In a two-hour Zoom symposium Tuesday, experts from the University of Tennessee Health Science Center and St. Jude Children’s Research Hospital looked at the coronavirus as scientists, delving into immunity rates, progress on vaccines and two clinical trials here that soon will need volunteers.
But they also saw the virus as sociologists, reflecting on the fatigue and anxiety it has caused as the city approaches Month 6 of life with it, and the affect that is having on mental health in general and the increased, intense stress for thousands of youngsters in particular.
“Unfortunately, when we looked at May of 2019 compared to May of 2020, we saw almost a threefold increase in the average number of ACEs (adverse childhood experiences) our patients and clients are reporting,” said Dr. Jason Yaun, associate professor of the Department of Pediatrics at UTHSC and head of outpatient pediatrics at Le Bonheur Children’s Hospital.
“We also saw significantly higher reported rates of food insecurity. And perhaps most telling, referrals to our psychologist increased from one at this time last year to 13 in May of 2020,” he said.
Because the number of reported child abuse cases dropped when schools closed and children have missed doctors’ appointments, “unfortunately we are afraid that that may mean that there is an unrecognized pandemic of child abuse going on as well,” Yaun said.
In a mental health study from Vanderbilt University released last week of more than 1,000 participants, about 25% of parents said their own mental health had diminished since the pandemic started; 14% said their children’s behavioral health had declined.
“We’re seeing a tandem impact on both parents, and parents and children in the U.S.,” Yaun said.
Noting that social inequities of poverty exacerbate the issues, he said poor parents are more likely to be exposed to the virus and more likely to live in poor environmental surroundings.
“So, it’s really just a circle of adverse childhood experiences leading to increased susceptibility in both parents and children,” he said.
Where we are
In April, when UTHSC held its first COVID-19 symposium, Dr. Jon McCullers compared the U.S. response to South Korea, which responded with mass testing and had contained the hot spots there to fewer than 1,000 total cases. Tuesday, he compared the U.S. to Germany, which mirrored the U.S. in the early days of the pandemic in its preparedness.
“They put in masking laws. They did social distancing. They had a very strong, centralized, federalized approach to the pandemic,” McCullers said. “And as you can see after about two months, they have completely controlled the pandemic in their country, and it has remained at negligible levels since then.”
In the U.S., for the last four to six weeks, there has been a steady rise in cases.
“And this really has been led by working age, young adults who are not social distancing, who are not wearing masks. They’re doing the opposite of all the things that Germany has done,” said McCullers, who is senior executive associate dean of clinical affairs at UTHSC, pediatrician in chief, Le Bonheur Children’s Hospital, and a member of the Memphis-Shelby County COVID-19 Task Force.
“Germany continues to increase the number of tests that they can do, and it is using this as a way to keep the virus under control,” he said.
“Whereas, the United States has essentially remained flat across the entire pandemic in terms of daily tests per confirmed case and has been unable to control the pandemic in any manner.”
The symposium and answers to audience questions will be posted here. The event is part of UTHSC’s commitment to lead and innovate in the pandemic. More than 585 people registered to attend the videoconference.
In April and May, Shelby County was reporting about 100 new cases a day, which rose only slightly after the back-to-business plans went into place on May 4 and May 18.
The surge here began happening, as it did in other parts of the nation, in late June. The Memphis mask order went into effect on June 26, followed by the county order on July 3.
After now “plateauing” with 350 new cases a day for several weeks, caseloads are coming down, which McCullers attributes to stepping up the enforcement of wearing masks and closing bars and restaurants that act as bars.
Even though testing data has been erratic in the last two weeks because testing labs are behind, “I think we can be fairly comfortable that this downward trend started a couple of weeks ago,” he said.
“I think it is really due to these mask mandates and looking at where transmission was occurring,” which he said was primarily among young people in social settings.
This week, the task force will introduce “tripwires,” McCullers said, to attack rising data points at their source.
“We have a number of actions we can do to stop transmission. We can start increased enforcement of mask rules, increased enforcement in bars. We can have further closure of more bars, schools, theaters, music venues. We can, in fact, return to the safer at home if we need to, if things get really out of hand.”
Conversely, if the numbers improve, specific thresholds will trigger opening and loosening restrictions.
“We would be reopening things that are closed, such as music venues, schools — if they’re closed — theaters and bars,” McCullers said, and allowing some events, which would have to be pre-approved by the health department.
COVID-19 hospitalizations have hovered at 300 in the last couple of weeks with about 100 more in ICU in hospitals across the region, which accounts for 85% to 90% of capacity. With the same tripwires at play, he said, an increase in patients would trigger changes in staffing models or curbs on elective surgeries.
“If we go up further on thresholds, we can open up our UTHSC field hospital.”
Alternative care site
Dr. Richard Walker is the CEO of the 401-bed alternate-care hospital that will open in the former Commercial Appeal building on Union Avenue. The space, he said, effectively doubles the number of regular hospital beds available in Downtown for adults who are not veterans.
The hospital will handle transfers of patients who need more time to recuperate. It will not take new COVID-19 patients.
“We have some limited functionality to support people on transport ventilators until they can be returned to an acute care hospital,” Walker said, noting the facility also has limited capacity for chest X-rays, basic chemistry and to store blood.
Since the beginning, he has said that the alternate-care facility will be the last resource the community has for housing patients with COVID-19.
“I think it’s super important to understand that really is our last-ditch disaster mode. And after that, there are no further options that easily exist.”
If it opens, it will be critical that the public “self-isolate, socially distance and wear masks,” Walker said, noting it will be 10 days to two weeks before stepped-up adherence shows up in case numbers.
“So, it’s going to be super important to get that message out if the alternate-care site has to be activated for any reason.”
Treatments and challenges
Walker, who also is the interim chairman of emergency medicine at UTHSC, has been working with doctors in internal medicine and pulmonary emergency care to refine the evaluation and triage process “from the time they hit the front door until they are on the floor in the ICU and are able to go home,” so beds are not unnecessarily used.
From colleagues in New York and a military physician on the UTHSC staff who served at Elmhurst Hospital in New York City this spring, Walker said Memphis ER doctors “got very good, early, real-time data on things that did and didn’t work.”
For instance, doctors now know that the length of time someone has been sick with COVID-19 is critical.
“People are far less likely — not impossible but far less likely — to deteriorate after day eight to 10 of the onset of symptoms,” Walker said.
“As we move forward to this pandemic and resources become more limited as hospitals initiate surge plans and then certainly if we’re forced to utilize the alternate-care site, more aggressive discharges home will likely occur,” he said, including patients who still need to be on oxygen.
“The other thing that’s going to be a challenge for us this fall and winter is, of course, differentiating COVID from other viral illnesses, both influenza and routine winter viruses.”
Early in the pandemic, doctors tried to rule out other infections with flu swabs or viral panels. Now that the viral test materials are so critical, that won’t be possible.
From a treatment point of view, several options are most effective for late-stage disease, including convalescent plasma; remdesivir; cortricosteriods, such as dexamethasone; the immunosuppressive tocilizumab; and drugs to prevent thrombosis or blot clots.
All of the therapies are being used in Memphis.
“To date, we have given about 60 to 65 patients convalescent plasma, and at least on the face of it, it appears that it is helping,” said Dr. Amik Sodhi, interim chief, division of pulmonary, critical care and sleep medicine at UTHSC. She is also the chief medical officer for the alternate-care hospital.
Baptist Memorial Health Care is also using convalescent therapy.
“Nationally, there are no randomized, controlled trials that compare convalescent plasma to usual care. However, the studies that have been published suggest that the therapy is safe, does not cause any untoward adverse effects, and there does seem to be a signal that it improves outcomes in these patients,” Sodhi said.
“We’re waiting for some additional studies to give us a direct comparison, but we’re very hopeful about this therapy. And it is available to patients in the city.”
St. Jude is doing work on antibodies, and in some cases, testing its own employees for the presence of them after they recovered from the infection.
“All but one person had really robust and measurable levels of both RBD (receptor binding domain) and spike antibodies,” said Paul Thomas, faculty member in St. Jude’s immunology department.
“And so our assay works, and what it also shows us, which has been repeated by labs across the world, is that most people make antibody responses to this virus. And so, it’s acting like a normal virus in that sense.”
UTHSC will be conducting clinical trials through its regional biorepository site. Both need volunteers. The first will be a six-month study of adults who think they had COVID-19 or were exposed. They will receive information on their antibodies. The second will be a two-month study of early immune response in children and adults, and what helps control the disease in the early stages.
Walker ended his portion of the symposium with Charles Darwin’s quote: “It’s not the strongest or the smartest to survive, but it’s the one that adapts the best.”
“What you’ve seen in the last three to four months would normally be three to four years’ or 10 years’ worth of adaptation and movement around a less-urgent emerging disease or medical process,” he said.
“And so really, swiftly adapting to the situation and acknowledging that things will change has been a lifesaver for all.”