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COVID-19 Reflection – Nurse Practitioner

My name is Lindsay and I started working in an urgent care center in New York City this past March. We recently moved from Florida to NYC for my husbands job. I’ve been a Nurse Practitioner for a little over 5 years now. I could have never imagined we’d be moving to NYC at the start of a pandemic! LOL

Needless to say, the epidemiology of COVID-19, a virus caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), has been the primary focus for me. Taking my doctoral bio-statistics and epidemiology course this past fall has been great, because it has allowed for me to have hands on experience with many of the course concepts: the natural course of this disease, testing accuracy, randomized controlled trials, and fatality rates.

One of the biggest challenges I have experienced, as a provider in this pandemic, has been the lack of approved outpatient COVID-19 therapies. Based on the current rules in New York, for the most part only hospitals are allowed to try different experimental COVID-19 treatments. Things like vitamins, hydroxychloroquine, steroids, and quercetin all could have potentially been researched on a very large scale in NYC. COVID-19 hit NYC hard, well before it affected most other states. Had NYC performed more Randomized Controlled Trials, other states could have had a better idea of what therapies worked and did not work. In order to receive experimental treatments, patients had to be sick enough to require hospitalization. Much like other viruses, COVID-19 may benefit from immediate treatment versus late treatment (as seen with Influenza).

Another major challenge I have experienced with this pandemic, is the accuracy of COVID-19 testing. Back in April we started using the Polymerase Chain Reaction (PCR) COVID-19 test by Roche, which was approved by Emergency Use Authorization (EUA). We started using the test, before we even knew the real accuracy of it. Immediately we started to see a trend of very sick patients, presenting with COVID-19 like symptoms but testing negative three days in a row before finally testing positive on day four or day five.

 

A systematic review of the accuracy of the COVID-19 PCR tests found false negative rates of between 2-29%, equating to a sensitivity of 71-98% (Watson & Brush, 2020). I did some more digging and per Roche’s website, I discovered that if the test was collected too early (typically, day 1-4), newly infected individuals may not have high enough concentrations of the virus present at the time of sampling (2020). Testing too late, sample contamination, and sample storage are other confounding problems with test accuracy (Roche, 2020). One last major issue with PCR testing, has been the wait times for results. With so many New Yorker’s testing every day, Quest Diagnostics has not been able to keep up with the demand. In June and July patients could wait as long as 16 days for PCR result (my personal experience).  

In an effort to speed up COVID-19 lab results, most places now offer a Rapid Detection test, which shows results in 15 minutes. Unlike the PCR tests, which detect snippets of the virus’s genetic material, antigen tests are less sensitive because they can only detect samples with a higher viral load, thus leading to more false negatives and false positives (Song, 2020). Because of this, the current protocol is to send a confirmatory PCR test for patients who do not present with COVID-19 like symptoms, but do test positive for the rapid antigen.

Next up on the urgent care agenda will likely be the distribution of COVID-19 vaccines (this is only my speculation). The company I work for has been on the forefront of this pandemic, and will likely be involved in the vaccination process as well. The goal is for the population to develop herd immunity, which is defined as “the resistance of a group of people to an attack by a disease to which a large proportion of the members of the group are immune” (Celentano & Szklo, 2019, p. 27). It is speculated that herd immunity for SARS-CoV-2 will be reached once 60% of the population has achieved immunity (McNaughton, 2020), but other research shows that it could be as high as 80% (Khalid, 2020). For example, herd immunity is 93-95% for measles and 92% for mumps (McNaughton, 2020).

Pfizer and Moderna are currently the front-runners for the COVID-19 vaccine. Pfizer’s vaccine was recently found to be more than 90% effective in the prevention of SARS-CoV-2, however the vaccine requires a storage temperature of -70 degrees Celsius (Ducharme, 2020). Moderna’s vaccine has been found to be 94.5% effective, and only needs to be stored at standard refrigerator temperatures for up to a month (Dunn & Pflanzer, 2020). The implementation plan for Moderna’s vaccine would be much more ideal, and would not require any special freezer units.

There is still so much to be learned about COVID-19 and how to handle pandemics. My hope is that we humbly learn from our numerous mistakes and do better in the future. When we encounter our next pandemic, governments need to put more focus on setting up appropriate testing sites and create a National reporting standard. Due to the inaccuracy of tests and unreliable reporting measures (Jason, 2020), it will likely be years before we know the true impact of this pandemic. I often wonder how this pandemic would have been handled, outside of an election year.

This paper was written for my Epidemiology class, but thought I’d share on my blog = )

References

Celentano, D. D., & Szklo, M. (2019). Gordis epidemiology (6th ed.). Philadelphia, PA: Elsevier.

Ducharme, J. (2020). Why you may not be able to get Pfizer’s frontrunner COVID-19 vaccine. TIME. https://time.com/5911543/pfizer-vaccine-cold-storage/

Dunn, A., & Pflanzer, L. (2020). Moderna’s coronavirus vaccine overcomes one of the biggest limitations of Pfizer’s shot. Business Insider. https://www.businessinsider.com/moderna-coronavirus-vaccine-temperature-stored-in-standard-refrigerator-2020-11

Jason, C. (2020). ICD-10 Codes unreliable for COVID-19 Symptoms, EHR Surveillance. ERH intelligence. https://ehrintelligence.com/news/icd-10-codes-unreliable-for-covid-19-symptoms-ehr-surveillance

Khalid, S. (2020). Herd Immunity for Covid-19: Is it going to work? Biomedica, 36(24), 60-61. http://thebiomedicapk.com/articles/723.pdf

McNaughton, C. D. (2020, June 19). Herd Immunity: Knowns, unknowns, challenges, and strategies. American Journal of Health Promotion, 34 (6), 692-694.

Roche. (2020). Roche COVID-19 Blog: News and Stores from the Frontlines. Roche. https://diagnostics.roche.com/us/en/roche-blog/COVID-19-testing-what-you-need-to-know-about-test-accuracy.html

Song, L. (2020). Rapid testing is less accurate than the government wants to admit. Propublica. https://www.propublica.org/article/rapid-testing-is-less-accurate-than-the-government-wants-to-admit

Watson, J., & Brush, J. (2020). Interpreting a covid-19 test result. BMJ. https://www.bmj.com/content/bmj/369/bmj.m1808.full.pdf

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