Latest / The SHEA Podcast / COVID-19: Isolation Precautions & Vaccination Considerations for Immunocompromised Patients, 2/25/21

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COVID-19: Isolation Precautions & Vaccination Considerations for Immunocompromised Patients, 2/25/21 · The SHEA Podcast

• 0:07
  SPEAKER_03: Welcome to the Rapid Response Podcast brought to you by the Society for Healthcare Epidemiology of America, SHA, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:24
  SPEAKER_03: I'm Dr.
• 0:25
  SPEAKER_03: Jessica Howard Anderson, an infectious disease fellow at Emory University School of Medicine, and I'll be the moderator of today's podcast.
• 0:33
  SPEAKER_03: Discussion on the podcast does not reflect today's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:43
  SPEAKER_03: Today is excited to launch this episode of the Podcast COVID-19 updates, What We Know Now.
• 0:49
  SPEAKER_03: Today's discussion will focus on isolation precautions and vaccine considerations for immunocompromised patients.
• 0:56
  SPEAKER_03: Our speakers today are Dr.
• 0:58
  SPEAKER_03: Tamara Palmore, NAH Clinical Center Infectious Diseases Specialist and Hospital Epidemiologist, and Dr.
• 1:04
  SPEAKER_03: David Henderson, NAH Clinical Center Senior Consultant and Immediate Past President of SHA.
• 1:11
  SPEAKER_03: Thank you for joining us today.
• 1:13
  SPEAKER_03: Before we start our discussion, I would like to turn it over to Dr.
• 1:16
  SPEAKER_03: Jennifer Hanarhan to get us started with a brief news and guidance update for the week.
• 1:22
  SPEAKER_02: As of February 24th, 2021, there have been 111,593,583 confirmed cases of COVID-19, including 2,475,020 deaths reported to the World Health Organization.
• 1:36
  SPEAKER_02: In the United States, 44,544,969 persons have received one or more doses of vaccine against SARS-CoV-2.
• 1:45
  SPEAKER_02: Two reports of SARS-CoV-2 transmission related to fitness facilities were published in the Morbidity and Mortality Weekly report, including description of a COVID-19 outbreak among attendees of an exercise facility in Chicago, Illinois from August to September 2020.
• 2:00
  SPEAKER_02: Fifty-five COVID-19 cases were identified among 81 attendees of indoor high-intensity classes at a Chicago exercise facility.
• 2:08
  SPEAKER_02: Twenty two persons with COVID-19 attended on or after the day's symptoms began.
• 2:12
  SPEAKER_02: 76% of attendees wore masks infrequently, including 84% of persons with COVID-19 and 60% of persons without COVID-19.
• 2:21
  SPEAKER_02: In order to reduce SARS-CoV-2 transmission in fitness facilities, attendees should wear a mask, including during high-intensity activities when greater than six feet apart.
• 2:30
  SPEAKER_02: In addition, facilities should enforce physical distancing, improve ventilation, and encourage attendees to isolate after symptom onset or receiving a positive SARS-CoV-2 test result and to quarantine after potential exposure to SARS-CoV-2 and while awaiting test results.
• 2:44
  SPEAKER_02: Exercising outdoors or virtually could further reduce SARS-CoV-2 transmission risk.
• 2:49
  SPEAKER_02: An early release article in emerging infectious diseases describes rapid spread and control of multidrug resistant gram-negative bacteria in COVID-19 patient care units.
• 2:58
  SPEAKER_02: This report describes the experience at the University of Maryland Medical Center and 800-bed tertiary care hospital.
• 3:05
  SPEAKER_02: In mid-May 2020, a cluster of four patients with multidrug resistant E.
• 3:09
  SPEAKER_02: coli was identified, and hospital-wide data showed an increase in multidrug resistant gram negatives.
• 3:14
  SPEAKER_02: During April 16th to July 15th, a total of 71 unique patients had positive clinical or surveillance cultures for resistant gram-negative bacilli.
• 3:23
  SPEAKER_02: Key infection control findings included tight physical spaces and close proximity of patients in double occupancy, multiple staff in contact with each patient in the team nursing model, and low compliance with hand and glove hygiene and gown changes between patients.
• 3:35
  SPEAKER_02: To limit staff exposure to COVID-19 patients, the unit had less support from ancillary services.
• 3:41
  SPEAKER_02: Instead, daily room and equipment cleaning and stocking of medications and supplies were performed by unit-based clinical staff.
• 3:47
  SPEAKER_02: Outbreak control interventions included discontinuation of double occupancy, frequent infection prevention rounds to promote hand hygiene and glob and gown changes between patients, increased environmental services support, and attention to disinfection of reusable equipment and high touch surfaces.
• 4:02
  SPEAKER_02: Surveillance culturing showed a decrease in positive cultures over time.
• 4:06
  SPEAKER_02: A study was published in JAMA on February 17th on the effect of a single high dose of vitamin D3 on hospital length of stay in patients with moderate to severe COVID-19.
• 4:15
  SPEAKER_02: This was a multi-centered double-blind randomized placebo control trial conducted in two sites in Sao Paulo, Brazil.
• 4:22
  SPEAKER_02: The study included 240 hospitalized patients with COVID-19 who were moderately to severely ill at the time of enrollment from June 2, 2020 to August 27, 2020.
• 4:32
  SPEAKER_02: Patients were randomly assigned to receive a single oral dose of 200,000 international units of vitamin D3 or placebo.
• 4:38
  SPEAKER_02: The study found that median length of stay was not significantly different between the vitamin D3 and placebo groups.
• 4:44
  SPEAKER_02: The difference between the vitamin D3 group and the placebo group was not significant for in-hospital mortality, admission to the ICU, or need for mechanical ventilation.
• 4:52
  SPEAKER_02: Mean serum levels of 25 hydroxyvitamin D significantly increased after a single dose of vitamin D3.
• 4:58
  SPEAKER_02: There were no adverse events, but an episode of vomiting was associated with the intervention.
• 5:03
  SPEAKER_02: The IDSA guidelines on the treatment and management of patients with COVID-19 were updated on February 17, 2021 to include a recommendation that among hospitalized adults with progressive, severe, or critical COVID-19 who have elevated markers of systemic inflammation, the IDSA guideline panel suggests hosalismab in addition to standard of care rather than standard of care alone.
• 5:26
  SPEAKER_02: This is a conditional recommendation with a low certainty of evidence.
• 5:30
  SPEAKER_02: And that's the news for this week.
• 5:32
  SPEAKER_03: Thank you, Dr.
• 5:33
  SPEAKER_03: Hanrahan.
• 5:34
  SPEAKER_03: I now want to move into the discussion with our speakers.
• 5:37
  SPEAKER_03: Thank you both again for joining us today.
• 5:40
  SPEAKER_00: Pleased to be here.
• 5:41
  SPEAKER_03: It's a pleasure to join you.
• 5:43
  SPEAKER_03: Great.
• 5:44
  SPEAKER_03: So our first question today is given the existing data about prolonged shedding of potentially viable virus from immunocompromised patients, many healthcare professionals are trying to figure out the best way to approach these highly immunocompromised patients.
• 5:59
  SPEAKER_03: What should they be considering?
• 6:01
  SPEAKER_03: And what are you at the NEH Clinical Center actually doing?
• 6:04
  SPEAKER_03: And does your approach change for the outpatient setting?
• 6:08
  SPEAKER_01: Well, we now know from more than two dozen cases in case series and case reports in the literature that highly immunocompromised patients can shed viable virus for a great deal longer than 20 days, which is the threshold that was initially identified.
• 6:24
  SPEAKER_01: This is different than just prolonged RTPCR positivity, which, as you know, can last for weeks in normal hosts and does not necessarily represent viable virus.
• 6:35
  SPEAKER_01: What we're talking about here is virus that causes cytopathic effect in culture.
• 6:41
  SPEAKER_01: The other tool other than culture that's used and that's useful in determining what is potentially viable virus, which I'll mention here, is subgenomic PCR.
• 6:52
  SPEAKER_01: And that is PCR detection of SARS-CoV-2 subgenomic mRNAs.
• 6:59
  SPEAKER_01: And what that is, is viral mRNAs that are required by the virus to express its assembly proteins.
• 7:06
  SPEAKER_01: Those mRNAs are transcribed only in actively infected cells, and they're not packed into virions.
• 7:14
  SPEAKER_01: They are a sign that the virus is actively replicating.
• 7:18
  SPEAKER_01: Subgenomic PCR can be done in a normal laboratory.
• 7:22
  SPEAKER_01: It doesn't require a viral culture facility.
• 7:25
  SPEAKER_01: And it might be a more accessible proxy for viable virus than viral culture.
• 7:31
  SPEAKER_01: It definitely is.
• 7:32
  SPEAKER_01: And it is a proxy, it's not directly assessing the presence of viable virus.
• 7:38
  SPEAKER_01: So that said, some studies show use subgenomic PCR to determine the presence of replicating virus.
• 7:46
  SPEAKER_01: At our hospital at the NIH Clinical Center, which is the clinical research hospital at the National Institutes of Health, where we have a majority of patients who are immunosuppressed.
• 7:58
  SPEAKER_01: First of all, we actually don't use a 10-day or 20-day cutoff as our normal cutoff for discontinuation of isolation.
• 8:06
  SPEAKER_01: We use 28 days for time and symptom-based criteria as our defaults.
• 8:10
  SPEAKER_01: So we already more than double the usual 10-day criterion.
• 8:14
  SPEAKER_01: But we do pre-procedure testing for many procedures and we therefore find an occasional immunocompromised patient who remains positive after the 28-day point.
• 8:25
  SPEAKER_01: And when we do, we look at the cycle threshold in those patients and re-isolate patients who appear not to be clearing the virus while we investigate further and do subgenomic PCR probably more than we do viral culture in those patients.
• 8:40
  SPEAKER_01: Most turn out to have had stem cell transplants andor some form of B cell depleting therapy, which reflects what's found in the literature.
• 8:49
  SPEAKER_01: Some of those patients appear to have ongoing high viral burden in the lungs with significant life-threatening pulmonary disease, requiring repeated treatments, intensive care, and some are ambulatory and don't require any oxygen, but do have this evidence of ongoing viral replication.
• 9:07
  SPEAKER_01: The challenges in the outpatient setting in our hospital are manageable.
• 9:11
  SPEAKER_01: We manage those patients in isolation, but it's harder to know what to tell them about how to manage their home situations.
• 9:18
  SPEAKER_01: These patients generally can't isolate indefinitely within their homes, if at all.
• 9:23
  SPEAKER_03: Yeah, those are all really important considerations and challenging issues.
• 9:27
  SPEAKER_03: Dr.
• 9:27
  SPEAKER_03: Henderson, do you have anything else to add?
• 9:30
  SPEAKER_00: I don't have a lot to add.
• 9:32
  SPEAKER_00: I would say that in my view, a whole raft of factors can influence sort of how you take care of these patients.
• 9:38
  SPEAKER_00: Dr.
• 9:38
  SPEAKER_00: Palmore has pointed out we tend to be really conservative.
• 9:41
  SPEAKER_00: And I think for these patients in their setting, whether it's at home or in the outpatient setting or in the hospital, being as conservative as you can possibly be makes the most sense.
• 9:53
  SPEAKER_00: Dr.
• 9:53
  SPEAKER_00: Pellmore mentioned that some of these patients get treated and retreated for ongoing infections.
• 9:58
  SPEAKER_00: Some of them you might not suspect that they're infected, but they are.
• 10:02
  SPEAKER_00: The other point that I would make is sometimes in those patients, I think it's the case, and Dr.
• 10:07
  SPEAKER_00: Palmore can straighten me out if I'm wrong about this, but their upper airway samples may actually be negative via PCR, whereas samples from the lung, if you take it directly by bronchoscopy, can be positive.
• 10:19
  SPEAKER_03: Yeah, I think that's what I've been hearing as well.
• 10:22
  SPEAKER_03: So Dr.
• 10:22
  SPEAKER_03: Palmore touched on this a little bit, but what research is NAH conducting around isolation precautions?
• 10:29
  SPEAKER_03: And do you know of any new emerging data specifically for amino compromised patients?
• 10:35
  SPEAKER_00: I'm not aware of any specific research protocols that we're conducting around the concept of isolation precautions.
• 10:41
  SPEAKER_00: I know that some of the NIAID team have reported on patients such as the ones we're describing who have B cell depletion and what appears to be just chronic ongoing infection as case reports, but I'm not aware of any research that's ongoing at the clinical center or even supported by NIAID about isolation precautions for immunosuppressed patients.
• 11:03
  SPEAKER_00: What about you, Tara?
• 11:04
  SPEAKER_01: Yes, agreed.
• 11:05
  SPEAKER_01: There's not specific research into the isolation precautions per se, but there's certainly a hot pursuit to understand what we're seeing in these patients whose infections persist for months in the lower respiratory tract.
• 11:18
  SPEAKER_01: So our colleagues have done subgenomic PCR and are sequencing isolates from patients with serial samples, looking at viral evolution and looking for the potential of reinfection with variants.
• 11:32
  SPEAKER_00: I think that's a really important point.
• 11:33
  SPEAKER_00: And that's the when someone maintains this kind of chronic ongoing infection for a long period of time, the likelihood of the spewing out virions is enormous, actually.
• 11:45
  SPEAKER_00: And it provides just the ideal setting for that to happen.
• 11:49
  SPEAKER_00: And so it's a it's an area where sequencing is really important for those patient cysolates.
• 11:54
  SPEAKER_03: Yeah, that makes sense.
• 11:55
  SPEAKER_03: And fairly related to that, you know, do you think facilities should have standard guidelines about when to discontinue transmission-based precautions in immunocompromised patients?
• 12:07
  SPEAKER_03: Say, for example, the set 20 days, or I know you just said you're using 28 days a lot of the time, or do you think this should really be an individualized decision every time, kind of made with the help of infection prevention teams?
• 12:20
  SPEAKER_01: I agree with CDC guidelines, which suggest that individualized decisions with expert guidance for severely immunocompromised patients are preferred.
• 12:31
  SPEAKER_00: I think it should be pointed out that this is not a one-size-fits-all recommendation.
• 12:35
  SPEAKER_00: I mean, immunocompromised patients come in a variety of flavors and can be more or less immunocompromised.
• 12:42
  SPEAKER_00: And I think the only way to do this is just as Dr.
• 12:45
  SPEAKER_00: Palmore has suggested.
• 12:48
  SPEAKER_03: So it doesn't sound like there are really strict guidelines that would fit for every single patient, which I completely agree with.
• 12:55
  SPEAKER_01: I do think that most immunocompromised patients will clear COVID-19 within 20 days.
• 13:02
  SPEAKER_01: So, you know, we're talking about a small subset of immunocompromised patients who will not, small but notable.
• 13:09
  SPEAKER_01: Right.
• 13:10
  SPEAKER_03: And is your 28-day guideline for just immunocompromised patients or for everyone?
• 13:15
  SPEAKER_01: In our hospital, we use it for everyone because a majority of our patients are immunocompromised.
• 13:22
  SPEAKER_03: So the next question is when and how should facilities consider a test-based strategy to discontinue transmission-based precautions?
• 13:29
  SPEAKER_03: Is this an approach that either of you would consider or suggest?
• 13:34
  SPEAKER_00: From my perspective, the tests in these patients are sort of ancillary.
• 13:39
  SPEAKER_00: I think the 28-day cutoff that we use in the clinical center makes sense for our patient population.
• 13:45
  SPEAKER_00: And I think to identify the people who have chronic ongoing infection, the subgenomic PCR provides a lot of assistance in trying to figure out whether the person is clearing the infection or not.
• 13:58
  SPEAKER_00: I pass that.
• 14:00
  SPEAKER_00: I think a test-based strategy would be difficult because, as I mentioned earlier, you'd have to be doing likely bronchoscopies on all these patients to get lower respiratory tract samples or at least invasive procedures to get those samples.
• 14:13
  SPEAKER_00: And I wouldn't want to rely on a test-based strategy that's just using standard PCR or upper respiratory specimens.
• 14:20
  SPEAKER_00: Dr.
• 14:20
  SPEAKER_00: Palmore?
• 14:21
  SPEAKER_01: I think the other situation in which a test-based strategy, possibly with imaging, it can be useful, is when trying to discontinue isolation earlier than a symptom-based criteria might enable.
• 14:32
  SPEAKER_01: For example, in someone who's not severely immune-compromised but has prolonged symptoms, for example, a person who is becoming a so-called long hauler.
• 14:42
  unknown: Yep.
• 14:42
  SPEAKER_03: Right.
• 14:43
  SPEAKER_03: And do you routinely send the subgenomic PCR tests on all of your immunocompromised patients that you're kind of waiting to possibly take off isolation precautions or only in select cases?
• 14:55
  SPEAKER_01: Only in select cases, only when we have prolonged RTPCR positivity at a cycle threshold that suggests that there's possibly persistent infectivity.
• 15:07
  SPEAKER_01: So for example, cycle thresholds below 30 or 32 longer than we would expect to be the case.
• 15:14
  SPEAKER_01: I see.
• 15:15
  SPEAKER_03: Great, thank you.
• 15:16
  SPEAKER_03: So as you both probably know, there's also new guidance on criteria for immunocompromised healthcare personnel returning to work to wait 20 days after their initial COVID-19 diagnosis, and that a test-based strategy could possibly be utilized.
• 15:32
  SPEAKER_03: What considerations should facilities be making in allowing personnel to come back to work?
• 15:37
  SPEAKER_01: Much as with patients who are immunocompromised, 20 days should work fine for a majority of immunocompromised healthcare personnel.
• 15:45
  SPEAKER_01: I think the recommendation for return-to-work decisions among severely immunocompromised healthcare personnel to be managed by specialists and with a test-based strategy makes sense.
• 15:57
  SPEAKER_01: So a small proportion of immunocompromised healthcare personnel, as with immunocompromised patients, will not have cleared the infection in 20 days.
• 16:06
  SPEAKER_01: So require special management.
• 16:09
  SPEAKER_01: Not only because of the infectivity of these personnel, but also because of their extreme vulnerability in the healthcare workplace.
• 16:16
  SPEAKER_00: I would really agree.
• 16:17
  SPEAKER_00: I think it's the case that the likelihood that someone would be profoundly immunocompromised and returning to the workplace seems pretty low.
• 16:25
  SPEAKER_00: But each such instance, a return to work strategy should be individualized.
• 16:30
  SPEAKER_03: Thank you.
• 16:31
  SPEAKER_03: So I'm going to transition a bit now to talk about vaccinations.
• 16:35
  SPEAKER_03: And as we start moving towards vaccinating the public, what is your approach to vaccinating immunocompromised patients?
• 16:42
  SPEAKER_03: Would you ever recommend testing for antibody response in immunocompromised patients?
• 16:47
  SPEAKER_00: So I would want to get a needle in their arm as fast as I could.
• 16:51
  SPEAKER_00: We would like to have them all vaccinated.
• 16:53
  SPEAKER_00: We recognize that some of these patients may not make optimal antibody or immune responses, but we would still want to get them immunized.
• 17:01
  SPEAKER_00: I can't see any reason not to do that.
• 17:03
  SPEAKER_00: In terms of recommending antibody testing for such patients, I wouldn't recommend that we do it as a routine, but I could envision a set of circumstances in which you might want to know the result for a given patient.
• 17:16
  SPEAKER_00: And I think that would, again, just be part of individualized care.
• 17:20
  SPEAKER_00: It's important to note, for example, for a patient who's undergoing conditioning for a transplant, you may want to, depending on the pull constellation of the patient's setting, you may want to vaccinate the person first and give them a chance to respond before you start the conditioning regimen if you feel like the disease will allow that, because that may give them a chance to avoid a serious infection down the line.
• 17:44
  SPEAKER_03: Right.
• 17:44
  SPEAKER_03: That's an important consideration.
• 17:45
  SPEAKER_03: Anything else, Dr.
• 17:46
  SPEAKER_03: Palmore?
• 17:47
  SPEAKER_01: Yes, I agree with Dr.
• 17:49
  SPEAKER_01: Henderson's point about trying to vaccinate patients who are going to be iatrogenically immunosuppressed.
• 17:55
  SPEAKER_01: I think that rheumatologists also have tried to find ways to pause immunosuppressive therapy, such as retoximab, like B cell depleting therapy, if they can, or delay therapy like that, which, if possible, in order to allow patients to be immunized before the next dose.
• 18:15
  SPEAKER_01: You know, as we know, it's not necessary to do serologic testing in most vaccine recipients, but I agree it may be reasonable to do limited testing in patients when there's good reason to worry about lack of response.
• 18:28
  SPEAKER_01: And again, those who've had recent B cell depleting therapy andor stem cell transplants or organ transplants might be those in whom you'd want to do limited testing.
• 18:38
  SPEAKER_01: And maybe even in the context of a formal study, as in a center like ours or in a cancer center, might consider doing that.
• 18:45
  SPEAKER_01: The other reminder is that serologic assays that measure antibodies to the nuclear protein do not reflect the immune response to the vaccine.
• 18:54
  SPEAKER_01: Only serologic assays that measure antibodies to spike protein.
• 18:58
  SPEAKER_00: That's a really important point.
• 18:59
  SPEAKER_03: It sounds like this is something, you know, over the next six months we might have more information on in terms of who to test for and what to do with that result.
• 19:08
  SPEAKER_01: Yes, of course, you're absolutely right.
• 19:09
  SPEAKER_01: We actually don't know the level of antibody that is a correlative immunity.
• 19:14
  SPEAKER_03: Similar to that, in patients where you can't delay their immunosuppressing condition, are there other best practices you would utilize?
• 19:24
  SPEAKER_03: You know, one example would be in HIV patients.
• 19:27
  SPEAKER_03: Would you ever consider delaying vaccination until CD4 count is above a certain threshold?
• 19:33
  SPEAKER_01: No, I would not delay immunization in HIV patients.
• 19:36
  SPEAKER_01: As we know, HIV patients who are stable have been included in clinical trials of all the vaccines to date.
• 19:42
  SPEAKER_01: And I see no reason to delay immunization in any subset of HIV patients.
• 19:48
  SPEAKER_00: I completely agree.
• 19:50
  SPEAKER_00: I think getting folks immunized is our top priority.
• 19:54
  SPEAKER_03: That certainly makes sense.
• 19:56
  SPEAKER_03: And so for our last question today, I wanted to ask you both how you think we can best move forward in treating immunocompromised patients in general to protect their health and safety as it relates to COVID-19.
• 20:10
  SPEAKER_00: So I think the theme we've had throughout this discussion is that you try to individualize the care of these patients to protect them the best we can during the course of their treatment.
• 20:21
  SPEAKER_00: I think one thing that is often not emphasized, that Dr.
• 20:24
  SPEAKER_00: Palmore touched on, is that they need to be especially careful when they're out in society and they should, I think, avoid, they should be sort of emphasizing all the things that we all are doing: mask wearing and physical distancing and hand hygiene to the greatest extent possible, whether they're at home or in any set of circumstances where they might find themselves at risk for exposure.
• 20:49
  SPEAKER_00: And then in terms of caring for them either as outpatients or in the hospital, following the tenants that Dr.
• 20:55
  SPEAKER_00: Palmore has laid out, I think really makes the most sense.
• 20:59
  SPEAKER_01: I would add that the household members and close contacts of our immunocompromised patients should be encouraged to be immunized as soon as they're eligible to do so, as well as encouraged to follow the same precautions of distancing, masking, and hand hygiene, and not letting up on those precautions just because things are getting better.
• 21:18
  SPEAKER_03: Thank you.
• 21:19
  SPEAKER_03: I think those are both really important points.
• 21:22
  SPEAKER_03: Well, thank you very much, Dr.
• 21:24
  SPEAKER_03: Palmore and Dr.
• 21:25
  SPEAKER_03: Henderson, for sharing your perspectives and experiences.
• 21:27
  SPEAKER_03: This podcast can be accessed on Shay's Online Education Center, Learning CE, under the Rapid Response Program.
• 21:34
  SPEAKER_03: You will also find resources such as the recorded webinars, healthcare facility outbreak preparedness, and the SHAY COVID-19 town halls.
• 21:42
  SPEAKER_03: New members can now receive 50% off 2021 SHA membership by using the coupon code WELLCOME2021 until March 31st.
• 21:50
  SPEAKER_03: This concludes this episode of the Rapid Response Podcast.
• 21:53
  SPEAKER_03: Thank you for tuning in.