BSTM hosts webinars to discuss COVID-19 and tropical diseases
On Wednesday, July 22, the fourth webinar will be held08/07/2020
Hot Tropics: this is the name of the program aired every fifteen days by the official channels of the Brazilian Society of Tropical Medicine (SBMT) that addresses topics of interest to the Tropical Medicine community, particularly at this time, the Tropical Medicine interface and the COVID pandemic in Brazil. The proposal is to open a space for discussion about the impact of this pandemic on the care of the population at different levels, emphasizing the importance of diagnosis and the impact on other diseases, in tropical conditions, as well as the situation of neglected tropical diseases in times of pandemic.
In the first episode, Clinical Management of COVID-19 in primary care, aired on June 10, Dr. Humberto Sauro Machado, community and family doctor at the Zilda Arns Family Clinic – Alemão Favela Complex, reported the experience in dealing with the pandemic of COVID-19 in his Basic Health Unit (BHU) with a focus on clinical management, with interface with epidemiological surveillance, community articulation and reorganization of flows in his BHU. This unit is composed of 14 teams, each with 3.300 registered users, totaling 45 thousand people served. Contextualizing the work of PHC in the care of patients with suspected COVID-19, Dr. Machado gave a brief narrative of a patient treated with flu-like syndrome and who later presented with severe acute respiratory syndrome, being seen at the same BHU and referred to the inpatient unit. After discharge from hospital, the patient had a neurological condition and was diagnosed with an ischemic stroke. This narrative demonstrates the importance of training primary health care in the initial care of patients with COVID-19, corroborating the attribution of primary health care, longitudinally, throughout the patients itinerary, from the opening of their flu condition to a serious complication and finally their rehabilitation and the treatment of sequelae.
Dr. Kleber Luz, an infectious disease physician and professor at the Federal University of Rio Grande do Norte (UFRN), stressed the importance of primary care in the care of COVID-19, because for a large part of the population and health professionals, this disease is considered to be of secondary and tertiary care, and as a disease in the Intensive Care Unit (ICU). Professor Luz recalled that prior to ICU care, a high percentage of patients are seen initially in primary health care units. For doctors working in primary care, Professor Luz calls attention to the pathogenesis and pathophysiology of COVID-19, calling attention to the understanding of the different clinical phases of the disease, which greatly contributes to a better understanding of the disease and the clinical management of patients. The professor explained that when talking about stages in tropical or infectious diseases, they refer to clinical stages and not stages of pathogenesis or pathophysiology of the disease. This imbroglio in this differentiation can cause confusion in the medical team that attends patients with or suspected of COVID. According to him, an infected patient can present severe manifestation of the disease in the first days due to decompensation caused by pre-existing comorbidities, such as diabetes, heart disease. That is, not necessarily, the fact that the patient is in the viremia phase means that he is well, and, not necessarily, the fact that he is on the 14th day of the disease means that it is severe, as there may be a manifestation of severity already in the initial period of the disease, which corresponds to the viremic period.
The webinar had as debaters Dr. Angelo Lindoso and Dr. Dorcas Costa, under the moderation of Dr. Guilherme Werneck. For an hour, the guests (presenters and panelists) instigated numerous questions from Internet users: “A patient who presents with IGG and IGM reagent 40 days after the onset of symptoms, at asymptomatic moment. How can we do the clinical management of him/her? In practice, do you observe thromboembolic complications in COVID-19 patients without risk factors? What is the role of anticoagulation in management? What clinical management for a patient with IgG and IgM reagent after more than 25 days of illness? Is discharge safe by clinical criteria after 14 days? Patients with positive nasopharyngeal RT-PCR after discharge: viral fragment or risk of transmission? IgG and IgM performed after 40 days, but only positive IgG. The patient has a tomography with 10% impairment. Is he considered positive and transmitting? This webinar with presentations, debates and questions served to resolve doubts regarding the handling of COVID-19 in primary health care.
The second episode of Hot Tropics, Diagnosis of COVID-19: clinical use and epidemiological surveys, aired on June 24, counted on the participation, as debaters, of Dr. Ester Sabino, former director of the Institute of Tropical Medicine at the University of São Paulo (USP), and Dr. Silvia Figueiredo Costa, associate professor in the Department of Infectious and Parasitic Diseases, Faculty of Medicine at the University of São Paulo. The presenters were Dr. Benedito Antônio Lopes da Fonseca, associate professor at the Ribeirão Preto School of Medicine at the University of São Paulo and Dr. Bernardo Lessa Horta, associate professor at the Federal University of Pelotas (UFPel). The moderation was held by Dr. Júlio Croda, infectious disease researcher at the Oswaldo Cruz Foundation (Fiocruz) and associate professor at the Federal University of Mato Grosso do Sul (UFMS).
In one of his first statements, Dr. Fonseca demystifies that it is ideal to collect samples by swab to detect the virus from the second to the third day or from the third on. He points out that in his experience this is not necessary, since the virus is detected from the first day. The professor cites a work published in The New England Journal of Medicine (NEJM) in which an outbreak that took place in a long-term elder-care home was evaluated and it was demonstrated that the virus is detectable before people develop symptoms. Dr. Fonseca also mentions his experience in making the diagnosis on day zero. For him, the main point is that RT-PCR is detectable for a long period, sometimes even for four weeks. The professor explains that it is difficult to keep a patient from isolation if one thinks only about the detection of RNA, not least because this virus is RNA, that is, detecting the RNA itself does not mean that there is viral replication and transmission of the virus, differently from bacteria.
Dr. Horta spoke about the Surveys, which arose from the need to know more about the real burden of COVID-19 in Brazil. He detailed that it is known until now that the most severe cases are those that usually seek services; part of the deaths is diagnosed; there is a series of indirect evidence from sub-registries; what the official system shows is only part of the iceberg. In view of this, it became evident that conducting a sero-epidemiological survey would be essential, since although similar surveys are being carried out in several countries, some are not even population-based, such as the one in New York, held in stores, markets, etc. Others were done quickly with people on drive-thru. Spain, on the other hand, also opted for the population-based survey. The objective of the Brazilian EPICOVID-19 survey carried out by Ufpel is to know: “what percentage of the population has already been infected?”; “have you had contact with the virus?”; “how is the evolution of this pandemic?”; “when comparing the regions of the country, which ones would be the most affected?”; “when there is a positive individual in the residence, what is the rate of intra-family transmission?”. According to Professor Horta, due to the urgency of the study, they used a rapid test and did not collect blood for the Elisa test, which would imply difficulties related to logistics and analysis time. Still according to him, the agility and simultaneity necessary to carry out the survey, both on the basis of that of Rio Grande do Sul (RS) and nation-wide, it was decided to work with sentinel city, a concept proposed by the World Health Organization (WHO), in which a site is chosen as a sentinel for what happens in that region. In this case, the host cities of the mesoregions of the Brazilian Institute of Geography and Statistics (IBGE) were used, both in RS and in Brazil. In the 133 cities studied, 25 census sectors are randomly drawn, 10 households are drawn in each of these sectors, and of these, one resident is randomly selected to participate in the survey, and this resident, answers the questionnaire and performs a quick test.
The questions came from Brazil and abroad. We have selected some: The production of the closest possible picture is only achieved with the use of epidemiological indicators that were fed with reliable data. Today we know that many companies test their employees, wouldnt it be interesting for these companies to provide these results so that COVID’s real situation in Brazil would be better understood? Can there be a cross reaction in the rapid tests, with other viruses such as zika, dengue or other coronaviruses? Considering the lowest percentage of positivity in asymptomatic patients, should pool testing be considered? If two consecutive negative PCR results should be obtained for a patient with COVID-19 to be discharged, knowing that RNA can persist for 6 weeks, even without indicating infectiousness? How can we explain individuals with positive PCR for more than 50 days? Why does this patient still have viral RNA? Recent studies (China and Italy) have shown a higher prevalence of IGA compared to IGG and IGM. What are the main differences of these antibodies? One of the treatments for critically ill patients is the transfusion of convalescent serum/plasma. I keep asking myself: are we offering “placebo-like” to these patients, given that these antibodies may not be neutralizing? Is an examination carried out to confirm that donor antibodies are neutralizing?
The BSTM believes that through online seminars, considered an efficient content format, and widely used lately, it has taken another important step in its history.
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