UCSF Medical Grand Rounds opened on a solemn note Thursday afternoon, marked by the fact that COVID-19 deaths across the country exceeded 100,000 Wednesday.
It is a number that could fill a very large sports stadium, and equals the populations of cities like San Mateo, Burbank, Boca Raton, and Ann Arbor, noted Dr. Bob Wachter, chair of the university’s Department of Medicine and moderator of the 90-minute forum.
“Take away any of those cities,” Wachter said, “and that’s a sense of the scale of what we’ve been experiencing.”
This reminder of the human toll was a prelude to a highly related topic: The elderly, who disproportionately represent a high percentage of U.S. deaths.
Thirty-seven percent of the 100,000 were nursing home residents, said Dr. Charlene Harrington, a professor emeritus at UCSF’s department of social and behavioral sciences, “which is quite shocking because they represent a very small percentage of older people.”
Their deaths could not be blamed entirely on residents being “frail,” Harrington said.
Instead, it seemed more a lack of monitoring at the homes. The pandemic meant “visitors were prohibited, ombudsmen were not allowed in — and, nationally, inspections of nursing homes were essentially stopped.”
A study she recently completed of California nursing homes showed that those with fewer nurses were twice as likely to see outbreaks. “So, they were unprepared and unable to handle infection-control practices,” Harrington said.
Sixty-seven percent of the homes, she added, had received violations for past infection-control deficiencies, “which is known to be one of the most serious problems in nursing homes before the virus.”
Dr. Carla Perissinotto, associate professor of medicine in the division of geriatrics, added that COVID-19 symptoms show up differently in the elderly. The Centers for Disease control, only a week ago, included “confusion” and “changing cognition” as COVID symptoms in the elderly, she said.
“Without some of these subtle findings, it is understandable that some of these long-term or other congregate living facilities were saying people were asymptomatic — when, in fact, they really weren’t asymptomatic,” she said.
Wachter wondered if there were alternatives, such as being cared for at home.
Perissinotto said that, yes, there are many safe and cost-effective models that can be widely replicated to take care of the elderly at home. “There’s absolutely models to show how people can come home safely,” she said. “The challenge is the additional support system. So it’s the assistance with daily living, it’s the nursing support.”
But unfortunately, she added, “we have seen, just in the last week, a proposal by the state to unfortunately cut many of the services that allow our patients to stay at home safely.”
General Hospital
Next up was a report about Zuckerberg San Francisco General and its experience so far.
The hospital received among the most COVID-19 patients in San Francisco, yet never experienced a surge. As of May 20, the hospital had seen a total of 172 patients, with its first patient arriving on March 10, according to Dr. Antonio Gomez, associate professor of medicine in the division of pulmonary and critical care at the hospital.
Around 50 of those have been ICU patients, and an alarming 73 percent of them have been Latinx, Gomez said, “which, as far as I know, has not been reported in any of the literature I see.”
Yet, overall, hospitalizations have remained low. Gomez described the initial panic in early March. “There was a source of tremendous anxiety,” he said. “Do we have enough ventilators? Do we have enough beds?”
During a forecasted peak of cases in mid-April, Gomez said the intensive care unit made 80 beds available. “We never got there, but we were ready for 80 ICU patients if we needed to” be, he said.
The hospital also had 67 ventilators at the beginning of the pandemic. “Again, we never came close to using that,” Gomez said, adding that about 25 percent of them were used during his intensive care unit’s mid-April peak, and the hospital has added around a dozen more ventilators since then.
The hospital also added nurses to staff those beds in the event of a surge.
Six patients have died so far, Gomez said.
Wachter brought up a previous Grand Round sessions in which UCSF doctors who had worked in New York hospitals described chaos and death in the ICUs there during the city’s peak of cases, and compared that to the relatively low number of deaths in San Francisco hospitals.
“Do you think it’s just a matter of workload and sort of chaotic-ness that makes a difference?” he asked. “Or do you think there are other things?”
“It plays a large part in our outcomes,” Gomez said. “We had time to prepare, so we weren’t really caught by surprise, necessarily.”
Gomez also said early social distancing measures throughout the Bay Area played a major factor, “really helping to limit the spread” and allowing “us to really bring that peak down so that we could better prepare.”
Testing
Dr. Chaz Langelier, assistant professor of medicine in the division of infectious diseases followed next to talk about testing, a topic Wachter said, that “seems to get more complicated every day.”
And it does.
Research, Langelier said, shows the diagnostic tests being administered in San Francisco and elsewhere likely have a 20 percent false-negative rate — meaning tests could be missing people who are actually positive.
But it’s not as bad as it sounds. Negative test results in an area where the infection rate is lower — like San Francisco — are more reliably negative. That conclusion is based on something called the “negative predictive value,” essentially how confident a person can be in their negative test results. In the Bay Area, he said, the prevalence of COVID-19 is quite low — he estimated around 1 percent — so negative tests are more reliable.
Langelier said that one day — maybe soon — we won’t have to bother with these so-called “PCR” tests, which is what we’re using now. He and his team are researching a method for detecting whether a person has the disease based on gene expressions in our nasal passages. “Perhaps this approach will overcome the significant false-negative rates that have been described for coronavirus PCR tests,” he said.
Wachter had some questions.
Assuming testing is available and feasible, he said, “what’s the right periodicity of testing to be able to say this person is safe to come to work?”
“Very good question,” Langelier said. “One that’s hotly debated.”
He said “negative predictive value” is important here. An individual in a population with a low rate of infection, like the Bay Area, can put a lot of faith in a negative test result and can go to work.
“Now, someone certainly could get exposed the day after they get the negative test,” Langelier said. And for someone who is traveling for work or is at a higher risk of exposure, “they might need to be tested more frequently than someone who is going to work and then just going home.”
Wachter pressed.
If we want to be as safe as possible and daily testing is not feasible yet, he asked, “what is the consensus?” Once a week? Twice a week?
Langelier said that answer depends on the availability of testing resources and accessibility, as well as what antibody testing says about immunity and the likelihood of being infected.
But, really, Langelier conceded: “I don’t think there’s a consensus quite yet.”
So, stay tuned. In the meantime, free tests are available to all San Francisco adults with just one symptom, including fatigue or a headache — and to all essential workers regardless of symptoms.