Memorystockphoto/iStock(NEW YORK) -- Masks are at the forefront of people’s minds as health care workers continue to face shortages during the coronavirus pandemic. Together with disinfection and hand-washing, N95 respirators have proven to reduce the infectious risk of COVID-19 in doctors and nurses.
N95 respirators are tight-fitting masks that filter out 95% of particles in the air and reduce exposure from small particle aerosols to large droplets.
In order to wear an N95 respirator effectively, achieving an adequate seal is essential. United States regulations mandate that health care workers get fit-tested every year, a process that involves spraying foul-tasting fumes around a person's head to see if the mask successfully blocks particles from entering the nose and mouth.
According to the Occupational Safety and Health Administration (OSHA), the test won’t be conducted if there is any hair growth (stubble, beard, mustache or sideburns) between the skin and the face piece sealing surface. That means anyone who plans to wear an N95 mask would need to shave their beards to ensure a good fit.
Eric Cioe Peña, MD, MPH, FACEP, director of global health at Northwell Health in New Hyde Park, New York, explained that "hair under the edge of the mask breaks the seal and makes it useless." As with many others on the front lines of battling COVID-19, Dr. Cioe Peña shaved his beard to get fitted for an N95.
Dr. Alina Bridges, associate professor of dermatology and pathology at the Mayo Clinic said that her institution updated their "no facial hair" policy. Effective immediately, "staff are required to be clean shaven for fit testing."
Hospitals have policies in place granting religious exemptions to shaving. For those who cannot shave or perhaps have "some structural abnormality or some respiratory [compromise] that prevents them from using these respirators," they can use powered air purifying respirators (PAPRs) -- but those are in short supply and cumbersome to wear.
For health care workers shaving their beards for the first time in years, frequent shaving can have downsides, particularly for those with coarse hair or prone to ingrown hairs, explained Houston-based board certified dermatologist Dr. Moneé Thomas.
Her advice is to apply "a warm, wet towel to the beard for a few minutes before shaving to open pores and make it easier to release ingrown hairs. Use shaving gel, shave with a single blade razor or an electric razor on the highest setting. Appling a 1% hydrocortisone immediately after shaving can greatly reduce irritation, she says. And above all: don’t pick at those ingrowns."
Even people without facial hair can develop skin irritation after long periods of wearing an N95 mask. New York-based board certified dermatologist, Dr. Whitney Bowe explained that "abrasions from speaking, mechanical tensions and friction causing a breach in the skin barrier,” which can lead to infection.
The skin, the scalp and beard, all have a microbiome, Dr. Bowe explained.
"The microbiome is the healthy bacteria that is there, our tiny warriors,” she said. “We need to fight the bad bugs and do everything to preserve to the delicate balance of the good bugs.”
Dr. Bowe recommended gently washing the face with soap and water, patting dry, not rubbing, then applying a healing balm.
"I love medical grade honey -- it is amazing for wound healing and natural. It goes through a special pasteurization process in the lab that kills off the bacteria. You can also use aloe, right from the plant, or cream or ointment. Yogurt, avocado, oatmeal, all very calming," Bowe advised.
While the The Centers for Disease Control and Prevention recommends N95 respirators for those on the front lines of the pandemic, what about everyday people and N95 masks? Should everyone shave their beards?
The CDC suggested that loose-fitting surgical masks can be worn by everyday Americans if they feel sick themselves, or if they are caring for a family member or loved one who is sick. Surgical masks help prevent contamination when a person coughs or sneezes.
Unlike N95 respirators that require a close shave, surgical masks don’t.
And having a beard or facial hair does not "trap" the virus closer to your face. Dr. Thomas explained that "the beard shares much of the same flora as facial skin. Therefore, most of the same precautions we take with our face to keep it clean and healthy should also apply to the beard.”
What does all of this mean? For now, shaving is recommended if you need to wear an N95 respirator and not a surgical mask.
art Photo/iStock(NEW YORK) -- As Los Angeles Mayor Eric Garcetti Wednesday recommended citizens to wear face coverings while in public amid coronavirus, medical professionals are weighing in about the benefits of wearing them.
“At this point, there really seems to be no question that everybody should be wearing a mask to protect themselves and more importantly, to protect their community,” Jeremy Howard, research scientist at the University of San Francisco said. “When you’re talking bits of saliva come out of your mouth, you don’t even see them.”
While the use of masks becomes the new normal and medical professionals like Howard recommend to use them while in public, the reality is that it is almost impossible to find just one to purchase.
But experts say that you can still protect your face with other types of face covers even if they are non-medical grade. In fact, it’s what officials like Garcetti emphasized.
“Do not take N-95 masks,” said Garcetti during a presser in Los Angeles Wednesday evening. “They are reserved for front line workers.”
“You are not doing surgery at home or during your shopping. So you don’t need these masks,” said Howard. “They are harder to fit. They are less comfortable.”
Instead, a piece of fabric made with cotton or an old sheet would work just fine. Howard also recommended a bandana or a scarf -- any material that will allow you to breathe while wearing it. A plus is if the material is able to stop liquid.
Here are some tutorials to make a face cover:
For the proficient sewer, a basic pattern involves two layers of fabric, three folds and elastic to go around the ears. You can either use a sewing machine or hand sew the face cover together -- it might just take a little longer. Deaconess Hospital provides instructions on how to make a face covers with ties on their website.
Another tutorial shows that you can forgo sewing by cutting up an old t-shirt together and tying the ends together.
Or if you are in a pinch and sewing is not your thing, a simple bandana with two hair ties works perfectly.
WHOOP(NEW YORK) -- As health officials were confronted this week with the possibility that as many as one in four people who have the novel coronavirus may not show symptoms, researchers are investigating whether subtle hints from wearable wellness devices could help identify asymptomatic cases -- a critical advantage in the race to trace the virus' spread.
The gadgets -- most commonly bracelets and rings -- track users’ physiological metrics, from sleep cycles to heart rate, and report the data back to a corresponding smart phone app. While at present those metrics remain untested by independent researchers, Dr. John Brownstein told ABC News the data gathered by the devices could someday help unveil otherwise hidden cases.
"It makes sense that these vital sign-tracking wearables could be valuable in early detection of the disease," said Brownstein, chief innovation officer at Boston Children's Hospital and an ABC News contributor. "Slight changes in heart rate and temperature can provide early clues into illness ahead of when -- or even if -- symptoms actually manifest."
As health care providers scramble to test and treat possible cases, at least two tech companies are suggesting they have data that could help, and researchers are beginning to evaluate how effective they could be.
In the meantime, there has been scant, but intriguing anecdotal evidence.
In Finland, a user of the smart ring made by Oura tested positive for COVID-19 earlier this month after waking up to find his "readiness score" -- a daily aggregate of physiological data, such as sleep quality and resting heart rate -- had plummeted.
"I felt tired a bit, I didn’t sleep well. But I didn’t feel sick at all," Petri Hollmen, the CEO of a Finnish event planning startup, told ABC News. "When I woke up, I checked the app for how I should feel. My readiness score was 54 [out of 100], which is really low. I don’t usually have anything like that except maybe after a very hard night at the bar. That was a surprise."
Hollmen used a thermometer to take his own temperature. It came back normal. Out of an abundance of caution, he said he called his doctor and went in for a test. Because he had no symptoms, Hollmen said he felt "guilty and even ashamed" for seeking help.
Within hours, though, his test came back positive.
"I was like, ‘no way – strange,’" Hollmen recalled thinking.
A similar case recently emerged in New York City, the American epicenter of the disease. On March 11, Brian Eisenberg, a 37-year-old user of a smart bracelet called WHOOP, tested positive for the disease.
That morning he woke up with a fever, one of the most common symptoms associated with the virus. But a closer examination of WHOOP’s metrics in the days leading up to his diagnosis indicates coronavirus may have been present before the onset of his high temperature.
Days before his fever emerged, Eisenberg’s app registered a substantial drop in his "recovery score" -- an aggregate metric similar to Oura’s "readiness score." Four days prior to his diagnosis, Eisenberg’s "recovery score" was 95 out of 100. The next day it dropped to 51, then 44. On the day he tested positive, he said his score was 7.
The same trend afflicted his heart rate variability (HRV) -- the amount of time between heart beats. Four days before his diagnosis he registered an HRV of 121 milliseconds (ms), then 74 ms the next day, and finally 37 ms on the day he tested positive.
"This sort of precipitous drop has only ever happened to me one time," Eisenberg said, "and that’s unfortunately when I had COVID-19."
Those anecdotes are now isolated incidents, and neither app is an approved medical device. But the app makers, researchers and scientists hope the wearable fitness apps could provide data with broader implications for early detection of infectious diseases like COVID-19.
"We believe that a noticeable increase in respiratory rate is a measurable precursor of COVID-19 symptoms based on individual cases that we have seen in our data," said WHOOP CEO Will Ahmed. "WHOOP data may be able to help identify the coronavirus during the incubation period before someone feels sick."
In that vein, both Oura and WHOOP have forged partnerships with medical researchers as part of an effort to validate their hypotheses.
On Wednesday, WHOOP announced a partnership with the Cleveland Clinic and Central Queensland University in Australia, where scientists will investigate the possible "connection between changes in respiratory rate and COVID-19 symptoms" based on data collected "from hundreds of self-identified COVID-19 cases among WHOOP members," according to a press release.
Oura partnered with the University of California, San Francisco last month to "study whether physiological data collected by the Oura ring, combined with responses to daily symptom surveys, can predict illness symptoms," the company said.
As part of the study, more than 2,000 UCSF health care workers who are "in daily contact with patients who may be afflicted with COVID-19" will wear the Oura ring, the company said. No results have been announced yet.
Brownstein said that drawing any conclusions about the device’s scientific viability before a closer examination is premature. But if the data checks out, public health officials could use that information to plot next steps in fighting the illness.
"When aggregated," Brownstein said, "these tools could provide early windows into disease hot-spots that can ultimately inform decision-making by public health officials."
ABC News(NEW YORK) -- Being a parent is never a cakewalk, but parenting during a pandemic is an entirely new challenge for millions of American families of children with special needs.
"Everything has radically changed," said Melissa Winchell of West Bridgewater, Massachusetts, whose 10-year-old daughter Moriah has both Down syndrome and autism.
For parents like Winchell, the shuttering of schools has meant the loss of a dozen or more helpers throughout the day -- a support network that does everything from teaching special needs children how to grip a pencil or zip their coat, to social skills and handling full-blown meltdowns.
Many parents have been abruptly thrust into the full-time roles of teacher and caregiver while working their paying jobs from home.
ABC News was given an inside look at how four families around the country are coping with the disruption to their lives and routines, mounting financial pressures and the imminent health threat posed by the novel coronavirus.
"Danny is medically fragile. So, the virus itself would be pretty devastating to him. So we have that we're contending with," said Megan Scully, a mother of three in Washington, D.C., whose 4-year-old son has a rare brain disorder that puts him at increased risk from COVID-19.
"One of the fights for us is keeping the 'front line' for us here at home instead of possibly having to go to the hospital," said Chris DeBatt, Danny's father. "So we are being very, very careful with the social distancing measures."
Rob Gorski of Akron, Ohio, a single father of three autistic sons and author of "The Autism Dad" blog, says the health risk for his eldest son, Gavin, has kept the family strictly quarantined inside the house for more than three weeks.
"One of the things that he has right now is a compromised immune system," Gorski said. "It's pretty stressful worrying about trying to keep him healthy and safe by not exposing him to anything really."
"Everybody's been sort of climbing the walls," Gorski added. "We have a small house."
The sobering, cloistered reality has been made more difficult without the support network many parents of young special needs kids have come to rely on: home health aides, therapists, coaches and teachers.
"They're not going to get the therapies they need. There's not going to be the socialization that he needs," said single mother Opal Foster of Silver Spring, Maryland, who worries about the impact of isolation on her son Jeremiah, who has Down syndrome.
"He definitely misses his friends," Foster said, with Jeremiah by her side. She, like many parents, is scrambling to arrange Zoom or Skype video-chats with familiar faces to try to recoup a sense of normalcy.
Winchell, an assistant college professor, is toggling between daycare for her 10-year-old daughter Moriah, who has autism and Down syndrome, and her job teaching and advising hundreds of students.
Her employer expects her to maintain a full-time course load online, lecturing, grading papers and overseeing a graduate program.
"I can't do a full load," said Winchell, describing herself as someone who prides herself on working hard and being able to juggle priorities.
"To even admit that this is not possible, is not even in my vocabulary," she said.
Scully, a news editor, and her husband Chris DeBatt, an Army National Guard contractor, have also become full-time caregivers while educating their other sons, ages 2 and 7, and keeping up with their day jobs.
"We are homeschooling a second-grader, and we are trying to get Danny's therapies in too the best that we can. But we just cannot replicate what they can do at school," said Scully.
Danny DeBatt was just beginning to learn how to communicate when the pandemic closed his school, a possible disruption to his progress.
Many parents are concerned about the pandemic's lasting impact on their children's emotional development.
"The grief almost feels fresh to them every day, almost like they're re-experiencing it all over for the first time," Winchell said. "So we're having a lot of, you know, just daily crying."
"I taught her the word 'coronavirus.' She knows the word 'COVID-19.' It's to the point now that she calls it 'stupid coronavirus,'" she said.
Then, there's the cabin fever.
The Gorskis haven't left their home in more than three weeks, a situation that has tested their patience with each other and family communication skills.
"The lack of adult contact is pretty challenging," said Rob Gorski. "I love my kids, and if I could be on lockdown with anybody, it'd be with my kids. But it does sort of take its toll."
During a family conversation recorded for ABC News, Gavin Gorski, 20, said he is "always trying to find ways to stay relaxed and stay calm," while 14-year-old Elliot said the "most important" coping mechanism has been sleep. And 11-year-old Emmet Gorski said his advice is to "stick with your parents, like we stick with our dad."
"I don't think so much about how to get through it, I just know that, like, my kids are relying on me and I have to do whatever I have to do," says Rob Gorski.
With much of the country binge-watching television shows and reading books, even as economic worries loom in the back of their minds, parents of kids with special needs who have recently lost their jobs are reeling.
"We just don't know how long it's going to last," said Foster, who was laid off from her job at a printing company last month. "I would love to say that everything will go back to normal tomorrow, that you just snap our fingers and everything will be back just the way that it was. But it won't."
"Trying to keep a positive attitude," Foster adds. "Jeremiah is always a beacon of sunshine as it is anyway."
A focus on the moments of love and laughter is a top survival technique, the parents told ABC News.
"It may not be pretty, and it may not be joyous, and it may not be how you want to get through something, but you'll get through it," said Chris DeBatt. "And there's something on the other side."
These parents of special needs children offered a poignant reminder that there is light at the end of the tunnel -- and light in those we love.
"I think this sense that nothing is permanent, that life's not a given, that life's so fragile -- that's, I think, what disabled families know," said Winchell. "That's the wisdom that we're bringing into the experience of quarantine and into COVID."
iStock/Halfpoint(NEW YORK) -- As the novel coronavirus outbreak rages on, researchers are learning more about which individuals are at risk of being severely sickened -- or dying -- from the disease.
A study published this week in the journal The Lancet examined data from individuals who tested positive for COVID-19 in 38 countries and found that risk of death from the disease rose with each decade of age.
The death rate among those who were sickened by the disease was roughly 0.03% for people in their 20s; 0.08% for people in their 30s; 0.16% for people in their 40s; 0.6% for people in their 50s; 1.9% for people in their 60s; 4.3% for people in their 70s; and 7.8% for people 80 years old and older, the researchers found.
Those at highest risk for severe disease and death were people over the age of 80 who had underlying conditions, including hypertension, diabetes, cardiovascular disease, chronic respiratory disease and cancer.
Many countries have struggled to effectively test their citizens for coronavirus. Most individuals who contract COVID-19 have mild symptoms or no symptoms at all, making it difficult for scientists to assess the disease's mortality rate without them being tested.
According to the new study, the researchers' best estimate for fatality among people who were sickened by COVID-19 in China was 1.4%, which is significantly lower than the 3.4% fatality rate earlier studies found.
The average time between the onset of COVID-19 symptoms and death was about 18 days, while the average time between onset of symptoms and discharge from the hospital was roughly 25 days.
Tero Vesalainen(NEW ORLEANS) -- When New Orleans freelance writer Sarah Netter first started coughing and showing a fever, her thoughts gravitated to the coronavirus outbreak that was starting to gain a foothold in the United States. When her breathing labored and her chest hurt, she became more convinced that these were the symptoms virus patients were consistently describing.
But then she was tested. The result: negative. Her doctor, she said, was “stunned.” Netter, a former ABC News producer, and her doctor remain unconvinced.
“You know, your symptoms match perfectly,” she said her doctor told her. “It could just be a random virus. But I'm pretty well versed in upper respiratory illnesses, and I have never had anything that felt like this.”
Medical experts say all evidence suggest the coronavirus tests becoming steadily more available are reliable. But as with any medical test, the coronavirus test cannot be expected to be accurate 100% of the time, so they still advise that people who test negative, if their symptoms are consistent with those of COVID-19, should consider getting re-tested and continue to quarantine until asymptomatic.
The are several tests for COVID-19 that are being used in labs across the country. Each of them looks for specific genetic material from the virus. If that unique genetic material is on the swab, the test reads positive. If the test does not find viral evidence on the swab, though, the test will read negative, even – in some cases – when the person might be infected.
The tests will “never be perfect,” said Dr. Angela Caliendo, an infectious disease expert at Brown University’s medical school. “You're going to miss people, particularly … early in disease with not a great specimen.”
It is too soon to know how many tests are producing false negatives. Molecular tests for viruses like the ones commonly being used for COVID-19 generally have very high sensitivities. According to the CDC, the same kinds of tests used for flu have a sensitivity in the range of 90-95%.
Roche, one of the largest manufacturers of tests, told ABC News that their coronavirus tests have a similarly high sensitivity of 95%, meaning that the tests could miss about 5% of infected people.
Others did not provide ABC News with a figure. Quest, for example, another major manufacturer, told ABC News that because the tests were approved by the FDA under an Emergency Use Authorization, “these FDA EUA assays have not been clinically validated. Hence there are no clinical sensitivity and specificity data for any of the FDA EUA assays.”
But Harlan Krumholz, a professor of medicine at Yale and director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation, has warned that the problem could be much bigger than that.
“Unfortunately, we have very little public data on the false-negative rate for these tests in clinical practice,” Krumholz wrote in The New York Times on Wednesday. “Research coming out of China indicates that the false-negative rate may be around 30 percent. Some of my colleagues, experts in laboratory medicine, express concerns the false-negative rate in this country could be even higher.”
While a positive reading is almost always reliable, said Dr. Mark Abdelmalek, false negatives can surface in cases where the test is administered incorrectly, or the sample is mishandled on the way to the lab.
“All tests have a chance of false negatives,” said Abdelmalek, an ABC News medical contributor. “It’s not that this test is faulty.”
There are a few scenarios, Abdelmalek explained, that can skew test results.
Faulty Collection: The preferred swab is from the back of the nose. Samples from the back of the throat or the nostrils are sometimes taken, but those could increase the chance of a negative test even if a person is infected.
Bad timing: If the test was conducted too early or too late, virus may not be detected. Swabs collected too early may not capture enough virus for a test to pick-up the virus particles. And if they are sampled too late, virus levels may have begun to subside, leaving too little of the virus to be detected.
Mishandling: Given the crush of tests being collected, samples that are not stored properly – refrigerated immediately, and frozen if they are held longer than 72 hours – can degrade before they are tested.
“Every test has a limit of sensitivities,” said Dr. Alan Wells, a professor of Pathology at the University of Pittsburgh Medical Center. “You can’t expect of every virus that if you have very, very low levels of virus, that I can find it because it's not there to be seen.”
“I know it's disconcerting for families and the public to hear that you can't find anything, but this is nothing that's different from any flu season where there are some respiratory pneumonia, pneumonias that tend to not be explained,” Wells told ABC News. “That's not as bad as it sounds. And the reason it's not as bad as it sounds is the treatment for most of these patients…is the same.”
While the idea of potentially suffering from COVID-19 but not testing positive for it sounds alarming, medical experts said it doesn’t need to be. Given the symptoms Netter was facing, for example, she said her doctors advised a course of treatment no different than the one for coronavirus.
“I'm still quarantined,” she said. “I'm going to wait until I'm 100 percent asymptomatic … [and] not going anywhere. I’m staying at home.”
Vadym Terelyuk/iStock(NEW YORK) -- Hospitals across the U.S. battling the coronavirus have been consistently reporting shortages of personal protective gear, ventilators and drugs used to help patients with pain management. But medical professionals in the state that's become the front line in America's fight against COVID-19 say they're concerned about the flow of oxygen itself to patients.
“The hospital was close to running out of oxygen," said an emergency room doctor at Elmhurst Hospital in Queens, New York, which has become known as the epicenter of the outbreak in the state. "With the number of patients we have, We are using up resources at an unusual rate."
Across the city in Brooklyn, Dr. Dorian Alexander at Brookdale Hospital said, "We burn through oxygen everyday."
"We're consuming oxygen faster than we've ever consumed oxygen in hospitals before," said Dr. Peter Papadakos, the director of critical care medicine and professor of anesthesiology, surgery and neurosurgery at the University of Rochester Medical Center.
The New York-Presbyterian system is trying to alleviate the stress on its hospitals by sending some stable patients home with small oxygen tanks, according to sources familiar with the matter.
In most cases, the patients have been discharged from the emergency department with often positive but not severe cases of coronavirus and are provided with a portable meter that measures oxygen levels to track how they are doing or home oxygen tanks. The patients, sources said, then have a follow-up a tele-visit from a physician within 12 to 24 hours.
COVID-19 patients who are hospitalized can develop pneumonia and end up in respiratory distress. When breathing becomes difficult patients often require supplemental oxygen. But the spike in demand for oxygen by coronavirus cases directly impacts other non-coronavirus patients, and could strain oxygen resources for everyone who relies on it inside and outside the hospital, Papadakos told ABC News.
"How do you ration it? There are hundreds of thousands of patients," he said. "You've seen them down in Florida or if you've taken a cruise, walking around with their little oxygen tanks. There's people getting oxygen at home in tanks. Your grandma, the lady down the street. What happens when they can't get oxygen because of the pandemic?"
The air people breathe is about 21% oxygen, but more highly concentrated, pressurized oxygen is a commodity, especially in medicine. In most circumstances, oxygen is produced in plants and facilities across the country two general ways. Larger, high-pressure tanks are typically sent to hospitals and other medical facilities. Lower pressure tanks, which are typically smaller, are designed for personal use.
One of the world's largest oxygen suppliers, Air Products, is "not currently experienc[ing] production shortages in our businesses, including medical oxygen," company spokesperson Art George said. "Where we can around the world, we are building inventory. Our employees are proud to be considered business critical and be making a vital contribution to this effort. This is a dynamic situation and we are preparing to take the appropriate steps to help meet potential future needs as best we can."
Air Products in the U.S. does not produce oxygen in tanks, according to George, but does provide oxygen to distributors who do. "We are giving high priority to distributors who deliver oxygen to the medical industry and prioritizing fill scheduling to this safety sensitive and critical industry," George added.
Linde plc, an Irish chemical company that owns and operates Praxair, and Airgas, together two of the largest industrial gas suppliers in the U.S., said they have seen an increased demand for oxygen from hospitals, medical centers and providers due to coronavirus cases, according spokespersons for both companies.
"As COVID-19 is predominantly a respiratory disease, and as patient numbers continue to rise, we're going to see an increase in demand for medical oxygen" said Dr. David Ferraro, the Society of Critical Care Medicine Fundamental Disaster Management vice chair.
He said it will be vital for hospital systems nationwide to keep a close eye on their current supply of oxygen, as if it were necessities like personal protective equipment, ventilators, regularly used medications and other resources related to COVID-19 -- as well as their supply chains. Current and potential shortages with which states like New York are dealing may become the problems of other states soon when their own surge begins, Ferraro said.
"Hospitals need to be smart and wise with oxygen use. We might take some aspects of medical therapy for granted, like the supply of medical oxygen. Oxygen for medical use still has to be produced, however, just like medications and [personal protective equipment]," he said. "We are realizing that there is not an infinite supply. Oxygen might become a limited commodity just like ventilators or medications if supply chains cannot keep up with our increased demand. If so, it will be just like a precious metal that we don't have an infinite amount of, such as gold."
Normal oxygen saturation levels are usually around 95-100%. According to COVID-19 guidance from the World Health Organization, patients in severe breathing distress should have oxygen saturation levels above 94%.
But Ferraro said there are ways for hospitals to conserve conserve oxygen use, suggesting they pay close attention to each patient's oxygen level to make sure only those who really need it, get it -- especially once breathing begins to improve. The World Health Organization guidance says for stable patients, the range may be 90-95% oxygen saturation depending on the patient.
"If a patient's oxygen saturations while on oxygen supplementation are well over this goal of 90 to 92%, we are potentially not conserving our oxygen utilization," said Ferraro. "If you had a band-aid shortage, why put five band-aids on a cut if you only need one?"
FilippoBacci/iStock(NEW YORK) -- With new stories emerging about the rapid spread of COVID-19, public health experts are now warning the public to stay inside even if they feel healthy. The reason? You may be an asymptomatic carrier.
"Asymptomatic transmission means you can be infected with the virus, have no symptoms and still be contagious," Dr. William Schaffner, professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center, told ABC News.
Most people who pass along the virus do so while they’re sick, usually because they’re coughing or sneezing, which sheds a lot of infectious viruses. But, there is still a significant number of people who transmit that are asymptomatic.
For example, Dr. John Williams, chief of the division of pediatric infectious diseases at University of Pittsburgh Medical Center Children’s Hospital, pointed out that "asymptomatic infection is common in children, occurring in 10-30%" of cases.
Experts don’t know what portion of adults with COVID-19 are asymptomatic.
"At a time when there is a lot of community transmission, figuring out how much is silent transmission is tricky at best," Dr. Todd Ellerin, chief of infectious disease at South Shore Health, told ABC News.
But this week, the Centers for Disease Control and Prevention Director Dr. Robert Redfield estimated asymptomatic transmission could be as high as 25%. And early data from pandemic hotspots seems to indicate that many people don’t have symptoms on the day they were tested.
For example, among the over 3,700 passengers on the Diamond Princess cruise liner who tested positive for COVID-19, more than 46% were not showing symptoms at the time they were tested. In Iceland, about half of the people who tested positive for COVID-19 were asymptomatic, according to one study.
And here in the United States, during the outbreak at a long-term care skilled nursing facility in King County, Washington, 23 residents tested positive, despite 13 being asymptomatic that day, according to the CDC.
This issue gets to the heart of why the COVID-19 pandemic has been hard to contain. Even though many people feel fine, they are still capable of transmitting the virus to others.
"The virus has a long incubation period so symptoms might not appear until five to 14 days," Dr. Simone Wildes, an infectious disease specialist at South Shore Health, said. "Therefore, people can be spreading the disease without actually knowing they are sick."
The European Center for Disease Prevention and Control estimates that the novel coronavirus that causes COVID-19 can be picked up by a conventional test about one to two days before symptoms appear.
This means that -- for a few days at least -- people have enough virus in their bodies to be detected by lab tests, but they might not feel sick yet. Some of them will never get sick, which means they are totally "asymptomatic," while others will eventually come down with symptoms, which is called "presymptomatic."
With testing in the United States still reserved mostly for those who are already sick, there's no way to know if you are one of these asymptomatic carriers. Right now, the country does not have enough tests to warrant mass testing among people who feel healthy.
"There may be a role for testing certain high-risk groups to rule out asymptomatic infection, but at this stage, that would be an exception and not the rule," Ellerin said. "That is not ready for prime time."
But our new understanding about asymptomatic transmission has public health experts weighing the merit of asking everyone to wear masks -- not just healthcare workers and people who are already feeling symptoms.
The federal government’s recommendations around mask-wearing could soon evolve, with Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, telling CNN that the idea that all Americans should wear masks is "under very active consideration."
"There isn’t a recommendation on that yet, but if it were to occur one of the driving forces would be to decrease transmission from a symptomatic or asymptomatic infected individual to uninfected individuals," Ellerin said.
For the time being, public health experts are asking everyone to assume they could be spreading the virus.
"This is why social distancing isn’t based on who 'looks sick,’" Williams said.
"You can catch [the virus] from someone who is perfectly normal and has no symptoms," said Schaffner. On the flip side, he said, "you can be perfectly healthy and be a risk to other people because you may have the infection and be contagious and not know it."
"Stay at home. No one wants to be the dreaded spreader," Schaffner said.
ugurhan/iStock(NEW YORK) -- As states sound the alarm over a lack of ventilators to help hospitalized novel coronavirus patients -- including a plea for 30,000 machines for New York state alone -- experts warned that even if the equipment arrives, facilities could face a shortage of health care workers trained to use them.
"If you have a thousand more ventilators magically appear, do you have the 20 ICU [Intensive Care Unit] doctors, 300 ICU nurses, 150 respiratory therapists and all of the [personal protective equipment] needed to support those 1,000 new ventilators?" Dr. Doug White, an intensive care physician with the University of Pittsburgh School of Medicine, told ABC News. "Simply put, ventilators don’t run themselves."
Personnel specially trained to treat patients with ventilators is just one of the latest possible second-order shortages that government and hospital officials are discovering as the battle against the coronavirus relentlessly drags on, a list that some doctors now say also includes critical drugs used to sedate patients who need to be intubated as part of their treatment.
New York Gov. Andrew Cuomo on Monday called on other states to send as many health care workers as they can to assist the strained system in his state.
There are approximately 6,800 licensed respiratory therapists in New York state, according to the state's Education Department, which handles professional licensing. They are specialists who closely monitor patients and adjust treatments using the lifesaving -- and, in some cases, highly sophisticated -- ventilators to breathe.
But even with the addition of hundreds of respiratory therapists expected to graduate from schools in New York this spring, the help of anesthesiologists and other physicians freed up by the postponement of elective procedures and tens of thousands of volunteer health care workers, health officials remain concerned about personnel shortages. They could limit hospitals’ abilities to treat patients at the peak of the outbreak in the state and nationwide that could be as many as two weeks away. Experts said those with specialty training are key.
New York state counts more than 75,000 cases of coronavirus infections so far, according to Cuomo. Nationwide, over 186,000 people have tested positive for the virus and more than 4,000 have died, according to a count by Johns Hopkins University.
Cuomo said Tuesday that in New York state 2,710 patients were currently in the state's intensive care units and nearly 300 had to be intubated and put on ventilators.
According to medical experts, the normal standard of care for a ventilated patient includes around-the-clock care from a team of nurses and respiratory therapists, under the supervision of an intensive care doctor.
Now, due to the influx of patients needing ICU care, one ICU doctor may now manage four times the number of ventilated patients they normally do, with a team of non-ICU specialist doctors working underneath them.
It's a strained system that could buckle even further if large numbers of front-line nurses and doctors contract the coronavirus due to shortages of personal protective equipment.
"This will likely result in a lower quality of care, and [it's] why the standard of care changes in an emergency," said White. "Critical care physicians are trained in respiratory and multi-organ failure in a way that no other specialty is."
When those physicians are transitioned from being directly involved to now managing a group of non-ICU doctors, it changes the care the patient gets, he said.
Dr. Greg Martin with the Society of Critical Care Medicine, a professional organization devoted to the care of the most critical patients, said it’s hard to project which workforce of the three -- doctors, nurses and respiratory therapists -- will be the first to become stretched. But he speculated it would be the 28,000 intensivist physicians or ICU doctors who work in the U.S.: "You will realize you can’t rely on the intensivists to be available for every patient."
Roughly 5,800 nurses in New York state are critical-care certified, according to the American Association of Critical-Care Nurses. Some 120,000 are credentialed for acute and critical care nationwide, the group said.
"You can’t win a war with no troops," Dr. Peter Papadakos, the director of critical care medicine at the University of Rochester Medical Center, told ABC News about the potential personnel shortage. "You can have fancy equipment, but if you don’t have any troops and if you don’t have any gasoline ... you lose the war."
Doctors fear drug shortages after 'tsunami of patients'
At Elmhurst Hospital in the borough of Queens in New York City, said to be the "ground zero" of infections in the U.S., the problem isn't a shortage of ventilators or even people -- it's drugs used to sedate patients when they're intubated, along with the equipment used to deliver those drugs, according to a doctor who works there.
In another New York City ICU, a critical care physician told ABC News their hospital is also having to confront drug shortages, including those used to sedate patients.
"If you aren’t sedating someone enough, you always run the risk of someone self-excavating, which is ripping the tube out of themselves because they’re too awake," the physician said.
When a patient is intubated, they are usually given a combination of sedatives and anesthetics before a breathing tube is inserted down their throat. Patients sometimes also require paralytic drugs to loosen up their vocal cords and other muscles to prevent damage when the breathing tube is inserted.
Patients continue to receive sedatives and pain relievers to keep them asleep while intubated, to prevent their bodies from fighting against both the breathing tube and the ventilator, which performs breathing functions for patients to allow their own lungs to heal.
With many COVID-19 patients requiring ventilators for weeks, some health officials are worried that the nation’s supply of necessary drugs won’t be enough to help the country weather a prolonged and sustained outbreak across multiple cities and states.
Dr. Erin Fox, who tracks and investigates drug shortages reported from hospitals around the country, told ABC News that some of the most commonly used drugs to intubate and maintain a patient on ventilator are running in short supply.
"We see a tsunami of patients coming our way, and we don’t see a tsunami of drug availability coming our way. It’s scary to think, you might not have enough medicine," she said.
Three of the drugs reportedly in short supply, according to Fox, are the sedative etomidate, an anesthetic ketamine and a muscle-relaxing medication called rocuronium. Several hospitals with whom ABC News spoke said they were running low on the critical medications.
While doctors and hospitals have the ability to use alternative drugs in some cases to help intubate and sedate patients, experts worry that a prolonged worldwide outbreak could severely stretch the global pharmaceutical supply chain, forcing countries to fight among one another for resources as several states have been forced to do for protective equipment in the U.S.
The American Society of Health System Pharmacists runs the database that monitors drug shortages reported from their 55,000 members across the country who work in hospital pharmacies. The demand for drugs is not just in hot spots, but nationwide.
"With all this surge capacity that's being built, do we have the drug supply to match it? Right now the answer appears to be 'no,'" said Dr. Michael Ganio, one of the society’s members.
At one health system that runs over 40 hospitals in Ohio and Virginia, a pharmacy director told ABC News they are starting to see shortages in medications used to sedate patients who are ventilated. Their pharmacy team is already coming up with contingency plans for when the preferred drugs run out.
"The problem is, we’re all using the same manufacturers and same wholesalers. We’re all competing for the same resource," the director said.
MarianVejcik/iStock(NEW YORK) -- Dozens of scientists across the globe are expeditiously developing and testing a variety of therapeutic treatments for COVID-19, the respiratory illness caused by a novel coronavirus. Meanwhile, dozens more are working to protect those who have not yet been affected by creating a vaccine.
The Department of Health and Human Services just announced that the government is working with major pharmaceutical and biotech companies to speed up the development of COVID-19 vaccine trials and, ultimately, the manufacturing of said vaccines.
As Dr. Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases, keeps reminding us, the development timeline for treatments and vaccines are "fundamentally different."
Although it likely will take more than a year before a vaccine is ready for the public, Fauci also said COVID-19 vaccine development is on track to be "literally the fastest that we have ever done."
With more people being infected and lockdown orders creating immense financial burdens with so many not allowed to work, the question becomes even more pressing: Is there a viable vaccine in sight?
Dr. Maria Elena Bottazzi, co-director of the Texas Children's Hospital Center for Vaccine Development, believes a previously stated 12- to 18-month timeline may be too optimistic.
"My concern is that people are hearing we are going to see things in a year or 18 months," Bottazzi told ABC News. "The reality is: That's probably not going to happen. We may have some real optimism and some safety evidence by then, but not a vaccine."
"There's a long road after safety -- you still have to do a lot of things before you can confirm the efficacy and give this to the public en masse," Bottazzi added. "That's the hard message. It's not just a 30- or 40-people trial to lead us to a solution."
The long road to vaccine development
Vaccines train a person's immune system to recognize a pathogen and attack it before it infects healthy cells. Vaccines can prime the immune system, give it a head start, get it ready to fight.
But before vaccines can be tested for efficacy, they undergo even more safety testing than ordinary medicines. As Bottazzi noted, vaccines are intended for use among healthy people and there's "a high bar to make sure they are going to do more good than harm."
Safety is the focus of Phase I testing, while Phase II involves determining whether or not the vaccines work. Bottazzi noted that many of the front-runner vaccine candidates that have received both media attention and critical funding dollars are new and unproven, and some use technology never used in humans.
"The vaccines that have been funded and accelerated are all novel technologies -- I'm not saying that they are not going to work, but they are novel," Bottazzi cautioned.
Some candidates, such as a vaccine by Cambridge, Massachusetts-based biotechnology company Moderna, use a technique never before been used on humans. Despite relying on new technology, Moderna's vaccine was rushed to Phase I trials before it was tested on animals, which, Bottazzi said "is very unusual."
Mass producing vaccines before they're proven
In a White House briefing last week, Fauci pointed out that vaccine production, too, would need to be expedited -- likely at an unusual stage of development.
Typically, pharmaceutical companies would wait to see if their vaccine works in clinical trials before ramping up production. Not so with this pandemic, because, experts have said, production on large quantities will need to begin before having complete data. That way, they can be ready to distribute widely when it's finally proven safe and effective.
"Even before you know something works," Fauci said, "you have to start producing it. Because once you know it works, you can't say, 'Great it works -- now give me another six months to produce it.'"
Those tactics present a risk, Fauci acknowledged, because it's unclear which vaccines now being tested will end up working, or working the best, but it's a risk developers must take. There's also concern using new technologies may create additional challenges.
"Vaccines should be easy to make -- generic enough that everyone can reproduce them, with minimum proprietary technology," Bottazzi said, adding that doing so can prevent "another big bottleneck for vaccines."
Her group at Texas Children's Hospital and other vaccine producers are staying with tried-and-true development methods, including the incorporation of a complimentary ingredient called an "adjuvant," which boosts the immune system's response to the vaccine.
"Our vaccine uses the simplest and safest adjuvant possible: aluminum, the only adjuvant that has been licensed all over the world," she said.
Not all vaccines, including several COVID-19 front-runners, use adjuvants, but many researchers consider it safer. Compounds including adjuvants require less of the new drug, also called the "antigen," which reduces potential side effects and makes the overall vaccines cheaper to produce.
"Adjuvants classically will allow you to get a robust immune response at a tenfold-lower antigen dose," said Dr. Ofer Levy, an infectious disease physician and leader of the Precision Vaccines Program at Boston Children's Hospital. "How are you going to scale a vaccine to a billion doses without an adjuvant? I'm not seeing it."
Echoing that newer vaccine technologies may be more expensive, time-intensive and difficult to mass produce, Levy said his group at Harvard instead is focusing on finding an adjuvant that's particularly effective in vulnerable populations.
In the meantime, experts are hopeful another type of therapy soon will be available: convalescent plasma, a still-experimental treatment in which antibodies from someone who recovered from COVID-19 are shared via infusion. This method could be used to treat those hospitalized with the novel coronavirus as well as boost the immune systems of healthy people at the greatest risk of contracting it.
Patients at New York's Mount Sinai Hospital now will be administered convalescent plasma under careful supervision.
Bottazzi said: "Bottom Line: Let's continue to be optimistic, but at the same time be aware that it will take a lot of time, trial and error, and failures."
utah778/iStock(NEW YORK) -- The United States health care system is mobilizing to triage a public health emergency that is rapidly taking members of its workforce out of the ranks.
Grim projections from the country's leading health officials over the weekend emphasized the toll the novel coronavirus could have on the U.S. healthcare workforce, one that is buckling under a surge in demand and an inadequate supply of protective gear that is endangering the lives of front-line responders.
At a White House coronavirus task force press briefing Sunday, Dr. Anthony Fauci said it is possible that 100,000 to 200,000 people in the U.S. will die from the novel coronavirus.
Amid an alarming rise in cases in California where hospitalizations have doubled and ICU admissions have tripled in recent days, Gov. Gavin Newsom launched an initiative Monday aimed at increasing the ranks of the state's health care workforce in advance of an expected surge in coronavirus patients.
"If you're a nursing school student, a medical school student, we need you," Gov. Newsom said at a press conference Monday.
The newly created California Health Corps will recruit health care providers, including medical students nearing completion of their studies, to address what the governor called the "human capital surge" that the state will need to ensure an adequate workforce is available to assist in the state's pandemic response.
Medical students nationwide, just months away from becoming resident doctors, are eager to alleviate the pressure on health care professionals by joining the fight.
"There’s a large group of resilient people out there who are ready to go on the front lines and help," said Lizzie Andrews, a fourth-year medical student at Texas A&M who will start her residency at NewYork-Presbyterian Brooklyn Methodist Hospital in June.
"We’ve been preparing for this for all four years and that’s what we want to do -- we want to help people," Andrews said. "That’s why we got into medicine in the first place."
Starting residency amid a global pandemic is something most medical students never imagined doing. Less than two weeks ago, fourth-year students were matched to the hospital residency programs where they will begin their careers as doctors. According to the National Resident Match Program, the 2020 match was the program’s largest in its history with a record-high of 40,084 applications for 37,256 positions.
Although some states require residents to have training licenses, New York law allows students who have graduated medical school to manage patients without a medical license, as long as it occurs under the supervision of a licensed physician and as a part of an accredited residency program.
Some schools are offering early graduation
In response to a similar directive from Gov. Andrew Cuomo to add to New York's health care workforce, New York medical schools announced last week they would allow fourth-year medical students to graduate early, in an effort to ease the burden the coronavirus has placed on the state's health care system. Columbia University Vagelos College of Physicians and Surgeons has offered its fourth-year medical students temporary employment at New York-Presbyterian Hospital until they depart for their respective residency programs, according to a letter sent to students and provided to ABC News.
But efforts to fast-track medical students to the front lines of the U.S. pandemic response are complicated by several factors, including inflexible state licensing requirements and a severe lack of personal protective equipment that is crippling the ability of existing first responders to do their jobs safely.
In Washington state, where the first U.S. coronavirus case was recorded in January, a spokesperson for the University of Washington School of Medicine told ABC News Monday the school has no plans to graduate its medical students early. The decision was in part due to the state medical board, which has not changed its licensing requirements to allow students to go into their residency training if they were to graduate early. The spokesperson also told ABC News the residency programs are currently overwhelmed and cannot handle the onboarding of new interns or residents and had also experienced issues related to a shortage of personal protective equipment.
In California, a spokesperson from Stanford University told ABC News Monday the school did not expect to adjust the date of graduation for medical students. The spokesperson also said Stanford Medicine did not have staffing shortages and was redeploying current staff to areas where they were most needed.
Elsewhere in the country, state governments and health officials are preparing for the surge in their own communities and facilitating the changes needed to increase the workforce with medical school graduates.
Amid an escalating situation in Illinois, Gov. J.B. Pritzker has prepared for the surge in coronavirus patients with response plans that include options to deploy medical students. Last week top health experts, including the Surgeon General Dr. Jerome Adams, warned Chicago was one of the major U.S. cities identified as future hotspots.
"The governor and his administration are exploring every option at our disposal to ensure the safety and well-being of all Illinois residents during this crisis," Jose Sanchez Molina, the governor’s deputy press secretary, said in a statement to ABC News. "The administration is working closely with universities across the state and early graduation for medical students is an option we are looking into."
In Massachusetts, the state worked with the deans of medical schools on early graduations to expand the "cadre of physicians" who can join the state's fight against COVID-19, the Secretary of Health and Human Services Marylou Sudders said during one of Gov. Charlie Baker's daily press conferences last week. According to Sudders, the state's Board of Registration of Medicine is prepared to provide medical school graduates with provisional 90-day limited licenses to practice medicine. Top Boston institutions, including Harvard Medical School, responded by announcing early graduation options for medical students.
In hard-hit southern California, at the University of California Los Angeles (UCLA) Dr. Clarence Braddock, the vice dean for education at the David Geffen School of Medicine, told ABC News Monday UCLA would offer early graduation to its medical students if they have met the requirements and are matched to a residency program that wants to start and hire them early.
"We’re going to need them," Braddock said in an interview with ABC News last week. "Maybe some places sooner than others, but we’re definitely going to need them."
He called the current situation surrounding the coronavirus pandemic unprecedented.
"I have been in medicine for close to 40 years and this is not like anything I’ve seen in my career," Braddock said.
Medical grad students face equipment shortages
While health experts acknowledge the assistance medical students can offer in the pandemic response, they remain divided on the extent of the role these soon-to-be doctors can play. Despite the willingness of medical students to join responders on the front lines, the critical shortage of personal protective equipment to safeguard them from infection has frustrated that process.
"In many ways, they are at their peak of medical knowledge," Dr. Humayun Chaudhry, the president of the Federation of State Medical Boards, told ABC News. "Many of them know the basic sort of physical diagnosis skills that they need, and they feel frustrated," Chaudhry said in the interview. "And I understand their frustration, but I think …we have to look out for their health as well."
Dr. Janis Orlowski, the chief health officer of the Association of American Medical Colleges (AAMC), said the organization was trying to respond to workforce and supply issues and make smart decisions about the involvement of medical students and resident physicians.
"We’re trying to expand the workforce and we’re trying to make sure that we keep the workforce safe so that they can continue to work," Orlowski told ABC News in an interview last Thursday.
She said younger doctors make more mistakes in using protective equipment and protective gowns, but that the AAMC would continue working on their involvement. Chaudry said he hoped the limited personal protective gear would be addressed.
"It would not be ethical, to be honest, to have thousands of medical students helping out in hospitals or in clinics or in county health departments without that equipment," he said.
Obstacles for foreign medical students
Another factor complicating the health care system's pandemic response is the thousands of foreign doctors set to come to the U.S. for residency programs in American hospitals. According to the Educational Commission for Foreign Medical Graduates, international medical graduates account for a quarter of the active physician workforce and stand to play a critical role in combatting COVID-19.
Their ability to contribute was in jeopardy after a March 18 announcement that the U.S. was suspending routine visa processing due to the coronavirus, which included the types of visas used for international medical graduates entering the U.S. for residency programs.
However, a new communication from the U.S. Department of State last Friday signaled the U.S. would resume processing J and H visa applications for medical professionals seeking to enter the U.S.
Despite the development, there are still significant obstacles for international medical graduates. Widespread international flight restrictions that may still be in place at the start of residency programs and embassy closures throughout the world are just some barriers they may encounter on the journey to the U.S. to begin residency programs.
In the event foreign doctors cannot travel to the U.S., hospitals will face real problems in meeting health care needs and combating the COVID-19 health care crisis, according to Dr. William W. Pinsky, the president and CEO of the Educational Commission for Foreign Medical Graduates.
"I think they’re going to have to deploy people differently," Pinsky said in an interview with ABC News. "It’ll be a real issue."
Hospitals nationwide are preemptively addressing any potential complications, including those involving foreign doctors, which might delay adding physicians to their ranks. Henry Ford Hospital in Detroit is proactively addressing the issues facing international medical graduates by working to ensure that anybody who is on a visa is not assigned to a critical rotation for the first month to two months of the residency program, according to Dr. Kimberly Baker-Genaw, the director of medical education.
Hospitals innovate to onboard residents
Although Henry Ford Hospital intends to welcome first-year residents in person, Baker-Genaw told ABC News the hospital is trying to be proactive in its onboarding plans.
"We have already implemented a plan to orient the group virtually and are working along a pretty rapid path to put that in place," Baker-Genaw said.
A spokesperson for the Inova hospital system, which maintains a vast integrated network of hospitals, primary care and emergency centers in Virginia, told ABC News that Inova was considering conducting resident orientation via Zoom remote conferencing services.
Braddock also told ABC News the UCLA hospital system was reviewing the workflow of onboarding new residents and actively exploring whether some of that process and training could be pushed to remote methods.
"We believe that the idea of accelerating the onboarding of residents is one of many effective strategies to supplement the workforce quickly and efficiently," Braddock said.
For medical students on the cusp of becoming resident doctors, the unprecedented health emergency of the coronavirus pandemic has brought an expedited end to their education and unconventional start to their professional careers.
"We are in uncharted territory," Emily Gonzalez, a fourth-year medical student who will begin her residency at Baylor University Medical Center in Dallas, told ABC News.
"It’s scary, but fourth-year medical students are ready to get involved. We are living history right now," she said.
fizkes/iStock(NEW YORK) -- On Monday, President Donald Trump’s administration took the unprecedented step to temporarily waive rules for the nation's largest insurer -- Centers for Medicare & Medicaid Services (CMS) -- giving some healthcare providers the ability to have phone-only visits with their patients as the coronavirus crisis rages on.
CMS covers at least 140 million Americans through Medicare, Medicaid, the Children’s Health Insurance Program, and Federal Exchanges -- typically covering a constituency of people with disabilities, the elderly, and those with low incomes, many of whom may be unable to access the advanced technologies required for telehealth -- seen as an important emerging tool in maintaining people's health amid the fight against the virus.
“During the public health emergencies, individuals can use interactive apps with audio and video capabilities to visit with their clinician for an even broader range of services,” CMS said in a statement. “Providers also can evaluate beneficiaries who have audio phones only.”
Up until this announcement, CMS had not allowed its beneficiaries to use the easiest method to communicate with their doctor: phone calls. While it had loosened its regulations to allow the use of FaceTime and Skype, patients still needed both “audio and video capabilities.” But nearly 35 million Americans do not use the internet, according to Pew Research Center, leaving some of the nation’s poorest unable to take advantage of telemedicine.
“Access to phone-only services is a health equity and social justice issue,” said Dr. Jared Skillings, the chief of Professional Practice for the American Psychological Association. “Many patients and some providers do not have access or capability to use cellphones with video chat. They may also not have internet service or broadband speed.”
As the novel coronavirus continues to spread across the country, infecting more than 160,000 people in the United States alone -- the most confirmed cases of any country in the world -- Americans continue to try to “flatten the curve” by self-quarantining inside their homes and physically distancing themselves from others.
So medical leaders from across the country pushed for regulations surrounding telehealth -- health services through telecommunication technology -- to change, trying to ensure healthcare providers could properly take care of their patients, as well as get paid for the work they do.
“One of the ways, and in a critical way, that we can continue to offer health services – where appropriate – is the use of telehealth,” said Dr. Patrice Harris, the president of the American Medical Association, recommending medical practices of all specialties should look into telehealth to keep providing services to their patients.
That’s why Skillings, Harris, and other leaders in the medical field pushed -- and are continuing to advocate for -- CMS, state regulators and private insurance companies to expand their policies to accommodate situations where simultaneous two-way audio and video capabilities are impossible.
But challenges still remain.
While CMS expanded access to neuropsychological and psychological testing by allowing telehealth for the first time, it still does not cover typical therapy services by phone, according to Dr. Stephen Gillaspy, APA’s director of health care financing.
This temporary deregulation -- that ignored therapy sessions -- came just a day after Trump suggested that there will be a rise in depression, saying "You're going to have mental depression for people. You're going to have large numbers of suicides.” And yet, access to phone-only therapy for Americans covered by CMS is unavailable.
“Now, that makes no sense for all kinds of vulnerable populations, older adults, people with lower-income, folks with disabilities," said Skillings. "I'll give you the best example I have heard from one of my best friend colleagues -- she said, ‘Why should people who are visually impaired have to do a video chat?’ That makes no sense.”
Additionally, the regulatory waiver is only temporary.
CMS is federally run, but insurance -- including telehealth policies -- is regulated at the state level. Every state and every private health insurance company has different policies. To add to the complexity, tens of millions of Americans are not insured, and tens of millions more are on self-insured plans, which have different policies than those who are fully insured.
Because there isn’t a one-answer-fits-all policy nationwide, patients can have a hard time recognizing which policy applies to them, furthering the difficulty of finding the proper care they need.
And because it is fundamentally up to the states to adopt these new rules and regulations, this will result in a fragmented adoption of policies and make it more difficult for multi-state providers according to Dr. Bill Mills, Chief Medical Officer at BrightSpring Health Services, a large, multi-state provider of intellectual or developmental disability and behavioral health services.
“As this goes forward, the people who are the most vulnerable already are also going to be the people who are the most impacted by this crisis,” said Skillings. “And so therefore, we need to make sure we take the most care -- we need to take care of everybody -- but we need to make especially sure we take care of them too.”
The business of telehealth
While emergency rooms scramble to address the influx of potential COVID-19 patients, many non-emergency doctors and health care providers are seeing a significant decrease in the number of patients they see, leading some to develop concerns about making ends meet. Providers such as gynecologists and pediatricians have said the number of patients they see has dropped significantly. Some have reduced their patient load from 40 a day to five.
Harris says, “the pandemic is impacting practices all across the board, impacting outpatient practices all across the board, diversity of specialties and a diversity of settings, from the larger practices to the small one.”
From a public health perspective, Harris believes this is in the best interest of the patients in many cases, saying “we are urging everyone to stay home unless they have an urgent or emergent need.” She says not going into a doctor's office limits the risk of infection for both the patient and the provider, and it saves necessary medical equipment -- like masks -- for providers directly dealing with the coronavirus.
While Harris says postponing a yearly physical check-up is okay, she said that many patients should be able to get the care they need through telehealth.
According to the AMA, physician use of virtual visits doubled from 14% in 2016 to 28% in 2019. While data has not yet been released on the increase of tele-visits since the coronavirus outbreak, the AMA has said it is expecting a significant increase and reliance on telehealth during the pandemic.
In the past, healthcare providers could only use HIPAA-compliant telecommunication services, which would protect both the patient and the provider through advanced encryption technology.
But on March 17, Trump relaxed the rules, allowing FaceTime and Skype.
“The crisis is going to go longer,” said Skillings. “And so because that's the case, we're not just looking at emergency conditions. At this point, we're trying to look at how can we provide care potentially for several weeks or even a few months.” It's still complicated
Understanding health insurance is notoriously difficult and Skillings warns there is a risk of relying on the rules and regulations set forth by the federal government.
“One of the things that providers also need to know is that even if the federal government waves some of their own regulations, states still have privacy restrictions, some of which are in place,” said Skillings.
States have taken a variety of approaches in dealing with the coronavirus -- whether that means issuing stay-at-home orders or limiting gatherings to no more than 10 people. Telehealth is no different. Some states have championed the use of telehealth, like Ohio, where Gov. Mike DeWine allowed Medicaid to cover mental health service visits through video or phone-only sessions. States like Maryland, New Mexico, North Dakota and Rhode Island have similar policies.
Governors from California, Illinois and Massachusetts have taken executive action to address the payment discrepancies between tele-visits and in-person visits, now requiring tele-visits to pay providers the same as in-person visits.
But several states, including Alabama, Idaho and Wyoming have not taken steps to facilitate broad telehealth access according to medical leaders.
Insurance companies, just like the states, have issued different guidance regarding telehealth. Scott Serota, CEO of Blue Cross Blue Shield (BCBS), which provides coverage to more than 106 million Americans, said in an online statement that BCBS is “also advocating for physician and health system adoption of ... video, chat and/or e-visits.”
“A member can have any of those functions and be able to utilize ‘alternative’ visits,” Dr. Vincent Nelson, vice president of medical affairs and interim Chief Medical Officer at Blue Cross Blue Shield Association, told ABC News. “However, their provider will also need to have the capability and will vary based on the individual Blue Cross and Blue Shield company.”
Since insurance is state-regulated, what is considered appropriate telehealth engagements will vary on a state-by-state basis, meaning BCBS has different policies based on each state. The BCBS Texas policy allows for "2-way, live interactive telephone or digital video consultations," while the Illinois policy is stricter, not allowing for phone-only visits, saying it allows for "2-way, live interactive telephone communication and digital video consultations” -- meaning the video and audio need to be simultaneous.
Coping with the help of telemedicine
The busier the day, the better. That’s how Nina Tang -- a varsity athlete, an undergrad researcher at a Columbia University science lab, a pre-med senior at Barnard College -- enjoyed spending her time.
But as Americans try to mitigate the risk of infection by staying at home, they need to find ways to cope with the isolation of the pandemic.
Tang said she’s been isolating in her apartment in New York City for over two weeks, only getting a breath of fresh air if she sits on her windowsill. She hasn’t seen anyone -- outside of FaceTime -- since March 21, the day her second roommate left the city. She said it's been "difficult at times."
She said she has had issues with her mental health in the past -- last spring, she had a hard time dealing with anxiety and depression. Since then, she’s been seeing a therapist weekly, where she felt comfortable “talking about anything that I was experiencing.”
Now, during this crisis, her therapy sessions have moved to video chat.
“We try to do video sessions,” Tang, who has private health insurance, told ABC News. “And we did that for our last meeting. There were a couple of meetings where either I wasn't in great internet connection, or I just couldn't get to great internet connection, so we would just have phone calls.”
But telehealth isn’t perfect for Tang, saying the sessions have felt "very different." She finds herself "not wanting to talk about how this whole situation with coronavirus, like self-quarantining, has affected" her.
Tang said her anxiety stems from the fear of being asymptomatic and then passing the coronavirus onto someone else.
“I don’t want to be a carrier,” she said. “And be responsible for someone else’s sickness or potential death.”
Mental health experts suggest feelings of anxiety, fear and depression are normal.
“It's no wonder that anxiety is going up right now,” said Skillings of the APA.
Skillings says to keep a regular schedule by waking up, eating and sleeping at the same time each day. He recommends exercising daily and finding time to socially engage with people -- whether that means having a virtual happy hour, calling a friend or a family member, or sending an old-fashioned note in the mail. Nina Tang has come to a similar solution as well.
“I try and have a very structured day, where I can at least point to different things that I accomplished that I can feel proud of later,” she said.
“There are people who have it worse than me,” Tang added. “And so I think there's been a strange balance between trying to validate the way that I'm feeling, but then also trying to keep in mind that I am probably on the more fortunate end of some people who are also going through the same things.”
ponsulak/iStock(NEW YORK) -- The coronavirus pandemic and the social distancing that comes with it can be isolating, anxiety-producing and stressful.
State-by-state orders to stay home can also make it hard to seek mental health help in a traditional way.
Thanks to technology, there is help online and on your phone. Here are seven apps that provide mental health and mindfulness support on the go:
Headspace has hundreds of guided meditation, including ones you can do on the go. It offers mindfulness tips on everything from managing stress to getting better sleep.
2. Insight Timer
This app offers nearly 10,000 free guided meditations to choose from. Users can modify the meditation to what they need at the moment, choosing from options ranging from ambient sounds to the sounds of bells.
Insight Timer also has more than 3,000 discussion groups and local meet-ups run by users. 3. Happify
Happify is one case where playing games on a smartphone can serve a meaningful purpose. The app, free with in-app purchase options, has different tracks –- from parenting to anxiety to confidence –- that are coached by trained professionals. Choose tracks and then play games and activities to progress.
Talkspace allows users to connect virtually with a licensed therapist. For $49 per week, there's private access to a therapist via text, audio or video chat, as often as daily or multiple times per day.
Creating a word cloud may not be the first thing that comes to mind when it comes to therapy, but it is a tool in this app. Stigma provides an easy way to journal and then visually display the prominent words in that writing as a way to track thoughts and feelings. The app can also track mood in a visual calendar and graph how each person's mood adjusts over time.
6. Anxiety Reliever
The clouds featured on this app's background give a clue to where it leads: A calmer and more peaceful state. The subscription-based app has audio sessions that focus on relaxation and overcoming anxiety and stress. 7. 10 Percent Happier
This app, created by ABC News' Dan Harris, features guided meditations, videos, talks and sleep content. The app also now features a Coronavirus Sanity Guide that offers free resources including a daily "live sanity break" and weekly podcasts.
If you are in crisis or know someone in crisis, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or contact the Crisis Text Line by texting HOME to 741741. You can reach Trans Lifeline at 877-565-8860 (U.S.) or 877-330-6366 (Canada) and The Trevor Project at 866-488-7386.
Kaiser Permanente(NEW YORK) -- An influx of coronavirus patients has overwhelmed the American health care infrastructure, leaving front-line medical providers to improvise creative solutions to the day-to-day pitfalls of treating those afflicted with the highly contagious disease.
The latest innovative solution found in hard-hit hospitals? Baby monitors.
"It’s a great example of nursing innovation with our front-line staff," Stacy Alves, a nurse at the South Sacramento Medical Center, where workers have started using baby monitors to check in with patients, said. "Some of the biggest problems can have simple solutions."
From coast to coast, nurses have begun using two-way baby monitors to interact with isolated patients showing symptoms associated with COVID-19. Those who have used the baby monitors say it’s a practical solution for staying connected to patients -- a novel way to fight the novel virus.
"Clinicians have always been taught to examine the patient and to try to be as personal as possible," said Dr. Ben Scott, the vice chair of the Society for Critical Care Medicine’s (SCCM) committee on telemedicine. "But in the current situation it has become clear that one of the things we may need to do is actually limit our contact with patients in a way that can be uncomfortable for care providers."
The problem is simple and widespread. Front-line health workers want to limit risky interactions and preserve equipment already in short supply. But how can they do that without losing a personal connection with their patient? How do you have a bedside manner without actually being at the bedside?
"We started brainstorming: what’s the best way to get something to scale that’s easy to use and won’t require a whole lot of training?" Dr. Stephen Parodi, an executive vice president at Kaiser Permanente, said. "So when one of our team members suggested baby monitors -- she’s a mom herself -- we said, ‘Wow, that’s not a bad idea.’"
Kaiser Permanente began introducing the idea at its facilities in California’s Santa Clara County, where the hospital beds were already filling up with possible COVID-19 patients.
"In terms of our nursing staff, it gives us peace of mind because we can directly observe our patients at all times and as nurses we like constantly assessing," Alves said.
On the other side of the country, a nursing team in New Jersey, where the count of positive cases in the state approached 20,000 on Tuesday, struck up the same idea.
Inundated with patients, and already facing a limited supply of personal protective equipment, nurses began "thinking outside the box," said Philip Johnson, the nursing director at Virtua Our Lady of Lourdes Hospital in Camden.
"The staff immediately were uncomfortable with the idea of not being able to communicate at will with their patients," said Johnson. "We talked about pulling in a contractor to install permanent video cameras, but even that doesn’t allow the two-way communication."
Then, again, a brainstorming session provided the answer. Nurses and other frontline workers at the hospital began asking friends and family to donate their baby monitors. Within days, the system was up and running.
"We were able to implement the monitors and immediately establish a line of sight with our patients, as well as two-way communications so they could easily, say, ask for a blanket without having to open the door every time," Johnson said.
The emerging use of baby monitors can be useful in addressing two major concerns confronting health care workers, experts said. First, by limiting the number of times a nurse has to enter an isolation room, the obvious benefit is fewer high-risk interactions with the patient.
"Because you’re minimizing the in-and-out to the room, you’re reducing the amount of exposure to the health care workforce," Parodi said.
But as health care facilities face a dearth of personal protective equipment, or PPE -- masks, gowns and gloves -- communicating via baby monitors also offers a way to preserve those limited resources.
"If you had to open the door every single time a patient asked for something, you’d have to don [protective equipment], go in there, see what they wanted, come back out, go get what they wanted, then redo that process again," Johnson said. "So every single time you’d have to use a whole set of PPE."
The benefits are clear, and nurses using the baby monitors say patients like the system, too. Alves said, "It gives patients a sense of comfort."
But experts characterize the monitors as a Band-Aid -- not a solution. From concerns about network security to limitations in the technology, health care professionals recognize the drawbacks.
Even so, health care providers say those drawbacks are worth it, at least in the near term, to combat an unprecedented demand on front-line workers.
"This is one of those extraordinary times when you can’t let the ideal be the enemy of what you need to do in real-time," Parodi said. "But we’ve made the judgment that because of the size and scale of this pandemic this is the right thing to do right now … and the benefit really outweighs the potential risk."
iStock/MarianVejcik(BOSTON) -- BY: Dr. Chloë E. Nunneley
As the novel coronavirus continues to spread across the country, those who are not infected can protect themselves by avoiding close contact with others and aggressively washing their hands. But beyond this, many are desperately hoping for another form of protection: a vaccine.
Vaccines work by exposing our bodies to something that resembles a certain pathogen, training our immune systems to recognize, attack and kill the invader. When presented with the real pathogen itself, our immune armies are ready to fight.
While not a treatment or cure, vaccines can help eradicate a disease by starving the virus of people to infect and transmit the disease.
Vaccines are especially needed by health care workers on the front lines and other vulnerable members of the population who have a higher risk of contracting the infection.
While the race to develop a COVID-19 vaccine is well underway with over 40 hopeful candidates, only three have entered “Phase I” of clinical trials, the first of three stages of human testing before drug approval.
Phase I testing is only a test to see if the vaccine is safe. Researchers won't know if it's effective until Phase II is studied. Below is a brief overview of these three candidates, plus three promising ones that are still in earlier stages of development.
STARTING IN HUMANS (PHASE 1)
mRNA-1273: The front-runner in the U.S., which is backed by the NIAID and developed by Moderna Therapeutics, is based upon a specific type of genetic material, mRNA. This vaccine, mRNA-1273, codes for a specific protein on the novel coronavirus -- the “spike protein” – the key into a human cell. An mRNA-based virus has never been approved for use in humans, but animal studies have been promising. This particular vaccine, however, was rushed to human trials before it was even tested in animals -- skipping a step in traditional vaccine development.
A Phase I trial testing the vaccine’s safety in 45 healthy adult volunteers began earlier this month at Kaiser Permanente Washington Health Research Institute in Seattle. The participants will receive two injections of low, medium or high doses of the vaccine and be monitored for any adverse events or immune response. The company is hopeful that it may have a vaccine as early as fall 2020 for some particularly vulnerable groups, such as health care workers. The Phase I safety study should be completed by June 2021. Ad5-nCoV: The front-runner across the globe, Ad5-nCoV, was developed by the Beijing Institute of Biotech and CanSino Biologics, a Chinese biopharmaceutical company. This vaccine uses a viral vector, a virus that has been engineered to not contain its infectious properties and instead delivers genetic material to the recipient. Phase I testing of this vaccine is underway at Hubei Provincial Center for Disease Control and Prevention, where 108 healthy adult volunteers will receive one of three doses of the vaccine to assess for safety. Ad5-nCoV is perhaps the most promising because CanSino has already produced a nearly identical vaccine, Ad5-EBOV, to protect against Ebola. The Ebola vaccine has already entered Phase II testing, meaning it’s even further along. Still, the official anticipated completion date for Ad5-nCOV safety testing is December 2020, with all testing completed by 2022.
ChAdOx1: The University of Oxford is one of the most recent groups to bring its vaccine candidate into human studies -- a major milestone. The vaccine is simultaneously being tested for both safety (Phase I) and efficacy (Phase II) by injecting 510 healthy participants with either vaccine or placebo. This vaccine uses an inactivated (non-infectious) virus that contains genetic material for the key protein on the novel coronavirus, similar to Ad5-nCoV in China. This viral vector, however, was derived from chimpanzees which, the researchers argue, creates an even more robust response than other viruses to which humans may have already been exposed. This vaccine is being funded by the United Kingdom government and is moving quickly. Still, its anticipated completion date of this phase isn’t until May 2021.
STILL IN LABORATORY (PRECLINICAL)
BNT162: Biopharmaceutical giant Pfizer, along with partner company BioNTech, is working on an mRNA-based vaccine that is similar to Moderna’s model. The duo was already working on an influenza vaccine using this scientific strategy so their vaccine candidate, “BNT162,” is moving particularly fast. Clinical trials are anticipated to begin in April in both the U.S. and Germany.
INO-4800: An entirely different technology is being developed by Inovio Pharmaceuticals, a company that uses a proprietary platform for “activation immunotherapy.” This vaccine delivers DNA, another genetic material, into a host’s cells by utilizing a hand-held smart device “CELLECTRA.” The DNA is translated into proteins that activate an individual’s immune system to generate a targeted immune response. While that may sound like science fiction, the company has used the same technology to rapidly advance vaccines against MERS, a closely related coronavirus, and HPV-related cervical precancer, among others. None of these, however, have completed their trial phase and entered the market. Trials for the COVID-19 specific vaccine, INO-4800, are anticipated to begin in April.
Sanofi recombinant DNA vaccine (unnamed): Last month, Sanofi Pasteur announced that it was partnering with the U.S. Department of Health and Human Services to create a DNA-based vaccine. Their vaccine, which is yet to be named, relies on recombinant (engineered) DNA that encodes for proteins found on COVID-19 surface -- the same basic principle of many of the other candidates. The company had been previously working on a vaccine for SARS, a close relative of the novel coronavirus, which showed promise in animal models. More importantly, however, Sanofi has proved immensely successful in the vaccine market: they have influenza vaccines, including Flublok and Fluzone, that are widely in use today. They claim that their technique -- and their experience with mass production of their products -- would allow a COVID-19 vaccine to be introduced much more quickly than traditional production methods. Still, human trials are yet to begin but will likely start in April.
Chloë E. Nunneley, MD, is a pediatric resident physician at Boston Children’s Hospital & Boston Medical Center and a contributor to the ABC News Medical Unit.