CHI St. Vincent CMO Dr. Gerry Jones. CHI St. Vincent

The novel coronavirus SARS-CoV-2 that causes the illness COVID-19 has been with us in Arkansas since March 11, almost exactly four months ago — presuming it did not go undetected earlier. More than 10,000 Arkansans have tested positive, 865 (at this writing) of them so ill they required hospitalization. Those aren’t large numbers in the grand scheme of things, and the new virus has infected the world for just a little over six months, so doctors and epidemiologists still have a lot to learn about many aspects of this virus new to humankind. 

Some changes in the way the public responded to the disease came quickly. Briefly, experts advised that it was pointless to wear surgical masks, which do not keep out microscopic virus particles, to protect against infection. But, after an April study showed that paper masks would block the wearer’s viral droplets, and because those who’ve contracted COVID-19 can be asymptomatic, the recommendation changed: Wear a mask to protect others from your sneezes and coughs. This point has been difficult to get across in some quarters. 

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Other early and widely reported discoveries: COVID-19 causes the loss of taste and smell while the virus is active; in many with that symptom, the disease is milder. COVID-19 causes blood clots in organs as well as the lungs. Some people with very low levels of oxygen in the blood seem unaffected: “happy hypoxics,” some call them, though there is nothing good about oxygen deprivation. Lately, the Centers for Disease Control and Prevention has said that touching surfaces that have been exposed to viral droplets are not the main way the virus spreads, so you probably can stop spraying your packages from Amazon with Lysol.

Large questions remain:

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Why do some people with the virus suffer no symptoms? Is the assumed factor of spread — one to three — correct? What is the complete picture of presenting symptoms? What is the full range of the disease’s effects on the body? Will it come back in the fall? What will happen if someone contracts the flu and COVID-19 at the same time? How long does it take to fully recover from hospitalization?

What is the real percentage of Arkansans who have been infected with the virus, and does that offer a period of immunity in the future? 

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Why did it turn into a deadly pandemic, unlike SARS, another coronavirus that emerged in China but which infected only a little more than 8,000 worldwide, according to the World Health Organization? Reported SARS infections in the U.S. totaled only 27, and there were no fatalities on our shores. But COVID-19 has swept the nation, killing more than 100,000 Americans to date; nearly 2 million people across the nation have become infected.  

As of mid-May, the Baptist Health system had admitted a total of 112 patients with COVID-19. The University of Arkansas for Medical Sciences had admitted 99. CHI St. Vincent had also treated COVID-19 patients (it declined to provide numbers). Those cases have given doctors and researchers some familiarity with the clinical progression of COVID-19. A couple of new therapies are also in use, including an experimental drug and convalescent plasma.  Some things learned:

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* The peak of infections Arkansas had in April was not the peak from which we would recover. Cases are rising again, due partly to increased testing but also to increased spread in Northwest Arkansas. 

UAMS
UAMS CEO Dr. Steppe Mette

* While the majority of people who come to the hospital with COVID-19 are suffering from respiratory symptoms, in some patients, their disease starts with gastrointestinal ailments, like nausea and diarrhea. Those symptoms “weren’t part of the symptom complex when COVID was first described,” said Dr. Steppe Mette, CEO for UAMS Medical Center. Dr. Eric Bravo, a hospitalist at Baptist Health Medical Center in Little Rock, said some of these patients have chalked up their symptoms to a stomach bug and stayed home.  

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Baptist Health hospitalist Dr. Eric Bravo.

* Mette described the progress of the illness as seen at UAMS: an initial week of fever, headache and upper respiratory distress, which Mette called “pretty manageable,” sometimes followed in the second week by severe respiratory issues and “severe systemic inflammation,” requiring intensive care. Those whose lungs require ventilation to breathe and who lose function in another organ, such as liver or kidneys, “have a high likelihood of dying,” he said, but the percentage of patients now placed on a vent is small. As of June 4, UAMS had treated 32 patients in ICU, and 16 of those required mechanical ventilation. 

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* While COVID-19 is highly infectious, it is most easily spread in congregate settings, such as prisons, nursing homes, churches and the like, Secretary of Health Dr. Nate Smith said. But in workplaces where people mask and maintain a social distance of six feet, the virus is less apt to transmit. 

* Some patients will develop cardiomyopathy, a weakening of the heart muscle, Bravo said. In his experience, patients who recover from the virus have recovered their heart function.

* It was known early on that patients over 65, especially those with comorbidities like diabetes or lung disease, are at the greatest threat from the virus, but even healthy middle-aged people get very sick. Bravo said he was surprised to see patients in middle age requiring oxygen and staying sick for as long as 10 days. “That’s a long time for a virus,” he said. “They feel terrible.” It’s much worse than the flu. 

Dr. Gerry Jones, chief medical officer at CHI ST. Vincent, said the hospital has admitted more young people — under 60 — in the past several weeks. The 45-64 age group in Arkansas accounts for 30 percent of positive cases, but only 22 percent of deaths; three-fourths of those who die of the disease are 65 or older. 

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* COVID-19 was first thought to spare young children, but complications from the infection have emerged. Multisystem Inflammation Syndrome was first detected in Great Britain and is now being seen in the United States in children who had the virus or were around someone who did. The disease is similar to Kawasaki disease, and is treatable; there have been no cases yet of the illness in Arkansas.

* Initially, it was thought that COVID-19 patients needed intubation quickly. That is no longer done; instead, medical workers try to delay putting patients on a ventilator as long as possible. National data indicate that mortality of patients on a vent is 80 to 85 percent, Bravo said. Most very ill patients are now started on high-pressure oxygen, delivered via a hose attached to a mask. Patients getting oxygen this way do not have to be sedated, as do those on ventilators, which can increase the risk of pneumonia. They can also eat. Recovery from ventilation is a long process because the sedation weakens the body and can cause confusion and other neurocognitive difficulties.

Baptist Health
Baptist Health CMO Dr. Eddie Phillips

* The mortality rate of Arkansans who are hospitalized for COVID-19 was 15.4 percent on the first of June, according to Mike Cima, the chief epidemiologist at the Arkansas Department of Health and a member of the governor’s COVID-19 Technical Advisory Board. The rate at Baptist Health, which had treated 112 patients, and UAMS, 99, is better: Chief Medical Officer Dr. Eddie Phillips put the Baptist system’s mortality rate through mid-May at 11.6 percent; UAMS’ was 11.2 percent. That compares to a death rate of hospitalized patients of around 20 percent in New York City. 

UAMS’ Mette said the lower rate of death in Arkansas can be attributed to fewer patients. “We’ve never had to limit resources, never had to deny a patient a ventilator,” Mette said, and the hospital workers can devote more time to the care of COVID-19 patients than those at hospitals overwhelmed by patients. “It’s a lesson in preparedness to take care of patients: Prepare for the next wave so you don’t overwhelm the health system.”

* There are reports from abroad of people who stay sick for a couple of months with diverse symptoms, something termed “long tail COVID” in Great Britain. Mette said UAMS has seen patients with persistent virus over a month after symptoms have stopped, but it’s unclear whether they can infect others. “We have to assume yes,” he said. He also said that the “vast majority” of patients who have been in ICU or on ventilators have gone home or into rehab. However, Mette did have one patient who was discharged feeling well but whose symptoms returned and came back to the hospital severely ill.

* Studies to date, based on a quick review by Wendy Nembhard, chair of the department of epidemiology at the College of Public Health of the University of Arkansas for Medical Sciences, indicate that asymptomatic people have the same viral load as those with symptoms, and they may infect people as easily. (This seemed to be the case at Cummins Prison, which initially did not remove inmates who tested negative for COVID-19 from barracks where asymptomatic positives were held.) “There’s probably not anybody truly asymptomatic,” CHI St. Vincent’s Jones said. “It’s a matter of asking the right questions.” 

* The good news: The personal protective equipment worn by hospital workers — face shields, goggles, N95 masks, gowns and gloves — protects against the disease. The only health care workers who became infected at the University of Arkansas for Medical Sciences were those treating a patient whose COVID-19 infection was unknown and so full PPE was not worn. Now, both UAMS and Baptist are testing all admitted patients for COVID-19, and both hospitals require employees to wear masks, face shields, goggles and gloves when they enter any patient room.

* Other issues that have been studied elsewhere include lung scarring, though Phillips noted that may be seen in any patient who has been on a ventilator for a while. The lung scarring connected with COVID-19 can also be traced to the immune system overdrive prompted by the virus, causing damage to lung tissue that might not heal. This damage has even been found in asymptomatic people, according to Chinese research. Other places have reported strokes in young, healthy people; and laboratory studies suggest that the virus may reduce fertility in males.  

* Research is going on in Little Rock: Both Baptist Health and UAMS are participating in trials of the antiviral drug remdesivir, which is given to very ill patients. UAMS is also using tocilizumab, which dampens immune response. Both hospitals are also using convalescent plasma, collected from COVID-19 patients in Arkansas who have recovered and have no detectable virus, as part of nationwide research into the efficacy of therapy with antibodies to the virus. Convalescent plasma is used in only the sickest patients: “We have to look at a transfusion as a transplant,” Jones said, because “we’re taking cells from another person, and there are inherent risks. There in the sickest patients, you come to a point where the benefit outweighs the risks.” CHI St. Vincent doctors have had a “couple of good responses” in patients treated with remdesivir, and St. Vincent and other hospitals in Arkansas have seen good results in patients who received plasma as well, though a few results do not rise to the level of science.

Arkansas’s number of coronavirus patients has surged in recent weeks. Increased testing — the state’s goal for June is 120,000, in line with the White House suggestion of 30 people per 100,000 in population accounts for most of the high numbers, but hospitalizations have risen as well, a sign of disease spread. On June 8, the health department announced the largest one-day rise of 26, all from Washington County. (Baptist Health’s Phillips said the system is seeing an increase in cases: It’s gone from an average of about nine a day before the recent rise to 15. Health secretary Smith said CHI St. Vincent had the highest number as of June 10, with 27 patients. As of June 10, 181 people were hospitalized with COVID-19.) New cases in Northwest Arkansas and Sevier County are traced to the poultry industry, whose workers labor side by side, and their families, also a factor for an increase in the transmission rate, the state health department says. At his June 8 COVID-19 update, Governor Hutchinson noted that in previous days, 41 cases were linked to only 15 households in Washington County. 

Increased testing in Arkansas is also showing the number of people infected with the coronavirus but who show no symptoms is around 50 percent. At the state health units, the percentage was higher: 74 percent of the positive tests came from people who did not feel sick. That number, combined with the fact that studies show that asymptomatic people can transmit the virus as easily as those who are showing symptoms, emphasizes the need for masking.

 “It’s only been three months,” St. Vincent’s Jones said about the pandemic, “but there are days it seems like it’s been a lifetime. … Despite the fact that it is appropriate and the time has come to begin to reopen [businesses], we’ve got to keep in mind that COVID is not over. It’s still here, and it’s important for us to understand that and take proper precautions.”

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