidance for all Persons with HIV
In current reports, individuals aged >60 years and those with diabetes, hypertension, cardiovascular disease, or pulmonary disease are at highest risk of life-threatening COVID-19, the illness caused by the virus known as SARS-CoV-2.
The limited data currently available do not indicate that the disease course of COVID-19 in persons with HIV differs from that in persons without HIV. Before the advent of effective combination antiretroviral therapy (ART), advanced HIV infection (i.e., CD4 cell count <200/mm3) was a risk factor for complications of other respiratory infections. Whether this is also true for COVID-19 is yet unknown.
Some people with HIV have other comorbidities (e.g., cardiovascular disease or lung disease) that increase the risk for a more severe course of COVID-19 illness. Chronic smokers are also at risk of more severe disease.
Thus, until more is known, additional caution for all persons with HIV, especially those with advanced HIV or poorly controlled HIV, is warranted.
Every effort should be made to help persons with HIV maintain an adequate supply of ART and all other concomitant medications.
Influenza and pneumococcal vaccinations should be kept up to date.
Maintain on-hand at least a 30-day supply—and ideally a 90-day supply—of antiretroviral (ARV) drugs and other medications.
Talk to their pharmacists and/or healthcare providers about changing to mail order delivery of medications when possible.
Persons for whom a regimen switch is planned should consider delaying the switch until close follow-up and monitoring are possible.
Lopinavir/ritonavir (LPV/r) has been used as an off-label treatment for patients with COVID-19 and clinical trials are underway globally. If protease inhibitors (PIs) are not already part of a person’s ARV regimen, their regimen should not be changed to include a PI to prevent or treat COVID-19, except in the context of a clinical trial and in consultation with an HIV specialist. In a small open-label trial, 199 hospitalized patients with COVID-19 were randomized to either 14 days of LPV/r plus standard of care or standard of care alone. No statistically significant difference was seen between the two groups, with regards to time to clinical improvement or mortality.1
Clinic or Laboratory Monitoring Visits Related to HIV Care:
Together with their health care providers, persons with HIV and their providers should weigh the risks and benefits of attending, versus not attending in-person, HIV-related clinic appointments at this time. Factors to consider include the extent of local COVID-19 transmission, the health needs that will be addressed during the appointment, and the person’s HIV status (e.g., CD4 cell count, HIV viral load) and overall health.
Telephone or virtual visits for routine or non-urgent care and adherence counseling may replace face-to-face encounters.
For persons who have a suppressed HIV viral load and are in stable health, routine medical and laboratory visits should be postponed to the extent possible.
Persons with HIV and in Opioid Treatment Programs:
Clinicians caring for persons with HIV who are enrolled in opioid treatment programs (OTPs) should refer to the Substance Abuse and Mental Health Service Administration (SAMHSA) website for updated guidance on avoiding treatment interruptions. State methadone agencies are also responsible for regulating OTPs in their jurisdictions and may provide additional guidance.
Guidance for Specific Populations
Pregnant Individuals with HIV:
Currently, there is limited information about pregnancy and maternal outcomes in individuals who have COVID-19.
Immunologic and physiologic changes during pregnancy generally increase a pregnant individual’s susceptibility to viral respiratory infections, possibly including COVID-19. As observed with other coronavirus infections, the risk for severe illness, morbidity, or mortality with COVID-19 may be greater among pregnant individuals than among the general population.2
Although limited, currently available data do not indicate that pregnant individuals are more susceptible to COVID-19 infection or that pregnant individuals with COVID-19 have more severe illness.6,7 Adverse pregnancy outcomes, such as fetal distress and preterm delivery, were noted in a small series of pregnant women with COVID-19 infection and have been reported with SARS and MERS infections during pregnancy.3-5
Findings from a small group of pregnant women with COVID-19 did not find evidence for vertical transmission of COVID-19, although at least one case of neonatal COVID-19 has been described.7-9
From the limited available data, children appear less likely to become severely ill with COVID-19 infection than older adults.10-12 However, there may be subpopulations of children at increased risk of more severe COVID-19 illness; in studies of infection with non-COVID-19 coronaviruses in children, younger age, underlying pulmonary pathology, and immunocompromising conditions were associated with more severe outcomes.13
If they develop a fever and symptoms (e.g., cough, difficulty breathing), they should call their health care provider for medical advice.
Call the clinic in advance before presenting to the care providers.
Use respiratory and hand hygiene and cough etiquette when presenting to the healthcare facility and request a face mask as soon as they arrive.
If they present to a clinic or an emergency facility without calling in advance, they should alert registration staff immediately upon arrival of their symptoms so that measures can be taken to prevent COVID-19 transmission in the health care setting. Specific actions include placing a mask on the patient and rapidly putting the patient in a room or other space separated from other people.
Guidance for Managing Persons with HIV who Develop COVID-19
When Hospitalization is Not Necessary, the Person with HIV Should:
Manage symptoms at home with supportive care for symptomatic relief.
Maintain close communication with their health care provider and report if symptoms progress (e.g., sustained fever for >2 days, new shortness of breath).
Continue their ARV therapy and other medications, as prescribed.
When the Person with HIV is Hospitalized:
ART should be continued. If the ARV drugs are not on the hospital’s formulary, administer medications from the patients’ home supplies.
ARV drug substitutions should be avoided. If necessary, clinicians may refer to recommendations on ARV drugs that can be switched in the U.S. Department of Health and Human Services (HHS) guidelines for caring for persons with HIV in disaster areas.
For patients who receive ibalizumab (IBA) intravenous (IV) infusion every 2 weeks as part of their ARV regimen, clinicians should arrange with the patient’s hospital provider to continue administer of this medication without interruption.
For patients who are taking an investigational ARV medication as part of their regimen, arrangements should be made with the investigational study team to continue the medication if possible.
For critically ill patients who require tube feeding, some ARV medications are available in liquid formulations and some, but not all, pills may be crushed. Clinicians should consult an HIV specialist and/or pharmacist to assess the best way for a patient with a feeding tube to continue an effective ARV regimen. Information may be available in the drug product label or from this document from the Toronto General Hospital Immunodeficiency Clinic.
When Receiving Investigational or Off-Label Treatment for COVID-19:
There is currently no approved treatment for COVID-19. Several investigational and marketed drugs are being evaluated in clinical trials to treat COVID-19 or may also be available via compassionate use or off-label use.
For patients receiving COVID-19 treatment, clinicians must assess the potential for drug interactions between the COVID-19 treatment and the patient’s ARV therapy and other medications. Information on potential drug interactions may be found in product labels, drug interaction resources, clinical trial protocols, or investigator brochures.
When available, clinicians may consider enrolling patients in a clinical trial evaluating the safety and efficacy of experimental treatment for COVID-19. Persons with HIV should not be excluded from these trials. Clinicaltrials.gov is a useful resource to find studies investigating potential treatments for COVID-19.
Additional Guidance for HIV Clinicians
Some Medicaid and Medicare programs, commercial health insurers, and AIDS Drug Assistance Programs (ADAPs) have restrictions that prevent patients from obtaining a 90-day supply of ARV drugs and other medications. During the COVID-19 outbreak, clinicians should ask providers to waive drug-supply quantity restrictions. ADAPs should also provide patients with a 90-day supply of medications.
Persons with HIV may need additional assistance with food, housing, transportation, and childcare during times of crisis and economic fragility. To enhance care engagement and continuity of ARV therapy, clinicians should make every attempt to assess their patients’ need for additional social assistance and connect them with resources, including navigator services when possible.
During this crisis, social distancing and isolation may exacerbate mental health and substance use issues for some persons with HIV. Clinicians should assess and address these patient concerns and arrange for additional consultations, preferably virtual, as needed.
Telehealth options, including phone calls, should be considered for routine visits and to triage visits for patients who are ill.
More information regarding ARV management in adult, pregnant, and pediatric patients, as well as recommendations for prophylaxis and treatment of specific opportunistic infections, can be found in the medical practice guidelines for HIV/AIDS.
Siston AM, Rasmussen SA, Honein MA, et al. Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States. JAMA. 2010;303(15):1517-1525. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20407061.
Alfaraj SH, Al-Tawfiq JA, Memish ZA. Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection during pregnancy: Report of two cases & review of the literature. J Microbiol Immunol Infect. 2019;52(3):501-503. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29907538.
Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020;395(10226):809-815. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32151335.
Shen K, Yang Y, Wang T, et al. Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts’ consensus statement. World J Pediatr. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32034659.
Ogimi C, Englund JA, Bradford MC, Qin X, Boeckh M, Waghmare A. Characteristics and outcomes of coronavirus infection in children: The role of viral factors and an immunocompromised state. J Pediatric Infect Dis Soc. 2019;8(1):21-28. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29447395.
Exercising in the winter can be hard! It’s cold, sometimes there is snow on the ground you could slip on, it gets dark early, feeling down in the winter is more common. The obstacles are many. However, just a little bit of exercise each day can be beneficial. The American Heart Association recommends about 20 minutes per day of moderate aerobic exercise, and combatting that seasonal depression with exercise can be done indoors. Bodyweight exercises do not require any special equipment, and can even be done on your couch while watching that new Netflix release! For added social benefit, invite a friend over for a new episode, find a set of exercises like these on darebee.com (it’s free and has a lot of options!), and get to exercising in your living room! It is important to remember to stay hydrated and to slowly scale up the intensity of your workouts. If you are not used to regular exercise, start slow and build your strength and abilities.
Level 1 is 3 sets.
Level 2 is 4 sets.
Level 3 is 5 sets.
Rest up to 2 minutes.
20 leg swings: a drawing of a person seated on a couch with one leg bent and foot on the floor, the other extended off the floor being raised from below the hips to about level with the figures hips
20-count raised knees hold: a figure seated on a couch with both knees bent and held off the floor
20 knees to elbows: figure seated on the couch with one foot resting on the floor, while the other is bent and raised above the figures hips. The opposite are bent at the elbow is crossing to touch the raised knee
20 flutter kicks: the seated figure has both legs straight and raised off the floor, one level with their hips, and the other slightly lowered but not touching the ground, switching the higher and lower legs without resting on the ground
10 raised leg twists: the figure is seated with both legs raised off the floor and extended straight, while their clasped hands are moved from one side of their body to the other- twisting at the waist
10 scissors: the figure is seated with both legs raised and extended straight, though crossed with one on top. The second figure shows the other leg on top, with arrows indicating moving the legs to alternate which is on top, all while in the air about hip level
The U.S Fire Administration cautions us that December through February are the prime time for home heating fires. As we discussed last week, the holidays can be dangerous times, but winter has dangers throughout the season. Just like you can take precautions to avoid slipping and falling, you can do some things to prevent home fires. Key to prevention is caution. Pay attention to possible sources of fire, and keep flammable materials at least 3 feet away from heat sources, like space heaters or fireplaces. Prevent electrical complications by only plugging a single heating device into an outlet, and make sure your vents and chimneys are clean. It is also important to install and regularly test carbon monoxide alarms. The CDC warns us that alternate forms of heating (that we might use during power outages, like gas ranges or portable generators) can cause a buildup of carbon monoxide, leading to poisoning of people and animals.
Home fires occur more in winter than in any other season. As you stay cozy and warm this winter, be fire smart!
Half of all home heating fires occur in the months of December, January, and February.
Heating equipment is involved in 1 of every 7 reported home fires and 1 in every 5 home fire deaths.
Keep anything that can burn at least 3 feet from any heat source like fireplaces, woodstoves, radiators, or space heaters.
Keep portable generators outside, away from windows, and as far away from your home as possible.
Install and test carbon monoxide alarms at least once a month.
Plug only one heat-producing appliance (such as a space heater) into an electrical outlet at a time.
Have a qualified professional clean and inspect your chimney and vents every year.
Store cooled ashes in a tightly covered metal container, and keep it outside at least 10 feet from your home and any nearby buildings.
Falls and motor vehicle accidents are leading causes of Traumatic Brain Injury, according to the CDC. Falls are more common in children and older adults, but winter ice and holiday decorating activities make this time of year a particularly dangerous one. Holiday decorations and candles can be a cause of electrical shocks and house fires. The stress and hectic pace of holiday preparation result in back injuries, cuts, burns and even food poisoning. Car accidents are also a major concern due to high volume traffic of people traveling, and winter conditions that make roads more treacherous. Paying attention to your safety, and always having someone else to lend a helping hand or take care of you in the event of injury is important as we are preparing for all the holidays that occur in the last two months of the year.
During the last two months of the year, about 200 people a day suffer decoration-related injuries. Most injuries are related to falling off ladders, stairs, furniture, rooftops and porches. The results are: fractures, concussions, and muscle pulls.
Thousands of people are treated each holiday season after sustaining an electrical shock. Electric incidents are mostly caused by carelessness and misuse of the decorations and can be the cause of cardiac arrests and tissue and nerve damage among others.
Christmas trees and decorations account for almost 2,000 fires each year. Thousands of candle-related fires happen during the holidays, with Christmas and New Year’s Day seeing most candle fires. The winter season also sees a rise in heating, cooking, and electrical fires.
Car crashes cause most injuries and fatalities during the holiday season. There are more drivers on the road. They are also stressed, rushed, and sometimes driving impaired. Fatigue and poor weather conditions can often be a factor.
Foodborne illnesses are most common around the holidays. Lack of hygiene while preparing or reheating food ruins numerous winter holidays each year. Storing cleaning products and chemicals near food or not using original containers can lead to accidental poisoning. Consuming leftovers that were not stored/refrigerated properly can cause illness.
Visitors who are unfamiliar with your house layout are more likely to trip and fall without proper lighting. Curious children may go through cabinets and people’s things, often finding medicines and other substances that can be lethal.
Cuts and Burns
Packaging-related injuries resulted in approximately 6,000 emergency-room visits in 2006. Excitement, rushing, complacency and fatigue can be dangerous when combines with sharp utensils. Numerous cuts, lacerations and burns are sustained while preparing holiday meals.
Over 84,000 people were treated for injuries related to carrying luggage in 2015. Rushing and the frustration of the holiday season make people forget to use proper lifting techniques.
Inflammatory Bowel Disease (IBD) refers to conditions that cause bowel inflammation. The two most common diseases are Crohn’s Disease and Ulcerative Colitis. These diseases are separate from Irritable Bowel Syndrome (IBS). Though abdominal pain can occur for all three conditions, Crohn’s and Ulcerative Colitis can cause lasting damage to the intestines and digestive system, while IBS usually does not. Though there is not currently a cure for Inflammatory Bowel Disease, there are treatment options to control inflammation and reduce symptoms for an improved quality of life. This infographic provides an overview of symptoms, the differences between the two diseases, and some anatomical information.
In a month lacking in the wealth of health observances throughout the rest of the year, we thought we would have a Fact about a lesser-known disease: Inflammatory Bowel Disease!
Inflammatory Bowel Disease (IBD) refers to two diseases of the digestive system, including Crohn’s Disease and Ulcerative colitis. A Venn Diagram is shown with Crohn’s Disease and Ulcerative Colitis as the two circles. The overlapping portion is labeled Inflammatory Bowel Disease.
IBD is very different from Irritable Bowel Syndrome (IBS).
An inflammation in any part of the digestive tract, most commonly the last portion of the small bowel and the first part of the large intestine. 25% of patients will also have inflammation around their anal area.
Inflammation of the large intestine (colon and rectum).
General IBD symptoms
Abdominal pain is common for Crohn’s and Uncommon for Ulcerative Colitis
Persistent Diarrhea is uncommon for Crohn’s and common for Ulcerative Colitis
Weight loss is common for both diseases
Joint Pain and swelling is common for Crohn’s and uncommon for Ulcerative Colitis
Fatigue is common for both diseases
Mouth sores and anemia/iron deficiency are common for Crohn’s and uncommon for Ulcerative Colitis
Bleeding and Urgency are uncommon for Crohn’s and common for Ulcerative Colitis
A diagram of a human body shows the placement of the liver, pancreas, stomach, small intestine, large intestine, and rectum
Treatment: “a personalized approach is key.” The goal is to achieve remission by improving symptoms and controlling inflammation for a better quality of life!
Medication, surgery, diet, nutrition
Effective plans focus on overall health while minimizing side effects and discomfort]
A protein produced by the immune system to recognize a foreign threat, attach to it, and begin the necessary process for neutralizing or killing it
Annette B. Gadegbeku, MD
Annette B. Gadegbeku, MD is Director of Adult Medicine at John Bell Health Center and Jonathan Lax Treatment Center of Philadelphia FIGHT Community Health Centers. Dr. Gadegbeku is a Family Medicine Physician who specializes in primary care for all ages (from pediatrics to geriatrics)!
Dr. Cruz is a board-certified pediatrician who serves as the Medical Director for our Pediatrics and Adolescent Health Center. He has presented and/or published in the fields of community violence and domestic violence prevention, quality improvement, behavioral health, curriculum development, and mentorship.