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Date: September 8, 2022

The Digest - GW Clinical Enterprise

**This email contains important COVID-19 information and updates. Please ensure that you read these emails in their entirety. Thank you!**

GW MFA | GW Hospital | GW SMHS

The GW Medical Faculty Associates

It’s time to put COVID boosters and influenza vaccines on your radar

COVID boosters are available at pharmacies for persons age 12 and up who have completed a primary series or been boosted at least two months ago. The vaccine is bivalent, containing spike proteins from Omicron subvariants BA4/5 as well as the original strain. Stay tuned for more information on availability of COVID boosters at MFA.

Influenza has been smoldering at low levels throughout the summer, but has generally taken a break from its seasonal pattern for the past couple of years. We can probably expect a substantial spike of influenza cases this fall/winter and need to be prepared by having patients and healthcare personnel (and our families) immunized early on. This is not the year to wait on influenza vaccination.

Please see yesterday’s “Fight the Flu!” email regarding how to obtain influenza vaccine for patients, and where staff can seek influenza immunization.

Please give Evusheld for pre-exposure prophylaxis to your immunosuppressed patients 

We encourage use of Evusheld (tixagevimab plus cilgavimab) for eligible patients. Remember that patients who received Evusheld more than 6 months ago and remain eligible should get another dose.

Evusheld is not authorized for the treatment of COVID-19, as post-exposure prophylaxis, or as a substitute for vaccination among vaccine-hesitant patients.

For administration in MFA, please see these prescribing and administration checklists for MFA providers and MFA staff.

If you have questions, please contact Jose Lucar, MD ([email protected]), or Tara Palmore, MD ([email protected]), for clinical practice; or Ryan Mouton, PharmD ([email protected]) for the MFA Clinic Dispensary.

GW Hospital

REMINDER!

GW Hospital Monkeypox Advisory #8

Situation

• Clinicians need to be aware of a large international monkeypox (MPX) epidemic.

Background and clinical description

• Most cases have occurred in men who have sex with men (MSM) but an increasing number of cases are found in transgender or cis-gender women and household contacts.
• MPX can be transmitted through direct skin-to-skin or mucosal surface contact, oral/respiratory droplets, or with clothing, towels, bed linens that have been in contact with body fluids or sores.
• Although the virus has been detected in semen, it is unknown whether transmission via semen or vaginal fluid can occur.
• Genome sequencing shows that the current outbreak involves a less virulent clade of monkeypox virus, and there have been very few deaths in the current outbreak.
• In some patients, MPX presents with a 1 to 3-day prodrome of fever, headache, body aches, and malaise, often with lymphadenopathy (swollen lymph nodes). Shortly after, mucosal and skin lesions appear. Some patients never have this prodrome.
• Lesions progress from rectal and/or oral lesions to a generalized skin rash that can include macules, papules, vesicles, and pustules (which may be painful or itchy). Vesicles and pustules may be centrally umbilicated. The rash affects the face and extremities more than the trunk, but can be found anywhere including the genitals, perianal area, palms and soles.
• Many have had few lesions or a single lesion involving only the genital area, groin, and/or perianal and rectal areas. It has even presented as isolated proctitis (inflammation of the lining of the rectum).
• The differential diagnosis includes VZV, HSV, and several common sexually transmitted infections, including gonorrhea, chlamydia, lymphogranuloma venereum, syphilis, and chancroid (H. ducreyi). If you are considering one of these diagnoses, consider MPX first and foremost.
• The incubation period is 7 to 14 days, with a range of 5 to 21 days. The illness typically lasts 2 to 4 weeks. Patients are infectious from the onset of symptoms until all crusts have fallen off and new skin has grown in.

Actions

• Maintain a high index of suspicion - especially based on social history and travel history. DO consider the diagnosis in a patient with a compatible syndrome but without demographic risk factors. Anyone who has been in close contact with someone who has MPX is at risk.
• Infection control/Occupational Safety:
• Patients need to be identified at point of triage when presenting with the above complaints.
• Place patients immediately in isolation in Rooms 1-5 in the ED or a private LDR.
• Clinicians should examine the patient in appropriate PPE (N95 with goggles or face shield or PAPR, gown, and gloves), keeping in mind that the oral and skin lesions themselves, and oral droplets, contain the virus.
• ED Charge nurse to keep a log of all staff who have contact with the patient, including EVS who is performing the terminal clean. This log is to go to ED Manager.
• Patients with suspected or confirmed MPX must be in a private isolation room with a closed door and a private toilet/commode, with no visitors allowed.

• Clinicians may consult with ID and Dermatology regarding the patient presentation if there is a clinical question regarding the differential diagnosis. If the ED feel that the patient should be ruled out or will most likely rule in as MPX, the ED may proceed with testing and public health reporting.
• If the physicians agree that this case may represent a case of MPX, the charge nurse contacts the House Operations Supervisor and the Microbiology laboratory at 202-715-4673.
• Enter a DC Health case report form for each patient at the time of testing:
• https://dccovid.force.com/provider/s

This serves to notify DC Health of a case and will provide you with a case number

• Complete all DC Public Laboratory forms and CDC form for specimen processing by hand
• These forms are required for specimen processing and must be included with the labeled specimen

The physician collects the specimens

The physician completes the DC Health and CDC case form to be hand delivered with the specimen to the microbiology laboratory (202-715-4673)

The laboratory will store the specimen in the microbiology freezer until collected by DC Health

Visitors

• No hospital visitors will be allowed with the exception: end of life, developmentally

delayed, and dementia patients. Please noted that these exceptions must be approved

by the administrator on call. Questions contact IP/ID

A terminal clean, including UV light cleaning, will need to be performed and the linen should be trashed because it is potentially infectious. Waste may be treated as regular medical waste for disposal.

Treatment

• GW Hospital is not able to provide Tpoxx for outpatients.
• For patients who are discharged but have a high risk for monkeypox, please provide

them with the MFA Infectious Disease Clinic phone number 202-741-3440 for further

treatment options.

• Note that off hours, Tpoxx is NOT available at commercial pharmacies. The

patient would need to follow up on the following business day with the MFA ID clinic or another provider.

• For patients requiring admission, contact Infectious Diseases for treatment options.
• Questions? Call ID or IP on call.

The GW SMHS

No Updates

This email is intended to serve as a digest of all messaging for our clinical faculty, students, and staff. This email is distributed at the close of business weekly, as we are managing operations during the COVID-19 pandemic. 

If you have feedback, please feel free to send to [email protected].