Responding to COVID-19 in the nursing home – an interview with Teena Chopra

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In this interview we speak to Teena Chopra (Detroit Medical Center and Wayne State University; MI, USA) about COVID-19 infection among the elderly population, including testing strategies, atypical presentation and the future requirements for a robust pandemic response. 

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First, could you tell us about yourself and your work?

My name is Teena Chopra, I’m a Professor of Infectious Diseases at Wayne State University (MI, USA) and I’m also the Hospital Epidemiologist for Detroit Medical Center (MI, USA). I have done infection control in nursing homes and I’m currently the Director of Infection Control at a long-term acute care facility in Detroit. I have a special research interest in infections in older adults, hence my area of interest is also helping our nursing home community through this epidemic.

How has your everyday job changed during the coronavirus outbreak?

It has changed immensely, particularly working as an epidemiologist and infectious diseases expert. We have seen a huge tsunami of COVID-19 cases and have had to adapt very quickly to taking care of these patients, not only managing them but also preventing infections in others who don’t have it. I’ve also been involved in the community with our nursing home population, as these individuals account for a large number of COVID-19 hospital admissions and at least 25% of COVID fatalities.

Could you tell us more about the challenges faced by the elderly community and those caring for them?

With COVID-19 permeating through our communities, it has selectively chosen nursing homes to ravage, and the vulnerability of this hard-hit population has exposed our lack of preparation. The clustering of cases in nursing homes and alarming mortality rates has made these places the new epicenters of this outbreak and our infection control measures are clearly not enough. As we are seeing numbers mount, our endeavors in testing, tracing and then containing are falling severely short.

As you already know, due to immunosenescence, old age predisposes this group of patients to infections. A lack of private rooms, along with close physical interaction with care givers, facilitates the transmission of pathogens, and this situation is compounded by immobility, poor hand hygiene, frequent colonization with other multidrug-resistant organisms and inappropriate use of antibiotics.

Could you tell us about your observation of COVID-19 coinfection with Clostridium difficile?

We have seen some patients who have come with coinfections with C. diff. and COVID-19 and they have been very sick, but these are again anecdotal cases. I have at least nine  COVID-19 and C. diff. coinfected patients at my facility. They have presented as very sick, much more so than others, with symptoms including diarrhea, which I usually don’t see with C. diff. alone. As we manage these patients further, we will learn more about their outcomes. But at this time, we know that we see COVID-19 and C. diff. as a coinfection. There is evidence that COVID-19 is excreted through the feces, and C. diff. we already know has a fecal–oral route of transmission. So the fact that there is contact transmission in both these diseases is very intriguing.

How are you using testing to reduce the spread of the virus in nursing homes?

We are testing every day and have made a lot of progress with the health department over the last week. We are going to make sure that we test every resident this week, then our plan is to re-test them, especially the ones who have tested negative, cohort accordingly, and monitor them on a regular basis.

Currently, we have a nasopharyngeal swab test that detects the RNA of the virus. The test is pretty reliable, but we have found that 30% of patients appear to be negative even though they may have symptoms. The fact that it can come out to be negative depends on how the swab was done and the time it was done during the course of the illness.

The other kind of test being developed is the serological-based testing, which detects their IgG levels against the virus. There are some tests that have recently come out detecting serological markers that are very specific to the SARS-CoV-2 spike protein of the virus and they have no cross-reactivity. Based on some studies from the University of Washington (WA, USA), they have shown very high sensitivity and specificity without any cross-reactivity. So there is good reason to believe, based on their validation data, that this test is going to be a gamechanger when we restart our economy, as it could help us to understand which patients have already been exposed to the virus  and which have not. I think that as we move towards the phase where we are going to slowly try to open up our hospitals to elective procedures and surgeries, the serological test could potentially augment the PCR-based test to inform clinical decisions.

When it comes to the older population, we should see a similar response but there might be some older patients who don’t mount up the same immunity, and it is a matter of time before we can understand that population as we ramp up our serological testing.

Going forward, what research or changes do you think are needed to address the issues you’ve observed?

We need to first understand the true attack rate of disease in nursing homes by testing all employees and residents, and subsequently contact tracing and quarantining this population. We then need to contact trace everybody who has been exposed to them and then re-test. Then we can think about the future of this particular population, especially considering that we don’t have private rooms for them and they are clustered together in small spaces – there have to be decisions made as to where we can space them out.

As we are determining the new ‘normal’ of everything, the risk profile of nursing homes and their vulnerability index is so high that we have to determine what should be considered their new ‘normal’. Is it safe to house them in clustered spaces, or is it safe to have places where they can have private rooms with private bathrooms? Decisions about that are very important at this time because we could have future pandemics. This is the time to understand the disease transmissions in these alternative healthcare facilities so that we can prepare for future pandemics.

We’ve always learned about the model of successful aging, but now we can see this model taking a new meaning. As we look at the SARS-CoV-2 virus and mortality in the older population, the model of successful aging will need to be updated following this pandemic to consider the impacts of COVID-19 on both objective and subjective criteria, such as activities of daily living and perceptions of quality of life. Most importantly, the model will need to consider not only chronic disease but also COVID-19 as an acute disease. This applies both now and after recovery because it could potentially leave a lot of subclinical damage to the cardiopulmonary system, the brain and cognitive functions, which can have lasting effects on the aging process.

In-depth systemic analysis of the disease in this population, understanding the short-term and long-term effects and their baseline cognitive decline and what happens after they recover from the disease, as far as their cognition and other brain and cardiopulmonary functions are concerned, is extremely critical.

I recommend that we pay particular attention to this population, not only now but even at a later time to examine the long-term effects. Additionally, while we are testing this population, those who test negative should be tested again because they may not mount up the same immune response and the same symptoms as the general population. So we have to keep regular checks on them in the form of screening, temperature checks and then eventually serological testing to understand their immunity.

How do you think we can use what we’ve learned to prepare for any future pandemics?

The nursing home issue is a collateral damage in our communities and as far as getting prepared for future pandemics is concerned, it’s really important that we understand that pandemic preparedness requires a whole biocontainment team. This team should include many different people such as hospital epidemiologists, social scientists, public health experts, logistics experts, ethical experts and critical care experts. As such, this is not a public health or critical care crisis, but in my opinion a humanitarian crisis, and the hospital epidemiologist like myself, in this new world after COVID-19, will have a changed role.

As we’ve noticed that hospitals have turned into warzones and healthcare systems have been overwhelmed, I envision the aftermath with caution. The pandemic has exposed the vulnerabilities within our hospitals and our public health systems. We have been operating with the premise that our health system has just enough of everything, underestimating the power of an infectious disease catastrophe like COVID-19, which has challenged us in every sense. It has challenged our clinical acumen, it has stretched thin our limited resources and uncovered inadequate planning. So how we learn from this saga will determine how we equip ourselves for future contagions. That’s why it’s vital at this time that we plan to mitigate any future infectious threats and consider how hospital epidemiologists can turn into pandemic experts, along with integrating services to build an armamentarium, which includes testing, surveillance, tracing and expert staff who should come together. Further, reporting data not only from hospitals but from nursing homes and sharing of scientific information is going to be key.

 To access more COVID-19 content, visit our COVID-19 Hub.

Disclaimer
The opinions expressed in this interview are those of the interviewee and do not necessarily reflect the views of Infectious Diseases Hub or Future Science Group.

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